Managing Dry Eye, Step by Step

Updated Guidance for Dry Eye

Hi. I'm Dr Christopher Rapuano, chief of the Cornea Service at Wills Eye Hospital in Philadelphia, where I'm speaking to you from the Alumni Society Newsroom.

The Tear Film & Ocular Surface Society (TFOS) published the original Dry Eye Workshop (DEWS) in the journal The Ocular Surface in 2007.^[1] Recently, after a 2-year effort, they published TFOS DEWS II^[2] in the same journal.

TFOS DEWS II involved 150 experts in dry eye disease from 23 countries, led by a steering committee of 25 doctors. It resulted in an almost 400-page document. I must admit that I have not read the entire document, but I have read a good portion of it and would like to talk about some of the key updates and additions included in the new TFOS DEWS II.

First, the definition of dry eye has been somewhat modified. The authors behind TFOS DEWS II write, "Dry eye is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles." The wording related to neuropathologic and neurologic pain represents additions to the definition.

TFOS DEWS II is divided into several chapters. In addition to the chapter on the definition and classification of dry eye disease, there are others on sex, gender, and hormones; epidemiology; tear film; pain sensation; pathophysiology; and then larger chapters on diagnosis as well as management and therapy. They tried to use an evidence-based approach for all of these chapters.

Management and Therapy for Dry Eye

Let's focus on management and therapy, because it's somewhat different from the [TFOS] DEWS I 10 years ago. They divided it into steps 1 through 4, depending on the severity of the dry eye.

Step 1 included education regarding dry eye, its management, treatment, prognosis as a chronic condition, modifying the local environment, dietary modifications (eg, essential fatty acids), and eliminating offending systemic and topical medications, especially those with preservatives. Regarding ocular lubricants, they recommended considering lipid-containing supplements if there is Meibomian gland disease present. Lid hygiene and warm compresses were also considered helpful.

When those treatments aren't effective, they go on step 2. This entails changing to a nonpreserved topical lubrication (perhaps using tea tree oil if Demodex is present); tear conservation, as in punctal occlusion with collagen plugs or silicone plugs; moisture chamber spectacles or goggles; and overnight treatments such as ointments.

They talk about potentially beneficial in-office treatments directed at the Meibomian gland, like physical heating expression with devices such as LipiFlow® or intense pulsed light therapy.

They also discuss prescription drugs to manage dry eye disease, including topical antibiotics or antibiotic/steroid combinations; limited-duration topical steroids; topical secretagogues; topical anti-inflammatory medications such as cyclosporine; topical LFA-1 antagonists such as lifitegrast; and even oral macrolide or tetracycline antibiotics. If that's not enough, step 3 addresses oral secretagogues and autologous serum.

Therapeutic soft contact lenses or rigid [gas-permeable] scleral lenses (eg, BostonSight® PROSE) are other possibilities.

The final step, step 4, recommends topical steroids of longer duration (though of course this comes with an increased risk for potential side effects), amniotic membrane grafts, or surgical punctal occlusion with cautery. Then there are other, more aggressive surgical approaches, such as a permanent lateral or even central tarsorrhaphy or salivary gland transplantation.

The [authors of TFOS] DEWS II did a lot of work.

It's a long read, but there's a lot of great information in it to not only help us with the diagnosis and management of dry eye disease but to also direct future research and efforts in dry eye disease.