Hydrate, hygiene, heat, and heal: streamline therapy with a 4-step plan for baseline DED management
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.
By Pamela E. Theriot, OD, FAAO
Confusion and overload are so common for patients and practitioners when it comes to treatment for dry eye disease (DED). Patients need easy-to-follow recommendations that make a real difference, and we need simple DED education in our practices.
I’ve chosen to model baseline therapy for patients with all levels of DED on proven science, so I’ve looked to step 1 of the Tear Film & Ocular Surface Society Dry Eye Workshop II (TFOS DEWS II) report’s staged management plan1 and the recent addition of data from TFOS DEWS III.2 Along with a discussion of lifestyle adjustments and blinking exercises, I provide my patients with a simple 4-step eye care plan that they will perform at home with over-the-counter products as part of their daily routine.
The 4 steps are: hydrate, hygiene, heat, and heal. It’s a catchy phrase that makes it easy to explain, understand, and follow. Even patients who need advanced treatments start and continue with these baseline therapies. Most importantly, the results for my patients have been very positive.
The Four Hs
According to the TFOS DEWS studies, treatment for tear film deficient patients should start with 4 daily eye care measures outlined in step 1, regardless of severity, and build upon them if needed. Although I ascertain the severity of a patient’s tear film deficiency and do a series of tests to pin down the root cause, I recommend baseline daily eye care for all patients as follows
Hydrate. A preservative-free artificial tear is essential. I base my specific recommendation for the drop and frequency on the exam and patient’s lifestyle. Most patients benefit from using tears in the morning, at night, and when needed.
For both meibomian gland dysfunction (MGD) and aqueous deficiency, I find that iVIZIA (Théa) is an effective tear with hyaluronic acid, which bonds to the ocular surface for longer retention on the eye. iVIZIA is safe for use with contacts, and the addition of trehalose offers osmoprotection, preventing dehydration. Another option for patients with MGD who do not wear contact lenses is Refresh Optive Mega 3 (AbbVie), which has flaxseed oil in the formulation to prevent evaporation, or Optase MGD Advanced (Optase), which contains a combination of sacha inchi seed oil, trehalose, and hyaluronic acid to strengthen the tear film and protect the eyes.
Hygiene. We talk all the time about making ocular hygiene part of people’s normal nightly hygiene routine (“Wash your face, clean your eyes, brush your teeth.”). Patients have a lot of great options; the exam and lifestyle, again, guide my recommendations.
When I see a lot of flaky dandruff in the lashes, I want patients to use a foaming cleanser to scrub their lids, such as Zocufoam (Zocular) or OcuSoft Platinum (OcuSoft). If flakes are not significant but I see eyelid inflammation, I suggest a hypochlorous spray such as Avenova OTC (Avenova) or Optase Protect (Optase) to reduce bacteria and inflammation. Hypochlorous spray is gentle, well-tolerated, and easy to use for almost any patient. For patients who are traveling, I recommend individually packaged wipes like the ones from iVIZIA, which allow for high-quality eye hygiene on the road.
Heat. For reliably effective warm compresses, I recommend that patients use a mask, not a washcloth, in the microwave. There are so many options, including traditional microwavable masks, plug-in ones, or air-activated disposable masks. I tell patients to use the mask once or twice per day, depending on the severity of MGD.
For my patients with ocular rosacea, who often indicate that heat worsens their eyelid redness, I recommend a far infrared mask like the Unclog mask (Unclogic). Infrared energy penetrates the skin to heat the meibomian glands more than the skin itself. I also like the REST device (Umay), which is rechargeable and has both heat and cool settings. It covers the eyelids without a lot of periocular heating and works well for rosacea patients.
Heal. I use the word “heal” to describe the role of nutraceuticals in helping the body produce the necessary components of a healthy tear film. Historically, I’ve had patients use a high-quality triglyceride form of omega-3 supplements such as DE3 Dry Eye Omega Benefits (PRN). TFOS DEWS IIII recommends adding vitamin D3 supplements for MGD patients as well. We now have the additional option of Blink NutriTears (Bausch + Lomb), which contains D3, antioxidants, and anti-inflammatories for MGD.
