Disclosures: Matossian reports she is a consultant to Johnson & Johnson, TearLab, Quidel, Bruder, Sun Pharma, Sight Sciences, Bausch + Lomb, Kala, Novartis, Allergan, BlephEx, NuSight and Alcon.
August 18, 2020
5 min read

Dry eye disease: Algorithms come of age

Evidence-based strategies supported by point-of-care testing and stepwise, combination therapy have taken caring for the ocular surface to a new level.

Disclosures: Matossian reports she is a consultant to Johnson & Johnson, TearLab, Quidel, Bruder, Sun Pharma, Sight Sciences, Bausch + Lomb, Kala, Novartis, Allergan, BlephEx, NuSight and Alcon.
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Not too long ago, patients who complained of dry eye disease symptoms were thought of as difficult or picky. Today, it is a whole new landscape as much work has been done to further our understanding of the etiology and consequences of DED.

DED can become worse after surgery and has been shown to affect preoperative measurements, and both factors contribute to postsurgical dissatisfaction.

Now, we are fortunate to have access to a growing number of evidence-based diagnostic tests and treatment modalities clinically proven to improve bothersome symptoms for our patients.

Cynthia Matossian
Cynthia A. Matossian

Although DED is a complex and multifactorial disease, an approach to DED identification and treatment can be structured in a straightforward and stepwise fashion. Here is my simple diagnostic and treatment approach, each resting on four pillars.

These are the four diagnostic pillars I apply to all of my patients.

1. Questionnaire

The first pillar is good history taking. To streamline this aspect for our busy clinic, we have narrowed down our questionnaire to three essential questions:

  • Does your vision fluctuate?
  • Do your eyes feel tired?
  • How often do you use artificial tears?

2. Osmolarity

I perform tear osmolarity testing (TearLab), noting trends over time. I also consider the intereye difference, which reflects tear film instability. Lack of tear film homeostasis can affect the accuracy of refractive diagnostic data used in surgical planning.

3. Inflammation

I perform testing with InflammaDry (Quidel) to identify the presence of the inflammatory biomarker MMP-9. If this test is positive, then I will always notch up my level of treatment to the next step. It is important to be aggressive if inflammation is present.

4. Meibography

I want to see the meibomian glands of each of my patients because that provides information regarding tear and lipid quality and quantity, directing my treatment choice. I use Dynamic Meibomian Imaging (LipiView, Johnson & Johnson Vision) to assess gland structure and functionality, ascertaining if intervention is appropriate.

Based on information gathered from my four diagnostic pillars, I apply my treatment pillars.

1. Education

Ultimately, if patients do not understand that they have a chronic progressive disease, they are not going to buy in to my recommendations, and there is little hope for compliance with cash-pay treatments and multilayered regimens. The key is education, which enables patients to understand their DED will not get better on its own nor with artificial tears alone. This is the biggest hurdle as well as the most time-consuming aspect of managing ocular surface disease patients.


Leveraging test results as teaching tools is one effective educational strategy. With meibography, I show patients their glands and contrast them to healthy ones. If they have a positive MMP-9 test, I hand them the test stick with the red stripe. I write down their tear osmolarity number on a small business card and give it to them as evidence.

2. Good tears

I counsel patients regarding appropriate artificial tears. Many take their anti-allergy drops — antihistamines and mast cell stabilizers — thinking that they are artificial tears, thereby potentially exacerbating their disease.

3. Omega essential fatty acids

As increasing dietary intake of omega fatty acids has been shown to help improve lid health and the quality of oil secretions, I recommend good-quality oral omega supplements to my patients.

4. Heated moisture mask

I have patients use a heated microwavable moisture mask (Bruder). Applying daily heat with the mask maintains proper meibum viscosity in the meibomian glands as more of an olive oil liquid consistency instead of allowing it to thicken and risk inspissation.

The above treatments work synergistically to extend the value of other in-office treatments I may recommend.

Customization based on level of disease

I customize the treatment based on the severity of disease, the presence of inflammation as shown in MMP-9 testing and the amount of defenestration of the meibomian glands. With inflammation, my treatment includes a prescription pharmaceutical product such as Xiidra (lifitegrast ophthalmic solution 5%, Novartis), Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) or Cequa (cyclosporine ophthalmic solution 0.09%, Sun Pharma). I may perform a mechanical treatment to heat and remove impacted old meibum from the glands, such as LipiFlow (Johnson & Johnson Vision), TearCare (Sight Sciences) or iLux (Alcon).

If the blood vessels along the eyelid margin are dilated, with telangiectatic small vessels along the eyelid margin, I recommend intense pulsed light (IPL) treatment. The photobiomodulation effect of IPL closes off abnormal blood vessels, which, in turn, improves gland health and meibum quality.

Patients with anterior blepharitis or excess biofilm buildup on their lid margins may benefit from an in-office microblepharoexfoliation treatment (BlephEx) performed by a physician or a trained technician. According to anecdotal reports, microblepharoexfoliation, if performed in conjunction with LipiFlow, TearCare, iLux or IPL, works synergistically to achieve improved ocular surface health. Thereafter, lid scrubs with foams, packaged cleanser towelettes or with an oscillating hand-held device (NuLids, NuSight Medical) can be recommended for daily at-home maintenance.

Often, patients need both pharmaceutical and mechanical treatments. Using the dental hygiene model, I tell patients to think of one therapy as the daily brush and floss (a topical eye drop and lid scrubs) and the other as the deep clean (an in-office procedure I might have to repeat once or twice a year depending on disease severity and patient compliance).



There is no magic wand or pill that makes dry eye disease disappear. I tell my patients that we have to work as a team: I assure them that I will do my best to help them, and in turn, they have to do their part by adhering to their prescribed daily regimen. I stack therapy options until the patient is comfortable and I have objective data that the disease is well managed.