Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

dry eye at initial presentation

1st line – topical lubricant

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ACUTE
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dry eye at initial presentation
1st line – 

topical lubricant

Help ocular surfaces regain their normal homeostatic states.[3]

There are many preparations available commercially that vary in electrolyte concentration, preservative concentration, osmolarity, and viscosity. However, most formulations have similar efficacies.[37]

Patients will usually try several preparations before finding one that suits them.

Regular application is tailored to patient requirements.

Temporary blurred vision may occur.

Mild symptoms can usually be managed satisfactorily with lubricants and lipid tear eye drops, along with lifestyle changes. Treatment can be started with hypromellose (0.3% or 0.5%), moving onto carmellose (0.5%), and then carbomer (0.2%). In predominantly evaporative dry eyes a lipid tear supplement eye drop is added.

Moderate symptoms may include blurred vision and light sensitivity and may restrict daily activities. They require more frequent use of tear supplements and/or use of a more viscous product. Treatment includes sodium hyaluronate (0.1%) and carmellose (1%).

Severe symptoms present as more pronounced due to desiccation of the corneal epithelium. Regular use of tear supplements and more viscous and gel lubricants should be beneficial. Additional treatments may be required. Most patients in this group need combination treatment with sodium hyaluronate (0.2%), hydroxypropyl guar, and paraffin-based ointments.

Night time treatment with white soft paraffin and retinol palmitate, light liquid paraffin and wool fat, or other combinations containing white soft paraffin and mineral oil can be used to support these treatments.

Availability of tear supplements may vary between countries. Consult your local drug formulary for more information.

Plus – treatment of any underlying cause

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ACUTE
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dry eye at initial presentation
Plus – 

treatment of any underlying cause

Treatment recommended for ALL patients in selected patient group

Causative medications (e.g., oral contraceptives, hormone replacement therapy, antihistamines, beta-blockers, anticholinergics, diuretics, psychotropic drugs, retinoids, topical ophthalmologic medications) should be ceased if possible.

Any underlying medical conditions (e.g., Sjögren syndrome, rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis/scleroderma, mixed connective tissue disorder, sarcoidosis, diabetes mellitus, Parkinson's disease, HIV, hepatitis C, vitamin A deficiency) should be treated.

Consider – topical ophthalmic corticosteroid

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ACUTE
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dry eye at initial presentation
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symptoms not resolved with topical lubricants
Consider – 

topical ophthalmic corticosteroid

Additional treatment recommended for SOME patients in selected patient group

Evidence suggests that short-term use may be beneficial; potential adverse effects should be discussed before treatment and monitored throughout (e.g., glaucoma and cataract).[41][42] Preservative-free drops should be considered/used in dry eye disease (DED).

Should not be used in patients with co-existing dendritic ulcers.

Temporary blurred vision and worsening of eye infection may occur.

Duration of treatment depends on response, ranging from 4 to 12 weeks.

Primary options

fluorometholone ophthalmic: (0.1%) 1 drop into the affected eye(s) up to four times daily

OR

prednisolone ophthalmic: (1%) 1 drop into the affected eye(s) up to four times daily

OR

dexamethasone ophthalmic: (1%) 1 drop into the affected eye(s) up to four times daily

Consider – punctal plug

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ACUTE
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dry eye at initial presentation
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symptoms not resolved with topical lubricants
Consider – 

punctal plug

Additional treatment recommended for SOME patients in selected patient group

Absorbable and non-absorbable punctal plugs have been shown to increase tear retention.[2][43][44][45] Plugs are inserted into lacrimal puncta using preloaded applicators or forceps.

Contraindications to punctal plugs include sensitivity to plug insertion and chronic lacrimal sac inflammation.

Consider – moisture chamber spectacles

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ACUTE
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dry eye at initial presentation
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symptoms not resolved with topical lubricants
Consider – 

moisture chamber spectacles

Additional treatment recommended for SOME patients in selected patient group

Goggles that wrap around the eyes can provide protection from irritants and help with moisture retention.

