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Considerations for a Patient With Dry Eye Disease


Mile Brujic, OD, FAAO, shares considerations from a patient case, highlighting diagnostic tools in dry eye disease as well as the ability of the patient to use medication.

Mile Brujic, OD, FAAO:I had the good fortune to share this case with colleagues in Boston, [Massachusetts,] where we had what I would describe as a fruitful conversation and discussion around these individuals or these patients. And the first thing that came up that we always question is, is what are some of the key considerations that we need to take into account when we’re managing our dry eye patients? And one of the things that really stood out was understanding what our diagnostic protocol is in our offices. And we had practitioners who had almost fully focused dry eye clinics in the round table. And we also had clinicians who were primary care doctors that were managing this in the midst of traditional patient flow as well. So there was this…conducive discussion around the whole conversation [of] how do we actually identify these individuals? And what we also found, too, is there was a range of things that all of us were doing, from identifying and beginning treatment that day to identification and then bringing back for further, more specified testing.

What I think we all came to a consensus [about] on that evening was something had to at least be done. And there [were] 2 big takeaways, in my mind. The first thing was, we need to cognitively be listening to our patients to understand how they’re functioning at whatever they’re doing on a daily basis. And that involves 2 things, comfort and visual stability, which is one of those underlying symptoms with drive that we sometimes tend to overlook and almost always really mitigated to some type of uncorrected refractive error. The second thing that truly came up was some type of objective testing that we could easily utilize to screen these individuals. And the use of fluorescein dye came up as a high-priority item. We’re placing it on the eye, looking for things like decreased tear film breakup time, corneal staining, conjunctival staining the line of marks, and the irregularity or irregularity of that line of marks. And also looking at the meibomian glands. Now, there are ways that we can easily screen this with live transilluminators that give us a direct indication of what the structure looks like. But more importantly, functionally, what does it look like? And we can do things like either press along the little margin with our finger or use things that are much more devoted to meibomian gland evaluation, which is the meibomian gland evaluator.

What really stood out about this case was the fact that I think we sometimes take things for granted in the way that our patients actually utilize the medications that we prescribe. And we sometimes don’t even think about asking about problems or concerns with utilizing eyedrops. We just assume that everybody can use those without any type of reservation. And what this really brought out to me was, first and foremost, [that] this individual is receiving treatment 1 year after we actually saw her and identified her. And it wasn’t because of any type of malicious intent by the patient. She couldn’t use the drop, and she was embarrassed, so she didn’t want to come back for her follow-up visit. And even when she came back in for her yearly visit, she told me she was a little embarrassed to tell us about her inability to use that.

The good news is that we now have alternatives and options for these patients, and, in this instance, it was really leveraging our understanding of the trigeminal nerve pathway and how it can promote more healthy ocular tears. And although we have a commercially available pharmaceutical agent through varenicline, [which is an] FDA approved as a BID [2 times a day] dosing regimen in the nostrils of both eyes. And I would even recommend to not necessarily dose it BID like you would a traditional eyedrop, where it may be in the morning and in the evening. My recommendation would be do it in the morning and do it at some point toward the end of the day when you’re starting to feel those symptoms again. So it might not necessarily be a 8 [o’clock or] 10 [o’clock] in the evening, it might be 4 or 5, 6 o’clock in the afternoon when you start noticing those symptoms [again].

And then there were several takeaways from the roundtable. Again, whenever you get a chance to speak to colleagues in an open environment like this, you realize there are things that you could have done better. And then there are also things that the clinicians bring up that they thought. I didn’t even think about things like that, but there were several things that were brought up as takeaways. And one is I think we all came to a mutual agreement that it is important to treat these individuals early because the earlier we treat them, the more manageable the signs and the symptoms that we see [with] those patients. And the longer we wait, the more difficult it becomes to help these patients get to a state of normalcy. At times, if it’s too severe, we can never restore that level of normalcy.

The other kind of big thing that was a takeaway is understanding the compliance component to treating individuals with chronic conditions. And that’s where we really had a conducive conversation around some of the more advanced procedures that we can do in our office to help our patients with dry eye disease. So, again, this was an interesting case. And one of the more interesting things for me was that it really drew in this whole concept of lack of compliance, not necessarily because the patient was not interested in pursuing treatment, but they just couldn’t pursue the treatment because they couldn’t use eyedrops or had a very, very difficult time using eyedrops and really thinking outside of the box and thinking about ways where we could deliver treatment to these individuals in alternative ways.

Transcript is AI-generated and edited for clarity and readability.

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