Why Proactive Dry Eye Care Should Be the New Standard

The founder of our surgical practice, Frank W. Bowden IIIwas way ahead of the curve 30+ years ago when he started championing the importance of stabilizing the ocular surface prior to surgery. We’ve adopted an approach where we don’t just treat dry eye a few weeks before surgery, we have made it our standard to actively seek out dry eye in every patient and address it as early in the disease state as we can. Like dentists promoting good oral hygiene before tooth decay occurs, we teach patients to do routine daily home eye care to keep their eyes healthy and their vision clear, even if they are asymptomatic. I firmly believe that one day, perhaps generations from now, all eye care practices — retail, private, and multispecialty —will educate all patients with consistent instructions for daily home eye care and encourage proactive “dry eye hygiene.”

Why proactive care?

We have enough to do in our eye exams to take care of patients… so why should every eye care provider be more proactive in making dry eye care recommendations?

If you stop to think about it, it just makes sense. It’s a response to the demands that everyone now places on their eyes. We’re making our eyes do things that they weren’t designed to do, from endless screen time with a reduced blink rate to exposing them to year-round indoor climate control. These perpetual stressors are now the norm, and combining these everyday stressors with the numerous traditional causes and contributing factors to dry eye, you can be sure that all our patients either already have dry eye disease or are at risk of developing it. Why delay management until patients experience discomfort, vision fluctuation, meibomian gland loss, contact lens dropout, or roadblocks to surgery?

We know dry eye is a chronic, progressive disease. We should strive to take care of it early while it is easier to address, as we do with other chronic diseases. It will take less chair time in the long run if we care for dry eye proactively and avoid train wrecks.

How can we teach preventive care?

Educating patients about preventive management of dry eye disease doesn’t take long once you work it into your everyday exam routine. Unlike patients with significant dry eye disease who need in-depth explanations, preventive care simply requires a brief conversation about causes, effects, and preventative treatments.

We’ve long used the dental model as an analogy for patients with dry eye disease, and the same applies to preventive care. Dentists don’t wait for a toothache to prompt their maintenance recommendations, and they don’t pick and choose who should brush, floss, and have dental cleanings because we're all at risk. I explain to patients that our eyes weren’t designed for current demands, and all of us either have dry eye disease or may get it one day. Using the dental model, I tell them that daily eye care is the way to address today’s demands. If they do their routine consistently, they’ll improve their ocular health and have fewer problems down the road. I don’t tell them that we can cure it. I don’t tell them that if they do preventative treatment, they definitely won’t get dry eye… I just equate the preventative dry eye treatments to dental hygiene, and it makes sense to them.

It's the philosophy in our group for all optometrists and ophthalmologists to treat dry eye proactively on every patient, so we don’t have a lone dry eye specialist in our group. Our ophthalmologists reinforce what the optometrists have told patients about the importance of dry eye maintenance before and after surgery to maintain their good outcomes. They get the same messaging from every provider they see. This makes patients more compliant and arms them with a better understanding of their disease, which makes them more willing to undergo the needed dry eye treatments.

What are proactive treatments?

For adults, proactive management of dry eye disease has four foundational components:

Nutritional supplement – Nutraceuticals created for dry eye disease can help improve meibum secretions, stabilize the tear film, and reduce inflammation. With several good supplements to choose from, I recommend HydroEye (ScienceBased Health) to patients because it's backed by published research showing that it helps downregulate inflammation, maintain corneal smoothness, and improve symptoms (1). This is a mainstay of our dry eye regimen. This formulation includes the unique omega fatty acid, GLA (gamma-linoloenic acid), which has a targeted effect on the ocular surface, helping to support tear production, promote healthy meibum production, and reducing inflammatory markers on the cornea and conjunctiva.

Eyelid hygiene – Eyelid hygiene helps clean the biofilm from the lids, which in turn helps to reduce inflammatory burden from exotoxins and promote a healthier, more balanced ocular ecosystem. Hygiene can be simple with a hypochlorous acid spray like Avenova (PRN) or Bruder (Hilco Vision) a cotton pad. Some patients prefer individual wipes, and they have several good preservative-free options from Bruder, OcuSoft, and Optase. The same brands make eyelid cleaning foams that patients can use at the sink or in the shower. For proactive care, I recommend cleaning the eyelids once a day.

Warm compress – A warm compress helps thin and release meibum. A warm washcloth isn’t warm enough for long enough to be effective, and repeated use of moist compresses can inflame the skin. I recommend that patients get a good quality mask that is not made of plastic. I find that an electrical mask like the Wizard Research Dry Eye Mask is consistent and convenient, or patients can get a microwavable Bruder mask with silicone beads (not gel). I tell patients to use the mask twice a day for eight minutes and then blink. If patients have significant lid inflammation, I start with cool compresses and then add back the warm compresses once lid inflammation has improved. The Bruder mask is good for both warm and cool use, making it very convenient.

