When eye drops are not enough - Next Steps for Dry Eye treatment
Dry eye is a chronic condition that requires active management. It can be frustrating to have success managing symptoms with drops (less irritation, less red eye, less blurred vision)... but then the wheels come off! Why does this happen?
1. Why Are My Dry Eye Drops No Longer Working
Based on my clinical experience, environmental change, blepharitis, condition progression, new concurrent condition, add systemic medications, eye drop change and/or eye drop preservatves are the main reasons for a dry eye flare-up.
Environmental change - Seasonal humidity changes are big drivers for flare-ups. If you were managing your symptoms successfully with twice-a-day drops and then the humidity drops in the fall, it is not unusual to have to increase treatment. Perhaps in the winter, you will need to use your drops 3-4 times per day. When the spring showers return, perhaps 2 times a day will once again be adequate to manage your ocular surface issues.
Changing seasons also bring environmental sensitivities and allergies like pollens and countless airborne antigens.
Blepharitis - Eye lid inflammation or infection can derail your management strategies. Sometimes blepharitis is the underlying cause of dry eye but sometimes it is a concurrent condition that exacerbates a well-managed dry eye.
Condition progression - The condition can unfortunately just get worse with birthdays and time.
New concurrent condition - This could be an eye condition or systemic condition. For example, diabetes, rosacea and some auto-immune disorders can be disruptive to proper tear film chemistry. A viral eye infection from the common cold virus is undoubtably going to derail ongoing ocular surface treatment.
Eye Drop change - This seems like an obvious one but this conversation happens weekly in the clinic.
Patient: "Doc, my eyes are worse again."
Me: "I'm sorry - Let's work on getting you more comfortable again. What drops are you taking right now"
Patient: "Well, I switched to a drop that I can get at Costco... starts with s?"
If you are successfully managing with a particular drop - do not change unless advised to do so by your eye doctor!
Systemic Medications - It is surprising to most folks that systemic medications can negatively impact good tear production and cause/exacerbate signs and symptoms. Reference: DEWS Report > tfosdewsreport.org
| Medication brand name | Generally used to treat |
| Absorica / Accutane (isotretinoin) | Severe nodular acne |
| Elavil (amitriptyline) () | Depression; also often used for chronic neuropathic pain and migraine prevention |
| Lopressor (metoprolol) | High blood pressure, angina, some arrhythmias, and heart failure |
| HydroDIURIL (hydrochlorothiazide) | High blood pressure and fluid retention / edema |
| Claritin (loratadine) | Allergic rhinitis and urticaria / hives |
Why do symptoms return even when I use drops daily?
Find an entire blog post written on this common question here. Dry eye disease is a chronic problem that requires ongoing treatment and management. This could be OTC drops, prescription drops, Omega 3's, warm compresses and often a combination of these. But none of this 'cure' you of the condition like an antibiotic cures an infection.
The condition name "Dry Eye" is inherently confusing as many patients with dry eyes excessively tear. Folks may have symptoms that do not match the expected dry, irritated feels.
A dry eye does not have to feel dry like the desert.
Are artificial tears only temporary relief?
There is therapeutic value in artificial tears. Ongoing treatment is the best way to prevent progression to more severe symptoms or a flare up to a more inflammatory condition - Acute Inflammatory Dry Eye
How long should eye drops take to work?
This is an excellent question by a recent patient and the answer is not the same for all. Not only does it depend on the circumstance and underlying severity/causes, but drops also work differently.
Talk to your eye care provider about your situation and what to expect. As for drops, a drop like Thealoz DUO has been clinically shown to reduce the chronic inflammation associated with dryness and poor tear chemistry. You would be an immediate symptom benefit from this drop but there is another positive benefit that grows with continued, extended use. See study reference here.
Can frequent eye drop use actually worsen symptoms or cause dependency?
There is mixed evidence for how preservative-containing eye drops effect the surface of the eye. If a patient has a compromised cornea with poor tear chemistry, I recommend to try and avoid any drop that is both > used regularly and contains preservative.
2. What Kind of Dry Eye Do I Have?
This is an extremely important factor in answering the title question of this blog post "When eye drops are not enough - Next Steps for Dry Eye treatment". Your type will likely need to be diagnosed by an Optometrist. There is a blog post here that will give you the dry eye type basics but see your eye care professional about this one.
