Dry eye: Finding optimal treatment calls for patient-clinician collaboration

Key Points

Given the plethora of over-the-counter and prescription approaches available for dry eye, patient and clinician agreement on the appropriate regimen is key to treatment success. Still, coming to that agreement can be difficult.

Following are five steps and the criteria for success, as seen through the eyes of patients and their physicians:

As an eye-care professional, you need to educate the patient and teach your patient the correlation between their symptoms and the disease. Once a patient understands that their symptoms are caused by problems with the ocular surface, convincing the patient to use the appropriate treatment is much easier.

Although this situation does not occur too often, it certainly isn't uncommon and it is often due to a physician missing a hint during an examination.

• CORRECT DIAGNOSIS Research into clinician perceptions of the most important diagnostic characteristics shows them to be research evidence, ease of use, and the time requirement, but careful assessment remains integral in capturing disease state.¹

Examination of the eyelids is required to assess potential meibomian gland dysfunction and blepharitis, for example. Furthermore, lissamine green staining should be performed in conjunction with fluorescein staining to capture conjunctival staining in addition to keratitis.

Assessing tear break-up time also is important, because that also is a clue to the stability and quality of the patient's tear film. Beyond that, the Ocular Surface Disease Index or other patient symptoms surveys also are useful in assessing patient symptoms, especially in catching early stages of dry eye.

One of the major problems with the management of ocular surface disease is the lack of a standardized approach. Recommendations put forth in recent years demonstrate an attempt to standardize our approach to both diagnosing and monitoring ocular surface disease.²

• FIND THE BEST TREATMENT As far as treatment is concerned, a good general rule is to be more aggressive in treating patients. This emphasizes to the patient that you are taking his or her ailment seriously.

In addition, compliance often is not good, so if you are suggesting more aggressive treatment and patients do not comply with everything you suggest, they are getting more treatment than they would if you suggested a less aggressive course.

Three primary situations exist that can lead to patient-physician disagreement regarding disease severity:

• ADDRESS TREATMENT CONCERNS After identifying the patient's disease severity, it is important to assess patient concerns with treatment. Being empathetic and expressing a desire to hear their concerns and work with them to find a shared solution is vital to treatment success.

Research presented at the 2009 annual meeting of the Association for Research in Vision and Ophthalmology demonstrated that the primary clinician-rated goals in treating patients with moderate to severe dry eye were maintenance and protection of the ocular surface, as well as lubrication and hydration of the ocular surface. But certainly we need to tend to patients' goals in treatment as well, because these are integrally tied to patient compliance.³

For patients who complain about visual blur or visual tasking difficulty, it may be best to recommend an ocular lubricant demonstrating visual function benefit.⁴

For patients with more severe disease that may not respond to ocular lubricant treatment alone, prescription cyclosporine 0.05% ophthalmic emulsion (Restasis, Allergan) may be added to the treatment regimen.

• COMPLIANCE, COMPLIANCE, COMPLIANCE Research on patient-preferred treatment attributes also has been performed. Cost of treatment always is important to patients and is shown to span direct costs, such as treatments or doctor's visits, indirect costs, for example, days of work lost, or decreased work time, and intangible costs such as quality of life, including visual functioning.⁵

Essentially, patients are looking for an inexpensive treatment that works well, without side effects, including minimal blur upon instillation, and one that works to improve their condition rather than offering purely palliative effect.

Artificial tear use has demonstrated a 50% dropout rate 1 year after clinician-recommended usage of the eye drops. Reasons that patients cited for discontinuation included finishing of the professional sample they received (38%), perceived lack of efficacy (21%), and improved condition (14%).⁵ Patient education and the ability of artificial tears to fulfill patient-desired attributes are likely to increase treatment retention rates.

I frequently recommend a polyethylene glycol/propylene glycol-based tear product (Systane Ultra, Alcon Laboratories) to my patients since I find that the properties of this newer drop fulfill desired treatment attributes.

In addition, I find that ointments often augment treatment routines through the increased residence time that they offer and due to the diminished concern for their blurring effect and cosmetic appearance when used immediately prior to sleeping.