Taking an evidence-based approach to dry eye

San Francisco-Much of the guesswork about how to manage dry eye disease was clarified by the results of the Dry Eye Workshop, which established a practical, easy-to-use assessment tool and stepwise treatment approach.

“Dry eye is a multifactorial disease of the tears and ocular surface,” said Deepinder Dhaliwal, MD, associate professor of ophthalmology and director, Cornea and Refractive Surgery at the University of Pittsburgh Medical Center. “The Dry Eye Workshop figured out, based on the evidence, what would should be doing for our patients. We no longer have to guess at the next step, we have a stepwise procedure that we can and should follow.”

Guidelines classify dry eye from level 1, mild and episodic, to level 4, severe and/or disabling and constant based on patient signs and symptoms. Stepwise treatment is based on the level and severity of disease, Dr. Dhaliwal said.

Level 1 treatment may be as easy as avoiding environment triggers such as heating or air conditioning ducts that direct air streams at the eyes. Computer screens should be placed lower than eye level to help patients avoid drafts that can dry the eyes. Omega-3 fatty acid supplements may help but antihistamines will exacerbate symptoms.

“You may think these patients don’t really have a problem, but they do,” Dr. Dhaliwal said. “You need to treat them to avoid progression to more severe problems.”

Level 2 treatment adds anti-inflammatories such as cyclosporine and steroids, tetracyclines, punctal plugs, secretagogues, and moisture chamber glasses.

Level 3 treatment adds serum contact lenses and permanent punctal occlusion. Clinicians should caution patients to limit the use of artificial tears in order to avoid “dishpan eyes” that can result from the washing away of mucins and natural oils on the ocular surface.

Level 4 treatment adds systemic anti-inflammatories and surgery as needed.

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