The Rhinestone Cowgirl
The Rhinestone Cowgirl
Assess the impact of ocular surface disease on the patient's quality of life.
KELLY NICHOLS, O.D., M.P.H., Ph.D.
Occasionally there are those dry eye patients who “find” you. This may occur as the result of a conversation in line at a grocery store, through a friend, or perhaps they find your name online. The underlying story is always the same, although the details — the fabric of the story — are remarkable and surprisingly unique for each patient. The chronologic history, told through the patient's experience, can provide rich information.
In my last column I discussed starting over with the case history. Here, I encourage you to take it one step further: Assess the impact ocular surface disease has on your patients' quality of life, and consider non-traditional management techniques for dry eye disease.
The other side of the story
As clinicians, we talk about “diagnosis” and “management” using specific terminology. Very early in training, we learned to “translate” patient lingo into doctor-speak. Unfortunately, we often forget what it's like to be a patient — that is, how challenging it can be to find the right words to describe what we experience (i.e. symptoms). We occasionally omit details we perceive as unimportant. In doctor-speak, we might be called “bad historians” (never!).
On the flip side, as clinicians, we are trained to make quick decisions based on the facts presented. We ask questions, expect answers, perform tests and assimilate this information into a nice, neat package, along with an appropriate ICD-9 code. The patient's personal story itself doesn't often play a role in the process, unless there is a Problem. That's Problem with a capital “P.” The “P” can stand for a Patient who is in Pain (or is a Pain), who is Persistent in what we perceive as a complaint. In effect, this means unfixed and non-responsive, essentially a failure. Everyone is unhappy. We rarely voice these thoughts, especially to patients. But they can offer a glimmer of light, illuminating where to begin managing the case, or at least outline the road previously taken (or, in many cases, the steps to avoid).
For nighttime use only.
Studies have shown eyecare providers routinely underestimate how much dry eye can interfere with a patient's life, even when the patient tells the doctor it does. The impact of underestimating the patient's complaint can be significant. Often, the patient seeks help elsewhere, even when the patient trusts and respects his/her current doctor.
Rhinestone cowgirl #1
A female professor recently contacted me after finding my name online, while looking for help to improve the significant eye irritation she experiences while working on the computer. (Her job requires hours of computer work each day). She and a skilled, friendly, and competent doctor had worked together on her dry eye status for some time. Even with her current management plan — cyclosporine drops twice daily, artificial tears, omega fatty acid supplementation (2 grams per day, when she can stomach it), and warm compresses — she still experienced great discomfort. She's both personally and professionally gratified by her work, which is why dry eye is such a burden to her.
Clinically, she looks similar to many dry eye patients. Her systemic health was excellent, and she is menopausal. Her lids show several obstructed meibomian glands inferiorly, but no signs of anterior blepharitis. Her tear break-up time is marginal at about 6 seconds OU, and she has grade 1 inferior and nasal corneal staining in both eyes. Lissamine green conjunctival staining showed grade 1 staining in the nasal and temporal inferior quadrants OU. Her Ocular Surface Disease Index (OSDI) symptom score is 25 (the moderate range is 22 to 35), and her non-anesthetized Schirmer score is 11 OD and 13 OS. Even though her OSDI score was not in the severe range, her self-reported symptom impact was obvious — she stopped to close her eyes often during computer use, and on many occasions she felt the symptoms were so bad she would get a headache and need to stop work all together.
When I asked if she ever considered using a humidifier or an eye mask at night, she replied that she had received an eye mask as a gag gift for her 50th birthday, complete with rhinestones (pictured above), but she never wore it.
Rhinestone cowgirl #2
A week or two later I heard from my professor again, and she had researched eye masks online. She found a “wonderful website” and spoke to the site's owner, whom I've also had the pleasure of interacting with related to dry eye.
Meet Rebecca Petris. She has had chronic dry eye since undergoing LASIK in 2001. As a result, she founded The Dry Eye Company and hosts a website, The Dry Eye Zone (www.dryeyezone.com), hoping to make information and products more accessible to others with dry eye. In effect, she has blazed the dry eye advocacy frontier before it was popular to have dry eye.
It's safe to say that many dry eye patients “find” Rebecca's website — so it's important that we, as providers, are aware of some of the more non-traditional approaches that are available. While adequate research is lacking on all non-traditional approaches, some are worth trying, including some of the nighttime eye masks and goggles.
Let the patient decide
While you may think that the goggles and wrap glasses are not as “cosmetically acceptable” as the advertisements claim, remember that you, as the doctor, aren't being asked to wear them. Also remember that you would not appreciate the benefits of these products, unless you suffer from dry eye. So, putting your own feelings aside, take the time to present these options and let your patient decide whether he or she is willing to sacrifice some cosmesis for comfort. A few hours at home with these products may make a difference, and presenting these options might just keep that patient in your chair. OM
|Non-Therapeutic Management Considerations|
You can view several of these products online at the Dry Eye Store (www.dryeyecompany.com).
► Change filter as directed
► Use at night or at work (e.g. computer use)
- Warm compress
► Rice “in a sock”
► Commercially available “rice baggie”
► Warm, wet wash cloth heated in microwave
- Eye mask (simple)
► To assist in keeping eyes closed at night Good for lagophthalmos
► May maintain ocular moisture
- Eye mask (goggle) e.g. Tranquileyes
► Soft rubber goggle with foam lined edges
► Moisture pads can be inserted to increase humidity in chamber
► Can be worn overnight
- Wrap glasses with foam edges (e.g. Onion Goggles)
► Wrap style frames decrease ambient air flow
► The foam edges can help create a “moisture chamber”
► Can be worn as regular glasses, e.g. for computer use
- Wrap glasses with foam edges and moisture inserts
► As above but with continuous release moisture inserts
► For daytime use
► Sold as Optimist Moisture Release Sunglasses (Dioptics Medical Products, San Luis Obispo, Cal.)
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: May 2010