Improve the main symptom to increase compliance
I saw a patient today who inspired this blog. She presented reporting dry, burning red eyes. She reported she could not read more than 15 minutes without needing to stop and was experiencing difficulty in her computer-based job. She had seen 3 eye doctors before me and was frustrated that everything she tried had not helped. What had she tried? The list was short: artificial tears.
My dry eye clinic patients typically come from 3 sources: referral from another eye doctor, referral from a current patient, and internet searches for a dry eye doctor.
Patients coming from an eye doctor usually arrive reporting some level of treatment. Previous treatments may have improved their symptoms somewhat, but typically the patients are not completely satisfied with their level of visual comfort. When asked, “What have you done for your dry eye?”, the common responses include tears and immunomodulators. Some may report using omega-3 supplements, oral doxycycline, and hot compresses with a mask. They usually indicate their doctors told them I have more treatments to help. This group is not very cranky.
Patients who found me by searching for a dry eye specialist have more to say given that their journey is less direct. They often report seeing multiple eye doctors for help with their dry eye and being told to use tears. They may be able to name them, or at best, describe the bottle, or report they used “the little vials” or the “green bottle”. They may have a history of punctual plugs, which may or may not be present. They may have tried a medication but often report it did not work. When asked how long they used it, they often say, “I used the sample and stopped.”
“Not that dry”
These patients often report being told their eyes are “not that dry” by previous doctors. This comment is typically followed by, “I do not want to go back to that doctor.” These patients are frustrated and cranky. I do not assume the previous doctor actually said that, but the fact that they perceived being told they do not have significant dry eye is important to note.
This can be discouraging when I have multiple visits like this in a single day. Having done this for
“a few” years (dare I date myself), I now see this as an opportunity rather than a headache. It is my goal to impress the patients and improve their symptoms.
The first thing I do is verbally acknowledge that I hear they are suffering and say I want to help them feel better. I like to review their symptoms by repeating what they told meand ask them, “What is your biggest problem in one word? Is it itching, redness, discomfort, pain, blur, reading, computers, tearing?”We narrow it down and focus on that symptom as the treatment goal for the visit.
Take a good history about previous treatments. Try for names, but often you must use descriptions: bottle caps, bottle sizes, vials or bottles, gel or watery, white or clear. Naming previously used tears is important for prior authorization forms. Patients often report using hot compresses, but you should ask how they use them. Patients often consider running hot water over their eyes in the shower to be a hot compress. If they use a washcloth, they may apply heat for only a few minutes.
Ask about previous surgery. Cataract surgery can increase symptomatology one level while laser-assisted in situ keratomileusis (LASIK) can increase it significantly. Even retinal surgery has sent patients to my office because it made their eyes feel worse.
I like to perform topography and aberrometry if the vision is reduced or the main complaint is vision-related. Perform biomicroscopy using sodium fluorescein and lissamine green dyes. Examine eyelids with palpation, consider eversion, and ask if their eye feels better after the numbing drop you instilled for Goldmann tonometry. Revisit symptoms to mentally link their symptoms to what you see.
Develop a plan
Then, come up with a plan to improve the patient’s symptoms. Remember that one-word symptom?That is my target.
Note I said improve their symptoms. While I do examine their eyes for clinical signs of ocular surface disease (OSD), they may not be impressed with a reduction in meibomian gland inspissation or lissamine green stain. Those patients not referred by their eye care provider are in my office because someone else did not meet their expectations.
I firmly believe that if you improve the patient’s main symptom, they will return and better adhere to your treatment plan long term.
I am more aggressive than patients’ previous eye care providers. At minimum, my treatment plans typically include supplemental omega-3 fatty acids, scheduled use of optical coherence tomography (OCT) and hot compresses for evaporative disease.
I am quick to prescribe immunomodulators—even if patients have tried them in the past—but only for a short time. Immunomodulators are great for long-term control with little drug interactions or contraindications. Significant inflammation may require a stronger treatment to yield subjective improvement.
A new topical steroid was recently FDA approved for short-term use during a “flare.” So, eye care providers may feel more comfortable using topical steroids for this purpose. Eyesuvis (loteprednol ophthalmic suspension 0.25%; Kala Pharmaceuticals) is an ocular corticosteroid approved for up to 2 weeks for the treatment of dry eye disease. I regularly use topical steroids for short-term treatments, often starting at 4 times per day and tapering 1 drop each week over 4 weeks.
End of visit
At the end of the visit, I review the treatment plan, which I give to the patient in writing. I return to the discussion of the primary symptom and explain how the treatment plan addresses their primary complaint. I see patients back in a month after starting treatment, and I will discuss what I am expecting at that visit.
By addressing patients’ main complaint, using more aggressive treatment, and discussing what to expect, patients feel more comfortable and are more likely to return as scheduled.