Treatment Guidelines

The Tear Film and Ocular Surface Society Guidelines

The Tear Film and Ocular Surface Society (TFOS) released the comprehensive TFOS Dry Eye Workshop II (DEWS II) guidelines in 2017, which served as a landmark update to the understanding and management of dry eye syndrome (DES). These guidelines were developed by an international panel of experts and provide detailed recommendations on various aspects of DES, including its definition, classification, epidemiology, pathophysiology, diagnosis and treatment. The primary aim of the TFOS DEWS II guidelines is to standardize the approach to DES, enhance clinical practice and foster research advancements, ultimately improving patient care and outcomes.

Before selecting the appropriate management approach, it is essential to conduct thorough questioning and diagnostic testing to confirm that the patient has DES and to determine whether they primarily exhibit signs of evaporative dry eye (EDE) or aqueous deficient dry eye (ADDE); see Presentation for more details. After the diagnosis is established, the TFOS DEWS II guidelines recommend the use of a stepwise approach to management based on severity (Figure 4-1). This approach aims to reduce or alleviate signs and symptoms of DES, maintain or improve visual function and reduce or prevent ocular surface damage. For more information on individual treatment options, see Treatment Options.

All of the management and treatment options listed in this stepwise approach have been shown, with varying degrees of evidential support, to alleviate DES symptoms. If patients do not respond to a given level of management or present with more severe DES, it is recommended to proceed to the next level of management. Where appropriate, therapies from the previous step may be continued alongside new treatments.

Step 1 focuses on foundational measures for managing DES. Patients should be educated about the condition, its management, treatment options and prognosis. They should be advised to modify their local environment to reduce DES triggers and be informed about potential dietary changes, including increased essential fatty acids (EFA) intake or supplementation. Identifying and potentially eliminating systemic and topical medications that may contribute to DES (see Comorbidities) is important. The use of various ocular lubricants is recommended, particularly lipid-containing supplements if Meibomian Gland Dysfunction (MGD) is present. Additionally, maintenance of lid hygiene and use of warm compresses are both encouraged to improve symptoms.

Step 2 introduces more advanced treatments. Non-preserved ocular lubricants are recommended to minimize preservative-induced toxicity. For patients with Demodex infestation, tea tree oil treatments or ivermectin are recommended (note that the guidelines pre-date the approval of lotilaner ophthalmic solution for Demodex blepharitis). Tear conservation techniques, including punctal occlusion and moisture chamber spectacles or goggles, may be appropriate for patients with evaporative dry eye (EDE). Overnight treatments like ointments or moisture chamber devices can provide additional relief. In-office procedures, including physical heating and expression of the meibomian glands, and intense pulsed light therapy for MGD could also be considered. Prescription drugs may be necessary, including topical antibiotics or antibiotic/steroid combinations for anterior blepharitis, topical corticosteroids (for a limited duration), non-glucocorticoid immunomodulatory drugs (e.g., cyclosporine), LFA-1 antagonist drugs (e.g., lifitegrast) and oral macrolide or tetracycline antibiotics.

Step 3 involves even more specialized treatments. Oral secretagogues can be used to stimulate tear production. Autologous or allogeneic serum eye drops are considered for their tissue regenerative properties. Finally, therapeutic contact lens options, such rigid scleral lenses, can be used to provide additional relief and protection to the ocular surface.

For cases where all previous treatments are insufficient, Step 4 includes the most intensive and invasive options. Longer-term topical corticosteroid use, typically not favored due to associated adverse events, may be considered. Amniotic membrane grafts can be used to promote healing and reduce inflammation. Surgical interventions like permanent punctal occlusion, tarsorrhaphy and salivary gland transplantation may be considered as last-resort measures to manage severe and refractory DES.

