During the COVID-19 pandemic, I saw an increase in screen use among my patients as they worked from home and spent more of their free time inside—a trend that has continued with a national appetite for remote work.
Since that time, I have also witnessed an increase in patients with symptomatic dry eye disease (DED); my colleagues have seen a similar pattern.
This is commonly attributed to the aforementioned increase in screen time, which has been shown to alter blinking dynamics.1
Studies on dry eye and prolonged screen use
Studies have demonstrated that prolonged screen use significantly reduces blink rate. Normally, individuals blink around 15 to 20 times per minute, but this rate drops to about 5 to 10 blinks per minute during screen use. This reduction is linked to increased symptoms of dry eye disease.1
A study highlighted in the Oman Journal of Ophthalmology supports these findings, indicating that extended screen time correlates with decreased blink rates and increased ocular discomfort due to tear film instability and reduced tear secretion.2,3
Research has risen alongside the dry eye complaints, with many studies examining the influence of digital screen use on DED,1,4-7 and other research leading to recent US Food and Drug Administration (FDA)-approval or late-phase trials of novel treatments.8
The impact of DED on patients
DED is a multifactorial disease, and even before the pandemic, influences such as the environment, systemic conditions, and medications contributed to the problem. The Tear Film & Ocular Surface Society Dry Eye Workshop (TFOS DEWS) II report, published in 2017, estimated dry eye to be prevalent in 5 to 50% of the global population.9
The report outlined that the US prevalence of symptomatic dry eye ranges from 6.8 to 21.6%, a number which, in my professional opinion, is increasing every day.
Shifts in work habits and lifestyle have led to a greater need for treatment across a variety of unique populations, which makes it particularly important to be mindful of the barriers to this treatment that our patients might face. Widespread accessibility to DED treatment is critical given the prevalence of the disease and the psychological, social, and economic impacts of the disease on patients.
Along with general quality of life impacts, I see DED reducing the efficiency of some patients to the point that they cannot complete their usual workload. As optometrists/physicians, we have an obligation to recognize these hurdles and provide our patients with accessible and approachable solutions.
Addressing the 4 big barriers to dry eye care
There are a variety of different barriers that patients face when seeking dry eye treatment related to geography, physical limitations, cost, and accessibility to specialized treatments.
1. Geographic obstacles
Patients living in sparsely populated or underserved areas may need to travel long distances for DED treatment. Access can also be a problem for elderly patients and others who have mobility issues. They often become dependent on family members or friends for transportation, and these caretakers can have busy schedules.
Telehealth helps alleviate this barrier somewhat, but in my opinion, it is only effective for initial screening and mild dry eye disease management. If mild DED is assessed during a telemedicine call, a specific over-the-counter (OTC) eye drop can be recommended, which often provides some relief.
I like to start my patients on Oasis Tears (Oasis Medical). Oasis Tears Plus PF eye drops contain a key ingredient called glycerin, which increases their viscosity. This thicker consistency helps to provide longer-lasting relief by staying on the eye surface longer, enhancing moisture retention and tear film stability, which is crucial for individuals with dry eye symptoms caused by extended screen time.10
Due to these factors, my patients often experience a good amount of relief from their symptoms. In more severe cases, I always recommend bringing the patient into the office and running further diagnostics as the next step.
A note on thicker drops and vision: While thicker eye drops can provide more sustained relief, they may temporarily blur vision immediately after application. This could potentially interrupt workflow for those who use screens for the first few minutes. Users might need to plan drop usage during breaks to minimize disruptions.10
Avoid contact lens dropout by managing DED
Offering DED care has additional benefits, since the ocular surface influences so much of what we do. In my experience, fewer patients will discontinue contact lenses, and there will be fewer vision-correction remakes if they have a healthy ocular surface.
One study highlighted that contact lens wearers often experience meibomian gland dysfunction (MGD), a major contributor to evaporative DED. The study found that the first 2 years of contact lens wear can result in meibomian gland dropout and gland orifice obstruction, although this effect stabilizes over time.11
Furthermore, treating DED in contact lens wearers has been shown to improve comfort and wearing time. Approaches such as using rewetting drops containing carboxymethylcellulose and hyaluronic acid, switching to daily disposable lenses, and using topical medications like cyclosporine ophthalmic solution can provide significant relief and improve the overall experience for contact lens users.12
Considering this, optometrists who do not currently offer DED treatments should consider adding it to their practice. A dry eye center can be initiated with a fairly modest investment, and information on how to get started is readily available online and at state-associated conferences.
Educate patients on at-home DED care
For patients with difficulties visiting the office, education about lifestyle and home care options, such as blinking exercises, proper eyelid hygiene, warm compresses, hydration, diet, humidifier use, and avoiding wind and smoke, can be done remotely.
