Dry eye treatment

1. Dry eye
Treatment
Abdallah sabry Elgameel

2. Strategy
 Level 1
 Education and environmental/dietary modifications
 Systemic medication review
 Artificial tear substitutes including gels and ointments
 Eyelid therapy
 Level 2
 Non-preserved tear substitutes
 Anti-inflammatory agents
 Tetracyclines
 Punctal plugs
 Secretagogues

3.  Level 3
 Contact lenses.
 Permanent punctal occlusion
 Level 4
 Systemic anti-inflammatory agents.
 Surgery
Strategy

4. Tear substitutes
 Drops and gels
Cellulose derivatives & Carbomer gels & polyvinyl alcohol & Diquafosol
 Ointments
used at bedtime to supplement daytime drops or gel instillation
 Eyelid sprays
liposome-based agent & stabilize the tear film and reduce evaporation
 Mucolytic agents
Acetylcysteine 5% drops
useful in patients with corneal filaments and mucous plaques
 Preservatives
potent source of toxicity…not more than three or four times daily…Polyquad / Purite

5. Punctal occlusion
Punctal occlusion reduces drainage, preserves natural tears and prolongs the
effect of artificial tears
Types
 temporary
 collagen plugs & silicone
 to ensure that epiphora does not occur following permanent occlusion
 Permanent
 Laser cautery & thermal coagulation
 severe dry eye who have had a positive response to temporary plugs
 avoided in patients, especially if young, who may have reversible
 All four puncta should not be occluded at the same time.

6. Anti-inflammatory agents
 Topical steroids
 fluorometholone
 acute exacerbations
 Omega fatty acid supplements
 omega-3 fish oil, flax seed oil
 facilitate the reduction of topical medication.
 Oral tetracyclines
 Doxycycline may be preferred to minocycline ( 3 months, low dose )
 control blepharitis, esp. meibomianitis & reduce tear levels of inflammatory mediators
 Topical ciclosporin
 reduces T-cell mediated inflammation of lacrimal tissue….increase in the number of
goblet cells and reversal of squamous metaplasia of the conjunctiva

7. Contact lenses
 fluid is trapped behind the lens, and they are effective at relieving symptoms from
secondary corneal changes
 Patients should be cautioned regarding the possibility of bacterial keratitis
 Types
 Low water content HEMA lenses : may be successfully fitted to moderately dry eyes
 Silicone rubber lenses : that contain no water and readily transmit oxygen are effective in
protecting the cornea in extreme tear film deficiency
 Occlusive gas permeable scleral contact lenses provide a reservoir of saline over the cornea.
They can be worn on an extremely dry eye with exposure

8. Optimization of environmental
humidity
Reduction of room temperature to minimize evaporation of tears
Room humidifiers but frequently disappointing
local increase in humidity can be achieved with moist chamber goggles or side shields
to glasses but cosmetically unacceptable

9. Miscellaneous options
Botulinum toxin injection
 to the orbicularis muscle may help control the blepharospasm
 at the medial canthus it can also reduce tear drainage
Oral cholinergic agonists
 pilocarpine (5 mg, 4 times/ daily) & cevilemine
 reduce the symptoms of dry eye and dry mouth in patients with Sjögren
syndrome.
 Adverse effects : blurred vision and sweating may be less marked with
cevilemine
Submandibular gland transplantation
 may produce excessive levels of mucus in the tear film.