How is dry eye treated and managed?

Treatments, treatments, and treatments... oh joy!

Away back in the day, one of my biggest hangups was the plethora of doctors who never seemed to venture beyond plug-n-drop.

Then Restasis joined the club. Then oh-so-gradually, plug-n-drop began morphing into something a little more sophisticated.

Happiness! There is life beyond artificial tears and expensive, complication-prone plugs and just plain expensive drugs! Only... oops... it might involve even more expensive devices and treatments. Sigh. Never mind. At least there are developments, and increased research and investment, and that's terribly important.

The plague of cookie cutter, one-size-fits-all treatment regimens, of course, persists in many an optometry and ophthalmology practice. Common treatments for aqueous deficient dry eye are still being foisted on unsuspecting MGD and lagophthalmos and RCE patients whose lacrimal glands are perfectly intact. But things are getting better. Eye doctors are, crucially, getting better at differential diagnostics in dry eye, and this is starting to guide their treatment recommendations more.

Formerly boutique MGD treatments have gone mainstream. Lipflow is everywhere, though due to its pricing and hit-and-miss success, not necessarily beloved everywhere. IPL continues to quietly gain momentum. I hear from people who have tried Pro-Kera much more frequently now than a year ago. And on down the line of a variety of treatments that were virtually unknown ten years ago.

Even formerly little-known treatments without commercial promoters are getting better known. Gone are the days when every caller to whom I mentioned autologous serum drops (I have been an inveterate educator on this option for more than 10 years) needed me to spell it for them... instead, THEY are sharing with ME about blood serum drops and asking if I've heard of them! Exciting times!

Best of all, my beloved PROSE and, more broadly, scleral lenses, not so long ago thoroughly disdained for dry eye applications, are rapidly heading mainstream. Perhaps too rapidly — new practitioners have had scant time to come up to speed on patients' actual needs. But it's just so good to see people learning about so many things that no one was telling them before!

Great cause for celebration, from my standpoint. After TFOS DEWS II is published, later this month, I'll be circling back to the treatment world and taking a closer look at all the options now on the table.

What is treatment, and what is management? 

Treatment encompasses the measures by which your doctor seeks to address dry eye disease and/or symptoms, including things s/he (a) prescribes for you, or (b) does to you (anything from in-office procedures to surgeries) or (c) instructs you to do. These may include:

• OTC drugs (artificial tears, gels, emulsions, ointments, sprays, etc.)
• Rx drugs (Restasis, Xiidra; topical antibiotics; topical steroids; systemic antibiotics; compounded drops and blood serum drops)
• Plugs & cautery
• MGD treatments like manual expression of the MGs; Lipiflow; IPL; Blephex; or, at home, warm compresses and lid hygiene, including OTC or Rx lid hygiene products
• Et cetera, et cetera, et cetera....

Management encompasses all the measures you take to improve your well-being, usually in parallel with treatment. (Incidentally, these are things The Dry Eye Shop are experts in — please make use of our free consultation services! We love brainstorming solutions!) These may include:

• Tools and strategies for managing dry eye at night: tapes, patches, goggles, shields, masks, ointments, learning to not open your eyes when you wake up, keeping drops on the nightstand, doing a warm compress right before bed
• Environmental modifications: Adjusting heat and A/C; humidifiers; using dry eye glasses; and so on.
• Computer use: Modifying time spent on computers; using special glasses; adjusting screen height and lighting settings; improving blink rates during computer use; and so on.
• Protective eyewear indoors and out.
• Lifestyle & activity modifications
• Dietary changes and supplementation
• Mental health & self care: assessing the global impact of dry eye on one's self; seeking treatment where appropriate; seeking personal support; seeking peer support; ramping down activities in the short term when necessary.

The roles of treatment and management in relation to each other will of course vary a lot. People have such a variety of needs and preferences and tendencies. Some will be content to address their issues at a purely medical level. Some, especially those with a profound mistrust of western medicine, will prefer to avoid the 'treatment' side altogether. Many, though, will benefit from a wise balance of medical treatments and practical management. 

The cruel truth of many health conditions is, of course, that in severe cases, the overall impact of the disease is such that it becomes extremely difficult to advocate for and care for one's self. In those cases, though, it's sometimes helpful to shift one's focus to the management side, and let the medical side go on auto-pilot for a bit without overthinking and over-sweating the details (assuming one is working with qualified professionals), while one comes to grips with what it will take to just keep going.

How do I know when something's working?

Treatment or management — is any of it actually working?

Such an important question, and yet so many people never have a sound basis to answer it!

Here are some simple questions to ask yourself when you're trying to decide whether something new you've tried is helping:

• How long have you been doing "it"?
• What exactly ARE you doing — i.e. exactly what combination of things?
• How many other things have you changed in that time? Have you changed 'extraneous' things like the type of lubricant you use, or overnight measures, or dry eye glasses, or other things?
• How are you measuring progress?
• Are you getting a medical opinion of progress at regular intervals, to assess your clinical improvement?
• Are you measuring symptom improvement in any rational way? (consider using OSDI to track symptom scoring on a regular basis)

It's not a simple equation. You can't effectively judge whether something 'works' if you're not willing to be methodical about evaluating it. 

Next, we'll look at long term results and how they play out!