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 Table of Contents  
Year : 2021  |  Volume : 59  |  Issue : 3  |  Page : 241-249

Current approach in surgical management of dry eyes – Dry eye review II

1 Consultant, Department of Cataract, Cornea and Refractive Services, Puducherry, India
2 Consultant Cataract, Pediatric Ophthalmology and Strabismus Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Puducherry, India

Date of Submission07-May-2021
Date of Acceptance09-Jun-2021
Date of Web Publication09-Sep-2021

Correspondence Address:
Dr. Bharat Gurnani
Consultant Cornea and Refractive Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Puducherry - 605 007
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_56_21

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Dry eye is a multifactorial disease of the tear film and ocular surface that manifests with symptoms of irritation, heaviness, visual acuity disturbance, and tear film instability with substantial damage to the ocular surface. It is characterized by inflammation of the ocular surface and increased osmolarity of the tear film. Due to the multifactorial and wide spectrum of etiology, it is often challenging to treat dry eyes. Comprehensive knowledge of pathophysiology, factors contributing to the disease process, and etiology of dry eye disease leads to more efficient management and treatment of the disease process. However, the treatment is marked by regional variation and differs among clinicians and ocular societies in terms of treatment options and diagnostic modalities available. Our previous review article was an intricate review of dry eye definition, epidemiology, classification, causes, diagnostic tests, management, and future trends of dry eye disease. This article will detail all the surgical management options available for dry eyes and recent upcoming modalities. This review aims to enlist all the surgical management options in a nutshell so that all the treating ophthalmologists, clinicians, cornea specialists, and dry eye experts have a detailed idea of the same and this article serves as a reference for better patient care.

Keywords: Dry eye, dry eye syndrome, multifactorial disease, surgical treatment

How to cite this article:
Gurnani B, Kaur K. Current approach in surgical management of dry eyes – Dry eye review II. TNOA J Ophthalmic Sci Res 2021;59:241-9

How to cite this URL:
Gurnani B, Kaur K. Current approach in surgical management of dry eyes – Dry eye review II. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2021 Dec 1];59:241-9. Available from: https://www.tnoajosr.com/text.asp?2021/59/3/241/325738

  Introduction Top

As per the 2017 International Dry Eye Workshop II report, dry eye is “a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.”[1] The dry eye syndrome usually presents with signs and symptoms such as foreign body sensation, heaviness in eyes, ocular irritation, grittiness, pain, redness, excessive tearing, photophobia, and restriction of daily activities affecting the well-being.[2] Advanced cases usually result in persistent epithelial defects, keratitis,[3] and limbal stem cell deficiency. A detailed literature review reveals the new concepts of the pathogenesis of dry eye to be caused by inflammation mediated by T-cell lymphocytes.[4],[5] The term “multifactorial disease” implies that dry eye disease (DED) is a complex functional disorder involving various signs and symptoms resulting from the interplay of various complicated processes.[6] The tear film, lacrimal glands, meibomian glands, cornea, conjunctiva, and eyelids all are enlisted the common term “ocular surface.”[7] The pathophysiological process which triggers the vicious cycle of DED includes inflammation, tear film instability, hyperosmolarity, and ocular surface damage.[8] Moreover, neuronal involvement and neurosensory abnormalities do have an important contributing role in the pathophysiology of DED.[6] DED can be broadly classified as aqueous deficient dry eye (ADDE) and evaporative dry eye (EDE); this classification is often used to make the diagnosis and identify the treatment modality.[9],[10] In the majority of patients with mild-to-moderate grade aqueous-deficient dry eye, pharmaceutical tear substitutes, and lubricants are used to control symptoms and prevent ocular surface damage.[11] However, in severe dry eye conditions caused by cicatricial disorders, such as Stevens–Johnson syndrome[12] and ocular cicatricial mucous membrane pemphigoid,[13] noninvasive treatments are insufficient, and patients are at risk of developing complications that can lead to blindness. The severe dry eyes usually require surgical intervention for correction of the disease process. This review aims to highlight the surgical management of dry eyes in detail along with areas of future research in dry eye disease.

