Management of Dry Eye & Ocular Surface Disease - Clinical Ocular Pharmacology Spring 2026

Yes, affects up to 49 million people in the US

Is dry eye disease a common condition?

-hobbies with near vision tasks

-reading

-sewing

-electronic device use

Dry eye is associated with what particular activities?

multifactorial -- creating a variety of treatments

Dry eye has ______ causation

patient compliance

All treatment options for dry eye disease require what?

Yes

Is dry eye disease chronic?

no

Is there a cure for dry eye disease?

A multifactorial, symptomatic disease characterized by a loss of homeostasis of the tear film and/or ocular surface, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities are etiological factors

What is the 2025 Definition of Dry Eye Disease from the DEWIII Report?

-Optical

-Protective

-Physiological

-Immunological

What are 4 functions of tears listed in this class?

-mechanical barrier for the ocular surface

-flushing

-dilution of antigens

How are tears protective of the ocular surface?

O2 reservoir for avascular cornea

What is the physiological property of tears on the ocular surface?

-antibodies to detect microbial antigens

-mast cells to detect allergic antigens

-lysozyme to denature proteins

What is the immunological function of the tears?

blurred or variable vision

What are the optical symptoms of tear compromise?

-dry, burning, FB sensation

-gritty, sandy, itchy

What are the symptoms of tear compromise related to the protective nature of tears?

conj injection

What are the symptoms of tear compromise related to the physiological nature of tears?

prone to infection and inflammation (allergies, SLK, inflamed pinguecula, etc.)

What are the symptoms of tear compromise related to the immunological nature of tears?

-meibomian glands

-glands of Zeis

Anatomy of the Tear Film

What are the lipid components of the film?

-main lacrimal gland

-accessory glands of Kraus and Wolfring

Anatomy of the Tear Film

What are the aqueous components of the tear film?

-goblet cells

-Glands of Henle and Manz

Anatomy of the Tear Film

What are the mucin components of the tear film?

Yes

Can tear film instability results from a poor mucin layer on the ocular surface?

86

DEWSII stated that ____% of patients with DED have excessive tear evaporation associated with meibomian gland dysfunction

-tear film deficiencies

-eyelid abnormalities

-ocular surface abnormalities

What are the subtype drivers of DED that DEWSIII defined?

1) evaluate symptoms

2) evaluate tear quantity

3) evaluate tear quality

4) evaluate tear function/ocular surface integrity

What are the testing strategies in dry eye diagnosis?

-Dry Eye Questionnaire (23 questions)

-Dry Eye Questionnaire (5 question)

-Ocular Surface Disease Index (12 questions)

-Ocular Surface Disease Index (6 questions)

-Standard Patient Evaluation of Eye Dryness (Tear Science)

What are the examples given of dry eye questionnaires that evaluate patient symptoms in DED?

Can compare their responses over time to see if treatment is subjectively helping DED symptoms. This is a motivating factor to continue treatment.

What is the benefit of using the SAME questionnaire in the same patient over a period of time?

No

Do Dry Eye Questionnaires replace case hx questions?

-Schirmer Test (<5mm in 5 min)

-Tear meniscus measurement (<0.3mm)

When is aqueous deficiency suspected?

Before you do anything else that could enhance/reduce tear output

When will you measure tear meniscus in an eye exam?

Tear Meniscus Measurement (Pic)

Tear Meniscus Measurement (Pic)

-assess the tear quality (clarity & debris)

-TBUT and NITBUT (<10sec)

-Tear Osmolarity (>308)

-InflammaDry

-Meibomian Gland Expression (MGE)

-Meibography

How are we able to evaluate tear quality/stability?

-NaFl staining

-Rose Bengal/Lissamine Green Staining

**assessing the tears ability to protect the ocular surface

How can we assess the functional ability of the tears?

