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Home » Dry Eye » What Treatments Can Relieve Dry Eye Syndrome? » Treating Lacrimal (aqueous) Deficiency

Treating Lacrimal (aqueous) Deficiency

dry eye ManhattanTypically dry eye patients start with some of the myriad over-the-counter artificial tears available today. If those are not enough, one might go on to punctal plugs or – more likely these days, with the greater emphasis on the “inflammatory component of dry eye” – try a topical steroid and/or Restasis (prescription drops).

Plug-n-drop seems to work pretty well for many patients with mild to moderate dry eye.

Artificial tears, gels, ointments

Is it okay to use preserved lubricants?

Don’t use a product with benzalkonium chloride (BAK) unless specifically directed by your eye doctor – and even then, please ask him/her about alternatives.

Do follow your Manhattan dry eye doctor’s instructions. If you’ve been told to avoid all preservatives, for example for a period following an eye surgery, do so. Your NYC eye doctor may also have particular views on which preservatives are safer than others.

How often should I use artificial tears?

When in doubt, go with Dr. Alan Schlussel and Dr. Hannah Canuto‘s advice.

There are some cases – particularly in severe aqueous deficient dry eye from primary auto-immune disease – where keeping the eyes wet with tear supplementation is a must, period, because otherwise the eyes would be at risk of abrasions or even ulceration.

But for the rest of us….

If you are using artificial tears more often than every 2-3 hours, you should (if you haven’t already) try alternative lubricants, and if you’ve exhausted those, then investigate some additional treatments to improve your tear film (particularly those related to meibomian gland dysfunction if applicable) and also look into eyewear and other strategies for managing pain and discomfort.

Many patients with moderate to severe dry eye symptoms from other causes (including a destabilized tear film, meibomian gland dysfunction etc) end up using artificial tears more as a means of controlling pain than for protecting against imminent damage. It seems clear to me that in at least some of these cases, patients can do themselves harm by over-using artificial tears. Your naturally tears have substances intended to protect and nourish the eye surfaces. When your natural tear film is destabilized, overloading it constantly with watery or oily supplements can further destabilize it by basically washing the good stuff right out.

There’s no magic answer for everyone of course. Some patients do seem to fare best when they use supplements whenever needed. Others have shown a distinct pattern of getting worse when they use more tears, and getting better when they use fewer.

Which products are best?

While there are definitely some perfectly useless products on the market, there is also definitely not a “Best” product.

Different products work best for different people. There are no shortcuts… you need to experiment. At t he Dry Eye Treatment Center of NY we offer a wide range of dry eye treatment options including: lipiflow and other advanced options.

What are gels useful for?

Gels are best for night-time use. They are thicker than artificial tears – though “liquid gels” may be somewhere in between – and theoretically last longer on the eye. For those whose dryness puts them in danger of corneal erosions at night, eye protection is critical and may eye doctors recommend gels for that protection. Putting a gel in both eyes and covering the eyes with an eye guard or plastic may be a useful way to keep the eyes lubricated at night.

Topical Steriods

The current trend in dry eye treatment tends to put heavy emphasis on inflammatory processes which may be causing dry eye. It is not uncommon for patients with moderate to severe symptoms to be given a short course of steroids before moving on to other treatments. Additionally, some doctors are using topical steroids in conjunction with Restasis.

Steroid eyedrops must be used cautiously, with regular monitoring of the intraocular pressure by the doctor, because of the risk of elevated intraocular pressure.

Examples: Pred Forte, Fluorometholone (FML), Lotemax, Alrex, Vexol


Prescription eyedrop for dry eye.
DESCRIPTION: Cyclosporine ophthalmic emulsion

Restasis was the first prescription dry eye drug to be FDA approved and remains the only prescription drop on the market though there are several others currently in development (see Drug Pipeline).

The active ingredient of Restasis is cyclosporine (0.05%). The vehicle for Restasis is actually marketed separately as an over-the-counter artificial tear product, Refresh Endura. Because early clinical trials reportedly did not show a very clear superiority of the drug over the vehicle, some doctors continue to recommend that patients first try Refresh Endura before trying Restasis.

Cyclosporine has a considerable history of use in treatment of extreme dry eye and has long been veterinarians’ preferred treatment for canine dry eye. Since the approval of Restasis, its conspicuous position as the only prescription dry eye drug has probably contributed much to its growing popularity in the treatment of more moderate dry eye symptoms. Indeed, the current trend in dry eye treatment in general is heavily emphasizing treatment of the inflammatory component.