Efficacy has been reported, but their use is not particularly widespread.[46][47]

Consider – oral antibiotic

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ACUTE
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dry eye at initial presentation
|
meibomian gland dysfunction/blepharitis
Consider – 

oral antibiotic

Additional treatment recommended for SOME patients in selected patient group

Tetracycline antibiotics have antimicrobial, anti-inflammatory, and anti-angiogenic properties.[38][39][40] Azithromycin may also be used as a second-line agent.

Generally used for around 3 months, but this varies with patient response to treatment.

Primary options

doxycycline: 100-200 mg orally once daily; or 40 mg orally (biphasic-release) once daily

Secondary options

minocycline: 100 mg orally twice daily

OR

azithromycin: 500 mg orally once daily for 3 days; given for 3 cycles with a 7-day interval between each cycle

Consider – lid hygiene and warm compresses

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ACUTE
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dry eye at initial presentation
|
meibomian gland dysfunction/blepharitis
Consider – 

lid hygiene and warm compresses

Additional treatment recommended for SOME patients in selected patient group

Patients with underlying meibomian gland dysfunction are encouraged to perform regular lid hygiene and apply warm compresses in conjunction with the regular use of lubricants.[2]

Lid hygiene should be performed twice daily with clean cotton wool buds. Debris is removed by gentle application of the bud tip to lid margins. Care is taken not to damage the ocular surface.

Various warm compression devices are commercially available for the treatment of meibomian gland dysfunction. Poor compliance commonly undermines the effectiveness of these compresses.

ONGOING

chronic dry eye

1st line – continued symptomatic relief as needed

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ONGOING
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chronic dry eye
1st line – 

continued symptomatic relief as needed

Lubricants are usually continued throughout treatment.

Absorbable and non-absorbable punctal plugs (inserted into lacrimal puncta) have been shown to increase tear retention.[2][43][44][45]

Moisture chamber spectacles can provide protection from irritants and help with moisture retention.

Lid hygiene and applying warm compresses is recommended for patients with meibomian gland dysfunction/blepharitis.

Consider – autologous/allogeneic serum eye drops

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ONGOING
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chronic dry eye
Consider – 

autologous/allogeneic serum eye drops

Additional treatment recommended for SOME patients in selected patient group

Autologous/allogeneic serum is the fluid component of blood post clotting.[3] Serum eye drops can be produced from unpreserved blood preparation. One meta-analysis reported that there may be some improvement in symptoms compared with artificial tears in the short term only (first 2 weeks of treatment).[48] Further large, high-quality, randomised controlled trials (RCTs) are warranted to confirm the effect.[48][49] Temporary vision blurring may occur. Autologous serum eye drops are time-consuming to prepare. Other biological tear substitutes such as allogeneic serum, umbilical cord serum, and autologous platelet lysate drops may also be used to improve DED.[48]

Amount used and duration depends on severity of the condition and patient response.

Consider – scleral contact lenses

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ONGOING
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chronic dry eye
Consider – 

scleral contact lenses

Additional treatment recommended for SOME patients in selected patient group

Provide protection and hydration to corneal surfaces. Evidence suggests they may help with the healing of persistent corneal epithelial defects secondary to dry eye.[3]

Many different materials and designs exist.

Consider – permanent punctal occlusion

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ONGOING
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chronic dry eye
Consider – 

permanent punctal occlusion

Additional treatment recommended for SOME patients in selected patient group

Permanent occlusion of the puncta (usually through punctal cautery) may be employed if patients notice significant improvement with absorbable/non-absorbable punctal plugs.[50] Trial with non-permanent occlusion is recommended for most patients.

Concerns associated with permanent occlusion include irreversible epiphora.

