The underlying cause should be treated.
Objective of management is to:
- relieve the symptoms of dry eye and improve quality of life
- make the ocular surface and tear film normal again
- prevent corneal damage whenever possible (1)
Patient education and tear substitutes are used primarily to manage patients at primary care.
- educate the patient about the nature of the condition and provide advice on how to avoid aggravating factors e.g. – medication, avoid long exposure to computers, TV (2)
NICE recommends the following as initial management of DES:
- reviewing the treatments already used and their response
- make necessary modifications to the environment at home or work to minimize evaporation of tears e.g. – computer use, air humidity
- review medication which might be responsible for or aggravate eye symptoms
- preservatives in topical eye medications may cause symptoms
- systemic medications such as antihistamines, β blockers, oestrogen therapy, tricyclic antidepressants
- identifying underlying medical or surgical conditions associated with DES
- e.g. - allergic conjunctivitis, blepharitis, Sjögren's syndrome, previous ocular or eyelid surgery (3)
Tear supplements
- artificial tears and ocular lubricants have been used commonly for the management of DES
- provides temporary relief and usually contain preservatives
- may include
- drops - hypomellose, polyvinyl alcohol
- gels - viscotears
- ointments- ointment remains in the conjunctival sac longer than drops and therefore is more effective as an ocular lubricant
- in patients with mild to moderate symptoms
- over the counter artificial tears alone may be sufficient
- use a less viscous formulation at the start (possibility of causing stinging and blurring is less)
- commonly used - hypromellose-containing drops
- frequent application is required since relief it provides is temporary
- more viscous products (containing carbomers or polyvinyl alcohol) may be less well tolerated but requires fewer application
- paraffin based ointments is more suitable for use at night since it can feel uncomfortable and cause blurring
- in severe symptoms - preservative-free artificial tears, perhaps with an ocular lubricant ointment to use at night
- acetylcysteine drops can be considered for people with visible strands of mucus (2,3)
Other treatments for dry eye include:
- topical anti-inflammatory drugs
- corticosteroids - generally recommended for short-term use
- cyclosporin A - recommended as an option, within its marketing authorisation, for treating severe keratitis in adult patients with dry eye disease that has not improved despite treatment with tear substitutes (4)
- antibiotics - tetracyclines and their derivatives
- prolonged topical antibiotic treatment can lead to local toxic reactions to the preservatives within the solutions and encourage development of bacterial resistance
- autologous eye drops – made from patient's own blood serum
- insertion of punctal plugs - to block the lacrimal glands so as to prevent nasolacrimal drainage of tears from eye (1,3)
- oral supplementation with polyunsaturated fatty acids (omega-3 and omega-6)
- nine double-blind randomised controlled trials (involving a total of 716 patients) have shown that supplementation improved the OSDI symptom score, relieved burning and eye watering, and reduced inflammatory response on the ocular surface (3)
Severe cases are usually managed in the secondary care (2).
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