Medications are a mainstay of treatment. Why? Well, they are easy to administer, generally well-tolerated and are sufficient to get the job done in early cases of dry eye. Let’s look at some of the common ones.
There are many types of artificial tears out there, and we will not delve into the differences between them at this time. Suffice to say, most will try to replenish the aqueous layer, at the very least. Some, like Soothe, also replenish some of the oil. Others like FreshKote, can provide all three layers of the tear film. Retaine is a positively-charged eye drop which tries to stick to the negatively-charged cornea in addition to acting like a gel. Gels tend to give longer lasting relief but do tend to blur the vision for longer.
Medications in a bottle, for the most part, have preservatives in them and can be toxic to the eye, especially if used over 4 times a day. Some folks with sensitive eyes may have significant worsening of the symptoms because of the artificial tears! They decide to up the frequency which only makes it worse! Preservative-free drops come in a vial and are safer for sensitive eyes and higher frequency of use. Of course, most people don’t know if they are sensitive to the preservatives or not, so we recommend preservative-free eye drops for our more symptomatic dry eye patients. The reason why medications have preservatives is to help prevent the bottle from getting contaminated with bacteria and allowing for multi-day use. That is certainly convenient. Medications in a vial can be recapped and reused that day but should be discarded by the end of the day or if the tip gets contaminated, whichever comes first.
These are available over-the-counter at your pharmacy. Some of the higher-functioning eye drops may need to be ordered from the company. At the end of the day, these are good for symptomatic relief, like all lubricants, but do not prevent the progression of the disease.
This treatment has been around for decades. Small pellets are placed in the inferior conjunctival pocket and they dissolve over time producing tears. This can be helpful for people who need lubrication with tears constantly but simply cannot do so, for logistic reasons. These can be helpful for those trying to sleep through the night, for instance. More severe cases may need two pellets placed instead of the standard one. These can be replenished as needed. They can be tricky to put in, however, and can leave behind a bit of residue which can be annoying.
These are even thicker than gels and give comfort for much longer periods of time. They will blur the vision significantly and are not practical for long-term daytime use. They can be great for bedtime, especially if there is concern for the eyes being open at night. They have their own preservatives and patients may develop a sensitivity. Like artificial tears, there are a number of brands and are available over-the-counter at the pharmacy. Sometimes patients need to play around with them until they find a brand they like.
This ointment is available on Amazon. Unlike other ointments, its purpose is not so much to lubricate as it is to provide Vitamin A to the surface of the eye. This can be helpful in cases of dry eye after conjunctival inflammation (e.g. viral conjunctivitis, chemical injury, drug allergy, ocular cicatricial pemphigoid). The resulting loss of goblet cells can result in decreased mucin and even a change in the surface of the conjunctiva.
At the Dry Eye Lounge, these are more of a mainstay of treatment than artificial tears. It is always better to treat the cause of a problem than just the symptoms. There are a few options, and like artificial tears there are pluses and minuses to each one. It is simply a matter of finding out which one is preferred.
There are a number of weak topical steroids that can be helpful for flare-ups. They are not typically used for long-term use due to the risk of cataract development and developing higher intraocular pressures (IOPs), which can lead to glaucoma. Examples include FlarEx, Inveltys, Lotemax, prednisolone acetate and any generic equivalents. Occasionally, these can be used for chronic control of inflammation in patients who have already had cataract surgery, as long as the IOPs stay in the normal range. Occasionally compounded versions of these such as preservative-free prednisolone acetate or spironolactone can be used.
This is the granddaddy of them all! It has been around for decades and has a proven track record. In FDA trials, it showed an improvement in tear production and an increase in goblet cells. It takes time to work (3-6 months) so there is some delayed gratification but can work earlier than that especially in patients with a lot of inflammation (e.g. Sjogren’s Syndrome). It comes in both vials and a bottle, the latter of which is a rare exception to the “all bottles have preservatives” rule, though the availability of both in the pharmacy changes periodically. It is well tolerated, with the biggest side effect being burning. This is because the eyes are dry; as the dryness improves, the burning does as well! Keeping the medication cold in the refrigerator or using an artificial tear beforehand cuts down on the burning significantly. Sometimes we use it in conjunction with topical steroids to calm the eye down and facilitate a transition to a safer long-term alternative like Restasis.
