Dry Eye Dx and Tx
Driving Compliance in Asymptomatic Patients
BY SCOTT SCHACHTER, OD, & AMBER GAUME GIANNONI, OD, FAAO
It is well established that the frequency of ocular surface disease (OSD) is very high and on the rise. It is also known that signs and symptoms of OSD don’t always match up. In conditions such as dry eye disease and blepharitis, we often see clinical signs, yet our patients don’t complain.
This leaves some practitioners with a dilemma. If we see an eye disease, should we ignore it if the patient is completely asymptomatic? After all, the old adage says, “if it if ain’t broke, don’t fix it.” However, that logic doesn’t really hold water. If we had asymptomatic high blood pressure, would it be acceptable for our primary care physician to ignore it? Patients come to us for an eye physical. If we see a treatable, chronic, progressive disease with potentially untoward effects, we need to address it. So, how do we get patients on board with treating a non-sight-threatening disease?
1) Show Conviction
Conviction manifests as a blend of confidence and sincerity. Know that the recommendations you make are in the patients’ best interest, and talk to them as if they were family. Patients will feel this sincerity and will value your recommendations.
2) Use Questionnaires
When I first started screening all of my patients for dry eye, I observed plenty of signs, yet few patients seemed to have any symptoms. I reached out to dry eye expert Kelly Nichols, OD, PhD, and asked whether she treated signs or symptoms. She said, “I treat signs and symptoms, but I don’t think there are very many truly asymptomatic dry eye patients. Perhaps you aren’t asking the right questions.”
An excellent point! Are patients really asymptomatic? Surveys such as the Ocular Surface Disease Index (OSDI) and the Standard Patient Evaluation of Eye Dryness (SPEED) can be immensely helpful in teasing out dry eye patients who may not believe that they have a problem.
3) Test Results
It’s hard to ignore a positive test result. Many point-of-care tests for dry eye deliver simple and quick results with high sensitivity and specificity. Many of these are relatively low cost and are covered by most insurance companies.
One test measures matrix metalloproteinase-9, a non-specific inflammatory biomarker produced by stressed epithelial cells that weakens epithelial junctions (Pflugfelder et al, 2005). A positive result can vary from a pink (mild) to a red (severe) line. Another test measures tear film osmolarity. Hyperosmolar tears are destructive to the surface of the eye and are linked to dry eye disease (Deng et al, 2015). The instrument gives a number read-out that you can share with patients and monitor over time for improvement.
As the saying goes, “a picture is worth a thousand words.” This is especially true when discussing OSD with asymptomatic patients. Seeing photos of their own crusty eyelashes, Demodex mites, or atrophied meibomian glands serves to educate patients, which will increase adherence to your treatment plan (Gold and McClung, 2006). It doesn’t have to be an expensive proposition, either—there are plenty of affordable imaging options, or you could always use your smartphone. CLS
For references, please visit www.clspectrum.com/references and click on document #249.
Dr. Schachter is in a practice in Pismo Beach, CA that focuses on ocular surface disease. He has been a Vision Source administrator since 2003 and is an adjunct faculty member at the Southern California College of Optometry at Marshall B. Ketchum University. He is a consultant for Allergan, B+L, Bio-Tissue, Blephex, ScienceBased Health, and TearScience. Dr. Gaume Giannoni is a clinical associate professor at the University of Houston College of Optometry and is the director of the Dry Eye Center at the University Eye Institute. She also sees patients in a private practice setting. She is a consultant or advisor to Alcon and Allergan.