For the millions of patients diagnosed with dry eye disease (DED), prescription eye drops are a common source of relief.1 However, this approach may be inadequate, expensive, or downright inappropriate for certain patients. Dry eye disease itself is a somewhat vaguely defined condition that can best be understood as an umbrella term encompassing a variety of signs and symptoms stemming from a range of etiologies, all of which factor in when selecting a treatment option.
“Dry eye is a heterogeneous disease with multiple causative factors, including mechanical factors such as exposure keratopathy and nocturnal lagophthalmos, contact lens overwear or intolerance, aqueous deficiency, meibomian gland dysfunction, blepharitis, and others” explains Saba K. Al-Hashimi, MD, assistant professor of ophthalmology in the Cornea Division at the David Geffen School of Medicine at the University of California, Los Angeles, and faculty member at the UCLA Stein Eye Institute
Although pharmaceutical eye drops have a role in managing many of these patients, regardless of ocular surface disease etiology, many in-office and at-home treatments can keep patients’ eyes in good comfort and good health.
The Need for Non-Pharma Options
Numerous factors may influence the need for non-pharmaceutical DED treatments. “Some patients may be under the impression that they can’t afford a chronic dry eye therapy, though many companies have patient assistance programs that are quite good,” says Kelly K. Nichols, OD, MPH, PhD, FAAO, dean and professor in the School of Optometry at The University of Alabama at Birmingham. “Other patients may have experienced adverse reactions to those pharmaceuticals or felt like the therapies did not work well enough, which may lead them to non-pharmaceutical options.”
Some of those adverse reactions are well known to any practitioner who prescribes these drops — burning, stinging, even blurred vision are common.2
But long-term adherence to a regular treatment regimen is often a challenge for patients with any chronic disease. Let’s face it — dry eye isn’t a terminal illness. Patients may believe the consequences of noncompliance are mild. If the drops are causing discomfort, and discomfort is what the patient is attempting to resolve, there’s a strong chance they’re going to discontinue drops on their own. And discomfort isn’t the only reason for discontinuation.
“Part of it may be inability to get to a pharmacy to pick up meds or inability to squeeze a bottle or tilt the chin up to put drops in – perhaps due to arthritis, stroke, or cervical spine issues, for example,” explains Cynthia Matossian, MD, FACS, founder of Matossian Eye Associates, president of the American College of Eye Surgeons, and lead author of a recent review regarding DED treatments beyond artificial tears.3 Forgetfulness can also be a factor, especially if “drops have to be used multiple times per day, and especially if there are many different drops – the more complex the drop regimen, the greater the probability of noncompliance.”
Patients using eye drops for other conditions may wish to manage their DED without drops. “In particular, patients on chronic glaucoma medications frequently have concordant dry eye exacerbated by repeated administration of preservative-containing drops, especially those with benzalkonium chloride,” according to Angie E, Wen, MD, assistant professor of ophthalmology at the Icahn School of Medicine at Mount Sinai in New York, and faculty member at the New York Eye and Ear Infirmary of Mount Sinai.4 “Even using preservative-free artificial tears may pose a hardship, as these patients are often already on multiple medications and may have difficulty maintaining a frequent drop regimen.”
Other individuals with DED may simply wish to explore various options to replace or complement pharmaceutical therapies and home-based treatments. For many of these patients, multiple treatment approaches are warranted and may include a combination of at-home and in-office therapies.
In-Office Lid Warming
These procedures “can be very helpful in cases where meibomian gland dysfunction is the main contributing factor to their dry eye symptoms, especially for patients who struggle to find time to consistently perform warm compress treatments at home,” explains Dr Al-Hashimi.
There are 3 in-office devices that involve heating the meibomian gland and evacuating the impacted meibum.5,6 With LipiFlow® (Johnson & Johnson), the clinician places a single-use activator inside each eye and turns them on, then removes and discards them at the end of the 12-minute procedure. “The device heats the meibomian glands from the inside and outside of the eyelids. The glands are sandwiched between 2 very pliable heaters that gently evacuate the inspissated material from the glands,” explains Dr Matossian, who says she undergoes this procedure herself annually.
