This document outlines a 4-level treatment strategy for dry eye, beginning with non-invasive options like artificial tears and progressing to more aggressive treatments like punctal plugs, anti-inflammatory drugs, and contact lenses. It also describes various artificial tear substitutes and therapies to reduce inflammation and drainage, such as punctal occlusion, tetracyclines, ciclosporin, and environmental modifications. The most advanced options discussed are punctal occlusion surgery, systemic anti-inflammatories, and scleral contact lenses for severe dry eye cases.

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.