Experts weigh in on dry eye management

I sat in on a panel discussion for media during Vision Expo West 2025 about interventional dry eye hosted by Lumenis. I took notes, transcribed the conversation, and edited it for better reading.

Because the overall piece itself is long, I'll share it in chunks.

Experts weigh in on dry eye management
Three dry eye-focused practitioners held a panel discussion during Vision Expo West in Las Vegas in September 2025 to share perspectives and offer advice to their colleagues.

Participants:
• Moderator: @Cory J. Lappin , OD, MS, FAAO; Montgomery, OH
• Celesta Ferreira, OD; Cypress, TX
• Periman, MD; Seattle, WA


Dr. Lappin: Where do we start with diagnosis with so much overlap between the symptoms and signs of multiple ocular surface conditions?

Dr. Periman: I have always subscribed to the belief that if you listen to the patient, they will tell you what is wrong. A careful history often points me in the right direction of underlying drivers. It is a critical part for me in my assessment diagnosis and treatment plan.

Dr. Ferreira: I'm looking at every single patient. We used to do only age 30 and up; now I'm doing age 8 and up. If they can fit their face in my meibiographer, we take a scan. We have to screen everybody and not be afraid of the screening. Take the time to do it.

Dr. Periman: Imagine if that was a primary care clinic where you fail to check blood pressure on everyone. You are going to miss dangerous, silent things that have a major health impact down the road.

Dr. Lappin: How do you determine what to use once you have diagnosed dry eye? Where do you start?

Dr. Periman: When I do that exam, I have already checked meibography, corneal staining, osmolarity, MMP-9—not necessarily in that order. That guides me. Often, you can see demodex collarettes on meibography. That is a big clue, and you see the altered meibomian gland structure and appearance in that context. My game plan is to identify all the mischief makers in the room and pick them off one by one.

Dr. Ferreira: Some doctors don’t know how to implement a protocol for dry eye diagnostics. They get bogged down on not knowing what to look for. I'm looking for demodex, rosacea, turbid glands, how the lid pulls down, the snap-back test. I like storytelling with visuals for patients. After I have captured my data, I show them every image. This is demodex. This is how we are going to treat it. This is rosacea. This is how we are going to treat it. You have to tie it back for patients to understand—if we simply tell them, “You have blepharitis and rosacea, you need to buy this treatment,” they get lost in the weeds. If they physically see it, it’s a complete game changer.

Dr. Lappin: They start to own their own condition when you present it to them that way.

Dr. Lappin: We have seen a lot of innovation in the past five years. I guarantee that we do not treat patients the same way five years ago that we do today. What motivated you invest in new technology? What pushed you from traditional, over-the-counter treatments to interventional dry eye?

Dr. Periman: It is the patient with the unmet need. In 2017, I had a wonderful plastic surgeon patient with impressive rosacea. I had just read studies saying that IPL could help with MGD and dry eyes. I suggest IPL to him, and his assistants in his office do it because he had a machine—I didn’t have one yet. He came back looking like a candy cane with a red forehead. I had a realization that rosacea is a local regional disease, and that drove me to to purchase a unit. Plus, I was tired of sending patients to my dermatologist, only to say they don’t have rosacea while it is staring me in the face. That unmet need pushed me to do it along with the drive to do everything I can to help the patient.

Dr. Ferreira: For me, it was myself. I have always been a dry sufferer. I have had chalazion surgery. I have had injections. I have done all the meds, all the drops, and still suffered wildly. Being able to step into the realm of treating myself and having full confidence in the advanced technologies I am bringing in was the game changer. I thought to myself, “If I can bring something in, I don’t have to get another surgery. I don’t have to get another injectable. I don’t have to use drops every single day. Why would I not do it?” So I brought in IPL and was blown away by my own recovery that I was like, “I’m going to keep going until I feel better. I’m going to keep buying toys because I know they work.” I have photos of myself with my chalazion surgery that I show patients. They look at it and they’re like, “I am my patient.” Trust that I would not put this device or this treatment on myself if I didn't believe in it.