  Literature Search Top

A systematic and detailed literature search was done using PubMed, Google Scholar, ePub, and Cochrane Library databases. The first step was oriented to search articles published for dry eyes AND (surgical treatment) AND (recent updates), surgical management of dry eyes, and dry eye disease management. The most relevant articles were reviewed from various national and international journals. A total of 152 articles were searched shortlisted, out of which 52 articles were selected and included based on the relevance and the rest 102 articles were excluded based on similar literature. The search strategy was not limited only by the year of publication. A manual literature search was also performed from authentic reference books on ocular surface diseases (OSDs) catering to surgical management of dry eyes.

  Surgical Treatments Available for Dry Top

Besides conservative management, the treatment of dry eyes can be grouped into (a) outpatient department (OPD)-based treatment or in-office procedure, (b) surgical treatment, and (c) other advanced surgical options. A flowchart showing surgical management options for dry eyes is given in [Figure 1].
Figure 1: The flowchart for surgical management for dry eyes

Click here to view

In-office procedures

The in-office procedures available for the treatment of dry eye disease include the following:

LipiFlow-Vectored thermal pulsation

LipiFlow (TearScience Inc., Morrisville, NC, USA) thermal pulsation, is a device used for thermal and mechanical stimulation of inner eyelids and has been employed in OPD settings to treat the blocked meibomian glands.[14] This is a newer upcoming promising treatment that uses thermal energy to melt the oily secretion and unblock glandular plugging by increasing the temperature of meibomian glands in patients with meibomian gland dysfunction (MGD) from the inner surface of the eyelid.[14] Kim et al. in their retrospective analysis of 189 eyes showed that in 39 eyes with abnormal tear film osmolarity (defined as >307 mOsms/L), vectored thermal pulsations significantly improved osmolarity from an average of 317.1 to 306.6 mOsms/L (P = 0.002). In the same analysis, matrix metalloproteinase (MMP)-9 assays were raised in 50% of 114 eyes pretreatment as compared to 26% of eyes posttreatment (P < 0.0001).[15] Lane et al. in early 2012 showed the positive results of LipiFlow™ use as compared to hot fomentation in improving both signs and symptoms of DED.[14] Few other studies have confirmed the benefits of LipiFlow™. According to some recent analyses, a single treatment's effects lasted for 6–9 months or longer.[16],[17],[18],[19] Hagen et al. compared a single LipiFlow™ sitting to a 3 month treatment course of doxycycline for the treatment of 28 patients with MGD.[20] Posttreatment, Standard Patient Evaluation of Eye Dryness (SPEED) scores improved in both groups but were significantly better in the LipiFlow™ group as compared to the doxycycline group (5.42 vs. 9.42, P = 0.030). These results suggested that LipiFlow™ may be a preferred treatment alternative for DED patients with MGD, thus avoiding the potential side effects and complications of long-term macrolide therapy.[20]

Meibomian gland probing (Maskin probe or hyfrecator probe)

First reported in 2010 by Maskin, a novel probing technique for treating MGD using a 2-mm solid stainless steel beveled probe inserted directly into meibomian gland orifices.[21] In this technique, intraductal probing is attempted to open the scarred orifices of the meibomian gland. The procedure is performed usually in an outpatient setting under local anesthesia with all aseptic precautions. The Maskin or the hyfrecator tip is used to release the contents of the meibomian glands. The success is determined by the appearance of a faint petechial hemorrhage at the orifices of meibomian glands. This is a method to rehabilitate the ocular surface. In 2010, Maskin showed that 24 out of 25 patients had prompt relief in tenderness and all showed full relief 4 weeks later. Retreatment was attempted only in 5 of the patients with a mean follow-up of 11.5 months.[21],[22] In 2018, in his other report on postprobing meibography on 50 eyelids (28 patients) he showed that 36% of lids had gland growth and 13 lids had a 6.23% increase in mean gland area. He concluded that not only there is a lengthening of shortened glands but also partial restoration of faded glands and proposed the idea of possible new gland growth.[48] Incekalan et al. examined both effectiveness and speed of relief among 80 eyes treated with either conventional meibomian gland disease treatments or a combination of conventional treatments above with a single session of intraductal meibomian gland probing performed at the first visit.[23] Their analysis showed that the subgroup treated with probing had significantly faster improvement in all measurements.[23]