Managing DES usually involves addressing chronic symptoms that require ongoing care, rather than short-term treatments. While certain treatments may be specifically indicated for particular aspects of an individual's ocular surface condition, many treatments can be beneficial for multiple components of DES. Eye care providers should use their clinical expertise to evaluate the significance of the various pathogenic processes, such as aqueous deficiency, MGD and inflammation, that may present with similar subjective complaints and signs of disrupted ocular surface homeostasis. In cases where there is clinical evidence of more severe complications, such as advanced eyelid involvement (e.g., chalazia, trichiasis), corneal neovascularization, or signs of microbial infection, additional approaches may be necessary. These could include intralesional steroid injections or excision for chalazia, eyelash epilation or cryotherapy for trichiasis and antiangiogenic drugs for neovascularization.

Enlarge 

The American Academy of Ophthalmology Guidelines

The American Academy of Ophthalmology (AAO) published the newest update to their Preferred Practice Pattern (PPP) guidelines for the management of DES in 2023. These recommendations cover various aspects of diagnosing and managing DES, from clinical examination and diagnostic tests to specific management options based on severity of the disease. The AAO PPP guidelines follow the same stepwise approach presented in the TFOS DEWS II guidelines (Figure 4-1), emphasizing the importance of treating any causative factors of the disease.

In case of mild dry eye disease (DED), the AAO PPP guidelines focus on addressing the exogenous and environmental factors that could contribute to the development and/or worsening of the symptoms, such as antihistamine or diuretic use, cigarette smoking, second-hand smoke exposure, air drafts and low-humidity environments. Humidifying ambient air, using side shields on glasses, adjusting airflow in work and home environments, and positioning computer screens below eye level are recommended to reduce discomfort during computer and reading activities. The AAO PPP guidelines advise using topical agents and increasing the use of artificial tears as the severity of DES increases. Lastly, blepharitis, meibomitis and eyelid abnormalities resulting from blepharitis, trichiasis, or eyelid malposition should also be addressed.

Key recommendations for management of moderate DES include using high-viscosity, non-preserved artificial tears, gels, or ointments for intense eye lubrication and employing long-term anti-inflammatory therapies such as topical cyclosporine A, lifitegrast, or short-term corticosteroids. Oral ω-3 fatty acid supplements may be considered to improve tear quality and reduce inflammation, providing additional support for managing moderate DES. However, the guidelines also note that a large-scale, masked, prospective study found that oral fatty acid supplements offered no benefit over a placebo in patients with moderate to severe DES over a 12-month period. Punctal plugs, eyeglass side shields and moisture chamber goggles are also recommended to help elevate symptoms.

The AAO PPP guidelines for severe DES treatment build upon the treatments for mild and moderate DES with additional, more aggressive therapies. Permanent punctal occlusion, preferably using thermal cautery, is recommended. In some cases, other surgical interventions such as tarsorrhaphy and minor salivary gland transplantation can be considered. Advanced treatments like autologous serum and autologous plasma eye drops, therapeutic contact lenses and systemic medications may be necessary. Oral cholinergic agonists like cevimeline and pilocarpine can alleviate symptoms of dry eye and dry mouth in Sjögren syndrome, but are associated with significant side effects.

Follow-up and Monitoring of Treatment Efficacy

The AAO PPP and TFOS DEWS II guidelines both emphasize the importance of regular follow-up appointments to monitor and adjust treatment plans for DES. The purpose of these follow-up evaluations is to assess the response to therapy, providing a basis for altering or adjusting treatment as necessary, monitoring for ocular surface damage and offering reassurance to the patient. The AAO PPP guidelines recommend frequent follow-ups, particularly for patients with moderate to severe DES, to evaluate treatment effectiveness and make necessary adjustments. The TFOS DEWS II guidelines similarly highlight the need for ongoing patient education and regular evaluations to monitor disease progression and treatment adherence. Both sets of guidelines stress that the frequency and extent of follow-up evaluations should be tailored based on the severity of the disease, the therapeutic approach and the patient's response to therapy. This individualized follow-up schedule ensures that management strategies remain effective and responsive to the patient's evolving needs.