I get a lot of questions—especially about "dry eye". By far the most common is some variation of what treatments do I use and when do I use them? I usually start by explaining that the answer isn’t that simple. After years of almost exclusively focusing on "dry eye", I’ve come to realize that successfully treating a "dry eye" patient is like putting together a giant jigsaw puzzle—no two puzzles are the same. Thankfully, there are some commonalities among patients that can make things easier, especially if you have some idea of what you are aiming for and then figure out how to accomplish it.

Starting at the beginning, current thinking suggests that "dry eye" represents a failure of the ocular surface environment to maintain homeostasis. Simple as that sounds, the reality is that it is far more complicated than any of us can fully understand. As best as I can explain it, a "dry eye" is caused by an ocular surface that is out of balance. The imbalance manifests as discomfort, variable vision, excessive tearing, chronic redness and other unsettling signs or symptoms. While we may be able to identify underlying pathophysiology, treating the cause alone is just not enough. Patients don’t experience causes, they suffer from effects.

Of the many ways the body has to manage imbalance, inflammation is among the most common. This isn’t new news, but ocular surface inflammation is often overlooked and frequently misunderstood. Does that mean that every patient should be treated with a steroid? Not quite. For some yes, as steroids like loteprednol, can be very effective, but even the safest are not completely safe for long-term chronic use. Thankfully, modern pharmacoengineered medications like lifitegrast can safely and effectively squelch ocular surface inflammation for the overwhelming majority of "dry eye" patients. So, is this modern miracle molecule a cure for "dry eye"? Not exactly, but it is an effective treatment for its signs and symptoms, alleviating at least some of the misery associated with this chronic and often progressive disease.

Yes, I know. MGD is, by far, the most common cause of "dry eye". I relentlessly diagnose and treat MGD, as do many of you. Still, the astute clinician realizes that myriad other factors can play significant roles in the "dry eye" puzzle. Regardless of cause or complicating factor, when it comes to "dry eye", it is increasingly apparent that all roads either lead to or pass closely by inflammation.

Arthur B. Epstein, OD, FAAO Chief Medical Editor artepstein@optometricphysician.com