Oral n-acetylcysteine (NAC), hyaluronic acid and/or rebamipide-based eye drops may also be effective for dry eyes. Ciclosporin Topical ciclosporin (topical ciclosporin A, tCSA) 0.05% ophthalmic emulsion is an immunosuppressant. The drug decreases surface inflammation. In a trial involving 1200 people, Restasis increased tear production in 15% of people, compared to 5% with placebo. It should not be used while wearing contact lenses, during eye infections or in people with a history of herpes virus infections. Side effects include burning sensation (common), redness, discharge, watery eyes, eye pain, foreign body sensation, itching, stinging, and blurred vision. Long term use of ciclosporin at high doses is associated with an increased risk of cancer. Cheaper generic alternatives are available in some countries. Conserving tears There are methods that allow both natural and artificial tears to stay longer. In each eye, there are two puncta – little openings that drain tears into the tear ducts. There are methods to partially or completely close the tear ducts. This blocks the flow of tears into the nose, and thus more tears are available to the eyes. Drainage into either one or both puncta in each eye can be blocked. Punctal plugs are inserted into the puncta to block tear drainage. It is not clear if punctal plugs are effective at reducing dry eye syndrome symptoms. Punctal plugs are thought to be "relatively safe", however, their use may result in epiphora (watery eyes), and more rarely, serious infection and swelling of the tear sac where the tears drain. They are reserved for people with moderate or severe dry eye when other medical treatment has not been adequate. If punctal plugs are effective, thermal or electric cauterization of puncti can be performed. In thermal cauterization, a local anesthetic is used, and then a hot wire is applied. This shrinks the drainage area tissues and causes scarring, which closes the tear duct. Other Heating systems that try to unblock the oil glands in the eye have some preliminary evidence of benefit. Fish- flax- and hemp-oil (omega-3) supplements are not effective in relieving symptoms. Surgery In severe cases of dry eyes, tarsorrhaphy may be performed where the eyelids are partially sewn together. This reduces the palpebral fissure (eyelid separation), ideally leading to a reduction in tear evaporation. Prognosis Keratoconjunctivitis sicca usually is a chronic problem. Its prognosis shows considerable variance, depending upon the severity of the condition. Most people have