A common complaint with Restasis is a sensation of burning. Data from the clinical trials indicate that 17% of patients experienced this and along with the high cost this remains a key reason for patient dropout. Some physicians prescribe Restasis along with a topical steroid or NSAID or precede Restasis with a short course of one. Many patients taking Restasis continue to need supplementation with artificial tears.

Patients being prescribed Restasis are usually directed to take it for a minimum of 6 weeks to 3 months in order to determine whether it will benefit them.

Punctal occlusion

Punctal plugs (punctum plugs) and cautery; getting plugged

Punctal occlusion means blocking some or all of the puncta (small openings in the corners of the eyes near the nose, through which tears drain). This is done in order to improve the lubrication of the eye surface by slowing down tear drainage in people who are aqueous deficient (have low aqueous tear production).

Punctal occlusion is one of the most frequently used techniques for treating dry eye, after artificial tear supplements. The two general approaches to punctal occlusion are punctal plugs (small plugs inserted in the puncta or canalicula) or punctal cautery (surgical sealing of the puncta).

What’s it all about?

The eyes have four drains, called puncta, through which tears (which are constantly renewed) exit. These are in the lower and upper corners of the eyelids nearest the nose.

For NYC patients whose dry eye symptoms are caused primarily by a deficiency in the water (aqueous) part of their tears, stopping the drains (called punctal occlusion) can sometimes help improve the symptoms. There are two ways to do this: using small plugs, or permanently sealing the openings with cautery. Plugs are far and away the most common of the two treatments. These include temporary collagen plugs, which dissolve by themselves, which can be placed in order to test the likelihood that silicone plugs or cautery will be helpful and will not result in tear overflow (epiphora).

What is a punctum and what are punctum plugs? (Where are punctum plugs placed in the eye?)

Puncta are the drainage ducts that your old tears, or extra tears, can escape through while your glands are making new ones. In each of your eyes, there is one punctum in the top eyelid and another on the bottom eyelid, at the corner of the eye that is towards your nose.

Punctal plugs do exactly what they sound like: They stop the drains, just like the plug in your kitchen sink. They are not quite as easy to put in as the plug in your sink, and they are definitely not as easy to get out (at least, not the kind that go right now into the canalicula).

Why might I get collagen plugs first?

Collagen plugs dissolve on their own, usually within a few days of insertion. They are a useful way to determine whether you might be a good candidate for permanent punctal plugs.

Some patients will experience tear overflow (epiphora) with punctal plugs. If they go straight to silicone plugs, then depending what type they get it may be difficult to remove them. Collagen plugs will not necessarily prove whether silicone plugs will be helpful, but they can help gauge patients who will have overflow or who simply are very unlikely to benefit.

What is it like to get plugs? Does it hurt?

Punctal plugs are sold with a long tweezer-y looking thing used to insert them. Now, how they are inserted depends partly on what kind of plug they are, for example, some fit right into the top of the punctum (and you can see the caps in the mirror) while others are shoved way down into the canaliculum. But broadly speaking, here is what will happen: Your eye doctor will put in some eyedrops to anaesthetise your eyes. He’ll then use one part of the tweezer-y thing to poke into the puntum and stretch it out a bit. Once it’s ready, he uses the other part of the thing to push the plug into the punctum. Plunk! It’s there. On to the next punctum.

What happens once the plugs are in?

After the anaesthetic wears off, you may be sore from the insertion process. Some people also have a reaction to the plugs that makes them feel uncomfortable – this may even last up to a few days. If this happens to you, please don’t despair, don’t claw at your eyes and unless it’s intolerable don’t force your eye doctor to remove them – chances are, the discomfort will pass and in a couple of days you’ll feel much better. On the other hand, if you see swelling or have constant pain, by all means call your dry eye doctor in New York.

A minority may find that their tears pool up and run over after the plugs are in. There’s even a fancy term for it – epiphora. Some people experience significant enough benefits from the plugs that they tolerate the overflow as the price they pay for healthier and/or more comfortable eyes. Too much overflow can be either embarrassing or convenient, depending whether it’s happening during a job interview or while your great aunt is telling you all about her latest hospitalization. But chronic overflow may be unhealthy as well as inconvenient, so by all means keep your doctor up to date on what’s going on.

Learn more about Punctal Plugs and Intracanalicular Plugs in NYC and West Orange, NJ.

Content provided by The Dry Eye Company and has been edited by the Dry Eye Treatment Centers of NY and NJ.