Rethinking the Diagnosis and Management of Evaporative Dry Eye

LEARNING OBJECTIVES

On completion of this CPD activity, participants should:

1. Recognise and understand the dominant drivers of dry eye disease in the large majority of presentations,
2. Describe the mechanism of action of NovaTears (perfluorohexyloctane) and how it differs from conventional aqueous and lipid-based tear substitutes, and
3. Be aware of evidence from GOBI, MOJAVE, KALAHARI, and the Phase 4 onset-of-action study supporting the efficacy, rapid onset, and long-term safety of NovaTears in patients with dry eye disease and clinical signs of MGD.

WRITER: Shao Ling

The prevalence of DED increases with advancing age and is higher in women than in men, with additional risk factors including extended screen use, contact lens use, and exposure to adverse environmental conditions. As the number of patients presenting with DED continues to grow, identifying the underlying disease mechanism has become increasingly important for guiding treatment decisions as each subtype may require a different therapeutic approach.

Treatments that primarily increase tear volume may provide limited benefit when tear film instability is driven by lipid layer dysfunction, while therapies targeting excessive evaporation are better suited to this mechanism. Identifying the underlying disease mechanism, therefore, has important implications for treatment selection, particularly in patients who continue to experience symptoms despite using aqueous-based lubricating eye drops.

The third Tear Film and Ocular Surface Society Dry Eye Workshop (TFOS DEWS III) Management and Therapy report moves beyond the aqueous-deficient/evaporative binary framework, recommending instead that clinicians identify the clinically relevant drivers – tear film, eyelid, or ocular surface – since most DED is now understood to be predominantly evaporative. This granular approach, rather than subtype alone, guides effective treatment.⁸

The Evaporative Origins of Dry Eye Disease

The tear film consists of three layers – an inner mucin layer, a middle aqueous layer, and an outer lipid layer. Disruption to any of these can destabilise the tear film and affect ocular surface health. DED was traditionally divided into aqueous-deficient dry eye (ADDE) and evaporative dry eye (EDE),⁶ though TFOS DEWS III has replaced this binary model and instead now classifies DED by specific cause – tear film layer deficiencies, eyelid anomalies, or ocular surface abnormalities – to guide more targeted management.⁸

Although more than half of patients with DED exhibit features of both forms, studies evaluating the predominant disease subtype suggest that purely ADDE accounts for only around 10% of cases.^1-3 By contrast, an evaporative component is present in up to 94% of individuals with DED,^1-3 with most cases being either predominantly evaporative or having a significant evaporative component.^1-5

Meibomian gland dysfunction (MGD) is the principal cause of EDE,^1,6,7 with reduced or altered meibum secretion compromising the tear film’s outer lipid layer and accelerating evaporation of the underlying aqueous layer. This profile highlights why therapies that target tear film lipid deficiency, rather than simply increasing aqueous tear volume, are of clinical relevance for the majority of patients with DED.

EyeSol Technology Mechanism of Action

NovaTears is formulated using patented EyeSol technology and contains a single active ingredient, perfluorohexyloctane, a semi-fluorinated alkane known in clinical development as NOV03 or PFHO. Unlike traditional lipid-containing artificial tears, which are typically oil-in-water emulsions stabilised with surfactants, NovaTears is a completely water-free formulation that contains no phosphates, surfactants, or preservatives. It is supplied in a multidose bottle that remains suitable for use for up to six months after opening.

Clinical evidence from three Phase 3 trials and one Phase 4 study, involving more than 1,300 patients with DED and signs of MGD, has shown that NovaTears produces statistically significant improvements in both the clinical signs and patient-reported symptoms of DED.^9-12

The unique physicochemical characteristics of perfluorohexyloctane underpin its mechanism of action. Its molecular structure combines a lipophilic hydrocarbon chain with an aerophilic fluorinated chain, enabling interaction with both the tear film lipid layer and the air interface.^13-15 Following instillation, its low surface tension (four times lower than water) allows it to spread quickly and evenly across the ocular surface.^15-16 It forms a thin monolayer at the air–liquid interface that replicates important functions of the native meibomian lipid layer, reducing tear evaporation, improving tear film stability, and lowering friction across the ocular surface. By limiting evaporative water loss, it also provides an environment that supports epithelial recovery and ocular surface healing.¹¹

