Whether you are preparing a patient for surgery, fitting contact lenses or addressing an ocular surface complaint, you have probably noticed some debris on patients' lids and lashes. Maybe you have even thought that a patient might have better comfort and vision if they took care of their eyes the way they do their teeth. After all, it's no secret that the dental industry had great success with its “brush, floss, rinse” campaign to fight cavities and prevent gingivitis.
Educate patients about healthier, at-home hygiene habits that stick
We believe it's time optometrists and ophthalmologists put similar attention on essential elements of ocular hygiene, since this is as foundational as brushing teeth. This Ultimate Guide will help you educate your patients about ocular health with a complete toolbox that includes information on everything you and your patients need to know about foundational care.
We already know what our patients should be doing, and we have the tools to help them. Therapies run the gamut from pharmaceuticals and over-the-counter (OTC) eye drops to in-office treatments, such as thermal pulsation or intense pulsed light (IPL) treatment. However, many patients are unaware of how essential ocular hygiene practices are to their well-being and quality of life. The good news? Studies show that when the message comes from an eyecare provider, the vast majority of patients are eager to learn and willing to adhere to an ocular hygiene regimen.1
Your patients' at-home hygiene and wellness routine is now more important than ever
Proper hygiene benefits virtually every patient. Specific lifestyle choices offer wonderful opportunities to initiate an ocular hygiene conversation. For example, you can emphasize hygiene with patients while discussing any of the following lifestyle factors such as digital screen viewing, make-up use, and/or contact lens wear.
Dry eye disease
Dry eye disease affects millions of people worldwide and is one of the most common causes for visits to eye care practitioners.2 Specifically, dry eye is defined as “a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.”2
The symptoms of dry eye disease encompass a broad range of patient-reported experiences that include, but are not limited to, discomfort, including grittiness and foreign body sensation, as well as photosensitivity, epiphora and visual disturbance.2,3,4,5 The effects of dry eye are likewise diverse and should never be trivialized as a nuisance condition. Dry eye disease also impacts society by way of reduced quality of life, and it carries an economic burden because it often affects workers’ vision and productivity.2
In addition to being considered underdiagnosed, dry eye is known to be undertreated.2,6,7,8,9 To that end, the TFOS DEWS II Management and Therapy Subcommittee forwarded an algorithm to guide treatment selection.10 It begins with low-risk, patient-applied OTC home therapies and progresses to more invasive approaches for more severe dry eye disease that doesn’t respond to more accessible treatments.2 For example, the committee’s recommendation for staged treatment of dry eye disease specifies the use of lid hygiene and warm compresses as first step in treating dry eye disease, whereas amniotic membrane grafts are considered a step 4 treatment.2 However, even when patients progress to higher levels of therapy, previous therapies may be continued.2 For example, if a patient requires tea tree oil treatment for Demodex (step 2), this therapy may be continued even if the patient also requires a topical corticosteroid (step 4).2
It is also important to note that some interventions, such as steroids, are for short-term treatment,2 whereas others, such as moist heat, are part of an overall ocular wellness routine that can safely be used over the long term. In fact, in 2021, TFOS published a report detailing international practice patterns for dry eye disease management, noting that lid wipes are among the most commonly used management approaches globally (81%).11 Furthermore, globally, 66% of practitioners recommend homemade warm lid compresses such as a face cloth, whereas 90% of ECPs in North America recommend commercially available lid compresses.11
Dry eye is a chronic disease, meaning it can require a lifetime of maintenance to keep symptoms at bay. To that end, no matter what prescription treatment or procedure is recommended, there are some very basic steps that all dry eye sufferers can benefit from to help prevent dry eye from interfering with their quality of life. These center on ocular hygiene and wellness. For example, keeping the lids clean is a must for patients who have dry eye disease. Whether or not the lids are the primary offender, lid debris and inflammation will exacerbate symptoms.
Dehydration is another concern. “Many medications for the eye and dry eye, in particular, have a dehydrating effect on the body,” said Joshua Davidson, OD, FAAO, FSLS, Williamson Eye Center, who recently developed an ophthalmic anti-inflammatory hydration beverage. "I was concerned with some of the ingredients, including sugar, that are present in other hydrating beverages that I was recommending to patients," says Dr. Davidson. "I wanted to create something to specifically support ocular health."
