WELLNESS

  ocular wellness

Creating Wellness on the Ocular Surface

Five management strategies to prevent or minimize OSD

ALAN G. KABAT, O.D., F.A.A.O.

Ocular wellness is not a new concept. For years, a small but vocal cadre of eyecare providers has seized the opportunity to educate their patients regarding such concepts as nutrition, UV protection, cessation of smoking, proper diet and regular exercise to maximize ocular health and avoid (or delay) such maladies as cataracts, AMD and diabetic retinopathy. From such initiatives have grown new technologies for the early detection of these ailments, as well as products and even procedures to help maintain and perpetuate ocular health.

In terms of the ocular surface however, wellness is still a new and largely unexplored territory. Currently, we recognize that dry eye disease (DED) overlies a number of contributory disorders implicating the ocular surface tissues, including such conditions as meibomian gland dysfunction, conjunctivochalasis, lacrimal insufficiency, demodicosis and lagophthalmos. We recognize too that each of these conditions can be managed in a number of ways, from the ultra-conservative to the highly invasive.

“Wellness” vs. “Illness”

The most striking difference between an illness model (i.e., the predominant strategy in healthcare today) and a wellness model is the extent to which the patient becomes an active participant in his or her own healthcare. In an illness model, the physician dictates therapy and employs actions that attempt to alleviate the signs and symptoms of a disorder as rapidly as possible. Typically, these efforts are discontinued as soon as the patient reports (or demonstrates) resolution of the acute complaint. Compliance is important to successful therapy, but the patient’s obligation usually ends there.

The wellness model, in contradistinction, stresses not only acute intervention but also the additional aspects of patient awareness, education and growth. For the physician, emphasis is placed on conveying an understandable grasp of the underlying pathophysiology and employing specific measures to affect a directional change away from illness and toward a state of maximum health, or wellness. In general, wellness necessitates a change in patient habits to diminish destructive or negligent behaviors, while amplifying proactive, healthy behaviors.

This chart has been modified from The Wellness Workbook: How To Achieve Enduring Health and Vitality (3rd edition) (Ten Speed Press, 2004).

Much as we would all like to have a “magic bullet” for our DED patients, the truth is that these conditions are often highly complex and require specific, targeted therapy. However, some aspects of ocular surface wellness are critical for success.

Here, I provide five management strategies that can be employed to avert or limit the development of ocular surface disease.

1 Regular hygiene of the eyelid margins

A study from The Ocular Surface revealed that an overabundance of bacterial microorganisms along the eyelashes and lid margin induces stress on the tear film, conjunctiva and cornea by promoting inflammation and altering the tear chemistry. Regular lid hygiene helps diminish this potential by keeping bacterial populations in check.

At my practice, when communicating lid hygiene to patients, I liken this practice to brushing and flossing of the teeth — something that should be done every day. We also recommend periodic in-office “deep cleanings” two or more times a year for those patients with a tendency toward more excessive colonization, such as the elderly and those with compromised immune systems. (See Figure 1.)

Figure 1: A patient receives an in-office deep lid cleaning.

2 Maintenance of meibomian gland health and tear lipids

Through time, the meibomian glands tend to demonstrate keratinization of the ductal epithelium and stagnation of meibum flow, leading to reduced tear lipids. In extreme cases, this process can even lead to meibomian gland atrophy and meibomian gland dropout, resulting in an irreversible dysfunction of tear production.

Maintaining healthy glands and patent ductal openings requires regular cleaning, heating and expression of the meibomian units. This can be conducted periodically in-office (see Figure 2), or patients can use a variety of home therapies, such as the use of warm compresses and digital lid massage, on a daily basis to achieve a similar effect.

Figure 2: A patient is treated for chronic meibomian gland dysfunction.

Patients can take an active role in their treatment via supportive therapy with lipid-restorative artificial tears, which can help to stabilize the ocular surface under conditions of extreme stress. Also, a recent study from Clinical Ophthalmology reveals that a diet containing an appropriate amount and balance of essential fatty acids can provide the body an enhanced ability to produce better and more functional tears.

3 Maximization of blink efficiency

Though we don’t often think about it, incomplete blinking (blink lagophthalmos) is one of the primary sources of exposure keratopathy and dry eye complaints. No drug or device currently corrects this malady easily, however, liberal use of ophthalmic lubricants often helps to temporarily alleviate interpalpebral dessication. Moreover, patient education regarding proper blinking techniques, or “blink exercises” as we call them, can prove most helpful. There are a number of websites that offer examples of these exercises, such as www.allaboutdryeye.com. Simply raising patients’ awareness regarding this deficiency often helps to substantially improve symptoms.

4 Control of ocular surface inflammation

In those patients who demonstrate ocular surface inflammation, it is paramount to maintain control of this element. The Ocular Surface reports inflammation is a primary driver of ocular surface disease, although it may originate from many sources, including microbes, contact lens wear, use of preserved ophthalmic pharmaceuticals and even systemic disease, such as rheumatoid arthritis, Sjögren’s syndrome and scleroderma. Eliminating or minimizing the sources of inflammation is the ideal management strategy, but when this is not possible or adequate, the ongoing use of anti-inflammatory agents, such as cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan), is critical. Recognizing these factors and prescribing treatment early in the course of the disease — and ensuring patient compliance through education — may mean the difference between success and failure.

5 Minimization of environmental effects

Finally, patients must understand that their immediate environment greatly affects the ocular surface. Factors such as heat, ultraviolet radiation, airborne pollutants, air movement and relative humidity can all affect the severity of patient symptoms. Therefore, maintaining a controlled environment whenever possible helps patients experience less discomfort, while promoting a healthier overall state. Some topics for discussion can include smoking cessation, avoidance of fans or direct heating/cooling vents, as well as specialized eyewear, such as sunwear and eyewear that promotes a moist chamber effect.

Common-sense care

The concept of ocular surface wellness may seem new and unusual to some, but in reality it is little more than common-sense eye care. Helping patients to understand the circumstances behind their condition and providing mechanisms to maintain a healthy ocular state are actions we strive to accomplish every day in clinical practice. It is simply a matter of adopting this strategy for ocular surface health, and giving every DED patient the option and tools to affect long-term change for the better. OM

Dr. Kabat is a professor at Southern College of Optometry and clinical care consultant at TearWell Advanced Dry Eye Treatment Center in Memphis, Tenn. He serves as a consultant for Alcon Laboratories and Bio-Tissue, and is on Clinical Advisory Boards for Nicox and TearScience. Send comments to optometricmanagement@gmail.com.