Several additional properties further distinguish the formulation from other lubricants. Its low vapour pressure enables the drop to remain on the ocular surface for longer after instillation,^16,17 while the small, instilled volume (approximately 10–12 µL versus 40–50 µL for aqueous eye drops) reduces overflow and wastage. Its refractive index is similar to that of water, helping to minimise temporary blurred vision immediately after application.¹⁴ Patients commonly report that the drop feels smooth and comfortable on instillation, with little or no stinging, burning, or irritation.^9-12

Clinically, these properties combine to provide rapid, comfortable lubrication with minimal disruption to vision, restoration of tear film function through reinforcement of the lipid layer and reduced evaporation, and support for corneal epithelial healing, with clinical studies demonstrating sustained benefits over treatment periods of up to 52 weeks.¹¹ Because its primary action targets excessive tear evaporation rather than replacing tear volume, NovaTears is particularly well suited to patients with evaporative DED associated with MGD, and may also benefit patients with aqueous deficient dry eye disease.

Phase 3 Evidence: The GOBI and MOJAVE Studies

The efficacy and safety of NOV03 (perfluorohexyloctane) has been established in two pivotal Phase 3 trials: GOBI9 and MOJAVE.¹⁰ Both were eight-week, multicentre, double-masked, hypotonic saline-controlled studies, conducted in adults with a self-reported history of DED in both eyes and clinical signs of MGD. Co-primary endpoints were change from baseline in total corneal fluorescein staining (tCFS) and eye dryness score, measured on a visual analogue scale (VAS), at day 57; the same measures at day 15 served as key secondary endpoints.

In GOBI, 597 patients were treated (NOV03, n=303; saline, n=294). At day 57, tCFS improved by a mean of 2.0 units with NOV03 versus 1.0 with saline (least-square mean treatment difference −0.97; P<0.001), and eye dryness VAS improved by 27.4 versus 19.7 (treatment difference −7.6; P<0.001). tCFS responders (≥3-step improvement) reached 41.2% with NOV03 versus 27.2% with saline, and eye dryness responders (≥30% reduction) reached 57.4% versus 46.6%.⁹

MOJAVE, enrolling 620 patients (NOV03, n=311; saline, n=309), replicated these findings: tCFS improved by 2.3 versus 1.1 units (treatment difference −1.2; P<0.001), and eye dryness VAS improved by 29.4 versus 19.2 (treatment difference −10.2; P<0.001).¹⁰ Responder rates were again significantly higher with NOV03: 50.0% versus 30.7% for tCFS, and 65.6% versus 45.3% for eye dryness.¹⁰

In a pooled analysis of both studies, mean improvement in tCFS was 1.8 versus 1.2 at day 15 and 2.2 versus 1.1 at day 57 (P<0.0001 for both); eye dryness VAS improved by 18.3 versus 11.9 at day 15 and 28.5 versus 19.3 at day 57 (P<0.0001 for both) (Figure 2).¹⁸ Both studies showed a significant improvement in the signs and symptoms of DED as early as week two with continued improvement through week eight.¹⁸

Figure 2. Rapid and sustained improvement in total corneal staining as early as week two through week eight.

Across both studies tolerability was favourable, with no serious ocular adverse events (AEs), low discontinuation rates due to AEs (0.2%), and a low rate of burning or stinging on instillation (0.5%). The most common ocular adverse reaction was blurred vision (2.1%), which was mostly mild and transient.^9,10,18

Long-Term Outcomes: The KALAHARI Extension Study

As DED is a chronic condition that requires ongoing management, evidence supporting sustained efficacy and long-term tolerability is consequential. The Phase 3 KALAHARI study, a multicentre, open-label, single-arm extension of the GOBI trial, evaluated the long-term use of PFHO (perfluorohexyloctane) over an additional 52 weeks. Participants instilled one drop into each eye four times daily. Among the 208 patients enrolled, 97 had received PFHO during the GOBI trial, while 111 transitioned from saline treatment in GOBI to PFHO in KALAHARI.¹¹

Patients who remained on PFHO maintained the improvements in tCFS and VAS scores achieved during the GOBI parent study. In contrast, participants who switched from saline to PFHO experienced marked improvements within four weeks of commencing treatment, with these improvements continuing throughout the extension period. At the completion of 52 weeks, the overall study population demonstrated a mean reduction of 2.1 units in tCFS and 33.7 points in eye dryness VAS relative to baseline in GOBI (Figure 3).¹¹

Figure 3. Mean change from GOBI study baseline in A) tCFS score (study eye) and B) eye dryness score (VAS) by study visit: GOBI–KALAHARI. *KALAHARI day 1 is the final visit in the GOBI study. Dashed lines represent GOBI treatment (PFHO, saline). tCFS score range: grade 0 (no staining) to grade 3 (heavy staining) for five areas of the cornea (maximum score 15). VAS score range (both eyes simultaneously): 0 (no discomfort) to 100 (maximal discomfort). SEM, standard error of mean.

