Given the plethora of over-the-counter and prescription approaches available for dry eye, patient and clinician agreement on the appropriate regimen is key to treatment success. Still, coming to that agreement can be difficult.
Five steps and the criteria for success, as seen through the eyes of patients and their physicians, follow:
As a physician, you need to educate the patient and teach him or her the correlation between his or her symptoms and the disease. Once a patient understands that his or her symptoms are caused by problems with the ocular surface, convincing the patient to use the appropriate treatment is much easier.
Further confounding patient-clinician agreement upon treatment is the conundrum occurring with a mismatch in clinical signs and subjective symptoms.
Although this situation does not occur too often, it certainly isn't uncommon and it is often due to a physician missing a hint during an examination.
Examination of the eyelids is required to assess potential meibomian gland dysfunction and blepharitis, for example. Furthermore, lissamine green staining should be performed in conjunction with fluorescein staining to capture conjunctival staining in addition to keratitis.
Assessing tear break-up time also is important, because that also is a clue to the stability and quality of the patient's tear film. Beyond that, the Ocular Surface Disease Index or other patient symptoms surveys also are useful in assessing patient symptoms, especially in catching early stages of dry eye.
One of the major problems with the management of ocular surface disease is the lack of a standardized approach. Recommendations put forth in recent years demonstrate an attempt to standardize our approach to both diagnosing and monitoring ocular surface disease.2
In addition, compliance often is not good, so if you are suggesting more aggressive treatment and patients do not comply with everything you suggest, they are getting more treatment than they would if you suggested a less aggressive course.
Three primary situations exist that can lead to patient-physician disagreement regarding disease severity:
Research presented at the 2009 annual meeting of the Association for Research in Vision and Ophthalmology demonstrated that the primary clinician-rated goals in treating patients with moderate to severe dry eye were maintenance and protection of the ocular surface as well as lubrication and hydration of the ocular surface. But certainly we need to tend to patients' goals in treatment as well, because these are integrally tied to patient compliance.3
For patients who complain about visual blur or visual tasking difficulty, it may be best to recommend an ocular lubricant demonstrating visual function benefit.4
For patients with more severe disease that may not respond to ocular lubricant treatment alone, prescription cyclosporine 0.05% ophthalmic emulsion (Restasis, Allergan) may be added to the treatment regimen.