Dry eye algorithms from the trenches

Dry eye algorithms from the trenches

By Marguerite McDonald, MD, FACS

In 2012, I wrote in an article that dry eye disease is a primary reason that patients seek our help. It’s four years later and they’re still coming, and will continue in increasing numbers due to changes in our modern lifestyle (increased computer use, more systemic medications, and so on). The following are nuts and bolts algorithms I’ve tweaked along the way, with advice on implementing them.


Tear osmolarity > 295 mOsm/L


    1. Preserved tears QID and PRN: NanoTears (Altaire) and FreshKote (FOCUS Labs) are my absolute favorites in this category; they have all three layers of the natural tear film, including substantial oil and mucomimetic layers. Others that I will recommend include Blink Tears (Abbott), Systane Balance (Alcon) or Refresh Optive Advanced (Allergan).

    2. Nutritional supplements: Usually Tozal* (Focus Labs); NASA designed this formula for astronauts in the space station. The patient takes three soft gels, over a two-minute span, once daily.

*Tozal also contains lutein and zeaxanthin. Also, these are the smallest soft gels available, so seniors shouldn’t fear swallowing them.


Tear osmolarity > 317 mOsm/L

Treatment (all of the above plus the following):

    1. Cyclosporine (Restasis, Allergan) BID OU: I tell patients to open a vial each night, use half, re-cap the vial and instill the other half in the morning before tossing the vial. After nine hours, vials must be disposed of — empty or not — to avoid bacterial contamination, I advise. If a patient is very responsible and financially strapped, I say it’s okay to refrigerate the vial and use it until it is empty.

    2. Lotemax gel (loteprednol etabonate, Bausch + Lomb) QID for two weeks then BID for two weeks: After one month, patients continue with cyclosporine unopposed. Lotemax gel gives immediate relief — either eliminates or reduces — the cyclosporine-associated stinging that some patients feel during the first few weeks of therapy. (On cyclosporine, patients don’t notice improvement for at least one month.) Don’t follow this regimen if the patient has glaucoma.

    3. When the TOT gets >325, switch from preserved to preservative-free tears administered every two, sleep-free hours. Instruct patients to dispose of all open unrefrigerated vials after they have been open for nine hours. Options are:

      • Refresh Optive (Allergan)

      • Blink (Abbott)

      • Systane Ultra (Alcon)

      • Retaine MGD (OCuSOFT) is well suited for those with evaporative dry eye, who comprise the majority of patients. (Unrefrigerated vials must be tossed after they have been open for nine hours.)

I also add Refresh PM or another bland OTC ointment at night, a one-inch strip OU QHS. Though it seems obvious, patients must be told that instilling is the last thing they do before they go to sleep. Tell patients to keep a mirror and the ointment tube on their nightstand; they can instill the ointment without getting out of bed. If they get up during the night, patients should instill another one-inch strip.

These patients should return for a follow-up in four to eight weeks.

Improved but still symptomatic

If the patient is better but still symptomatic or if TOTs are not close to the normal range, add punctal plugs. Oasis Medical Form Fit (Oasis Medical) plugs are one size fits all, and sit below the punctum so they are invisible; no corneal abrasions result from partially dislodged “collar button” style plugs. This brand has not been associated with dacryocystorhinitis, as have some of the other intracanalicular plugs, and they can easily be flushed out with a syringe of BSS when the rare patient needs them removed for epiphora. I usually put in four plugs simultaneously, but if there is any doubt, I start with the lower two and bring the patient back again in another four to eight weeks to see if the upper plugs should be inserted. As mentioned, I try to avoid the classic “collar button” style plugs because they can cause corneal abrasions, but I use them when I need extra-small plugs.


Diagnostic test

Use Sjö test (Bausch + Lomb) laboratory blood test for Sjögren’s syndrome when:

    • TOT scores are 330 mOsm/L or higher on first encounter

    • Males have an initial score of 325 mOsm/L or higher

    • Patient complains of having a dry nose (nose bleeds, and so on), dry mouth and/or dry vagina

    • Compliant patients do not respond to their treatment regimen in the expected fashion.

This is a blood test that is performed at a LabCorp facility, though in spring 2016, Quest will also offer it. A positive test means the ophthalmologist must go at least one level higher on the treatment algorithm, as these patients are more resistant to treatment. Share positive test results with the patient’s primary care physician and dentist. Patients also should be followed by a rheumatologist, as many organ systems could be involved. Their chance of developing non-Hodgkin’s lymphoma is 19 times greater than in the general population.

Intractable dry eye

High TOT scores, filamentary keratitis and/or severe symptoms in spite of maximum treatment.


Autologous serum tears: The serum tears are made from the patient’s own blood and loaded with growth factors that help the cornea heal. They are unpreserved and must be kept cold, so patients carry a small cooler with them or tuck their serum tears into the small Frio cold pack that diabetics use to keep insulin syringes cold.

ProKera Slim (Bio-Tissue) amniotic membrane: Patients wear this contact lens-like device for five to seven days on one eye before it is removed; a fresh one then is placed on the second eye. It is placed sequentially because vision drops by several lines while it dissolves. Another pair is not usually required for months or years. (see related story, page 41.)

Other, more exotic treatments (topical tacrolimus, Aczone [dapsone, Allergan] clindamycin, Flagyl, [metronidazole, Pfizer]) are best managed by a cornea specialist.


