A Typical Day Treating Ocular Surface Disease
A Typical Day Treating Ocular Surface Disease
How the prevalence of allergy, blepharitis and dry eye impact your medical clinic.
Marc Bloomenstein, O.D., F.A.A.O., Scottsdale, Ariz.
Let me make something clear from the outset. I do not have a dry eye clinic. However, I treat dry eye in my clinic.
The prevalence of ocular surface disease, including allergy, blepharitis and, of course, dry eye is staggering and has become the emphasis of what I do in the exam lanes. Patients want to see better, see clearly and not have to think about their eyes; they should just work. Every opto-metric practice is a medical clinic, equipped with doctors who have the skills to provide their patients with ocular diagnosis and treatments. I will exemplify what a typical day is for me in my practice that treats ocular surface disease.
The start of the day
My day starts with a Venti coffee (because how can you tackle the day without some java?) then into the exam lanes. My first patient, J.M., is a 19-year-old college student who says that his vision is blurred when he is working. My first instinct when I read "vision change" is to assume that something is affecting the vision to cause changes. J.M. does not wear spectacles, and the technician has measured his uncorrected vision at 20/15 O.U. and J1+ O.U.
As I open the door to walk into the exam room, I notice the patient seems to have been out in the sun or is really flushed, especially in the face. I always ask my patients whether they are using any artificial tears. This question is meant to weed out the patients who feel that over-the-counter (OTC) lubricating drops are not medication. A multi-sponsored Gallop survey revealed that 60% of the drops that patients use for dry eye are either allergy or redness-relief drops, which often times can be a deterrent to relief as opposed to the perceived benefit your patient is attempting to achieve.
J.M. says he isn't using any drops. He does tell me, however, that he uses isotretinoin, a retinoid used to treat severe recalcitrant nodular acne. Isotretinoin is known to dry all the mucosal tissue and, thus, has significant effect on the eyes.
A lissamine strip confirms that J.M. has grade 2 dryness. I perform a cycloplegic exam on J.M., evaluating the health of the eyes and find that everything is normal.
J.M. is the typical patient who feels that he will see the optometrist only when he's not seeing well — and only then because he has a vision insurance plan to cover the cost of the visit. I realized before I ever laid my eyes (yes pun intended) on J.M.'s eyes that he was either using isotretinoin or a tetracycline derivative. Since those medications are a predisposing factor of dry eye, my differential diagnosis was elucidated. More to the point, before I tested J.M., I already knew that I would start him on a dry eye therapy.
The first line of defense when dealing with any form of dry eye is to keep the ocular surface lubricated. While I feel a significant percentage of my patients already use lubricating drops, it is important to find the right drop for the patient.
As J.M. had no signs of lid disease, I started him on an artificial tear that contains a viscosity enhancer, which, therefore, creates a long-lasting viscous drop that doesn't blur vision. Our office staff then scheduled J.M. to return in one month for an evaluation and progress report.
This table lists the predisposing factors for ocular surface disease. Also see the article, "Why So Dry?", for additional information.
Much like the way we treat any disease, dry eye is not dissimilar and, as a result, demands a medical follow-up visit. As a strong proponent of preventive medicine, I want to ensure that I can alter the treatment regiment when necessary. Therefore, the follow-up visit is as important as the initial diagnosis. (Remember that proper billing of the second visit is critical so that your are compensated for your time.)
The contact lens patient
My next patient presented on a "cool summer day" of 113°F. She was a contact lens wearer. I must freely admit that I am not a contact lens optometrist, but rather an optometrist who can see contact lens patients. In fact, I tend to aggressively avoid contact lenses, as I know doctors exist who are considerably more adept at this speciality.
B.R., a 51-year-old female presented to the office to renew her contact lens prescription. You know her refrain: "Everything is great, I just need to order more contacts."
B.R. has a medical history that consists of a hysterectomy and, thus, uses hormone replacement therapy (HRT). B.R. says she wears her contact lenses for upwards of eight hours and says she has noticed of late they are not as comfortable toward the end of her day. B.R. tells me she uses a "rewetting" drop (code for some red eye relief drop from the grocer), but only when her eyes feel tired or appear "swollen."
B.R.'s vision was correctable to 20/20 OU, although an over-refraction of 0.25D O.D. and 0.50D O.S. provided a sharper sense of clarity for B.R.
Her eyelids had a shallow layer of bubbles on the lower lid margin, some creamy appearance to the meibum and trace injection to the lid margin. The conjunctiva and cornea were clear. Her tear breakup time (TBUT) measured at eight seconds O.D. and six seconds O.S. Upon examination, the lens, vitreous and retina were all within normal limits.
