This document discusses the management of dry eyes through various treatment modalities. It outlines treatments for tear insufficiency like artificial tears, biological tears, and tear conservation approaches. Treatments for lid abnormalities like anterior blepharitis and meibomian gland dysfunction are also covered. The document also discusses environmental modifications, anti-inflammatory therapies, and surgical approaches for dry eye management. A step-wise approach to treatment is recommended starting with education, lubricants, and lid hygiene, and progressing to more advanced treatments if needed.

1. MANAGEMENT OF DRY EYES
SUSHANT SHAH
M. OPTOM

2. MODALITIES OF TREATMENT
• TREATMENT OF TEAR INSUFFICIENCY
• TREATMENT OF LID ABNORMALITY
• ENVIRONMENTAL MODIFICATIONS
• ANTI-INFLAMMATORY THERAPY
• SURGICAL APPROACH
• TREATMENT OF UNDERLYING SYSTEMIC CAUSES

3. TREATMENT OF TEAR INSUFFICIENCY
1. TEAR REPLACEMENT APPROACH:
a) ARTIFICIAL TEAR SUBSTITUTES:
• AQUEOUS SUPPLEMENTS:
• CONSTITUTES OF VISCOSITY-ENHANCING AGENTS, OSMOTIC AGENTS, OSMOPROTECTANTS,
ANTIOXIDANTS, PRESERVATIVE, BUFFERING AGENTS.
• ENHANCE LUBRICATION, PROLONG RETENTION TIME ON OCULAR SURFACE , INCREASE TEAR
FILM THICKNESS, IMPROVES TEAR BUT
• LIPID SUPPLEMENTS:
• A VARIETY OF OILS, SUCH AS MINERAL OILS AND PHOSPHOLIPIDS, HAVE BEEN INCORPORATED
IN OCULAR LUBRICANT FORMULATIONS TO HELP RESTORE THE LIPID LAYER OF THE TEAR
FILM
b) BIOLOGICAL TEAR SUBSTITUTES
• AUTOLOGOUS SERUM AND ADULT ALLOGENEIC SERUM (BLOOD DERIVATIVES), UMBILICAL CORD
SERUM
c) OTHER AGENTS

4. TREATMENT OF TEAR INSUFFICIENCY
2. TEAR CONSERVATION APPROACHES:
a) PUNCTAL OCCLUSIONS:
• PRESERVE NATURAL TEARS AND PROLONG EFFECT OF ARTIFICIAL TEARS BY BLOCKING
THEIR DRAINAGE
• IT MAY BE :
I. TEMPORARY OCCLUSIONS:
• COLLAGEN PLUGS ARE USED WHICH USUALLY DISSOLVES IN 1-2 WEEKS TIME
• INITIALLY ALL 4 PUNCTA ARE OCCLUDED IF EPIPHORA OCCURS UPPER TWO PLUGS ARE
REMOVED
II. REVERSIBLE OCCLUSIONS:
• SILLICON/LONG ACTING COLLAGEN PLUGS WHICH USUALLY DISSOLVES IN 2-6 WEEKS
III. PERMANENT OCCLUSIONS:
• DONE IN SEVERE CASES AND REPEATED SCHIRMER <2MM
• CONTRAINDICATED IN PATIENTS WHO DEVELOPES EPIPHORA FOLLOWING TEMPORARY
OCCLUSIONS

5. TREATMENT OF TEAR INSUFFICIENCY
b) MOISTURE CHAMBER SPECTACLE AND HUMIDIFIERS:
• MOISTURE CHAMBER SPECTACLES ARE EYEGLASSES SPECIALLY DESIGNED TO SLOW
EVAPORATION OF THE TEARS, BY PROVIDING A HUMID ENVIRONMENT AND
MINIMIZING AIRFLOW OVER THE OCULAR SURFACE.
3) TEAR STIMULATION APPROACHES:
• SEVERAL TOPICAL PHARMACOLOGIC AGENTS THAT STIMULATE AQUEOUS, MUCIN
AND/OR LIPID SECRETION ARE COMMERCIALLY AVAILABLE IN CERTAIN MARKETS, OR
UNDER DEVELOPMENT.

