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How to Build a Better Dry Eye Protocol

Gloved hand using dropper to administer eye drops to young woman

Dry eye disease affects more than 16 million people across the United States, and the numbers are rising. As such, an increasing number of people seek professional medical treatment for dry eyes each year. However, not all practices use the same steps for diagnosing and treating dry eye symptoms.

As part of our ongoing efforts to develop best practices for various eye procedures, we’ve compiled a list of recommendations for treating dry eye based on recent work by the Dry Eye Workshop (or DEWS II). Use this information to help refine your dry eye protocol so that your patients can benefit from streamlined and effective service.

Dry Eye Diagnosis: Go Slowly and Be Careful

Our understanding of dry eye disease has grown significantly in recent years and now includes a much broader spectrum of possible causes. This is why it’s necessary to take a more cautious and exploratory approach when diagnosing dry eye and choosing appropriate remedies.

Use the Right Definition

Previous attitudes about dry eye attributed it to one of two causes: dysfunction of the meibomian glands or lower tear volume in patients. However, the DEWS II research shows that both conditions may be present in people with dry eyes. Dry eye has since been redefined as:

“…a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.”

This definition encourages practitioners to view dry eye disease as a spectrum rather than the result of a single process. Using this definition makes it easier to accurately identify, diagnose, and treat all types of dry eye.

Dry Eye Treatment: a Four-Step Process

We’ve outlined four steps below that every practice can use to create a more comprehensive dry eye protocol. Generally, the treatments listed in these steps increase according to the resources required for each — so doctors and patients should work their way up from the first one gradually.

Optometrist holds the eye of a patient open and examines with light in office

Step One: Patient Education

A patient’s actions can alleviate many dry eye symptoms. The first step should always be to educate the patient and encourage them to adopt healthier habits. Consider:

  • Describing the condition and possible treatment options
  • Suggesting dietary modifications to supplement essential fatty acids
  • Suggesting changes to the patient’s home or work environment
  • Identifying topical medications the patient is taking that might be making their dry eyes worse
  • Recommending ocular lubricants
  • Recommending warm compresses and at-home lid hygiene routines

Step Two: Mild Therapies

Use the following systemic and topical treatments after exploring the options listed in the previous section:

  • Ocular lubricants (without preservatives)
  • Tea-tree oil
  • Use of punctual plugs (occlusion)
  • Moisture chamber eyewear
  • Ointments and moisture chamber equipment that functions overnight
  • In-office meibomian gland expression (with massage, heat therapy, or intense pulsed light)
  • Topical medications including antibiotics and steroids
  • Oral antibiotic medications

Step Three: Advanced Therapies

If a patient is not responding to any of the treatments listed in step two, consider the following measures:

  • Oral medicines that promote secretion (secretagogues), such as pilocarpine and cevimeline
  • Serums derived from the blood or a patient (autologous) or someone with similar blood typing such as a relative (allogenic)
  • Rigid scleral lenses, soft bandage lenses, or other types of therapeutic contact lenses

Step Four: Contingencies

In cases where none of the above methods have succeeded, the following techniques may be useful:

  • Using topical anti-inflammatory drugs for extended periods
  • Amniotic membrane grafts
  • Salivary gland transplants
  • Tarsorrhaphy, in which the eyelids are sewn partially shut to make the eyelid opening narrower
  • Other surgical approaches

Note that some of the treatments in this section come with greater risks than the therapies in steps one through thee. For instance, Tarsorrhaphy typically results in cosmetic side effects that patients find undesirable.

Dry Eye Protocols Should be a Gradual Progression

The critical thing to bear in mind when creating a dry eye protocol for your practice is not to overreact. Take time to understand each patient’s condition in detail so that you can start by recommending slight modifications to their behaviour. Only try more advanced or elaborate procedures after exhausting simpler alternatives.

Since so many people suffer from dry eyes, there’s no such thing as a “one size fits all” solution. Building an effective dry eye protocol will allow you to provide meaningful individualized care for each of your patients who experience dry eye disease.

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  • Written by: Bryan MacDonald

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