Long-term Management of Dry Eye Disease
Long-term Management of Dry Eye Disease
Gary N. Foulks, MD, FACS
Dry eye disease is a chronic condition for which we have no cure. However, dry eye disease often responds well to available treatments. There is significant incentive to manage dry eye disease promptly because in chronically dry eyes the tear film degrades, leading to ocular surface damage that produces persistent low-grade inflammation. This, in turn, can lead to further ocular surface damage. The result can be a downward spiral that in some patients produces debilitating morbidity.
Signs of dry eye disease chronicity include vascularization of the peripheral cornea, formation of filaments on the ocular surface, and in the most severe cases, keratinization of the surface epithelium, usually seen first on the conjunctiva but occasionally on the cornea as well. Patients may report symptoms such as difficulty maintaining vision, episodic discomfort, mucus discharge, and increasing impairment of vision as the disease progresses in severity.
Although dry eye disease often progresses fairly slowly, there are some individuals in whom the disease develops quickly. While we do not yet know why some people progress faster than others, there is the suggestion that people with underlying immunologic disease, such as Sjogren syndrome, may have dry eye exacerbations that correlate with other inflammatory aspects of their disease.
Severity Guides Treatment
Management of dry eye disease is increasingly guided by disease severity. There are two primary methods for grading disease severity, one involving tear function and the other ocular surface damage. Consensus reports have incorporated both in their grading systems, along with patient symptoms.1,2 These reports recommend tear supplementation, environmental and behavioral modification, and nutraceutical supplements for mild cases of dry eye disease. Of these, artificial tears are the predominant clinical treatment.
There are many options in the artificial tear category: drops that reduce the osmolarity of the tear, drops that induce lipid emulsion, and drops that create a soft gel matrix on the surface of the eye. Lipid emulsion drops are useful for evaporative dry eye; and for aqueous-deficiency, drops that dilute and stabilize the tear film or protect the surface, such as gelling drops, are most useful.
For moderate dry eye disease, antiinflammatory medication such as topical cyclosporine or a pulse of topical steroid can be added as treatments. (Some practitioners now advocate the use of cyclosporine in mild cases of dry eye disease as well.) Cyclosporine is typically used for at least 6 months to achieve maximum efficacy. Punctal plugs may also be considered; dissolvable versions can be used before the instillation of permanent punctal plugs.
For the most severe, treatment-resistant cases of dry eye disease, practitioners may suggest autologous serum or surgical measures to reduce eye surface exposure, such as lid sutures or lateral lid adhesion. Autologous serum drops, made from a protein-rich serum derived from a patient’s own blood and diluted with artificial tears, typically adhere to the ocular surface better than artificial tears alone. However, the drops require refrigeration between uses, making them inconvenient for many patients, and they carry a risk of infection. As with all treatments, the potential benefits must be weighed against potential risks.
Although dry eye disease cannot be cured, we have many options available to manage it. Consensus treatment paradigms use severity—as determined by tests of tear function and ocular surface damage, as well as symptoms—to design treatment plans. We now have many good options for the management of dry eye disease, including long-lasting artificial tear formulations and antiinflammatory medications that are safe for chronic use. For more severe disease there are options such as autologous serum and tarsorrhaphy. But the goal, wherever possible, is to break the pathogenetic cycle and halt disease progression before aggressive measures such as those are necessary.
- Behrens A, Doyle JJ, Stern L, Chuck RS, McDonnell PJ, the Dysfunctional Tear Syndrome Study Group. Dysfunctional Tear Syndrome: A Delphi Approach to Treatment Recommendations. Cornea. 2006 Sep;25(8): 900-907.
- 2007 Report of the Dry Eye WorkShop. Ocul Surf. 2007;5(2):65-204.
Gary N. Foulks, MD, FACS, is the Arthur and Virginia Keeney professor of ophthalmology, University of Louisville, Louisville, KY, and is editor-in-chief of The Ocular Surface.