6. TREATMENT OF LID ABNORMALITY
1. ANTERIOR BLEPHERITIS:
• LID HYGIENE, LID SCRUBS USING A MILD DILUTION OF BABY SHAMPOO APPLIED WITH A SWAB
OR COTTON BUD
• SHORT DOSE OF ANTIBIOTIC
2. MEIBOMIAN GLAND DYSFUNCTION:
• LIPID BASED TEAR SUBSTITUTES
• APPLY A WARM COMPRESS OVER EYES FOR FIVE TO 10 MINUTES – USE A CLEAN FLANNEL
RINSED IN HOT WATER, REHEATING REGULARLY TO KEEP IT WARM.
DEVICES FOR WARM COMPRESSIONS: BLEPHASTEAM, MGDRX EYE BAG ®, EYEGIENE® MASK
• PHYSICAL TREATMENT:
WARM COMPRESSION  PHYSICAL FORCE  INTRADUCTAL PROBING
USE FINGER OR COTTON BUD TO MASSAGE THE SKIN TOWARDS LASHES. FOR TOP LASHES, APPLY
PRESSURE DOWNWARDS TO THE LASHES AND FOR THE BOTTOM LASHES, MOVE IN AN UPWARDS
DIRECTION.

7. ENVIRONMENTAL MODIFICATIONS
3. BLINKING ABNORMALITIES AND CORNEAL EXPOSURE:
• TEAR SUPPLEMENTS, OINTMENTS (TYPICALLY INSTILLED AT NIGHT),
MOISTURE GOGGLES, NIGHT TIME EYESHIELDS THAT ACHIEVE MECHANICAL
CLOSURE OF THE LIDS, SCLERAL CONTACT LENS
• SCLERAL LENS CAN BE USED IN TREATMENT OF DRY EYE IN STEVENS
JOHNSON'S SYNDROME, SJOGRENS SYNDROMES
• ENVIRONMENTAL MODIFICATION SUCH AS HUMIDIFICATION, AVOIDANCE OF
WIND/DUSTY OR SMOKY ENVIRONMENT, AVOID FACING TOWARDS AC
• DISCONTINUING OR CHANGING MEDICATIONS THAT CAUSES DRY EYE DISEASE
• LIFESTYLE CHANGES : TAKING REGULAR BREAKS FROM READING OR COMPUTER USE ,
LOWERING COMPUTER SCREEN BELOW EYE LEVEL.
• CONTACT LENS WEAR:
• SHIFTING FROM HYDROGELS TO SILICON HYDROGELS, PRESERVATIVE FREE LUBRICATING
EYE DROPES, CHANGING CL REPLACEMENT MODALITY

8. SURGICALS APPROACHES
• TARSORRHAPHY: EYELIDS ARE PARTIALLY OR TOTALLY CLOSED USING SUTURES
• LID CORRECTION : DERMATOCHALASIS, PTOSIS, LOWER LID BLEPAHAROPTOSIS
• SALIVERY GLANS TRANSPLANATAION – EXTREME DRY EYES
• STEROIDS
• CYCLOSPORINE A
ANTI-INFLAMMATORY THERAPY

10. • LEVEL 1:
• EDUCATION REGARDING THE CONDITION, ITS MANAGEMENT, TREATMENT AND PROGNOSIS
• MODIFICATION OF LOCAL ENVIRONMENT
• ELIMINATION OF OFFENDING SYSTEMIC AND TOPICAL MEDICATIONS
• OCULAR LUBRICANTS OF VARIOUS TYPES (IF MGD IS PRESENT, THEN CONSIDER
LIPIDCONTAINING SUPPLEMENTS)
• LID HYGIENE AND WARM COMPRESSES OF VARIOUS TYPES
• LEVEL 2:
IF ABOVE OPTIONS ARE INADEQUATE CONSIDER:
• NON-PRESERVED OCULAR LUBRICANTS TO MINIMIZE PRESERVATIVE-INDUCED TOXICITY
• TEAR CONSERVATION APPROACH
• MOISTURE CHAMBER SPECTACLES/GOGGLES
• IN-OFFICE, PHYSICAL HEATING AND EXPRESSION OF THE MEIBOMIAN GLANDS
• TOPICAL ANTIBIOTIC OR ANTIBIOTIC/STEROID COMBINATION APPLIED TO THE LID MARGINS
FOR ANTERIOR BLEPHARITIS (IF PRESENT)
• TOPICAL CORTICOSTEROID (LIMITED-DURATION)

11. • LEVEL 3:
IF ABOVE OPTIONS ARE INADEQUATE CONSIDER:
• AUTOLOGOUS/ALLOGENEIC SERUM EYE DROPS
• THERAPEUTIC CONTACT LENS OPTIONS
• SOFT BANDAGE LENSES
• RIGID SCLERAL LENSES
• LEVEL 4:
IF ABOVE OPTIONS ARE INADEQUATE CONSIDER:
• TOPICAL CORTICOSTEROID FOR LONGER DURATION
• SURGICAL PUNCTAL OCCLUSION
• OTHER SURGICAL APPROACHES (EG TARSORRHAPHY, SALIVARY GLAND
TRANSPLANTATION)