Researchers Quantify Global Dry Eye Approaches

Doctor apply artificial tears gel to senior woman patient eye for treatment dry eye
The Tear Film & Ocular Surface Society surveyed management techniques across the globe.

Dry eye disease management differs widely between continents and countries, with a wide range of management strategies utilized at each disease severity level, according to survey results published in The Ocular Surface. 

Researchers set out to evaluate the clinical dry eye disease prescribing and management patterns of eye care physicians globally, in terms of both disease severity and subtype. Results of this study allow clinicians to “benchmark their practice to their peers, identify areas of varying practice across the world” and demonstrate where additional research is required to optimize patient management. 

Investigators designed the survey based on current dry eye disease management options as reported by the Tear Film and Ocular Surface Society (TFOS) DEWS II. The survey was designed in English, then translated into 14 languages to allow for international participation. A survey link was distributed to potential participants through email, TFOS Ambassadors, conference seminars, professional colleges, and university alumni communities, and was available between February 2018 and August 2019. 

Questionnaires were completed by a total of 1136 eye care clinicians: 37% ophthalmologists, 58% optometrists, and 5% opticians, from 51 countries on 6 continents. The majority of participants were from Europe, the UK, and Scandinavia (n=459). 

Average years of participant experience in practice was 11.8±7.9, which was similar across professional backgrounds.

Just more than 1000 (n=1085) eye care professionals provided a response describing the severity of dry eye disease in the patients they manage. In clinical practice, patients with intermittent to moderate symptoms of dry eye disease were most common (34% of symptomatic patients), while 13% of clinicians reported seeing patients with severe symptoms and 56% reported that this “was the least common patient they encountered.” 

Eighty five percent of clinicians reported actively managing dry eye disease. Among clinicians who did not prescribe, 96% provided advice to patients on topics including hydration, healthy eating, and office environments. Numerous dry eye disease treatments were utilized by respondents; independent of disease severity and subtype, the most commonly used approach to management were advice (87%), low and high unpreserved viscosity-enhancing lubricants (85% and 80%), and lid wipes or scrubs (81%). 

Management differences were globally identified. Low viscosity artificial tears were more commonly prescribed compared with high viscosity products (n=817 vs 768), while unpreserved products were prescribed more compared with preserved products (n=762 vs 672). Ointments were more common than lipid containing lubricants, while high viscosity lubricants were recommended in similar numbers as ointments. 

Demodex lid cleansing with home-use wipes were recommended by more practitioners compared with in-office treatments, and homemade warm lid compresses are more commonly recommended than commercially available warm lid compresses or face masks. 

In terms of pharmaceutical therapies, practitioners were more likely to prescribe topical than oral antibiotics. Azithromycin was used similarly in both topical and oral forms, although a slight preference towards topical use was noted. More practitioners prescribed topical secretagogues than oral secretagogues, while topical immunomodulators like tacrolimus were prescribed “slightly more frequently” than lifitegrast — although corticosteroids were much more frequent than tacrolimus. 

A wide range of dry eye disease treatments are offered at different disease severities. Some treatments are prescribed across all severity levels, such as artificial tears and nutritional supplements, while others are prescribed more frequently as disease severity increases, like in-office lid management. 

Investigators analyzed the percentage of practitioners who chose a specific management approach by severity level and identified a statistically significant difference both between and within continents. Between continents, the primary differences were the use of pharmaceuticals at lower severity levels in North America, Asia, and the Middle East, and the use of unpreserved lubricants and homemade warm compresses at higher severities in Latin America. 

On a global level, practitioners tend to have well-defined management behavior when treating patients with dry eye disease by subtype. 

Study limitations include the knowledge that surveys are subject to selection bias and are more likely to attract practitioners who are more actively involved in treating the condition compared with the “average” practitioner. 

“To our knowledge, this is the largest international survey of [dry eye disease] prescribing practices to date and the first to explore how the severity and subtype might influence management choices,” according to researchers.

“In the absence of comparative and prognostic clinical studies, the results allow clinicians to benchmark their practice against their peers, highlight areas of disparate practice where further research is warranted to ensure optimized patient management, and may be useful in informing industry on how best to target product development,” the study says.  


Wolffsohn JS, Trave-Huarte S, Jones L, Craig JP, Wang MT; for the TFOS ambassadors. Clinical practice patterns in the management of dry eye disease: A TFOS international survey. Ocul Surf. Published online May 5, 2021. doi:10.1016/j.jtos.2021.04.011