Long-term use of PFHO, four times daily, was safe and well tolerated in patients in the KALAHARI study, with a safety profile consistent with that reported in the previous GOBI and MOJAVE short-term studies of PFHO. Ocular adverse events were reported by 13.9% of participants over the 52-week extension, although these were predominantly mild or moderate in severity, and no serious ocular adverse events were observed. Treatment acceptability was also high, with participants rating instillation comfort at a mean score of 8.4 out of 10.¹¹

Overall, these findings indicate that PFHO provides improvements in both the signs and symptoms of DED over the long-term, while maintaining a favourable safety profile, supporting its use as a long-term management option for patients with evaporative dry eye associated with MGD and dry eye disease due to aqueous deficiency.

Onset of Action: Phase 4 Clinical Data

A separate prospective, multicentre, open-label Phase 4 study examined how quickly patients experience symptom relief. Ninety-nine adults with a history of DED of six months, or longer, instilled PFHO four times daily in both eyes for 14 days, rating symptom severity, symptom frequency, and treatment satisfaction on 0–100 visual analogue scales.¹²

Mean overall DED symptom severity fell significantly from a baseline of 72.1 to 27.8 by day seven, the study’s primary endpoint (P<0.0001). Notably, meaningful relief was apparent much earlier: mean VAS scores fell to 38.5, five minutes after the first instillation, and to 31.7 at 60 minutes post-dose on day one; reductions of 46.6% and 56.3% respectively (P<0.0001 versus baseline at all time points).¹²

Patients with DED experienced significant and meaningful reductions in the severity and frequency of dry eye symptoms within the first two weeks of treatment, with notable symptom reduction as soon as five minutes and 60 minutes after instillation on day one.¹²

A similar pattern was observed across all eight individual symptoms assessed, including burning/stinging, itching, and blurred vision. Ocular surface disease index (OSDI) total score fell from 50.5 at baseline to 18.4 at day 14 (change −32.1; P<0.0001), and median treatment satisfaction rose from 75.0 at five minutes post-instillation to 90.0 at day 14 (Figure 4).¹²

Figure 4. Patient-reported severity of overall dry eye symptoms. Error bars represent SD. *P < 0.0001 versus baseline (paired t test). †Primary endpoint. CFB change from baseline, SD standard deviation, VAS visual analogue scale.

Only one adverse event was reported across the 99 participants – a single case of moderate eye pain, judged unrelated to treatment.12 These findings suggest that patients using NovaTears can expect both an immediate symptomatic response after a single instillation and continued improvement with regular use over the following weeks.

Practical Considerations

For clinicians considering NovaTears, the dosing regimen evaluated consistently across the clinical trials was one drop in each eye four times daily. Across the four studies, no serious ocular safety concerns were identified, including during treatment extending beyond 12 months. Patients with clinical evidence of MGD or an established evaporative component to their DED are likely to derive the greatest benefit, although its mechanism of action also supports use in patients who also suffer from ADDE.

As a preservative-free, phosphate-free, and surfactant-free formulation, NovaTears may be particularly suitable for individuals who experience irritation or hypersensitivity with long-term use of conventional preserved lubricants. In Australia, NovaTears is available on the Pharmaceutical Benefits Scheme (PBS) for patients with severe dry eye syndrome who are sensitive to preservatives in multi-dose eye drops. Its preservative-free multidose bottle, with an in-use shelf life of up to six months after opening, also suits patients requiring frequent, long-term therapy.

Conclusion

Collectively, the Phase 3 (GOBI, MOJAVE, KALAHARI) and Phase 4 studies provide a robust, consistent evidence base of more than 1,300 participants with DED and clinical features of MGD, supporting NovaTears as a differentiated therapeutic option for evaporative dry eye disease. Unlike conventional lubricants that primarily aim to increase aqueous tear volume, its formulation targets the tear film lipid layer to reduce evaporation, addressing a key mechanism involved in the majority of DED cases. As part of a comprehensive approach to MGD management, NovaTears may be used alongside other supportive strategies such as warm compresses and lid hygiene. The breadth of evidence from its clinical development program – rapid onset of action, sustained efficacy over eight weeks, and durability of effect over 52 weeks – provides a strong foundation for considering NovaTears as a targeted, well-tolerated treatment option for patients presenting with signs of MGD.

