Dry Eye Syndrome Treatment & Management

  • Author: C Stephen Foster, MD, FACS, FACR, FAAO; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Jan 25, 2012
 

Consultations

A rheumatologist can be consulted if a systemic collagen vascular disease is suspected.

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Approach Considerations

The International Dry Eye WorkShop (DEWS) Subcommittee members reviewed the Delphi Panel (the Dry Eye Preferred Practice Patterns of the American Academy of Ophthalmology and the International Task Force Delphi Panel on Dry Eye) approach to the treatment of dry eye and modified it.[1]

Treatment recommendations are based on disease severity.

  • level 1
    • Education and environmental/dietary modifications
    • Elimination of offending systemic medications
    • Preserved artificial tear substitutes, gels, and ointments
    • Eyelid therapy
  • level 2 – If level 1 treatment is inadequate, add the following:
    • Nonpreserved artificial tear substitutes
    • Anti-inflammatory agents
      • Topical corticosteroids
      • Topical cyclosporine A
      • Topical/systemic omega-3 fatty acids
  • Tetracyclines (for meibomianitis, rosacea)
  • Punctal plugs (after control of inflammation)
  • Secretagogues
  • Moisture chamber spectacles
  • level 3 - If level 2 treatment is inadequate, add the following:
  • Autologous serum, umbilical cord serum
  • Contact lenses
  • Permanent punctal occlusion
  • level 4 – If level 3 treatment is inadequate, add the following:
  • Systemic anti-inflammatory agents
  • Surgery
    • Lid surgery
    • Tarsorrhaphy
    • Mucous membrane grafting
    • Salivary gland duct transposition
    • Amniotic membrane transplantation

Recanalization and punctal occlusion surgery

A study by Ohba et al assessed the rate of recanalization and the efficacy of punctal occlusion surgery using a high heat-energy–releasing cautery device to treat severe dry eye disease and recurrent punctal plug extrusion.[8] The study concluded that the device was associated with a low recanalization rate and demonstrated improvements in ocular surface wetness and visual acuity. In patients with dry eyes, close puncta. If plugs are not available or are repeatedly lost, cautery or hyfrecation is indicate for permanent closure, beginning with the lowers and then the uppers if necessary.

A study by Mataftsi et al found that punctal plugs offer an effective and safe treatment for children with persistent symptoms and should be considered.[9]

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Contributor Information and Disclosures
Author

C Stephen Foster, MD, FACS, FACR, FAAO  Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution

C Stephen Foster, MD, FACS, FACR, FAAO is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association of Immunologists, American College of Rheumatology, American College of Surgeons, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, American Uveitis Society, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Royal Society of Medicine, and Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Erdem Yuksel, MD  Fellow, Department of Ophthalmology, Massachusetts Eye Research and Surgery Institute, Medical School of Gazi University

Disclosure: Nothing to disclose.

Fahd Anzaar, MD  Fellow, Massachusetts Eye Research and Surgery Institute; Clinical Research and Education Coordinator, Ocular Immunology and Uveitis Foundation

Disclosure: Nothing to disclose.

Anthony S Ekong, MD  Consulting Staff, Department of Ophthalmology, Marshfield Clinic

Anthony S Ekong, MD is a member of the following medical societies: American Academy of Ophthalmology and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Jack L Wilson, PhD  Distinguished Professor, Department of Anatomy and Neurobiology, University of Tennessee Health Science Center College of Medicine

Jack L Wilson, PhD is a member of the following medical societies: American Association of Anatomists, American Association of Clinical Anatomists, and American Heart Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Christopher J Rapuano, MD  Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Institute

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology

Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; RPS Ownership interest Other; EyeGate Pharma Consulting fee Consulting; Bausch & Lomb Honoraria Speaking and teaching; Bausch & Lomb Consulting; Merck Honoraria Speaking and teaching

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

  1. Dry Eye Workshop (DEWS) Committee. 2007 Report of the Dry Eye Workshop (DEWS). Ocul Surf. April 2007;5(2):65-204. [Full Text].

  2. Lambiase A, Micera A, Sacchetti M, et al. Alterations of tear neuromediators in dry eye disease. Arch Ophthalmol. Aug 2011;129(8):981-6. [Medline].

  3. Nien CJ, Massei S, Lin G, Nabavi C, Tao J, Brown DJ, et al. Effects of age and dysfunction on human meibomian glands. Arch Ophthalmol. Apr 2011;129(4):462-9. [Medline].

  4. Galor A, Feuer W, Lee DJ, et al. Prevalence and risk factors of dry eye syndrome in a United States veterans affairs population. Am J Ophthalmol. Sep 2011;152(3):377-384.e2. [Medline].

  5. Behrens A, Doyle JJ, Stern L, et al. Dysfunctional tear syndrome: a Delphi approach to treatment recommendations. Cornea. Sep 2006;25(8):900-7. [Medline].

  6. Gilbard JP, Farris RL, Santamaria J 2nd. Osmolarity of tear microvolumes in keratoconjunctivitis sicca. Arch Ophthalmol. Apr 1978;96(4):677-81. [Medline].

