Eyeworld

C OCTOBER 2025 | EYEWORLD BONUS ISSUE | 11 by Ellen Stodola Editorial Co-Director About the physicians Vincent de Luise, MD Assistant Clinical Professor of Ophthalmology Yale University School of Medicine New Haven, Connecticut John Sheppard, MD Professor of Ophthalmology Eastern Virginia Medical School Medical Director Lions Eye Bank of Eastern Virginia Norfolk, Virginia Identifying different types of dry eye W hen considering patients with dry eye, it is imperative for physicians to understand the types of dry eye disease in order to best address a patient's issues and choose an appropriate treatment. Vincent de Luise, MD, and John Sheppard, MD, discussed in depth dry eye sub-types and their identification. Ocular surface diseases can be referred to by many names, Dr. de Luise said. These include dry eye disease, tear dysfunction syndrome, dry eye syndrome, and keratoconjunctivitis sicca. The 2017 Tear Film and Ocular Surface Dry Eye Workshop II (TFOS DEWS II) 1 consensus is that dry eye disease (DED) is an ocular surface condition in which evaporation-induced tear hyperosmolarity is a trigger for a cascade of events leading to ocular surface damage, tear film instability, and inflammation, he said. There are two basic forms of dry eye dis- ease. Aqueous deficient dry eye (ADDE) disease is a result of reduced basal tear secretion (acces- sory lacrimal glands), and evaporative dry eye (EDE) disease is the outcome of excessive tear evaporation, most often from meibomian gland dysfunction (MGD) and lipid dysregulation, or from mucin abnormalities from goblet cell dys- function or exposure, Dr. de Luise said. "There is also a neuropathic aspect to dry eye disease, with dysfunction of corneal nerves being anoth- er component." While we tend to think of aqueous deficient dry eye disease as inflammatory and evaporative dry eye as mechanical (especially if the underly- ing cause is meibomian gland dysfunction), it is important to remember that both of these DED types have inflammation as a major part of their underlying etiology, he said. "In addition, DED in any given patient is not uncommonly heter- ogenous, displaying symptoms and signs of both DED types." Furthermore, Dr. Sheppard noted that the TFOS DEWS II report acknowledged the sig- nificance of neurosensory abnormalities in the genesis of DED and the importance of afferent trigeminal signals regulating the production of aqueous, lipid, and mucin tear film components. Dry eye disease is common, Dr. de Lu- ise said, noting that more than 100 million Americans have symptoms referable to DED, about 40 million have been diagnosed with DED, and about 20 million who have been diag- nosed are thought to have sufficient insurance coverage to start and stay on a prescription DED medication for a length of time. He mentioned that only about 2.5 million of the 20 million are on an FDA-approved DED medication. There are several reasons for this discon- nect, Dr. de Luise said. First of all, some patients are not aware of treatment options. Other pa- tients are not that symptomatic. These patients may find relief and improved visual quality with relatively simple strategies, such as over- the-counter (ideally non-preserved) artificial tears and gels, environmental modification and ambient humification (cold air humidifiers), hydration, reduction in daily contact lens wear time, and frequent blinking. "Some have found a benefit to altering their diet to include more omega-3 FFAs," Dr. de Luise said, noting leafy greens and wild-caught salmon. Oral fish oil supplements or oral flaxseed supplements may provide value. Dr. de Luise said other patients may achieve DED symptom relief from episodic pulse thera- py with off-label topical loteprednol etabonate for aqueous deficient DED flares or from topical azithromycin off-label or oral doxycycline or minocycline off-label for evaporative DED. Most patients with DED have the evapo- rative type, Dr. de Luise noted. "A majority of patients who are being evaluated for cataract surgery have underlying DED (usually MGD) or another type of ocular surface disease, and many may not even be aware." Dr. de Luise said that both aqueous de- ficient dry eye and evaporative dry eye can present in similar manners, with overlapping symptoms and signs. Dr. Sheppard agreed that there is frequently overlap between the two types. "It's pretty rare that a patient is exclusively one or the other," he said, adding that you need to look at the spectrum. In that spectrum are various levels of dysfunction in the integrated, interdependent components of the ocular surface unit. 2 He added that many doctors and clinicians prefer to use the term "ocular surface disease," continued on page 12

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