Managing Disease with Confidence

Dry eye disease (DED) is now one of the most common presentations in Australian optometry. Once considered a minor irritation, even mild dry eye is now understood as an early stage of a chronic, progressive condition that impacts comfort, vision, daily function, and overall wellbeing. As digital behaviour intensifies and environmental conditions become harsher, optometrists face increasing numbers of patients with early evaporative signs and a greater clinical need to intervene early, effectively, and consistently. Early dry eye is not simply a clinical finding. It’s a predictable opportunity to implement consistent, patient-centred care across any practice environment.

WRITER Shaina Zheng

UNDERSTANDING THE CAUSES OF MILD DRY EYE

Mild dry eye arises from a combination of lifestyle, environmental, and ocular surface factors. Understanding these drivers helps optometrists tailor treatment precisely to the underlying mechanism, a central principle of the DEWS III report, published by the Tear Film and Ocular Surface Society in 2025.1

The TFOS DEWS III definition reinforces that mild dry eye represents early tear film homeostasis disruption, driven by instability, hyperosmolarity, inflammation, and neurosensory changes.1 These changes are subtle, but clinically meaningful.

Meibomian Gland Dysfunction: The Core Driver

Meibomian gland dysfunction (MGD) now accounts for most dry eye presentations, estimated to be up to 90% of dry eye cases.2

Contributing factors include:

• Incomplete or infrequent blinking,

• Digital screen use,

• Lid margin disease,

• Cosmetic build-up / poor lid hygiene,

• Hormonal shifts (menopause is a major driver),

• Environmental exposure (air conditioning, heating, low humidity), and

• Contact lens wear.

These factors reduce lipid quality, obstruct glands, and create an unstable tear film.3,4

Increased Digital Load

Screen use decreases blink rate by 50–60%,5 leading to:

• Incomplete blinks,

• Reduced lipid expression,

• Faster evaporation, and

• End of day discomfort and blur.

Environmental and Lifestyle Factors

• Air conditioning / heating,

• High airflow environments,

• Low humidity,

• Sleep deprivation, and

• Systemic medications (antidepressants, antihistamines, acne medications).

Early Ocular Surface Inflammation

Even mild dry eye may involve inflammatory processes, contributing to symptoms like stinging, photophobia, or reflex tearing.

Because these risk factors are universal, mild dry eye is highly suitable for standardised detection and early intervention across diverse clinical settings.

First-Line Treatment Framework

DEWS III encourages personalised but structured care. A repeatable first line pathway helps clinicians deliver consistent, high-quality treatment, regardless of practice size or resources.

Lipid Enhanced Lubricants

Given the predominance of MGD, most patients benefit from a lipid containing eye drop that supports lipid layer stability.

These drops include: Rohto Dry Aid, Cationorm, Systane Complete/Balance, and Nova Tears.

Realistic Treatment Timelines The landmark six-month randomised control trial by Craig et al. demonstrated:

• Most symptom improvements occur within four weeks.

• Tear break-up time objective signs may take three to four months to fully improve.6

With this in mind, an essential message to communicate to patients is: “Dry eye improves gradually with lipid-based eye drops. The first month should bring some symptom relief, the following months should restore the surface.”

Lifestyle and Behaviour

Foundational interventions that significantly support mild evaporative disease:

• Warm compresses 40°C (10–15 minutes daily),7

• Blink training (conscious full blinks, squeeze blinks, reminders),

• 20-20-20 visual hygiene,

• Humidifiers in dry environments,

• Screen positioning below eye level,

• Avoiding fans or air flow towards the face,

• Adequate hydration, and

• Lid hygiene (for early blepharitis or cosmetic debris).

These recommendations are highly accessible, low cost, and can be effective for mild dry eye cases.3,4

WHEN TO INTRODUCE CICLOSPORIN

While often associated with moderate disease, ciclosporin can be appropriate for patients with low grade ocular surface inflammation or fluctuating tear production.