3. Are Over-the-Counter Eye Drops the Right Choice for Me?
OTC vs. Rx medications
I do not have statistics to back up this up but directionally in-clinic, ~1 in 1000 dry eye patients use a prescription medication (e.g. Restasis) to control their symptoms. Rx drops are immune system modulating drugs to help locally suppress the immune response. They sting, are generally expensive and take 6-12 weeks to start to work. In many folks they work wonderfully but my point is that there has to be a high level of motivation to move to Rx meds. All OTC options are generally exhausted before the move is made to Rx meds.
There are studies around the benefits of these drug pre-refractive / pre-cataract surgery and this would be a separate conversation. Speak to your eye care professional about Rx drug interventions.
Preserved vs preservative-free eye drops: does it matter?
This is another area of great debate. As noted above - There is mixed evidence for how preservative-containing eye drops effect the surface of the eye. If a patient has a compromised cornea because of poor tear chemistry, I recommend to patients that they err on the side of caution and avoid any drop that is both > used regularly and contains preservative.
Why redness-relief drops can make dry eye worse
See this Blog post on Safe Eye Whitening
The most important thing to understand PRIOR to your use of any eye whitener is that you need to treat any underlying reasons for chronic red eyes and not use a whitener like Lumify to mask symptoms. Dry eyes, lid issues, infections are all possible reasons for red eye that Lumify is contraindicated and should not be used! See your eye care professional for guidance.
4. What Are the First Treatment Steps Beyond Eye Drops?
The first tier of dry eye management is almost always a blanket lubricating eye drop recommendation by pharmacists, eye doctors, medical professionals,. But what if drops alone are not enough... What's next?
As a 30 year Optometrist, I tend to think stepwise about a patient who presents with dryness symptoms AND has been using good non-preserved drop (like Hydrasense, Soothe non-preserved, HYLO, Systane non-preserved, TheraTears etc.) consistantly, minimally twice per day with limited relief.
At the highest level, a basic workup would be:
1] Is there an underlying systemic issue here?
2] Are there environmental factors like heavy computer use? allergies? CPAP use?
3] Are there anatomical lid issues?
4] Is there corneal pathology present?
5] What root cause suspected - evaporation? Low volume?
Our dry eye workup sheets (TOO SMALL TO READ HERE) follow this direction of investigation...
Once patient education and/or any medical treatments have been provided, it is time to move on to the lids.
5. Why Treating the Eyelids Is Critical for Dry Eye Relief
How eyelid inflammation contributes to dry eye
Eyelid inflammation (e.g. puffy lids, flakes in lashes and irritated lid margins) is called blepharitis. The resulting meibomian gland dysfunction (MGD) contributes to both cause and symptomology. MGD reduces and degrades the oily layer that normally slows tear evaporation. Loss of tears makes the tear film less stable, causes blurry vision and ocular surface inflammation, which then worsens symptoms in a self-perpetuating cycle.
Why eyelid cleaning is different from face washing
Eyelid cleaning is different from face washing because it targets the eyelid margin and lashes, where oils, debris, bacteria, and inflammatory buildup collect and affect the tear film; routine face washing usually cleans the surrounding skin but does not adequately clean the lid margin itself. Eyelid hygiene is specifically recommended for blepharitis/lid-margin disease, not just general skin cleanliness.
Some cleaners like Blephaclean and Teatree oil based products target microbes and mites. Soap just can not do this.
6. Warm Compresses and Heat Therapy: Do They Actually Help?
YES! When used properly and regularly, warm compresses help get the oils flowing from your lids. In-clinic, I describe this as step 1 in getting your own body to produce better tears.
See this BLOG post on warm eyelid compresses, how to use them why they are so important - A home remedy that works!
7. Can Supplements and Nutrition Improve Dry Eye?
A significant emphasis of this website is around Omega 3's for good reason. In-clinic, Omega 3 supplementation consistently gets high marks from those long struggling with dry eye. In a step-wise progression, I typically recommend adding Omega 3 supplements concurrently with warm compresses.
We have many Omega 3 related resources available to help here
NutraVege Vegan Algae Omega3 (75 Softgels)
8. When Are Prescription Dry Eye Treatments Needed?
As noted above, I do not have statistics to back up this up but directionally in-clinic, ~1 in 1000 dry eye patients use a prescription medication (e.g. Restasis) to control their symptoms. In many folks they work wonderfully but my point is that there has to be a high level of motivation to move to Rx meds. All OTC options are generally exhausted before the move is made to Rx meds.
If you have reached this level - speak to your eye care provider. There are two main choices in Canada: Cequa, Restatis.