Insurance coverage can be spotty and the cost of these dry eye medications high, so sometimes it is good to have other options. One such option, is Klarity-C, a compounded cyclosporine from Imprimis Pharmacy in New Jersey, which comes in bottle form. It is a slightly higher percentage of cyclosporine. There is no proof that this works better and it, may in fact, burn more but is available for a reliable cost of $50/month, with or without insurance. This is an excellent option for our self-pay patients, for whom cheap, long-term, anti-inflammatory coverage was once an impossibility.
The (relatively) new kid on the block! This has been around for a few years and was FDA-approved for improving the signs and symptoms of dry eye, specifically corneal staining and dry eye questionnaires, respectively. Because of its mechanism of action, it tends to work faster, on the order of 4-6 weeks, which patients love! It comes in vials, which don’t recap. The side effects are a bit more varied than Restasis and include burning, irritation, temporary bad taste in the mouth and/or temporary blurry vision. These are thankfully mild and well-tolerated and tend to become less of a nuisance over time. We advise our patients to use it first thing in the morning and when going to bed at night, so any blurry vision is not bothersome.
This is not FDA-approved for eye use, but it has been used for decades off-label for preventing rejection in high risk corneal transplants, among other conditions. We tend to find it works well for ocular surface diseases in the allergic spectrum like eczema, as well as graft-versus-host disease which affects bone marrow transplant recipients. It can also be helpful in bad dry eye cases where steroids cannot be used and other anti-inflammatory eye drops may not be sufficient.
This is potent anti-inflammatory eye drop that is used for severe inflammatory dry eye, such as ocular cicatricial pemphigoid. The classic systemic medication had been oral dapsone, but since topical meds have less systemic side effects, this can be a more palatable option. This is ordered from Green Park Pharmacy in Houston, TX.
These hormone eye drops can be effective for dry eye that seems to occur with age onset. Menopause or hysterectomy being a clear symptomatic starting point in women, with men being harder to diagnose. Low testosterone levels in the blood may be a good indicator for the latter. Women can use testosterone eye drops without worrying about the systemic side effects (e.g. unwanted facial hair). The medication needs to be purchased from a specialty outside compounding pharmacy, which is admittedly a nuisance but can work wonders on the right people! For instance, women who have had breast cancer and are on systemic anti-estrogen therapy long term can have an impressive resolution to their symptoms!
In severe cases that are resistant to normal treatment, this can be an excellent option. It involves having your blood drawn and spun down with a centrifuge. The blood cells are removed with the remaining platelet-rich serum chalk-full of valuable regenerative factors! It is diluted, placed in container(s) and frozen. The medication comes from you so there is no worry about blood-borne diseases, but it does need to replenished 1-3 months later so the cycle can start anew. We currently get this from the Lions Eye Bank of St. Louis with some help from local blood draw centers but are working on being able to provide PRP eyedrops directly in clinic!
Omega-3 supplements can be particularly effective in the treatment of early meibomian gland disease. As discussed in the previous section, What Can Go Wrong? not enough omega-3 fatty acid intake results in thickening of oil glands and worsening of ocular inflammation. There are LOTS of omega-3 supplements out there! Many of them are taken for cardiovascular benefit and we cannot speak as to that here, but not all of these supplements are effective from an eye standpoint. Just for some semblance of standardization, we recommend and do carry Hydroeye in our office. We like Hydroeye because it contains both a long-chain omega-3 (fish oil) and a short-chain omega-3 (GLA, a derivative of black currant seed oil) and it has worked for our patients anecdotally. Other supplements such as Nordic Naturals can be quite effective as well. We have also seen remarkable improvement with krill oil from local health food stores like Chamberlan’s Natural Foods. Big box stores like Costco and Walgreens make their own supplements but, as a rule, they tend not to work very well. Sometimes, patients cannot take oral fish oil supplements because they are vegetarian or because it causes too much burping and GI distress. In those cases, we recommend black currant seed oil oral supplements and Refresh Mega artificial tears, respectively.
Now medications and conservative therapy may not work in moderate and severe cases. Recovery could plateau, the medications could have side effects or not be cost effective, or the patient could require more urgent resolution to their symptoms due to their discomfort. Severe cases seem to be resistant to complete resolution with medical treatment, though they can be helpful as part of a maintenance regimen. By no means are procedures a replacement for medical therapy. They serve better as a powerful adjunctive therapy.