Meibomian gland liquefaction and expression (MiBo Thermoflo)

The MiBo Thermoflo (MiBo Medical Group, Dallas, TX, USA) helps by increasing meibomian gland liquefaction and secretion, further enhancing the tear film quality and dynamics in DED patients.[24] Before application, the lid is coated with ultrasound gel and then the handheld probe is used to massage the external lid for approximately 10 min.[24],[25] Two sittings are recommended 2 weeks apart. Trails have demonstrated increased tear break-up time (TBUT), osmolarity, Ocular Surface Disease Index (OSDI), and SPEED, 4 months posttreatment in 51 patients. However, in a case report by Kenrick and Alloo, the treatment did not show any promise. A randomized trial is still lacking to investigate this instrument further.[26]

TearCare system

The TearCare system (Sight Sciences, Menlo Park, CA, 2019, USA) is a combination of the therapeutic effect of warm compress therapy with manual meibomian gland expression to treat MGD. This works by the placement of single-use, flexible iLid™ clinical trial applicators over each tarsal plate which deliver constant, regulated heat at 41°C–45°C over a 12-min treatment time, during which the patient is told to blink normally to allow natural meibum expression.[6] The next step is a manual meibum expression by the physician. The study conducted by the manufacturers on 24 patients demonstrated that on a 4-week follow-up visit, mean TBUT increased by 11.7 ± 2.6 s in the TearCare group as opposed to a decrease of 0.3 ± 1.1 s in the warm compress group (P < 0.001) with statistically significant results maintained over the 6-month follow-up period. TearCare group patients also showed a statistically significant improvement in conjunctival and corneal staining as well as subjective symptoms as measured by the SPEED, OSDI, and SANDE questionnaires over the entire 6-month follow-up period.[6],[27] Larger, randomized, control clinical trials are needed in the future to further evaluate the efficacy and safety of the TearCare® system.

Lid-margin scrubbing (BlephEx)

BlephEx™ (Scope Ophthalmics, London, UK) is used for blepharitis treatment as an add-on supplement to lid scrubs. It has a disposable handheld single application medical-grade microsponge to remove the debris from eyelashes and lids. Connor et al. in their prospective study demonstrated the positive effects of BlephEx™ in treating dry eye symptoms; in the small study of 20 patients, the authors found that MGD and blepharitis grading (using Efron Grading Scale), TBUT, and OSDI improved significantly 4 weeks after BlephEx™ treatment compared to baseline.[28] In another report, the same group separately reported a group of 10 patients who tested positive for MMP 9 who were subsequently treated with BlephEx™ and all found to be negative for MMP 9 after treatment.[29] A large randomized, masked, clinical trial is still needed to further investigate the safety and efficacy of the treatment compared to other blepharitis treatments.

Intense pulsed light therapy

Intense pulsed light (IPL) therapy is a novel treatment for EDEs. The filters in the IPL handpiece cause the light emitted from the flash lamp to be absorbed by oxyhemoglobin. The emitted light is converted to heat which in turn causes the ablation of vascular structures. This process of photothermolysis is the suggested mechanism of IPL in dry eyes. By this mechanism, blood vessels are destroyed by targeting the chromophores in blood vessels. The destruction of telangiectasias vessels prevents the access of inflammatory mediators into the meibomian glands. Additional mechanisms include the local warming effect causing meibum expression through the glands and eradication of bacteria plugged in the glands.[30]

