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    Comprehensive Ophthalmology, Cornea/External Disease

    This Editors’ Choice summarizes the management of painful symptoms in patients with dry eye disease, according to the Tear Film and Ocular Surface Society’s (TFOS) Dry Eye Workshop II (DEWS II).

    Introduction

    Dry eye (DE) is a common disease defined by the Tear Film and Ocular Surface Society’s (TFOS) Dry Eye Workshop II (DEWS II) as “a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.”

    Presentation

    Patients typically present to the eye care provider with painful DE symptoms described as dryness, burning, aching or tenderness; and visual related symptoms such as poor or fluctuating vision. Treatment begins with the identification of factors that may underlie these symptoms. The ophthalmologist should look for nociceptive sources of pain such as inflammation, aqueous deficiency, unstable tear film, Meibomian gland disease or anatomic abnormalities.

    Management

    These abnormalities may be addressed as follows: inflammation with anti-inflammatory agents (i.e., a short course of corticosteroids, cyclosporine or lifitegrast), Meibomian gland disease with agents that improve Meibomian gland health (e.g., office- and home-based lid hygiene procedures, topical and oral antibiotics, intense pulse light) and anatomical abnormalities with procedures to improve anatomy (conjunctivoplasty, eyelid tightening).

    Next steps

    Individuals who report persistent pain despite these interventions should receive a neuropathic examination. While the optimal treatment of neuropathic ocular pain is not established, published options include local therapies (e.g., autologous serum tears), adjuvant therapies (e.g., transcutaneous electrical stimulation, botulinum toxin injections) and oral agents (e.g., pregabalin, gabapentin, nortriptyline).

    The TFOS DEWS II report can be downloaded at tearfilm.org