Given the deleterious effects of dry eye disease (DED) on the tear film, cornea, and conjunctiva, its prevalence among our patients, and its negative effect on refractive surgery outcomes, reviewing current at-home treatments makes sense.
Here, I discuss these interventions in alphabetical order.
Antibiotics
Prescription antibiotics can improve meibomian gland function and blepharitis, due to their antimicrobial and anti-inflammatory characteristics. The currently available topical antibiotics: AzaSite (Thea Pharmaceuticals), DuraSite (Sun Pharma), and doxycycline (various manufacturers).
Artificial Tears
These typically contain a combination of ingredients resembling natural tears, often including electrolytes, viscosity agents, and preservatives for prolonged shelf life. Additionally, some formulations incorporate lipid components to enhance tear film stability and reduce evaporation. These components work synergistically to mimic the complex composition of natural tears, providing moisture to the ocular surface and, therefore, symptomatic relief for the DED patient. There are numerous manufacturers of artificial tears — with preservatives and preservative-free. We should have our patients check the recall list, if they say they are already using drops at home.
Calcineurin Inhibitors
Calcineurin inhibitors modulate the immune response. Specifically, these medications act by blocking T-cell activation and suppressing the inflammatory cascade implicated in DED pathogenesis. The currently available calcineurin inhibitors: Cequa (Sun Ophthalmics), Restasis (AbbVie), tacrolimus ointment (various manufacturers), Xiidra (Novartis), and Vevye and Klarity-C (Harrow Health).
Corticosteroids
Topical corticosteroids dampen the inflammatory cascade, promoting a more favorable microenvironment on the ocular surface. Because long-term use can lead to elevated IOP, cataract progression, and even corneal melt, topical corticosteroids should be considered as a temporary treatment. The currently available topical corticosteroids: Dexafree (Thea Pharmaceuticals), Dropodex (Rayner Pharmaceuticals Limited), Eysuvis (Kala Pharmaceuticals), Flarex (Harrow Health), Lotemax (Kala Pharmaceuticals), Maxidex (Novartis), and Pred Forte (AbbVie).Topical steroids are often prescribed initially to reduce the inflammation and provide patient comfort fast. Often, steroids act as a bridge, while the calcineurim inhibitors can take effect in the background.
Intranasal Neurostimulation
Intranasal neurostimulation delivers tiny electrical currents to the anterior ethmoidal nerve, which activates the nasolacrimal reflex and, in turn, increases tear secretion. The currently available at-home intranasal neurostimulation treatments: iTear100 (Olympic Ophthalmics), TrueTear (PriceVision Group), and Tyrvaya Nasal Spray (Viatris). These options are ideal for patients who cannot apply eye drops, those who wear eye makeup that smudges with eye drops, and contact lens wearers, who often experience dry eye symptoms.
Lid Hygiene
This includes warm compresses, lid scrubs, foams, and sprays designed to improve DED caused by meibomian gland dysfunction, blepharitis, and/or Demodex. (The number of manufacturers exceeds the space allotted.) Specifically, these interventions promote meibum flow. When dealing with blepharitis, in particular, antibiotic and corticosteroid ointments should also be used to control inflammation.
In the case of Demodex, medical-grade tea tree oil wipes and ivermectin ointment reduces mite infestation. Xdemvy (Tarsus Pharmaceuticals) is FDA-approved to eradicate these mites.
Regular lid hygiene complements many in-office DED treatments. For a list of such treatments, visit bit.ly/CP1121InOfficeDEDTreatments. The latest additions to this list are Lacrifill canalicular gel and radiofrequency treatment. Lacrifill (Nordic Pharma) is a cross-linked hyaluronic acid derivative that is FDA-cleared to temporarily block tear drainage by the occlusion of the canalicular system. Radiofrequency treatment helps to unblock the meibomian glands.
Ocular Nutritional Supplements
Omega-3 and omega-6 supplementation reduces the inflammatory component of DED, which, in turn, decreases DED symptoms. The currently available options: Dry Eye Omega Benefits (PRN), EZ tears (Eye Promise), TG Omega-3 (MacuHealth), Tozal (Focus Laboratories), Focus Relief Plus (Covalent Medical), HydroEye (ScienceBased Health), and Pro Omega 2000 (Nordic Naturals). Ideal candidates for oral supplementation are those who have inflammation of the ocular surface. The oral supplements can add benefit, from a systemic standpoint, for elderly patients who may have difficulty placing eye drops multiple times a day. Oral omega-3 and omega-6 can work synergistically with topical lubricants to reduce surface inflammation, and promote a healthier ocular surface.
Scleral Contact Lenses
Scleral contact lenses create a protective reservoir of fluid between the lens and the cornea. This reservoir hydrates and lubricates the ocular surface, reducing DED-induced dryness and discomfort. The following companies offer scleral contact lenses: Acculens, Advanced Vision Technologies, Art Optical, BostonSight, CooperVision, Essilor Custom Contact Lens Specialists, Metro Optics, TruForm Optics, Valley Contax, Visionary Contact Lens, and X-Cel Specialty Contact Lens.
Semifluorinated alkane
This stabilizes the tear film to prevent evaporation. Evaporation results in such symptoms as ocular dryness, unstable vision, burning, and irritation. The currently available option: Miebo (Bausch + Lomb), a preservative-free, water-free, and steroid-free drop with perfluorohexyloctane.
Customizing Care
These treatments offer the corneal specialist the ability to customize treatment based on DED root cause. Thus, by prescribing one or more of them, we facilitate relief from this chronic condition. Also, our prescriptions of these treatments, along with brief patient education on their value, can instill the patient compliance needed for effective management. CP