Digital screen viewing
Today’s patients are averaging more time in front of screens and digital devices than ever before. While data is still being collected, studies have shown that digital eye strain among children alone increased by 50-60% since 2020, with symptoms expanding to include recent onset esotropia, vergence abnormalities, and increased progression of existing myopia.12
During screen time, patients tend to blink 60% less than average, which can lead to an increase in eye dryness and irritation13,14 and a corresponding decrease in tear breakup time (TBUT).
“The increase in digital device use in today’s world has decreased the average age of onset for ocular surface disease due to the reduction in blink reflex noted in several studies. This has resulted in meibomian gland loss and worsening evaporative dry eye disease," notes Lisa K. Feulner, MD, PhD, Advanced Eye Care. “We know that ocular surface disease is chronic and progressive. Patients need to be educated that ignoring daily ocular surface care can cause permanent changes that are more difficult to treat as the disease progresses.”
Just as you wouldn’t run a marathon without eating properly and getting a good night’s rest the evening prior, clinicians emphasize that patients shouldn’t expect their eyes to perform at their peak if they’re not well-cared for before putting them to work.
“If a patient is a contact lens wearer, a gamer, or has some pre-existing ocular surface disease, it’s our duty to educate them on common sense routines including hydration, lid cleansing, and warm compresses,” adds Cynthia Matossian, MD, FACS, ABES, founder, Matossian Eye Associates. “Just because it’s obvious to us does not mean that the patient comprehends the importance of these simple preventative behaviors.”
“This is one area where we can have a huge impact on the vast majority of our patients,” said Paul M. Karpecki, OD, FAAO, Kentucky Eye Institute. “If we recommend daily hygiene to every patient and even a small percentage of them follow our advice some of the time, it could put a big dent in overcoming patient discomfort, contact lens dropout, and more.”
Lid and lash make-up use
Many clinicians describe the cringe-worthy way patients misuse makeup or neglect to remove it from their skin, lashes, and eyelid margins, but Dr. Matossian has a different, more optimistic perspective.
“If a patient is wearing makeup, I’m already ahead because they are used to a routine that involves taking time to care for their eyes,” she said. “It’s a lot harder to have a conversation about hygiene with someone who places no importance on skin care routines or who doesn’t devote any time to it.”
Discussing hygiene with patients who wear eye makeup can begin with a basic observation. For example, if you see fresh or residual eye makeup, use this to segue into a discussion of the importance of lid wipes or sprays as a way to ensure that they don’t develop meibomian gland dysfunction (MGD), a stye, or another condition that will require them to discontinue make-up, even just temporarily.
Meibomian gland dysfunction
Extensive clinical research has consistently identified MGD as a primary factor in the majority of dry eye disease cases. Recent studies show that 86% of individuals suffering from dry eye also exhibit symptoms of MGD.15,16,17,18 In fact, MGD is considered a main cause of dry eye disease.15,19
MGD can have a significant impact on comfort and vision,” said Darrell E. White, MD, founder, Skyvision Centers. “But why let it get to that point?”
“The current pharmaceutical therapies are like having an all-star quarterback on your team. But regardless of the players, you’re not going to win on MGD unless you can create a more ideal ocular environment on lashes and lid margins,” said Dr. White.
The MGD treatment menu is extensive and includes pharmaceutical therapy as well as in-office procedures.
“Before and after in-office treatment, we rely on a moist heat compress,” Dr. White added. “A single-use compress can be employed in the office prior to manual expression or microblepharoexfoliation. It’s also helpful to use hypochlorous acid spray and a lid wipe after warming the glands in the office. Patients can then be sent home either with a supply of single-use masks or with a durable, multi-use compress. I recommend the Bruder compress to all my patients because the consistent, moist heat allows it to penetrate the lids quickly and efficiently.”
The MGD treatment menu is extensive and includes pharmaceutical therapy as well as in-office procedures.
“Before and after in-office treatment, we rely on a moist heat compress,” Dr. White added. “A single-use compress can be employed in the office prior to manual expression or microblepharoexfoliation. It’s also helpful to use hypochlorous acid spray and a lid wipe after warming the glands in the office. Patients can then be sent home either with a supply of single-use masks or with a durable, multi-use compress. I recommend the Bruder compress to all my patients because the consistent, moist heat allows it to penetrate the lids quickly and efficiently.”
