“I want to understand the connection between dry eyes and inflammation and how it contributes to my ongoing discomfort.”
“I've tried various treatments for my dry eyes without success, and I suspect inflammation might be a contributing factor.”
“I know that inflammation can exacerbate dry eye symptoms, but how can I address it effectively?”
Many of my patients who come into our Denver office are experiencing persistent discomfort and irritation in their eyes and want to know if there is a connection between dry eyes and inflammation.
Inflammation is a major cause of dry eye disease but that does not mean that everyone with dry eye has inflammation. This can lead to frustration as the mainstay of dry eye treatment involves treating inflammation, but unfortunately, these treatments are not effective for everyone and can be very expensive. Fortunately, we have a quick, easy and affordable point-of-care test called InflammaDry® that can tell us if inflammation is present.
This is crucial to determining an effective treatment regimen. If the InflammaDry test comes back negative, it does not make sense to treat patients with anti-inflammatories, but often these are the first line of treatment for dry eye disease. Likewise, if a patient has significant inflammatory mediators in their tear film, treatments like punctal occlusion can worsen symptoms.
The connection between your immune system and your eyes is intricate. Inflammation, which is your body's reaction to injuries and infections, is meant to be a short-term fix but can become chronic. Having dry eyes will worsen inflammation and this is the reason medical professionals often refer to dry eye disease as a "vicious cycle of inflammation."
Determining the underlying cause of inflammation can be trickier, but when we find inflammation, we know treatment with anti-inflammatories is beneficial
Inflammation may be caused by decreased tear production, autoimmune diseases, allergies, rosacea, Staphylococcal or Demodex blepharitis, “pink eye” or viral conjunctivitis.
Sometimes, a short course of steroid therapy can help ease symptoms. We’ll look at long-term treatment of inflammation in the next section.
There are different types of anti-inflammatory treatments available:
Steroid Eye Drops
Corticosteroids are widely used in the treatment of allergic and inflammatory conditions. Steroids profoundly affect the inflammatory response by way of vasoconstriction (shrinking blood vessels) and decreased movement of immune cells into tissue. They don’t come without risk, however; extensive use of corticosteroid eye drops can lead to problems like high eye pressure and cataracts, although some steroid eye drops are much safer than others and can be used long term if needed under close physician supervision.
Non-Steroid Anti-Inflammatories
Cyclosporine and lifitegrast are the mainstay of non-steroidal anti-inflammatories used to treat dry eye. Cyclosporine is not soluble in water, making it difficult to formulate. Initially it was formulated in castor oil, but that caused blurred vision and was not well tolerated. Cyclosporine works as an immunosuppressant by inhibiting calcineurin, an activator of T-cells (a type of white blood cell that helps fight infections). It halts the inflammatory cascade in the conjunctiva by stimulating natural tear production and increasing goblet cell density (production and secretion of mucins that lubricates the ocular surface).
Restasis was the first medication approved by the FDA to treat dry eye disease. It is in an oil-in-water emulsion with 0.05% cyclosporine. The most common side effect is burning. Clinical studies have shown an increase in Schirmer’s and decrease in corneal staining at 6 months.
Essentially, 6 months were needed for Restasis to be fully effective so efforts were made to improve drug penetration and effectiveness and decrease side effects such as stinging.
Xiidra (lifetegrast) was the second medication FDA approved for the treatment of dry eye in 2016. It also inhibits T-cell activation. The effectiveness was studied in 4 randomized, controlled trials of 12 weeks duration using Fluorescein corneal staining and an Eye Dryness Score (EDS) to determine it’s effectiveness. Xiidra was shown to be safe and effective at 3 months.
Cequa became available in 2019 with a concentration of 0.09% cyclosporine. This clear, aqueous nanomicellar solution containing 0.09% CsA has been reported to deliver therapeutic concentrations of CsA with minimal discomfort to patients.This formulation provides 3x more penetration into the ocular tissue, and 1.6x more conjunctival absorption. Cequa was compared to vehicle (the substance the active ingredient is in) and showed an increase in Schirmer score after 12 weeks, and a decrease in corneal and conjunctival staining after four weeks.
Vevye is also cyclosporine and was FDA approved in 2023. It is the first topical cyclosporine that is water free and instead uses perfluorobutylpentane as a vehicle. This is similar to another drop used to treat dry eye, Miebo, which is perfluorohexyloctane. The higher concentration and the preservative-free formulation provides improved efficacy as well as better tolerability. In studies, this novel formulation showed a consistently larger reduction in corneal and conjunctival staining compared with both vehicle and Restasis over the 16-week treatment period, with an early onset of effect, noticeable after 2 weeks of treatment.
Doxycycline
Doxycycline is a type of antibiotic that also has anti-inflammatory and lipid-regulating properties, making it useful for treating meibomian, particularly when associated with ocular rosacea. A placebo controlled trial proved that doxycycline showed a significant improvement in tear secretion, tear evaporation and dry eye symptoms after one month of treatment. The problem with doxycycline is that GI side effects are common. Azithromycin has been shown to have similar properties to doxycycline but with better tolerability.
Recent data suggest that a single dose of oral azithromycin can change the ocular surface microbiome for at least 6 months, which may explain the persistent therapeutic effects that many patients report months after a single pulsed course of azithromycin.
Doxycycline has been found to be effective when taken in low doses over a long period of time, which may have a lower incidence of side effects. Importantly, when taken at lower doses, doxycycline doesn't have its usual antibiotic effects. Instead, it only works to control inflammation, sparing healthy bacteria in the body and maintaining a healthy balance. Studies have shown that taking 40mg daily (or 20mg twice a day) can significantly reduce inflammation in conditions like rosacea, a skin disorder that affects the eyes.
One of the reasons why doxycycline works well for eye conditions is because it can easily penetrate multiple layers of tissue in the eye due to its chemical properties. This allows it to reach its target molecules and reduce inflammation effectively.
For patients with ocular rosacea, taking doxycycline has been shown to reduce symptoms like irritation, improve tear film stability, and lessen the severity of eye problems associated with the condition.
We Treat Dry Eyes & Inflammation Holistically
Many of our patients can manage dry eye inflammation with topical medications, dietary supplements, and lifestyle modifications. Preventive measures to reduce the risk of dry eye inflammation include proper eye hygiene, hydration, and regular eye exams.
More serious conditions, however, call for long-term management strategies for maintaining ocular comfort and minimizing the recurrence of inflammation.
Here at the office of Lauren Zimski M.D, we understand the intricate relationship between dry eyes and inflammation. We can help you diagnose the underlying root cause of your condition and come up with a plan to treat both factors for optimal eye health.
Contact us today for a personalized evaluation and treatment plan tailored to your specific needs. You can schedule an appointment online, or contact us through our online form or at 303-863-1231.