A typical day at work finds me with a patient who has four of the predisposing factors for dry eye — age (older than 50) gender (female), contact lens wear and medication use. (See Table 1, left.) On the surface, she seems asymptomatic. B.R. exemplifies a patient who could be doing better or who will continue to have problems without the assistance of lubrication, lid massaging and medical intervention. With two chronic progressive eye conditions, such as is the case with B.R., the question for most O.D.s is: When do I start treating? My philosophy has always been that if you do not treat, then someone else will, and you can wave good-bye to the patient that liked you but loves the new doctor. (See "Treating Asymptomatic Patients, below.")
Treating this type of patient with a name brand tear and starting her on cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan) will give her eyes the opportunity to reduce the inflammatory cascade that is wreaking havoc on her ocular surface, due to her HRT and contact lens wear.
However, the lids can not be neglected. Since saponification is the hallmark of meibomian gland dysfunction (MGD), warm compresses and lid massage with a commercial lid cleanser is needed. Selling a commercial cleanser at your office is one way to ensure your patient is using the proper treatment. My conversation with B.R. goes like this:
"Well, everything looks good, but there is some inflammation on your lids that is contributing to your end-of-the-day feeling of discomfort. Since you are a female and using HRT, these also contribute to drying your eyes further. I want you to be comfortable in your contact lenses, so I am going to start you on a couple forms of treatment. I am confident this treatment will help you to wear your contact lenses longer and more comfortably. I need to see you back in about four to six weeks to make sure there is not a problem. This is a medical condition, so when you return I can bill your medical insurance (which alleviates S.H.'s concerns of out-of-pocket expenses). So, let's get that bottle of foam and set up that appointment for next month."
I may have thrown in a couple of quips and puns to liven up the end of the conversation, but this is a discussion I have repeatedly with patients. Addressing the contributing factors that lead — or may lead — to decreased quality of vision, alerting the patient to the ability to "make it better" and validating that their ocular surface disease a medical condition should all be included in your discussion.
After the visit with B.R., I had a handful of 20/15 LASIK follow-ups (30-second exams), then I went into see another comprehensive evaluation patient, S.H., a 35-year-old male who knows that his eyes are dry. He uses artificial tears, Restasis and has a history of systemic antihistamine use. S.H. says he doesn't want to be dilated today and is still complaining of his dry eyes.
His uncorrected visual acuity is stable at 20/20 OD and 20/15 OS. The slit lamp exam does not show any significant issues with the lids, corneas or anterior chambers. S.H. does have a pingueculum nasally OU, and the lissamine green stain is trace with a slightly decreased TBUT of 12 and 14.
S.H. presents as that patient in whom a reply of "I do not know" isn't an option — he wants answers. A young healthy patient with good acuity but symptoms, S.H. has been followed in the practice every four months, and now his complaints seem more apparent.
As in our other patients, I am aware that S.H. has at least two of the dry eye predisposing factors (allergy, antihistamine use) and perhaps more aggressive treatment is needed. In the absence of lid disease, I tell S.H. that we should put some plugs in his lower lid to maintain the lubrication and abate the dryness. Punctal plugs are a great adjunct to other dry eye therapies and are synergistic with anti-inflammatory therapies.
I don't discontinue Restasis when I add another therapy. I recommend a tear that is more viscous than the tear S.H. previously used and insert the plugs into his inferior puncta. S.H. will be seen again in four weeks to make sure the plugs are comfort able. Lastly, I reiterate to S.H. that a 2004 Gallup Study concluded that 83% of all allergy sufferers have ocular symptoms, and systemic allergy medications and ocular allergy medications do not target the same cells. Adding a prescription-strength ocular allergy medication may contribute to improving the dry eye. S.H. also leaves the office with an allergy script.
An aggressive conclusion
I could continue to have you shadow me during my day, but I think you got the gist. As doctors, we need to aggressively help our patients, who should not be left to help themselves. Every encounter in the lanes is a medical opportunity to achieve the end point of excellent quality of vision.
Now, off to see an 11-year-old who is playing with my transilluminator and scaring his younger sister who is screaming as loud as a young girl upon seeing Justin Bieber take the stage. OM
|Treating Asymptomatic Patients|
|We all have cameras on our phones or, some are lucky enough to have slit-lamp cameras. When dealing with asymptomatic patients, take a picture of the eye, and show it to your patient. If you don't have a camera masquerading as a phone or you don't have a slit-lamp camera, open a reference book to illustrate the medical condition. Why? Because visually connecting the image to your description will assist in getting your patient to follow your treatment regiment.|
Dr. Bloomenstein is director of optometric services at the Schwartz Laser Eye Center in Scottsdale, Ariz. He' a founding member of the Optometric Council on Refractive Technology. E-mail him at drbloomenstein@schwartz laser.com, or send comments to opto firstname.lastname@example.org.|
Optometric Management, Issue: November 2010