Ocular surface disease (OSD) is a double threat, inducing chronic discomfort and hindering vision, the latter of which complicates every corrective method we have. The result: spectacle remakes, contact lens drop-out and post-cataract surgery dissatisfaction. It’s important to properly treat all types of OSD, especially those that may not be on your radar. We discuss them below, along with effective treatments and new drugs on the horizon that could give your patients much-needed relief.

Mucin-deficient Dry Eye

Although we treat lipid-deficient and aqueous-deficient dry eye, many of us exclude mucin deficiency as a third potential subtype. I believe there are three stages to this form:

(1) conjunctival staining

(2) staining with mucin strands

(3) filamentary keratitis

If a patient exhibits staining, start with a short course of steroids. Vitamin A ointment Qhs (Hylo Night, Optase) is surprisingly effective for goblet cell recovery. Immunomodulators (e.g., lifitegrast, cyclosporine) have been shown to aid goblet cells, and biologic drops are quite helpful. These include autologous serum (Vital Tears) and cytokine-extract drops (Regener-Eyes). Amniotic membrane (BioTissue, Atlas) would only apply in the presence of filamentary keratitis, although a 15mm version could assist with conjunctival staining. In non-responsive filamentary keratitis, consider compounding acetylcysteine 10% drops TID, which has a bad odor but can dissolve mucin.


To identify this condition, look closely at the eyelids for telangiectasia, tylosis or capped glands, and become proficient at meibomian gland expression. Also, have the patient gaze down and scan the base of the upper lashes looking for collarettes, which are pathognomonic for Demodex blepharitis.

New to market is MyboClean, a brush and lid spray that combines aloe, coconut oil and Manuka honey (known to have antimicrobial, antiparasitic and anti-inflammatory properties). BlephEx in-office treatments, IPL and low-level light therapy have also shown efficacy. 

A therapeutic candidate known as TP-03 (Tarsus Pharmaceuticals) is showing almost complete eradication of the Demodex mite with BID dosing for six weeks. Given the strong clinical data and safety profile, this drug could receive FDA approval next year.

Omega Fatty Acids

If someone told me there is a nutritional supplement that could effectively treat dry eye disease, I would be skeptical. Having treated over 1,200 patients with a gamma-linolenic acid (GLA)/fish oil combination (HydroEye, SBH), I’m convinced it exists. Every day I have patients without symptoms that are only using hydrating compresses (Bruder), lid scrubs (OcuSoft) and HydroEye. They comment on the noticeable difference and, should they stop using HydroEye, their symptoms return quickly. But don’t rely on my experience: a GLA/fish oil combination has more studies on its efficacy than any other omega supplement to date, including positive results in aqueous-deficient DED, post-PRK DED, SS-KCS, contact lens intolerance, MGD and post-menopausal DED.1-7

Mask-associated Dry Eye

Lately, we’ve been seeing a significant increase in not only hordeola and chalazia, but also blepharitis, DED and even conditions like recurrent corneal erosion (RCE). The key is to perform the Korb-Blackie lid light test. Patients who show inadequate lid closure are developing more DED and even RCE. I personally have suffered from recalcitrant RCE for more than 25 years; I’ve had more recurrences since masks were introduced than over the last 20 years combined. That doesn’t mean I won’t wear a mask to see patients, but we need to be aware of the effects of redirected air flow on our patients.

OSD comprises the largest patient population an OD will see. Fortunately, our talents and our treatments continue to keep pace with today’s needs.

Dr. Karpecki is medical director for Keplr Vision and the Dry Eye Institutes of Kentucky and Indiana. He is the Chief Clinical Editor for Review of Optometry and chair of the New Technologies & Treatments conferences. A fixture in optometric clinical education, he consults for a wide array of ophthalmic clients, including ones discussed in this article. Dr. Karpecki's full list of disclosures can be found here. 

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2. Macri A, Giuffrida S, Amico V, et al. The effect of LA and GLA on tear production, tear clear-ance and on the ocular surface after PRK surgery. Graefes Arch Clin Exp Ophthalmol. 2003;41:561-6.

3. Aragona P, Bucolo C, Spinella R, et al. Invest Ophthalmol Vis Sci. 2005;46(12):4474-9.

4. Kokke KH, Morris JA, Lawrenson JG. Contact Lens Anterior Eye. 2008;31(3):141-6.

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7. Sheppard JD, Singh R, McClellan AJ, et al. Cornea. 2013;32(10):1297-1304.