Seeing patients eye to eye

Image credit: Adobe Stock / ©Andrey Popov

With an ever-expanding range of treatment options for dry eye disease, it can be easy for providers to fall for the trap of a “kitchen sink” strategy, throwing everything at our patients all at once in hopes of finding any treatment that works. The downside to this strategy is that patients can quickly become overwhelmed or discouraged and drop out of their treatment regimen altogether. I believe a better approach is to incorporate new treatments one by one—and start with at-home therapies that can easily be added to their existing routine—to enhance patient compliance and streamline their care.

Adding a supplement makes it easy for patients

As a patient with dry eye, I am intimately familiar with what it is like to struggle with the condition. After having my last child and coming off prenatal vitamins, I became highly symptomatic and could only wear contact lenses intermittently. Adding a nutraceutical back into my regimen brought symptom relief and allowed me to continue wearing my lenses. Consequently, nutritional supplements have become a cornerstone of my dry eye practice. This is not only due to their efficacy but also their ease of use: They constitute a treatment option that seamlessly fits into my patients' lifestyles, making compliance less onerous than with some newer at-home device-based and even pharmaceutical therapies.

Most of my majority–Medicare-aged patient population are using lubricating eye drops when I first see them, indicating they have self-diagnosed dry eye. Additionally, most are also taking prescription medications and nutritional supplements. For the past 10 years or so, I have encouraged my patients to add nutraceuticals aimed at improving their ocular surface to their daily routine. More recently, the science has pointed to HydroEye (ScienceBased Health). As someone who comes from a research background, the clinical evidence for this product is important to my decision-making process, as is its ease of use.

The data show that the key ingredient in HydroEye, a fatty acid derived from black currant seed oil called gamma-linolenic acid (GLA), has a more targeted effect for dry eye than fish oil or flaxseed, helping to promote tear production, while reducing inflammation. The nutraceutical's patented formula is made specifically to support dry eyes and its GLA helps modulate the body’s inflammatory response.¹ GLA has been shown to improve dry eye symptoms in variety studies,^2-7 and HydroEye has been specifically validated in a randomized, controlled clinical trial.⁸ I tell my patients that HydroEye has the "Dr McVey stamp of approval" because it is what I take.

Nutraceuticals do take a little time to take effect, but it gives those patients who are unhappy using lubricating drops another therapy option, and it does not take a lot of chair time or equipment for the eye care provider. A supplement can be a good next step without being difficult to implement, and it does not require much extra effort for patients to make it part of their daily routine.

Treatment algorithm

As part of my algorithm, I suggest patients use warm compresses, and I recommend a tea tree oil-containing eyelid cleanser when appropriate. I specifically like Oust (OcuSoft) as it contains coconut oil and is less irritating than other brands I have tested. It also works as a makeup remover and many of my patients appreciate that 2-in-1 benefit.

Along with looking for signs of meibomian gland disease, I look at patients’ corneal staining. If their condition has an inflammatory component, I will prescribe a cyclosporine-containing product or lifitegrast (Xiidra; Novartis). Otherwise, I like varenicline nasal spray (Tyrvaya; Viatris) because it helps them produce more tears naturally.

I also use long-acting, dissolvable punctal plugs for a significant number of patients. It is important to clean up the tears before adding a plug, and if there is any kind of ropiness to the tears, I make sure to first treat the allergic disease. Patients appreciate their comfort as well as the "set it and forget it" therapeutic option. Serum tears are a big part of my practice as well, especially for patients with neurotrophic keratitis. Although it is less common for my patients to opt for office-based procedures that are not covered by insurance, some of our practice locations do offer options like intense pulsed light and Systane iLux (Alcon).

Compliance and honesty

Optometrists and surgeons have very different jobs: Surgeons fix patients' problems and send them home. Optometrists, on the other hand, persuade patients to care for themselves. In some ways, that makes our job a bit harder, and that is why I try not to pile on multiple treatments at the same time. Rather, I recommend 1 or 2 options and follow up with the patient in 2 months. That is long enough to give the treatment time to work, but not so long that the patient loses their motivation. The strategy also helps me better evaluate efficacy and understand which therapies are effective.

It is important to me—and I have more success—when I meet patients where they are. I believe in discussing adherence in an open and honest manner. For example, I tell them as a dry eye patient myself, I sympathize with them. In fact, one of the reasons why I lean heavily on nutritional supplements is, in part, because I don’t like using eye drops. When a patient admits to what they are actually doing or not doing, whether it be for glaucoma or dry eye, I always thank them for their honesty instead of reprimanding them for their noncompliance. I tell them, “I can’t help you if you don’t tell me what you are doing or what you are willing to do.” I let them know that even if I keep adding more therapies, if they are not using what I have prescribed, we will not make any progress. I welcome their honesty so that we can make the right choices together.

References

1. Kapoor R, Huang YS. Gamma linolenic acid: an antiinflammatory omega-6 fatty acid. Curr Pharm Biotechnol. 2006;7(6):531-534. doi:10.2174/138920106779116874

2. Barabino S, Rolando M, Camicione P, et al. Systemic linoleic and gamma-linolenic acid therapy in dry eye syndrome with an inflammatory component. Cornea. 2003;22(2):97-101. doi:10.1097/00003226-200303000-00002

3. Macrì A, Giuffrida S, Amico V, Iester M, Traverso CE. Effect of linoleic acid and gamma-linolenic acid on tear production, tear clearance and on the ocular surface after photorefractive keratectomy. Graefes Arch Clin Exp Ophthalmol. 2003;241(7):561-566. doi:10.1007/s00417-003-0685-x

4. Aragona P, Bucolo C, Spinella R, Giuffrida S, Ferreri G. Systemic omega-6 essential fatty acid treatment and pge1 tear content in Sjögren’s syndrome patients. InvestOphthalmol Vis Sci. 2005;46(12):4474-4479. doi:10.1167/iovs.04-1394

5. Kokke KH, Morris JA, Lawrenson JG. Oral omega-6 essential fatty acid treatment in contact lens associated dry eye. Cont Lens Anterior Eye. 2008;31(3):141-146. doi:10.1016/j.clae.2007.12.001

6. Pinna A, Piccinini P, Carta F. Effect of oral linoleic and gamma-linolenic acid on meibomian gland dysfunction. Cornea. 2007;26(3):260-264. doi:10.1097/ICO.0b013e318033d79b

7. Brignole-Baudouin F, Baudouin C, Aragona P, et al. A multicentre, double-masked, randomized, controlled trial assessing the effect of oral supplementation of omega-3 and omega-6 fatty acids on a conjunctival inflammatory marker in dry eye patients. Acta Ophthalmol. 2011;89(7):e591-597. doi:10.1111/j.1755-3768.2011.02196.x

8. Sheppard JD Jr, Singh R, McClellan AJ, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 2013;32(10):1297-1304. doi:10.1097/ICO.0b013e318299549c