Navigating the Rapid Evolution of Dry Eye Treatment in Private Practice

Dry eye treatment has been evolving rapidly. When I started treating the condition in 2006, there were not many diagnostic tools available, and we had only one therapeutic medication. In 2023 alone three medications were approved for dry eye disease (DED), and two more have PDUFA dates in 2025. With an increasing number of therapeutics – as well as multiple interventional treatments – we now have targeted therapies that provide patients better access to relief and solutions.

In order to make the most of these advances, it is vital to have good systems in place to keep up with developments and implement new treatments and diagnostic processes as they appear. We must begin by continually remaining informed through articles, podcasts and meetings; staying curious is essential to evolving our management of patients.

I am intentional about building a cultural foundation in my practice that welcomes change. When hiring for my team, I specifically tell them that if they want to be doing the same thing every day, my practice is not for them.

Once I have a receptive team, communication is a central part of making sure everyone is educated and onboard with new processes and treatments. I work with an associate doctor and 12 other team members, and we stay in constant communication.

As we develop better processes and add technology, we identify how to measure success. Responsibility for a given metric is assigned to a team member, and after 2-to-4 weeks, we reconvene to look at what is and is not working. This kind of assessment is essential.

A comprehensive protocol

Our dry eye protocol begins when patients are asked questions during early phone calls and then complete our SPEED (Standardized Patient Evaluation of Eye Dryness) questionnaire. When the patient arrives for their appointment, they are given a second questionnaire that includes more elements of lifestyle, as well as very specific questions about factors such as sleep apnea, dry eye, and rosacea. The questionnaires are essential because they uncover DED in patients who come to the office for their comprehensive eye exam.

Once the technician picks up the patient, they look at the SPEED questionnaire. If the patient scores 6 or above out of a total of 28, I have standing orders in place to do osmolarity and MMP-9 testing.

When I walk into the room, I already know about symptoms, osmolarity, and inflammation. I then have the patient at the slit lamp, where I check for conditions such as Demodex blepharitis, ocular rosacea, and an incomplete lid seal. I look at the cornea with vital dye and assess the epithelium and the patient’s tear meniscus height. Lastly, I push on the glands to see if they are expressing, and review meibography. Throughout the entire process, I am explaining to the patients what I am looking for.

Based on my findings, I form a plan with the patient and create a thoughtful checklist that they can take with them. The patient will come back four weeks later so that we can reassess what is working in the first implementation and take a deeper dive if needed. This follow-up appointment is essential for patient adherence and compliance.

My optician arrives at the end of the consultation and I hand-off the patient with our plan verbally discussed. It is important not to miss the opportunity present at this point. The opticians are often the team members who receive questions, and they must be able to provide educated answers in line with your practice.

The written protocol is based on many algorithms and peer reviewed literature. We form a customized plan based on what that patient needs, and it is written on a checklist that has every treatment we do, whether that is OTC, therapeutic, or interventional. Marking the patient’s treatments on a list of about 25 treatment options helps me psychologically build the groundwork that there are additional options if we do not achieve the results we need in this first round.

The checklist is constantly evolving as we add new treatments. This means we are also always updating educational material for patients. We are moving to the use of QR codes for patients, so that we can easily change the PDF behind the code.

Treatment advances

I find it exciting to have a wide range of treatment options and the ability to fit an option so closely to a patient’s specific needs. I can now treat Demodex blepharitis with lotilaner 0.25 percent ophthalmic solution. I can make nutrition and nutraceutical recommendations based on an increasing amount of clinical research. I have vetted this already on behalf of the patient so that I can give them confidence in the supplement. I have the option to perform intense pulsed light therapy for patients with rosacea. As is evidenced in these examples, we are now able to manage patients in a much more targeted way than ever before. Of course, we have always wanted the silver bullet to help patients with dry eye, but because DED is a multifactorial disease this simply does not exist.

We can choose from many classes of medication. If a patient has inflammation, we can turn to the immunomodulator category. We have options that utilize the patient’s own blood supply with autologous serum and platelet-rich plasma (PRP). If I have a patient that has evaporation and I need to preserve their natural tear film, I can utilize perfluorohexyloctane, as well as therapies such as lacrimal occlusion.

If I want the body to make its own tears on the patient's demand, then I turn to neurostimulation. There is currently a nose spray on the market, a mechanical device, and we have a drop under investigation that has an expected FDA review date in May.

I use OTC drops to help support the front surface, but I never use OTC lubrication to actually manage a disease. That is not the intended purpose of the drops. Natural tears contain over 2,000 proteins, as well as water, electrolytes, mucins, and lipids, and we cannot artificially create them. I recommend lubricating drops that are preservative free, and I like them to contain trehalose to provide a protective mechanism on the front surface.

Encouraging visual hygiene

I have taken the concept of visual hygiene – parallel to the dental hygiene we all know – and applied it to our practice. In addition to promoting regular checkups, I encourage actions at home. I advise patients to follow the 20-20-20 rule – looking at something 20 feet away for 20 seconds every 20 minutes. I also recommend measures such as conscious blinking, getting enough sleep, and eyelid cleansing with appropriate products.

I discuss nutrition with my patients and talk about the importance of omega fatty acids. I encourage my patients to eat a diet rich in these acids, but I live in Oklahoma, and no one is eating fatty salmon three times a week. I like my patients to take an omega supplement that also contains gamma-linolenic acid (GLA), which has been shown in clinical studies to help regulate the body's inflammatory response (1, 2).

We are big proponents of vetting products in our practice, and we follow recent clinical research for this. HydroEye (ScienceBased Health) is one of my foundational tools for visual hygiene. It contains GLA, along with other omega fatty acids and nutrient cofactors, and has been shown to provide significant dry eye relief in a double-blind, placebo-controlled clinical trial (3). I recommend it to all of my dry eye patients and ask them to continue taking it as part of their visual hygiene regimen, even if their symptoms have subsided.

Opportunities and challenges

The pace of change in the dry eye space is rapid, which brings us both opportunities and challenges. Even with continuous advancement in dry eye treatments and diagnostics, having good systems in place can make diagnosing and treating dry eye disease very straightforward. At the same time, if dry eye care is not a good fit for your practice, you can find a trusted referral partner within your community. It is an absolute honor for me to help manage my optometry and ophthalmology colleagues’ patients. I want to challenge us as a profession to establish systems that translate innovation into meaningful change and results for our patients.