Dry Eye Disease: Prescription Drop Strategy
When artificial tears are not enough
Non-preserved artificial tears can dilute inflammatory mediators and provide short-term symptom relief, but they do not reliably address the underlying drivers of moderate to severe dry eye disease (DED). In many patients, DED behaves as a chronic, multifactorial inflammatory condition. Prescription therapy aims to reduce surface inflammation, stabilize the tear film, and support the lacrimal functional unit, in parallel with mechanical and environmental measures.
Start with the dominant mechanism
DED management is most effective when it is mechanism-based. Document whether signs and symptoms point primarily to aqueous deficiency, evaporative disease from meibomian gland dysfunction (MGD), or a mixed picture. Many patients have overlap, so treatment plans often combine an anti-inflammatory maintenance drop with targeted evaporative support, plus eyelid therapy and practical habit changes.
Immunomodulators for long-term control
Topical immunomodulators are a foundation for long-term pharmacologic management in aqueous-deficient or mixed DED. Their role is to down-regulate T-cell mediated inflammation affecting the lacrimal functional unit and ocular surface.
- Cyclosporine A formulations: Calcineurin inhibitors (for example, cyclosporine 0.05% and 0.09%) reduce T-cell activation and cytokine release, with the goal of improving basal tear production and surface integrity over time. Clinical improvement is gradual, so counseling should set expectations that meaningful change may take several months of consistent twice-daily use.
- Lifitegrast: An LFA-1 antagonist that interferes with T-cell adhesion and activation. Many patients report earlier symptom change than with traditional cyclosporine, sometimes within a few weeks, though sustained benefit still depends on regular ongoing dosing.
Choice between agents is guided by symptom profile, surface findings, prior response, tolerability, and formulary or coverage considerations. There is rarely a single best option for every patient.
Evaporative disease and MGD-focused therapy
In evaporative DED driven by MGD, improving the lipid layer is central. Lid hygiene, heat-based therapies, and in-office options are often paired with medications that reduce evaporation. Perfluorohexyloctane is a water-free drop designed to spread across the tear film and reduce evaporative loss. It is commonly positioned as an adjunct for patients with DED associated with MGD rather than a replacement for inflammation-directed maintenance therapy when inflammation or aqueous deficiency is also present.
Short-term steroid induction and flare control
Because immunomodulators act over weeks to months, many clinicians use a brief course of a soft topical steroid (for example, loteprednol or fluorometholone) as induction when starting long-term therapy or during symptomatic flares. A short taper can reduce surface inflammation, improve comfort, and enhance tolerance of the maintenance drop. As with any steroid, intraocular pressure monitoring and clear instructions about duration and taper matter.
Follow-up and realistic timelines
Prescription drops work best within a structured plan. Set expectations for timeline, document baseline signs, and schedule follow-up to reinforce adherence and adjust therapy. Treatment can be escalated or simplified as the ocular surface stabilizes, especially when eyelid therapy, environment, and systemic contributors are addressed in parallel.