Can the optimum artificial tear treatment for dry eye disease be predicted from presenting signs and symptoms?

Purpose: To assess dry eye treatment with four preservative-free dry eye artificial tear treatments to facilitate evidence-based prescribing. Methods: A randomised, single masked crossover trial of Clinitas Soothe, Hyabak, Tears Again and TheraTears artificial tears was conducted on 50 symptomatic dry eye patients, aged 60.8 +/- 14.2 years. At baseline and after trialling each treatment for 4 weeks, signs and symptoms were assessed using the Ocular Surface Disease Index (OSDI), non-invasive tear break-up time, fluorescein tear break-up time, tear meniscus height (TMH), Phenol Red test, lid-parallel conjunctival folds (LIPCOF), ocular surface staining, and lipid layer grading and osmolarity (baseline visit only). Results: OSDI (p = 0.002), LIPCOF (p = 0.014) and conjunctival staining (p < 0.001) significantly improved from baseline, however, the impact of each dry eye treatment on ocular symptoms and signs was similar. Clinitas Soothe and Hyabak were preferred by 34%/30% of participants, but only subjective comparison with the other drops influenced this choice. TheraTears was preferred (by 24%) by those with a lower baseline tear volume (p = 0.01) and Tears Again (by 12%) by those with a thinner baseline lipid layer (p = 0.04). The treatment that afforded the greatest improvement in clinical signs did not consistently match each individual's preferred treatment. Conclusions: If prescribed to a general dry eye population, the artificial tears performed similarly, improving symptoms and conjunctival signs. However, osmolarity balanced artificial tears were the preferred treatment in individuals with low baseline tear volume and lipisomal spray for individuals with a baseline lipid layer deficiency.