Something About Mary
Something About Mary
Five steps to starting over with dry eye therapy … and why you should try it.
KELLY NICHOLS, O.D., M.P.H., Ph.D.
We've all been there: Busy waiting room, unexpected patient “issues,” staff out sick, and then you learn Mary is here to see you. Mary is your worst dry eye patient, the one you can't fix. You inherited her when you entered the practice 6 months ago. The thing is, Mary reminds you of your grandma, your favorite aunt, your mother. You want to help Mary.
You enter the exam room and receive the same warm smile as always. Mary's eyes look red and watery, as if she'd just thought of something sad. Her symptoms are the same as last visit, almost constant dryness and irritation, and a gritty sensation that “comes and goes,” depending on the day. Interestingly, Mary accepts the way her eyes feel, even though it affects her quality of life. Sound familiar?
The kitchen sink
Often, when I see or consult about dry eye patients, they are referrals from excellent doctors who have tried everything but the kitchen sink. That's what dry eye management often feels like for moderate-to-severe cases — try everything and hope something works. I am reminded daily how challenging this is. For example, while screening dry eye patients for a clinical trial, I asked two women (not our patients) about their current dry eye therapies. The first had been taking cyclosporine (Restasis, Allergan) but her doctor had discontinued the drop about 2 months ago. She was currently using a topical steroid (Alrex, Bausch+Lomb) twice a day, tobramycin drops once every other day, and artificial tears several times a day. The second patient was using cyclosporine for dry eye, as well as oral acyclovir, and had just discontinued trifluridine (Viroptic, GlaxoSmithKline) “for dry eye” (per the patient). What's going on here? We can all speculate about both cases: patients' misunderstandings, doctors' choices, and so on, but in the end, this is tough stuff.
Let's get back to Mary. Generally, when I inherit a dry eye patient, she has tried so many things and each for such a short time that it's easiest to start over. What do I mean by that? I mean really start over, clean slate, blank paper. If Mary were in my chair, I would follow my top five steps to “starting over” with dry eye therapy.
Step 1. Take a very detailed therapy history.
The history is critical with dry eye patients for two reasons. First, it's important to find out what therapies the patient has tried, the duration of the therapy, if it worked and, if so, how well it worked, according to the patient and also the previous care provider. Second, you'll save time in the long run if you really listen to the patient and try to understand the remaining concerns, unmet needs and willingness to try “less than conventional” therapies. You'll also gain your patient's trust. Let's face it — treatment options are limited, so it's good to know the history before you discuss the same therapies the patient has tried before.
Step 2. Find out the worst and most bothersome symptom upon awakening and at the end of the day.
Early in my clinical research endeavors, I worked with many clinicians and researchers to better understand symptoms. We discovered symptoms are more pronounced at the end of the day than in the morning. Although it's important to understand how bad the symptoms can get at the end of the day, it's also important to learn how a patient's eyes feel at the beginning of the day. This can help in monitoring treatments and in uncovering environmental factors that may contribute to the disease. Take, for example, the 45-year-old woman whose eyes feel “fine” in the morning yet become dry and irritated over time with computer use at work. When questioned, she has to think about whether or not her eyes bother her on the weekends. Just the fact that she stopped to consider how her eyes felt is telling. The recirculated air and computer monitor placement in the office are likely contributing to her symptoms.
Morning symptoms, once dismissed as less important than end-of-day symptoms, are making a comeback in importance with the recent increased emphasis on meibomian gland disease (MGD). A recent population-based phone survey, assessing the prevalence of blepharitis symptoms (anterior and posterior MGD) found that morning symptoms, including red eyelids on awakening, flaking or crusting on lashes and burning of the lids, were commonly associated with a previous blepharitis diagnosis. Interestingly, 15% of the survey respondents reported they experienced symptoms thought to be related to blepharitis (morning symptoms) half the time in the last year. This speaks to the importance of asking about morning symptoms and following up on those symptoms with treatment. The survey results can be found at www.icareinamericasurvey.com.
Paging a doctor to the Eye and Ear Care aisle.
Step 3. Get an accurate, realistic assessment of compliance — past, present and future.
It's likely your patient has searched for relief in the artificial tear aisle at the grocery store or pharmacy. Marketing surveys have shown that patients presenting with dry eye complaints as the primary reason for the visit have already tried at least one artificial tear and have “failed,” according to the patient. Is this a compliance issue? Early work by the late Jeff Gilbard, M.D., showed that mild to moderate dry eye patients using TheraTears artificial tears four times a day showed an increase in goblet cell density. Sure, I believe it, if you can get a mild dry eye patient to actually use drops consistently four times a day. I have also encountered patients who use artificial tears six times an hour, so compliance is relative. Understand your patients' compliance limits. Will they be willing to use warm compresses twice a day? Wear moisture chamber goggles? Swallow four fish oil capsules per day? Have a blood draw for autologous serum? Use a humidifier?
Step 4. Discontinue everything.*
Discontinue everything, but don't reinvent the wheel. *If a patient is stable on a therapy and believes it's working (or you do), then continue that therapy and augment it with additional therapies. If a patient has tried everything, and you believe the therapies were not administered long enough or with appropriate compliance to achieve a positive effect, start over. My modified version of the Dry Eye Workshop (DEWS 2007, The Ocular Surface) management scheme begins with lubricants, lid hygiene and topical azithromycin (AzaSite, Inspire Pharmaceuticals) if the meibomian glands are involved. For more advanced cases, I add omega fatty acid supplementation followed by immune modulators (cyclosporine and/or topical steroid), punctal occlusion, moisture chamber glasses/goggles, autologous serum, and bandage or scleral lenses. Adding little things, such as semi-protective eyewear or a humidifier at night or in a dry office, can make a big difference.
Step 5. Create a custom management plan and get the patient's buy-in.
Have you noticed we haven't even looked at the patient yet? Test results often don't correlate with symptoms or with other tests, so your diagnostic findings probably won't be surprising, nor will they drastically alter your therapy decision based on your initial impressions. This is not a free pass to skip the exam, however. In fact, you will need a careful baseline examination so you can assess therapy success or failure. Document carefully with photography if possible (to be discussed in future columns—stay tuned) and discuss your findings, including symptoms as a measurable outcome, with your patient to create buy-in to the plan. Be sure to follow up with dry eye literature or informative Web sites. Dry eye patients are looking for information.
Back to Mary. You are pleased to discover your management plan has significantly reduced her dependence on artificial tear use, which has saved her money. Her eyes are not as red as they used to be, so her family doesn't comment about the redness anymore. Although Mary is still symptomatic, her symptoms have improved with the use of a humidifier and a nighttime eye mask. You haven't “fixed” Mary, but you have gained one loyal patient, and with that, her entire family as new patients. Yes, there's something about Mary. OM
DR. NICHOLS IS ASSOCIATE PROFESSOR AT THE OHIO STATE UNIVERSITY COLLEGE OF OPTOMETRY. SHE LECTURES AND WRITES EXTENSIVELY ON OCULAR SURFACE DISEASE AND HAS INDUSTRY AND NIH FUNDING TO STUDY DRY EYE. SHE IS ON THE GOVERNING BOARDS OF THE TEAR FILM AND OCULAR SURFACE SOCIETY AND THE OCULAR SURFACE SOCIETY OF OPTOMETRY AND IS A PAID CONSULTANT TO ALCON, ALLERGAN, INSPIRE AND PFIZER.
Optometric Management, Issue: March 2010