Dr Leigh Plowman discusses a key drug that tackles the symptoms of dry eye disease while he tries to understand what is driving the condition with his patients.
Many dry eye sufferers have got it pretty tough.
Itchiness, dryness and pain are some of the symptoms they have to deal with.
But possibly the bigger challenge is the change in lifestyle they must consider if they are to tackle why they are having issues with their eyes.
Optometrists with expertise in dry eye are increasingly aware the disease is often a symptom of wider problems in their patients’ health and lifestyles, from what they eat to how they work and sleep.
To tackle that bigger fire, they must first cool the symptoms and calm the patient before they can discuss the wider, more holistic changes that may be needed.
Dr Leigh Plowman likes this analogy.
Often, when dry eye patients visit his independent optometry practice in Colac, Victoria, he suggests steroids to tackle the wider set of symptoms, followed by a course of lifitegrast 50 mg/mL (brand name: Xiidra), a prescription eye drop that Bausch + Lomb took over form Novartis in September 2023.
“Steroids are like a fire truck to put out a bush fire; they really help to douse it [symptoms] down,” he says. “And then an immunomodulator like Xiidra is like a garden hose to put out the spot fires and help prevent flare-ups.”
Dr Plowman knows that feeling of joy and relief from the symptoms of dry eye. He too has suffered from the disease.
Which is why he is always “excited” by the opportunity to help dry eye patients and improve not only their vision but their wellbeing.
“To me, the real motivation is when I can see the improvements in patients’ quality of life, how they can get by a whole day with not thinking about their eyes, not having this frustration.”
Before they can get to that point, he needs to better understand their lifestyle and the causes of dry eye. And before that he must first put out those fires.
“Inflammation is the key driver of dry eye,” says Dr Plowman. “We know that it is a chronic, progressive condition, and we’ve got this double vicious cycle from meibomian glands getting blocked up, causing evaporation, and reduced tear production, so less moisture.
“Both of those perpetuate themselves in real time, and they cause this cycle of inflammation, and that causes damage to the surface.”
Xiidra – which comes in single-use ampoules – helps to break that cycle.
“We know that it works on T cells,” he says. “It targets the LFA [lymphocyte function-associated Antigen-1] receptor on T cells and helps to inactivate these so that they can’t perpetuate the cycle of dry eyes.
“We know that it works on the surface of the eye, definitely on the conjunctiva, and it was recently discovered that there are T cells on the cornea.
“There’s also been some evidence that Xiidra can migrate to the lacrimal gland [which helps to keep the eye surface lubricated and clean] and reduce inflammation inside the gland itself.”
Dr Plowman recommends a 12-month course of Xiidra, which he says gives patients the maximum benefit of the drug.
Studies have shown that those benefits can be enjoyed long before that.
Real-world research involving 12 eyecare providers and 1,288 patients showed “significant symptom resolution within one to three months for most patients”.
The study, led by Dr Francis Mah, director of cornea and external disease and the co-director of refractive surgery at Scripps Clinic Medical Group in San Diego, was presented at the 2025 American Society of Cataract and Refractive Surgery (ASCRS) annual meeting earlier this year.
It said that improvement in symptoms was sustained over the course of the treatment, “with a mean duration of 29 months”.
The US Food and Drug Administration (FDA) approved the therapy in 2016 based on the drug’s success in four studies.
In those studies, a larger reduction in the eye dryness score (EDS) was observed with Xiidra at six and 12 weeks. In two of the four studies, an improvement in EDS was seen with Xiidra at two weeks.
The most common adverse reactions reported in 5 to 25% of patients were irritation, altered taste sensation (dysgeusia) and reduced visual acuity.
Dr Plowman has treated up to 20 patients with Xiidra and says those reactions are very brief and can be mitigated by getting patients to close their eyes for 30 seconds after using the drops.
“That helps to close off the tear ducts so that it doesn’t drain into their throat.”
Despite those brief reactions, he says many of his patients “find their eyes feel so comfortable that they want to continue with it longer than 12 months”.
But he prefers to see the drug as an opportunity to settle the patients’ symptoms while he takes the time to find out what is really behind their dry eye disease.
“We’ll ask them how well do you sleep at night? Do you feel refreshed in the mornings? Or do you ever snore sometimes?” he says.
“Also, how’s your cholesterol? Do you have any insensitivities with food like gluten or dairy.
“I like to involve the GP with this, so I’ll be writing to the GP and saying, I can see ocular surface inflammation and I’d love it if you could have a look at some key blood tests for me and see if there are any inflammatory markers, nutritional markers or genetic risk factors that could be there for inflammation.”
Like many others, he believes lifestyle plays a key part in dry eye disease and its treatment.
“We tend to be more office-based, not moving around as much, sitting at a desk, staring at a screen,” he says.
“All of those demands seem to place more on the body, and in the meantime our diet may not be 100%, we might not be getting the right nutrients and adding to that tiredness, stress and the demands of life.”
That can be compounded for patients with rheumatoid arthritis, lupus, Sjögren’s syndrome, rosacea, and other autoimmune conditions.
Dr Plowman says these patients, in particular, can benefit from Xiidra.
But it might not be for everyone.
Xiidra is part of the health department’s Black Triangle Scheme used to monitor the safety of new prescription medicines and those used in new ways. Optometrists can access it via the Special Access Scheme (SAS), meaning they must document why their patients need this particular drug and whether they have tried more freely available alternatives, such as cyclosporine in the case of dry eye.
Dr Plowman says this is often not a problem and approval can be sorted in a few days, as long as practitioners are able to demonstrate why the drug is warranted clinically.
“Sometimes the patients have tried cyclosporine in the past but maybe not tolerated it well.”
Also, because it is on the SAS, patients must either cover it with their health insurance or pay out-of-pocket.
Dr Plowman says that equates to about $150 a month in Australia.
For many of his patients, that’s a small price to pay for long-lasting relief from symptoms and some “sanity”.
For Dr Plowman, that small investment in Xiidra can help him make a bigger investment towards improving his patient’s quality-of-life.
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