 

[Dr. Stanley Hallock]

Ok .....so we can put something up your nose......or stimulate your cold receptors in your cornea.....or we can make (really?) one portion of your lacrimal gland(s) grow back six months later....or we can antagonize your LFA-1 for a couple of months if you'll stand the taste perversion..........or what we can coat your eye with a wax that's liquid at room temperature........etc.

But you know what I never hear reference to.......because no one discusses this >> (sorry, background first)

The composition of tears is different for reflex/blink tearing....and psychogenic/emotional tearing.....and something like "I'm cutting up an onion" tearing (whatever is that whoopie scientific name) .......THIS > WHAT ARE THE COMPOSITIONS OF THE TEARS THESE VARIOUS 'WONDER' DRUGS CREATE ??

 

[Gretchyn Bailey]

Dr. Lappin: Why did you choose the IPL device that you did?

Dr. Periman: I am heavily driven by science. The majority of papers in the peer-reviewed literature are based off the Lumenis Optimal Pulse Technology platform, so to me that confers an excellent layer of confidence and comfort. As more of our colleagues expand their practices and state laws continue to change, knowing that you have a device with FDA approval is another layer of confidence for our colleagues.

Dr. Ferreira: I think it differentiates our practices because there are a plethora of IPLs on the market for literally zero dollars, and I often get asked, “Why did you make such a big investment?” It is the biggest question I am asked. I wanted to have safety and efficacy. I loved that Lumenis did their work to give us the backing that I can feel safe putting this on my patients, on myself. I don’t have to worry about peace of mind or if this device going to work. Is it going to irritate, is it going to have side effects that I can’t control? The approval is huge. I was going only with the device that I knew was FDA approved, but I knew I was making an investment for my patients. At the end of the day, it’s all about the best care we can offer, not about the cheapest device you can purchase.

Dr. Periman: Having that device is how you and I started working together. We share some patients. Knowing that I have a colleague who has the same platform, uses it regularly, and knows how to use it, that’s a confident referral.

Dr. Lappin: We all have a referral network with patients who live all over. If I couldn’t find a doctor I knew, I would go to the doctor locator because I know they have made the investment. You can do your homework, and come to your own conclusions. But when you’re investing in any device, a patient will look you in the eye and ask why you picked the device that you chose. Do you want your answer to be it was the cheapest one? I know I wouldn’t want to hear that.

Dr. Lappin: What is dynamic muscle stimulation? How is it different than IPL?

Dr. Ferreira: It has been a game changer in the last five years. I used to focus just on the eye area. Now I am looking at the full face. Are there certain conditions or treatments patients are doing at home that could be affecting the lids? Dynamic Muscle Stimulation technology allows us to treat that unmet need that we never knew we could treat other than with surgeries. We can address an issue that we never knew we could.

Dr. Periman: Aesthetics and health of the eye blend together. As we gain these incredible new tools, we are getting better at global assessment. I describe it to patients as vector management. That paper-thin avicularis muscle is not designed to hold the weight of your face. So, we need to change the vectors and strengthen that poor little muscle. It’s just hanging on. I am amazed at how weak weak the inferior vicularis is, that lid laxity component, and how much it responds to the deep muscle stimulation. The OptiLift platform uses gentle RF first. I explain to patients, it’s like going to a personal trainer at the gym. You warm up before you work out. We work on teaching that muscle a proper contraction and a complete blink.

Dr. Ferreira: Pulsing with these devices is gentle and comfortable, and patients tolerate it very well. When you see it, you know that the muscles can work and that we can retrain them.

Dr. Lappin: My challenge to everyone right now—you don’t need to alter your exam—is to look for inferior scleral show. Often, we don’t know the natural position of our lids, and it is a natural base position. The lower lid should be right at the margin of the iris. If you see any white between that, that is a sign of lid laxity.

Dr. Lappin: Let's talk about kids again. Our blinking behavior is so affected by screens. Are we atrophying the muscle because we’re no longer completely blinking because we’re just staring? Blink rate and pattern hasn’t been tied to dry eye, but incomplete blinking has. Is that because we are training ourselves to undercontract?

