Breaking barriers to dry eye treatment adherence

The contents of this article are informational only and are not intended to be a substitute for professional medical advice, diagnosis, or treatment recommendations. This editorial presents the views and experiences of the author and does not reflect the opinions or recommendations of the publisher of Optometry 360.

Helping patients achieve meaningful results doesn’t have to be challenging. 

By Maria Sampalis, OD

In my practice, treating patients with dry eye disease (DED) is as much about building rapport, gaining patients’ trust, and setting expectations as it is about selecting the right therapy. One of the biggest clinical challenges I see with my patients is not diagnosing their condition but rather getting them to stick to their prescribed treatment long enough to see meaningful results.

It’s often necessary to experiment with several DED therapies before landing on one that works for a patient. From lack of efficacy in individual patients to side effects such as burning and stinging and costly monthly prescriptions, patient adherence to DED medications is a persistent obstacle. Fortunately, newer therapies have begun to shift the landscape toward better patient compliance. In my experience, some of these innovations not only provide comfortable, lasting symptomatic relief but also remove many of the barriers that have traditionally led patients to discontinue drops.

Incidence of DED

Large-scale, population-based studies show a clear upward trend in both the prevalence and incidence of DED over time, and it affects multiple demographic groups.^1,2 A retrospective analysis of nearly 10 million US military health system beneficiaries provided the first evidence of an increase in the incidence and prevalence of DED.

DED prevalence rose from 0.8% in 2005 to 3.0% in 2012. The increases were observed in men and women, across all age groups. The annual incidence also increased from 0.6% to 0.9%, and the increase in incidence started in young adulthood.¹

A nationwide population-based Taiwan study showed the incidence of DED more than doubled over a 15-year span.² The increase was seen across nearly all age cohorts, beginning in early adulthood. The annual age-adjusted incidence rates in men and women went from 0.97 and 2.06 per 1,000, respectively, in 2001 to 2.52 and 4.91 per 1,000, respectively, in 2015.

As DED continues to become more prevalent in our increasingly screen-centric world,³ the challenges associated with managing patients with this condition are something every optometrist will need to navigate. 

Factors Affecting Adherence

Patients often walk into my clinic frustrated, either because they’ve been told by others their eyes “look fine” despite persistent symptoms or because they’ve tried several over-the-counter remedies without success. When I start them on a prescription therapy, many expect immediate results. But as we know, anti-inflammatory drops for DED like first-generation cyclosporine formulations and lifitegrast often take time to work.

A nonrandomized, multicenter, open-label clinical trial of 412 patients enrolled in prior phase 3 trials for cyclosporine ophthalmic emulsion 0.05% (Restasis, AbbVie) yielded modest improvements in both objective and subjective measures. Patients noted that symptoms began to resolve in the first 3 months of prior treatment with cyclosporine.⁴ The treatment, however, is not indicated for the symptoms of DED.

An open-label study assessing 12 eye care professionals’ real-world experience with lifitegrast ophthalmic solution 5% (Xiidra, Bausch + Lomb) in DED showed moderate to high patient satisfaction with the treatment; however, near to complete symptom resolution was only achieved after 1 to 3 months.⁵

In this world of instant gratification, waiting months to feel better can be a tough ask for patients. If relief doesn’t come fast enough, patients might stop using it. In contrast, cyclosporine ophthalmic solution 0.1% (Vevye, Harrow), a cyclosporine dissolved in a semifluorinated alkane, has been shown to provide clinically meaningful and statistically significant improvement over semifluorinated alkane perfluorobutylpentane in total corneal fluorescein staining (tCFS) by day 15.⁶

Other studies have shown that cyclosporine ophthalmic solution 0.1% provided a clinically meaningful and statistically significant improvement in other measures of DED, including proportion of central corneal staining responders, conjunctival staining, and improvements in tear production.⁷

In the phase 3, single-arm, open-label extension ESSENCE-2 OLE study, continuous symptom improvements in visual analog scale symptoms from baseline were noted in responders after use of cyclosporine ophthalmic solution 0.1% over a 52-week period.⁸ These included the following:

• Sensation, frequency, and awareness of dry eyes
• Blurred and fluctuating vision
• The ability to read, drive at night, and look at screens

Individuals who saw 3 or more grades of improvement in tCFS saw a statistically significant improvement in 6 of 8 measured symptoms by day 29.⁸ Further, on average, patients returned to normal healthy tear production levels by month 12.

