The American Academy of Ophthalmology (AAO) is the largest association of eye physicians and surgeons globally. Their mission is to protect vision and enhance quality of life by establishing the benchmarks for ophthalmic education and championing the interests of patients and the general public.  

AAO regularly releases Preferred Practice Pattern® guidelines (PPP) aimed at defining the key characteristics and elements of high-quality eye care. These guidelines are crafted by a team of experienced ophthalmologists, methodologists, and other experts in the field, utilizing the most up-to-date scientific research available. PPPs offer valuable insights into best practices for eye care, focusing on the overall pattern of practice rather than individual patient care.

In this edition of our Guidelines Timelines Series, we will be reviewing the AAO Dry Eye Syndrome Preferred Practice Pattern from 2018 versus the current iteration from 2024. While we won’t cover everything in the guidelines, we will cover some of the highlights and key takeaways. Without further ado, we’ll go ahead and dive in! 

AAO Dry Eye Syndrome Guidelines (2023 and 2018)

Major Changes & Key Takeaways: 2023 vs 2018

Both guidelines emphasize that dry eye syndrome is a prevalent ocular condition that significantly affects the quality of life of those affected due to discomfort and visual impairment. Dry eye can also impact the outcomes of cataract, corneal, and keratorefractive surgeries.

It is important to highlight that the latest version emphasizes the significance of clinical examination as the gold standard for diagnosing dry eye syndrome, also known as dry eye disease or keratoconjunctivitis sicca.

Medication Updates

US Food and Drug Administration (FDA) approved several treatments for dry eye syndrome since the 2018 version, including:

  • EYSUVIS (loteprednol etabonate ophthalmic suspension
    • Kale Pharmaceuticals (Acquired by Alcon Inc.)
    • Approved for dry eye disease in October 2020
    • Eysuvis was the first corticosteroid eye drop to be approved by the FDA for the short-term treatment of dry eye disease in 2020.

  • TYRVAYA® (varenicline solution) nasal spray
    • Oyster Point Pharma (Acquired by Viatris Inc.)
    • Approved for dry eye disease in October 2021
    • It is a cholinergic agonist indicated for the treatment of the signs and symptoms of dry eye disease.

  • MIEBO™ (perfluorohexyloctane ophthalmic solution)
    • Bausch + Lomb
    • Approved for dry eye syndrome in April 2023
    • It is a semifluorinated alkane indicated for treatment of the signs and symptoms of dry eye disease.

  • VEVYE™ (Cyclosporine Ophthalmic Solution)
    • Novaliq (Acquired by Harrow)
    • Approved for dry eye syndrome in June 2023
    • It is the first and only water-free cyclosporine dissolved in a semifluorinated alkane approved to treat both the signs and symptoms of dry eye disease.

According to the Dry Eye Syndrome PPP 2023, treatment options include topical loteprednol 0.25%, lifitegrast 0.5%, cyclosporine 0.05% and 0.09%, varenicline nasal spray, and perflurohexyloctane ophthalmic solution. These treatments have shown potential for improving patient symptoms and/or signs, however, there is no definitive evidence to suggest that one is more effective than the others in head-to-head trials. Unfortunately, there is a lack of direct comparison in prospective clinical trials available in the literature.

Also noted in the 2023 PPP that recent research has revealed that about 10% of patients diagnosed with clinically significant aqueous tear deficiency dry eye also have underlying Sjӧgren’s syndrome. Additionally, a meta-analysis has shown that among autoimmune diseases, primary Sjӧgren’s syndrome is the most strongly linked to lymphoid proliferative malignancy.

Both the 2018 and 2023 guidelines, highlight:

  • Patients with dry eye syndrome who are considering keratorefractive or lens-based surgery should be aware that their dry eye symptoms may worsen following the procedure. It is important to address any pre-existing factors that contribute to dry eye syndrome before undergoing surgery in order to minimize the risk of exacerbating the condition. While dry eye symptoms are common in the initial months post-surgery, they typically improve over time.
  • Dry eye syndrome is a common cause of patient dissatisfaction after intraocular refractive and/or cataract surgery. Research shows that approximately one third of individuals experience dry eye symptoms that persist beyond the typical postoperative period of 3 months. It has been found that baseline ocular surface and tear film parameters can help predict which patients are at risk for developing dry eye. Therefore, it is essential for all patients undergoing lens-based surgery to be assessed and treated for dry eye both before and after the procedure.

Thank you for following along with our Guidelines Timelines Series on AAO Dry Eye Syndrome Preferred Practice Pattern. Sign up for alerts and stay informed on the latest published guidelines and future installments of our Guidelines Timelines.

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