Dr. Periman: I'm asking if patients clench their teeth at night—bruxism. We know from the literature that bruxism is associated with a 2.8-fold increased relative risk. So, I am often finding these things together. Are we talking about a bit of trigeminal nerve dysfunction? And then disuse, atrophy, and weakness of the inferior lid contributing to that laxity—we’re learning all the time. I find that when I treat the bruxism with Botox, not nightguards, it helps so much.

Dr. Lappin: It’s that balance. The muscles don’t exist in isolation; they all work synergistically. They push, and they pull. If one of them is off, it’s going to throw off the whole system. If we can work on the obicularis, this changes the way we think about blinking because often we think the lids are just thin skin—the bulk of our lids is muscle tissue.

 

[Gretchyn Bailey]

Dr. Lappin: How do you talk to your patients? How do you make that connection between the lids and blinking and closure and dry eye?

Dr. Periman: I think a demonstration is a connection for patients. These patients are complaining of waking up in the middle of the night with super dry eyes or toward the end of the day from incomplete blinking. At the slit lamp, I will ask them to close their eyes. If you see quivering of the upper eyelid, we call that the jumping obicularis sign. I will use my non-dominant hand to support the mid-face and brow to replicate the relief of of the inferior obicularis. Patients say that feels so much better, and the quivering and shaking improve. Also, I will ask them to use their palms to squish their cheeks up like a little kid watching TV to take the weight off that obicularis muscle. When they say, “I feel so much better,” I say, “I can help you with this technology. I am going to strengthen that muscle you are more comfortable.It is lid laxity improvement. It ties back to this blinking thing which is this brave new world and how we think about ocular health.

Dr. Ferreira: There are two different types of patients we see. There are the ones who know they have an issue and the ones who don’t know. You clearly can see it for some—they understand the mechanism of action of aging and fat pad accumulation. They understand why we want to treat it. Then you have a patient like the 8-year-old who kept reporting to mom that she was having severe pain. The school nurse wasn’t taking her seriously. She did not look aged. She did not have a fat pad. Her eyes looked tight and toned. When I did her snap-back, she was performing like a 50-year-old; her lids would not snap back. When I asked mom, she said her daughter was notorious for reading at night in the dark for hours on her iPad. I was thinking she was probably not blinking. She is aging her eyes at the level of a 50-year-old because it’s a muscle that she’s working too soon. I treated her with Opti-Lift technology she said, “I feel better, Dr. C.” For an 8-year-old to tell you that, I got choked up. We need to look for this in the ones you would never expect.

Dr. Lappin: The epidemic is already here. We are way past the time where the classic, post-menopausal female patient is your kind of patient. If you have watched any kid on an iPad, they don’t ever blink. You can see their eyes start to waver sometimes, or they will squeeze their eyes tight, and then it’s off to another 10 minutes of no blinking.

Dr. Periman: That just makes things worse. We don’t need blinking exercises, stop wasting your breath. It gaslights the patient, and it’s not effective. And patients are not going to do the exercises, anyway. They don’t strengthen the muscle the way the DMST that OptiLift does.

Dr. Lappin: How have you started incorporating it into your dry eye protocols?

Dr. Ferreira: It’s getting incorporated into every protocol. Unless there is a very rare case where the patient has the most toned lids I have ever seen, the snapback is perfect, and there is no sign of inferior corneal signs—which hasn’t happened yet. It is a part of every conversation. Now that I have the technology to treat it, I am more aggressively looking for it. I will videotape patients’ blink and snap-back. Video helps them to understand that concept so much easier than me showing them their meibum squeezing out like toothpaste. I have an anterior segment camera at the slit lamp that allows me to take 30-second videos.

Dr. Lappin: The idea that health, beauty, and function are separate is a false dichotomy. If you look traditional signs of what’s attractive to us—symmetry, tight lid positioning—that’s a sign of health. We deem things that are attractive are signs of health and function. It’s very much a false either/or.

Dr. Lappin: What would you say is one of the most prominent misconceptions about dry eye?

Dr. Periman: There is a lot of mythology around cosmetics and ocular surface disease— published papers that I think are incorrect, citing the wrong references, and misappropriating blame when we need to back up and think globally. It’s not just a single ingredient in a single skincare product or cosmetic—that’s a false herring. You need to back up and look at skin conditions. Rosacea is incredibly common with dry eye and MGD. Treat it with your OptiLight, then strengthen the muscle with Opti-Lift. Telling someone just to change their mascara is not it.

