Marguerite McDonald, MD: Tracy, a little change of subject here. Do you make specific recommendations to your patients on artificial tears, preservative-free, lipid-based?
Tracy Swartz, OD, MS, FAAO: I do. I will take a look at what their lids look like, what the cornea looks like, what the tear film is doing, look at topography, take a look at the Inflammatory. But I think it’s important, first of all, sometimes you have to start with the artificial tears because if a patient comes to you, and it always amazes me when this happens, but they come to you with this long list of complaints, and I say,“OK, what are you doing?” and they respond, “Nothing." In that situation, because you have to do the prior authorization for so many of these medications now, you have to do a trial of artificial tears. In those instances, I will tell them, “I need you to get this tear.” I don’t say go use artificial tears. I say “I want you to use a specific one.” I do that based on the different types of ingredients that a lot of the over-the-counter tears now have.
There are demulcents and then there’s emollients. The demulcents are sort of the older stuff a little bit, and they provide lubrication in the form of a mucoprotective film. They alleviate discomfort, they allow the product to stay along the ocular surface. The most common one is the carboxymethylcellulose, or CMC. Depending on the concentration of the CMC, that determines the viscosity. That lowers the concentration, like maybe 0.2, that can be used during the day. But something that’s approximately 1%, is going to be a little thicker, the patient is going to complain that you making them use that during the day is going to cause blurry vision, it’s going to cause debris or maybe sticky stuff on the eyelids, and they’re going to want to use that at night.
Emollients, because I do tend to lean towards everyone has evaporative tear disorders, I’m kind of a fan of the emollients. I do like those that have the fats or the oils to increase the lipid layer thickness of the tear film. Stabilize the tear film so it stabilizes their vision and reduces evaporation, allows them to read a little bit longer or to use the computer a little bit longer. Those typically use a combination of mineral oil, light mineral oil, or the white petrolatum. I like to supplement the lipid layer if there is a component of lid disease, which I kind of feel like a lot of times there is.
A few quick notes. TheraTears is a hypo-osmolar drop, which if you have someone with really high osmolarity, it may or may not be beneficial, and FreshKote is the opposite, that’s a hyperosmolar drop, which I really like to use that over-the-counter prep if I have EDMD [Emery-Dreifuss muscular dystrophy] or maybe arecurrent corneal erosion. I really like sodium hyaluronate with the CMC. That’s the newest product from Refresh. I really like that to increase lubrication. I find that it acts like a thicker, viscous drop, but it doesn’t blur the vision and it doesn’t leave that sticky stuff all over the patient’s eyelids. I’ve had a lot of success with that.
For those that have moderate to severe keratitis, contact lens wearers, those that might take glaucoma medications, I will use single-use vials to reduce the amount of preservatives, because that’s going to increase the hyperosmolarity and I don’t want to do that.
Typically what I do is I’ll tell a patient I want you to use this drop, and I will either give them a sample or I’ll give them a coupon with a picture of the drop that I want them to use, and I will write the directions on the coupon and I tell them maybe this is cheaper at Kroger than it is as Walmart or whatever. I try to give them as best directions to really be specific and I’ll start with the artificial tear. I do use artificial tears, and then I have them back in a month because then I’m looking to see what progress we made in that month. I want to know did they use the tears 4 times a day, because so many times they don’t, and that tells me how adherent that patient is going to be, which is going to drive my treatment plan. Maybe I’m going to be more likely to do things in the office if I told them to do something 4 times a day and they did it once a week. I want to know how quickly their symptoms resolved, and I want to know how they felt things are going, and I want them to make sure that they know that I’m listening to their complaints. I’ll revisit the main complaint, and then at that 1-month visit, I’ll continue to talk about what we think we need to do for a treatment plan.