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  • AAO PPP Cornea/External Disease Committee, Hoskins Center for Quality Eye Care
    Cornea/External Disease
    Compendium Type: I

    By the American Academy of Ophthalmology Preferred Practice Pattern Cornea/External Disease Committee: Esen K. Akpek, MD,1 Guillermo Amescua, MD,2 Marjan Farid, MD,3 Francisco J. Garcia-Ferrer, MD,4 Amy Lin, MD,5 Michelle K. Rhee, MD,6 Divya Varu, MD7 David C. Musch, PhD, MPH,8 Steven P. Dunn, MD,9 Francis S. Mah, MD10

    As of November 2015, the PPPs are initially published online-only in the Ophthalmology journal and may be freely downloaded in their entirety by all visitors. Open the PDF for this entire PPP or click here to access the PPP on the journal's site. Click here to access the journal's PPP collection page.

    1 The Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland
    2 Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
    3 Gavin Herbert Eye Institute, Department of Ophthalmology, Univeristy of California, Irvine, California
    4 Mercy Clinic Eye Specialists, St. Louis, Missouri
    5 John A. Moran Eye Center, University of Utah, Salt Lake City, Utah
    6 Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York
    Dell Laser Consultants, Austin Texas
    Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan
    Michigan Cornea Consultants, P.C., Southfield, Michigan
    10 Departments of Cornea and External Diseases, Scripps Clinic Torrey Pines, La Jolla, California


     Dry eye is a common ocular condition that has a substantial impact on the quality of life of afflicted individuals owing to discomfort and visual disability. Dry eye may compromise results of corneal, cataract, and refractive surgery.

     No single test is adequate for establishing the diagnosis of dry eye. The constellation of findings from multiple tests can add greatly to the clinician’s understanding of the patient’s condition.

     Pharmacological and procedural treatments are associated with improvements in patient symptoms and clinical signs, although chronic therapy and patient compliance are necessary in most instances.

     Omega-3 fatty acid products without ethyl esters have been recommended and widely used in the treatment of dry eye. However, a prospective, multicenter, masked large-scale trial of 3000 mg of omega-3 fatty acids for 12 months did not show any benefit in patient symptoms or signs over placebo.

    Topical cyclosporine treatment has long been used in the treatment of dry eye and shown to have clinical benefits. Topical cyclosporine, in some instances, leads to long-term treatment-free remission of patient symptoms and signs.

    Lifitegrast is a lymphocyte function-associated antigen-1 antagonist developed to treat dry eye syndrome (also known as dry eye disease), but the exact mechanism of action of lifitegrast in dry eye is unknown. Topical lifitegrast 5% has been approved by the US Food and Drug Administration for treatment of dry eye. Published studies show benefit in signs (corneal and conjunctival staining) as well as symptoms (eye dryness score and ocular discomfort) over a period of 3 months. Although the drug seems to be safe over 12 months, long-term efficacy and side effects are unknown.

     Dry eye patients considering keratorefractive surgery, particularly LASIK, should be cautioned that the dry eye condition could become worse after surgery. Dry eye symptoms are common in the first few months after surgery and tend to subside with time. Patients can safely undergo LASIK surgery if a pre-existing dry eye condition can be improved preoperatively.

     Dry eye is one of the main reasons for patient dissatisfaction following cataract surgery. Dry eye symptoms that continue beyond the normal postoperative period of 3 months might be seen in about one third of individuals. Baseline ocular surface and tear film parameters predict the patients at risk. Therefore, all patients undergoing cataract surgery should be evaluated and managed for dry eye preoperatively.

     Approximately 1/10 patients with clinically significant dry eye have an underlying Sjӧgren syndrome A recent meta-analysis found that, among autoimmune diseases, primary Sjӧgren syndrome is the most strongly associated risk factor for malignancy, with an incidence rate of 18.9% (95% CI, 9.4–37.9). Therefore timely diagnosis and appropriate management of patients with underlying Sjӧgren syndrome is relevant.

    Literature Search

    Dry Eye Syndrome PPP - 2018 - Literature Search.pdf