Dr. Ferreira: I think the other misconception is that topicals are going to fix dry eye. It is a Band-Aid over the scar. I felt so limited when I was thinking all I can do is give this patient a drop because I know it is fixing only 10 to 12 percent of one type of this disease. Now, I can walk into the room confidently, look at the patient, and, no matter what I’m finding, I know I have something to treat this. I call my treatments my trifecta, when I combine intense pulsed light, DMST, and radio frequency—you can fully treat a patient. My one ask of every doctor is to do a little research, and if you don’t want to treat dry eye, send your patients to someone who knows how.

Dr. Periman: I think it is an opportunity to collaborate. If you have colleagues who are using a lot of pharmaceuticals—and I still use them, too. But when you get to the point where it’s not enough and the patient is not making the gains they need, refer to each other.

Dr. Ferreira: We’re not going to take your patients. We’re sending them right back to you.

Dr. Lappin: I absolutely agree with that. In the gestalt of dry eye, everything has its place. With dry eye, often it is the “and,” not the “or.” I tell a patient, “I want to keep you on the fewest number of treatments to get you to where you need to be.” Every treamtnet is necessary because if you leave one stone unturned, that’s going to be the one still causing the problem.

Dr. Lappin: How do these in-office, interventional treatments help us with compliance?

Dr. Periman: You want to minimize that patient’s burden and disease. With these in-office technologies, patients routinely report back they are down to just a few artificial tears a day, or they don’t need to refill their expensive drop because they are doing so well. Removing that daily burden of disease is one of the best gifts we can give patients, and they don’t realize it at the time until they look back at how far they have come.

Dr. Ferreira: The book Buy Back Your Time by Dan Martell is about how I can get more time for me to be more effective during the day. For me, it’s about how can I give my patients more time? One, for them not to be pondering about this disease. Two, you don’t want them using 10 drops a day every 30 minutes. If they don’t have to think about it, they can go to their kid’s game and not wonder if they brought their lubricant. Removing that burden is the game changer we all want to be able to do.

Dr. Lappin: The other question we get is, “How often do you repeat these procedures?” We all say it’s personalized, but I’ve had plenty of patients say they’ll have the procedure every single month after their first series because they tell me it cuts it down their daily maintenance.

 

[Charles A McBride]

Disclosures please. -c

 

[Gretchyn Bailey]

Disclosures please. -c

Charlie, it was the very first line: I sat in on a panel discussion for media during Vision Expo West 2025 about interventional dry eye hosted by Lumenis.

I transcribed and edited myself. Lumenis has not seen this content before I shared it. They are not paying us to share it.

You'll notice the thread where it lives: ODwire Journal. That means it's something I created myself, without sponsor support, and me retaining editorial control.

 

[Charles A McBride]

I thought it should be made clear that they are paid by Lumenis.

 

[Gretchyn Bailey]

You mean the ODs involved? I would assume they are. I have no information on that, so I cannot include that disclosure.

 

[Dr. Stanley Hallock]

My thought about composition totally ignored.......but wait a minute.....by my weighing in here and by virtue of the title.....it makes me an expert !! ......yippie. ,,,,after all these years I'm finally an expert

 

[Gretchyn Bailey]

Here is the last part of the discussion.


Dr. Lappin: Where do you see dry treatment going in the next five years?

Dr. Periman: What I am most excited about is targeted and specific modalities that address unmet needs, back to where we started the conversation. What drives me is meeting the unmet need because it is such a busy, noisy, messy disease state. It’s having the right tool for the right job. We are going to have more and more as we go. We are going to get better at this.

Dr. Ferreira: For me, the biggest thing is educating our medical peers on how prevalent dry eye is for our patients in rheumatology, endocrinology, and obstetrics. Allow them to understand that every systemic condition can have a link to dry eye. The body works as a unit. If those of us in medicine don’t understand we all need to work together, we are going to miss the boat on a ton of dry eye.

Dr. Lappin: I like the fact that I feel like every time we get something new, we are getting closer to those root causes. And thankfully, we are seeing more of our colleagues who are interested in dry eye and ocular surface disease.