References 

1. Lemp MA, Crews LA, Sullivan BD et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-478. doi: 10.1097/ICO.0b013e318225415a.
2. Rabensteiner DF, Aminfar H, Horwath-Winter J, et al. The prevalence of meibomian gland dysfunction, tear film and ocular surface parameters in an Austrian dry eye clinic population. Acta Ophthalmol. 2018;96(6):e707-e711. doi: 10.1111/aos.13732.
3. Badian RA, Utheim TP, Sundling V, et al. Meibomian gland dysfunction is highly prevalent among first-time visitors at a Norwegian dry eye specialist clinic. Sci Rep. 2021;11(1):23412. doi: 10.1038/s41598-021-02738-6..
4. Tong L, Chaurasia SS, Mehta JS, Beuerman RW. Screening for meibomian gland disease: its relation to dry eye subtypes and symptoms in a tertiary referral clinic in Singapore. Invest Ophthalmol Vis Sci. 2010;51(7):3449-3454. doi: 10.1167/iovs.09-4445.
5. Amano S, Inoue K. Clinic-based study on meibomian gland dysfunction in Japan. Invest Ophthalmol Vis Sci. 2017;58(2):1283-1287. doi: 10.1167/iovs.16-21374.
6. Stapleton F, Alves M, Jones L, et al. TFOS DEWS II epidemiology report. Ocul Surf. 2017;15(3):334-365. doi: 10.1016/j.jtos.2017.05.003..
7. Chhadva P, Goldhardt R, Galor A. Meibomian gland disease: the role of gland dysfunction in dry eye disease. Ophthalmology. 2017;124(11S):S20-S26. doi: 10.1016/j.ophtha.2017.05.031..
8. Perez VL, Chen W, Sullivan DA. TFOS DEWS III: executive summary. Am J Ophthalmol. 2026;282:135-145. doi: 10.1016/j.ajo.2025.09.035.
9. Tauber J, Berdy GJ, Vittitow JL, et al. NOV03 for dry eye disease associated with meibomian gland dysfunction: results of the randomized phase 3 GOBI study. Ophthalmology. 2023;130(5):516-524. doi: 10.1016/j.ophtha.2022.12.021.
10. Sheppard JD, Kurata F, Epitropoulos AT, Krösser S, Vittitow JL. NOV03 for signs and symptoms of dry eye disease associated with meibomian gland dysfunction: the randomized phase 3 MOJAVE study. Am J Ophthalmol. 2023;252:265-274. doi: 10.1016/j.ajo.2023.03.008.
11. Protzko EE, Segal BA, Vittitow JL, et al. Long-term safety and efficacy of perfluorohexyloctane ophthalmic solution for the treatment of patients with dry eye disease: the KALAHARI study. Cornea. 2024;43(9):1100-1107. doi: 10.1097/ICO.0000000000003418.
12. Bacharach J, Kannarr SR, White DE, et al. Early effects of perfluorohexyloctane ophthalmic solution on patient-reported outcomes in dry eye disease: a prospective, open-label, multicenter study. Ophthalmol Ther. 2025;14:693-704. doi: 10.1007/s40123-025-01097-z.
13. Vittitow J, Kissling R, DeCory H, Borchman D. In vitro inhibition of evaporation with perfluorohexyloctane, an eye drop for dry eye disease. Curr Ther Res Clin Exp. 2023;98:100704. doi: 10.1016/j.curtheres.2023.100704.
14. Schmidl D, Bata AM, Garhöfer G, et al. Influence of perfluorohexyloctane eye drops on tear film thickness in patients with mild to moderate dry eye disease: a randomized controlled clinical trial. J Ocul Pharmacol Ther. 2020;36(3):154-161. doi: 10.1089/jop.2019.0092.
15. Meinert H, Roy T. Semifluorinated alkanes – a new class of compounds with outstanding properties for use in ophthalmology. Eur J Ophthalmol. 2000;10(3):189-197. doi: 10.5301/EJO.2008.1838.
16. Agarwal P, Khun D, Rupenthal ID, et al. Preclinical studies evaluating the effect of semifluorinated alkanes on ocular surface and tear fluid dynamics. Ocul Surf. 2019;17(2):241-249. doi: 10.1016/j.jtos.2019.02.010.
17. Tsagogiorgas C, Krebs J, Luecke T, et al. Semifluorinated alkanes – a new class of excipients suitable for pulmonary drug delivery. Eur J Pharm Biopharm. 2010;76(1):75-82. doi: 10.1016/j.ejpb.2010.05.011.
18. Fahmy AM, Harthan JS, Vittitow JL, et al. Perfluorohexyloctane ophthalmic solution for dry eye disease: pooled analysis of two phase 3 clinical trials. Front Ophthalmol. 2024;4:1452422. doi: 10.3389/fopht.2024.1452422.

