Beyond the tear film: The emerging role of periocular rehabilitation in comprehensive dry eye care

Dry eye disease (DED) is increasingly recognized as a disorder of the entire ocular surface unit rather than simply a deficiency of tears. In addition to tear film stability, eyelid anatomy, meibomian gland function, blink mechanics, and periocular tissue health contribute to ocular surface homeostasis. A broader management perspective to managing dry eye can possibly include periocular rehabilitation as a complementary framework for comprehensive dry eye care. This framework would integrate eyelid biomechanics, periocular tissue health, and evidence-based adjunctive therapies alongside conventional ocular surface management.

The eyelids contain important structures that support ocular surface function, including meibomian glands, orbicularis muscle, sensory nerves, blood vessels, and lymphatic vessels. Emerging research has demonstrated that ocular and periocular lymphatic systems contribute to tissue fluid homeostasis, immune cell trafficking, and regulation of inflammatory responses.^1-3

The lymphatic system maintains tissue balance by transporting excess interstitial fluid, proteins, inflammatory mediators, and immune cells away from tissues. Lymphatic vessels are present in ocular adnexal structures, including the eyelids and conjunctiva, where they contribute to local immune regulation and tissue homeostasis.^1,2

Manual lymphatic drainage and the periocular environment

Manual lymphatic drainage (MLD) is a gentle technique using slow, rhythmic skin movements intended to facilitate superficial lymphatic flow. Unlike traditional massage, MLD uses minimal pressure because lymphatic capillaries are located superficially within the skin.

The strongest evidence for MLD support in the periocular/facial area exists in the management of lymphedema and postoperative/procedural edema. MLD may provide benefits in select patients with edema-related conditions, although results vary and additional controlled studies are needed.^4-6

At present, there are no clinical trials demonstrating that facial lymphatic drainage improves DED, meibomian gland function, or tear film parameters. However, because periocular edema and eyelid inflammation frequently accompany conditions such as meibomian gland dysfunction (MGD), ocular rosacea, and blepharitis, lymphatic-directed techniques remain an area of clinical interest as a supportive component of eyelid care.

Dynamic muscle stimulation and blink function

Blink quality and completeness are increasingly recognized as important contributors to tear film stability. Incomplete blinking may contribute to increased tear evaporation and impaired meibomian gland secretion.⁸

OptiLIFT Dynamic Muscle Stimulation represents an emerging approach designed to stimulate facial muscles, including the orbicularis oculi. Theoretically, improved orbicularis function may support eyelid movement and blink mechanics. Muscle contraction also contributes to normal venous and lymphatic fluid movement through physiologic pumping mechanisms. However, direct evidence demonstrating that OptiLIFT improves lymphatic drainage or dry eye outcomes is currently unavailable, and additional clinical investigation is needed.⁷

Hydrogel eye patches: Supporting the periocular environment

The skin surrounding the eye is among the thinnest in the body and is particularly susceptible to barrier disruption, dehydration, and environmental stress. Maintaining skin hydration and barrier integrity is an important component of periocular skin health.^9,10

Physician-designed hydrogel patches, such as those from EyeDerm, represent an example of adjunctive periocular care. These formulations may contain ingredients selected to support hydration, skin barrier function, and comfort, including hyaluronic acid, glycerin, sorbitol, niacinamide, dexpanthenol, antioxidants, peptides, botanical extracts, and soothing skin-conditioning ingredients.

Hyaluronic acid and humectants such as glycerin and sorbitol attract and retain water within the stratum corneum, supporting skin hydration.^9,11 Niacinamide has been shown to improve epidermal barrier function and increase ceramide synthesis, whereas dexpanthenol supports hydration and skin barrier repair.^12,13

Although hydrogel patches have not been shown to treat DED or directly increase lymphatic flow, hydrogel patches may provide adjunctive benefits in periocular edema management through cooling, hydration, and gentle surface contact.¹⁴ Although these effects may facilitate comfort and temporary fluid redistribution, direct stimulation of lymphatic flow has not been established. For ocular surface safety, periocular products should be applied over the infraorbital skin and orbital rim, avoiding direct placement along the eyelid margin, where migration into the tear film may contribute to irritation.¹⁴

Clinical perspective

Eyelid edema and inflammatory changes can alter eyelid anatomy, tissue compliance, and blink mechanics, potentially contributing to incomplete blinking and impaired meibomian gland function. Periocular rehabilitation should be viewed as a complement, not a replacement, for evidence-based dry eye therapies. A comprehensive approach may include established treatments for tear film dysfunction and MGD, combined with supportive strategies addressing eyelid comfort, blink mechanics, periocular hydration, and tissue health. Approaches aimed at optimizing eyelid mobility, muscle function, and periocular tissue health may therefore represent a logical adjunctive component of comprehensive dry eye care, although clinical studies are needed to establish efficacy. As research continues to clarify the role of ocular lymphatics, eyelid biomechanics, and periocular tissues in ocular surface disease, these emerging approaches may provide additional tools for personalized dry eye care.

References

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11. Papakonstantinou E, Roth M, Karakiulakis G. Hyaluronic acid: a key molecule in skin aging. Dermatoendocrinol. 2012;4(3):253-258. doi:10.4161/derm.21923

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14. Surowiecka A, Strużyna J, Winiarska A, Korzeniowski T. Hydrogels in burn wound management—a review. Gels. 2022;8(2):122. doi:10.3390/gels8020122