Ocular Surface Disease

Artificial Tears for Dry Eye Disease: Choose the Right Drops for Patients’ Individual Needs

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By Nathan Lighthizer, OD, FAAO

Dry eye disease (DED) has historically been undertreated, and many patients still rely on self-treatment for this complex, progressive condition. Like others who treat DED, I’ve been taking a more interventional approach to treatment, implementing in-office treatments early in the disease process and laying out a management plan for my patients.

Artificial tears play a key role in this process. They’re part of every management plan, regardless of DED’s severity. Rather than leave patients to select artificial tears on their own from store aisles filled with a confusing array of choices, it’s essential for me to recommend the right tears for my patients based on the science and my clinical experience. Here’s my decision-making process and a complex case where the right artificial tear made all the difference.

Address Four Things
Selecting the right artificial tear and usage schedule for a patient depends in large part on the severity of their DED. I consider their symptoms, SPEED score, diagnostic tests, and ocular surface exam. Next, I develop a DED management plan to address four goals: 1) stabilize the tear film, 2) minimize inflammation, 3) improve meibomian gland function, 4) reduce bacterial biofilm on eyelids and lid margins.

Artificial tears help us meet goal #1, and they can be augmented with punctal plugs. However, it’s essential to recommend the specific high-quality, branded artificial tear that’s best for the patient and ensure that they avoid private label eye drops, over 30 of which have undergone FDA recall this year for bacterial contamination.

Therapies aimed at other goals include omega supplements, anti-inflammatory treatment (intense pulsed light, or IPL), thermal expression of the meibomian glands, lid scrubs, in-office lid margin exfoliation, and myriad other options. Artificial tears help maintain a hydrated ocular surface throughout all of these treatments, and they give patients some control over their symptoms on those days when their symptoms are worse.

When I make my recommendation, the first characteristic I look for is a preservative-free formulation because I want to avoid preservatives such as BAK that can be drying or irritating to the ocular surface, particularly when tears are used frequently. There are several quality preservative-free tears now on the market. The exception where I permit preserved tears is when a patient with intermittent mild DED already has a preserved tear they like and the ocular surface looks good, but I explain that they should switch to a preservative-free options if they start using their drops more frequently.

I sometimes recommend a preservative-free tear with a lipid component for patients with significant meibomian gland dysfunction who do not wear contact lenses. In other cases, I specifically choose a preservative-free tear that’s compatible with contact lenses. I also prefer that my patients use a preservative-free tear that comes in a multi-dose bottle rather than vials. I’ve found that vials can be nearly impossible to use for patients with poor dexterity, and even patients with good dexterity get frustrated with them.

Case: The Right Tears for Severe DED
I saw a 47-year-old female patient for a dry eye evaluation in January 2020. As soon as I walked in the room to meet her, I could see that her eyes were red and inflamed as though she’d been crying for hours. She told me, “I just don’t know what’s happened in the last year. My eyes have just fallen off a cliff!” DED was affecting all aspects of her life: work, hobbies, and interacting with her kids and grandkids.

Diagnostics: The patient had 2+ bulbar injection OU. Her SPEED score was a 24—the highest I’ve seen on a scale that goes to 28. She had grade 2 diffuse inferior SPK OU. Her ODSI score was 77 on a scale of 0 to 100, and her tear osmolarity was 318 OD and 317 OS. Her MMP-9 inflammatory marker test was positive. Meibomian gland expression showed meibum ranging from cloudy to cheesy. Noninvasive tear breakup time (NITBUT) and examination of the meibography glands further supported the diagnosis of DED. (See Figure 1)

Treatments: Treatment for a severe case like this one is multifaceted. I immediately started the patient on a preservative-free artificial tear (Refresh Plus, Allergan), which comes in single-use vials. Due to the positive inflammation test, she was started on loteprednol (Lotemax, Bausch & Lomb) QID as well as cyclosporine 0.09% (Cequa, Sun Ophthalmics) BID.

We scheduled two inpatient treatments: IPL therapy (OptiLight, Lumenis) for inflammation and thermal expression (TearCare, Sight Sciences) to clear the inspissated meibomian glands. OptiLight was completed in 6 treatment sessions, with an annual follow-up treatment. We also repeat TearCare every 6-12 months as needed. After the patient’s initial in-office treatments, her severe DED began to improve, with occasional flares that required a short-term steroid.

At a follow-up visit in June 2022 (2 ½ years after initial therapy), I switched this patient to iVizia artificial tears 2-4 times per day (morning, night, and as needed). She uses them more when she’s going through a tough spell, particularly with environmental changes like turning the heat on in winter. After using the preservative-free tear I’d initially recommended, the patient said iVizia was more soothing and effective in helping her manage her own ocular comfort and handle problems as they arose, and she’s continued to use this drop ever since. She also loves the multi-dose bottle because it’s easy to use and she’s not losing vials in her purse. It’s an example of how we can continually improve patient care by recommending new products that we think will be a better fit for our patients.

Results: We continue to manage the patient’s DED in a positive way. Her OSDI score now hovers between 20 and 30 depending on the day, which shows that she has significantly improved from where she started (OSDI of 77). She still has occasional setbacks, but she’s able to be symptom-free most of the time because of her rounds of OptiLight and TearCare, as well as the iVizia tears she now prefers to keep her eyes hydrated every day and handle tough situations. In-office treatment interventions are helping this patient, but her artificial tears continue to play a foundational role in her success. By taking control of the artificial tear decision and recommending a specific, high-quality, preservative-free product, we’ve helped this patient achieve a new level of comfort and control over her dry eye disease.

Nathan Lighthizer, OD, FAAO, is an optometrist, associate dean, the founder and chief of the specialty care dry eye clinic, and director of continuing education at Northeastern State University Oklahoma College of Optometry in Tahlequah, Oklahoma. Disclosures: Dr. Lighthizer is a consultant for Abbvie, B&L, Lumenis, Sight Sciences, Sun Pharma, and Thea