Another device, TearCare® (Sight Sciences), is similar, except that you place an adhesive heating strip is placed on the outside of the upper and lower eyelids, and it heats the glands for 15 minutes, says Dr Matossian. “The clinician then removes the strips and manually expresses the glands using a metal paddle. Yet another lid-warming device is the iLux2 (Alcon), a “handheld device that heats the glands, and as the provider is going along the lid margin, the impacted content is manually squeezed from the glands.”
Dr Al-Hashimi notes that patients may not feel a dramatic difference after in-office lid warming, even with objective improvement in their meibomian gland dysfunction. “It is thought that this treatment is best delivered earlier on, before there is meibomian gland atrophy and more as a preventive measure to ensure dry eye does not worsen over the years.”
Intense Pulsed Light Therapy
An in-office option typically administered in 4 separate sessions, intense pulsed light (IPL) is often recommended for patients with ocular rosacea and meibomian gland dysfunction. Using a handheld device, the “broad beam light therapy targets the telangiectatic vessels with the goal to decrease the load of inflammatory mediators at the lid margin and ocular surface,” says Sabrina Mukhtar, MD, assistant professor of ophthalmology at the University of Pittsburgh School of Medicine in Pennsylvania.7
“The majority of patients — about 70% — saw improvement in their symptoms by the end of the series” in research investigating the use of IPL for DED, according to Dr Al-Hashimi.8
Dr Matossian emphasizes the frequent need to combine treatments to achieve complementary and synergistic effects: “Depending on the severity of the disease, an in-office lid warming and evacuation treatment may need to be followed by an IPL series to help patients achieve the comfort and symptom relief they deserve.”9
IPL should not be used in patients with Fitzpatrick skin types higher than 4 on the Fitzpatrick scale, a 2022 study explains.7
Patients with aqueous-deficient dry eye (ADDE) generally experience the greatest benefit from intranasal stimulation. This modality “works on the trigeminal pathway to stimulate more tear production from the lacrimal gland, which offers patients suffering from ADDE an alternative mechanism for tear production,” Dr Mukhtar explains.10
Varenicline is an FDA-approved intranasal prescription treatment used twice a day that “pharmacologically stimulates the trigeminal parasympathetic pathway to create a complete tear instantly,” says Dr Matossian. “So, it’s a nasal spray in lieu of an eye drop – some people find it easier to use a nasal spray than to get drops into the eye.”
There is also a prescription-based handheld device called iTear® (Olympic Ophthalmics), which the patient places on each side of the nose for 30 seconds to provide external, mechanical stimulation of the trigeminal nerve to produce a complete tear.11
“The external device may be a very good choice if a patient can’t afford the nasal spray,” Dr Nichols suggests.
Side effects including sneezing, coughing, and throat and nose irritation may affect compliance with intranasal approaches, adds Dr Mukhtar.
Financial cost is the main potential downside of these various approaches, especially for lid-warming and IPL, which are not covered by insurance. The cost of these therapies ranges from $400 to $1000 per lid-warming treatment, and $900 to $1600 for the 4 sessions of IPL, Dr Al-Hashimi estimates.
Additional Pharma-Free Considerations
Dr Nichols reiterates that all patients should be advised to practice “good ocular hygiene and contact lens practices, such as appropriate replacement and storage, and to take regular breaks from electronic devices to rest the eyes by blinking and restoring the tear film.”
Warm compress eye masks and lid scrubs “used at home are excellent ways to maintain results from in-office therapies and as adjuncts to pharmacologic treatment,” Dr Wen says.
Punctal plugs can be especially effective for ADDE patients, according to Dr Al-Hashimi. They are also an option for patients with Sjögren disease or graft vshost disease.3,12
“Additional options include low-level light therapy and radiofrequency, which may be good for patients who are not IPL candidates,” Dr Mukhtar notes.13 “Serum eye drops are also a nonpharmaceutical option in which blood is taken from the patient and spun down to extract proteins, growth factors, and anti-inflammatory mediators found in serum to make preservative-free eye drops.”14
For optimal effectiveness, providers should aim to tailor treatment strategies to the underlying cause or causes of each patient’s DED. “For instance, lid warming and IPL can help in meibomian gland dysfunction and evaporative dry eye, while biofilm debridement and Demodex treatment will help those with significant blepharitis,” Dr Wen suggests. “Patients with ADDE will still benefit significantly with medications such as lifitegrast and cyclosporine as well as tear supplementation.”