The light is converted to heat-inducing ablation of vascular structures. This by the process of photothermolysis selectively destroys blood vessels by targeting chromophores within the blood vessels. The infiltration of inflammatory mediators to the meibomian glands is prevented by destroying the telangiectatic vessels along the eyelid. Other proposed mechanisms include a mild local warming effect to allow better expression of meibum and destruction of bacteria that cause inflammation at the level of the meibomian glands. IPL helps by improving the dysfunction of the meibomian glands.[31],[32],[33],[34],[35],[36]

The various proposed mechanisms are the following:

  1. Meibomian gland warming to melt and express the meibum[37]
  2. Functional improvement of the meibomian gland[38]
  3. Intravascular thrombosis of the small blood vessels, telangiectasia of the eyelid margin, reducing the levels of proinflammatory mediators that contribute to dry eye[32],[33]
  4. Neurotrophic effect on the cornea and a neuroimmunomodulatory effect on the meibomian glands[39],[40]
  5. Decreasing tear osmolarity, helping to control the inflammation of the ocular surface[41]
  6. Alleviating cellular functions such as collagen biosynthesis, fibroblasts regeneration, and motility in immunoregulatory cells[42],[43]
  7. Reduction of inflammation by reducing the load of Demodex mites.[44]

Mechanical and therapeutic devices

  Intranasal tear neurostimulator (TrueTear) Top

Intranasal tear neurostimulator (ITN, TrueTear®, Allergan, plc), a Food and Drug Administration-approved treatment for aqueous tear deficiency DED, benefits by stimulating the mucosal nerves via small electrical currents to increase natural tear production via the nasolacrimal reflex pathway of the lacrimal function unit. The device is made up of two small probes, one for each nostril, with five levels of stimulation intensity to be selected by the user. Some of the commonly reported side effects of the device are burning sensation, pain, epistaxis, nasal discomfort, congestion, headache, and facial pain. Few of the important contraindications are patients with pacemakers, implantable defibrillator, metallic devices, chronic nasal conditions like allergic rhinitis, nosebleeds, etc.[45]

  Mechanism of action Top

To understand the mechanism of ITN, we must understand first the lacrimal functional unit. It consists of the lacrimal gland, accessory lacrimal glands, conjunctiva, cornea, goblet cells, and sensory and motor nerve for maintaining tea production, quality, and quantity. The afferent fibers include branches of ophthalmic and maxillary branches of the trigeminal nerve with additional nerves in the nasal mucosa. Stimulation of these nerves increases tear production and lack of stimulation causes reduced production, for example, trigeminal neuralgia, trigeminal nerve paralysis secondary to parotidectomy, tracheostomy, etc.[46]

Sheppard et al. in their first trial depicted that mean Schirmer's scores were significantly greater with active intranasal (25.3 ± 1.5 mm) versus extra nasal (9.5 ± 1.2 mm) and sham (9.2 ± 1.1 mm) applications (P < 0.001).[47] In their second clinical trial, subjects used the device 2–10 times daily for 6 months. At follow-up, stimulated Schirmer's scores were significant as compared to unstimulated scores (17.3 ± 1.3 mm vs. 7.9 ± 0.7 mm, P < 0.0001).[47] Gumus et al. in their analysis showed that a single intranasal application of the ITN increased tear meniscus height by 28.8% in dry eye patients.[48] Degranulated to nondegranulated goblet cell density ratios in dry eye patients increased to 4.71 ± 4.48 when compared to baseline (0.74 ± 0.62) and extra nasal (0.57 ± 0.54) application (P < 0.001).[48]

  Therapeutic eyewear Top

  1. Moisture chamber spectacles – These spectacles wrap around the eyes to retain moisture and protect again foreign body and irritants in dry eyes[49]
  2. Contact lenses[50] – Various types of contact lenses have also been tried; these are available in the following types:

  • Highly oxygen-permeable lenses (overnight wear)[51]
  • Gas permeable scleral-bearing hard contact lenses with or without fenestration[52]
  • Silicone rubber lenses[53]
  • Cryopreserved sutureless amniotic membrane (AM) is available as a 5- to 10-day contact lens.[54]