The treatments for anterior and posterior blepharitis overlap substantially, so I will use the term “blepharitis” unless specified. Some blepharitis symptoms are typical (especially burning, often worse in the morning), but many overlap with other ocular surface diseases, including dry eye. To make matters more confusing, blepharitis either causes or exacerbates most cases of dry eye: 86% to 92% of dry eye patients have evaporative dry eye due to meibomian gland disease.

To identify the patient’s stage of blepharitis, I use the classification published by the International Workshop on Meibomian Gland Dysfunction (MGD) in 2011 (information and pictures are available at Until your doctors become familiar with this scheme, post pictures of each stage above a desk in each exam lane. This can be very helpful in increasing consistency of how you grade blepharitis. The doctors can also point to these images while instructing the patient on the diagnosis and treatment plan.

For each patient, even those with no symptoms, firmly press the middle third of both bottom lids with the index finger while at the slit lamp to determine if the glands are normal (a small amount of clear fluid is expressed), engorged with altered meibum, or scarred shut. This maneuver takes only three seconds per eye and is indispensable for diagnosing MGD.



Hot soaks and scrubs twice a day. A warm wet washcloth, wrung dry, rubbed over closed lids for two minutes loosens the altered meibum and/or lid scurf so that the scrubs (with disposable OTC pads or sheets soaked in nontoxic lid shampoo formulated for this purpose) are more effective. Demonstrate the proper scrubbing technique, which requires a bit of dexterity, full range of shoulder motion and coordination. For patients who are allergic to the scrub pads or cannot execute the scrubbing maneuver (due to arthritis, stroke, and so on), I recommend they scrub twice daily with OCuSOFT foaming gel cleanser. The patients pump the foam onto clean hands and work it into the lid margins with their index and middle fingers.

Treatment: Omega 3 nutritional supplements


Treatment (all of the above plus the following):

Azithromycin 1% solution (AzaSite, Akorn) into the lid margins BID just after soaks and scrubs BID: If the patient’s insurance does not cover AzaSite, I have the patient use erythromycin ointment, especially when simultaneously treating dry eye. I instruct patients to apply a one-inch strip of erythromycin ointment in both eyes at night and another two strips if they get up in the middle of the night.

Liposome spray: Tears Again Advanced Liposome spray (OCuSOFT) is the only liposome spray available domestically. Instruct patients to gently close the lids and administer two pumps of the spray over each eye from a distance of about 10 inches; then rub into their lid margins.

LipiFlow: I usually advise this during the follow-up visit, which occurs four to eight weeks later. Patients who are adherent but who are still symptomatic, or patients who hate the regimen outlined above, are the two groups that are receptive to thermal pulsation therapy (see below).


Treatment (all of the above plus the following):

Doxycycline hyclate 50 mg QD PO: Document that female patients are not pregnant or planning on getting pregnant, as doxycycline can cause the infant to develop small brown teeth. Instruct the patients to take the doxycycline with food or drink at roughly the same time every day, but not within one hour of consuming dairy. Also, tell patients on doxycycline to wear a hat, a shirt/cover-up and sunblock while enjoying the sun.


Treatment (all of the above plus the following):

Start the doxycycline at 50 mg or 100 mg BID for 10 days, then 50 mg once daily.

Soaks and scrubs four times a day.

On their return visit three months post-treatment, the patients usually have improved symptoms, improved BCVA, improved slit lamp findings and their tear osmolarity scores have dropped (improved) substantially. OM


Since 86% of dry eye patients are also blepharitis patients,1 the combined regimens are challenging, in terms of the time and financial investments. When explained properly, many patients see the wisdom in having a LipiFlow treatment.

I tell patients that the LipiFlow effect lasts approximately one year, with a range of six to 36 months, as reported in LipiFlow literature. Bigger selling points are that LipiFlow can: help many patients get back into their contact lenses; prepare them for LASIK or cataract surgery; or “stack the deck” so they get accurate preoperative measurements with an even lower chance of a postoperative infection.

On the day of the treatment, I use a hockey stick blade to gently debride the lid margin to remove the thin fibrovascular membrane that often occludes the orifices of the meibomian glands. Post-treatment, I prescribe Lotemax gel QID OU for one week, which also enhances the effect.

I provide a list of what to jettison from their regimen, one item each month, and see them back at three months post-treatment.

For instance, I tell stage-four patients that if they feel well one-month post-treatment, they can try stopping the doxycycline. The second month, they can try dropping the morning dose of AzaSite; the third month, the evening dose. The fourth month, they can try dropping the morning soak and scrub. I always tell patients that there is patient-to-patient variability in how they will respond to treatment, so if they begin to feel poorly, they should add back the last thing they dropped.

Also, explain that while they will feel a little better each day after the LipiFlow treatment, it will take six months before they reach maximum benefit.

On their return, patients often have improved best-corrected vision and much-improved tear osmolarity scores. Sharing these landmarks with the patients reinforces their decision to have the LipiFlow treatment.


1. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous deficient and evaporative dry eye in a clinic-based patient population. Cornea. 2012 May;31:472-478.

About the Author

Marguerite McDonald, MD, is clinical professor of ophthalmology at NYU Langone Medical Center in New York, NY. She is also an adjunct clinical professor of ophthalmology at Tulane Health Sciences Center, New Orleans, LA and cornea/refractive/anterior segment specialist with Ophthalmic Consultants of Long Island, Lynbrook, NY. Dr. McDonald performed the first laser vision correction procedure in 1988.