In the same vein, many patients with DED will need to use eye drops between in-office treatments for sustained results. “There are many very good artificial tears on the market, and clinician recommendation often weighs heavily with patients,” Dr Nichols points out. “I would advise clinicians to spend time reviewing the latest developments in the field, both pharmaceutical and nonpharmaceutical, so they can provide the best patient care possible.”
- Farrand KF, Fridman M, Stillman IÖ, Schaumberg DA. Prevalence of diagnosed dry eye disease in the United States among adults aged 18 years and older. Am J Ophthalmol. 2017;182:90-98. doi:10.1016/j.ajo.2017.06.033
- Ozdemir S, Yeo SWJ, Lee JJ, Bhaskar A, Finkelstein E, Tong L. Patient medication preferences for managing dry eye disease: The importance of medication side effects. Patient. 2022;15(6):679-690. doi:10.1007/s40271-022-00586-8
- Matossian C, Crowley M, Periman L, Sorkin S. Personalized management of dry eye disease: Beyond artificial tears. Clin Ophthalmol. 2022;16:3911-3918. doi:10.2147/OPTH.S384819
- Maeng KJ, Lee K, Kim S, et al. Effects of glaucoma medication on dry eye syndrome and quality of life in patients with glaucoma. Korean J Ophthalmol. 2021;35(6):467-475. doi:10.3341/kjo.2021.0068
- Bzovey B, Ngo W. Eyelid warming devices: Safety, efficacy, and place in therapy. Clin Optom (Auckl). 2022;14:133-147. doi:10.2147/OPTO.S350186
- Beining MW, Magnø MS, Moschowits E, et al. In-office thermal systems for the treatment of dry eye disease. Surv Ophthalmol. 2022;67(5):1405-1418. doi:10.1016/j.survophthal.2022.02.007
- Barbosa Ribeiro B, Marta A, Ponces Ramalhão J, Marques JH, Barbosa I. Pulsed light therapy in the management of dry eye disease: Current perspectives. Clin Ophthalmol. 2022;16:3883-3893. doi:10.2147/OPTH.S349596
- Arita R, Mizoguchi T, Fukuoka S, Morishige N. Multicenter study of intense pulsed light therapy for patients with refractory meibomian gland dysfunction. Cornea. 2018;37(12):1566-1571. doi:10.1097/ICO.0000000000001687
- Vegunta S, Patel D, Shen JF. Combination therapy of intense pulsed light therapy and meibomian gland expression (IPL/MGX) can improve dry eye symptoms and meibomian gland function in patients with refractory dry eye: A retrospective analysis. Cornea. 2016;35(3):318-322. doi:10.1097/ICO.0000000000000735
- Yu MD, Park JK, Kossler AL. Stimulating tear production: Spotlight on neurostimulation. Clin Ophthalmol. 2021;15:4219-4226. doi:10.2147/OPTH.S284622
- Ji MH, Moshfeghi DM, Periman L, et al. Novel extranasal tear stimulation: pivotal study results. Transl Vis Sci Technol. 2020;9(12):23. doi:10.1167/tvst.9.12.23.
- Harthan JS, Shorter E. Therapeutic uses of scleral contact lenses for ocular surface disease: patient selection and special considerations. Clin Optom (Auckl). 2018;10:65-74. doi:10.2147/OPTO.S144357
- Giannaccare G, Vaccaro S, Pellegrini M, et al. Serial sessions of a novel low-level light therapy device for home treatment of dry eye disease. Ophthalmol Ther. 2023;12(1):459-468. doi:10.1007/s40123-022-00619-3
- Valencia Castillo SL, Martín ES, García Frade LJ, García-Miguel FJ. Autologous serum eye drops improve tear production, both lachrymal flow and stability tests and conjunctival impression cytology with transfer in dry eye disease. Blood Transfus. 2021;19(1):45-53. doi:10.2450/2020.0009-20