Sooner or later, every practitioner experiences a dissatisfied patient. It can be very challenging for a clinician to address an individual who feels underwhelmed or unhappy with the results of a particular treatment.
On occasion, patients return after an in-office meibomian gland dysfunction (MGD) procedure and report they did not achieve the results they expected. Knowing how to avoid this situation when possible and effectively addressing the disappointment when it does occur is imperative to maintaining a good relationship and ensuring patient loyalty.
After 10 years of performing a range of MGD procedures, I have some pearls and tips on how to avert this situation and successfully manage it during follow-up.
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Set realistic patient expectations for MGD therapies
There are three key steps to setting realistic patient expectations: evaluation, education, and meibography review. After administering the ocular surface disease index (OSDI) or SPEED questionnaires, I evaluate the patient’s symptoms logging their primary dry eye complaint, perform an eye exam to establish tear break-up time (TBUT), and gain a pre-treatment level of MGD. This information will serve as a benchmark for their initial as well as follow-up visits.
First and foremost, it is crucial for patients to understand that dry eye disease (DED) is a multifactorial and complex clinical entity, and MGD is just one part of the puzzle. In addition, they should receive an overview of the available procedures and the capabilities of each.
Next, review their meibography with them. Share the level of their MGD and make them aware that patients with mild dysfunction, who do not have significant meibomian gland atrophy, tend to respond better to a singular treatment. Comparatively, their counterparts with moderate to severe atrophy will likely need multiple treatment options since they have lost the majority of their glandular tissue and in extension functionality.
Once they understand you will be taking a polytherapy approach, they can make an informed decision—taking financial commitment into consideration—on whether or not they would like to embark on a treatment regimen.
Anatomic function versus symptomatology in MGD
When explaining the specific treatment, I divide the desired results into two categories: anatomic function of the meibomian glands and symptomatology. Though we hope to see both a reduction of symptoms and advancement in meibomian gland function, the value of positive anatomical changes cannot be overstated.
And, from my clinical experience, I have deduced that Food and Drug Administration (FDA) cleared in-office MGD procedures, such as TearCare, to improve the anatomy, which in turn leads to elevated glandular function. I emphasize to patients that by improving the glandular function now, we can reduce the risk of irreversible atrophy and more severe symptoms later, as we currently do not have the tools or technology to revive or regrow the meibomian glands.
With this knowledge in hand, they can see the benefit of addressing the disease state early and opting to initiate or continue in-office MGD procedures, along with at-home maintenance.
Treat co-morbid conditions as well as the MGD
Alongside dry eye and MGD, make certain to assess and address any comorbid conditions..
Factors that can lead to or exacerbate dry eye include:
- Ocular allergies
- Medications (i.e., antihistamines, decongestants, pain relievers, etc.)
- Digital eye strain from computer use
- Hormone changes
- Systemic diseases, including diabetes, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, Graves' disease, and Sjögren's syndrome
- Ocular diseases such as glaucoma, ocular rosacea, or myopia
Any coexisting condition needs to be treated and/or co-managed simultaneously to achieve optimal results.
Quantify improvements during follow-ups
As it often takes the eyes time to recuperate and produce healthier oil after relieving the obstruction, I suggest scheduling a 2-month follow-up exam. During this visit, remeasure TBUT and review symptomatology.
To help them better see their improvement, gauge favorable alterations in their normal, every day activities by asking questions such as:
- Have you noticed being able to read longer?
- Can you utilize your computer for a longer span of time?
- Are you wearing your contact lenses more often or for a more extended period?
Once they are made aware of their real-world progress, their level of satisfaction may grow.
Final thoughts
Dry eye disease, along with its meibomian gland component, can be very frustrating for patients who have often seen multiple doctors in their quest for relief. Support your patient by acknowledging their disheartenment and assuring them you are on their team.
This starts with educating on the multifactorial nature of DED and MGD and stressing how the in-office procedures are designed to not only alleviate their current symptoms but improve their anatomy leading to fewer issues in the future.
Once they understand their condition and the capabilities and limits of the different treatments, they can adopt reasonable expectations, making dissatisfaction less likely to occur.