Many patients now use different types of eyelash extenders or false eyelashes, and they may not remove the lashes or the glue. Others apply eyeliner on the waterline of the eye (the area of skin between the base of the lash line and cornea, where the eyelids meet when closed), which can obstruct the meibomian glands. More commonly, patients may not remove makeup at night, before they go to bed, or they don't do a thorough job. This obstructs the natural orifices of the glands and can exacerbate ocular surface disease. When makeup is left on the eyelid margin, it not only occludes the oil glands, it also ends up in the tear film, creating a target for pathogens as well as a breeding ground for bacteria and infectious organisms.
Contact lens wear
Contact lens designs and materials have advanced, but discomfort remains a problem that leads to double-digit dropout rates year after year.21,22
A clinical study at the School of Optometry, University of Alabama at Birmingham found that subjects using Bruder masks with MediBeads® technology to warm the meibum and promote oil flow had significantly improved meibomian gland scores and experienced steeper declines in their overall Eye Discomfort Assessment scores.22 They ultimately increased comfortable wear time of their contact lenses by up to three hours simply by using the compress.22
Hydration is also crucial and should be emphasized with all patients—particularly with contact lens wearers. “Research demonstrates that proper hydration can reduce signs and symptoms of dry eye disease,” said Dr. Matossian.
Blepharitis
Blepharitis is a broad medical term that applies to a wide range of ocular conditions. Translated from the native Greek, blepharitis literally means “inflammation of the eyelids". The term anterior blepharitis refers to those conditions that affect the eyelid skin, base of the eyelashes, and the eyelash follicles. In contrast, posterior blepharitis affects the meibomian glands and is typically synonymous with MGD.23
Anterior blepharitis can be further subdivided by etiology, e.g., staphylococcal and seborrheic blepharitis; which represent the two most common forms of the disease. With regard to presentation, we expect patients with anterior blepharitis to demonstrate swelling and irritation of the eyelids, most specifically involving the lid margins. You will usually see some amount of scaly or crusty debris in the lashes as well, with or without associated eyelid thickening and redness.
Staphylococcus and Seborrheic Blepharitis: Images courtesy of Alan G. Kabat, OD, FAAO
Most clinicians who employ or have employed ocular hygiene regimens do so with the intent of treating anterior blepharitis. The use of moist heat compresses in combination with mild, detergent-based lid cleansers can help to soften, loosen, and remove lash debris that is the hallmark of these conditions. These same treatment strategies impart antimicrobial benefits to address the excessive bio-burden of resident bacteria that underlies Staphylococcal blepharitis, and also clear away the excess dirt and oils associated with both staphylococcal and seborrheic blepharitis.
Hypochlorous acid spray is another treatment option that directly addresses bacterial overgrowth as well as the inflammation that it spurs in anterior blepharitis.24
“Hygiene can be key to successfully treating blepharitis,” said Dr. Karpecki. “If patients cleaned their lids and lashes even once a day, they would clear off bacteria, biofilm, cosmetic residue, and other pathogens that can lead to or flare a blepharitis case.”
About 25 million Americans are impacted by Demodex blepharitis.25 Demodex mites contribute to blepharitis in several ways: direct mechanical damage, as a vector for bacteria, and by inducing hypersensitivity and inflammation. These mites represent a significant threat to optimal ocular health and are a major contributor to dry eye disease. Patients with Demodex blepharitis may present with waxy, cylindrical debris at the base of the lashes, which are indicative of Demodex mites.25
Demodex Sleeve and High-Magnification of Demodex Mites : Images courtesy of Alan G. Kabat, OD, FAAO
Natural remedies, such as tea tree oil, have proven to be efficacious as a first-line treatment against Demodex populations.26,27 Since today’s clinicians are looking more carefully for signs of Demodex than ever before, there’s an opportunity to control mite populations before symptoms get out of hand by harnessing the power of this organic compound.
“This is great news for patients because it means we can intervene sooner—often before disease progresses to a stage where costly pharmaceutical management is necessary,” said Dr. Matossian. “Similarly, eyecare providers can help patients maintain healthy lids following a course of treatment. “Patients who keep their lids clean with natural, 1% tea tree oil wipes, cleansers and lotions may not need to repeat pharmaceutical treatments as often.”
Ocular allergies
When it comes to complex conditions like allergies, we often think of spring and fall as the two major seasonal peaks. But patients may also have perennial allergies from pet dander, dust mites, and down feathers, which can exacerbate ocular symptoms. No matter the season, outcomes can always be enhanced by at-home care. The benefits are twofold.
