Treating Advanced Dry Eye

Dry eye is a multifactorial disease — a disorder of the tear film that causes tear deficiency, excess evaporation, or both. These problems lead to damage of the ocular surface and ocular discomfort.

On the spectrum of dry eye disease, the worst-case scenario is advanced disease which presents with severe or disabling discomfort that occurs frequently or may be constant. Visual acuity is reduced, usually severely, and there is marked staining of the cornea and conjunctiva, often with filaments on the cornea or even ulceration. Tear break-up time can be immediate.

Long-term presence of the disease is often associated with corneal scarring, pannus and/or vascularization. Lid margin disease is also present, with concomitant severe meibomian gland dysfunction/keratinization, and trichiasis and/or symblepharon. Systemic diseases (e.g., Sjogren’s Syndrome, ocular cicatricial pemphigoid, Stevens-Johnson syndrome) can cause or contribute to severe dry eye.

A range of available treatments

According to ophthalmologist Peter McGannon, MD, dry eye disease can be treated in a wide variety of ways. “Choices depend on whether there’s evaporative tear dysfunction or aqueous tear deficiency, and if there are other signs and symptoms,” he explains.

Mild symptoms are typically treated with artificial tears used as needed. Increased disease severity calls for additional treatments — more frequent use of preservative-free artificial tears, gels and ointments. Twice daily lid hygiene and omega-3 fatty acids can improve meibomian gland dysfunction (MGD). In cases with a significant amount of inflammation, a pulse of topical steroids can help.

Topical cyclosporine is appropriate for those with predominantly aqueous tear deficiency who find no relief in artificial tears, fish oil or lid hygiene, but can be helpful in lid margin disease. Punctal plugs are another good option for those with aqueous tear deficiency, unless they mainly have lid margin disease. In those cases, oral tetracyclines can be very helpful.

Certain patients with advanced dry eye will fail to achieve any relief with these treatments. For them, plasma tears or 5 percent compounded serum albumin tears have proven to be helpful, as have topical steroids. If possible, the latter should not be used on a long-term basis. Topical cyclosporine, sometimes at higher concentrations than what is commercially available, and/or topical tacrolimus can be safe and effective alternatives.

Maintaining patients on topical and often systemic anti-inflammatories is essential if cicatrizing disease is present. If needed, systemic immunosuppression calls for close work with those who are familiar with immunosuppressant medications, i.e., the patient’s dermatologist or rheumatologist.

Lid margin disease

Meibomian gland dysfunction is the lid margin disease most relevant to dry eye. Dr. McGannon reports that low-delivery MGD is caused by obstruction of the ducts of the meibomian glands. Without a functioning lipid layer in tear film, the aqueous layer evaporates too rapidly and concentrates inflammatory factors on the surface of the eye.

This increases ocular surface inflammation and damages ocular surface cells, decreasing tear production and promoting more inflammation. “This vicious cycle perpetuates itself until it is broken via the use of lubricants, lid hygiene, and anti-inflammatory agents,” says Dr. McGannon.