Biologics for Dry Eye Disease

Not all patients who have moderate to severe or refractory dry eye disease (DED) achieve symptomatic relief with traditional therapies. This is where biologic therapies come in. In fact, the Tear Film & Ocular Surface Society’s DED Workshop III report reinforces the role of such therapies for patients who fail conventional management or even as first-line treatment, emphasizing individualized treatment pathways based on disease severity and etiology¹.

While it is important to recognize the broader landscape of biologic treatments—including recombinant nerve growth factor options, systemic immunomodulators, and emerging regenerative therapies—this article focuses on three widely used interventions: autologous serum tears (AST), platelet-rich plasma (PRP), and amniotic membrane therapy (see “Accessing Biologic Therapies for DED”).

AST

• How it works

The growth factors, vitamins, immunoglobulins, and cytokines contained within AST have been shown to support epithelial proliferation, differentiation, and wound healing². As such, AST can improve both signs and symptoms of DED, including reducing corneal staining, improving tear film stability, and enhancing patient-reported comfort^3-5.

AST are most commonly com-pounded at concentrations ranging from 20% to 50%, although higher concentrations (up to 100%) may be used in severe cases. They are typically dosed four to eight times daily, depending on disease severity. Many practitioners will start with a 30% concentration at a six-times-a-day dosage to encourage both effectiveness and tolerability for the patient. Preparation involves venipuncture followed by centrifugation and dilution with sterile saline. The drops are stored frozen and thawed prior to use to maintain stability and reduce contamination risk.

• Ideal patients

Given how they work, AST are particularly beneficial in patients who have autoimmune disease, graft-versus-host disease, and persistent epithelial defects⁶. They are also well suited for patients who have severe aqueous-deficient DED, including Sjögren syndrome, and are often considered a first-line biologic due to their physiologic similarity to natural tears. Limitations include cost, access, and storage requirements. Emerging options may help address some of these barriers by improving stability and not requiring refrigeration.

PRP

• How it works

PRP contains high levels of platelet-derived growth factors. These factors may promote epithelial healing and modulate inflammation, improving DED symptoms, such as burning, foreign body sensation, and photophobia, and clinical signs, including tear breakup time and corneal staining^7-10.PRP is prepared via centrifugation of autologous blood without dilution, resulting in a high concentration of growth factors. It is commonly dosed four to six times daily, though this varies depending on the preparation method and facility.

• Ideal patients

These include those who have poor epithelial healing, neurotrophic features, such as hypoesthesia, or insufficient response to AST. PRP may also be beneficial in patients who have recurrent corneal erosion, postsurgical ocular surface compromise, or more advanced disease requiring enhanced regenerative potential.

AMNIOTIC MEMBRANE THERAPY

• How it works

Amniotic membranes use biologic tissue derived from the innermost layer of the placenta. This tissue contains a rich extracellular matrix, growth factors, and antiinflammatory mediators that promote ocular surface healing through multiple mechanisms, including reducing inflammation, inhibiting fibrosis and scarring, promoting epithelial regeneration, and supporting corneal nerve healing. Two primary forms are available: cryopreserved membranes, which retain great biologic activity, and dehydrated membranes, which offer long shelf life and ease of storage. Both function as biologic bandages that protect the ocular surface and facilitate tissue repair.

• Ideal patients

Amniotic membranes are well suited for patients who have moderate to severe ocular surface disease, significant corneal staining, persistent epithelial defects, severe inflammatory DED, or painful conditions, such as neurotrophic keratitis. Their rapid onset of action and in-office application make them particularly useful for acute stabilization of the ocular surface, especially in patients who have not responded to other therapies.^11,12

FEASIBLE OPTIONS

Biologic therapies provide regenerative and antiinflammatory mechanisms that go beyond traditional treatments. Understanding how these therapies differ allows us to better individualize treatment and optimize outcomes.