How prescription drops treat inflammation, not just dryness
Cyclosporine prescription drops (Restasis/Cequa) are used when symptoms are is being driven by ocular surface inflammation, not just a lack of lubrication. They help reduce inflammatory activity on the ocular surface and are approved to increase tear production in certain patients, so the goal is to improve the eye’s underlying inflammatory environment rather than simply “wet” the eye for a few minutes like an artificial tear.
What patients should expect when starting medicated therapy
Improvement is often gradual and may take about 3 to 6 months. This is mostly related to the immune system of the eye turning over approximately every 90 days
Why prescriptions are often combined with at-home treatments
Patients receiving Rx medications for dry eye are recommend to still use Omega 3's, warm compresses and lubrication drops.
9. What In-Office Dry Eye Treatments Do Optometrists Offer?
Many advanced in-clinic dry eye treatments are aimed less at “adding tears” and more at treating the underlying driver, especially meibomian gland dysfunction (MGD), which is a major cause of evaporative corneal issues. In practice, these procedures are usually selected when symptoms persist despite standard home care such as lubricants, lid hygiene, and warm compresses, and the best option depends on whether the main problem is gland obstruction, inflammation, rosacea-related lid disease, or exposure/eyelid abnormalities.
LipiFlow is a form of thermal pulsation treatment. It applies controlled heat to the inner eyelids while simultaneously applying pulsatile pressure to help evacuate obstructed meibomian glands. The goal is to improve the oil layer of the tear film so tears evaporate less quickly. Evidence supports improvement in symptoms and gland function for some patients, although reviews also note that results are variable and that LipiFlow is not always clearly superior to simpler heat-based approaches in every study.
IPL (intense pulsed light) is used mainly for patients with MGD, especially when there is associated ocular rosacea or lid-margin inflammation. It delivers pulses of light to the skin around the lids and is often paired with meibomian gland expression (MGX). The proposed benefits include reducing abnormal peri-lid vessels and inflammation, improving meibum quality, and stabilizing the tear film. Recent systematic reviews and major clinical centers report that IPL can improve symptoms and signs in appropriately selected patients, particularly as part of a broader MGD treatment plan.
Plasma pen / plasma jet treatment is a newer office-based option being used in some clinics for refractory MGD, blepharitis, and lid-margin disease. The concept is that plasma energy may help reduce hyperkeratinization and improve lid-margin function, but compared with IPL and thermal pulsation, the evidence base is still more limited and less standardized. There is at least a registered clinical trial in refractory MGD, and trade/clinic literature is optimistic, but this is the category where clinicians should be especially careful to separate emerging technology from well-established consensus therapy.
How long results typically last
LipiFlow: Results may last several months, and some studies have shown benefit up to 12 months after a single treatment, but durability varies by patient and ongoing lid disease.
IPL: Improvement often builds over a treatment series, and published reviews suggest benefit commonly lasts around 6 months, after which maintenance treatments may be needed. Some studies report longer follow-up, but 6 months is a practical expectation.
Plasma pen / plasma jet: The duration of effect is less well established. Compared with LipiFlow and IPL, there is much less published long-term evidence, and available clinical-trial information mainly supports that it is still an emerging option rather than one with a clearly defined durability window.
References:
DEWS II Study: https://www.tearfilm.org/public/TFOSDEWSII-Executive.pdf
US National Eye Institute: https://www.nei.nih.gov/eye-health-information/eye-conditions-and-diseases/dry-eye/causes-dry-eye
AAO Blepharitis Preferred Practice Pattern: https://www.aao.org/Assets/92ce1735-7c83-45f0-8a58-72997bfc2375/638442007744570000/blepharitis-ppp-2-22-24-pdf
Restasis Insert: https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/050790s020lbl.pdf
https://www.meyespa.com/pages/contact-us
Away from corporate influences and their churn, I believe in time and an unhurried environment. At mEYEspa and my clinic, we are UNcorporate Optometry. I have special interest in occupational vision needs, concussive injury to the visual system and dry eye management. I am the owner of mEYEspa and a dedicated to the delivery of relevant information and clinic-tested eye care products. -Doctor of Optometry - University of Waterloo 1994 -Honors Bachelor of Science – Waterloo 1994 -Registered Ontario College of Optometrists -Member of Ontario Association of Optometrists -Member of Canadian Association of Optometrists -10 year straight winner of 3 Best Rated Optometrists London ON
