Dry Eye Journal #1: Sometimes Less Is More

All case studies are published with the patient's knowledge and consent. Identifying details have been withheld.

Presentation

A 29-year-old presented to Spectacle with a long history of severe dry eye symptoms — persistent discomfort, redness, and fluctuating vision that had been significantly affecting their daily life. They had already sought help elsewhere, and arrived carrying a bag of four different prescribed eye drops, all of which they were using regularly.

The first thing that caught my attention wasn't the dryness. It was the drops.

Every single one of them contained benzalkonium chloride — the preservative found in the majority of multi-dose eye drop formulations. As I've written about previously, BAK is a detergent that at repeated doses is directly toxic to the ocular surface. It disrupts the tear film's lipid layer, damages the goblet cells responsible for mucin production, and over time causes measurable surface damage. This patient was applying it to already-compromised eyes, four times over, every day.

Sometimes the treatment is the problem.

The images below were taken on presentation using fluorescein dye under cobalt blue light — damaged areas of the eye's surface absorb the dye and fluoresce brightly, showing the extent of the problem directly.

[clinical] Diffuse punctate corneal staining on presentation — widespread epithelial damage visible across the entire corneal surface

[clinical] Inferior conjunctival staining on presentation — significant epithelial damage with mucous debris along the lower lid margin

[clinical] Extensive inferior conjunctival staining showing a 'crazy paving' pattern — indicating severe, widespread epithelial surface disruption

Step One — Stopping Everything

After a full anterior segment examination and tear film assessment, we made a decision that can feel counterintuitive: we stopped all of their current drops and asked them to return in two weeks with nothing in their eyes.

This isn't a decision to take lightly. Patients understandably feel anxious about stopping treatment, particularly when their symptoms are severe. The conversation matters — explaining why, what to expect, and what we're looking for at the review.

At the two-week follow-up, the ocular surface looked meaningfully better than it had on presentation. The chronic insult of the preservatives had been removed, and the surface had started to recover. Symptoms hadn't resolved — there was still visible inflammation and dryness — but the baseline had shifted in the right direction.

[clinical] Two weeks after stopping all preserved drops — the diffuse corneal staining has reduced considerably, though some inferior staining persists

Step Two — Addressing the Inflammation

With the confounding factor of the preserved drops removed, we could now see clearly what we were dealing with: active ocular surface inflammation alongside tear film instability. The inflammation needed addressing directly.

A two-week course of preservative-free topical steroids was prescribed. These work by suppressing the inflammatory cascade at the surface — reducing the redness, the sensitivity, and the cellular damage that inflammation perpetuates. The response was considerable. By the end of the course the eyes looked and felt substantially improved.

Step Three — Maintenance

With the inflammation brought under control, we introduced a preservative-free lubricating drop three times daily to support the tear film during recovery. Initially, this held things well.

Over the following weeks, however, the familiar pattern began to return. The inflammation and dryness crept back gradually — the underlying condition reasserting itself despite the lubricants. It became clear that drops alone weren't going to be sufficient long-term management for this patient.

Step Four — Omnilenz

After careful discussion about the options available, the patient was interested in trying an Omnilenz therapeutic lens. The Omnilenz is a contact lens inserted directly onto the eye that contains amniotic tissue — the innermost layer of the placenta, which is rich in growth factors, anti-inflammatory proteins, and healing compounds that have been used in ophthalmology for decades to support ocular surface recovery. Once in place, the amniotic tissue is gradually absorbed by the eye, slowly releasing these healing factors over the wearing period. It is particularly suited to patients with significant ocular surface disease where standard drops and anti-inflammatory treatments have provided only temporary relief.

One thing worth setting expectations around: the benefits of Omnilenz are rarely immediate. On removal, the eye may look and feel similar to before. The improvements tend to emerge gradually over the following weeks as the healing factors take effect — and when they do come, they can be long-lasting.

The lens was fitted and left in situ for two weeks before removal — one eye at a time, to allow comparison of the treated and untreated surface.

[clinical] The Omnilenz in situ — the amniotic membrane contact lens sits on the ocular surface, with conjunctival injection visible indicating the active inflammatory state being treated

The Result

The improvement to the surface integrity is visible directly in the fluorescein image taken one week after removal — and reflected in the patient's symptoms. The chronic redness, the surface staining, and the subjective discomfort all showed meaningful improvement, with further gradual recovery continuing in the weeks that followed.

[clinical] One week after Omnilenz removal — the corneal surface is substantially clearer, with the diffuse punctate staining largely resolved compared to presentation

Lifestyle

Treatment alone rarely tells the full story. Throughout our time together, we discussed lifestyle factors that were almost certainly contributing to the severity of the condition — extended hours at a screen with reduced blink rate, inconsistent and shortened sleep, and an irregular diet. None of these are easy to change, and this isn't about blame. But a dry eye assessment that ignores these factors isn't a complete one. Managing the eye surface without addressing what's driving the inflammation is treating the symptom, not the cause.

What This Case Illustrates

A few things stand out from this patient's journey that are worth highlighting:

Preserved drops in a compromised eye can perpetuate the very problem they're supposed to treat. When someone presents with severe dry eye who is already on multiple drops, reviewing those drops — particularly their preservative content — is as important as assessing the eye itself.

A careful washout period has diagnostic as well as therapeutic value. Removing the preservative burden clarified what we were actually treating and allowed the surface to begin recovering before we introduced anything new.

Inflammation and dryness are often intertwined. Managing one without the other rarely achieves lasting improvement. In this patient, addressing the inflammation first created the conditions in which lubricant therapy and then the Omnilenz could be effective.

Patient age matters. Severe dry eye in a 29-year-old warrants thorough investigation. This isn't a condition to manage indefinitely with over-the-counter drops — it's worth understanding what's driving it and treating the cause, not just the symptoms.

If you're managing dry eye symptoms that haven't responded well to drops you've been prescribed or bought yourself, it may be worth a fresh assessment. We offer dry eye consultations from £80, including a full tear film evaluation and imaging.

Danish Sheikh BSc(Hons) MCOptom DipTp(IP) is an independent prescribing optometrist and dry eye specialist at Spectacle, Claygate, Surrey.