Lissamine Green

Which correlates more with patient's symptoms? NaFl or Lissamine Green

No

REVIEW: Is there a cure for dry eye disease?

to restore homeostasis of the ocular surface

What is the main goal of dry eye treatment/management?

when symptoms dictate treatment

Global Principles of Dry Eye Management

When do you start to treat DED?

maintain

Global Principles of Dry Eye Management

During dry eye treatment, you should ____ the health of the ocular surface

the primary cause of the tear film instability;

**Which layer is affected? Is there inflammation present?

Global Principles of Dry Eye Management

You can rehabilitate the tear film by treating what?

the degree of symptoms and severity of the disease

Global Principles of Dry Eye Management

With dry eye treatment, the level of treatment needs to match what?

quantitative

Global Principles of Dry Eye Management

You should document the _____ indicators of treatment effectiveness, such as SPEED score, osmolarity score, TBUT, staining, etc

Tear supplementation with OTC Artificial Tears and OTC oral omega-3 fatty acids

Step 1 Aqueous Deficiency Treatment Hierarchy

Enhance the patients OWN TEAR FILM

Step 2 Aqueous Deficiency Treatment Hierarchy

-Rx pharmaceuticals (Restasis, Cequa, Vevye, Xiidra)

-Immunomodulators (Tryotyr, Tyrvaya)

-Neuromodulators

-Neurostimulation

-Punctal plugs

-Sleep mask/goggles

What are some Step 2 DED treatments that can be implemented to enhance the patient's OWN TEAR FILM?

-oral secretagogues

-amniotic membrane

-autologous serum

-scleral lenses

What are some Step 3 DED treatments that can be implemented to enhance the patient's OWN TEAR FILM?

Tarsorrhaphy

What is Step 4 DED treatment that can be implemented?

increase the quantity and quality of tear film

What is the goal of AT Supplementation?

-Low viscosity

-BAK preserved

What are the least effective AT on the market?

-Advanced Eye Relief

-Soothe

-Tears Again

-Hypotears

-Murine Tears

-Visine Tears

-Most all generic store brands

What are the low viscosity, BAK preserved ATs that are on the market today?

-Tears Naturale II preserved with Polyguad

-Genteal preserved with Polyguad

-Systane preserved with Polyquad

What are the Low Viscosity, non-BAK preserved ATs?

-Soothe

-Systane Ultra PF

-Refresh Relieva PF

-Refresh Optive

-Theratears

What are the Low Viscosity, Non-Preserved Artificial Tears on the Market today?

No

Is there any toxicity to the ocular surface associated with repeat ed use of Low Viscosity, Non-Preserved Artificial Tears?

Post-LASIK patients for the first 12 weeks after sx. LASIK patients DO NOT have good corneal sensitivity and do not know when their eyes are dry.

Low Viscosity, Non-Preserved Artificial Tears are mandatory for what patients?

-Refresh Tears

-Refresh Optive

-Refresh Relieva w/ Purite

-Blink Tears w/ OcuPure

-Threatears with sodium perborate

What are the Low Viscosity, Vanishing Preservative ATs on the market today?

Preservatives provide antimicrobial action in the bottle but break down into harmless components when they are exposed to light

What is the concept of vanishing preservatives for ATs?

Yes -- but the FDA requires indication on the bottle so that CL wearers know which AT are allowed to be used with their CLs in the store

Can Low Viscosity, Vanishing Preservative ATs (or Non Preserved AT) be used with contacts?

-Refresh Contacts w/ Purite

-Refresh Relieva Contacts w/ Purite

-Blink Contacts w/ OcuPure

-Systane Contacts w/ Polyquad

What are the Low Viscosity, Vanishing Preservative ATs for CONTACTS on the market today?

-Refresh Optive Gel Drops

-Refresh LiquidGel

-Blink Gel Tears

-Systane Gel Drops

What are the MODERATE VISCOSITY ATs that are available on the market today?

Increases the contact time of the AT on the eye. Fewer doses are needed

What are the advantages to MODERATE VISCOSITY ATs (GELS)?

-Blur on instillation

-CL wearers cannot use these

What are the disadvantages to MODERATE VISCOSITY ATs (GELS)?

-Theratears Liquid Gel

-Celluvisc

What are the HIGH VISCOSITY Ocular Lubricants?

-Systane Nighttime

-Refresh PM

-GenTeal Tears

-Retaine PM

What are the ointment Ocular Lubricants?

No -- d/t increased contact time on the ocular surface

Do High Viscosity Gels/Ointments have preservatives in their formulations?

Yes

Are there AT with lipid components in them?

-Systane Balance perserved with Polyquad

-Systane Complete preserved with Polyquad

-Soothe XP preserved with Polyquad

-Blink Triple Care

-Refresh Digital & Optive Advanced preserved with Purite

-Refresh MEGA-3 PF

-Retaine MGD PF

What are the AT on the market that have lipid component in them?

No -- blur possible d/t the lipid component of the AT

Do AT with a lipid component mix well with contacts?

