Survey Shows Patient Dry Eye Drop Preference

More patients with dry eye report a preference for treatment with cyclosporine A to lifitegrast, although some strongly prefer lifitegrast.

Patients who used both lifitegrast and cyclosporine A (CsA) report a dry eye drop preference for cyclosporine A (CsA), according to a study of subjective patient survey responses published in Cornea.

The researchers included responses from 64 patients (mean age, 66.73±13.17 years; 83% men) at the Miami Veterans Affairs Medical Center. All patients were clinically diagnosed with dry eye disease (DED) and were treated with CsA 0.05% twice daily for an average length of 49.47±42.15 months. Treatment was then shifted to lifitegrast 5.0%, for a mean duration of 3.27±2.46 months. Three months after switching agents, the patients rated DED symptom improvement. 

Of the 64 participants, 25 (39.1%) strongly preferred CsA and 8 (12.5%) mildly favored CsA, compared with 12 (18.8%) who strongly favored lifitegrast and 2 (3.1%) who mildly preferred lifitegrast. The remaining patients either had no favored drug (12, 18.8%); or were unable to tolerate either medication (5, 7.8%).

Patients were also polled regarding visual improvement as well as pain and discomfort. Regarding pain and discomfort, 65.6% of patients reported improvements after using CsA, while 37.5% of those who used lifitegrast. For patients using CsA, 34% reported improvements in vision, compared with 22% using lifitegrast. 

Despite CsA being more frequently preferred, a proportion of our population mildly or markedly preferred lifitegrast, and the preference could not be determined by our phenotyping strategy.

While using cyclosporine, 33% reported 1 or more side effects; however, while using lifitegrast, 66% of patients reported 1 or more side effects. Using either drug, the most frequently reported side effect was burning and blurry vision — although 2 patients using CsA experienced tearing, and 2 patients using lifitegrast noted poor taste and dryness.

“Interestingly, none of the captured clinical metrics (demographics, comorbidities, and ocular surface findings) predicted subjective treatment preference, suggesting these parameters are insufficient to determine which individual would benefit from which agent,” the researchers explain. Based on these results, the study authors speculate the DED subtype, along with assessment of tear immune-related proteins and growth factors, may ultimately be a method to customize therapy. “Despite CsA being more frequently preferred, a proportion of our population mildly or markedly preferred lifitegrast, and the preference could not be determined by our phenotyping strategy. Although it is not clear which modalities would serve as better predictors of patient preference, tear fluid soluble factors (ie, cytokines, chemokines, soluble adhesion molecules, and growth factors) have been found to differ between DED subtypes and may be an important indicator of treatment effect.”

Cyclosporine inhibits growth and activity of T cells, by entering T cell cytoplasm and binding to cyclophilin. This combination impedes calcineurin and resulting proinflammatory mediators. In contrast, lifitegrast imitates intercellular adhesion molecule 1 (ICAM-1) and hinders the combination of ICAM-1 with lymphocyte function-associated antigen 1 (LFA-1) on leukocyte cell surfaces — limiting dendritic cell movement to lymph nodes and therefore fewer naïve T cells are activated.

Prior studies have found differing tear proteins related to DED subtypes (eg, tumor necrosis factor alpha (TNF-ɑ) varied when comparing non-Sjögren syndrome aqueous tear deficiency (non–SS-ATD) with meibomian gland dysfunction (MGD)-related evaporative dry eye. In MGD, tear samples showed higher amounts of ICAM-1 vs control individuals. Further, research indicated for those with raised ICAM-1 in tears or conjunctiva, such as in MGD or diabetes, lifitegrast may excel; but rather CsA for Th2-mediated ocular allergies or vernal conjunctivitis. Limitations of this analysis include a retrospective single center design, possible recall bias, lack of data for objective ocular surface improvement, and a longer therapy period for CsA than lifitegrast (P =.03). Overall, this investigation determined there may be a greater need for DED therapy individualization.


Locatelli EVT, Acuna KA, Betz J, et al. Comparison of subjective responses to cyclosporine 0.05% versus lifitegrast 5.0% in individuals with dry eye disease. Cornea. Published online on February 27, 2023. doi:10.1097/ICO.0000000000003266