dry eye

Dry Eye: How to Provide Follow-Up Care

Reassessing clinical findings and ongoing patient communications are the keys to success.

GREGG ERIC RUSSELL, O.D., F.A.A.O., DIPL., Gadsden, Ala.
ERNEST BOWLING, O.D., M.S., F.A.A.O., DIPL., Marietta, Ga.

You're knowledgeable about clinical conditions and have kept abreast of ophthalmic literature and developing clinical science. You've listened carefully to your patient and completed a thorough examination. The patient's complaint of foreign-body sensation, light sensitivity and variable vision has resonated in the history, and you've found evidence of punctate staining and a rapid tear break up time (TBUT). Your diagnosis is clear, and you've discussed your findings in great detail with the patient. He has dry eye. As easily as the words roll off your tongue, however, the challenge has only just begun…

Start with the case history

Dry eye will vary with season, work or home environment, medications and the patient's own unique physiological makeup.¹ Start the diagnostic process with the case history. Document the patient's answers to a few important questions, including whether he's taking any systemic medications for blood pressure, his sinuses, allergies or psychological concerns. Medications suspected of contributing to dry eye include diuretics, beta blockers, tricyclic antidepressants, antihistamines and antipsychotic drugs. Is there a seasonal component for his subjective complaints? Does the patient experience increased difficulty with dryness while doing more near work activities? The answers to these questions help frame the suggestions that you will make in the case summary and patient discussion.

Collect physical data

Once you've collected initial information, it's time to collect physical data. The history should point you toward the appropriate tests to consider. None of the tests described in this section are perfectly accurate, but each helps point you in the right direction.²

► Visual inspection. Take a very close look at the patient's eyes while you're having a face-to-face discussion with him about case history. Carefully note aperture size, lid position and blink quality and frequency. Repeat this process every time the patient returns, and reference it to previous visits.

Asking your patient to blink is like trying to remind him to breathe, so it's doubtful the frequency of blink will improve. Making the patient aware that the intermittent blur he experiences is likely due to dry eye might encourage him to make a forceful blink. Advise that wind gusts or ventilation ducts that blow in the direction of the patient's face contribute to excessive drying. This helps him to understand that he can make work station adjustments to alleviate dry eye.

► Dye evaluation.³ Vital dye staining is critical to an initial assessment and tells you a lot about ocular performance. The mere presence of staining confirms either a tear film quality or quantity problem, and it gives you a scorecard of how the patient is doing at that visit. Indeed, this is another test that you should repeat during each visit, and you should note the presence extent, and position of the staining.

Coupling this evaluation with subjective data of comfort level allows you to determine whether the patient is improving at subsequent visits. Fluorescein has always been the "go to" stain in the eyecare practitioner's office for both TBUT and corneal punctate staining, but lissamine green and rose bengal stains have valuable applications as well. Lissamine green is more easily tolerated than rose bengal, but both vital dyes stain the exact same dead and devitalized cells.⁴ Every patient visit should include a slit lamp examination and vital dye staining with sodium fluorescein and lissamine green to assess the ocular surface.

► Schirmer testing. As criticized as the test is, it still provides you with an idea of basal tear performance and is part of a baseline dry eye evaluation. If the test is positive (defined as less than 10mm of wetting within five minutes) and the patient is undergoing medical treatment for his dry eye, then it's reasonable to repeat Schirmer testing after two to three months. As an adjunct, the phenol red thread test is probably tolerated more than the Schirmer strip and provides accurate data.⁵ It's much quicker — 15 seconds, vs. five minutes for the Schirmer test — so it's a better choice for a "quick and dirty" assessment of tear volume in a busy practice.⁶

Develop an ongoing management plan

Unlike the diagnosis of a cataract or ectropion, the diagnosis of dry eye can wax and wane and frustrate both the patient and the doctor. The journey of patient care starts by including the patient in his care process and defining the treatment plan. Without going into excessive detail on points that other article authors have discussed at length, the focus here is more on what to do after the diagnosis and initial treatment.

So let's assume you've initiated a treatment plan. How often should you see the patient for follow-up visits? First, explain to the patient that dry eye is a chronic disease. It never goes away, but the goal of treatment is to make him comfortable. Second, tell the patient that he plays a very significant role in dealing with his condition. Alert the patient to the fact that medications can have side effects. Educate the patient on the relationship and side effects he may experience with the previously mentioned medications. Don't blame your patient's primary-care physician for prescribing medication for his condition. Instead, send a letter to the physician outlining your findings, recommendations and concerns. It's always a good practice to include the patient's primary-care physician in any treatment recommendations.

