In the film “The Perfect Storm,” a Massachusetts-located commercial fishing boat called the Andrea Gail becomes lost a sea, due to a rare convergence of adverse meteorological ingredients, known as the film’s title. It can be argued that the COVID-19 pandemic has created “The Perfect Dry Eye Disease Storm,” due to mask wear, which has birthed the diagnosis mask associated dry eye, or MADE (See bit.ly/3iqmfz8 ), and increased screen time.
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This iteration of Practicing Medical Optometry (PMO) is part of an ongoing series focusing on medical optometry offerings of glaucoma, AMD, dry eye, and more. You can find the previous issues of this section for download here.
Additional articles in this edition include:
Regarding the latter, a recent Ipsos survey, commissioned by Alcon, shows nearly 80% of Americans are spending more time on screens because of the COVID-19 pandemic — and of those, nearly half have experienced their eyes feeling dry as a result.
“I am not only seeing the emergence of new patients, but also the worsening of those who had previously controlled dry eye disease (DED),” notes Cecelia Koetting, O.D., F.A.A.O, of Virginia Eye Consultants and Optometric Management’s “Dry Eye” columnist.
As is the case with all DED patients, COVID-19-affected DED patients are either seeking answers and effective treatments from their doctors or self-prescribing with OTC solutions that may not be providing them with symptomatic relief.
So, how can optometrists uncover these new patients to prescribe them the most appropriate treatments? Four optometrists who have seen their fair share of such patients provide tips here.
CREATE A NEWSLETTER
Tim Trinh, O.D., F.A.A.O, of All Eyecare Optometry, in Thousand Oaks, Calif., points out that in light of the COVID-19 pandemic, it’s important to let patients know that DED can be more than just a nuisance.
“A newsletter can be sent out to patients educating about the disease, but also any potential in-office treatments that are available,” he explains. “These patients, as was the case with before-COVID-19 DED patients, don’t realize that DED can reach a debilitating state, and they also don’t recognize what can be done about it.” (Find more information about communicating with patients at bit.ly/0521PatientComm .)
USE HOME QUESTIONNAIRES
Dr. Trinh adds his practice now has all patients complete a DED questionnaire at home vs. at the office to give patients time to consider their symptoms, if any. He says that this approach also gives the practice ample time to flag patients before a visit and tailor the conversation to DED from the start.
“By starting that conversation earlier, we’ve found it allows a better acceptance of their condition,” Dr. Trinh says. “By the time they get to me, the patient has already received some education about DED and is, therefore, more open to a dialogue about the condition.”
Dr. Trinh says he utilizes the SPEED Questionnaire as well as the Advanced Dry Eye Questionnaire for moderate-to-severe DED patients. He points out that he also stresses the importance of a medical history evaluation to determine whether potential underlying issues, such as autoimmune diseases, medications, or hormonal risk factors, could be at play.
TRIAGE PATIENTS
“It’s important that technicians are well-trained to be able to weigh in on what chief complaints may make the patient a best-fit for what specific tests,” Dr. Koetting offers.
Doing so can save both the patients and the practice time, while ensuring appropriate social distancing.
Dr. Koetting says a number of diagnostic tests are easily accessible in her practice, including validated DED patient questionnaires, tear osmolarity, MMP-9, meibography, and more, to aid her in the definitive diagnosis of DED. (More on DED diagnostics on p.23.)
She adds that she’s been using more photographic evidence of DED during the COVID-19 pandemic, as it “really helps patients to better understand their condition as well as take it seriously.”
OBSERVE REFRACTION
Dr. Trinh adds that refraction can also be an educational opportunity for the patient.
“If blinking alters the patient’s vision, addressing this with the patient during refraction can open their eyes to how DED has a negative effect on vision, prompting them to accept the diagnosis and employ treatment.”
DON’T DROP THE BALL
Once optometrists have uncovered COVID-19-affected DED patients and have gotten patient buy-in to the DED diagnosis, it’s crucial they identify the underlying cause, so they can prescribe the most appropriate therapeutic interventions, say those interviewed.
“DED is very individualized. The key really is to tailor the treatment to the patient’s specific issue,” Dr. Koetting explains. “We must get the underlying cause under control and then move to a stabilizing treatment.”
Dr. Trinh agrees.
“Targeted treatments are the key to helping patients find success,” he says.
He adds that it is also important to take disease severity into account.
“…Many mild DED cases can be addressed with home hygiene and nutritional supplementation,” he explains. (More on DED therapies on p.28.)
Laurie Sorrenson, O.D., F.A.A.O, of Lakeline Vision Source, in Cedar Park, Texas, says she uses low-level light therapy and thermal pulsation with great success on patients who have substantial meibomian gland dysfunction.
Dr. Koetting adds that O.D.s should not shy away from steroids when they’re warranted or out-of-pocket treatments when they’re the best treatment. “We are doing our patients a disservice when we are not more aggressive about our treatment approach. Not only will patients appreciate feeling better, but we can help them prevent long-term problems if we can get their DED under control now.”
MORE RESEARCH NEEDED
While Dr. Koetting says she’s seen an influx of DED patients and some whose DED has worsened since the COVID-19 pandemic, she also notes she has seen some of her established DED patients improve as well during this difficult time.
“For some, the work-from-home conditions — and not being in an office building with forced air, which we know environmentally contributes to ocular dryness — I think has improved their condition,” she says. “Some patients working from home have also been better about their care regimen.”
Dr. Sorrenson says she has realized in seeing new DED patients during the COVID-19 pandemic that many of their symptoms are actually caused by either a vertical or horizontal imbalance in the eyes.
“We have prescribed considerably more glasses with prism or contoured prism over the last year than we have ever done before,” she points out. “We check vertical phorias and look for convergence insufficiency routinely now.”
Damon Dierker, O.D., F.A.A.O, of Eye Surgeons of Indiana, points out there is still much to learn regarding the COVID-19 pandemic’s effect on DED.
“I would imagine that in the future we will have better advice in terms of mask recommendations and an overall better understanding of how it’s contributing to what we’re seeing,” he says. OM
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