Dr. Lappin: If you could give one piece of advice to a colleague who is starting a dry clinic or just interested, what would it be?

Dr. Periman: Get good at your clinical exam. Then start to understand how the tools fit in to address the different things you find when you do a detailed exam.

Dr. Ferreira: Screen everybody. Don’t screen just the people you think have dry eye because you are missing about 50 percent of the condition if you are waiting for them to present. Screening, understanding what you are diagnosing, making it relatable to patients, and being confident in your prescription of these devices. Many times doctors get hung up on the fact that it’s not an insurance-covered procedure, but not everything in life that’s good is covered by insurance. Are we going to offer only something that’s covered when we know there is a plethora of technologies like OptiLight and OptiLift that can change lives? Don't be afraid to talk about that aspect of it.

Dr. Periman: Never assume what it is important to a patient. Our job as clinicians is to present the ideal treatment and talk about what is possible. When you present it as the ideal treatment plan, I find that patients buy in. Don’t assume what they are willing to invest in and present them with all the options.

Dr. Lappin: My advice would be: Don’t be afraid to focus on dry eye if you’re really passionate about it. Don’t be afraid to dive in and dedicate a whole day of your week to dry eye.

Questions
Is there a specific way that you are educating patients about dry eye? Are you reaching out in your community to let folks know that you have special tools to treat dry eye?

Dr. Periman: There are many pathways for that. Some patients are surprisingly savvy. For example, you’ll see on Reddit there is a lot of conversation about it. Patient awareness is at an all-time high, which is helpful in guiding the treatment options discussion. We are very collaborative where we are and welcome doctors to visit. I think the patient wins when you’re able to share patient care and create that comprehensive treatment package. Social media is a great tool for showing the aesthetic lid laxity changes in these patients with OptiLift, the improvement in skin color and texture tone with OptiLight, and the improvements in MGD with OptiLight. You are able to hashtag these things to promote your practice, and patients find you.

Dr. Ferreira: When I was slower in the beginning as a cold start, I had time. So, I went out into the community and met with rheumatology groups and endocrinology groups. I introduced myself and gave them a cover letter explaining what I treat, why it’s important, and gave them specific conditions linked to dry eye that I knew that they were going to see. They have patients with lupus and Sjögren’s, and they now feel like they can call me.

Differentiating yourself will set you out from other eyecare providers and will allow them to find you and your technology. I now have patients coming to me who say they saw the list of my technology on my website. The amount of patients who say I want to come to you because you’re the only one in this area with the FDA-approved version is huge and more than an ROI. It’s exactly why I purchased it.

Dr. Lappin: The dry eye cohort is one of the most astute, well-studied patient groups I have ever encountered. They are not getting answers from their doctors, quite frankly, so they’re trying to do it on their own. My practice goals are twofold: to be a resource for patients and to be a resource for other doctors. I want to be a place where patients can trust that I can help them. I hope our patients don’t have to be as savvy any more, that they don't feel like they have to take that burden upon themselves.

You say two or three minutes for these tests, but some practitioners are seeing patients every 15 minutes. They say they have no time for more testing due to reimbursements, and they are unable to reduce managed vision plan participation because of their patient base.

Dr. Periman: Get off the hamster wheel. Stop being a slave to the system.

Dr. Lappin: Part of the reason why they’re seeing patients every 15 minutes is because that’s what they have to do to make ends meet. If they start seeing dry eye patients, they can see a patient every 30 minutes. My intake exam is an hour long because we are getting reimbursed for what we do. Ask yourself: Could you provide a different type of care where you don’t have to see someone every 15 minutes? You can get better reimbursement by taking a step back and fully focusing on the dry eye, and you won't be on that hamster wheel.

Dr. Periman: Start small with a half-day clinic, and you’ll be shocked at how fast it will grow.

