Treating the Self-Medicating Dry Eye Patient
Help set your patients straight when it comes to seeking treatment.
BY PAUL A. WILLIAMS, O.D., F.A.A.O., Tacoma, Wash.
T he self-medicating patient is prevalent in all of health care -- and eye care is no exception. How often when you're taking patient histories do you hear one say, "I don't tell my family doctor this, but . . ." and relate a health concern that they're self medicating (either treating themselves or altering the treatment plan of another doctor without that doctor's knowledge).
One of the more common conditions for which patients self medicate lies in our own field -- dry eye syndrome (DES). DES is one of the most prevalent ocular disease processes. Various studies place its incidence as high as 20% to 40% in some populations. This article will focus on how to spot a self-medicating dry eye patient and turn him into a loyal patient who relies on you for treatment.
The manifestations of DES compromise not only the health of the eye but also its visual performance. In spite of these issues, DES is also one of the most commonly undertreated and mistreated ocular conditions -- and this is largely because of patient self diagnosis and self medication. In most cases, the self-medicating patient wants to ask for help but doesn't. Meeting his needs could relieve his eye health and vision concerns and also win you a patient for life.
PHOTO BY PAT SIMIONE
Self medicators 101
The first challenge for any self-medicating patient is to decide on a diagnosis. One problem, however, is that DES symptoms are so widely varied and diverse that patients frequently assume they have a number of conditions other than DES. These patients may present to you after self-treating with an antibiotic, allergy medication or other inappropriate agent because of their own incorrect diagnosis. Self-medicating DES patients may find relief from their symptoms, but most admit to facing frustration with DES for many years.
The opposite is frequently true as well, with patients denying that they have a problem, either because of lack of knowledge, acceptance of the symptoms as "normal" or because they're unaware of potential treatment.
Whatever the scenario, the result for the self-medicating patient is a lack of treatment for the specific concern and subsequent needless suffering. And once a patient diagnoses himself with DES, he faces another challenge: deciding which treatment to use.
They have their reasons
Not only do a variety of causes exist for DES, but a variety of over-the-counter (OTC) treatments also exists, which often confuses patients and confounds effective treatment. How can patients correctly choose between preserved and non-preserved lubrication therapy or moderate vs. high-viscosity therapy, let alone whether lubrication therapy is even the correct treatment for their condition? Will the treatment they choose simply relieve some symptoms, masking an underlying disease process that's causing the DES symptoms in the first place?
Often times, the result of self medicating for the patient is frustration, ineffective treatment and, worst of all, ongoing, unresolved symptoms. So why do they do it?
Everyone has an excuse
DES patients self medicate for a number of reasons. The most obvious is to relieve their symptoms in a self-directed, immediate manner, without having to see a doctor. DES patients find many options available OTC, which provide a sense of direction in resolving their symptoms. Some patients use the excuse that they're "too busy" to seek treatment or that they're financially unable to seek care.
Inevitably, there will come a time when the self-medicating patient sees an eye doctor while he's self medicating. If he admits to the symptoms or concerns for which he's self medicating, he may not want to confess that he self treats -- either because he doesn't see OTC products as "medication" or he doesn't want to admit to something the doctor may not approve of. In this scenario the self-medicating patient may be so confident in his self diagnosis and treatment that he'll self medicate even when his doctor directs otherwise.
Understandably, we sometimes become as frustrated as our self-medicating patients. So keep the following in mind.
The first challenge we face is that self-medicating patients tend not to acknowledge what they are doing. They also tend not to follow a dosing pattern, as would a patient prescribed a therapy, resulting in variable symptoms and visual performance. For the contact lens wearer, we are further frustrated by variable performance in contact lenses and subsequent lens failure.
So how do we identify self-medicating DES patients? Unfortunately, no specific profile identifies this category, so we need to rely on some basic clinical instruments to first diagnose the DES patient. Then we must provide education and discuss the proper treatment indicated in each specific DES patient's case.
When diagnosing DES, elicit the patient's symptoms (you can give questionnaires in a pre-testing format). This information, combined with a comprehensive eye health and systemic history, will assist you in tying in symptoms, medications and systemic disease to potential health concerns, including DES. We target the use of many medications such as behavioral medications, hormone therapies, hypertension medications and OTC medications that cause dryness.
Your moment to shine
Reviewing the history and medications with your patient opens an opportunity to review possible DES symptoms with him. Symptoms they took for granted or dismissed as normal may now be cause for further discussion.
As the patient realizes that he's receiving more than just a routine examination, he will begin to enhance the history he provides. This gives you a chance to educate the patient on how his other health concerns and medications affect the eye, and reinforce the importance of eye health and vision care as a part of his overall health care.
Converting the patient
Once you've identified a self-medicating DES patient, set the goal of converting him into an effectively-treated DES patient. Educate him that DES is a real health issue. Acknowledging the concern, however, is only the beginning. You must inform the self-medicating patient why he has DES. Otherwise he won't accept, let alone comply with, your treatment recommendations.
Once the patient agrees to treatment, we must deliver a comprehensive treatment plan. Too often we hear patients tell us that another doctor gave them a sample of a lubricating drop and told them to "try this and we'll see you in a year." For no other disease do we treat by dispensing samples and dismissing the patient for a year. Patients need plans that they can follow. Here's how to establish one.
Setting up a treatment plan
Outline the initial course of action and follow-up procedure. If the patient's symptoms are aggravated by an active, chronic lid disease, treat the lid disease, set an appropriate follow-up period and then have a staff member follow-up with a "patient progress call" part way through the initial treatment period. This is an excellent opportunity for the staff to identify and relay any problems the patient may have with the treatment.
If the patient isn't experiencing appropriate improvement, you can recommend that he come in for an earlier follow-up appointment. If the patient is improving, the "patient progress call" provides both you and him with reassurance and further reinforces to the patient that you care about his well being. Patients who have mild DES or a poorly lubricating contact lens to whom you've dispensed a sample of lubrication therapy may not need reappointment, but some follow-up is necessary, even if it's just a phone call.
Have an alternative in mind
Like many other conditions, DES is a multifactorial condition encompassing tear film insufficiency for one or more reasons, inflammation, allergic disease and other health changes. One answer is rarely the solution when more than one problem exists. The patient needs to understand the initial treatment plan may be just that -- a first step.
For patients who have allergic conjunctivitis, treat the allergic disease first and then reassess your diagnosis of DES. Let the patient know that you see concerns for both diagnoses and that treating the allergic disease is just the beginning. This reinforces to the patient the significance of his concerns and that self treatment may not be the best course of action. If your recommended treatment is lubrication therapy, then lessen the tendency for the patient to continue self-medication by not only discussing what agent you want them to use, but also why other options aren't appropriate for their condition.
Encourage the right choice
Regardless of the patient or the condition, it's always important to raise a patient's awareness of his problem. As for the self-medicating patient, however, we must go beyond this measure and explain the condition, why it came to be in each particular patient's case, what we want to do about it and what alternative therapies are available. It's important discuss with the self-medicating patient which therapies are appropriate. From that point, every patient has three choices:
1. Follow your recommendations
2. Choose his own therapy
3. Do nothing.
Hopefully, by educating patients we can ensure that they make the right choice.
is in private practice and is director of the Dry Eye Treatment and Research Center. He is a fellow in the American Academy of Optometry.
Optometric Management, Issue: January 2004