Welcome back to Dry Eye Fireside Chat. In this episode, Damon Dierker, OD, FAAO, sits down with Mahnia Madan, OD, FAAO, to discuss how optometrists should evaluate dry eye treatment results and when they should alter management strategies to optimize outcomes.
Preparing to pivot DED therapies
Every optometrist who treats dry eye disease (DED) is likely to encounter patients who, after having been on level one and/or level two therapies, are still not happy with their results. When eye drops, nutritional supplements, heat masks, and prescription medications are not providing the expected results, it is time for reevaluation and reeducation to improve outcomes.
As an optometrist practicing in Vancouver, Canada, in an MD/OD practice with a robust referral-based DED patient base, Dr. Madan benefits from a full gamut of anti-inflammatory and in-office therapies, including platelet-rich plasma for dry eye management.
However, even with these treatments in her armamentarium, sometimes finding the right therapy or combination of therapies can be tricky. Clinicians must be flexible and willing to pivot when necessary.
Code Red: Recent real-life scenario
To illustrate this point, Dr. Madan shared a recent case of a patient who had been referred for chronic hyperemia. As a pediatrician, the female patient had spent numerous hours in a mask each day over the past 3 years, potentially aggravating her DED.
The redness was particularly worrisome because she was consistently asked what was wrong with her eyes and whether she had an infection. Aside from the redness, she did not voice complaints of stinging, burning, or any other irritation.
After her initial work-up, Dr. Madan prescribed immunomodulators, a steroid, and a 3-month follow-up. At this visit, the patient reported she did not see any difference in symptoms, prompting a reevaluation of the condition.
This started with Dr. Madan asking herself:
- Are the immunomodulators not working?
- Is the steroid not working?
- Should I be looking at other factors that could be causing this?
This exploration was followed by a candid conversation with the patient.
Patient expectation and education
Addressing patient expectations and offering them insight into the nature of dry eye is instrumental in achieving satisfaction. Dr. Madan points out that with dry eye being a multifactorial disease, you not only have to look at symptoms improving but signs improving.
She explained, “I think it's really important to have that conversation with your patients. It’s the way we connect with them and let them know that you're both part of the same team.”
Sample patient conversation:
“I know it is disappointing that you are not noticing symptomatic improvement in redness; however, when I look at your eyes, I do see that your tear break-up time is better, and there is improvement in your tear meniscus. This is not a case of treatment failure but perhaps treatment limitation.
Let’s explore other things that could be going on and lifestyle factors that may be contributing. Then we will reassess treatment and see what more we can do. With additional treatment, I'm expecting some of the signs to continue to get better, which we hope translates into symptomatic relief as well.”
After further probing, Dr. Madan found out that, because of wearing a mask, this particular patient seldom drank water throughout the day. Dehydration could be a contributing factor that the patient can address. For Dr. Madan, the next clinical step was punctal plugs.
Treatment failure vs. treatment limitations
Elaborating further on limitations as opposed to failure, Dr. Madan gave the analogy of weight loss requiring both diet and exercise—just as the most stringent exercise will not yield maximum weight loss without making changes in diet—dry eye treatment requires a holistic approach, weighing all physiological and lifestyle components.
To further illustrate this point, Dr. Dierker also offers an analogy: “I think you can make the parallel to glaucoma. If someone who is treatment-naive does a selective laser trabeculoplasty (SLT) or has a prostaglandin analog and their pressure gets better, but is still not at goal, does that mean that your treatments failed? No, it means they need more treatment.”
Resetting the ocular surface
Dr. Dierker agrees that when therapy isn’t working, the first course is to step back and look at the larger picture, including if they are instilling any over-the-counter substance, such as a preservative-laden drop, that could be affecting results.
The next step is to hit reset on the ocular surface. He recommends ocular surface lavage with Rinsada to deep clean the conjunctival fornices, as well as the bulbar and palpebral conjunctiva, to flush out irritants, toxins, and inflammatory mediators.
When change is for the better
At a certain point, one may realize that the treatment either needs to be changed or enhanced. Dr. Madan said, “In the end, you want to see the ocular surface not symptomatically improving, but also the signs improving. And you also want to stabilize this condition so that it doesn't progress.”
Both optometrists consider the only truly failed treatment to be one that the patient either cannot tolerate due to extreme discomfort or cannot comply with due to physical limitations. However, they also agree that a change in regimen is sometimes required.
According to Dr. Dierker, “In dry eye, when it's multifactorial, and there are multiple things that we need to address, sometimes addressing one part is only going to give you an incomplete response.” To address all aspects of the disease, one may need to alter doses, add a prescription, administer in-office treatments, and recommend lifestyle modifications.
At this juncture, another patient conversation is also warranted.
Sample patient conversation:
“It really looks as if you've given it [treatment] your best effort, and I think it's time to try a new therapy. I’d like to share the pros and cons of _________ and see how you would feel about trying that.”
The role of platelet-rich plasma in dry eye management
For Dr. Madan, one of the most effective therapies to introduce to patients who are not responding well to other treatments is platelet-rich plasma (PRP). Platelet-rich plasma harnesses the platelets from a patient's blood to create a biologic therapy of enriched plasma containing growth factors that are similar to the individual’s natural tear film.
PRP eye drops are rich in vitamins, cytokines, and other growth factors that promote healing of the ocular surface.1,2 The downsides of PRP drops are that they require a blood draw, must be refrigerated, and are currently costly.1,2
As to patient selection for PRP, Dr. Madan said, “Patients I find to be very suited for this therapy are the ones that have or exhibit a lot of corneal damage that is perhaps not improving in the timely fashion that it should.” These individuals include those who have undergone laser assisted in situ keratomileusis (LASIK) / photorefractive keratectomy (PRK) surgery or suffer from recurrent corneal erosions or neurotrophic keratitis.
To decrease the long-term treatment burden, she suggests adding PRP to existing therapies until the corneal surface is as healthy as possible and then returning to more accessible and affordable therapies.
Final thoughts
Treating dry eye disease demands a multifaceted evaluation and an individualized plan, as opposed to a one-size-fits-all approach. Even with this, a patient may not initially achieve the anticipated results; however, it does not mean the therapy is a total failure.
Oftentimes, due to the complex nature of DED, it simply means additional treatments should be added to address the various components of the condition. Luckily, dry eye clinicians now have a plethora of options to optimize outcomes and improve quality of life.