Another factor affecting patient adherence is burning or stinging on instillation. DED drops may burn due to imbalanced pH levels, preservatives like sorbate, sodium perborate, and stabilized oxychloro complex in the formulation, or compromised corneal nerves. For many patients with DED, especially those using drops chronically or alongside other topical therapies, preservative-free formulations such as cyclosporine ophthalmic solution 0.1% offer a significant advantage. Unlike DED drop formulations that use preservatives, which have been shown to exacerbate ocular surface inflammation, disrupt tear film stability, and damage corneal epithelial cells with long-term use,⁹ cyclosporine ophthalmic solution 0.1% causes limited burning or stinging on instillation (reported in 8% of patients), spreads evenly over the ocular surface, has a longer residual time (saturating the ocular surface for up to 8 hours), and increases the penetration of cyclosporine.¹⁰

Preservative-free drops are gentler on the ocular surface and associated with fewer adverse effects than preservative drops, particularly in patients with moderate to severe DED or preexisting ocular surface disease.¹¹ Studies have demonstrated that switching from preservative to preservative-free artificial tears can lead to improvements in tear break-up time, ocular surface staining, and DED symptom scores, making them a critical consideration for improving both comfort and adherence in DED management.^9,11

Lastly, cost and insurance hurdles may be major factors in compliance. Prior authorizations can delay patient access to treatment for days or weeks, especially for those unfamiliar with navigating these steps. Additionally, when a medication is expensive or patients are forced to pay out of pocket and they do not feel immediate relief, it becomes harder for them to justify continued use.

Prescribing Issues

Older adults comprise a large percentage of my DED patients. In my experience, they are especially vulnerable to adherence issues. Many are not comfortable with digital tools that facilitate access to specialty pharmacies and discount programs. They’re also more likely to be affected by formulary restrictions and copay surprises if they are on Medicare compared with younger patients who have other forms of insurance. Even my younger, tech-savvy patients can become discouraged when faced with a complicated pharmacy process.

Access programs designed to help clinicians prescribe a medication without waiting for prior authorizations may reduce the barrier to treatment. Vevye Access for All ensures patients know the cost of the medication upfront and are contacted quickly by a pharmacy via text or phone to arrange delivery. The streamlined process means fewer delays and fewer calls to my staff for help troubleshooting.

I’ve also had success with similar programs in the past and feel they have the potential to change how we prescribe DED medications, not just for efficiency but for outcomes. When patients can access their treatment without financial or logistical friction, they’re more likely to stay on therapy and follow through on their care plan, improving clinical results and their quality of life.

Setting Realistic Expectations

I’ve found the key to improving adherence is managing patient expectations from the start. Although patients often feel quicker relief with cyclosporine ophthalmic solution 0.1%,^6,7 I like to prep them that any prescription DED drop may take time to work and that it is normal to go several weeks before feeling better. Further, I explain the benefits of completing the full course of treatment, even if symptoms improve. In my experience, about 90% of my patients who use cyclosporine ophthalmic solution 0.1% find the drop eases their ocular discomfort compared with about 60% with older cyclosporine formulations. Miebo has been a great addition to my practice for evaporative DED. I use it in addition to an anti-inflammatory like lifitegrast ophthalmic solution 5%.

Building check-ins into our dry eye protocol has been helpful to address adherence issues early. When a drop causes irritation or does not help after a reasonable time, we talk about switching to a more tolerable option or an advanced in-office treatment.

