In this episode of Dry Eye Fireside Chat, Damon Dierker, OD, FAAO, and Richard Maharaj, OD, FAAO, discuss rescue therapies for dry eye disease, including how to identify, educate, and manage patients in need of these interventions.
Rescue in sight for dry eye patients
"My team and I really rely on a multimodal approach, incorporating evidence-based protocols and advanced diagnostics. However, there can be bumps in the road and points where we as a team really need to steer the ship,” noted Dr. Maharaj.
As managing partner of optometry services at Prism Eye Institute in Ontario, Canada, a collaborative ophthalmology-optometry group that focuses on complex treatment-resistant cases, Dr. Maharaj and his team see well over 5,000 cases each year.
Nevertheless, although they develop routine long-term ocular management plans for each patient, there can be unexpected setbacks. This is where rescue therapies come in—interventions used to address acute issues unreceptive to a patient’s standard management regimen.
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Identifying when to intervene
What signs signify that a patient might be experiencing—or about to experience—a flare? Dr. Maharaj also evaluates contact lens intolerance.
”Sometimes a patient will tell me that they stopped wearing their contact lenses for a couple of weeks, and although it may be said in passing, their tone and body language can indicate displeasure at losing the quality of day-to-day living and freedom, and could be a potential reaction to a flare.”
Visual instability is another sign he takes note of. “Around winter, we’ll usually have some patients that complain of blurry vision, attributing this to the longer nights and poorer weather—however, vision stability shouldn’t be an issue if the tear film is stable,” Dr. Maharaj says. “It’s another potential symptom of an ongoing or upcoming flare.”
No shame, all gain with dry eye flares
“It’s been my experience that patients can feel like they’ve failed when they have a dry eye flare," he added. Therefore, he works to dispel any negative connotations around rescue therapy by explaining that it is an opportunity to press reset on whatever issue they’re facing.
According to Dr. Maharaj, “An analogy I often use is dental care: you can brush your teeth and floss every day and still get a cavity—when that happens, we need to first deal with the cavity before anything else, but it’s not the end of the line.
Framing it like this helps patients to understand that rescue doesn’t mean failure; it’s actually a necessary part of regaining control and homeostasis.”
Educate early on dry eye
Dr. Maharaj reminds us that we don’t need to wait until rescue therapies are needed to begin education. “I aim to do much of the heavy lifting at a patient’s initial visit by letting them know that I expect that they may experience an average of four to six flares in a given year.”
Having this knowledge can mean that patients are less likely to feel that their core therapies are failing when they experience flares. However, if doubt does occur, Dr. Maharaj reminds patients of where they started prior to treatment and how effective the current strategies have been thus far.
He added, “Photography is also a great education tool, which is why it’s important to always have it on hand to show patients where they were, where they are, and where they could be.”
Amniotic membranes for short-term relief
“DEWS III was recently rereleased; it advocates for addressing the subtype first1—this requires us to identify the core etiology, which in turn can really help to drive rescue therapy," explained Dr. Maharaj.
To this end, he treats instances of flares as one-off occurrences and typically doesn’t alter a patient’s long-term management plan following rescue therapy implementation.
“As a general rule, I keep patients either on a 3 or 6-month interval for their maintenance sessions, and then we handle flares as and when they show up.” However, in the short term, Dr. Maharaj often employs amniotic membranes as a rescue treatment modality.
“I’ve found amniotic membranes to be a really nice fire blanket; putting it on the cornea quickly calms any inflammation," he explained. “It can serve as a literal reset of the cornea.”
In closing
Flares can serve as opportunities for education and encouragement. Dr. Maharaj stated, “When a flare does occur, alongside reminding them that it’s not the end of the line but a rescue, I also like to use it as an opportunity to encourage patients to be proactive and preventative, not reactive.
It’s a chance to ensure patients are staying attuned to their maintenance schedule, which can be really key in reducing the number of these flares that do occur.”
