Since focusing on dry eye disease (DED) in 1997 and starting a dry eye/cornea practice two years later, I’ve made a lot of mistakes and learned from legends like Donald Korb, OD. But now I know what to do—and what not to do. 

Check Under the Hood

The eyelids are the key to almost 86% of DED.1 Begin with a detailed observation of the eyelids:

  • At the slit lamp, assess for collarettes at the base of the lashes indicating Demodex blepharitis. 
  • Scan for debris, discharge and biofilm indicating bacterial/staphylococcal blepharitis. 
  • Express the lower nasal to central glands. If the meibum is turbid, thickened, paste-like or non-expressible, the patient likely has MGD. 
  • Look for a frothy tear film or froth on the eyelid margins, which indicates saponified oils in MGD. 
  • Watch as the patient blinks to see if there is partial or incomplete closure. Perform the K-B test to assess for improper eyelid closure. Have the patient close their eyes, then shine a penlight onto the closed lid to see if light escapes inferiorly. 
  • Check for lid laxity, entropion and ectropion. 

Find a Map

The TFOS DEWS II diagnostic approach, while it seems complex, is actually straightforward, effective and easy to perform:2 

  • Ask triaging questions about how patients’ eyes feel and look, whether they use artificial tears, digital device use and blurred vision.
  • Look at risk factors such as smoking, certain medications, contact lens wear, previous ocular surgery and systemic diseases.
  • Use a validated DED questionnaire such as the DEQ-5 or SPEED.
  • Perform one to two homeostasis-determining tests, such as osmolarity testing, tear film break-up time and ocular surface staining.
  • If you note DED signs and symptoms, determine the subtype. For evaporative DED, express the meibomian glands and perform meibography, if available. For aqueous deficiency, look at the tear meniscus height when you instill NaFl dye.

A Winding Road

I’ve found the traditional approach to DED usually results in frustration for everyone. Instead, consider these clinical pearls: 

  • DED starts as episodic, but if the disease progresses, the patient will require life-long therapy.
  • Educate patients that it will be three to six months before they notice symptomatic improvement.
  • Use a slit lamp camera system to recall previous signs and educate patients; also consider patient education tools for efficiency.
  • Don’t just treat the tear film; also address the obstructed glands, blepharitis and inflammation. 
  • For aqueous deficiency, consider 180-day dissolvable punctal plugs.
  • Add a red eye treatment, such as alpha-2 specific agonists, to boost patient confidence.
  • Provide in-office procedures such as low-light level therapy, BlephEx, intense pulsed light and thermal in-office treatments directed at the meibomian glands.
  • Consider a dental model of in-office treatments combined with at-home maintenance.
  • Incorporate biologics such as amnionic membrane, autologous serum and cytokine extract drops. 
  • Multiple options exist if a therapeutic drop is too expensive. For example, cyclosporine now has three formulations: Restasis (Allergan), Cequa (Sun Pharma) and Klarity-C (Imprimis).
  • Research shows omega fatty acid supplements with GLA and fish oil are effective and safe.3-6
  • A 10-second eyelid debridement dramatically helps patients with MGD/evaporative DED.
  • The best option for DED flareups is topical corticosteroids such as loteprednol for four to seven days.

Note: Dr. Karpecki consults for companies with products and services relevant to this topic.

1. Lemp MA, Crews LA, Bron AJ, et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-8.

2. Wolffsohn JS, Arita R, Chalmers R, et al. TFOS DEWS II Diagnostic Methodology report. Ocul Surf. 2017;15(3):539-74.

3. Sheppard JD, Pflugfelder SC, McClellan AJ, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 2013;32:1297-1304. 

4. Liu A, Ji J. Omega-3 essential fatty acid therapy for dry eye syndrome: a meta-analysis of randomized controlled studies. Med Sci Monit. 2014;20(1):1583-9.

5. Zhu W, Wu Y, Li G, et al. Efficacy of polyunsaturated fatty acids for dry eye syndrome: a meta-analysis of randomized controlled trials. Nutr Rev. 2014;72(10):662-71.

6. Mudil P. Evaluation of use of essential fatty acids in topical ophthalmic preparations for dry eye. Ocul Surf. October 4, 2019. [Epub ahead of print].