Options in Dry Eye Therapy
Dry Eye Therapy
Dry eye can rapidly become the bane of a patient's existance. Relief can be difficult to find and patients often travel from doctor to doctor seeking help.  Today a number of different therapeutic approaches can target the spefiic cause or causes of your dry eye.  They include:
Eye drops or artificial tears have long been an accepted therapy for dry eyes. Using drops would seem logical - add water to an eye that’s dry, dry eye disease is far more complex than just a lack of moisture. This is the primary reason simple drop formulations offer relatively little sustained benefit for patients and with too frequent application drops can actually cause harm by washing away or diluting important tear components. 
Modern eye drops target specific dysfunction of the tears and tear structure. It is important to understand that drops for dry eye are not all the same. Artificial tear drops can be divided into three main groups:

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Moisture drops primary add moisture to the eye’s surface. The better products including Advanced Vision Research's TheraTears and Alcon's Bion Tears offer balanced formulations. Their role is to add volume to an aqueous (moisture) deficient tear film.






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• Cushioning drops contain bulking agents - typically methylcellulose derivatives are designed to cushion the tears and action of the lids. Products like Allergan’s Refresh
® and Optive® are popular and useful for some, however, these generally older formulations have been largely superseded my modern targeted formulations.



systane-freshkote
• Advanced formulations include drops that mimic the function of tear components – in some cases nearly as effectively as natural tears. These include products like Alcon’s Systane® Ultra which mimics natural mucins to improve tear stability and viscoelasticity. AMO’s Blink® Tears contain hyaluronic acid which can help cushion and stabilize the tears. Several eyedrops act as lipid supplements. The best of these incorporate phospholipids which function as a bonding agent between the tear’s lipid outer layer and the underlying tear structure. Alcon’s Systane® Balance and FreshKote® by Focus Laboratories are the best of the lipid-based formulations. Note that FreshKote® requires an Rx.
Many artificial tears are available in both preserved and non-preserved unit dose versions. Modern preservatives have minimized the advantages of non-preserved drops for most patients,
Other over the counter eye products include a variety of gels, sprays and ointments. In general the gels are designed to afford greater protection for more severe dry eye or challenging environments. They last longer than comparable non-gel products. Ointments and sprays should be used after consultation with your doctors.
Because dry eyes are also sometimes red eyes, some patients are tempted to use drops aimed at reducing redness. Do not use drops intended to whiten the eyes. They typically contain ingredients that can worsen dry eye by disrupting the normal balance of the tears and irritating the ocular surface.
Modern advanced formulation drops provide far greater clinical performance than earlier products were able to. However, the many different products on the market and their complexity make it imperative that you seek professional advice to help you determine if drops will be of help and which drops will be of greatest benefit.

Nutritional Supplements and Dietary Considerations
Nutritional supplementation has become a well-accepted therapy for dry eye.  Numerous studies have found that omega-3 fatty acids can containing supplements decrease dry eye symptoms, positively impact meibomian gland secretion, and also possess anti-inflammatory effects.
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There are a variety of natural sources for omega-3s including cold-water fish, such as herring, sardines and salmon. Supplements containing flaxseed oil or fish oil are often recommended.  HydroEye®, EyePromise® EZ Tears and Systane® Vitamin Healthy Tears are examples of products formulated specifically for the eye. However, some patients choose more common Omega-3 supplements available from health food stores. Some clinicians recommend that patients make sure that they consume sufficient water.  Dividing your body weight by 16 yields the recommended number of cups of water you should be consuming per day – although that should be taken as a general recommendation. In general, consuming more water can’t hurt and may help so its worth a try.
Punctal Plugs
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In healthy people, the rate of tear production, evaporation and drainage remain in good balance regardless of environmental or other challenges.
One strategy to retain more tears in the eye for longer involves restricting drainage using plugs that occlude the drainage system. Despite years of use, punctal plug use remains somewhat controversial. Some clinicians believe that tear stagnation and complications associated with plugs outweigh their benefits. With advances in pharmacologic management, use of punctal plugs has generally diminished, but they remain a viable option for some patients. A variety of different plugs that either fully block or restrict tear drainage can be inserted in a quick, painless in-office procedure.

Medications for Dry Eye

Currently the only medication indicated and approved by the FDA for treating dry eye in the United States is Allergan’s RESTASIS®. 

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An ophthalmic emulsion containing the immunomodulator cyclosporine, Restasis® has been found to increase tear production in clinical trials. Restasis® is appropriate for patients who have inflammatory dry eye. Clinical trials failed to demonstrate any increased tear production in patients who were using anti-inflammatory eye drops or had punctal plugs. Restasis® is taken twice daily and may take weeks or longer for any effect to be observed.







Restasis
Topical steroid medications are often prescribed either alone or in conjunction with tiniating Restasis® therapy. Dry eye is often accompanied by inflammation and steroids are the most effective way to squelch inflammation. However, steroids are not for long-term use as they have numerous potentially serious complications including glaucoma and cataracts. Steroids are typically used either for intermittent pulse therapy or for a limited time. A doctor must closely supervise steroid use.

Azasite


Antibiotics such as oral tetracycline class agents like doxycycline and topical drugs like azithromycin (Azasite®) are often used to help manage meibomian gland dysfunction. These drugs have effects that extend beyond their antibiotic indications including anti-inflammatory and lipid modifying properties. The use of steroid and antibiotic medications to treat dry is considered off-label as it is not approved by the US FDA, but both are commonly prescribed and well accepted medically.


Treatment for meibomian gland dysfunction (MGD)

There has been a veritable renaissance of thinking regarding dry eye in recent years. MGD has increasingly been recognized as a primary cause of dry eye disease. Treatment for MGD has typically consisted of warm compresses performed at home with lid massage to express the meibomian glands. In office treatment has centered around manually expressing the meibomian glands to clear blockage. These approaches are still performed, however, new research has suggested that vigorous massage of the eyes after warm compresses can cause permanent distortion and negatively effect vision so this is no longer recommended.

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The LipiFlow® device provides thermal pulsation to warm the meibomian glands through the inside of the lids and gently massage thickened meibum (lipid) and debris from the gland. This system is approved by the US FDA for the treatment of MGD and evaporative dry eye and has been shown to be safe and effective.
Additional treatments for MGD include IPL (intense pulsed light) therapy and probing the glands. IPL uses a high intensity xenon flash lamp to deliver light energy to the lower lid area, which is thought to liquefy congealed lipids while also sealing off blood supply which carry inflammatory mediators to the meibomian glands. IPL has been used successfully to treat patients with rosacea, skin disorder that often has associated ocular problems such as MGD. Probing is thought to open sealed glands but is somewhat controversial due to possible inadvertent damage to gland structures.

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TearScience produces the LipiFlow® and LipiView® devices for treating MGD. The LipiView® provides a detailed view of the tear film using interferometry which permits precise measurement of lipid layer thickness down to nanometer levels.