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Modern approach to the treatment of dry eye, a complex multifactorial disease: a P.I.C.A.S.S.O. board review
  1. Pasquale Aragona1,
  2. Giuseppe Giannaccare2,
  3. Rita Mencucci3,
  4. Pierangela Rubino4,
  5. Emilia Cantera5,
  6. Maurizio Rolando6
  1. 1 Department of Biomedical Sciences, Ophthalmology Clinic, University of Messina, Messina, Italy
  2. 2 Ophthalmology, Magna Graecia University of Catanzaro, Catanzaro, Italy
  3. 3 Institute of Ophthalmology, Florence, Italy
  4. 4 Ophthalmology, University of Parma, Parma, Italy
  5. 5 Ophthalmology, Israelitic Hospital, Rome, Italy
  6. 6 Ocular Surface Unit, ISPRE, Genoa, Italy
  1. Correspondence to Maurizio Rolando, Ocular Surface Unit, ISPRE Genova, Genoa, Italy; maurizio.rolando{at}


Dry eye disease (DED) is a growing public health concern affecting quality of life and visual function, with a significant socio-economic impact. It is characterised by the loss of homoeostasis, resulting in tear film instability, hyperosmolarity and inflammation of the ocular surface. If the innate immune response is unable to cope with internal bodily or environmental adverse conditions, the persistent, self-maintaining vicious circle of inflammation leads to the chronic form of the disease. Treatment of DED should be aimed at the restoration of the homoeostasis of the ocular surface system. A proper diagnostic approach is fundamental to define the relevance and importance of each of the DED main pathogenic factors, namely tear film instability, epithelial damage and inflammation. Consideration also needs to be given concerning two other pathogenic elements: lid margin changes and nerve damage. All the factors that maintain the vicious circle of DED in the patient’s clinical presentation have to be considered and possibly treated simultaneously. The treatment should be long-lasting and personalised since it has to be adapted to the different clinical conditions observed along the course of the disease. Since DED treatment is frequently unable to provide fast and complete relief from symptoms, empathy with patients and willingness to explain to them the natural history of the disease are mandatory to improve patients’ compliance. Furthermore, patients should be instructed about the possible need to increase the frequency and/or change the type of treatment according to the fluctuation of symptoms, following a preplanned rescue regimen.

  • Cornea
  • Conjunctiva
  • Eye Lids
  • Ocular surface
  • Tears

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  • Contributors PA, RM, PR, EC, MR designed and directed the project; all authors conceived the idea of the review; PA, GG, MR drafted the manuscript with input from all authors; RM, PR, EC provided critical feedback. All authors contributed to the final version of the manuscript.

  • Funding This paper was supported by an unrestricted grant from Théa Farma S.p.A.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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