To optimize care for dry eye disease (DED), clinicians are recommended to take a stepwise approach based on each patient’s pathophysiology and disease severity. Efforts are needed to identify and treat all possible factors that contribute to DED.


The prevalence of DED varies widely, with global estimates ranging from 5% to 33%, which may reflect differing patient populations and inconsistent diagnostic criteria. Research shows that patients with moderate-to-severe DED may have a lower quality of life due to ocular pain and difficulty in performing daily activities. Currently, there is no cure for DED, meaning ongoing treatment and patient management will be required.

Beyond patient symptoms, clinicians can determine the signs of DED by using diagnostic tests that combine subjective and objective assessments, including patient questionnaires, non-invasive tear breakup time, tear film osmolarity and inflammatory marker tests, ocular surface staining, meibomian gland imaging and function, and eyelid conditions such as blepharitis and Demodex. “These diagnostic tests guide clinicians to develop individualized treatment plans,” says Bridgitte Shen Lee, OD, FBCLA, FAAO.


A Stepwise Approach

The Tear Film & Ocular Surface Society Dry Eye Workshop (TFOS DEWS II) Report outlines a stepwise approach based on a patient’s pathophysiology and disease severity (Table). “The TFOS DEWS II recommendations provide evidence-based protocols for managing this complex and variable disease,” says Dr. Shen Lee.

In general, management should begin with conventional, low-risk, and easily accessible therapies for early stage DED and progress to more advanced treatments for more severe forms of the disease. However, since there is significant heterogeneity in DED, management approaches should not be overly formulaic. The recommendations may be modified and overlapped based on a patient’s unique profile.

Step 1 approaches of the TFOS DEWS II recommendations include patient education, dietary modification, lid hygiene, use of lubricating eye drops, and modification of environmental factors. If these strategies are inadequate, progression to step 2 strategies is recommended and includes nonpharmacologic and pharmacological management. Step 3 involves the use of oral secretagogues and autologous or allogeneic serum eye drops, while step 4 includes topical corticosteroids for longer durations, amniotic membrane grafts, surgical punctal occlusion, and more complex surgical approaches. “Most patients with DED can be successfully managed in steps 1 and 2,” Dr. Shen Lee says. “Progression to steps 3 and 4 is reserved for more severe cases.”


Important Conversations

Considering the multifactorial nature of DED, a multi-targeted therapeutic approach is often required. “One treatment does not replace another,” says Dr. Shen Lee. “Some treatments may target multiple aspects of DED. Clinicians are recommended to review all systemic and topical medications that patients are taking to identify therapies that may cause or aggravate DED. A review of cosmetic product use and their ingredients should also be conducted.”

Management of DED should also include digital lifestyle discussions. “About 80% of American adults report using digital devices for more than 2 hours per day,” Dr. Shen Lee says. “This puts significant strain on the eyes and can potentially aggravate DED symptoms. Clinicians should educate patients on ways to reduce various digital eye strain symptoms, including eye fatigue, dryness, headaches, neck and shoulder pain, and blurred vision. Basic healthy digital habits include 20/20/20 blink exercises. For every 20 minutes looking at the device, take a 20 seconds break and look 20 feet away, and then blink fully.  Preservative-free lubricating drops should also be used as needed. An annual comprehensive eye exam and discussing the symptoms are recommended.”

Lifestyle changes and local environment modifications are recommended. These include avoiding exposure to smoke and environmental pollutants, increasing fluid intake, reducing alcohol consumption, and taking omega-rich supplements.


Vigilance Required

“Asking patients in-depth questions about what they are experiencing and using is critical to identifying possible factors that contribute to DED,” says Dr. Shen Lee. “This also allows us to customize treatment strategies so patients will be more likely to stick to their treatment plan. Clinicians must emphasize the need to adhere to therapeutic plans to increase potential for treatment success. Careful follow-up and detailed patient instructions are also important to determining if patients are consistently implementing recommended approaches and to assessing improvements in signs and symptoms.”