Part 1: The Paradigm Shift in Treating Dry Eye


In part one of a two–part series, Josh Johnston, OD discusses the paradigm shift in treating patients with dry eye.

Treating dry eye disease (DED) has truly evolved over the past years, and even more so recently with new diagnostics, therapies and FDA-approved drugs. We all know DED is progressive and can be hard to treat, which is actually one of the reasons I like it so much. It’s an exciting time for those of us treating DED. The paradigm shift has changed and there are new, novel products and therapies at our disposal that allow us to provide better options to patients and improve clinical outcomes.

red eyeOur practice has 15 doctors – eight MD’s, seven OD’s, with two resident optometrists. I run our dry eye clinic, and one of our goals has been to increase internal and external referrals. Our doctors, website, social media, advertisements, and search engine optimization has helped drive patients into our dry eye clinic, many of whom have sought help at other practices to no avail, and are often frustrated and further down the pathology path as far as severity.

We typically start with the SPEED questionnaire. Our technicians then take the patient to an exam room and do LipiView® and LipiScan™, InflammaDry® testing, and tear osmolarity testing in both eyes. From there the patient comes to see me where I review the data, and do fluorescein staining, lissamine staining, perform a tear breakup time (TBUT), lid closure evaluation and meibomian gland expression. This is our baseline dry eye exam – all of the tests that, when combined, help point me in the direction of a diagnosis. I then put the patient into one of four categories (similar to DEWS), with four being the most severe on the “spectrum”, and then determine the most appropriate treatment.

Download the

Level one patients don’t get much treatment beyond artificial tears. Level two usually starts with cyclosporine, or Xiidra®, and other adjunctive therapies. I consider a patient to be level three when they have more diffuse punctate keratiitis staining, filamentary keratitis, severe symptoms and patients with decreased vision. I typically think of PROKERA for those patients that fall into a level three or four, so those that have more severe, corneal involved dry eye. We also talk to patients about the overall health of their eyelids and examine their lashes, and recommend Cliradex Light for lid hygiene and Cliradex for cases of Demodex.

Many patients we see have tried various treatments or others may still have mild to moderate dry eye, but we want to try to prevent this from progressing over time. As we all know, there is no magic bullet or cure, and treating dry eye isn’t as efficacious as other things we do in eye care. For me, education is key. I spend time explaining why they have dry eye, the severity, and risk factors, and then recommend treatment. I find if you do this initially, patients will understand and feel validated as many have been suffering for a while and in some cases their complaints have been dismissed. All of this ties into the treatment plan and ultimately increases compliance and leads to better outcomes.

One of the great things I have found about offering PROKERA is when I tell patients about it, they are excited to hear about something novel and different. Many of these patients have been suffering for quite some time and are desperate for relief. PROKERA is a great tool that can offer long-lasting relief to patients because it heals the ocular surface quickly rather than just temporarily relieving symptoms. Our patients really like learning about the technology, how it was developed, and the science behind the healing properties and regenerative effects. Telling patients you are healing their cornea, which has nothing to do with producing more tears, and that this is truly a new and different plan of attack, can be very motivating for patients.

Download the


Josh Johnston, ODJosh Johnston, OD, FAAO practices at Georgia Eye Partners where he is Clinical Director, Residency Director and oversees the practice’s Dry Eye Clinic, one of Bio-Tissue’s Dry Eye Centers of Excellence (DECE). His clinical focus is on ocular surface disease, including dry eye and other corneal diseases, and his background includes extensive experience co- managing surgical patients before and after LASIK, cataract and other advanced corneal and refractive surgical procedures.