Education is one of the most valuable tools in general when it comes to treating dry eye. In addition to making patients aware of their options, it can help them to understand their condition and the affiliated health risks, thus they may be more willing to make dry eye care a priority.
2. Patient difficulty administering medications
It is not unusual for some patient populations, particularly elderly patients, to have trouble administering eye drops themselves. Here a support structure, either through family members, friends, or professionals, is helpful.
For patients who may not have access to this type of network, it becomes important to offer longer-lasting treatment options such as punctal plugs or at-home solutions that are more manageable for those with mobility or physical challenges.
I recommend nutraceuticals for all my dry eye patients, but find them especially helpful in this case, providing a systemic path to building a healthy tear film. I often look to HydroEye (ScienceBased Health) as one of the earliest steps on my treatment ladder after drops. HydroEye contains gamma-linolenic acid (GLA), derived from black currant seed oil, which has been shown to help modulate the body's inflammatory response.8-9
The clinical trial evaluated post-menopausal women, and at the conclusion of the study, there was a significant decrease in inflammation for two markers, increased corneal smoothness, and increased natural tear production. The fact that the nutraceutical was found to be effective by a strong double-blind, randomized, multi-center, controlled trial gives me confidence in the product.13
For moderate to severe DED conditions that do not respond adequately to lifestyle changes and at-home intervention, in-office treatments such as intense pulsed light (IPL), TearCare (Sight Sciences), or BlephEx (BlephEx) can also be a good solution and a logical further step in the treatment ladder.
These treatments will inevitably require more frequent office visits on the part of the patient, but they often have a lighter compliance load afterward.
3. Cost hurdles to DED care
Pharmaceuticals for dry eye are often very expensive, and out-of-pocket costs can be high. There are also several in-office treatments available that, though highly effective in treating the root cause of dry eye, are not currently covered by insurance. If your office accepts medical insurance, coverage could help a large portion of your patient population.
For example, required documentation includes all of the following:
- Chief complaint
- History
- General medical observation
- Visual acuity
- External ocular exam
- Adnexal exam
This code can be used to focus on a specific eye condition and is not considered “comprehensive.” In addition, 99XXX codes can be used as well to follow up on these patients with DED. Medicare does a great job accepting these office visit codes and others, such as punctal occlusion procedure codes.
While the cost of pharmaceuticals and medical devices and reimbursement rates are largely out of our hands, we do have the ability to educate clients about less expensive options, such as lifestyle changes and home care options. Changes in diet and the use of proven nutraceuticals as well as environmental adjustments, such as humidifier use, can have a positive influence at minimal cost to the patient.
When expensive procedures or pharmaceuticals are deemed necessary, eyecare providers should look for ways to make these treatments more readily available for patients, such as:
- Increasing recommended OTC options
- Offering payment plans
- Making sure the patients get all applicable insurance coverage
- Exploring other financial support options, such as manufacturer discounts or price bundling
4. Hesitation of ODs to refer patients
Not every optometrist can—or will—be able to provide a top-to-bottom suite of dry eye treatments. It is important that we connect with other DED providers and build a referral network, so that if a patient is in need of an in-office treatment that we cannot provide, we can facilitate the treatment through a referral.
To ensure that referred patients return, optometric offices should focus on exceptional patient care and robust communication. Providing personalized care, clear explanations of diagnoses and treatments, and convenient follow-up methods such as phone calls or emails fosters trust and satisfaction.
Additionally, the referral doctor can ensure the patient returns by giving detailed referral information, maintaining direct communication with the receiving office, and creating a feedback loop. Secure messaging systems and regular check-ins between offices can further strengthen coordination and patient care continuity, making patients more likely to return.
I sometimes see the hesitation to refer patients to other optometrists, out of concern that referring them elsewhere means that the patient won’t come back. We have to develop a relationship with our patients around trust and value, and then believe that they will return to us even if referred to another doctor for a specific procedure.
Finally, it is key that the public be educated to understand that we, as therapeutic optometrists, are the first line of defense for dry eye care. Many people often turn to their trusted primary care physician as a first step with any health concern; however, I believe it is more time- and cost-effective for them to go directly to a specialist.
Conclusion
With increased screen use, I am seeing more patients from all age groups with DED. Education is a major tool, allowing us to not only highlight the resources a patient does have but also encourage patients to make dry eye care a priority.
An understanding of DED and the treatments available is important to motivate younger patients to take time off work or out of otherwise busy schedules to care for their condition.
Some barriers to DED diagnosis and treatment are out of our hands; however, we owe it to our patients to do what we can within the scope of our influence and make them aware of the options that are available to improve the quality of their lives.