Ciclosporin:

• Reduces T-cell-mediated inflammation,

• Improves tear production,

• Restores goblet-cell density, and

• Supports long-term ocular surface stability.8

DEWS III places ciclosporin at Stage 2, meaning it is suitable when patients have persistent symptoms despite correct first-line therapy. It is also suitable when clinical signs of ocular inflammation are present, such as conjunctival hyperaemia, conjunctival or corneal staining, reduced tear stability, lid margin inflammation, and elevated osmolarity.

One hallmark of early dry eye is its relapsing course. Patients may experience temporary symptomatic improvement, followed by predictable flare-ups triggered by intensive screen usage, air-conditioned environments, stress or changes in blink behaviour. Without intervention, these episodic flares can become increasingly frequent as meibomian gland function declines.

Realistic Treatment Timelines Patients should be advised that it may take eight to 12 weeks to notice benefits, aligning expectations with the known mode of action.

A simple, clear first-line protocol improves confidence, reduces clinical variance, and supports consistent messaging across clinicians and practices.

DIAGNOSTICS AND TECHNOLOGY

One of the major shifts in recent years is the increasing availability of dry eye diagnostics and in-office therapeutic technologies within optometry. Technology strengthens clinical confidence and patient understanding, especially in early disease.

Even in mild dry eye, the use of technology can significantly enhance diagnostic accuracy and guide targeted treatment.

NON-INVASIVE BREAK-UP TIME

Non-invasive break-up time (NIBUT) provides an objective measure of tear film stability without fluorescein. It is useful for baseline assessment, monitoring improvement over months, and predicting patient adherence success.

Tear break-up time (TBUT) remains a valuable and widely used clinical measure of tear-film instability. DEWS III defines a TBUT of <10 seconds as abnormal, mirroring the NIBUT diagnostic threshold. TBUT is particularly useful when fluorescein staining is already being performed. Values under five seconds strongly suggest evaporative dysfunction or lipid layer deficiency. When used alongside NIBUT, TBUT enhances diagnostic confidence and helps track improvements in tear film stability as patients adopt targeted interventions.

Meibography

Meibography allows direct visualisation of the meibomian glands, providing structural information that complements functional assessment. Common findings include:

• Gland truncation,

• Dropout,

• Tortuosity, and

• Early gland compromise.

Even patients with mild DED can demonstrate early meibomian gland changes. Identifying these structural abnormalities helps validate the need for timely management and supports patient understanding when symptoms are not adequately controlled by conservative measures alone.4

Tear Osmolarity

Elevated tear osmolarity reflects tear film instability and inflammatory stress within the ocular surface environment. Even mild cases of dry eye may demonstrate increased osmolarity, indicating that the tear film is already functionally compromised. Persistent hyperosmolarity supports escalation to in-office treatments when symptoms fail to improve with first-line conservative therapies.1,9

IN-OFFICE THERAPIES

Meibomian Gland Expression

Manual meibomian gland expression assists in mobilising stagnant meibum, improving lipid layer quality, and enhancing tear film stability. It is particularly appropriate for mild-to-moderate gland obstruction and can support symptom improvement when used alongside routine dry eye therapies.4

Lid Debridement and Cleaning

Lid margin debridement and biofilm removal help restore a healthier lid margin environment and improve meibum outflow. Procedures such as BlephEx, Zest, or in-office mechanical debridement reduce keratinisation and bacterial biofilm, supporting better gland function and overall ocular surface health.

Thermal Pulsation and Intense Pulsed Light

Thermal-based treatments (e.g., radio frequency and low-level light therapies) and light-based therapies (e.g., intense pulsed light) are well established options for improving meibomian gland function and reducing inflammation associated with MGD.

Under DEWS III, these interventions are recognised as adjunctive therapies that may be considered when obstructive MGD or periocular inflammation persist despite initial conservative treatment.

Potential benefits include:

• Improved meibum quality and gland function,

• Reduction of periocular inflammation, particularly in patients with rosacea-associated MGD, and

• Enhanced tear film stability and symptomatic relief.

While often used in moderate disease, emerging evidence supports their consideration earlier in the disease spectrum, particularly when:

• Lifestyle or occupational factors contribute to chronic gland stress,

• Conservative measures (warm compresses, lubricants, lid hygiene) provide insufficient control, and

• Early structural gland changes are present and may benefit from proactive intervention.