Dr. Ferreira: I work a lot with doctors on implementation coaching. My biggest question before we start any coaching is, “Let’s talk about your mindset and why are we stuck there?” It’s a fear because we were trained to see 50 people or your practice won’t survive. I use myself as an example. I’m a cold start. I backed off and decided to switch to four dry eye exams per day: four in the morning or afternoon or two and two . My practice grew more than when I accepted every single vision plan. Robust practices are very nervous about changing their mindset. I tell them start slow. Add one dry eye initial exam in the morning and one in the afternoon. See how it changes your clinic. Many say that one patient equated to about 30 VSP or EyeMed co-pays. I spent 45 minutes instead of an entire day and made more profit than if I would have seen those 30 patients.

Dr. Lappin: Challenge yourself. Pick one hour like a Friday morning. You will not let anything be scheduled but a dry eye exam. Hold yourself accountable to it so you feel a bit of a sting if there is nothing scheduled. Only fill it with dry eye. Force yourself to do it.

 

[Dr. Stanley Hallock]

And once again I say / ask ..........what's the composition of the 'product' as an eye drop versus what is (including all the natural trace components) that of the natural tear. The natural tear is not a whole bunch of sterile water and a wetting agent (or two) plus some salt and a buffer and a preservative and something that controls pH variation from batch to batch. ...or other 'magic stuff'.

 

[David Gregory Luce]

And once again I say / ask ..........what's the composition of the 'product' as an eye drop versus what is (including all the natural trace components) that of the natural tear. The natural tear is not a whole bunch of sterile water and a wetting agent (or two) plus some salt and a buffer and a preservative and something that controls pH variation from batch to batch. ...or other 'magic stuff'.

I hear you, tears are complicated beyond me.
I would imagine you don’t prescribe OTC eye drops, true?

I hope you get some quality track time!

 

[Dr. Stanley Hallock]

OTC eye drops......Patient preference can vary as much as there are as many brands when it comes to Art. Tears......so I give Patient a note that lists a few brands and say > try 'em or the next one if you don't like the first.
I recall the publication(s) by Dick Hill out of Ohio State decades ago......conclusion in every article was > some people are going to like one and somebody else will prefer a different one.......because of the different pH - or - viscosity - or salinity variations. He published three different articles in 3 different Journals listing the differences of several OTC tears (so he fulfilled terms of his contract to publish the number of papers he was supposed to) but each article addressed only one of the variables as pH or salinity or viscosity.......and of course he used the same bottles for each article....and probably had his Teaching Assistant actually do all the lab work.
As to Art. Tears and the whole preservative brew-ha-ha so only recommend Preservative free......I don't really buy it that BAK is all that bad for a person using the drops only 2 or 3 times a day.
OTC - I like Gel drops for many Patients - just like above - the brand might vary they prefer
OTC - Pataday green (use BID for 2 days and decide if it works......then, if it helps, use QD ....or Alaway
OTC - Lumify is the only "red-out" drop I mention.

 

[David Gregory Luce]

OTC eye drops......Patient preference can vary as much as there are as many brands when it comes to Art. Tears......so I give Patient a note that lists a few brands and say > try 'em or the next one if you don't like the first.
I recall the publication(s) by Dick Hill out of Ohio State decades ago......conclusion in every article was > some people are going to like one and somebody else will prefer a different one.......because of the different pH - or - viscosity - or salinity variations. He published three different articles in 3 different Journals listing the differences of several OTC tears (so he fulfilled terms of his contract to publish the number of papers he was supposed to) but each article addressed only one of the variables as pH or salinity or viscosity.......and of course he used the same bottles for each article....and probably had his Teaching Assistant actually do all the lab work.
As to Art. Tears and the whole preservative brew-ha-ha so only recommend Preservative free......I don't really buy it that BAK is all that bad for a person using the drops only 2 or 3 times a day.
OTC - I like Gel drops for many Patients - just like above - the brand might vary they prefer
OTC - Pataday green (use BID for 2 days and decide if it works......then, if it helps, use QD ....or Alaway
OTC - Lumify is the only "red-out" drop I mention.

Gotcha,
I have found personally and with many patients that Refresh Mega3 or iVizia OU BID everyday like an actual daily thing has reduced signs and symptoms of dry eye. I educate that your eyes will still be dry or whatever but the severity and duration will be worth the daily habit and expense.

I got on the trehalose band wagon after reading some information about this particular sugar that on the inactive ingredient list.
-Greg