How three-step approach eases consult with new chronic dry eye patients

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To make the most of the limited time for seeing patients, it helps to structure visits for dry eye disease following a plan that addresses diagnosis, testing, education, and treatment, but also taps technology to improve efficiency and help patients find reliable information.

Dr.Stonecipher

By Nancy Groves; Reviewed by Karl Stonecipher, MD

Greensboro, NC- If at least 20% of the patients who walk into the typical ophthalmology practice have dry eye disease, then taking them through diagnosis, education, and treatment could consume a substantial part of the day. Nevertheless, it is essential to find an approach that will be beneficial for the patient but not overwhelm the doctor’s schedule, according to Karl G. Stonecipher, MD.

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At his clinic in Greensboro, NC, Dr. Stonecipher applies a three-step process of identifying patients with dry eye disease, showing them objective data, then educating them and outlining a treatment regimen. This approach takes advantage of new technology, such as mobile apps, and also overcomes the problem of limited chair time by shifting much of the educational responsibility to the patient. By referring patients to websites known to have reliable information, the doctor can devote more time to tasks that can only be done in the office.

“The smartest thing that can help the average patient is to get them educated about their disease,” Dr. Stonecipher said. “The typical physician doesn’t have the time to do this with their patient load and time constraints, so you have to structure your visits so that the patient walks out with a plan, their questions are answered, and they feel that the doctor cares.”

Identify, assess

The first step is to identify the patient. While many whose disease is chronic or severe will have already been to several other doctors and tried multiple over-the-counter products, others will arrive with a list of complaints suggesting dry eye but not a formal diagnosis. Still, others may present for a routine exam then suspect they have dry eye after reading literature in the waiting room or learn their diagnosis only when going over test results with the doctor.

The Ocular Surface Disease Index (OSDI) questionnaire is the gold standard for assessing dry eye disease, but Dr. Stonecipher also uses a new instrument, the single-item University of North Carolina Dry Eye Management Scale (UNC DEMS), to evaluate his patients. A recent study (Cornea, vol. 33, No. 11, November 2014) demonstrated that it was a valid and reliable questionnaire. The UNC DEMS can be obtained through that article and used as a single-question subjective test.

If a patient’s score on either test suggests dry eye disease, Dr. Stonecipher then uses objective data to confirm the diagnosis and help explain it to the patient. He performs lissamine green staining and then has the patient look in a mirror to see how the staining pattern has highlighted the driest areas of the eye. The other staining option is fluorescein, which can be recorded by the physician after review with the slit lamp exam.

“If fluorescein is the stain of choice, I will additionally record tear break-up time, but my preference is to use lissamine green and allow the patient to see the results,” Dr. Stonecipher said.

Educate, implement treatment plan

The third step is to continue educating the patient and implement a treatment plan. One of his sources of guidance is the recommendations released in 2006 by the International Task Force Delphi Panel on Dry Eye (revised a year later by the International Dry Eye Workshop), which outline a stepwise treatment based on disease severity levels. 

At level 2, for instance, Dr. Stonecipher will usually prescribe a corticosteroid, cyclosporine, or both to reduce inflammation before considering a further step, such as punctal plugs.

While guidelines and preferred practice patterns are useful, treatment recommendations must also be guided by the patient’s presentation and information about their environment, lifestyle, hobbies, and habits. “It also has to be reasonable,” Dr. Stonecipher said. “If you send the patient out the door with an astronomically challenging array of things to do, they’re not going to do it. We all know that compliance is the number one issue. Patients need direction, discipline, and a way of narrowing their options. Having specific steps to follow helps achieve this goal.”

But even after receiving an explanation of dry eye disease and their test results, patients often have many questions, usually arising from Internet searches. Dr. Stonecipher said he usually addresses a few questions at the end of a visit, but he also refers patients to carefully vetted websites where they can learn more about dry eye disease and participate in discussion forums.

Making patient accountable for education

The first visit ends with asking the patient to schedule a follow-up in 2 months. At that visit, Dr. Stonecipher has the patient retake the OSDI or UNC DEMS and repeats staining or other tests. By having a patient answer a questionnaire via an app on his phone, Dr. Stonecipher can demonstrate through an improved score that a patient has made progress, which may encourage continued compliance with treatment recommendations. If progress has not been achieved, then the treatment options are redirected and the patient is brought up to speed on the new regiment.

“By having the accountable for their education and by having a subjective and objective way to follow the successes or failure, dry eye disease can become easier to manage with less chair time,” Dr. Stonecipher said.

Patient information resources:

www.dryeye.com

www.mydryeyes.com

https://www.nei.nih.gov/health/dryeye/dryeye

www.sjogrens.org

Karl G. Stonecipher, MD

P: 336-282-5000

E: stonenc@aol.com

Disclosures: Dr. Stonecipher is a consultant or advisor, lecturer, speaker, and researcher for Alcon and Allergan; consultant or advisor, lecturer, and researcher for Nidek, Presbia, and Refocus Group; consultant and lecturer for B+L, Laser ACE, and STAAR Surgical; an investor in Alphaeon; and an employee of TLC Laser Eye Centers.