When eye drops are not enough - Next Steps for Dry Eye Management

Dry eye is a chronic condition that requires active management.  It can be frustrating to have success limiting 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

Environmental change - Fluctuations in seasonal humidity play a significant role in triggering flare-ups. If you have been effectively controlling your symptoms by using eye drops twice daily, a decrease in humidity during the fall can often require an adjustment in your routine. For instance, during the winter months, you might find it necessary to apply your drops three to four times a day to keep your symptoms in check. Then, as the spring rains arrive and humidity levels rise again, reducing your usage back to twice daily may once more be sufficient to manage your ocular surface concerns effectively.  

Changing seasons also bring environmental sensitivities and allergies like pollens and countless airborne antigens. 

Blepharitis - Inflammation or infection of the eyelid can significantly disrupt your plans. In some cases, blepharitis is the primary cause of dry eye, while in other instances, it occurs alongside dry eye and worsens a condition that is otherwise being effectively managed. Understanding this distinction is crucial for developing appropriate management strategies and ensuring better outcomes for patients dealing with these eye conditions.

Condition progression - The condition can unfortunately just get worse with birthdays and time.

New concurrent condition - This could be either an unrelated eye-related issue or a broader systemic condition. Conditions such as diabetes, rosacea, and certain autoimmune diseases can interfere with the normal chemistry of the tear film, causing complications. Additionally, a viral eye infection caused by the common cold virus will almost certainly interrupt any ongoing intervention aimed at managing the ocular surface.

Eye Drop change - This seems like an obvious one but this conversation happens weekly in the clinic.

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?

Dry eye disease is a long-lasting condition that needs continuous care and treatment. Management options may include over-the-counter eye drops, prescription medications, Omega-3 supplements, warm compresses, or frequently a combination of these approaches. However, it is important to understand that none of these interventions completely eliminate the condition in the way that an antibiotic can fully cure an infection.

Are artificial tears only temporary relief?

There is therapeutic value in artificial tears.   Ongoing intervention 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?

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 Management".   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 topic remains controversial. As mentioned earlier, the evidence regarding the impact of preservative-containing eye drops on the eye's surface is inconclusive. For patients with a compromised cornea due to poor tear film chemistry, I advise them to be cautious and avoid using any eye drops that are both used frequently and contain preservatives. Taking this precaution helps to minimize potential risks and protect the delicate surface of the eye.

Why redness-relief drops can make dry eye worse

See this Blog post on Safe Eye Whitening

Before using any eye whitener, it is crucial to first identify and address any underlying causes of persistent red eyes rather than simply using a product like Lumify to conceal the symptoms. Conditions such as dry eyes, eyelid problems, or infections can all lead to redness, and in these cases, Lumify is not recommended and should be avoided. It is important to consult with an eye care professional to receive proper diagnosis and advice tailored to your specific situation.

---

4. What Are the First Support 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.) consistently, 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 Supporting Eyelid Health 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.