These technologies fit within a tiered, evidence-aligned management pathway, supporting clearer communication with patients about the rationale for escalating care.

FOLLOW UP AND REVIEW

Mild dry eye is chronic, but very manageable when monitored, making follow up the most important step.

A structured four-to-six-week review is essential to:

• Evaluate adherence,

• Reinforce technique,

• Re-assess tear-film stability,

• Adapt treatment,

• Escalate when appropriate,

• Manage flare patterns before they worsen, and

• Initiate in-office treatments if symptoms persist.

This approach aligns with DEWS III recommendations to provide ongoing patient education and stepwise escalation. When follow up becomes a routine part of mild dry eye care, patients feel better supported, and practices see better clinical outcomes, greater patient satisfaction, and stronger long-term therapeutic relationships.

CONCLUSION

Mild dry eye care does not need to be complicated. It needs to be consistent, structured, and patient-centred. And modern optometry is more capable than ever before to diagnose and manage this condition effectively.

Your structured approach should combine:

• Targeted lipid enhancing lubrication,

• Behavioural and lifestyle modifications,

• Early anti-inflammatory therapy when indicated,

• Technology supported assessment, and

• Consistent review intervals.

By adopting this strategy, optometrists can confidently improve comfort, visual performance, and quality of life for patients long before dry eye becomes moderate or severe.

Shaina Zheng BOptom OcTherapeutics GAICD is a co-owner optometrist at Eyecare Plus Mermaid Beach in Queensland. She currently serves as the Vice President of the Dry Eye Society, where she drives professional education, clinical best practice initiatives, and industry collaboration. She is also the founder of Dry Eye Impact, an organisation dedicated to advancing patient-focused dry eye care through innovation, compassion, and collaborative professional networks across Australia.

References

1. Tear Film and Ocular Surface Society, DEWS III report, available at: tearfilm.org/paginesin-report/7454_7453/ eng/ [accessed Feb 2026].
2. Nichols KK, Foulks GN, Bron AJ, et al. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011;52(4):1922- 1929. doi:10.1167/iovs.10-6997a.
3. Geerling G, Baudouin C, Aragona P, et al. Emerging strategies for the diagnosis and treatment of meibomian gland dysfunction: Proceedings of the OCEAN group meeting. Ocul Surf. 2017;15(2):179-192. doi:10.1016/j. jtos.2017.01.006.
4. Craig JP, Nelson JD, Azar DT, et al. TFOS DEWS II report executive summary. Ocul Surf. 2017;15(4):802- 812. doi:10.1016/j.jtos.2017.08.003.
5. Murakami DK, Blackie CA, Korb DR. All warm compresses are not equally efficacious. Optom Vis Sci. 2015;92(9):e327-e333. doi:10.1097/ OPX.0000000000000675.
6. Craig JP, Muntz A, Wang MTM, et al. Developing evidence-based guidance for the treatment of dry eye disease with artificial tear supplements: A six-month multicentre, double-masked randomised controlled trial. Ocul Surf. 2021;20:62-69. doi:10.1016/j. jtos.2020.12.006.
7. Rosenfield M. Computer vision syndrome: a review of ocular causes and potential treatments. Ophthalmic Physiol Opt. 2011;31(5):502-515. doi:10.1111/j.1475- 1313.2011.00834.x.
8. Sheppard JD, Nichols KK. (2023). Dry eye disease associated with meibomian gland dysfunction: Focus on tear film characteristics and the therapeutic landscape. Ophthalmol Ther. 2023;12(3):1397-1418. doi: 10.1007/ s40123-023-00669-1.
9. Sall K, Stevenson OD, Mundorf TK, Reis BL. Two multicenter, randomized studies of the efficacy and safety of cyclosporine ophthalmic emulsion in moderate to severe dry eye disease. CsA Phase 3 Study Group. Ophthalmology. 2000;107(4):631-639. doi:10.1016/ s0161-6420(99)00176-1.