DRY EYE DISEASE (DED) continues to be a frequent concern in the United States, with a JAMA article from this February estimating that 5% of U.S. adults have the condition. For our dry eye disease issue, we’ve invited four optometrists – Glenn S. Corbin, OD, of Wyomissing Optometric Center (Wyomissing, Pa.); Vin T. Dang, OD, FAAO, of Empire Eye & Laser Center (Bakersfield, Calif.); Scott Hauswirth, OD, FAAO, of UCHealth, Sue Anschutz-Rodgers Eye Center (Aurora, Colo.); and Cecelia Koetting, OD, FAAO, of Hines-Sight (Denver, Colo.) – to answer a series of questions on DED selected by Optometric Management’s chief optometric editor, April Jasper, OD, FAAO.

OPTOMETRIC MANAGEMENT: WHAT IS THE BEST WAY TO IMPLEMENT NEW DED TECHNOLOGIES (BOTH DIAGNOSTIC- AND TREATMENT-RELATED) INTO THE PRACTICE?

Dr. Glenn Corbin: Train your staff, both those directly or indirectly involved with the technology. It is important that all staff understand and know what technology we use, and why. At my practice, we will typically schedule a brief staff meeting to introduce any new technology or discuss new procedures. If we have any written materials from the vendor that we might be giving to our patients, we request that the staff review the materials, so they can address any patient questions. Patients often ask questions based on what they read in brochures from the vendors.

Dr. Vin T. Dang: Make sure the entire practice buys in to adapting to the new technology. Generate excitement from all the departments, from front- desk employees who are fielding phone calls about potential dry eye patients, to the technicians who are screening these patients, and the other doctors in the practice not specializing in DED evaluation and management; then, market your services to local ODs and MDs.

Dr. Scott Hauswirth: First is understanding the needs of your practice — what demographics you serve and what it can support. Next is understanding what information the diagnostic devices are giving you and how you will explain the results to a patient in a way they can understand. This is the same on the therapeutic side. Then comes training the staff — every member of your staff should be comfortable with a diagnostic or therapeutic device and be able to explain it to a patient in a rudimentary way. Patients ask a lot of questions, and you want all your team [members] on the same page and projecting the same information. For example, we perform meibography on all new dry eye evaluations and intermittently as follow-up [appointments]. The technician running the test should be able to explain the image to the patient if there is some degree of dropout or atrophy, or give a reference to what our expected normal looks like. Staff does not go into why these changes have occurred, but should be able to explain [what is] contributing to their symptoms and that I will be able to evaluate their condition further. This is helpful because the patient is already processing that information when I see them and I build or expand on this, filling in the details.

Dr. Cecelia Koetting: Repeat, remind, and repeat. It takes time to change our habits. If we bring in a new treatment or diagnostic test, it doesn’t matter what it does if we don’t use it. Find a way to break the normal routine and implement it heavily for a few weeks to get into the habit of using it. For example, when adding meibography to the mix at our office, I asked my technicians to perform it on all new patients, using it during dry eye evaluations and routine exams. This helped them become more proficient at performing the test, as well as implementing it into the routine.

OM: UNDER WHAT CIRCUMSTANCES AND FOR WHAT PATIENTS IS IT APPROPRIATE TO USE PRESERVATIVE-FREE (PF) TEARS?

GC: Any time I have a compromised cornea and/or conjunctiva, I prescribe preservative-free products. If the cornea and/or conjunctiva are not compromised, but the patient is on other topical meds, especially for glaucoma, then I also prescribe only PF products.

VD: Generally speaking, my artificial tear of choice is always going to be a preservative-free option. Other circumstances in which I would recommend a PF option is when patients are already using some form of artificial tears five times daily that’s preserved.

SH: I almost never recommend preserved artificial tears, to be honest. If a patient only needs to use an artificial tear every once in a while, then I’m OK with a preservative [tear], otherwise I direct patients to stay away from them. Preservatives are designed to keep medications sterile; they are both cytotoxic and neurotoxic, so unless they are being used sporadically, it is not something that I believe we should be utilizing often, especially in a patient whom we have diagnosed with ocular surface disease.

