Thanks to television advertising, any patient presenting to your office with complaints of dry eyes is probably already aware of two types of therapies: over-the-counter artificial tears and prescription medications. Eyecare professionals, however, know that additional treatments for dry eye disease (DED) may be required for some patients to achieve significant, sustained relief. Fortunately, effective in-office treatments are also available. Additionally, because trained personnel administer them, the possibility of patient error is eliminated.

The following list of in-office DED treatments may be used individually or in combination.

Amniotic membranes

For more severe cases of DED (defined as those that do not show sufficient effect after a 3- to 6-month trial of more conservative treatments), amniotic membranes can be placed on the ocular surface for 1 to 2 weeks to serve as protective corneal bandages, promote epithelial growth and decrease ocular surface inflammation.¹ Amniotic membrane contains basement membrane and an avascular stromal matrix that is similar in composition to the conjunctiva. This, in theory, promotes healing of the corneal epithelial cells and limbal stem cells, while preventing scar and vascular formation.

Inform patients that their vision will be reduced while amniotic membrane is in place in that eye.

Adverse reactions: Blurred vision, induced by the covering of the cornea, and mild discomfort.

Examples: Prokera (BioTissue), AmbioDisk (Katena)

Autologous serum tears (AST)

Another treatment for refractory DED, AST are tears produced from a patient’s own blood and require the separation of the liquid and cellular components of the blood. These tears contain many of the biological nutrients and growth factors found in natural tears. They address DED by stimulating tear production and stabilizing the ocular surface.

A recent study found autologous serum tears could be an effective treatment for DED, improving ocular surface disease index, tear break-up time, and rose bengal staining score.² AST can be manufactured in various concentrations and can be dosed four to six times daily. Typically, patients must be screened for infectious diseases; once cleared, they can have blood drawn every 3 to 4 months to replenish their supply.

Adverse reactions: May increase the bacterial load in the eyes, contributing to conditions such as pink eye.

Examples: Currently, no clinical formulations of AST exist, so they must be compounded.

Intense pulsed light (IPL)

IPL uses short but powerful bursts of light of a specific wavelength to gently heat the skin around the meibomian glands to melt any obstructions present in the glands. With the removal of any obstructions, the glands gain increased oil production that results in healthy tears. A 2020 review of the published literature on IPL for meibomian gland dysfunction (MGD) found that the therapy can improve tear film stability, meibomian gland functionality, and subjective feeling of ocular dryness.³ Results can be maintained via periodic treatments.

Adverse reactions: Blistering, skin burns. Patients with a recent history of photosensitive medication or blood thinner use do not make good candidates. Darker skin pigmentation has a risk of depigmentation.

Examples: M22 (Lumenis), E-Eye (E-Swin USA), Quadra Q4 Platinum Series IPL and OptiLight (Lumenis)

Microblepharoexfoliation

In this treatment, the eyelashes and lid margin in patients who have MGD and/or blepharitis are debrided to provide symptomatic relief. A handpiece attached to a single-use medical grade sponge rotates the sponge, so that when the sponge tip (after being soaked in a lid cleanser) is placed along the lid margin, it quickly debrides the eyelashes and lid margin. All four lids can be treated in about 6 to 8 minutes; patients can resume their normal activities immediately afterward. One to two treatments per year are typically recommended to maintain symptomatic relief. It is often paired with thermal procedures (see below). A 2021 study showed that microblepharoexfoliation combined with meibomian gland expression is an effective clinical strategy for treatment of moderate to severe MGD.⁴

Adverse reactions: A tickling sensation during the procedure (numbing drops are placed prior to the device’s use), and red or irritated lids, which subside within a day.

Example: BlephEx (Alcon)

Thermal pulsation/localized heat therapies

These address patients who have MGD and are unable to gain symptomatic relief from at-home warm compresses and lid hygiene. It entails application of controlled, localized heat and pressure to the eyelids, causing the release of lips from blocked meibomian glands. It works on upper and lower eyelids to evacuate inspissated meibum and improve drainage of meibomian glands.

Thermal pulsation can be offered every 6 to 12 months and should be used in conjunction with the therapies such as topical cyclosporine and microblepharoexfoliation for best results.⁵

Adverse reactions: Burning, corneal abrasion, eyelid/eye pain, foreign body sensation, inflammation, itching, red eyes, tearing, and discharge.

Examples: TearCare (Sight Sciences), LipiFlow (Johnson & Johnson Vision) and iLux (Alcon).

Ophthalmic inserts

The hydroxypropyl cellulose ophthalmic insert provides continuous lubrication to the ocular surface without having to place artificial tears. After initial insertion and some in-office training, the insert is placed in the inferior fornix by the patient, typically once daily, and provides preservative-free lubrication. It is indicated for treatment of moderate-to-severe DED, including keratoconjunctivitis sicca. According to a multi-center clinical trial by, this insert significantly reduced symptoms and signs of moderate-to-severe DED.⁶

Adverse reactions: Transient blurring of vision; ocular discomfort or irritation; matting or stickiness of eyelashes; photophobia; hypersensitivity; eyelid edema and hyperemia.

Example: Lacrisert (Bausch + Lomb)

Platelet rich plasma (PRP) and plasma rich in growth factors (PRGF)

These alternative hemoderivative tear formulations have shown promise as successful treatments for moderate to severe DED. The composition of PRP and natural tears is similar, though in addition, PRP/PRGF therapy supplies several essential growth factors, vitamins and anti-inflammatory cytokines that can facilitate ocular surface restoration and healing.⁷ PRP and PRGF can be dosed similarly to AST and can be given for multiple rounds in cases of severe DED.

Prior to obtaining PRP, PRGF or AST, patients should be tested for any infectious diseases (ie, HIV, hepatitis or syphilis) that could preclude them from being good candidates.

Adverse reactions: No significant adverse reactions have been reported.

Punctal cautery

This procedure entails permanent closure of all four puncta if the patient has punctal scarring that precludes placement of punctal plugs or if abnormal punctal or canalicular anatomy causes plugs to constantly dislodge. Punctal cautery is performed with high temperature thermal cautery applied to the area of the puncta or canaliculi or both to induce scarring.

Adverse reactions: Cauterization may need to be repeated in up 25% of cases because of recanalization.⁸

Punctal plugs

These tiny devices (about the size of a grain of rice) are inserted in the eye’s tear ducts, or puncta, to block tear duct drainage to keep the surface of the eye moistened. The result is relief of dry eye symptoms such as chronic dry, itchy, or burning eyes. Doctors use a procedure called punctal occlusion surgery to insert punctal plugs. They may be a temporary or long-term solution and can also be helpful when managing postoperative dry eye symptoms from cataract or refractive surgery.⁹ Insertion can be performed at the slit lamp with minimal risk and minimal discomfort. The devices are available in dissolvable and semi-permanent materials.

Adverse reactions: A scratchy, slightly irritating sensation in the corner of the eye, inflammation, watery eyes or an allergic reaction.

Conclusion

With these many tools at the disposal of eyecare practices, DED patients have a far higher chance of finding relief. And because they are administered within the practice, there is greater peace of mind that the treatments have their optimal chance to work. OP

This article contains previously published material from Jennifer Loh, MD, ("Reviewing In-Office Dry Eye Disease Treatments," Corneal Physician, November 2021) and Nandini Venkateswaran, MD, (“Removing Barriers to Diagnosing and Treating Dry Eye,” Ophthalmology Management, May 2022).

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