Eye care professionals must take patients with dry eye seriously, spend more time to determine underlying issues and use the full range of treatments available to tailor an appropriate treatment for each patient.
These were the firm words delivered by Professor Stephanie Watson from the Save Sight Institute and Sydney Eye Hospital at an exclusive dry eye dinner for optometrists in late February.
One in five people in Australia – or 4,000,000 people – live with dry eye and 800,000 have severe dry eye. Those with moderate to severe dry eye rate the condition as being as severe as chronic angina.
Professor Watson, who is a specialist in corneal surgery at the Sydney Eye Hospital, told her audience the incidence of dry eye would continue to increase due to an ageing population.
…it’s essential to assess the patient and tailor the treatment to them – there is no magic bullet because dry eye is so complex…
“People are living longer and working more on computers in air conditioned environments which all promote evaporative dry eye. Australia’s natural climate also leads to more dry eye – hot weather leads to increased tear evaporation, as do cool dry days, and some patients find that pollution causes their dry eye to worsen.”
More Clinical Approach RequiredShe said a more clinical approach needs to be taken when prescribing treatment for dry eye.
“Dry eye is quite a big label – the condition can involve different aspects of damage – whether that be to tear production, quality of tears or tear function. She said there are many conditions that mimic dry eye. “It’s a bit like filling a shopping trolley – all the groceries on the shelf can look the same but when you look more closely, they’re not… and this is where management can go wrong”.
Within the generic dry eye label, Professor Watson said there will be many reasons for treatment. “You may find you need to manage your patient for aqueous tear deficiency or a problem with eye lid function – perhaps the person is not blinking sufficiently. Or perhaps your patient is one of the 10 per cent of the population whose eye lids do not close completely when they are asleep,” she said, adding that this syndrome is more common among the Asian population.
She cautioned that results from tear film osmolarity are often not reliable, which means it is necessary to use ancillary data in your diagnosis. “That means examining patients for clinical signs of other conditions such as conjunctivochalasis, which often goes undiagnosed, rosacea, which is a common reason for meibomian gland dysfunction or toxicity from preservatives.”
The Treatment Step Ladder
Professor Watson said just as dry eye is complex to diagnose, the condition can be difficult to treat.
“It is unlikely that you’ll find one treatment that will fit all patients– so it’s essential to assess the patient and tailor the treatment to them – there is no magic bullet because dry eye is so complex.”
She described the step ladder of treatments as beginning with lubricants for mild dry eye conditions, preservative free lubricants for moderate to severe dry eye and extending to lubricants that protect the ocular surface and lubricants with lipids. Professor Watson also described newer types of lubricants, newer modes of treatment and the role of omega 3 fatty acids.
Professor Watson said there are not many current studies that compare different types of treatments, particularly with regard to lubricants. The signs and symptoms (identified in the studies) don’t usually correlate. Professor Watson said more money is required to fund dry eye research so that the condition can be better understood and better treatments – and even cures –identified.
Patient Education Imperative
In the meantime, she said, patient education is one of the most important aspects of managing dry eye. “It’s important to spend time with patients to explain their dry eye and the treatment plan so they have a complete understanding of how they can best manage the condition. You might tell a patient to massage their eyelids but if they don’t understand how to do that, you’ll find they come back some time later and they’ve had no relief – they’ve been massaging their eyelids in all sorts of obscure ways. Or you’ll advise them to use the eye drops as needed and find they’re only using drops once a day, in which case they might just as well not use them at all.”
She said it may take an investment in time, but the benefits each patients will experience from a tailored approach to dry eye will be well worth the effort.