Surgical management

Lacrimal apparatus management

Punctal plugs – They help to achieve either partial or complete punctal occlusion with or without cautery and are an important aid in the treatment of dry eye disease. This is one of the most vital and practical therapies for conserving tears. The aim is to reduce the physiological outflow of the tear film down the nasolacrimal system.[55]

Available types include the following:[56]

  1. Absorbable plugs – These plugs are made of collagen or polymers that sometimes dissolve by themselves or may be removed by saline irrigation; the occlusion duration range is 7–180 days
  2. Nonabsorbable plugs – These plugs are made of silicone, two types of capped silicone punctual plugs, and intracanalicular silicon plugs
  3. Thermoplastic plugs (e.g. SmartPLUG; Medennium, Irvine, CA, USA) – These plugs are made up of a thermosensitive, hydrophobic acrylic polymer with a unique property to changes from a rigid solid to a soft, cohesive gel. This change occurred when the temperature changes from room temperature to body temperature
  4. Hydrogel plugs (e.g. Oasis Form Fit; Sigma Pharmaceuticals, Monticello, IA, USA).

Lid-based procedure


It denotes temporary or permanent closure of eyelids using bolster and sutures either totally or partially. The other methods by which this can be achieved include taping, glue, and Botox-induced ptosis. This helps by retaining the tear film, preventing drying and desiccation, and further improving the ocular surface lubrication. The main indications include persistent epithelial defects and severe ocular surface inflammation refractory conventional medical treatment. This is usually reserved as an end-stage treatment.[57] A study reported that about 20% of patients reported being unhappy with cosmetic appearance.[58]

Essential blepharospasm

It is the abnormal contraction of eyelid musculature. Also called benign essential blepharospasm, it a bilateral condition resulting from focal cranial dystonia resulting in episodic eyelid closure. A previous study reported a 40%–60% incidence of dry eyes and reduced Schirmer's secondary to blepharospasm. Another study reported increased tear film cytokines promoting inflammation secondary to epidermolysis bullosa. Botulinum toxin A has been tried for the treatment of dry eyes. It causes chemodenervation of the orbicularis muscle. It also causes increased tear film height, TBUT time, tear clearance and helps improve dry eye symptoms. However, the effects are temporary and need a repeat dose after 3 months. Several studies have reported worsening of dry eyes when the toxin is injected close to the lacrimal gland.[59],[60],[61],[62]


Dermatochalasis is described as the presence of loose and redundant eyelid folds of the skin. It is often seen in middle-aged and elderly people and is a common sign of periocular aging. The upper eyelid involvement is more than the lower eyelid.[63] In few cases, it is commonly associated with steatoblepharon (orbital fat herniation) and blepharoptosis. In the review by Tear Film Ocular Society, level 2 and 3 evidence has shown that 46%–51% of patients with dermatochalasis have dry eye symptoms and 55%–86% had subjective symptomatic improvement postupper eyelid blepharoplasty. However, objective improvement is minimal supporting it to be a psychological concept.[63],[64]

Blepharoptosis (ptosis)

Excessive friction and continuous rubbing of the upper eyelid with ocular surface secondary to dry eyes may result in disinsertion and thinning of levator aponeurosis, thus inducing ptosis.[65] Moesen et al.[66] in their trial revealed that a low Schirmer's score was more common on ptosis patients than in controls. Similarly, Watanabe et al.[67],[68] in their case series found a significant reduction in tear quality and quantity after surgical intervention.

Lower lid blepharoplasty

Aging results in lower lid laxity and ectropion. Transcutaneous lower lid blepharoplasty is the treatment of choice for ectropion and lower lid laxity.[69] Dry eye disease is a common occurrence postlid surgery and it is common for patients to complain of heaviness, dryness, and epiphora postsuccessful surgical lid intervention.[70] The most common cause of postoperative DED is lagophthalmos, lower eyelid malposition, ocular surface exposure, etc.[71],[72]