First, ocular hygiene can reduce ongoing exposure by removing allergens from lids and lashes. “A gentle lid wipe, used twice daily, can have a big impact,” said Dr. White. “We assume that patients with allergies are washing their face and eyelids regularly, when in truth many patients are just splashing water on their faces much of the time.”
Second, patients dealing with discomfort and itchiness will appreciate simple, at-home solutions that can alleviate minor discomfort. “If the lids are inflamed, I add a hypochlorous acid spray,” said Dr. Karpecki. “It’s a phenomenally effective treatment to kill bacteria and other microorganisms that may be present, while wiping the eyes aids in the mechanical removal of dead cells and other biofilm. The result is a cleaner surface and potentially better vision, especially if the patient wears contact lenses.”
"One challenge we face in practice is disentangling allergy from dry eye symptoms", comments Cecelia Koetting, OD, FAAO, Dipl. ABO, University of Colorado Anschutz Medical Campus. With AllerFocus,™* ODs and MDs can use evidence-based results to identify allergies without leaving the practice. Many insurance plans reimburse for this 15-minute, in-office, skin prick test, which is also pain-free, needle-free, and identifies 78 of the most common environmental allergens, such as plants, grasses, fungus, mold spores, animal dander, insects and dust mites.
*AllerFocus testing can be performed in ALL states with an MD onsite. Limitations apply for OD-only practices. Please visit bruderpro.com/allerfocus for more information.
Upcoming ocular surgery
If you are preparing patients for cataract or refractive surgery, you already know that the ocular surface and tear film play a critical role in obtaining accurate measurements and optimizing postoperative outcomes.28,29
“Any optometrist who prepares the ocular surface before surgery is going to make it so much easier for their patients,” said Dr. Feulner. She encourages all of her cataract and refractive surgery colleagues to partner with their co-managing optometrists to begin the conversation—and ideally the treatment—before referral. “There is so much more satisfaction when we are all working together as a team,” she said.
Dr. Feulner suggests the following script for her MD colleagues: “Your optometrist and I have this simple protocol, and I appreciate you following it because it can help facilitate a better outcome from your surgery.”
Many ODs and MDs find that pre-op patients are more motivated to engage in short-term, healthy behaviors. This presents an excellent opportunity to kick start good habits that can last a lifetime. To that end, many clinicians provide comprehensive care kits to presurgical patients, offering a range of ocular hygiene products, including wipes, spray, and a mask that delivers moist heat. Kits are great for post-op patients too—especially if they need a comfort boost.
We all play a role in proper patient hygiene
“Most of our patients spend much more time taking care of their teeth than they do their eyelids and lashes,” notes Dr. Karpecki. “But is it really their fault?”
At the end of the day, it’s up to patients to use hygiene products, but they will never do it if you don’t ask them to or explain why it’s important.
“Of course, patients won’t always do everything we ask them to do,” notes Dr. Matossian. “But predictions of non-compliance do not release us from the responsibility of educating patients about what they should be doing to protect their eyes.”
What’s more, research shows that patients are likely to be more adherent than you might guess.
“The key is to construct a patient education script that allows you to keep conversations brief, efficient and effective,” said Amy Hellem, PhD, FAAO. “A recent survey of pre-operative cataract surgery patients found that 83% would be willing to buy and use hygiene products in the weeks leading up to their surgery if their eyecare provider recommended it.”1
Download a printable version of the cheat sheet.
Use technology to help educate patients
In a perfect world, eyecare providers could quickly run a battery of ocular surface health tests on every patient as part of their comprehensive exam since having objective data and images to share with patients is often an effective motivator in terms of encouraging better ocular hygiene. In his practice, Milton Hom, OD, FAAO, Canyon City Eyecare, performs 5 tests on all of his patients. "The Bruder Ocular Surface Analyzer (BOSA) is unbelievably fast. It's very easy to put into our workflow," he says of his new all-in-one testing device, which captures results in 15 seconds.
Dr. Hom's device creates a customizable treatment plan. In addition to offering this clear, understandable patient report, Dr. Hom says the results help him with prior authorizations.
As the saying goes, you miss 100% of the shots you don’t take. The benefits of ocular surface hygiene basics are well-established. It’s time to start emphasizing their importance as a key element in every patient encounter.
