How to Discuss Dry Eye With Patients

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7 min read

In this episode of Interventional Mindset, Amanda Steele, OD, reviews the best approaches to discussing dry eye with patients.

When treating dry eye disease (DED), it is critical that patients have an understanding of the nature of their disease and a clear picture of the treatments that are available to them.
The patient education process has three essential components: increasing their knowledge of the disease, making them aware of the current treatment options, and defining their role in the treatment process.

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1. Discuss dry eye as a chronic disease

First and foremost, it is vital that patients comprehend the chronicity of this disease. They must understand that dry eye disease is a chronic condition that will require long-term management and, most often, a combination of treatments.
In addition, they must appreciate the multifaceted essence of DED and that a coalescence of factors over a span of time created the disease. It did not develop overnight, nor will it be “cured” overnight. Do not be remiss in including information on inflammation and the fact that it is also a chronic underlying condition that might have acute exacerbations from time to time called dry eye flares.
It's also very important that patients understand the composition of the tear film and how compromised tear quality might contribute to DED. When discussing the multi-layered characteristics of tears, I find a simplistic explanation is best.

Sample script for an explanation of tear layers:

“Tears contain three layers similar to the oceans’ on Earth. There is an oil layer that is produced by the glands of your eyelid to keep tears against the eye surface. Then there is a watery layer, aka the aqueous layer, that is produced by the lacrimal glands located under each eyebrow towards the side of your face. And finally, there is a mucus layer produced by a thin clear tissue just above the white part of your eye which is velcro-like to hold the layers together film.”

Also, be sure to explain pre-existing circumstances and conditions that contribute to DED.

Include in the discussion:

  • Prior and current medications
  • Chemotherapy, radiation, and other oncology treatments, which can cause lacrimal gland obstruction and associated meibomian gland loss and thinner lipid layers
  • Systemic diseases, especially those in the autoimmune family
  • Digital screen usage since this contributes to evaporative dry eye

2. Outline DED treatment options

With the enormous volume of tear products on the market today, patients are often confused about which drop will best serve them. It is imperative to empower patients by helping them understand which tears will best treat their specific type of dry eye disease and primary symptoms. To do this, eyecare providers must stay abreast of the products currently available to the public by visiting local pharmacies on a regular basis to examine the various over-the-counter offerings and note their active ingredients.
Pass on this knowledge and clarify the difference between preserved and non-preserved, as well as the required treatment regimen for each. Make sure they grasp that preserved tears should be applied no more than three to four times a day, as the long-term use of preservative drops is linked to ocular surface damage and increased punctate epithelial keratitis along with subtle to pronounced conjunctival hyperemia. If they require more frequent relief or have a known sensitivity to preservatives used in these products, it is suggested they switch to a non-preserved formulation, such as iVizia.
Furthermore, it is paramount to explain the difference between mild evaporative DED, for which a simple non-preserved lubricant may be the preferred initial DED treatment, compared to meibomian gland dysfunction (MGD), where these patients will likely require a drop with both a lubricant and oil component.

3. Inform patients of available dry eye procedures

In addition to outlining the best tear products, introduce the current in-office procedures that improve meibomian gland and ocular surface health leading to diminished dry eye symptoms. Point out that, though results will alleviate symptoms for a time, they are not permanent; however, treatments can be repeated as needed.

Thermodynamic procedures

Illustrate to the patient how thermodynamic procedures (i.e., LipiFlow, TearCare, and iLux2) could enhance meibomian gland function. Explain that during the procedure, their glands will be heated to allow expression and clear obstruction. In turn, these thermal techniques can assist in restoring glandular function and the quality of the meibum secretion, which is necessary to maintain tear film homeostasis and a healthy ocular surface.

Intense pulsed light therapy (IPL)

For patients who need treatment beyond the meibomian glands, especially those with rosacea or other vascular conditions leading to inflammation, IPL could be an excellent option.
IPL can be described as non-laser red and infrared pulsed light geared to potentially restore the function of meibomian glands, destroy telangiectatic blood vessels, reduce the load of Demodex mites, and facilitate positive cellular function, all leading to a healthier ocular surface.

Punctal plugs

Punctal plugs are a quick and easy way to raise tear volume but are often an underutilized resource. Before inserting punctal plugs, be certain to check inflammatory levels through a point-of-care test (i.e., MMP-9, Lactoferrin, IgE, etc.).
If significant inflammation exists, focus the initial treatment on reducing these levels using either a steroid, such as loteprednol (Eysuvis) or fluorometholone acetate (Flarex), or an anti-inflammatory medication, such as cyclosporine (Restasis and Cequa) or lifitegrast (Xiidra), or chemical neurostimulation, such as varenicline (Tyrvaya), or a combination. For patients, punctal plugs can be likened to tiny stoppers that prevent the valuable tear fluid needed to keep the surface moist from draining from the eye.

4. The patient’s role in treatment success

The duty of an eyecare provider is that of both clinician and patient advocate, which entails empowering patients to also advocate for themselves. Due to the chronic nature of DED, which might be complicated further by acute dry eye flare-ups, patients are often frustrated and disappointed.
However, furnishing facts about their disease and management options, making them confident in their ability to choose over-the-counter products, and providing them with at-home treatments instills a greater sense of control and improves compliance.

In conclusion

Ensure the patient understands that dry eye is essentially a puzzle with many different pieces, and—though it may take several different approaches and treatments combined—there is a solution to the DED puzzle.
Remind them the key to success is a willingness to explore the range of treatments and adhere to the agreed-upon management plan.
Amanda Steele, OD
About Amanda Steele, OD

Dr. Steele earned her undergraduate degree at Meredith College in Raleigh, NC followed by her Doctor of Optometry degree from Southern College of Optometry in Memphis, TN graduating with top clinician awards in both her final years. Dr. Steele completed a fellowship in refractive surgery co-management at LaserVue in Orlando, FL.

Dr. Steele returned to Raleigh in 2001 where she practiced all facets of comprehensive eye care at Eye Care Associates/MyEyeDr and received the Optometrist of the Year Award in 2008. She was invited to join the faculty of Duke University Eye Center in Durham as Assistant Clinical Professor of Ophthalmology in 2018 where she specialized in ocular surface diseases such as meibomian gland dysfunction and dry eye disease. She worked collaboratively with the surgeons and provided post-operative care in addition to comprehensive eye care.

Dr. Steele has had the privilege of mentoring many Triangle-area optometrists throughout the last several years in clinic as well as in local continuing education lectures. She is an active member of the American Optometric Association, North Carolina Optometric Society and the Eastern District Optometric Society. Dr. Steele has dedicated her career to the research and management of ocular surface disease and is very passionate about educating patients about their visual system as well as diagnosing and treating their ocular conditions. She is particularly passionate about treating dry eye disease.

Amanda Steele, OD
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