Conjunctival procedures


It is the loose, nonedematous, redundant, inferior bulbar fold of the conjunctiva. It is located between the globe and eyelid and encroaches over the limbus and cornea with lid movements. It is the result of aging and is an important cause of DED. The prevalence is 54% in patients in DED.[73] The severity of conjunctivochalasis is recorded by the lid-parallel conjunctival folds score and is positively correlated with more severe dry eyes. Epiphora, irritation, and dry eyes are major problems secondary to conjunctivochalasis and can be reversed by surgical correction of conjunctivochalasis. The conservative management includes lubricants, topical immunosuppressants, and punctual occlusion. If not responding to conservative management, the patient should be subjected to conjunctival resection. Other recommended treatment modalities are electrocoagulation, argon laser conjunctivoplasty, and thermal cauterization. In all studies (Level 3 evidence), some level of improvement in symptoms has been reported in over 75% of patients.[74],[75],[76]

Conjunctival surgery and amniotic membrane grafts

A number of conjunctival disorders, namely pterygium, pinguecula, Stevens–Johnson syndrome, ocular cicatricial pemphigoid, and limbal stem cell deficiency, are major causes of DED. The elastotic wing-shaped fibrovascular fold of conjunctiva encroaching over the cornea causes uneven tear film and evaporation over the ocular surface, thus increasing the severity of DED. The pterygium and pinguecula resection is indicated with conjunctival or AM grafting. Concurrent application of mitomycin C application further reduces the risk of recurrence, however can result in potentially serious complications such as scleral thinning, ulceration, and delayed conjunctival epithelialization. Ocular inflammation secondary to Stevens–Johnson syndrome and ocular cicatricial pemphigoid can be controlled by conjunctival resection which will further prevent dry eyes. However, the prerequisite is inflammation control by steroids and topical and systemic immunosuppression to prevent postoperative recurrence and reduce the severity of the disease.[77],[78]

Severe dry eyes can result in nonhealing epithelial defect, keratitis, corneal melt, and scarring. The treatment is AM grafts for persistent epithelial defects in cases of ocular cicatricial pemphigoid, Stevens–Johnson syndrome, and other severe OSDs. These membranes have a high concentration of neuropeptides and neurotransmitters, including acetylcholine and catecholamine to promote healing.[79],[80]

There are two types of amniotic membrane:

  1. Cryopreserved amniotic membrane: Cryopreserved AM, such as ProKera (BioTissue), and thinner PROKERA® SLIM (Bio-Tissue, Doral, FL, USA) are preserved and stored in a freezer. The membrane is held inside a thermoplastic ring that permits the device to be inserted similarly to a scleral lens and holds the tissue firmly in place. The graft dissolves after a week and the conformer later can be removed[81],[82]
  2. Dehydrated amniotic membrane: Dehydrated AM, such as AmbioDisk (IOP Ophthalmics), are dehydrated tissues that are inserted over the ocular surface or the target area with an overlying bandage contact lens (BCLs).[83]

To date, only a few case studies have been published on its use.[84],[85] One Cheng et al. in their study showed improvement symptom profile after 4 months in dry eye patients who used the PROKERA® SLIM for approximately 5 days on average.[81] They also demonstrated reduced corneal and conjunctival staining and improved visual acuity.

Mechanical dacryoreservoirs

Patients with severe DED (TBUT <10 s and Schirmer's score <1 mm) require frequent application of lubricants which may disrupt their daily activities resulting in reduced quality of life. For these subjects, drug-eluting reservoirs through a catheter hold promise for continuous lubrication of the ocular surface. Kwon et al.[86] in the rabbit model showed that a microinfusion pump for diabetic patients to deliver insulin when used for lubricating the ocular surface with artificial tear had a similar effect. A similar effect was observed for the delivery of steroids through the pump. Murube et al.[87] in their prospective trial of 21 patients with severe dry eyes implanted a drug-eluting reservoir under the anterior abdominal wall with a silicone catheter connected and going from the chest, neck to the conjunctival fornix. They showed a subjective improvement in DED symptoms in these patients. These mechanical dacryoreservoirs are a valuable treatment option in severe ADDEs when other measures have failed.[88]