Case One: Sjögren’s Syndrome: An Optometrist’s Perspective

WRITER: Ambiga Theivendradas

Sjögren’s syndrome is a chronic autoimmune disease, characterised by lymphocyte infiltration of the exocrine glands of the lacrimal and salivary glands, leading to severe aqueous deficient dry eye and dry mouth.¹ Patients with Sjögren’s syndrome-associated dry eye present with symptoms of foreign body sensation, burning sensation, eyestrain, photophobia, blurry vision, and red eyes, all of which can have significant impacts on their quality of life. Many patients can present with significant ocular symptoms, despite conventional lubricant therapy.

Alice Walker,* a 39-year-old female, was diagnosed with seropositive Sjögren’s syndrome in December 2022. During her initial visit in November 2022, she presented with severe ocular discomfort, complaining of sensitivity to air and periocular discomfort.

Examination

• Best corrected visual acuities were R 6/4.8-2, L 6/9.5.
• Baseline OSDI was 90.9, indicating severe symptoms. No superficial punctate keratopathy was noted in either eye. An old area of pannus was observed on the right inferonasal cornea.
• Fluorescein tear break-up time (FLTBUT) was R 3s, L 4s.

Ms Walker’s severity of symptoms appeared disproportionate to her ocular surface signs. Mild meibomian gland dysfunction was present bilaterally. A Schirmer test with topical anesthetic (Alcaine) showed R 4mm and L 5.5 mm of wetting after five minutes. Based on the reduced Schirmer test, she was referred to a general practitioner (GP) for testing for Sjögren’s syndrome. This resulted in a seropositive Sjögren’s syndrome diagnosis. No other general health concerns were noted, and no medications were taken at this stage.

Over the course of two years (between 2022 and 2024), multiple preservative free lubricants were trialled alongside heat masks and lid hygiene, with minimal symptom relief. There was poor tolerability to both ciclosporin formulations (Ikervis 0.1% and Cequa 0.09%) due to excessive stinging on instillation, and the patient discontinued their use. Temporary punctal plugs provided limited relief of symptoms.

In early 2025, general health and dietary preferences were queried, and the patient presented blood test results from 2022. These results showed a low thyroid stimulating hormone (TSH) level of 0.08 mIU/L (normal range 0.4–4.0 mIU/L), indicating hyperthyroidism. The underlying cause of hyperthyroidism had not been investigated at that stage. Low vitamin D and B12 were also noted. The patient advised that she followed a vegetarian diet, and that no further blood tests had been done since 2022.

Ms Walker was advised to instill one drop of Hylo-Forte and NovaTears + Omega-3, four times daily, with a five-minute interval between drops. She was also advised to recommence Ikervis 0.1%, one drop nightly, and to continue using the heat mask once daily. A discussion was held on incorporating vitamin D, vitamin B12, and omega-3 supplements into her diet. A letter to the GP was written to investigate hyperthyroidism. Due to the symptoms being disproportionate to the clinical signs, Ms Walker was referred to an ophthalmologist for consideration of serum eye drops, suspecting corneal neuropathic pain.

In late 2025, Ms Walker returned for a review appointment and reported significant improvement in symptoms. She found NovaTears + Omega-3 aided her symptom relief. She had not attended the ophthalmologist appointment as her symptoms had improved. The GP investigated hyperthyroidism and the outcome of this was unclear. Her current treatment regimen was Hylo-Forte and NovaTears + Omega-3, instilled four times daily with a five-minute interval between drops. She continued using her heat mask once a day and discontinued the ciclosporin, after retrying for a short period of time, due to poor tolerability. She reported incorporating vitamin D and omega-3 supplements into her diet. In addition to the recommended supplements, Ms Walker incorporated magnesium and calcium supplements. Vitamin B12 supplementation was not commenced.

Discussion

Hyperthyroidism can worsen dry eye through exposure keratopathy related to Graves’ disease or through elevated levels of Interleukin-8 (IL-8)(3). IL-8, a chemokine, has been implicated in the inflammatory cascade that leads to the worsening of dry eye disease.² Hyperthyroidism investigations are warranted in this case to determine the cause and prevent further worsening of dry eye symptoms.

