Clinical Pearls from Dry Eye in the Desert!
Woo University’s fifth Dry Eye in the Desert hybrid event was a raging success, filled with unique courses focused on the important topic of dry eye. Leading industry experts shared clinical tidbits and unparalleled insight into the dry eye space. The event was available in person and online, providing an intimate space for dialogue for those who could make it out to Phoenix as well as accessibility to those who were unable to attend in person via zoom’s online platform.
In Dr. Blair Lonsberry’s, “The Eye of the Storm: Understanding Ocular Allergies,” the role that allergies play in ocular surface disease was thoroughly addressed. The presentation explains the role of histamine and mast cell activation in allergic responses and outlines various treatment options, including OTC and prescription medications.The two most commonly encountered allergic eye conditions would be acute presentations such as seasonal allergic conjunctivitis and perennial allergic conjunctivitis. However, chronic allergic conditions such as vernal conjunctivitis, atopic conjunctivitis, and giant papillary conjunctivitis should be considered as differential diagnoses. Some hallmark signs of any allergic condition include itching, redness, chemosis, tearing, and lid swelling. Dr. Lonsberry provided a detailed overview of medications used to treat ocular allergies, categorized into different classes based on their mechanism of action and . The following was discussed:
1. OTC and Prescription Medications
A. Vasoconstrictors (Ocular Decongestants)
Mechanism: Alpha-adrenergic agonists that constrict blood vessels to reduce redness.
Examples:
○ Tetrahydrozoline HCl (Visine Maximal Redness Relief, Opt-Clear)
○ Naphazoline HCl (Naphcon, AK-Con, ClearEyes)
○ Phenylephrine HCl (Prefrin, Neofrin)
○ Oxymetazoline HCl (Visine L.R., OcuClear)
Limitations: Short duration (<2 hours), rebound hyperemia, and do not relieve itching.
Side Effects: Stinging, blurring, potential intraocular pressure (IOP) fluctuations, contraindicated in narrow-angle glaucoma.
B. Antihistamines
Mechanism: H1-receptor antagonists that block histamine to relieve itching and swelling.
Examples:
○ First-Generation (shorter duration, more side effects): Pheniramine (found in Naphcon-A, Opcon-A, Visine-A).
○ Newer H1 Antihistamines (longer duration, fewer side effects):
■ Levocabastine (Livostin)
■ Emedastine (Emadine)
■ Bepotastine (Bepreve)
● Benefits: Faster relief for ocular symptoms compared to oral antihistamines.
● Limitations: Dry mouth, blurred vision, and other systemic side effects.
C. Mast Cell Stabilizers
● Mechanism: Prevent mast cells from releasing histamine, reducing allergic inflammation.
● Examples:
○ Cromolyn Sodium (Generic 4%)
○ Nedocromil (Alocril)
○ Lodoxamide (Alomide, 2500x more potent than Cromolyn)
○ Pemirolast (Alamast)
● Usage: Requires consistent use before full effects; best for chronic allergy prevention.
D. Dual-Action Drugs (Antihistamine + Mast Cell Stabilizer)
● Mechanism: Provide immediate relief by blocking histamine while also preventing future allergic reactions.
● Examples (OTC and Prescription):
○ Olopatadine (Pataday 0.1%, 0.2%, 0.7%)
○ Bepotastine (Bepreve)
○ Alcaftadine (Lastacaft)
○ Cetirizine (Zerviate)
○ Ketotifen (Zaditor, Alaway)
○ Azelastine Hydrochloride
E. NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)
● Mechanism: Inhibit COX enzymes, blocking prostaglandin synthesis to reduce inflammation and itching.
● Examples:
○ Ketorolac (Acular, commonly used for short-term relief)
○ Diclofenac (Voltaren)
● Limitations: Less effective than antihistamines for allergy symptoms, may cause stinging.
F. Corticosteroids (Steroids)
● Mechanism: Strong anti-inflammatory agents that inhibit histamine release and immune cell activity.
● Examples:
○ Ketone-Based:
■ Prednisolone (Pred Forte, Pred Mild) – Most effective but highest side effect risk.
■ Dexamethasone (Maxidex) – Strong but with higher IOP risk.
■ Rimexolone (Vexol) – Used for post-op inflammation.
○ Ester-Based ("Soft Steroids") (Safer with fewer side effects):
■ Loteprednol (Alrex, Lotemax, Eysuvis, Inveltys)
○ Newer Stronger Steroids:
■ Difluprednate (Durezol) – More potent than Pred Forte, but high IOP spike risk.
● Limitations: Long-term use can lead to cataracts, glaucoma, and delayed wound healing.
● Contraindications: Not used alone in bacterial/fungal infections, significant corneal epithelial defects, or uncertain diagnoses.
2. Oral Medications
A. First-Generation Oral Antihistamines
● Examples:
○ Mild Sedation: Brompheniramine, Chlorpheniramine (Chlor-Trimeton)
○ Moderate Sedation: Clemastine
○ Strong Sedation: Diphenhydramine (Benadryl), Promethazine (Phenergan)
● Side Effects: Drowsiness, dry mouth, blurred vision. Used more for nighttime symptom relief.
B. Second-Generation Oral Antihistamines (Less Sedating, Longer-Lasting)
● Examples:
○ Fexofenadine (Allegra)
○ Loratadine (Claritin), Desloratadine (Clarinex)
○ Cetirizine (Zyrtec), Levocetirizine (Xyzal)
● Benefits: Fewer side effects than first-generation.
● Limitations: If one doesn’t work, switching to another may help.
