Article Date: 12/1/2008

Mastering Dry Eye Disease
Building a Profitable Dry Eye Practice

Mastering Dry Eye Disease

Learn about the patient's perspective and the effects of this complex disease.

By John W. Lahr, OD, FAAO

Most clinicians will tell you that more than half of their patients complain of a range of mild to severe dry eye symptoms. Dry eye and the broader area of ocular surface disease present a ripe opportunity for enhanced patient care and practice growth. But not if we continue as we have in the past.

People want their eyes to feel better, and they want them to stay that way. Studies suggest that up to one-third of patients want to know if their doctors can provide them with better relief than the drops or ointments they've tried from the store or previous recommendations from eyecare professionals. This is what our patients say, but are we hearing it?

When we give patients free artificial tear samples or tell them to buy them over the counter, we're ignoring the fact that this is a chronic condition that requires long-term attention. We need to understand our patients' needs. As such, we must treat dry eye as the disease that it is.

Understanding Our Patients

In phone and Internet surveys, Gallup found that more than 90 million Americans have two or more symptoms of dry eye. Just 37% of them — and 65% of contact lens wearers — report the symptoms to their doctors, yet 77% describe the problem as very bothersome. What's more, 49% of those surveyed have had dry eye for up to 5 years, which may point to inflammation and lacrimal gland dysfunction.1

This survey suggests that many patients in your practice have dry eye symptoms, which they may not bring to your attention. To identify these patients, it helps to see the problem from their perspective.

One study looked at 210 patients with mild to moderate dry eye, Sjögren's and no dry eye.2 Consider how patients rated their dry eye problems, compared to how doctors rated the dry eye based on questioning and tests:

• Severe: patients 19%, doctors 9%

• Moderate: patients 36%, doctors 20%

• Mild: patients 23%, doctors 50%

What's more, when researchers in another study asked patients to compare the discomfort they experience from moderate dry eye to the discomfort of a systemic condition, they chose the chest pains of an angina attack.3 Clearly, there is a measurable disconnect between patient and doctor perceptions of dry eye — an important factor to consider in planning a treatment that provides a satisfying outcome for your patients. And with so many patients failing to report dry eye symptoms, good listening and careful evaluation with a dry eye questionnaire like the Ocular Surface Disease Index are essential.

Grasping a Complex Disease

During a dry eye workshop, as we defined dry eye, we noted that it's "accompanied by increased tear osmolarity." Many of us haven't looked into osmolarity very deeply, but in the next year or so, instrumentation will allow us to measure osmolarity, adding another scientific measure to our dry eye diagnosis.

Tips for Lubricants and Plugs
I use lubricant for all dry eye patients and punctal plugs for many. Here are some simple tips from my experience.
Lubricants: Patients think, "If I put drops in my eyes, the problems will be fixed." But many of them find that they need to use it again after 30 minutes. If patients need to use drops more than 4 times a day, I have them discontinue artificial tears with preservatives to avoid preservative sensitivities.
Punctal plugs: Even if I control the inflammation and the patient is using loteprednol etabonate (Lotemax, Bausch & Lomb), cyclosporine (Restasis, Allergan) and/or Omega 3 supplements, the patient may still have inadequate tear volume. I've found that intra-canalicular plugs that sit vertically in the canaliculus are the easiest to use. My favorite is the Oasis Form Fit plug (Oasis Medical) because it's easy to apply and easy to remove if you must. It's a hydrophilic material — 10% substance and 90% water — and there's no need to wait for shrinking from body heat or any need for sizing.

Simply put, osmolarity is the thickness of the tear film. Normal tear film is a very complex system, including the mucin layer, aqueous and lipid layers. When these break down, the tear layer thins, but more importantly, the eye loses balancing components that make it healthy.

Osmolarity breakdown causes many problems. When inflammatory issues increase osmolarity, the tears have fewer good components and more salt, causing discomfort, increasing the likelihood of surface cytokines and decreasing goblet cells. Over time, breakdowns actually cause breaks in the cellular junctions. Patients develop conjunctival staining, followed by corneal staining.

As we continue to find that dry eye is the most common disease in our practices, advances like those related to osmolarity are welcome. We need to take advantage of every tool at our disposal — from questionnaires to the latest diagnostic techniques — to ensure that we identify and treat dry eye patients effectively.

Dr. Lahr is medical director and vice president of provider relations for EyeMed Vision Care in Mason, Ohio.

  1. Multi-Sponsor Surveys Inc. The 2005 Gallup Study of Dry Eye Sufferers: Summary Volume. August 2005.
  2. Chalmers RL, Begley C, Venkataraman K, et al. The grading of dry eye severity: A comparison of clinician and self-assessment. Paper presented Dec. 15, 2002, at the annual meeting of the American Academy of Optometry.
  3. Schiffman R. Utility assessment among patients with dry eye disease. Ophthalmology. 2003;110:1412-1419.

Optometric Management, Issue: December 2008