WELLNESS

FIVE WAYS TO OCULAR SURFACE WELLNESS

HELP DRY EYE PATIENTS ACHIEVE A HEALTHY OCULAR SURFACE

Kelly K. Nichols, O.D., M.P.H., Ph.D., F.A.A.O. Birmingham, Ala.

THE CONVENTIONAL medical model in the United States is focused, almost entirely, on the diagnosis and management of disease. In a few critical areas developed through 50+ years, including dental screenings, vaccinations, and yes, a dilated eye examination, the concept of prevention has been raised to the level of public awareness, albeit controversy still exists. Why is our health care model so afraid to promote wellness?

Patients are tuned to be aware of diseases and interact with the medical system, not to maintain health, but to find relief from illnesses. So, how do we work with our patients to shift their focus from disease to prevention and wellness?

Here are five day-to-day concepts that you can use in your practice to accomplish this.

1 BELIEVE IN THE IDEA OF PREVENTION

The World Health Organization describes health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Thus, attainment of health requires prevention of disease — or, at minimum, efforts directed toward keeping good health.

In public health terms, prevention includes halting a disease before it even starts. How are we to do this? In terms of ocular surface disease, there is no guidance on how it can be prevented, largely because we don’t understand why dry eye occurs in all patients. What we do know, however, is how to recognize dry eye disease. If we can diagnose dry eye early, or begin to recognize common risk factors among our dry eye patients, we can prevent the progression of the disease, and this is a worthy goal.

2 LISTEN TO YOUR PATIENTS

Every day, patients talk to us about how their eyes feel, and often we continue to ask the same question—“do your eyes feel dry or irritated?” How often do we follow that question with “when,” “how often,” “how long has this been happening,” and “what works/doesn’t work?” Timeliness and, more importantly, the impact of these symptoms to the patient’s quality of life are imperative. Sure, taking the time to ask these questions dips in to our total time with a patient, yet it can make more of an impact than most diagnostic tests in terms of monitoring success with treatment. Your most valuable tool as a clinician is your ability to listen carefully to patients and to act appropriately.

3 LOOK AT YOUR PATIENTS

Have you ever been to a dental appointment and had the feeling you were seen as just teeth in a mouth? I would say most of my dental exams felt this way 10 years ago, but now my hygienist and dentist screen for mouth and neck cancer, and ask questions about dry mouth and associated systemic diseases and medications. To me, the experience is more satisfying (if you can call a visit to the dentist that!). Our patients are not just eyeballs behind the slit lamp, even though our magnified view of the eye helps with the “full body” approach. Our assessment starts the second the patient walks into the clinic. Staff can be extremely valuable in this process and can assess mobility (think arthritis), medication use (screen for ocular drying medications) and detect dermatological signs (rosacea), to name a few. All this happens before the photopter or slit lamp, but certainly does not end there.

This mild lissamine staining indicates early stage dry eye disease.

4 DETECT OCULAR SURFACE DISEASE EARLY

In epidemiologic terms, primary prevention refers to preventing a disease and reducing new cases. Maintaining healthy habits, such as diet and exercise, is an example. Secondary prevention refers to detecting a disease early in its course to best affect change. Screening practices, such as some of the tests/questions we use for dry eye are examples, and should be our target for early detection of the disease. Tertiary prevention is aimed at improving outcomes after an established condition is diagnosed, and often is aimed at appropriately managing the downstream sequelae of the disease. So, how can we incorporate a dry eye screening protocol into a busy office setting? The recent Dry Eye Summit Meeting did just that.

In an effort to identify an appropriate screening tool for dry eye, more than 30 leaders in dry eye disease gathered in Dallas, Dec. 11 to 13, 2014, for the meeting. Joining the experts at this summit were representatives from 17 pharmaceutical and medical device companies, who provided invaluable industry insights into the diagnostic tools and treatments available to eye care doctors, and how these tools are used. The group developed a minimum dry eye symptom screening that could be asked to all patients:

1) Do your eyes ever feel dry or uncomfortable?

2) Are you bothered by changes in your vision throughout the day?

3) Are you ever bothered by red eyes?

4) Do you ever use or feel the need to use drops?

In addition, three basic clinical tests round out the screening, and at a minimum, should be considered in each patient for primary dry eye disease:

1) Eyelid examination

2) Staining

3) Tear film instability

Taken together, one or more abnormal responses/clinical findings warrants a closer look or even forms the basis of a diagnosis. Don’t wait until all findings are negative — if you do, the window of prevention has been missed.

5 DO SOMETHING

Unfortunately, this is where prevention efforts often fail. It is hard to see the benefit of “doing something” for both the doctor and the patient, if the outcome isn’t overly obvious. It is even more difficult to change a patient’s behavior in an environment where we are conditioned to treat existing disease — not early phase or emerging disease.

Shifting from a reactive to a preventive model in health care requires a mental shift toward behaviors that promote wellness. For new behaviors to be adopted, attitudes must change — patients’, doctors’ and, in some ways, society’s. Fortunately, there is increasing interest in preventative models in health care delivery. Dentists adopted and have practiced prevention for almost 100 years by promoting brushing and flossing, and in more recent times, cancer screening. What is the dry eye equivalent to flossing? While we do not have hard evidence to support any one activity, there are several worthy candidates.

Consider your patient, who has mild dry eye symptoms and a history of personal or familial rosacea. At-home warm compress therapy is a logical choice, as would be a lipid-based artificial tear, once daily. Let me stress, disease does not need to be so obvious to practice prevention. Do something! A patient who has been to the pharmacy and has purchased eye drops on his or her own is a red flag. Perform the minimal dry eye screening, or dive deeper into a medically oriented dry eye exam. Whatever you do, don’t let the patient leave your office without clear recommendations, including appropriate prescriptions. Do something! How about your female teenage contact lens wearer who wears gobs of makeup? Send her home with instructions to use lid wipes. Again, Do something!

Low tear prism is one of the first signs of dry eye disease.

MAKE A COMMITMENT

Patients appreciate being taken care of, and prevention efforts are an easy way to connect with your patients about eye health. Make these five steps your office mantra, and the long-term dividends will pay out for you, and your patients. OM

KELLY K. NICHOLS, O.D., M.PH., PH.D., is dean and professor of optometry at the University of Alabama at Birmingham School of Optometry. In addition, she serves as a medical adviser to the Sjögren’s Syndrome Foundation. She also is an executive board member of the Tear Film and Ocular Surface Society, a founding member of Ocular Surface Society of Optometry, co-editor of “Ocular Surface News” and on the editorial board of The Ocular Surface. Email her at nicholsk@uab.edu, or send comments to http://tinyurl.com/OMcomment.