Dry eye and ocular allergies

Modern approaches to the diagnosis, detection, and treatment of dry eye, and its relationship to ocular allergy.

Undiagnosed dry eye or ocular allergies can have a long-term effect on the comfort of our patients’ eyes and directly impact their quality of life.

After dry eye diagnosis and detection, initial treatment steps include education, environmental changes, and oral omega-3 supplements. Depending on the data collected by diagnostic tests, we can incorporate additional treatment options.

Here, we will discuss the numerous modern approaches to the detection and subsequent treatment of dry eye disease (DED).

Signs and symptoms

Often, when patients come in for an eye exam or a problem visit, they do not make the connection between their symptoms and DED or ocular allergies. However, as technicians, we automatically make the correlation to dry eye and/or ocular allergies when patients present with ocular itching, a sandy or gritty feeling in their eyes, intermittent blurry or fluctuating vision, excessive tearing, or burning.

At times, patients may come to the office for their general eye examination and do not bring up any of these eye symptoms during their screening. This is why it is important to have educated ophthalmic assistants who can “play detective” to draw out the ocular issues that these patients experience. Once we identify the symptoms, we, as eye-care professionals, are encouraged by our ophthalmologists to initiate testing that can help them make the correct diagnosis.

Allergy vs. dry eye

As soon as a patient presents a chief complaint that falls into the dry eye category, a trained technician in our practice is empowered to initiate the SPEED questionnaire. The modified SPEED questionnaire provides the eye-care provider with the next direction to test for: dry eye, allergy, or both. Allergy testing is very beneficial to both the patients and the physician. With a 20-minute in-office test performed by a technician with the physician in the office and an EpiPen on the desk, patients can know which allergens to avoid in their everyday lives based on their geographic region. The allergy test is either performed on the same visit if patients have the time or they are asked to return for a separate appointment if they have taken oral antihistamine medication, such as Zyrtec or Claritin, within the past three to five days. Allergy testing helps physicians confirm the diagnosis of allergic conjunctivitis, whether seasonal or perennial, and treat accordingly.

Upon completing in-office allergy testing, we can determine the underlying cause for the ocular itch. In addition to prescribing an anti-allergy eyedrop such as Pataday, Pazeo, Patanol, or Bepreve, we stress avoidance education. For example, if the allergy test shows a strong allergy to feathers and a patient has down pillows and a down comforter, we recommend that the patient change to fiberfill, a synthetic material. If the allergens are outdoor trees or shrubs, showering before going to bed is key to avoid spreading the pollen in the bed. If the patient shows severe reactions to multiple allergens, it may be beneficial to refer the patient to an allergist.

Dry eye diagnostics

Dry eye testing comes in many different forms. In our practice, we test almost all patients who indicate a complaint on our modified SPEED questionnaire or who come in with a specific dry eye symptom. Even if the patient presents with no specific ocular surface complaints, the testing may show otherwise, allowing us to catch the disease early. Here are the tests that we perform:

  • Tear Osmolarity (TearLab). This test measures the osmolarity (salt content) of a patient’s tears. Performed by the technician before instilling drops in the eyes, it is key in detecting DED.
  • InflammaDry (Quidel). This test detects elevated MMP-9 pro-inflammatory biomarkers, which are high in patients with inflammatory DED. Technicians perform this test before instilling any drops into the eye. If the patient has a positive InflammaDry test, we know the patient has inflammation somewhere on the surface that we need to treat.
  • Lissamine green corneal staining. Performed by the physician, this stains the lid margin, the conjunctiva, and cornea and allows the physician to identify an uptake pattern that may be consistent with DED.
  • Fluorescein to measure tear break up time (TBUT) and to assess corneal staining (Figure 1).

    Figure 1: Fluorescein staining of the corneal surface. Using the cobalt blue filter on the slit lamp, the fluorescein will light up the areas where there is DED.

  • LipiView (TearScience). This scans the meibomian glands along the lower eyelids to provide a glance at the health of the patient’s meibomian glands (Figure 2). If a patient’s LipiView shows significant gland drop out, then we know this patient’s glands are not producing enough oil to adequately lubricate the ocular surface, known as meibomian gland dysfunction. Then, we can discuss how to preserve what is left. The treatment plan for this patient includes a LipiFlow (TearScience) treatment.

    Figure 2: LipiView captures an image of the meibomian glands in both lower eyelids. This patient has severe meibomian gland drop out, which is a large contributor to DED.

Dry eye treatment

Most patients think dry eye and they immediately associate its treatment with artificial tear use. They are not aware of other treatments, and a large portion of our patient population comes to our office using Visine, a product with a vasoconstrictor designed to “get the red out.” We switch these patents to an artificial tear.

Each patient is different — consequently, customized treatment plans will best address each patient’s ocular surface disease needs.

Depending on the severity of the corneal surface pathology, an initial treatment plan in our office includes:

  • Omega 3 fish oil oral supplements. We recommend PRN (Physician Recommended Nutraceuticals), which comes in capsule or liquid form (for those who have trouble swallowing capsules). We typically start a patient on two capsules (or 1 tsp) daily with food — it is key for patients to take the Omega 3 supplements with their biggest meal for better GI absorption. For patients who cannot tolerate other fish oils, we recommend HydroEye (ScienceBased Health), a proprietary blend of omega fatty acids, antioxidants, and other key nutrients.
  • Heated mask. We recommend the Bruder microwavable mask, which helps heat the meibomian glands and allows the oils to flow for proper lubrication.
  • Artificial tears. Patient use as needed for relief throughout the day.

We re-evaluate patients after one to three months to give the initial treatment plan time to work. When the patient returns to our office, we repeat our testing to assess therapeutic response to the treatment. If we see no objective improvement and/or if the patient feels no symptomatic improvement, then we add to our treatment plan. The treatment plans are like building blocks: we stack them on top of each other, without excess, until we find the right combination to treat the underlying pathology.

Our next step is a prescription medication, Restasis (Allergan) or Xiidra (Shire), that helps treat the underlying inflammation. Both FDA-approved prescription products interfere with the inflammatory cycle on the ocular surface and are used twice daily. The decision of whether to use Restasis or Xiidra is a complex process for the physician. Often, if the patient has tried Restasis without success, we then initiate Xiidra. Or, we start new DED patients on Xiidra if we want them to get symptomatic relief sooner.

If we stack Restasis or Xiidra on top of the initial treatments and the patient still feels discomfort, we then move to our in-office treatments: intense pulsed light (IPL) and/or LipiFlow. Both are designed to heat the meibomian glands and express the content, evacuating the glands, allowing them to start fresh and make new meibum or oils to aid in lubricating the ocular surface.


Ocular allergy and DED symptoms can present in similar ways, and it can be difficult to differentiate between them without performing proper diagnostic tests. The decision regarding a treatment plan is a partnership between the physician and the patient.

Using the experiences and symptoms of the patient and the results of diagnostic testing, we can customize a plan to address the entire spectrum of ocular disease: whether dry eye, ocular allergies, or both. OP