-All Blink products

-IVIZIA products

-Refresh Relieva preserved with Purite

-Systane Hydration PF

-Heyedrate Clinical

What AT are on the market today that have Hyaluronic Acid/Sodium Hyaluronate in their formulation?

ultra high molecular weight HA

What is special with Heyedrate Clinical AT?

great lubricant and hydrating agent

What is the purpose of hyaluronic acid in an AT formula?

high oncotic pressure to restore epithelial integrity and diminish microcystic edema

What does FreshKote have?

Yes -- while also pulling water out of epithelial cells to restore the ocular surface

Is FreshKote approved as a CL rewetting drop?

False, FreshKote has a much lower conc of hyperosmotic agents

True or False:

FreshKote = Muro128

Patients with EBMD and Dry eye

Who is FreshKote good for?

Generally, these trigger inflammation and disease

What is the problem with having omega-6 fatty acids in the American Diet?

1:1

What is the IDEAL RATIO of omega 6:omega 3 fatty acids in a healthy diet?

anti-inflammatory

Omega 3 fatty acids have ______ properties

ALA/LNA do not absorb/convert as well as omega-3s from fish oil

Are omega-3s in flax oil helpful?

EPA & DHA

Omega-3s in fish oil contain what 2 substances which CAN BE absorbed and utilized by human tissue?

1000

Preferred Formulations of Oral Omega-3 Supplements of Dry Eye have at least _______mg/day of combined DHA and EPA

Yes -- Dry Eye Omega, MaxiTears Dry Eye Formula, Retaine OM3

Are there many supplements out there targeted for dry eye that have over 1000mg of combined DHA and EPA in them?

Yes -- Theratears Nutrition, Blink Omega-3 Gel

Are there many supplements out there targeted for dry eye that DO NOT HAVE over 1000mg of combined DHA and EPA in them?

Yes -- Tears Again Hydrate (none) & HydroEye (100mg EPA)

Are there supplements out there targeted for dry eye that have almost no combined DHA and EPA in them?

Yes

Are Carlson's Fish Oil & Nordic Naturals Ultimate Omega helpful forms of Omega-3 Fatty acids?

-lutein

-zeaxanthin

-curcumin

-Vit D

What are the key ingredients in Blink Nutritears?

No -- very similar to an AREDS2 formulation

Does Blink Nutritears contain DHA or EPA?

-Increase Schirmer Wetting

-Eyes stay hydrated 33% longer

What are the benefits of Blink Nutritears?

2-4 weeks

What is the onset of action of Blink Nutritears?

-Restasis (0.05% cyclosporine)

-Cequa (0.09% cyclosporine)

-Vevye (0.1% cyclosporine)

-Xiidra (5% lifitegrast)

What are the Immunomodulators that are used for Dry Eye (RX ONLY)?

Keratoconjunctivtis Sicca

What is the FDA Indication for Restasis (Topical Ophthalmic Medication for Aqueous Deficiency)?

1 gtt BID OU

What is the Dosage for Restasis (Topical Ophthalmic Medication for Aqueous Deficiency)?

Keratoconjunctivtis Sicca

What is the FDA Indication for Cequa (Topical Ophthalmic Medication for Aqueous Deficiency)?

1 gtt BID OU

What is the Dosage for Cequa (Topical Ophthalmic Medication for Aqueous Deficiency)?

Tx of the signs and symptoms of dry eye disease

What is the FDA Indication for Vevye (Topical Ophthalmic Medication for Aqueous Deficiency)?

1 gtt BID OU

What is the Dosage for Vevye (Topical Ophthalmic Medication for Aqueous Deficiency)?

Tx of the signs and symptoms of dry eye disease

What is the FDA Indication for Xiidra (Topical Ophthalmic Medication for Aqueous Deficiency)?

1 gtt BID OU

What is the Dosage for Xiidra (Topical Ophthalmic Medication for Aqueous Deficiency)?

~30 days

What is the onset of action of the topical immunomodulators?

0.003% acoltremon

What is the generic formulation of Tryptyr?

Dry eye disease

What is the FDA Indication of Tryptyr (0.003% acoltremon)?

TRPM8 thermoreceptor agonist that increases the basal level of tear production

What is the MOA of Tryptyr (0.003% acoltremon)?

BID dosing

What is the dosing of Tryptyr (0.003% acoltremon)?

topical neuromodulator

Tryptyr (0.003% acoltremon) is a _________

Tryptyr MOA (Pic)

Tryptyr MOA (Pic)