Vitamin D deficiency is associated with worsening dry eye symptoms and reduced tear production in patients with dry eye.³ Vitamin B12 deficiency is also associated with increased risk of dry eye disease.⁴ Oral omega-3 supplementation may improve dry eye symptoms by reducing tear osmolarity, increasing tear stability, and reducing basal tear levels of pro-inflammatory cytokines in people with dry eye disease.⁵ The addition of the nutritional supplements vitamin D, B12, and omega-3 in this patient’s diet may improve dry eye disease symptoms.

Ciclosporin can significantly improve dry eye symptoms in Sjögren’s syndrome associated dry eye disease by downregulating pro-inflammatory cytokines.6 Ms Walker found cyclosporin intolerable due to stinging and ceased its use.

NovaTears + Omega-3 contains perfluorohexyloctane, a lipid-based drop that spreads rapidly across the tear film and reduces evaporation by stabilising the lipid layer. NovaTears + Omega-3 is primarily indicated for evaporative dry eye and may provide symptomatic relief for patients with Sjögren’s syndrome associated aqueous deficient dry eye by improving the lipid layer, preventing further evaporation of an already attenuated aqueous layer.

NovaTears + Omega-3, coupled with Hylo-Forte can be a good combination, optimising both the lipid and aqueous layers of the tear film. As this is a single case, the exact reason for the symptom improvement cannot be established, since other treatments (Hylo-Forte, nutritional supplements, and investigation of hyperthyroidism) were initiated concurrently. NovaTears + Omega-3 can be a valuable adjunct treatment, alongside a multimodal, holistic treatment plan in patients with refractory Sjögren’s syndrome associated dry eye disease.

References 

1. Wu KY, Kulbay M, Tran SD, et al. An overview of the dry eye disease in sjögren’s syndrome using our current molecular understanding. Int J Mol Sci. 2023 Jan 13;24(2):1580. doi: 10.3390/ijms24021580.
2. Rana HS, Akella SS, Aakalu VK, et al. Ocular surface disease in thyroid eye disease: A narrative review. Ocul Surf. 2022 Apr;24:67-73. doi: 10.1016/j.jtos.2022.02.001.
3. Liu J, Dong Y, Wang Y. Vitamin D deficiency is associated with dry eye syndrome: a systematic review and meta-analysis. Acta Ophthalmol. 2020 Dec;98(8):749-754. doi: 10.1111/aos.14470.
4. Markoulli M, Ahmad S, Wolffsohn JS, et al. TFOS Lifestyle: Impact of nutrition on the ocular surface. Ocul Surf. 2023 Jul;29:226-271. doi: 10.1016/j.jtos.2023.04.003.
5. Deinema LA, Vingrys AJ, Downie LE, et al. A Randomized, double-masked, placebo-controlled clinical trial of two forms of omega-3 supplements for treating dry eye disease. Ophthalmology. 2017 Jan;124(1):43-52. doi: 10.1016/j.ophtha.2016.09.023.
6. Moawad P, Shamma R, Hassanein D, Ragab G, El Zawahry O. Evaluation of the effect of topical tacrolimus 0.03% versus cyclosporine 0.05% in the treatment of dry eye secondary to Sjogren syndrome. Eur J Ophthalmol. 2022 Jan;32(1):673-679. doi: 10.1177/1120672121992680.

Case Two: Sjögren’s Syndrome and Surgery: An Ophthalmologist’s Perspective

WRITER: Dr Kenneth Ooi

Claudia Braun,* a 55-year-old female midwife and pharmaceutical employee, presented with worsening symptoms of evaporative dry eye, particularly exacerbated by menopause, frequent computer use, and windy days. She reported significant eyelid sticking upon waking. Her symptoms were worse on the right with the presence of a right nasal pterygium significant for cosmesis.

Ms Braun was presbyopic and she often had allergic conjunctivitis.

Her medical history was significant for asthma, seasonal allergies, depression, and menopause. She was unsure as to her cholesterol levels and vitamin D sufficiency. Within her family, her daughter was being investigated for dry mouth.

Ms Braun had previously been prescribed Premarin, Ventolin, inhaled steroids, and occasional oral antihistamines. At presentation, she was using Viscotears 4–5 times daily.

A systemic review for autoimmune indicators was initiated due to the possibility of Sjögren’s syndrome. The patient reported recent tinnitus, joint stiffness in the toes, ankle swelling, and new skin dryness.