CK: At this point, I think that there is no reason to not automatically reach for [a] preservative-free [drop] first. There are so many different formulations for both aqueous-deficient and lipid-deficient patients that we can use. Why add one more thing to the front surface that may exacerbate DED?

OM: WHAT ARE YOU SEEING THAT’S NEW AND DIFFERENT ABOUT DED TREATMENT IN THE LAST TWO YEARS?

GC: I think the increased emphasis on diagnosing and treating meibomian gland dysfunction (MGD) is well deserved; numerous vendors offer competitive devices to assist in this area, which gives practitioners options. Since MGD is the main cause of DED, in most cases, the need to effectively treat MGD is paramount to a successful outcome. Understanding the science behind MGD and how treatments can improve patient signs and symptoms is a critical component of managing these patients.

VD: We’re seeing a shift in the diagnostic and treatment paradigm — DED can no longer be ignored or treated with only one prescription medication and OTC tears. MGD is taking center stage when treating DED patients.

SH: One of the main reasons I enjoy being in this space is because it continues to evolve. We are seeing [the] development of new pharmacologic targets, which impact inflammation, nerve stimulation, and even inhibit pain receptors. We have a growing number of diagnostics and in-office treatment options, fitting just about every budget.

CK: There is more focus and understanding about blepharitis and Demodex blepharitis and how this effects our patients’ DED. Once we have identified the problem, it allows us to make better clinical decisions as to what is the most appropriate treatment for our patients. If we are thinking the patient has evaporative dry eye and treating the MGD only, but ignoring the concomitant blepharitis and Demodex, we aren’t really getting to the root of the problem.

OM: WHAT DO YOU THINK WILL CHANGE ABOUT DED MANAGEMENT AND TREATMENT IN THE NEAR FUTURE?

GC: Hopefully, we will take advantage of the pipeline with more pharmaceuticals to treat DED. I would like to see more patients being treated, or referred, for comprehensive DED evaluations and treatment.

VD: Increased awareness of the disease process and our understanding of the pathophysiology of DED. I am also excited about the new pipeline therapies [hopefully] coming to help our patients.

CK: There are a few new pharmaceuticals coming to the DED/OSD space that I am excited about. Number one is a drug for improved treatment of Demodex, which has been found to effectively resolve Demodex blepharitis, and has been well-tolerated with no serious treatment-related adverse events.

OM: THE TERMS “OSD” AND “DED” ARE SOMETIMES USED INTERCHANGEABLY. DOES THIS CAUSE ANY CONFUSION OR MISCOMMUNICATION AMONG EYE CARE PROFESSIONALS AND/OR PATIENTS?

GC: OSD is a term that incorporates DED, allergic eye disease, recurrent corneal erosion, and other corneal/conjunctival diagnoses. Patients don’t use either of these terms, and they only know or understand what the doctor has shared with them. As far as professionals, these terms are interchangeable and most ECPs don’t differentiate between them, in my opinion. One issue I see is that too many ECPs don’t necessarily recognize and/or treat DED. Many don’t perform diagnostic testing nor have the technology to address MGD. So, I don’t think that there is confusion as to the terminology, rather an unintended ignorance of what can be done to manage our dry eye patients.

VD: Yes, I reserve OSD as a broad term that includes DED and not vice versa. I have been trying to teach my residents and interns the proper acronyms to not create more confusion within our profession.

SH: I think of dry eye disease as a subset of the broader phrase “ocular surface disease.” I generally use OSD because it encompasses more. We can talk about the impact of the neurosensory system, the health of the limbus, and the role of the lids as they pertain to the etiologies of a patient’s problem, rather than it just being about “dryness.” It’s actually much more than dryness.

CK: This is a great question, and I am guilty of this myself. I think it does cause some confusion. While we as practitioners know that DED in true essence is OSD, OSD is a more all-encompassing term. Very rarely is someone suffering from only DED with no other concomitant problems, such as MGD. Patients recognize the term DED though, and it is much easier for them to grasp rather than introducing a whole new term, along with all the treatments. Still, I try to discuss what I am seeing with the patient, so they have a better understanding and treatment adherence in the long run. OM