Preservative-free lubricant – Given the number of preservative-free artificial tears now available, I don’t recommend a single specific product for every patient, but I do stress the need to see “preservative-free” on the label. I have some “greatest hits” that I specifically recommend to patients based on their individual needs, and at times I guide patients to try different brands to find their own favorite. The bottom line with artificial tears is they are like breath mints in our dental analogy. They are not enough alone, but they are friends in the dry eye fight, and I recommend them for every patient (even asymptomatic ones) to use four times per day to start.

Because my colleagues and Idiagnose dry eye disease in kids as young as eight-ten years old and frequently see the problem in teenagers, we recommend a modified preventive eye care regimen for younger patients with signs or symptoms. The important thing is to get ahead of dry eye and get kids in the daily habit of caring for their eyes (again, just like dentistry). With their parent or guardian present, I explain that preventive care is good for the whole family. Parents can start cleaning young children’s eyelids a few times a week and putting in lubricant drops morning and night, which gets them used to caring for their eyes. Teenagers or willing younger patients can add a warm compress a few times a week and clean their lids once a day in the shower. With nutraceuticals, we consult with the pediatrician prior to starting, but we regularly use a half dose of HydroEye for teenagers with their doctor’s approval.

What if patients already have dry eye?

The regimen for proactive dry eye management is foundational. We use the same foundation for people who already have the condition and add individualized, appropriately aggressive treatments. A multifactorial disease requires a multifactorial approach to treatment. For example, a patient with mild signs and symptoms might benefit from a prescription immunomodulator (Cequa, Sun Pharma; Vevye, Harrow; Xiidra, B&L), tear stimulator (Tyrvaya, Viatris; Tryptyr, Alcon), or anti-evaporative agent (Meibo, B&L) along with regular, in-office eyelid exfoliation treatments. For moderate and severe cases, we build on the lower-level treatments with additional pharmaceuticals for synergistic pharmacologic effect. Amniotic membranes (AMT) are used as a “reset button” to initiate treatment or when flare-ups occur. We primarily use the EyeDisc (VisuLogix) as our go-to AMT and reserve the Prokera Slim or CAM 360 (BioTissue) for more severe cases. We offer all the necessary therapies, such as thermalpulsation, IPL, LLLT, Tixel (Novoxel), and meibomian gland probing treatments, frequently in concert with each other for added effect. Punctal plugs or Lacrifill Canalicular Gel (Nordic Pharma) are offered once patient’s root cause has been addressed but further help is needed to increase tear availability to the ocular surface.

Autologous serum eye drops (Ocubio) are an asset that we add earlier in moderate cases to promote healing, reduce inflammation, and hopefully prevent neurotrophic keratitis (NK). We test all dry eye patients for NK yearly, and we find it often. We use the Corneal Esthesiometer (Brill) to aid early diagnosis of NK with a standardized, repeatable test. Autologous serum and AMT are our first-line treatments for stage 1-2 NK, and then we add Oxervate (Dompe) for patients with stage 2-3 NK. We also have a low threshold to address co-conspirators such as demodex with Xdemvy (Tarsus) and tightening conjunctivochalasis with the NuVissa Plasma Pen.

It's essential to note that any dry eye treatment will fail if we don’t see patients back again until their annual exams. Remember, dry eye is a chronic, progressive disease. I approach follow-up the same way I do for my patients with glaucoma: the only way I can be sure that treatment is working and that the patient remains compliant is to have them come back for repeated testing and follow up. When they are controlled, we see them every three-four months. When they are uncontrolled, we see them as often as needed. I adjust treatment based on the assessment, the diagnostics, and a conversation about the patient’s experience. It is metric driven and evidenced-based, not treatment by potpourri.

Is proactive care the new standard?

I'm passionate about trying to prevent dry eye or reduce its severity by educating every patient I see about performing routine maintenance. I take pride in being able to treat advanced dry eye cases, but I would love to see fewer of them. I envision that someday ocular hygiene will be as commonplace to the public as dental hygiene. Dental hygiene is a habit that’s deeply ingrained in society, but it had to start somewhere. Over a hundred years ago, the dental profession decided that it was important enough to preach preventative maintenance for everyone, and generations later it is commonplace. We should do the same. There will always be people with severe dry eyes, but we can take a modern approach to a modern problem with proactive care to reduce the frequency in the general population.