Managing dry eye in the setting of specialty lenses is somewhat dependent on the ocular condition, but patient expectations can be an integral part of the fitting process. To start, whether it is a new or an established patient, it’s important to know and discuss the patients’ objectives. It is helpful to establish with patients whether you are able to realistically resolve those issues or whether the goal is to simply manage those objectives.
Start with the Chief Complaint
For new patients, as with all patients, the first thing to explore is their chief complaint. Regardless of whether this is dry eye or blurred vision, dissect the chief complaint as much as possible. Is one eye worse or are both the same? Do patients wake up with the problem or does it present later in the day? What currently makes it better and what makes it worse are helpful clues with regard to evaporative versus aqueous deficient dry eye or even for establishing whether the problem is simply related to contact lens solutions. From there, I turn over every stone.
What are a patient’s current treatments, and what is working? In some cases, new patients may present with many different current treatments that they continue to use simply because no one ever told them to stop. I also ask about previous treatments and why they stopped them. This could reveal the severity of symptoms or noncompliance, and it could even provide a background of how to move forward. Additionally, anatomical issues (such as scarring or cataracts) warrant a modification of expectations, as they might prove to be a barrier.
Lastly, I ask every new patient “What is your goal today?” This is the most useful question to achieve successful GP fits, whether small-diameter GP or scleral lenses.
For established patients, the most common statement that I hear is “Doc, I need new contacts!” My response is always “Why do you feel that way?” Their responses usually vary but can be broken down into the categories of blurred vision or discomfort (sometimes both). As with new patients, establishing in which eye and at what time of day the issues occur are keys to solving the mystery. My first concern is lens power, condition, and/or warpage. If one of these lens problems exists, it must be fixed first to move on to other issues such as a disconnect in lens care or re-treating the surface.
The next options include taking dry eye management to the next level, such as switching from a corneal GP to a scleral or refitting scleral lens wearers with a toric periphery or a larger diameter. The tricky part is knowing what, when, and why. Current dry eye treatments can help, but sometimes ocular pain can be beyond the level that standard therapies can resolve. Conversely, a poor ocular surface naturally creates issues such as debris and mucus on the lens. With the latter, changing solutions or adding another step to the dry eye regimen could help. However, for some severe ocular surface conditions, it may be a case of managing rather than resolving symptoms.
For both new and established patients, discussing goals can help. Some problems we can solve, but others we can only manage. Having the appropriate discussion sets the tone for both patients and practitioners so that everyone is on board. I also try to be optimistic and let patients know that future technology is always a possibility. CLS