Consider – ciclosporin eye drops

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ONGOING
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chronic dry eye
Consider – 

ciclosporin eye drops

Additional treatment recommended for SOME patients in selected patient group

Ciclosporin eye drops are approved for use in patients with chronic dry eyes and repressed tear production.[3] One Cochrane review concluded that the evidence for ciclosporin eye drops in the management of DED is inconsistent.[55] Published trials were short-term; larger and longer-term clinical trials are required to establish therapeutic efficacy and safety.[55] Ciclosporin eye drops are typically given as a second-line or adjunctive treatment and can be used in combination with any other treatment. However, practice varies and topical ciclosporin may be used earlier.

Allow a 15-minute interval between administration of ciclosporin and other eye drops.

Use is contraindicated in patients with active ocular infections.

Temporary vision blurring may occur.

Duration depends on the severity of the condition and patient response.

Primary options

ciclosporin ophthalmic: (0.1% emulsion) 1 drop into the affected eye(s) once daily

Consider – topical or oral antibiotic

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ONGOING
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chronic dry eye
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chronic meibomian gland dysfunction/blepharitis
Consider – 

topical or oral antibiotic

Additional treatment recommended for SOME patients in selected patient group

Evidence suggests that long-term adjunctive treatment with a topical antibiotic or low-dose oral doxycycline is effective for patients with chronic meibomian gland dysfunction/blepharitis.[51]

Usually used for 3-month periods initially.

Primary options

erythromycin ophthalmic: (0.5%) apply to the affected eye(s) up to six times daily

OR

azithromycin ophthalmic: (1%) 1 drop into the affected eye(s) twice daily for the first 2 days, followed by once daily

Secondary options

doxycycline: 100-200 mg orally once daily; or 40 mg orally (biphasic-release) once daily

Consider – thermal pulsation or intense pulsed light therapy

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ONGOING
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chronic dry eye
|
chronic meibomian gland dysfunction/blepharitis
Consider – 

thermal pulsation or intense pulsed light therapy

Additional treatment recommended for SOME patients in selected patient group

Thermal pulsation devices (e.g., LipiFlow®) provide heat and express the lacrimal gland, acting in a similar way to the combined action of blinking and applying warm compresses.

Intense pulsed light may also be used for patients with meibomian gland dysfunction.

Limited evidence supports both of these approaches to meibomian gland dysfunction.[3][52][53] One Cochrane review concluded that LipiFlow® performs similarly to commonly used treatments for DED.[53] An earlier Cochrane review concluded that there is a scarcity of RCT evidence for intense pulsed light therapy.[52]

Consider – cholinergic agonist plus possible referral

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ONGOING
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chronic dry eye
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Sjögren syndrome
Consider – 

cholinergic agonist plus possible referral

Additional treatment recommended for SOME patients in selected patient group

For patients with Sjögren syndrome-associated keratoconjunctivitis sicca.[54]

Pilocarpine is frequently associated with excessive sweating (diaphoresis) and may be poorly tolerated.

Some patients may need to be referred to a rheumatologist and require systemic immunosuppressant therapy.

Primary options

pilocarpine: 5 mg orally four times daily

Secondary options

cevimeline: 30 mg orally three times daily

Consider – surgery

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ONGOING
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chronic dry eye
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continued ocular surface damage despite maximal medical treatment
Consider – 

surgery

Additional treatment recommended for SOME patients in selected patient group

Surgical treatments include amniotic membrane transplantation, lid tarsorrhaphy, and, more rarely, transplantation of salivary gland tissue onto the ocular surface.[2][56]

Amniotic membrane transplantation involves suturing amniotic membrane to ocular surfaces, covering the cornea. It may promote corneal epithelium healing.

Lid tarsorrhaphy involves partially sewing the eyelids together to narrow the openings. It is usually done at the lateral aspects.

Surgery is rarely performed. However, small numbers of patients with end-stage dry eye may be suitable for certain surgical approaches. End-stage dry eye may be defined as dry eye with continued ocular surface damage despite maximal medical treatment.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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