Eyeworld

C ORNEA 24 | EYEWORLD BONUS ISSUE | OCTOBER 2025 by Ellen Stodola Editorial Co-Director About the physicians Eric Donnenfeld, MD Ophthalmic Consultants of Long Island Garden City, New York Alice Epitropoulos, MD Central Ohio Eye and Plastic Surgery The Eye Center of Columbus Columbus, Ohio W hen treating dry eye patients, it's possible to encounter patients who do not respond to treat- ment. Two experts discussed how to proceed with these pa- tients and get them the care they need. Dry eye is the number one reason for oph- thalmology and optometry visits, said Eric Donnenfeld, MD. Unfortunately, many patients have decades of discomfort and loss of visual function and quality of life due to their dry eyes. He noted that treatment for dry eye patients generally follows a pecking order. "There have been many different nomograms developed for managing dry eye," he said, adding that the ASCRS Preoperative OSD Algorithm is a very good one. Essentially, you start with artificial tears as first-line therapy. "Probably my biggest complaint is people who complain of significant dry eye, they go to see an eye doctor, and the eye doctor's knee-jerk response is to change the drops to a different artificial tear. Almost with 100% certainty, changing one tear to another is not going to resolve a patient's dry eye prob- lem," Dr. Donnenfeld said. "If a patient is not getting the desired improvement with tears, we need to move on to more advanced therapy." After artificial tears, Dr. Donnenfeld said there are different classes of therapies to prog- ress to—immunomodulators (like cyclosporine and lifitegrast), tear secretagogues, and tear film stabilizers. Dr. Donnenfeld said he has been very impressed with XDEMVY (lotilaner, Tarsus) to treat Demodex blepharitis. "Demodex may be the missing link in the treatment of meibomian gland dysfunction," he said. Dr. Donnenfeld has found success in treat- ing patients with an immunomodulator and a tear film stabilizer, noting that his go-to combi- nation is lifitegrast and perfluorohexyloctane. For patients who still aren't getting relief fast enough, he is also a big believer in using low-dose corticosteroids. He noted EYSUVIS (loteprednol etabonate ophthalmic suspension, Alcon) and said loteprednol is a good way to manage these patients short term. Alice Epitropoulos, MD, said it's quite com- mon for clinicians to see patients who do not respond to dry eye treatment. "I would estimate that 15–30% of patients with dry eye symptoms fall into a 'non-responsive' or 'partial response' category, though this varies depending on how treatment success is defined," she said. "Many of these patients have chronic, multifactorial disease that progresses over time. Delayed treat- ment can lead to worsening symptoms, tear film instability, persistent inflammation, structural changes, and reduced quality of life." Reasons patients don't respond Dr. Epitropoulos explained that there are several potential reasons why some patients may not respond to treatment. While many individuals experience relief from standard therapies like artificial tears, anti-inflammatory eye drops, or lifestyle modi- fications, a subset of patients continue to suffer from persistent symptoms. "This is especially true for those with neuropathic or chronic ocu- lar surface pain, a subtype of dry eye where the discomfort is driven more by nerve dysfunction than by tear film deficiency or ocular surface disease." Dr. Epitropoulos said that neuropathic ocu- lar pain is frequently underdiagnosed, and these patients may not respond to standard anti-in- flammatory or tear-enhancing therapies. She noted that patients with neuropathic pain often describe burning, stinging, or aching sensations that don't correlate with clinical findings. Their symptoms often remain unre- sponsive to standard treatments for dry eye disease. "Unfortunately, effective treatment op- tions for this group are limited, and managing their condition can be particularly challenging," she said. "These patients may benefit from a multidisciplinary approach, including system- ic medications like autologous serum, topical compounded morphine drops, neuromodula- tors, antidepressants, psychological support, or referrals to pain management specialists." Dr. Epitropoulos noted that EyeCool Therapeutics is working on technology aimed at improving or alleviating chronic ocular surface pain. This procedure involves delivering cold energy to the long ciliary nerves, temporarily disrupting the myelin sheath and inhibiting pain signaling. This approach is designed to reduce Handling patients who are non-responsive to dry eye treatments continued on page 26

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