3. Intranasal Medications
● Examples:
○ Fluticasone Propionate (Flonase) – Provides some ocular allergy relief, but not as effective as eye drops.
● Best Use: Combined with ophthalmic drops for improved results with fewer systemic effects.
4. Systemic Steroids (Oral & IV)
● Used for Severe Inflammatory Conditions
○ Examples:
■ Prednisone (Oral, commonly used by optometrists)”
■ Methylprednisolone (Medrol Dose Pack, IV for severe cases)
○ Indications:
■ Posterior segment inflammation, optic neuritis, uveitis, scleritis, and severe allergic reactions.
○ Side Effects:
■ Weight gain, osteoporosis, hyperglycemia, fluid retention, mood changes.
○ Tapering Needed: To prevent rebound inflammation and adrenal insufficiency.
You can find Dr. Blair Lonsberry's handouts click below:
In Dr. Kramer’s presentations, “Managing the Dry Eye and Lid Disease Spectrum: Acute, Chronic, and Complex Cases” and "Unlocking Eye Beauty’s Growth Potential: Ocular Aesthetics for Optometric Practice,” an in depth overview of dry eye disease and lid disorders are addressed. Dr. Kramer provides a broad view into the dry eye space, providing solutions for both acute dry eye and more severe cases. Dry eye disease is classified as a multifactorial condition that is often associated with discomfort, redness, and epiphoria. Treatments can range from artifical tears and steroids for acute cases to in-office procedures like gland expression, punctal occlusion, and scleral lenses for chronic conditions. Education and personalized treatment plans should be prioritized for long term management and prevention. Dr. Kramer goes on to expand the world of dry eye by including that of ocular aesthetics. This provides an exciting new avenue for management of these conditions. The development of new treatment options such as Intense Pulsed Light (IPL), Radiofrequency (RF), Low-Level Light Therapy (LLLT), and Microblepharoexfoliation offer both medical and aesthetic benefits. Integrating these treatments into an optometry practice significantly enhances both practice growth and patient success. Unlike temporary solutions like artifical tears, theses non-invasive procedures provide lasting improvements in ocular health and comfort while simultaneously offering aesthetic benefits such as stimulating collagen production. The inclusion of cash-pay aesthetic services assists in diversifying revenue streams while reducing dependence on insurance reimbursements. These services encourage repeat visits and increases patient retention. By incorportating these techniques into practice, eye care practitioners position themselves as leaders in dry eye management and can attract a larger patient base.
The following is a comparison of Intense Pulsed Light (IPL), Radiofrequency (RF), Low-Level Light Therapy (LLLT), and Microblepharoexfoliation based on Dr. Kramer’s presentation:
1. Intense Pulsed Light (IPL)
● Primary Use: Treats dry eye disease, MGD, ocular rosacea, and periocular aesthetics.
● Mechanism: Broad-spectrum light targets abnormal blood vessels (telangiectasia) to reduce
inflammation and redness.
● Benefits:
○ Improves tear film stability and meibomian gland function.
○ Reduces ocular rosacea, redness, and inflammation.
○ Stimulates collagen production, enhancing periocular skin tone.
● Treatment Plan:
○ Typically 4-6 sessions spaced 2-4 weeks apart.
○ Maintenance every 6-12 months.
● Considerations:
○ Avoid sun exposure before/after treatment.
○ Not recommended for darker skin tones (Fitzpatrick V-VI).
2. Radiofrequency (RF)
● Primary Use: Enhances gland function, skin tightening, and collagen production.
● Mechanism: Controlled heat liquefies thickened oils in meibomian glands, improving secretion and tear film stability.
● Benefits:
○ Treats MGD and dry eye disease.
○ Stimulates collagen and elastin production for skin tightening and wrinkle reduction.
○ Provides a natural lifting effect, reducing eyelid laxity.
● Treatment Plan:
○ Requires 3-4 sessions spaced 1-4 weeks apart.
○ Maintenance every 4-6 months.
● Considerations:
○ Can be combined with other dry eye and aesthetic treatments.
○ Safe, non-invasive, minimal discomfort, no downtime.
3. Low-Level Light Therapy (LLLT)
● Primary Use: Targets inflammation, ocular surface stress, and periocular rejuvenation.
● Mechanism: Uses red and near-infrared wavelengths to reduce pro-inflammatory cytokines and improve ocular surface health.
● Benefits:
○ Enhances meibomian gland function and tear film stability.
○ Promotes cellular repair, wound healing, and tissue regeneration.
○ Stimulates ATP production, increasing energy for healing.
● Treatment Plan:
○ 3-4 sessions spaced 1-2 weeks apart.
○ Maintenance every 4-6 months.
● Considerations:
○ Non-invasive, painless, and suitable for chronic dry eye sufferers.
○ Can be combined with IPL, RF, or thermal pulsation for enhanced results.
4. Microblepharoexfoliation
● Primary Use: Removes bacterial biofilm, debris, and Demodex mites from the eyelid margins.
● Mechanism: Gently exfoliates the eyelids using a specialized device to clear collarettes,
blockages, and inflammation.
● Benefits:
○ Improves eyelid hygiene and meibomian gland function.
○ Reduces blepharitis, eyelid redness, and irritation.
○ Enhances tear film quality and dry eye relief.
● Treatment Plan:
○ 1 initial session, followed by maintenance every 4-6 months.
○ Severe cases may require additional treatments.
● Considerations:
○ Ideal for blepharitis, MGD, Demodex infestations, and contact lens discomfort.
○ Quick, non-invasive, and improves both eye health and aesthetics.