Simple Patient Education
While keeping baseline therapy simple with the 4-step plan, I educate patients about DED, emphasizing that following the management plan can help them feel better and prevent their tear film deficiency from worsening. I use the dental analogy with a bit of a twist, explaining that it wasn’t so long ago that people didn’t brush their teeth, and tooth loss was common. Similarly, routine daily eye care can prevent permanent loss of meibomian glands, something we see more and more often due, in part, to extended screen time.
I give patients a handout that includes basic information about DED, as well as space for me to write specific brand names and instructions for all 4 categories of products. For example, I will write the recommended brand of artificial tears and explain how frequently to use them. The handout reminds them to opt for a preservative-free product to diminish the toxins going into their eyes. It also includes basic recommendations for screen use (breaks, blinking exercises) and environmental changes (redirecting fans and heaters and using humidifiers).
After patients leave, they receive an email sequence that reminds them of the 4 simple steps and offers helpful videos, such as one that shows how to scrub their lids.
New patients return after 6 to 8 weeks of using the 4-step baseline management and, in some cases, prescription medications, at which point I judge the effects. Some patients don’t need any other treatment, and we follow up in 3 to 6 months. Others might need further prescription medication, intense pulsed light, radiofrequency treatment, or thermal pulsation.
Although in-office treatments might allow patients to reduce the frequency of warm compresses or as-needed artificial tears, patients continue the 4-step baseline management to support their eyes and prolong the effects of other treatments. After the first few months, caring for their eyes with this simple plan becomes ingrained.
Case Study: Regaining Health and Confidence
Chief Complaint: Recurrent styes, red and irritated eyes, and interrupted professional and social activities due to eye appearance.
Janet, a 75-year-old professional actress living in San Francisco, set up a virtual consultation with me in 2021 for help with her red, irritated eyes. She was experiencing recurrent styes, affecting both upper and lower lids and alternating between her right and left eyes. Ocular inflammation and redness were not only physically uncomfortable but also emotionally distressing. Janet found herself canceling Zoom performances, virtual meetings, and social activities because she felt self-conscious about how her eyes looked.
I recommended that Janet implement the simple 4-step at-home routine—hydrate, hygiene, heat, and heal—to reduce redness, help prevent recurrent styes, and restore her ocular comfort and confidence. For her specific needs, I recommended iVIZIA artificial tears morning, night, and as needed; Avenova OTC spray cleaning morning and night; a traditional microwavable mask twice a day; and DE3 Dry Eye Omega Benefits.
When we had our virtual visit after 6 weeks of consistently following the routine, Janet noticed a dramatic improvement. Her eyes felt more comfortable and appeared less red and the recurring styes disappeared. Most importantly, she regained her confidence. She returned to Zoom performances, virtual meetings, and the stage she loves. Janet’s experience is a powerful reminder that simple, consistent eye care can restore quality of life. Four simple steps provide a comprehensive, practical approach to managing DED both from the outside and from within.
References
- Jones L, Downie LE, Korb D, et al. TFOS DEWS II management and therapy report.Ocul Surf. 2017;15(3):575-628. doi:10.1016/j.jtos.2017.05.006
- Jones L, Craig JP, Markoulli M, et al. TFOS DEWS III management and therapy report. Am J Ophthalmol. June 2025. doi:10.1016/j.ajo.2025.05.039
Pamela E. Theriot, OD, FAAO, is Clinical Director of the Dry Eye Relief Center at Lusk Eye Specialists in Shreveport, Louisiana. Her TEDx talk about navigating eye health in a screen-filled world is live on YouTube, and you can read her DED blog at www.pamtheriot.com. Disclosures: Dr. Theriot is a paid KOL for Optase, Bruder, and Alcon and an in-paid KOL for Théa and Allergan.
