Eyeworld

C OCTOBER 2025 | EYEWORLD BONUS ISSUE | 13 References 1. Craig JP, et al. TFOS DEWS II Definition and Classification Re- port. Ocul Surf. 2017;15:276–283. 2. Sheppard JD, Nichols KK. Dry eye disease associated with mei- bomian gland dysfunction: focus on tear film characteristics and the therapeutic landscape. Oph- thalmol Ther. 2023;12:1397–1418. 3. Lemp MA, et al. Distribution of aqueous-deficient and evap- orative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31:472–478. there is now a new era in DED management: targeting by subtype and symptomatology to better individualize DED treatment." It is imperative, Dr. de Luise said, for the clinician to establish the three pillars of the DED treatment paradigm: 1) The presence of dry eye (is this DED or a masquerader; see page 28 for more on dry eye masqueraders) 2) The type of DED (aqueous deficient, evapora- tive dry eye, exposure, or combined) 3) The severity of DED Treatment can then be initiated and strati- fied by DED type, symptomatology, and severity. Dr. de Luise noted various FDA-approved dry eye medications and different mechanisms of action, including immunomodulators, lipolytics, evaporation reducers, cold receptor agonists, and trigeminal nerve agonists, as well as tech- nologies focusing on MGD, thermal pulsation, intense pulsed light therapy, low level light therapy, and punctal plugs. While Dr. de Luise said there is no fool- proof strategy to effectively treat all types and severities of dry eye, especially the most severe forms that are usually seen in Sjögren's patients, it is still valid and efficient to treat based on type and severity. "It is useful to consider the DED types as mild, moderate, and severe, and to use a step-wise strategy for treatment, start- ing with least invasive and proceeding to more invasive strategies," he said. Dr. Sheppard stressed the importance of managing the interventions for a patient. "To give a patient too many things to do is un- reasonable," he said. "We should pick out the most obvious therapeutic and the most obvious environmental intervention and move forward." However, with this strategy, he said you also have to manage how quickly each treatment response will manifest. For example, a pharma- ceutical intervention, like lifitegrast or punctal plugs, may be more fast acting than a nutrition- al/environmental intervention. "If you're going to have multiple interventions, pick a quick onset and a gradual onset so you know what's going on," he said. Additionally, physicians will need to consider if they are trying to prepare a patient for surgery. In these cases, the dry eye may need to be addressed more quickly and aggressively. Dr. Sheppard also noted the use of warm compresses, but he added that these have to be done chronically. There are also many lid wipes/massages available, and hypochlorous acid can be useful. He finds hypochlorous acid sprays or wipes useful for dry eye and blephari- tis, as well as preop surgical preparation. When the patient has components of both types of dry eye, it can be even more challeng- ing. Dr. de Luise noted that one large study 3 found that even though 50% of DED patients had a pure evaporative mechanism and 14% had pure aqueous deficiency, more than a third of patients (36%) had a mixed etiology of both aqueous deficient and evaporative dry eye. An effective strategy is to determine which of the two major types is most prominent, and continued on page 14 Dr. de Luise's step-wise strategy for treatment Aqueous deficient dry eye Mild: Patient education, environmental modification, humidification, reduction in computer and cell phone use, reduction in contact lens wearing time, frequent blinking, dietary modification, and non-preserved eye drops and gels Moderate: Short courses of a topical ester- based corticosteroid, followed by long-term topical non-steroid immunomodulators; after inflammation is reduced, consider punctal plugs Severe: Moisture chamber goggles, oral secretagogues, autologous serum tears or allogenic platelet-rich plasma, scleral lenses, PROSE AMT lenses, and lateral tarsorrhaphy Evaporative dry eye Mild: Dietary modification to increase ome- ga-3s, ambient humidification, lipid-based eye drops, or home-based eyelid warming Moderate: MIEBO (perfluorohexyloctane ophthalmic solution, Bausch + Lomb) eye drops, pulsed courses of topical azithro- mycin, courses of oral minocycline or oral doxycycline, and eyelid warming and com- pression technologies Severe: All strategies in moderate level, plus consider intense pulsed light therapy

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