The Ocular Surface xxx (2017) 580e634 Contents lists available at ScienceDirect The Ocular Surface journal homepage: www.theocularsurface.com TFOS DEWS II Management and Therapy Report * Lyndon Jones, FCOptom PhD a, , Laura E. Downie, BOptom PhD b, Donald Korb, OD c, Jose M. Benitez-del-Castillo, MD PhD d, Reza Dana, MD e, Sophie X. Deng, MD PhD f, Pham N. Dong, MD g, Gerd Geerling, MD FEBO h, Richard Yudi Hida, MD i, Yang Liu, MD j, Kyoung Yul Seo, MD PhD k, Joseph Tauber, MD l, Tais H. Wakamatsu, MD PhD m, Jianjiang Xu, MD PhD n, James S. Wolffsohn, FCOptom PhD o, Jennifer P. Craig, MCOptom PhD p a Centre for Contact Lens Research, School of Optometry and Vision Science, University of Waterloo, Waterloo, Canada b Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Victoria, Australia c Korb & Associates, Boston, MA, USA d Department of Ophthalmology, University of Complutense, Madrid, Spain e Department of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, MA, USA f Stein Eye Institute, UCLA, Los Angeles, CA, USA g Department of Corneal and External Disease, Vietnam National Institute of Ophthalmology, Hanoi, Viet Nam h Department of Ophthalmology, University Hospital Duesseldorf, Germany i Department of Ophthalmology, Santa Casa de Sao Paulo, University of Sao Paulo, Sao Paulo, Brazil j Schepens Eye Research Institute, Massachusetts Eye & Ear, Boston, MA, USA k Department of Ophthalmology, Yonsei University Medical College, Seoul, South Korea l Tauber Eye Center, Kansas City, MO, USA m Department of Ophthalmology and Visual Sciences, Paulista School of Medicine, Sao~ Paulo Hospital, Federal University of Sao~ Paulo, Sao~ Paulo, Brazil n Department of Ophthalmology and Visual Science, Eye, and ENT Hospital, Shanghai Medical College, Fudan University, China o Ophthalmic Research Group, Aston University, Birmingham, UK p Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand article info abstract Article history: The members of the Management and Therapy Subcommittee undertook an evidence-based review of Received 2 May 2017 current dry eye therapies and management options. Management options reviewed in detail included Accepted 3 May 2017 treatments for tear insufficiency and lid abnormalities, as well as anti-inflammatory medications, sur- gical approaches, dietary modifications, environmental considerations and complementary therapies. Keywords: Following this extensive review it became clear that many of the treatments available for the manage- Dry eye disease ment of dry eye disease lack the necessary Level 1 evidence to support their recommendation, often due Dry eye workshop to a lack of appropriate masking, randomization or controls and in some cases due to issues with se- Management TFOS DEWS II lection bias or inadequate sample size. fl Therapy Re ecting on all available evidence, a staged management algorithm was derived that presents a step- wise approach to implementing the various management and therapeutic options according to disease severity. While this exercise indicated that differentiating between aqueous-deficient and evaporative dry eye disease was critical in selecting the most appropriate management strategy, it also highlighted challenges, based on the limited evidence currently available, in predicting relative benefits of specific management options, in managing the two dry eye disease subtypes. Further evidence is required to support the introduction, and continued use, of many of the treatment options currently available to manage dry eye disease, as well as to inform appropriate treatment starting points and understand treatment specificity in relation to dry eye disease subtype. © 2017 Elsevier Inc. All rights reserved. * Corresponding author. E-mail address: [email protected] (L. Jones). http://dx.doi.org/10.1016/j.jtos.2017.05.006 1542-0124/© 2017 Elsevier Inc. All rights reserved. L. Jones et al. / The Ocular Surface xxx (2017) 580e634 581 Contents 1. Introduction . ................................................ 582 2. Treatments for tear insufficiency . ........................................... 583 2.1. Tear replacement approaches . .......................583 2.1.1. Artificial tear substitutes . .. .......................583 2.1.2. Biological tear substitutes . .......................586 2.1.3. Other agents . .......................589 2.2. Tear conservation approaches . .......................589 2.2.1. Punctal occlusion . .......................589 2.2.2. Moisture chamber spectacles and humidifiers . .......................590 2.3. Tear stimulation approaches . .......................591 2.3.1. Topical secretagogues . .......................591 2.3.2. Lipid stimulation . .......................592 2.3.3. Oral secretagogues . .......................592 2.3.4. Nasal neurostimulation . .......................592 2.3.5. Various tear stimulation methods . .......................592 3. Treatments for lid abnormalities . ........................................... 593 3.1. Anterior blepharitis . .......................593 3.1.1. Lidhygiene......................................................... .......................... .......................593 3.2. Meibomian gland dysfunction . .......................594 3.2.1. Ocular lubricants . .......................594 3.2.2. Warm compresses . .......................594 3.2.3. Physical treatments . .......................596 3.3. Blinking abnormalities and ocular exposure . .......................597 3.3.1. Treatment for corneal exposure . .......................597 3.3.2. Entropion and ectropion . .......................597 3.3.3. Contact lenses . .......................597 4. Anti-inflammatory therapy . ................................................ 598 4.1. Topical glucocorticoids . .......................598 4.1.1. Basic research . .......................598 4.1.2. Clinical studies . .......................599 4.1.3. Complications . .......................599 4.1.4. Steroid pre-treatment . .......................600 4.1.5. Preservative-free options . .......................600 4.1.6. Sex steroids . .......................600 4.2. Non-glucocorticoid immunomodulators . .......................600 4.2.1. Cyclosporine A . .......................600 4.2.2. Tacrolimus . .......................601 4.2.3. Non steroidal anti-inflammatory drugs . .. .......................601 4.2.4. Biologics . .......................602 4.2.5. Neuropeptides . ..