Dry Eye Treatments: Cyclosporine, Lifitegrast, and Plugs Explained

For millions of people with dry eye disease, finding relief isn’t just about grabbing a bottle of artificial tears. When over-the-counter drops stop working, doctors turn to targeted treatments that fix the root cause - not just the symptoms. Three of the most common prescription options are cyclosporine, lifitegrast, and punctal plugs. Each works differently, has different timelines for results, and comes with its own set of trade-offs. Knowing how they compare can help you make smarter choices with your eye doctor.

How Cyclosporine Works - And Why It Takes So Long

Cyclosporine, sold under the brand name Restasis and generics like Cequa, is an immunosuppressant eye drop. It doesn’t add moisture - it tells your body to start making more tears again. Dry eye isn’t always about not enough tears. Often, it’s because your eyes are inflamed, and that inflammation shuts down tear production. Cyclosporine calms that inflammation.

But here’s the catch: it doesn’t work fast. Most people don’t feel better for 3 to 6 months. That’s because it’s rebuilding your tear glands, not masking symptoms. A 2023 study in JAMA Ophthalmology showed 71.6% of users had measurable improvement in corneal damage after 4 weeks - but that doesn’t mean they felt better yet. The real win comes later: longer-lasting tear production, fewer flare-ups, and less reliance on drops.

Side effects? Burning or stinging when you apply it. About 73% of users report this in online forums. The fix? Keep the bottle in the fridge. Cold drops hurt less. You also have to take it twice a day, 12 hours apart, and wait 15 minutes after applying before putting in contacts. It’s a hassle - and that’s why many people quit before it works. A post-marketing study found 68% of patients stop using it before the 3-month mark.

Lifitegrast: Faster Relief, But a Metallic Taste

Lifitegrast, branded as Xiidra, works differently. Instead of targeting inflammation broadly like cyclosporine, it blocks a specific protein (LFA-1) that causes immune cells to attack the eye surface. This gives it a faster start. Many users notice relief in as little as 2 weeks - sometimes even 10 days.

In the OPUS-2 clinical trial, 47.4% of people using lifitegrast had a 7-point or better drop in dryness scores after 14 days, compared to just 37.7% on placebo. That’s a real difference for someone suffering daily. But there’s a downside: a strong metallic or bitter taste. About 18% of patients stop taking it because of this. The trick? Use it right before bed. Swallowing a sip of water after applying helps wash it down, and lying down reduces the taste lingering in your mouth.

It’s also twice-daily, like cyclosporine. But unlike cyclosporine, it doesn’t require refrigeration. And while it doesn’t rebuild tear production long-term like cyclosporine, it gives you quicker symptom control - which is why some doctors recommend it for patients who need fast relief or can’t tolerate the initial burn of cyclosporine.

Punctal Plugs: A Physical Solution

Punctal plugs are tiny devices inserted into the small tear ducts at the inner corners of your eyelids. Think of them like stoppers in a sink. They keep your natural tears from draining away too fast, so your eyes stay wet longer. Unlike drops, they don’t change your body’s chemistry - they just conserve what you already have.

There are two types: temporary and permanent. Collagen plugs dissolve in 3 to 10 days and are used to test if you’ll benefit. Silicone plugs last indefinitely and can be removed if needed. The procedure takes less than 10 minutes and is done in the office. Success rates are high - 92% of first attempts work.

People who get them often say, “My eyes stopped watering all the time.” That’s because dry eye can trigger reflex tearing - your eyes flood with poor-quality tears when they’re irritated. Plugs reduce that cycle. But they don’t fix inflammation. If your eyes are red, gritty, and burning, plugs alone won’t solve it. That’s why many doctors combine them with cyclosporine or lifitegrast.

Downsides? About 28% of users report plugs falling out (extrusion), especially collagen ones. Some feel a foreign body sensation, especially in the first week. A 2023 study found 23% of temporary plugs dislodged within two weeks. Still, for many, the immediate relief is worth it.

Cost, Coverage, and Real-World Use

Let’s talk money. Restasis (cyclosporine) costs about $590 for a 30-day supply. Xiidra (lifitegrast) is slightly more at $622. Punctal plug insertion runs $150-$300 per eye, not including the doctor’s visit. Insurance often covers these, but prior authorization is common.

Restasis has a patient assistance program that covers 78% of commercially insured people. Xiidra offers a $0 co-pay coupon for the first month. Generic cyclosporine is cheaper - sometimes under $100 with coupons. Punctal plugs are one-time costs, but if they fall out, you pay again.

Adherence is a problem across the board. Only 41% of people are still using cyclosporine after 6 months. For lifitegrast, it’s slightly better - but the taste turns people off. Plugs have higher satisfaction if they stay in place, but extrusion ruins the experience.

Which One Should You Choose?

There’s no one-size-fits-all answer. But here’s how most eye doctors decide:

• If you have moderate to severe dry eye with visible corneal damage, start with cyclosporine. It’s the gold standard for long-term healing.
• If you need relief fast - maybe you’re preparing for surgery, a big presentation, or just can’t stand the grit anymore - try lifitegrast. Give it 2 weeks. If the taste is unbearable, talk to your doctor about switching.
• If you’ve tried drops and still feel dry, especially with watery eyes or discomfort after screen time, ask about punctal plugs. They’re low-risk and can be added to any medication.

Many patients end up on combination therapy. A 2023 Dry Eye Workshop report found 78% of experts recommend using cyclosporine + plugs together for severe cases. The drops fix the inflammation and rebuild tear production. The plugs keep the good tears in longer. It’s like fixing the faucet and plugging the drain.

What’s Next in Dry Eye Treatment?

The field is evolving. A new once-daily version of lifitegrast (Vevye) is in late-stage trials and could be approved by mid-2024. That would be a game-changer for adherence. There’s also a new type of collagen plug that releases cyclosporine slowly over time - called Cyclplug - showing 40% better results than regular plugs in European studies.

Meanwhile, newer drugs like rebamipide (approved in Japan, under review in the U.S.) and Tyrvaya (a nasal spray that triggers tear production) are entering the market. These may eventually replace some current options.

But for now, cyclosporine, lifitegrast, and punctal plugs remain the backbone of prescription dry eye care. They’re not perfect. They require patience, persistence, and sometimes a little trial and error. But for people who’ve suffered for years with red, burning eyes - they’re the difference between managing symptoms and actually getting better.