  7. Lemp MA, Bron AJ, Baudouin C, Benítez Del Castillo JM, Geffen D, Tauber J, et al. Tear osmolarity in the diagnosis and management of dry eye disease. Am J Ophthalmol. May 2011;151(5):792-798.e1. [Medline].

  8. Ohba E, Dogru M, Hosaka E, et al. Surgical punctal occlusion with a high heat-energy releasing cautery device for severe dry eye with recurrent punctal plug extrusion. Am J Ophthalmol. Mar 2011;151(3):483-487.e1. [Medline].

  9. Mataftsi A, Subbu RG, Jones S, Nischal KK. The use of punctal plugs in children. Br J Ophthalmol. Jan 2012;96(1):90-2. [Medline].

  10. Baiza-Duran L, Medrano-Palafox J, Hernandez-Quintela E, Lozano-Alcazar J, Alaniz-de la O JF. A comparative clinical trial of the efficacy of two different aqueous solutions of cyclosporine for the treatment of moderate-to-severe dry eye syndrome. Br J Ophthalmol. Oct 2010;94(10):1312-5. [Medline].

  11. Abelson MB. Dry eye, today and tomorrow. Review in Ophthalmology. 2000;11:132-34.

  12. American Academy of Ophthalmology. External disease and cornea. In: Section Seven: Basic & Clinical Science Course. American Academy of Ophthalmology; 2007-2008.

  13. Barabino S, Rolando M, Camicione P, et al. Systemic linoleic and gamma-linolenic acid therapy in dry eye syndrome with an inflammatory component. Cornea. Mar 2003;22(2):97-101. [Medline].

  14. Bron AJ, Tiffany JM, Gouveia SM, et al. Functional aspects of the tear film lipid layer. Exp Eye Res. Mar 2004;78(3):347-60. [Medline].

  15. Geerling G, Maclennan S, Hartwig D. Autologous serum eye drops for ocular surface disorders. Br J Ophthalmol. Nov 2004;88(11):1467-74. [Medline].

  16. Gilbard JP. Dry eye disorders. In: Albert DM, Jakobiec FA, eds. Principles and Practice of Ophthalmology. Vol 2. WB Saunders Co; 2000:982-1000.

  17. Karadayi K, Ciftci F, Akin T, et al. Increase in central corneal thickness in dry and normal eyes with application of artificial tears: a new diagnostic and follow-up criterion for dry eye. Ophthalmic Physiol Opt. Nov 2005;25(6):485-91. [Medline].

  18. McCulley JP, Shine WE. The lipid layer of tears: dependent on meibomian gland function. Exp Eye Res. Mar 2004;78(3):361-5. [Medline].

  19. Murube J, Nemeth J, Hoh H, et al. The triple classification of dry eye for practical clinical use. Eur J Ophthalmol. Nov-Dec 2005;15(6):660-7. [Medline].

  20. Ohashi Y, Dogru M, Tsubota K. Laboratory findings in tear fluid analysis. Clin Chim Acta. Jul 15 2006;369(1):17-28. [Medline].

  21. Perry HD, Donnenfeld ED. Dry eye diagnosis and management in 2004. Curr Opin Ophthalmol. Aug 2004;15(4):299-304. [Medline].

  22. Pflugfelder SC. Advances in the diagnosis and management of keratoconjunctivitis sicca. Curr Opin Ophthalmol. Aug 1998;9(4):50-3. [Medline].

  23. Stern ME, Gao J, Siemasko KF, et al. The role of the lacrimal functional unit in the pathophysiology of dry eye. Exp Eye Res. Mar 2004;78(3):409-16. [Medline].

  24. Tatlipinar S, Akpek EK. Topical ciclosporin in the treatment of ocular surface disorders. Br J Ophthalmol. Oct 2005;89(10):1363-7. [Medline].

  25. Yoon KC, Heo H, Im SK, et al. Comparison of autologous serum and umbilical cord serum eye drops for dry eye syndrome. Am J Ophthalmol. Jul 2007;144(1):86-92. [Medline].

  26. Zoukhri D. Effect of inflammation on lacrimal gland function. Exp Eye Res. May 2006;82(5):885-98. [Medline].

 
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Table 1. Dry Eye Severity levels[1, 5]
Dry Eye Severity level1234 (Must have signs and symptoms.)
Discomfort, severity & frequencyMild and/or episodic; occurs under environmental stressModerate episodic or chronic, stress or no stressSevere frequent or constant without stressSevere and/or disabling and constant
Visual symptomsNone or episodic mild fatigueAnnoying and/or activity-limiting episodicAnnoying, chronic and/or constant, limiting activityConstant and/or possibly disabling
Conjunctival injectionNone to mildNone to mild+/–+/++
Conjunctival stainingNone to mildVariableModerate to markedMarked
Corneal staining (severity/location)None to mildVariableMarked centralSevere punctate erosions
Corneal/tear signsNone to mildMild debris, decreased meniscusFilamentary keratitis, mucus clumping, increased tear debrisFilamentary keratitis, mucus clumping, increased tear debris, ulceration
Lid/meibomian glandsMGD variably presentMGD variably presentFrequentTrichiasis, keratinization, symblepharon
TFBUT (sec)Variable≤10≤5Immediate
Schirmer score (mm/5 min)Variable≤10≤5≤2
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