Explain to the patient that the amount of time spent reading is directly correlated to the severity of a dry eye condition. Sometimes asking the patient whether he notices a difference in his dry eye symptoms during work time vs. leisure time will help to make this correlation more easily understood. It's well known that one's blink rate decreases during activities, such as reading, driving or intense conversations. Further, if fans or vents are blowing at the patient's face, he's going to experience severe dry eye symptoms. Low humidity is associated with greater dry eye problems, high humidity with less.⁷ Flying long distances (high-altitude travel) or driving long distances can also decrease blink rate and aggravate dry eye symptoms.⁸

Dry eye patients are more likely to experience greater discomfort during winter months because indoor environments are warmer and more arid than the outdoors. During times of excessive pollination in the spring, symptoms may also heighten. Patients who wear contact lenses are likely to be uncomfortable in those lens materials that lend themselves to excessive drying. Consider recommending rigid gas permeable, silicone hydrogel or other lens materials that have anti-dry eye labeling to these patients. Also, don't forget about the fact that contact lens care systems can be a great source of discomfort to some patients as well.

Deliver options

Developing an ongoing treatment plan starts with information and ends with options for the patient. Start conservatively, and introduce alternatives based on the severity of symptoms. At this point, the patient should have a very clear understanding of what he can do to help assist with the alleviation of his dry eye discomfort. If your patient experiences an increase in dry eye symptoms during winter months, consider recommending a humidifier. If the onset of the symptoms occurs first thing in the morning, consider suggesting a nighttime eye lubricant. If your patient's symptoms appear only when in his home, ask whether he has a cat or dog that sleeps in his bed or whether the home has any mold damage. An allergy may be contributing to his dry eye condition.

If the patient's symptoms are worse at work, suggest redirecting air vents or using tear supplements. Be mindful of the answers and findings so you can adjust and titrate recommendations. Some of these include punctal occlusion, topical steroids, lubricant eyedrops and/or cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan) therapy, a referral for lid revision (if there is significant ectropion or other pertinent lid misalignment), nighttime lubricants or lid taping. Omega-3 oral supplementation or the increased dietary intake of salmon, tuna or herring — all of which contain omega-3 oil — may also help.

If the patient's complaint doesn't improve fairly quickly with the dispensing of artificial tears and/or ice packs (generally within four to seven days), modify the treatment plan, and consider other therapeutic options. If the patient doesn't show improvement within three weeks of oral supplementation, consider adding topical steroids or other topical anti-inflammatory agents. Because no specific treatment works for everyone, defer to clinical findings and case history. If the patient is worse, review his case history to see whether anything has changed, and reassess clinical findings.

When to follow-up

Recall that decisions are based on the severity of the problem. Minimal impact dry eye issues gauged by the patient as being tolerable might require only a yearly visit. Moderate to severe dry eye issues might require four-to six-month evaluations depending on the patient's comfort and health. There is a great amount of flexibility in this process. Studies confirm that developing a plan and adhering to it ultimately helps the patient.⁹

Ongoing communication is a genuine component to the art of healing. Providing the patient with a simple reminder card listing all the discussed elements (and documenting that he received it) gives the patient a simple "owner's manual" to which to refer, so he can become active in his own care and well being. The sad reality is that many patients don't completely hear what we say and don't always read printed handouts. However, printed material and Web site links are important. You need to empower patients in their care, and be proactive in the process. Self-research helps the patient to understand materials at their leisure and relate to their individual treatment plans.

Two-way communication is absolutely critical. Improve communication by providing the patient phone or e-mail access to you and your staff. Train your technicians and office staff to answer simple questions by giving them carefully worded scripts to follow.

The way you management patients ultimately makes or breaks their confidence in you. Feel confident in your ability to help your dry eye patients in situations in which help is warranted. OM

References furnished upon request.

	Dr. Bowling is an associate professor and director of the primary eyecare service at the University of Alabama at Birmingham School of Optometry. E-mail him at drbowling@alltel.net.
	Dr. Russell practices at the Marietta Eye Clinic. He specializes in contact-lens fittings for patients who have keratoconus, corneal scars and refractive surgery complications. Contact him at (770) 427-8111.