That’s a Relief! Communication, Compliance, and Embracing Innovation are Key to Better DED Treatment

Beyond joyous celebrations, the holiday season is a time often associated with niggling health complaints — ranging from winter chills and coughs to heartburn and hangovers caused by excessive consumption at parties. Tis’ the season for all sorts of optometric considerations, too, with one of the most important, being the enfant terrible, dry eye disease (DED).

DED is one of the most commonly encountered conditions of late, and its sheer prevalence is only likely to grow. Unfortunately for most people, it is a chronic condition — one that they have to learn to manage.

Around 16.4 million Americans (6.8% of the adult U.S. population) have been diagnosed with DED, and an additional 6 million (2.5% of adults) may experience dry eye symptoms but have not been diagnosed with DED. That means up to 10% of the total adult population in the United States is likely to be affected by the condition, and that ratio is projected to grow in the coming years.1

So what can optometrists do to meet the rising demand for treatment for a condition that is widely prevalent and yet remains poorly understood by much of the lay community? DED, after all, is not a condition that most people would be able to readily identify despite understanding the symptoms well enough. Itchy, sore, red, and tired eyes are complaints they’ll be aware of, but it can prove challenging that DED is what it is — a disease. It is not a minor complaint that will just go away.

1. Communicate with other clinicians

To understand how optometrists can better meet this rising demand for DED treatment, we spoke with Dr. Elise Kramer, a specialist in DED and ocular surface diseases based at the Miami Contact Lens Institute in Florida, USA. Dr. Kramer has experienced a record number of referrals from other clinics experiencing high patient volumes.

For Dr. Kramer, the key to successfully tackling the emerging crisis in DED is to work closely with all stakeholders in patient treatment, both with ophthalmologists and optometrists.

“There’s both patient education and then there’s practitioner education,” explained Dr. Kramer. “Obviously, DED is something that we’re all taught about in optometry school. But this education is not necessarily focused on the way it should be. There’s so much more to learn, especially about how to communicate with patients,” she said.

“A lot of practitioners may not have the time to fully educate their patients about DED because they have a busy practice. That happens, so if they don’t have the time or resources, then they should be co-managing those cases with practitioners who do. After all, it’s hard to sit down with patients and really talk to them if there’s 60 in the waiting room,” she continued.

2. Simplify treatment

Dr. Kramer is optimistic about the developments that can expect from optometry in 2023. And in her opinion, the key to achieving the best patient outcomes is to simplify treatment.

DED treatment requires a high level of compliance to work, so treatment needs to fit in with a patient’s daily routine. So for Dr. Kramer, finding treatments that are easy to take and can be monitored by the patient’s primary care team, even if they go to multiple clinics, is the best way forward.

“I’m hoping eventually we can simplify treatment for dry eye to something more realistic for patients because there are so many parts of treatment and sometimes that can be overwhelming for them. There are a lot of different pharmacological products that are in the pipeline. So I’m looking forward to other things that are going to be released,” enthused Dr. Kramer.

3. Embrace innovation and technology

DED treatment is predicated on more than education, of course, and there are exciting developments in this field as more research time is given to improving treatment.

LipiFlow Thermal Pulsation System

There are a number of intriguing developments that can be observed in diagnostics, treatment, as well as in palliative care. One of the best examples is the LipiFlow by Johnson & Johnson (Jacksonville, Florida), a device that controls the application of sterile, single-use activators under and over one’s eyelids, which do not actually touch the eye ball to dissolve the gland obstructions caused by meibomian gland dysfunction (MGD) — one of the primary causes of DED.

Dr. Kramer uses LipiFlow at her clinic and she points to its simple design and ease of use as being a considerable asset for her patients. Treatment for DED needs to be easy to access and undergo for patients, she said, and shouldn’t focus solely on addressing the root cause of DED either. Treatments that can alleviate the symptoms of the disease should be considered even if they come in novel forms.

“LipiFlow is an FDA-approved treatment for meibomian gland evacuation, and having that stamp of approval means patients are a little bit keener on it. There’s a lot of solid evidence that it’s beneficial for patients who have MGD or posterior blepharitis. It’s a great treatment,” confirmed Dr. Kramer.

Eximore Integrated Pack & Release Drug Delivery System

Another device that may be able to alleviate the issue of packed waiting rooms is the Eximore (Rosh Haayin, Israel) Integrated Pack & Release Drug Delivery System, also known as EXP-TC. It’s a non-invasive punctal plug that is designed to optimize patient compliance via consistent dosing. It uses the eye’s dissolved natural tears to diffuse active drugs through the plug’s composite nano-channel, then the tears distribute and deliver the active drug to the eye.

This preserves the eye’s natural tears and the device can offer mono or combo therapy via the same delivery port. Crucially for overstretched clinicians, it is a non-invasive procedure, meaning the 1 mm plug can be fitted in a doctor’s office. Eximore reports that EXP-TC is undergoing trials involving 20 patients at the Hospital de la Ceguera in Mexico City.

Tyrvaya Nasal Spray

“There’s also a new nasal spray that helps with the quality and volume of dry tears, it’s called Tyrvaya,” shared Dr. Kramer. “It is particularly interesting because it can be used while wearing contact lenses, whereas a lot of dry eye treatments cannot. Besides preservative-free artificial tears, a lot of the immunomodulators need to have the contact lenses removed. So it’s definitely an improvement,” she added.


While nasal sprays are a pretty cool and innovative development in DED, it’s eye drops that are going to feature more commonly — and one of these is NOV03. Developed by Novaliq (Heidelburg, Germany) under license in the US and Canada by Bausch + Lomb (Laval, Canada), NOV03 is an investigational, proprietary, water-free, single-component preservative-free eye drop. Designed to prevent excessive tear evaporation, it can restore tear film balance, stabilize the lipid layer, and penetrate the meibomian glands.

NOV03 has successfully undergone phase 3 trials with few subjects experiencing ocular adverse events (9.6% NOV03 group, 7.5% control group), and change from baseline in tCFS was statistically significantly greater in the NOV03 arm compared to the control saline group. The US Food and Drug Administration (FDA) has now assigned NOV03 a Prescription Drug User Fee Act (PDUFA) action date of June 28, 2023.

With exciting developments on the horizon, Dr. Kramer is optimistic about the good things we can expect in DED treatment in 2023. NOV03, LipiFlow, EXP-TC, among others, are all likely to help improve compliance — a key issue in DED treatment.


* O’Neil EC, Henderson M, Massaro-Giordano M, Bunya VY. Advances in Dry Eye Disease Treatment.Curr Opin Ophthalmol. 2019;30(3):166-178.

Editor’s Note: This article was first published in COOKIE magazine Issue 10.

Dr Kramer

Dr. Elise Kramer is a residency-trained optometrist in Miami, Florida, who specializes in ocular surface disease and specialty contact lens design and fitting. She has a doctorate degree in optometry from the Université de Montréal in 2012. During her fourth year, she completed her internship in ocular disease at the Eye Centers of South Florida and went on to complete her residency at the Miami VA Medical Center. Her time there included training at the Bascom Palmer Eye Institute, the nation’s top eye hospital. After her residency, Dr. Kramer became a fellow of the Scleral Lens Education Society (SLS) and now serves as its treasurer. Dr. Kramer is a member of the American Optometric Association and the International Association of Contact Lens Educators, as well as a Fellow of the American Academy of Optometry and the British Contact Lens Association. She is also the Delegate of International Relations for the Italian Association of Scleral Lenses. Dr. Kramer has published several important articles and reviews and participates in clinical research trials. She enjoys giving lectures all around the world in several different languages about ocular surface diseases and specialty lenses.


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