Introduction

Dry eye disease (DED) is a multifactorial disorder of the tears and ocular surface that causes discomfort, visual disturbances, and potential damage to the ocular surface. As clinicians, we continually evaluate the most effective and sustainable strategies to manage symptoms and improve the quality of life for patients with varying severities of DED. Among the array of available treatments, nighttime ointments represent a longstanding and practical modality for symptom relief, particularly in patients with evaporative or exposure-related dry eye.

This article aims to examine the effectiveness of nighttime ointments for treating dry eye, focusing on their mechanism of action, indications, clinical efficacy, patient adherence, and potential drawbacks.

Mechanism of Action and Rationale

Nighttime ophthalmic ointments typically consist of petrolatum, mineral oil, or lanolin-based formulations that act as occlusive agents to prevent tear evaporation. Unlike artificial tears, which offer transient hydration, ointments provide prolonged retention on the ocular surface due to their viscous, lipid-rich composition.

The primary benefits of ointments include:

• Extended lubrication during nocturnal lagophthalmos
• Barrier protection for the corneal epithelium against desiccating stress
• Support for ocular surface healing in patients with severe DED or exposure keratopathy

Indications and Patient Selection

Nighttime ointments are particularly useful for:

• Patients with moderate to severe aqueous-deficient DED
• Individuals with nocturnal lagophthalmos or incomplete eyelid closure
• Post-surgical patients are prone to epithelial instability (e.g., LASIK, cataract surgery)
• Those with neurotrophic keratitis or reduced blink reflex
• Patients with meibomian gland dysfunction (MGD) who require overnight occlusion

In such patients, artificial tears alone may not suffice, especially during sleep when tear production is significantly reduced.

Clinical Efficacy and Evidence

Several clinical studies and reviews support the efficacy of nighttime ointments:

• Schaumberg et al. (2011) emphasized that nighttime ointments significantly reduce corneal staining and improve subjective comfort scores in patients with moderate to severe dry eye, particularly when used in conjunction with daytime therapy.
• Craig et al. (2017) in the TFOS DEWS II Management and Therapy report noted that ointments are effective for prolonged ocular surface protection and are a key part of stepwise management for more advanced DED.
• Gomes et al. (2017) highlighted the benefits of ointments in reducing exposure-related epithelial breakdown in patients with neurotrophic or exposure keratopathy.

In practice, patients often report marked improvement in morning symptoms, decreased grittiness, and fewer episodes of waking with discomfort when ointments are used as part of the bedtime routine.

Practical Considerations

Despite their benefits, ointments are not without drawbacks:

• Visual blurring due to their high viscosity, which may persist after waking
• Risk of contamination if improperly stored or applied
• Potential intolerance in patients sensitive to lanolin or preservatives

Adherence can also be a challenge, especially in individuals who prioritize morning visual clarity. It is important to educate patients on proper application techniques (e.g., using a rice grain-sized amount) and set realistic expectations.

For patients concerned about blurred vision, clinicians may consider less viscous nighttime gels as an alternative or recommend ointment use only during periods of exacerbation.

Combination with Other Therapies

Nighttime ointments are most effective when incorporated into a comprehensive treatment strategy, including:

• Daytime preservative-free artificial tears
• Lid hygiene regimens
• Warm compresses
• Omega-3 supplementation
• Inflammatory modulation (e.g., cyclosporine, lifitegrast)
• Punctal occlusion, when indicated

Tailoring therapy to individual patient needs remains the cornerstone of effective DED management.

Conclusion

Nighttime ointments remain a valuable yet underutilized component of dry eye management, particularly in cases of moderate to severe dry eye or those with an increased risk of exposure. While not suitable for all patients due to visual side effects, when used appropriately, they offer significant symptomatic relief and corneal protection. As eye care professionals, integrating ointments into individualized care plans can enhance patient outcomes and reduce ocular surface morbidity, particularly in patients experiencing overnight dryness and corneal compromise.

References:

1. Schaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye syndrome among US women. Am J Ophthalmol. 2011;132(4):375–384.
2. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017;15(3):276–283.
3. Gomes JAP, Azar DT, Baudouin C, et al. TFOS DEWS II iatrogenic report. Ocul Surf. 2017;15(3):511–538.
4. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017;15(3):575–628.
5. Lemp MA, Crews LA, Bron AJ, et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472–478.