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Dry Eye Treatment Approaches and the Use of Artificial Tears


Experts discuss various treatment approaches for patients with dry eye disease (DED). They also highlight the challenges and drawbacks of using artificial tears to treat DED.


Bill B. Trattler, MD: Thank you guys so much. That was just a great overview of all the different variety of ways we can diagnose patients with dry eye. And now we can get to the fun part, which is how we treat patient’s dry eye. Let's start with Dr. Nichols. You know, there's so many different ways you can treat patients. Let's talk about [if] your patient comes in. They only have had artificial tears. What's your kind of first line treatment for patients? If you want to separate evaporative versus aqueous-deficient, that's perfectly fine too.

Kelly K. Nichols, OD, MPH, PhD: I'm going to take a tiny little step back before that, though. I think it really depends on how they're coming to you, where they are in the dry eyes road. Because they make it to like a practice where, you know, a specialty practice and they've never seen anybody before. Like they think that they've they have dry, they've heard something on TV, they've gone to the market, you know, found something on their own. But then there's also people who have this long history. And so, they may look like they've not tried anything, but they've tried a lot, maybe not a lot for a long time, like they've never stayed on anything consistently. So, it really does depend on how they're coming to you, where you start. So if they're like a naive to everything [patient], they're usually not, because they've tried something on their own, like artificial tears, and so your next step should be a process so that you can follow a process with your patients depending on what type of dry eye they might have, whether you think it's aqueous-deficient or it's evaporative or some combination of both. And if it's one or the other, you're going to lean towards some different treatments, especially if you think there's a lot of inflammation there or not, or how bad their meibomian glands might look. So, what you don't want to do is like what I call a "kitchen sink it," all at one time where you're just throwing everything in at once. So, you should start with what you think is the most predominant factor of their dry eye, the finding of their dry eye, and go from there. But I don't know that there's a simple answer to that because they all come to you different, you know, from their history and what they've tried before. Finding out what they've failed is really important to success, I think, in a new setting.

Bill B. Trattler, MD: Now, those are great points. I totally appreciate exactly what you're saying because this is a difficult question. But for time reasons, we'll just try to make sure everyone gets some thoughts here. Dr. Brimer, when you see a patient, and I really want to set the stage as Dr. Nichols shared, there's not just one type of patient, but let's imagine a patient that is a contact lens wearer, they've used artificial tears and now they're coming to see you because they're having contact lens intolerance. What is your typical first line treatments for these types of patients?

Crystal Brimer, OD: I want to look at the underlying cause of what's creating the dryness. So, if it's a contact lens patient, I'm going to look at the material and I'll look at how they clean them, is it daily disposable, that sort of thing. But I'm just not the person that typically recommends tears much at all. And [it's] fine, if it's an occasional dry eye and its situational dry eye, I want them to use preservative-free tears. But most of the time and again, my perspective is different because they're coming to be more advanced. So, we've got to throw that out there. But most of the time they've gotten where they are because they've been using the tears chronically for years and it's progressed because they've pacified the emergent need by putting tears on it. So, they've made it through another day and another day, but meanwhile, things were getting worse. So, I tell patients, I'm not going to stop you on your tears. You can keep using them for now. But my goal is to figure out what's going on so that you don't need them anymore. And when you come back to me and you say, "Oh, I'm just using tears, you know, once or twice a week." Then we know we're where we need to be. So, I'm not going to change the tears. I am going to look at the material. I'm going to look at what their modality is, how they're cleaning them. But primarily, I'm going to take those contacts off and say, what else is going on here that we need to address more at the root cause?

Bill B. Trattler, MD: These are a beautiful way of approaching this type of patient. You're absolutely right. Well, let me ask Dr Matossian about artificial tears in general. What are your thoughts on artificial tears in general? Are there some challenges them or are you happy with them? And how often do you, you know, as Dr. Brimer suggests that she doesn't stop tears, but maybe tears aren't always the answer. I'm just curious of your thoughts on tears.

Cynthia Matossian, MD, FACS: You know, Bill, there are challenges with artificial tears. The first one is if we as eye care providers don't take the time to look at what's going on and instead just very rapidly or superficially say, "Oh, Mr. Jones or Mrs. Jones, just use some artificial tears." We are not doing the patient the service that they deserve. We need to dig and figure out the cause and appropriately treat. Just throwing tears just to kind of mollify the patient is not ideal. Secondly, if we don't specifically recommend a type of tear, we're also doing that patient a disservice. Have you recently checked the shelves in the grocery store or the drugstore, in the eye section? It's row after row after row of different types of artificial tears. So, somebody who is not an expert in the field, how are they to choose? They don't know. So, they go either A, the cheapest one, B, that's on sale, or thirdly, they buy something completely wrong, like an anti-allergy drop to get the red out because their eyes are red due to DED (dry eye disease), not from allergies, or they get an eye whitener. So, this then further exacerbates a dry eye condition. So, these are the challenges. We need to help our patients by digging deeper to specifically recommend certain types. And lastly, like Crystal said, preservative free artificial tears are the way to go. These are people who are already suffering. They're in your offices for a reason. And the preservatives in tears can make the situation worse.

Bill B. Trattler, MD: There's just such great points. I totally agree with you. So now that you've pointed all those issues out and ways of approaching artificial tears, I'm going to go back to Dr. Brimer and ask the next question, which is, okay, so they exhaust artificial tears, they've used them and they're not doing anything. So now you're ready to use an anti-inflammatory agent. I guess the question is, when do you make a decision? When decide, okay, now it's time to add an anti-inflammatory agent into the therapy for dry disease.

Crystal Brimer, OD: Two situations. So if a patient comes to me and it is very obvious they are on fire, their eye's red, their lid margins are thick and hyperemic, there's a lot of telangiectasia, there's just chronic inflammation, and especially if the patient's in a lot of pain, I know that a lot of the other things I'm about to ask them to do are going to involve delayed gratification. And so, if I go ahead and give them a steroid to kind of quench the fire at the moment, it's going to help them stay on course and stay on track to do what I'm asking them to do, because they're going to get some relief early on. Now, when I do that, honestly, I like to use a steroid ointment because I'm asking them to do other things. And that way it's only a once-a-day dosing and it kills two birds with one stone because it gives them that nighttime lubrication. And I'm not doing refills. I'm just trying to get them over this hump so they can feel a little relief while the other stuff is kicking in. And the other times that I'll do it is more when we're along the journey and there's a flare. So, I don't think that was really your question, but I threw it in there. And typically, I'm going to implement more in-office procedures than I am going to [use] a chronic drug. So, I use chronic anti-inflammatories, but I'm more likely to do a quick steroid to put out the fire, do in-office procedures to get to the root cause, and then if I need that ongoing anti-inflammatory, then I'll incorporate that.

Bill B. Trattler, MD: Okay, beautiful. And I totally agree. I mean, you made some great points on how we can use steroids so effectively for a dry eye patient in different scenarios.

Transcript is AI-generated and edited for clarity and readability.

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