In a fast-paced practice, dry eye offers us a chance to slow down, develop a personalized care plan, and make a meaningful, lasting difference in a patient’s life. We can go beyond the questionnaire and exam to really learn about a patient’s symptoms. They tell us how the disease affects their life – the trips not taken, the hobbies not enjoyed, the distracting discomfort – and we can actually help them get back to enjoying their lives without thinking about their eyes. With a patient-centric approach, we can match patients’ frustrations to clinical findings and employ an effective combination of tried-and-true therapies and exciting new advances to offer a tailored approach for fast, long-lasting relief.

Laying the groundwork for personalized care

A more personalized approach to medicine begins with getting to know our patients and understanding their specific ocular surface disease. We listen to their frustrations and ask about their goals. This essential part of the process helps us build an accurate understanding of their pathology so we can target the biggest challenges to their ocular health. The SPEED survey also aids the process by putting a number on a patient’s pain, enabling us to track gradual change over time that would otherwise be hard to quantify.

When we correlate a patient’s experiences with the clinical examination, we can begin putting the pieces together to plan the best treatment strategy. For example, sudden, severe pain might allude to corneal erosion resulting from dry eye disease. Complaints of morning symptoms may point to lagophthalmos.

Correlating the patient’s subjective experiences to the clinical examination is often enough, but an expanding toolbox of diagnostics offers more information. I test tear osmolarity (salt content in the tear film), which is elevated in patients with evaporative dry eye disease. A test for the inflammatory mediator metalloproteinase-9 (MMP-9) test tells me if there is an inflammatory component. I also test tear volume and tear breakup time. This comprehensive picture of the patients’ condition directly informs choices for disease management.

Combining new and time-tested therapies

Because dry eye disease is a chronic condition with no silver bullet therapy, we have to find innovative ways to manage it. In the past few years, we have gained new tools to improve pathologic signs and alleviate symptoms so we can provide symptomatic relief as soon as possible. In my practice, the best outcomes for personalized care come from using new therapies alongside existing modalities that address different aspects of the disease:

• HydroEye. Whether the underlying causes of a patient’s disease are inflammation, aging, or other problems, they can benefit from a dietary supplement that supports healthy meibum and helps control inflammation from the inside out. My patients use HydroEye (ScienceBased Health), a blend of the unique anti-inflammatory omega fatty acid GLA, plus omega-3 fatty acids, vitamins and minerals which has been clinically shown to relieve dry eye symptoms, support corneal smoothness and reduce inflammation¹. It's a simple thing that patients can control, which is why they’re happy to take supplements. This has been part of my approach for many years, and I have seen significant improvements from nutraceuticals.

• Miebo. Perfluorohexyloctane (Miebo, Bausch and Lomb) is an exciting step forward for patients with evaporative dry eye, or meibomian gland dysfunction (MGD). This waterless drop locks in moisture and prevents evaporation to stabilize the ocular surface. It's also very lubricating, so patients feel immediate relief while gaining longer-term protection against dryness. This is a contrast to immunomodulators that take weeks to work. This drop checks a lot of boxes, which makes it a good choice for many management plans.  

• Tryptyr. Another exciting recent addition to dry eye therapy is the TRPM8 receptor agonist acoltremon (Tryptyr, Alcon), an eye drop that stimulates the cold receptors in the cornea, mimicking the sensation of tear evaporation and triggering tear production. Because nerves respond quickly to a stimulus, the drop works fast. Most importantly, it triggers the lacrimal functional unit to produce complete tears, with aqueous, proteins, and oils (not just aqueous reflex tears). After several months, I see deeper healing in my patients who use this drop compared to some other medications. I prescribe it for aqueous deficiency and patients with both aqueous deficiency and MGD.

• Lacrifill. Punctual plugs have been around for a long time, but I think some practitioners ignore them in favor of newer technologies. I find there is no substitute for physically blocking the tear drainage system to keep more tears on the eyes. In addition to silicone plugs, we now have cross-linked hyaluronic acid gel (Lacrifill Canalicular Gel, Nordic Pharma), which does a very complete job of blocking the entire lacrimal drainage system. It’s very comfortable for the patient, and the hyaluronic acid helps moisturize the ocular surface. Lacrifill works well alone or in combination with topical medications.

• TearCare. Because MGD is so common, I think it’s essential to offer a treatment option for thermal expression of inspissated meibomian glands. We use a very simple, effective in-office treatment (TearCare, Sight Sciences), often treating at the start of dry eye management to get the glands functioning better, followed by periodic retreatment as needed.

• Intense pulse light (IPL). When inflammation is part of the problem, especially in patients with rosacea, IPL targets inflammation in the cheeks and eyelid area. This in turn improves oil production and tear quality. The procedure also makes the eyelids healthier so they can blink better. The eyelid area takes on a more youthful appearance, an aesthetic benefit that patients consider to be a big plus with IPL. A lot of innovation is going on right now with other low light therapies that promise to improve both dry eye disease and appearance.

There are many rewarding aspects of creating a personalized dry eye management plan. In addition to getting to know my patients, rather than writing a quick prescription and sending them out the door, I enjoy the reward of following this fast-changing area of science. Something new is always coming. Because I see some patients with dry eye disease related to injury or multiple surgeries, one area I watch closely is potentialtherapies that regulate ocular pain topically without the consequences of systemic pain modulators. I hope to see a candidate for this area soon.

Focusing on the impact

Personalized dry eye management improves patient care by combining the personal connection and deep understanding that patients want (and that we often enjoy as well) with advanced treatment technologies. Matching patients’ experiences to clinical observations, we gain the opportunity to make a meaningful difference in their lives. The options available to us are more plentiful than ever, offering the benefits of instant and long-lasting effects. In the next few years, we can be sure that ongoing innovations will continually make it faster, easier, and more effective to fight dry eye disease.