Diagnosing mild dry eye and developing an effective management plan to suit each patient is often difficult. Establishing the seriousness of the issue and working with patients who oppose the use of regular eye drops, is imperative.
Mild dry eye, Hmmm, do we bother? Next patient already waiting, boss wants optical coherence tomography (OCT) done, haven’t had a coffee in three hours, still need to organise date for tonight…
Sound familiar? I think we would all agree that if a patient is reasonably happy we generally don’t go looking for problems. We are all busy at work and for some, also busy after work! So, if we choose to do nothing, is a mild dry eye patient going to cause us concerns down the track? Should our duty of care dictate that we should help these ‘happy’ patients?
In writing this article I thought it best to reflect on what I do with a mild dry eye patient. I have chosen, call it insanity, to spend considerable time and money positioning myself as a practitioner that loves dry eye. I know, what was I thinking? This patient group can be extremely difficult to diagnose at times, let alone find a management plan to make them happy. Sometimes the case history alone can take a full lunch break. So when would I decide that it is worth spending the extra clinical time to help a mild dry eye patient?
MILD VS. MILD
The short answer is, it all depends on the case history. The term ‘mild’ can mean very different things for different patients. A blokey bloke working in the mines could be seen as being ‘less of a man’ if he seeks treatment for a ‘mild’ condition. On the other hand, a prominent socialite would be expected to explore all possible treatment options for the mildest of problems. So how do we know when to invest the time?
We first need to identify if there is a mild problem. This could present itself in a conversation as follows:
Me: “Mrs Jones, are you experiencing any discomfort with your eyes?”
Px: “No, I am just here for new glasses as I broke my old ones.”
Me: “Do you experience any fluctuation in your vision?”
Px: “At work sometimes my vision goes blurry, but that is because of my dry eyes.”
Me: “So your eyes can feel dry?”
Px: “No, they just get tired as I work long hours.”
Sound familiar? This can go on and on and on! So, when it happens, I take a particular course of action to determine whether the condition warrants treatment or dismissal.
Firstly, I decide if the patient is motivated to do anything about it. There is no point discussing a management plan involving potentially many products and processes for the patient to just say, “Thanks for that but it really isn’t that bad!”. Dammit, there goes my toilet break! My plan of attack in this situation is as follows:
Me: “Okay, so your vision can fluctuate at work. This is likely to be due to your eyes drying out. Would you like me to discuss ways in which we could improve your tear film and eliminate the vision fluctuations?”
If the response is, “No, it really doesn’t bother me”, I suggest recording the discussion and moving on.
If the response is, “Yes it can be annoying, can you fix it?”, I invest time into solving the patient’s mild dry eye.
LIFESTYLE AND SUPPLEMENTS
DEWS II has made treating mild dry eye patients easy, with a list of Step 1 options to discuss with mild dry eye patients. I feel some of these are often overlooked as trivial, yet they can be beneficial for this patient demographic. Examples include:
- Discussing general hydration:
- How much water do you consume each day?
- How many caffeinated drinks do you consume per day?
- Do you consume energy drinks?
- Discussing the office environment:
- Is your office cold? Can you increase the temperature?
- Is there a vent directly above your desk? Can it be closed off ?
- Have you tried placing bowls of water on your desk?
- Purchasing a humidifier can help, could you do this?
- Discussing blink rates and work breaks:
- Do you get a break from your screens?
- What do you do during the break?
- Are you aware that you blink less while using a computer?
- Educate the patient on ‘blink breaks’ during the day
- Discuss partial blinking and its effect on vision later in the day
- Discussing the role of systemic medications:
- Do you take antihistamines, beta blockers, antidepressants, anxiolytics, isotretinoin, diuretics, antipsychotics, anti-Parkinsonian medication, estrogen, or are you undertaking chemotherapy?
- Ensure if they are a contact lens wearer that lens wettability is not a contributing factor to their symptoms, and 6. Discuss the role of essential fatty acids:
- Do you eat three to four meals of deepsea fish per week?
- Do you take fish oil tablets? If so what dose?
- If you are allergic to fish or can’t tolerate the taste, have you tried flaxseed oil and are you aware of the benefits?
- Discuss the optimum dosage and timeline to expect change. For me this is 1600mg/day of omega 3, with a timeline of three months before benefits can be expected.
The next step is to discuss the role of eyedrops. Once again, I would start the discussion with, “Would you like me to recommend some eye drops to help manage your symptoms?”. Surprisingly a lot of people don’t want to use drops. This may be due to cost, not being able to use them effectively, the ‘she’ll be right’ attitude, fear that it might make the condition worse, or that they may become dependent on the drops.
So, if you are to discuss drops, which ones?
I like to keep things simple whenever possible. I believe this helps compliance and reduces the risk of the patient becoming overwhelmed. To this end, I like to explain why I have recommended a drop, how often to use it each day, how long they need to use it for, and to return to me should the recommendations not work. It is important to let the patient know that you are happy to see them if things are not improving and that there are other options available. There is a common perception by patients that all drops are the same and if they don’t work when used once a day then they are no good.
My drop recommendations are as follows:
Aqueous supplement – multidose/ preservative free
Lipid supplement – multi-dose/preservative free/spray
For mild cases of dry eye, you can often use a multidose bottle with both elements contained in the one formulation. Unfortunately, when choosing a lipid supplement the options are significantly reduced. Because of this, don’t be afraid to use two drops. One for aqueous and a different drop for lipid supplementation. I have found the layering of drops to be very successful and if the patients understand why you are doing it, they become very compliant. In terms of dosage, I always factor in the “I’m really busy, I just didn’t have time to put the drops in!” patient response. If I think they need four drops a day, I tell them to use it six times a day. I also like to tell them how long I think they will need to use the drops for. Many patients expect them to work in a day or two which just isn’t the case.
MOTIVATION AND SUCCESS
Mild dry eye is certainly a condition that needs assessment and attention, however, the degree of treatment and intervention may very well depend on the patient’s motivation.
Jason Holland B.App.Sci (Hons) (Optom), PGOT, CASA CO runs a glaucoma and advanced dry eye clinic in Brisbane. He is the national director of optometry for the Optical Superstore Group and he served as the director and treasurer for Optometry Australia, Queensland and Northern Territory for nine years until 2017. He served on the Optometry Australia National Board for three years and currently sits on the Deakin Optometry Advisory Board.