Focus on Dry Eye

The talk: Effective dry eye treatment begins with it

Good communication is critical for successful management of the condition.

By Leejee Suh, MD

As a cornea specialist, I will often see a new patient who is deeply frustrated about his dry eyes. He will bring in several different artificial tears or medicated eyedrops, complaining that none of them worked and that he saw a doctor about his dry eyes a year before.

Now it’s my turn. I need to convince him that working together, we can bring him relief. Unfortunately, that is not so easy. We still don’t have a perfect understanding of the causes of dry eye, and the fact that symptoms of dry eye often overlap with other conditions only makes the task more difficult.

Thus finding effective treatment for our patients is often a matter of trial and error — that is, it’s going to take some time. That’s the last thing a frustrated patient wants to hear.

How do you keep the patient’s trust and cooperation that are essential to managing a chronic condition such as dry eye? I have found that I can boost a patient’s morale by taking the time to make a sincere effort to educate him about dry eye in the first visit, and then by diligently conducting check ups to monitor his condition.

What’s your mind-set?

Before you can communicate effectively with your patient, you may need to change your own view of dry eye. Quite honestly, a lot of physicians seem to consider dry eye a nuisance rather than a condition. That attitude contributes to a tendency among ophthalmologists to not treat dry eye vigorously. We need to embrace dry eye as a legitimate disease, whether we’re comprehensive ophthalmologists or cornea subspecialists.

For starters, we need to forego the almost knee-jerk reaction of recommending artificial tears. Instead, we must look at the new definition of dry eye: It’s not just a lack of tears, but a multifactorial condition of the tear system and ocular surface, with frequent symptoms of discomfort and disturbance in vision and instability of the tear film. As a cornea specialist, I try to be more aggressive in my treatment of dry eye and I think that helps not only in seeing results, but also in patient adherence and outcomes.

A TWO-PRONGED APPROACH

Once you are in the proper frame of mind to address dry eye optimally, it’s time to tailor both a message that will click with frustrated dry eye patients and an approach that genuinely relieves their symptoms.

Framing a meaningful message

When it comes to the message, here are the points I make sure to hit:

• Dry eye is a chronic condition. Explain that the patient needs to invest time and effort to get better, just as he needs to exercise and diet to lose weight. Then, again as in weight loss, it takes effort to maintain that improved condition.

• Dry eye can be time-consuming and the results can be variable. This applies for both patient and ophthalmologist. As the physician, you may go through some trial and error before you find the most effective treatment for an individual, but make it clear you are committed to helping him.

• Dry eye is multi-factorial, so treatment must be multi-faceted. For instance, tell the patient that treatment may not involve only one artificial tear. And besides prescribing an artificial tear for an individual’s type of dry eye, I will also address lifestyle. If I discover that this patient spends 13 hours a day on the computer, I will instruct him to make a conscious effort to blink more often or to otherwise change his environment.

• Dry eye can cause permanent damage to the eye. This can result if the patient does not get treatment and stick to it. Emphasize that dry eye is not merely a nuisance condition. While I do not usually try to scare patients, I do try to make them understand the importance of getting treatment for their condition and complying with it. A potentially serious consequence could be in store otherwise.

The clinical approach

The focused examination must involve a thorough history. This entails discussing the patient’s lifestyle. Once you have explained dry eye is multifactorial, you can address the patient’s environment and how that contributes to the condition. Explore how much time the patient spends on the computer, if his home has ceiling fans and other possible environmental factors.

Your patient education efforts should start to pay off here because having heard about the multifactorial nature of dry eye, the patient is more likely to take seriously your instruction on changing his environment. For example, when I treat a postmenopausal woman, we discuss the hormonal influences on the tear film, and we talk about using artificial tears and topical cyclosporine, which can improve tear production.

A thorough history, however, also means conducting a more comprehensive examination of the eyes than you might be used to. I don’t mean just looking at the cornea, but also looking at the patient’s face and joints to rule out conditions such as rosacea or arthritis. You need to take a step back and look at the patient, then you zoom in closer — evaluating the lid margin, because blepharitis and meibomian gland disease can be huge contributors to dry eye. Ophthalmologists often overlook the eyelids in dry eye.

HIT THEM WHERE THEY LIVE

A matter of diet and nutrition

Discussing lifestyle with the patient allows me to segue to talking about nutritional supplements. I talk about using omega-3 fatty acids. And I don’t speak for any of these vitamin supplementation companies, but some supplements on the market are geared to eye health. Usually, however, I tell patients to try omega-3 fatty acids that have a manufacturer-recommended daily dose.

No instant gratification

Whether your treatment plan involves prescription medications, nutritional supplements, artificial tears or any combination of these three, make it clear to your patients that any therapeutic plan will take time to yield results. You will need to emphasize this message more than once in the course of your time with the patient.

For example, when I start a patient on cyclosporine, I explain how the drug works, that we think dry eye is an inflammatory disease and cyclosporine is an anti-inflammatory drug, which builds up tear production — and that this effect can take time. I warn the patient that he may not see results for up to three months. I instruct the patient to use concomitant artificial tears to obtain some relief in the meantime. If the condition is severe, I will start the patient on topical steroids as well. And I explain, yet again, the treatment can take weeks to work.

Follow-up: The piece de la resistance

After you have educated your patient about dry eye, taken that thorough history and discussed a treatment plan, you have one last, essential step to take: follow-up. Let the patient know that you want to see him again soon. I schedule another visit before the patient leaves my office — typically within six to eight weeks.

At the follow-up, I check the tear film and production, and I ask for another visit a few months later, where I’ll check the tear film again. This practice differs from the common approach to dry eye, but it is no different from what we would do to check on glaucoma or retinal conditions, so why wouldn’t we follow it for our dry eye patients? If we want patients to act on our message that ignoring their dry eye could lead to ocular damage, we have to make our actions support that message.

The follow-up at shorter intervals demonstrates that you do not want your patient to fall through the cracks. I find this approach is crucial to patient compliance and outcomes. Patients are vested in their treatment plans if you follow up with them. OM

About the Author
	Leejee H. Suh, MD, is an associate professor of Ophthalmology and the Director of the Laser Vision Center and the Cornea Fellowship Program at Columbia University’s Edward S. Harkness Eye Institute, New York. Her email is lhs2118@columbia.edu. Disclosure: Dr. Suh disclosed she is a consultant to Allergan.