Surgical management of glands

Major salivary gland transplantation

The three major salivary glands parotid, submandibular, and sublingual glands play a major active role in lubricating the ocular surface. The aim of salivary gland transplantation is to provide functioning exocrine tissue to a severe dry eye. A functioning salivary gland not only is a source of lubrication but also provides epitheliotropic factors that are a nutritious source for functional tears. The main indications of transplantation include congenital alacrima and aqueous deficiency dry eye secondary to cicatricial conjunctivitis.[89],[90]

Parotid duct transposition

In this procedure, the secretory duct of the parotid gland is transplanted from its original position abutting the premolar teeth to the mouth to the lower conjunctival fornix.[91] In this procedure, the nerves innervating the glands are maintained, hence a gustatory reflex of epiphora results with purely serous secretion. The main complications include blepharitis and keratitis from excessive secretion.[92]

Microvascular submandibular gland transplantation

In this procedure, the free partial or total submandibular gland with a vascular pedicle and the secretory duct are transferred to the temple. A microvascular anastomosis with facial vessels is done and the duct is sutured into the conjunctival fornix. At present, the submandibular gland is the only major salivary gland that is currently being used to provide lubrication to the eye by means of transplantation.[93],[94] It is only indicated in patients with absolute aqueous tear deficiency and when all other potential treatments have failed. These patients benefit from relief of severe symptoms and some signs of DED, but the procedure does not help with visual improvement. Qin et al.[94] compared total versus partial submandibular gland transplantation and showed severe epiphora in 19 out of 22 patients with a total submandibular gland graft, versus 6 out of 20 eyes with a partial transplant. In their analysis, the secretion from the gland was stimulated by heat or physical activity and could be blocked by anticholinergics.[95],[96] The hypersecretion can be reduced surgically by decreasing the size of the gland or by partial ligation of the duct.[97]

Minor salivary gland autotransplantation

Recently, the upcoming treatment is the use of oral and nasal mucosa for reconstructing the fornices. This will help in providing mucin to the ocular surface, but results are encouraging to provide enough lubrication for graft survival. Another option is the use of lip mucosa for reconstructing the conjunctival fornix in severe DED.[95] This treatment has excellent success in terms of graft survival. Minor salivary glands secrete predominantly mucin, with buccal salivary glands showing the highest flow rate. The transplantation improves symptom profile with an increase in TBUT and Schirmer's score. The major complications include temporal labial hypoesthesia or graft necrosis, epiphora, heaviness, and lax eyelids causing entropion. Sant' Anna et al. in their report of 19 patients with severe DED secondary to SJS showed a significant improvement in teat volume in about 70% of patients and improved corneal transparency and visual acuity in 54% and 100% of subjects, respectively.[98],[99]

Other advanced or surgical options

  1. Glue with BCLs – Cyanoacrylate glue and BCLs for sealing the corneal perforation or descemetocele[100]
  2. Patch graft – Corneal or corneoscleral patch graft for an impending or corneal perforation[101]
  3. Limbal stem cell transplantation[102]
  4. Prosthetic Replacement of the Ocular Surface Ecosystem lens therapy.[103]

  Conclusion and Future Directions Top

Based on our two reviews on dry eye disease, it can be concluded that dry eye can now be divided into aqueous deficient, decreased wettability, and evaporative type. It presents with varied signs and symptoms, hence better terminology is dry eye syndrome. In addition, to the symptoms of dry eye, though to a greater or lesser extent, it involves the neuropathic pain component also. Mild-to-moderate dry eyes can be managed with conservative management with sequential follow-up. Severe and advanced cases not responding to conventional treatment require surgical intervention, as listed above. To date, dry eye was considered to be an OSD, but recent basic and epidemiological studies have changed the concept that dry eye is a lifestyle disease. Future research is needed to determine the role of lifestyle interventions not only on the treatment efficacy but also on the prevention and management of dry eye disease.

Compliance with ethical standards

The article has not been submitted elsewhere for consideration of publication. The article complies with the ethical standards by Declaration of Helsinki.


We would like to thank Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Pondicherry.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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