Article Date: 6/1/2008

Clinician's Perspective on Dry Eye

Clinician's Perspective on Dry Eye

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by Paul Karpecki, OD, FAAO

Three concerns are top of mind when discussing the diagnosis and treatment of patients with dry eye. The first is clinical care. The second is patient flow and the third is the medical practice model.

Clinical Care

A crucial part of clinical care is knowing when to stop treatment with artificial tears and advance to the next step.

When you go to the artificial tear aisle, the choices are staggering. It's daunting for most patients and for doctors. How do you know when to go to the next drop and when to choose something that targets the underlying disease?

We make clinical judgments based on information-gathering. Patients are asked to fill out a questionnaire when they walk in. The questionnaire covers predisposing factors, medications, systemic diseases, previous surgeries and environmental concerns that relate to dry eye. It also includes a box for artificial tear use and brand name, which helps determine if patients are on a good artificial tear product, such as Blink® Tears.

We see fewer patients addicted to over-the-counter eye drops than we saw addicted to vasoconstrictors. However, some patients become so severely addicted to artificial tears that they overuse them to the point of washing out their own natural tears.

The next step is determining how to successfully sort this out. Do they need lubrication alone, or an oil-based coating? Many factors play a role. Does the patient need tear volume, or something that's more soothing, enhances vision, or coats or enhances specific layers of the tear film?

Patients will go from doctor to doctor looking for relief from inflammation. Once I know inflammation is present, I use a targeted medication, such as cyclosporine, loteprednol, oral doxycycline or omega-3 supplements.

Clinical care has to do with identifying the patients and problems, determining which segment of the dry eye spectrum they're in, and treating accordingly.

Some patients become so severely addicted to artificial tears that they overuse them to the point of washing out their own natural tears.

Patient Flow

It's important to make things as simple as possible, which also applies to developing the medical side of the practice model. You need not disrupt your contact lens and primary care practice. Try to implement one-stop utilization. Begin by training the front desk staff on medical versus vision insurance.

Next, always obtain a complete patient history and utilize questionnaires, which are very useful for gathering vital information quickly.

You'll need a system for analyzing tear osmolarity changes and dry eye factors, using lissamine dye and fluorescein dye. You'll have to measure tear breakup time, tear meniscus height, and, on rare occasions, perform the Schirmer's test to assess the tears and the quality of the tears. I think in the future we'll have better diagnostics for this purpose. For now, I use both lissamine green and fluorescein.

I measure the tear breakup time and assess the tear meniscus and the quality of tears present. Whichever test is the most telling is the test I use for monitoring the patient's improvement.

For all patients, I measure the tear breakup time and assess the tear meniscus and the quality of tears present. Whichever test is the most telling is the test I use for monitoring the patient's improvement. I don't do every test every time because I want to streamline patient flow.

I assess for dry eye with lid disease and without it. Trying to treat a patient with significant meibomian gland dysfunction with artificial tears will have limited success as opposed to targeting the underlying disease.

Medical Practice Model

Many optometrists traditionally have had a good contact lens practice and a good primary care practice. It really is a paradigm shift to go to a medical model.

First, they have to understand the importance of collecting the patient's information. They do this for the vision care plan and should also include the medical insurance plan, even if patients don't carry any, just to get a sense of what they have.

They'll need to know when to schedule a patient on the medical side versus on the vision insurance side.

This means bringing a patient back if he comes in for an eye exam and you discover ocular surface disease. Maybe you bring them back for the medical portion. It means making the patient aware of his condition. It also requires continuous follow-up for chronic diseases.

A good example of the medical model is my shoulder injury. I had an X-ray and received treatment. Then, they had me return so they could reassess my condition, even though I felt better.

In our primary care model, we often treat the patient immediately for whatever condition we discover. Or for patients with no eye health issue, once they've had their contact lenses fitted or their spectacles ordered, we'd simply plan to see them again in a year or two.

For chronic diseases, the medical model requires continuous follow-up every 6 months and, eventually, every year. That would mean an initial exam for dry eye, 1-month assessment, 3-month assessment and maybe punctal occlusion at that visit, and follow-up every 6 months to a year after that, depending on a patient's overall improvement and ocular health.

All of this encompasses a very different way of managing patients, which is the medical model. It can be difficult for ODs to switch over because they're used to a system that they've been successful with in the past. Some try the medical model, but with the additional steps and third-party insurance and other factors involved, they may become discouraged.

Remember that 10,000 Americans are turning 50 every day, so this is a tremendous opportunity. There's a lot of dry eye disease out there. The goal is not to take away from contact lenses or primary care, but to enhance your practice. The diversity makes for an interesting day. It's a very satisfying way to practice. ■

Dr. Karpecki graduated from Indiana University and completed a fellowship in cornea and refractive surgery at Hunkeler Eye Centers in affiliation with Pennsylvania College of Optometry in 1994. He served as director of research for Moyes Eye Clinic in Kansas City and ran one of the largest dedicated dry eye clinics in the Midwest. In February 2007, he took a position with the Cincinnati Eye Institute working in cornea/external disease and research. He has lectured in over 300 symposia covering four continents, was invited to the Delphi International Society at Wilmer-Johns Hopkins that includes the top 25 dry eye experts in the world, and was invited to serve on the National Eye Institute's dry eye committee. This was a task force established by the U.S. Department of Health and Human Services to better understand and treat dry eye disease in women. A noted educator and author, Dr. Karpecki serves on the editorial boards of seven professional journals.

Are Your Patients Addicted to Eye Drops?

Addiction to OTC dry eye drops is a common theme in eyecare offices throughout the United States. We may identify the problem with an office questionnaire or a thorough evaluation of the patient's medical and ocular history. Many patients are reluctant to believe that reaching for dry eye drops from the moment they awaken until the moment they retire at night is habit-forming or an addiction. Are these products helpful? Sometimes, but other times – no.
The theme is repeated in every eyecare office in America when the practitioner, for one reason or another, doesn't manage the diagnosis, treatment and recommendation of options for relieving the symptoms of chronic dry eye or ocular surface disease.
It's important to make time in a busy schedule to listen to your patient's complaints of dry eye nuisances. Sometimes these accelerate to a vision-threatening ocular disease. "Drop addiction" can become a rebound clinical manifestation that requires removal of the products, clinical assessment of the etiology and magnitude, and careful selection of new options.
Dry eye is a significant ocular problem. The marketplace has many choices for treating the problem, including new Blink® Tears from AMO. We encourage you to evaluate each product, look at the science and choose the best option for your patients, so they can find a better solution for their symptoms.

David W. Hansen, OD, FAAO (DipCL) Director,
Global Professional Services

Optometric Management, Issue: June 2008