Manage dry eye by focusing more on patient needs

December 1, 2009

Patient-centered practice management consists of making improvements in the business and operational aspects of your optometry practice to enhance the patient experience.

For the patient with chronic dry eye, this means adopting a team approach. He or she should understand fully the causes and contributing factors to dry eye, learn to use new treatment technologies appropriately, be compliant with treatment plans, and be monitored closely so treatments can be modified as needed.

Chronic dry eye can result from hormonal changes (more common in females), aging, common systemic and topical medications, vision correction surgery, dry environments, sun exposure, smoking or exposure to second-hand smoke, certain autoimmune diseases, contact lens wear, and blepharitis.

Initial reduction of dry eye symptoms involves making patients aware of exacerbating factors (e.g., drinking caffeine, smoking, or sitting near forced air ventilation) and encouraging them to increase water intake.

I recommend artificial tears a specific number of times a day, or more if patients feel they need it. I recommend a specific brand to help me accurately measure success of therapy. Additionally, I educate patients about not using artificial tears that contain benzalkonium chloride. For some, nighttime ointments work well as an adjunct to drops. Omega-3 fatty acids taken daily also seem helpful.

For patients with blepharitis contributing to the dry eye, either topical azithromycin or oral doxycycline can be a useful addition to good lid hygiene. In the past, if these initial measures did not work, I would prescribe therapeutics to reduce inflammation, including topical corticosteroids and cyclosporine A, and use punctal occlusion.

However, I now utilize an intermediate option between artificial tears and anti-inflammatories, especially among patients who use artificial tears more than four times a day. I use a hydroxypropyl cellulose ophthalmic insert (Lacrisert, Aton Pharma) that is a sterile, preservative-free, once-daily sustained release prescription device that helps retain moisture, stabilize the tear film, and lubricate the eye.

The insert, which is approved by the FDA for use in patients with moderate-to-severe dry eye, contains 5 mg of hydroxypropyl cellulose. It is self-administered into the inferior cul de sac of the eye, where it slowly dissolves over the course of a day and acts to thicken the precorneal tear film.

The FDA approved the device more than 20 years ago. Because dry eye awareness was lower and practitioners were less systematic in their treatment algorithms, the medication did not realize widespread use and was in scarce supply until 2006, when Aton Pharma acquired the rights to distribute it and expanded its availability.

Taking a closer look

I had avoided prescribing the insert in the past because I felt that patients must surely feel it in the eye. However, after I read more about the science behind it and how it could be used as adjunct to artificial tears, I decided to take a closer look and obtained samples that I used on myself and staff members. To my surprise, the insert was extremely comfortable and unnoticeable.

Clinical studies have demonstrated the insert's ability to improve dry eye symptoms by increasing tear-film breakup time and decreasing rose bengal staining.1-6 A recent chart review study of patients who used the ophthalmic insert showed their median length of therapy to be more than 5 years, with nearly 65% using the inserts for more than 2 years.7 Long-term use is simplified because the insert can be used concurrently with other dry eye treatments.

Results from a large (n = 520) multi-center, open label patient registry study of the ophthalmic insert were presented at the Association for Research in Vision and Ophthalmology annual meeting.8 Treatment over 4 weeks resulted in significant reductions in mean severity of dry eye symptoms and significant improvements in mean ocular surface disease index scores by more than 21%, over and above any improvement patients may have gained from previous dry eye therapies administered before the study.

Treatment with the ophthalmic insert also resulted in significant improvement in quality-of-life measures, including reduction of mean occurrence of discomfort in heated areas and significant improvements when performing housework. The most commonly reported adverse event leading to discontinuation was blurred vision, observed in 8.7% of patients.

Trying it out

I prescribe the ophthalmic insert for patients who have used artificial tears for at least a month and who report using them more than four times per day. After I explain how the medication works, I will place it in the patient's eye and ask them a minute later if they feel the insert; nine out of 10 say no. I tell the patient to leave it in the eye, and then I have an assistant call them to follow up the next day. If the response is positive, I will have the patient back to the office to be trained on how to insert the device.

This training is essential. A flexible plastic applicator is supplied with the product to help the patient administer it. The learning curve is usually much quicker than an initial contact lens instruction and, once proficient, patients can insert the device very quickly. Regardless of age, many find it easier than using artificial tears several times a day. The technician who teaches the patient how to place the insert should then call to check on progress after a few days and plan a follow-up appointment within a month.

Most patients who were trained properly respond well and many reduce their use of artificial tears. I particularly recall one patient, a woman with epithelial basement membrane dystrophy with recurrent corneal erosions. She started using the insert every other day and observed that her vision seemed a bit gummy or blurred on the day of use, but her eyes were comfortable the next day. I recommended that she insert it at bedtime, and then take it out the next morning, an approach that works for the few patients who experience blurriness.

The ophthalmic insert is a unique product that can be used long term, and, in conjunction with other dry eye treatments, can provide relief to chronic dry eye patients. Incorporating it or other new modes of therapy will inevitably lead to successful management of chronic dry eye patients, which will be certain to boost your practice.

Mile Brujic, OD, is a partner in a multi-location group practice in Bowling Green and Lima, OH. He lectures nationally on contemporary topics in eye care. Dr. Brujic has received honoraria from Aton Pharma Inc. for consulting services. Readers may contact him at brujic@prodigy.net
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References

1. Hovding G, Aasved H. Slow-release artificial tears (SRAT) in dry eye disease: Report of a preliminary clinical trial. Acta Ophthalmol. 1981;59:842–846.

2. Breslin C, Katz JI, Kaufman HE, Katz IM. Slow-Release Artificial Tears. Symposium on Ocular Therapy. 1977;10:77–83.

3. Katz JI, Kaufman HE, Breslin C, Katz I. Slow-release artificial tears and the treatment of keratitis sicca. Ophthalmol. 1978;85:787–793.

4. Lamberts D, Langston D, Chu W. A clinical study of slow-releasing artificial tears. Ophthalmol. 1978;85:794–800.

5. Werblin TP, Rheinstrom SD, Kaufman HE. The use of slow-release artificial tears in the long-term management of keratitis sicca. Ophthalmol. 1981;88:78–81.

6. Hill JC. Slow-release artificial tear inserts in the treatment of dry eyes in patients with rheumatoid arthritis. Br J of Ophthalmol. 1989;73:151–154.

7. Wander A, Koffler, B. Retrospective Case Series Study of the Hydroxypropyl Cellulose Ophthalmic Insert. Ocular Surface. 2009; vol 7, no. 3: 154–161.

8. Koffler B, Lacrisert (hydroxypropyl cellulose ophthalmic insert) Significantly Improves Symptoms of Dry Eye Syndrome and Patient Quality of Life. 2009 Annual Meeting of the Association for Research in Vision and Ophthalmology, poster 4660/D904.