Examination

• Visual acuity on her right eye (RE) 6/6+4, left eye (LE) 6/4.
• Intraocular pressures were 14 mmHg.
• Eyelids were notable for posterior blepharitis; however, there was no lagophthalmos or lid laxity.
• Ocular surface in both eyes had marked conjunctival injection and minor punctate epithelial erosions, along with slightly inflamed pingueculae and right nasal pterygium.
• Tear break-up time (TBUT) was severely reduced at three seconds in both eyes.
• The rest of the examination revealed clear lenses, healthy discs, maculae, and fundi.

Initial Management

A conservative approach was initiated with Ms Braun advised to focus on lid hygiene (baby shampoo alternating with Sterilid along with heat and massage), lubricants (Hylo-Forte, NovaTears, and VitA-POS), and systemic checks for serum fasting lipid levels and vitamin D as she wanted to avoid topical steroids.

Initial Follow-Up

She was marginally better after six weeks, with reduced eyelid sticking with VitA-POS but found Hylo-Forte drying and reverted back to Viscotears, aided by NovaTears on top. She reported that her allergic symptoms, however, had increased in the meantime.

She was also noted to have hypercholesterolemia and vitamin D deficiency.

Examination

Advanced testing revealed aqueous deficiency at 1 mm in five minutes (without local anaesthetic) after a Schirmer’s test.

Bulbar redness scores from keratography imaging were RE 2.8 and LE 2.0 (Figures 1A and 1B). Tear meniscus height was low (0.22 mm RE, 0.24 mm LE). Non-invasive TBUT RE 6.50 secs LE 7.46 secs (Figures 2A and 2B). Meibography demonstrated lower lid gland dropout (Figures 3A and 3B). Lipid layer video review revealed thickened in parts with slow spreading.

Figure 1A and 1B.

Figure 2A and B

Figure 3A and B.

Subsequent Management

Ms Braun was sent back to her general practitioner to address hypercholesterolemia and low vitamin D levels. She was started on Cromo-Fresh eye drops, twice a day, along with FML four times daily and Hycor instead of VitA-POS at night to taper off over four weeks. Viscotears and NovaTears were continued and Lacritec (counselled on blood thinning properties) were started, at three times/day.

Subsequent Follow-Up

Ms Braun reported acceptable ocular surface comfort one week off steroids. She continued to use Viscotears and NovaTears (prior to the advent of NovaTears + Omega-3) along with VitA-POS and Lacritec twice a day.

Ms Braun said she was keen for pterygium excision and a conjunctival autograft.

Post-Op

Following recent surgery, Ms Braun is using Viscotears, NovaTears + Omega-3, Ikervis on her right eye and VitA-POS (nightly) to maximise three layers of tear film health with topical non-steroidal anti-inflammatory control. She uses Cromo-Fresh and Claratyne in the afternoon, and Lacritec twice per day, tolerated along with sea buckthorn oil once per day.

Case Three: Collaborative Cataract Case: An Optometrist’s Perspective

WRITER: Cassandra Ly

Optimising the ocular surface before cataract surgery is important because untreated dry eye can affect pre-operative measurements, visual outcomes, and patient satisfaction. This case report demonstrates how collaborative management between an optometrist and surgeon improved symptoms and facilitated successful cataract surgery in a patient with longstanding evaporative dry eye disease.

Johnny Smith,* a 68-year-old male retired bus driver, presented for cataract assessment, reporting worsening distance and near vision, more noticeable in the left eye. He also reported dry eye symptoms for 20 years and had rosacea.

Mr Smith’s medications included perindopril, amlodipine, and allopurinol for blood pressure control and gout. He had previously used lubricating eye drops as required, with variable relief.

Dr Kenneth Ooi discussed cataract surgery with the patient in the context of longstanding dry eye, explaining that surgery may worsen ocular surface symptoms.

Examination

A comprehensive assessment found unaided visual acuity was RE 6/24, LE 6/36, improving to 6/9 with pinhole in both eyes.

Intraocular pressures were RE 19 mmHg and LE 17 mmHg using non-contact tonometry.

The patient’s OSDI score was 57.5, consistent with severe symptoms.

TBUT was RE 8 seconds, LE 10 seconds.

Schirmer testing, measured after five minutes with local anaesthetic, was RE 6mm and LE 9mm.

Slit lamp examination revealed ocular rosacea with inferior lid telangiectasia, mild anterior blepharitis, and moderate MGD, greater superiorly in both eyes.

