If you’re like me, you may not think of yourself as the “dry eye guy.” I may be “the cataract guy,” “the LASIK guy,” or “the cornea transplant guy,” but I am not a specialist in dry eye disease. Yet, invariably we all see dry eye frequently in our practices. Given its prevalence and its impact on so many aspects of ocular health and quality of life, we need to decide how we will address it.

Find Your Sweet Spot

I often use the three layers of an Oreo cookie as an analogy when discussing different approaches to managing dry eye. Some of us represent the top layer, fully embracing the concept of the Dry Eye Center of Excellence. This level of commitment brings numerous benefits, such as opportunities to be involved in research, to partner with industry, to participate in speaker panels and seminars, and attract patients wanting the most comprehensive approach to their condition. Expanding your practice to include a segment dedicated to dry eye also has the potential to increase revenue and grow your patient base through referrals. Of course, there are some challenges. Physicians and staff must adapt to a new specialty that requires integrating a battery of unfamiliar diagnostic tests and therapies, which they may view as disruptive. In addition, as you make the transition, you must communicate well and manage patients’ expectations to avoid confusion and misunderstandings. Patients who have been referred for cataract surgery may not understand why the conversation now involves red eyes and blocked glands.

Some ophthalmologists represent the bottom layer of the Oreo, although I believe this group is dwindling. Treatment is based entirely on symptoms, and severely symptomatic patients are referred to dry eye specialists. In an era when awareness of the importance of treating dry eye patients is growing, this may not be the best approach. When I diagnose dry eye in new patients and start them on a treatment regimen, their number one question is, “Why wasn’t I treated sooner?” So, in addition to compromising a patient’s ocular health in the face of this progressive disease, you risk your reputation and that of your practice when you’re not actively involved in diagnosing and managing dry eye.

Personally, I have chosen the middle layer — or, as I like to call it, “the sweet spot.” By reducing the number of days that I operate from four to three, I can continue to be a surgeon, while better integrating ocular surface and dry eye management into my busy practice. I’ve found that recommending nutritional supplements, along with LipiFlow (TearScience) and meibomian gland imaging, has been minimally disruptive and I can successfully manage more than 90% of patients diagnosed with dry eye.

Proactive or Reactive Approach?

My approach to treating a patient recently diagnosed with dry eye will be based on the following:

1. symptoms
2. findings on examination
3. recent or upcoming surgical procedures.

Ideally, I prefer treating earlier in the disease process — being proactive rather than reactive. Consider, for example, what appears to be an asymptomatic cataract patient (Figure 1). Upon examination, I find most of these patients are actually symptomatic, but they dismiss their symptoms as a normal process associated with aging. So, we have a discussion, and together we decide if we will proactively treat the dry eye prior to surgery, which is usually preferable. Some patients prefer to hold off on treatments, particularly if their treatment involves an out-of-pocket expense. By having the discussion prior to surgery, patient expectations are established and documented. Introducing this discussion after surgery rather than before surgery can be seen as a complication by the patient.

Furthermore, treating the ocular surface before surgery offers the benefit of improving the accuracy of IOL selection, which is even more critical in the premium IOL patient. If the patient tells me the dry eye treatment I am recommending is not in his or her budget at that time, I explain the potential ramifications of waiting: “Just be aware that cataract and corneal surgery (LASIK) impacts the ocular surface with irrigation, medications, and incisions that cut nerves. Premium intraocular lenses, particularly diffractive multifocal lenses, require a stable tear film and ocular surface for the best possible outcome.”

Dry Eye Disease: Then and Now

Not long ago, the belief was that dry eye was primarily the result of insufficient tear production, in many cases, linked to hormonal changes. Treatments, including artificial tears, punctal plugs, and Restasis (cyclosporine, Allergan), were directed toward alleviating dry eye symptoms.

Today, we know that dry eye is much more than tear quantity and includes tear quality and instability, the lipid component has become our focus. We, as doctors, have become more proactive in educating our patients and in recognizing, diagnosing, and treating this disease that can degrade ocular structures over time.

This is not complicated. When the basis for a patient’s dry eye is mechanical — an obstruction — I treat it with LipiFlow, a therapy that is extraordinarily effective in 93% of my patients. I refer the remaining 7% to my dry eye specialist at Duke. We also have a rheumatologist at Duke, whose entire practice consists of managing Sjögrens Syndrome.

Transition to Maintenance

Once meibomian gland dysfunction has been addressed, patients should start a maintenance regimen. One important component is daily eyelid and eyelash hygiene. I recommend Avenova (NovaBay) lid and lash cleanser, a product that I use even though I don’t have a severe dry eye problem. I also recommend that patients add the nutritional supplement HydroEye (ScienceBased Health) to their daily routines.

LipiFlow is also an effective maintenance therapy. The average patient returns for treatment about every 3 years. Although it’s more costly than artificial tears, this therapy is effective over the long term, and if patients think of it in the context of the cost of a cup of Starbucks coffee per day, they can appreciate its value. In fact, one of my patients has been coming to my office for a LipiFlow treatment about once a year for the past 5 years. She doesn’t want the dry eye symptoms she experienced in the past to recur, so she makes room in her budget for this therapy.

Choose Your Level of Involvement

If you’re a busy surgeon, you may not want or need to add all of the available dry eye therapies to your practice. But, given what we know about the consequences of dry eye disease, I believe it is incumbent upon us to take an active role in its management. The exact role and degree of involvement can be unique to each of us. ■