Effectiveness Matters

Every DED treatment has pros and cons, and not every drop is right for every patient. What matters most to me is getting patients the relief they need without adding unnecessary complexity to their lives or to mine. Whether it’s a newer drop with fewer side effects or an older standby with proven efficacy, DED treatment must be accessible, tolerable, and effective to promote long-term patient adherence.

As eye care providers, we are always looking for the best way to care for patients. Sometimes, that means adding new treatments to our toolbox. Other times, it’s about finding smarter ways to connect patients with therapies we trust. Removing barriers—such as time to efficacy, sensory, or cost—is the first step in helping our patients stick with DED therapy long enough to feel better.

Maria Sampalis, OD, graduated from New England College of Optometry in 2007. She is the Founder of Corporate Optometry on Facebook, which has more than 33,000 members. Her social media network reaches more than 70,000 eye care professionals. She was Young OD of the Year in Rhode Island in 2016, Vision Monday’s Influential Woman in Optometry in 2019, and World Council of Optometry Eye Care Hero 2020, Women in Optometry Theia Award 2024. Dr. Sampalis practices in Rhode Island.

Disclosures: She is a consultant and speaker for various companies in the industry, including Barti, Harrow, and Lenz Therapeutics. 

References

1. Dana R, Bradley JL, Guerin A, et al. Estimated prevalence and incidence of dry eye disease based on coding analysis of a large, all-age United States health care system. Am J Ophthalmol. 2019;202:47-54. doi:10.1016/j.ajo.2019.01.026
2. Lin IC, Kuo YK, Liu HY, Chien LN. Trends in diagnosed dry eye disease incidence, 2001 to 2015: a nationwide population-based study in Taiwan. 2022;41(11):1372-1377. doi:10.1097/ICO.0000000000002987
3. Al-Mohtaseb Z, Schachter S, Shen Lee B, Garlich J, Trattler W. The relationship between dry eye disease and digital screen use. Clin Ophthalmol. 2021;15:3811-3820. doi:10.2147/OPTH.S321591
4. Barber LD, Pflugfelder SC, Tauber J, Foulks GN. Phase III safety evaluation of cyclosporine 0.1% ophthalmic emulsion administered twice daily to dry eye disease patients for up to 3 years. Ophthalmology. 2005;112(10):1790-1794. doi:10.1016/j.ophtha.2005.05.013
5. Koetting C, Schweitzer J, Nichols KK, et al. Real-world experience with lifitegrast ophthalmic solutions in patients with dry eye disease: a provider survey in the USA and Canada. Ophthalmol Ther. 2025;14(9):2109-2124. doi:10.1007/s40123-025-01190-3
6. Data on file, Harrow.
7. Akpek EK, Wirta DL, Downing JE, et al. Efficacy and safety of a water-free topical cyclosporine, 0.1% solution for the treatment of moderate to severe dry eye disease: the ESSENCE-2 clinical trial. JAMA Ophthalmol. 2023;141(5):459-466. doi:10.1001/jamaophthalmol.2023.0709
8. Wirta DL, Galor A, Aune CA, et al. Long-term safety and efficacy of a water-free cyclosporine 0.1% ophthalmic solution for treatment of dry eye disease: ESSENCE-2 OLE. 2024;44(6):692-700. doi:10.1097/ICO.0000000000003567
9. Baudouin C, Labbé A, Liang H, Pauly A, Brignole-Baudouin F. Preservatives in eyedrops: the good, the bad, and the ugly. Prog Ret Eye Res. 2010;29(4):312-334. doi:10.1016/j.preteyeres.2010.03.001
10. Agarwal P, Korward J, Krösser S, Rupenthal ID. Preclinical characterization of water-free cyclosporine eye drops – factors impacting ocular penetration ex vivo and in vivo. Eur J Pharm Biopharm. 2023;188:100-107. doi:10.1016/j.ejpb.2023.05.005
11. Agarwal P, Craig JP, Rupenthal ID. Formulation considerations for the management of dry eye disease. 2021;13(2):207. doi:10.3390/pharmaceutics13020207