Lid-parallel conjunctival folds were greater nasally than temporally in both eyes, with Grade 1 temporal superficial punctate keratitis in RE.

Lens assessment revealed moderate bilateral nuclear sclerosis and dilated fundus examination was unremarkable apart from mild age-related drupelets.

The findings and proposed ocular surface optimisation plan were communicated to Dr Ooi. Given the severity of symptoms and evident MGD, Dr Ooi and I agreed to commence a structured pre-operative dry eye regime prior to surgery.

Management focused on education, adherence, and pre- and postoperative consistency. The patient was counselled to continue lid hygiene using lid wipes, commence warm compresses followed by lid massage twice daily, and maintain his dietary omega-3 intake twice weekly. NovaTears was recommended four times daily in both eyes, starting one week prior to surgery and continuing post-operatively. NovaTears was selected because its perfluorohexyloctane formulation targets excessive tear evaporation and lipid layer instability, which were considered key contributors to this patient’s symptoms and signs.^1,2

At one day post left cataract surgery, after one week of treatment, the OSDI score had improved slightly to 52.5. After one week postoperatively (and two weeks of maintaining the regime), the OSDI had improved substantially to 17. Anterior blepharitis had resolved, inferior lid telangiectasis remained the same, and tear meniscus height was 0.22 mm in both eyes. TBUT measured RE 5 seconds and LE 10 seconds. While some variability in objective measurements was observed, tear film stability remained unchanged in the operated eye despite expected transient post-operative ocular surface changes. Right corneal superficial punctate keratitis had resolved, although Grade 1 superior temporal was noted in the left eye. Schirmer values relatively unchanged RE 5mm and LE 6mm, consistent with the treatment targeting tear film evaporation rather than aqueous tear production.

Although objective measurements demonstrated some variability, the marked reduction in OSDI score and increased patient comfort highlighted the clinical value of symptom improvement. Addressing the ocular surface before surgery also increased patient confidence and contributed to a smoother postoperative experience. This case report displays the importance of identifying and treating evaporative dry eye disease before cataract surgery. Through patient education, targeted management, and communication between optometrist and surgeon, substantial symptom improvement can be achieved.

*All patient names changed for anonymity.

References

1. Schmidl D, Bata AM, Garhöfer G, et al. Influence of perfluorohexyloctane eye drops on tear film thickness in patients with mild to moderate dry eye disease: A randomized controlled clinical trial. J Ocul Pharmacol Ther. 2020 Apr;36(3):154-161. doi: 10.1089/jop.2019.0092.
2. Bacharach J, Kannarr SR, White DE, et al. Early effects of perfluorohexyloctane ophthalmic solution on patient-reported outcomes in dry eye disease: A prospective, open-label, multicenter study. Ophthalmol Ther. 2025 Apr;14(4):693-704. doi: 10.1007/s40123-025-01097-z.

This article is sponsored by AFT Pharmaceuticals, distributor of NovaTears.

Shao Ling BPharm (Hons) PGCertClinPharm is the Global Clinical Educator at AFT Pharmaceuticals, where he leads the development of high-impact educational content, drives medical marketing initiatives, and provides expert clinical support.

Ambiga Theivendradas BOptom GCertClinEd is a Senior Clinical Teaching Instructor at Melbourne Eyecare Clinic, within the Department of Optometry and Vision Sciences at The University of Melbourne. She has over 10 years of experience providing eye care in private practice. Ms Theivendradas has a special interest in dry eye disease and is involved in the management of complex dry eye presentations while educating and mentoring optometry students in evidence-based dry eye assessment and treatment.

Dr Kenneth Ooi MBBS (Adel) MSurg (Ophth) FRANZCO is a consultant general ophthalmologist and cataract and refractive laser surgeon, practising in Sydney. Dr Ooi is a Clinical Senior Lecturer at the Save Sight Institute, Sydney Eye Hospital Campus and is a Conjoint Lecturer at the School of Medical Sciences, UNSW. He holds an international patent for a novel dry eye drop – Topical Atorvastatin for blepharitis and dry eyes – and is currently conducting dry eye research through the Save Sight Institute, University of Sydney.

Cassandra Ly BVisSci MOptom is a clinical optometrist practising at the Sydney Eye Clinic in Brookvale and Darlinghurst, New South Wales. She collaborates closely with ophthalmologists in the assessment and co-management of patients across general ophthalmology, including evaluation for refractive surgery and ongoing patient care