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Why an effective campaign must be readily available for physicians to implement
Compliance rates increase significantly when patients understand what their medication does, how to take it properly, and what will happen if they do not take it.
By Marguerite B. McDonald, MD, Special to Ophthalmology Times
Chronic dry eye disease, also known as keratoconjunctivitis sicca, is a condition involving abnormalities and deficiencies in the tear film, which may be initiated by a variety of causes.
The incidence of chronic dry eye has been estimated by many authors; it is thought to affect at least 5 million people over the age of 50 in the United States,1,2 but I believe that this is a low estimate.
At least 75% of the patients who come to my cornea referral practice have dry eye disease. In the past, dry eye was a difficult disease to quantify and measure, and treatment options were somewhat limited. However, diagnostic and treatment modalities have improved dramatically , making it a dynamic and profitable practice focus.
The number of patients with dry eye who experience serious complications, such as corneal scarring and significant vision loss, is small. However, the number of patients whose cataract or laser vision correction surgery will be negatively affected, or that are miserable due to fluctuating vision or red and irritated eyes is incredibly high. Untreated ocular surface disease makes pre-surgical refractive measurements less accurate and affects surgical outcomes; thus, we have always had a focus on ocular surface disease in our practice.
Several years ago we decided to make our practice a center of excellence for dry eye disease. We invested in several diagnostic and treatment tools (including tear osmolarity testing, TearLab; LipiView Ocular Surface Interferometer, TearScience; LipiFlow Thermal Pulsation System, TearScience; and Oculus Keratograph 5M, Oculus Inc.).
In addition, we invested in patient education software (LUMA and ECHO, Eyemaginations). These animated patient education programs make complex topics understandable to the patient. We often play a loop with a variety of topics in the waiting room as well as in the dilation area, making sure that information on dry eye is always included.
If patients have any trouble understanding a topic, we have iPads available so that the technicians and coordinators can show them specific segments again. Video segments are also available for placement on one’s website; they can be e-mailed to patients, allowing them to watch as many times as they want or share with family members.
We physicians often think that we have explained a pathology or treatment very clearly, and inevitably, there will be patients that did not understand or ask questions. Frequently, new patients will present who have taking a drug, such as brimonidine tartrate (Alphagan, Allergan) for 10 years, and when I ask them if their glaucoma is controlled, they will respond that they did not know they even had glaucoma.
The dry eye educational materials take concepts that are difficult to understand in the abstract, and use images and animation to explain aqueous deficient versus evaporative dry eye and the roles of the lid margins and the meibomian glands. They employ easy-to-understand language where each word is selected so that it is meaningful without being overly technical. This saves a great deal of time for our physicians and technical staff. When we sit down to talk with patients about their pathology, they already understand the anatomy of the eye, the disease pathology, and some of the treatment options.
Treatment compliance rates increase significantly when people understand what their medication does, how to take it properly, and what will happen if they do not take it. The treatment regimen for dry eye disease includes medications and cleansing techniques that take time, technique, and money.
Many patients are on a fixed income and are spending hundreds of dollars per month on co-payments. Unless they understand why they need a particular medication, they are not going to spend their money. Even with great insurance coverage, dry eye medications such as cyclosporine (Restasis, Allergan) are often high-ticket items. Patients must understand why the drug is prescribed as well as the need to take it consistently and long term in order to feel relief.
In another example, patients with blepharitis are often instructed to perform lid scrubs twice a day. Patients that have not been educated properly will come for a follow-up visit and report that they have been doing the scrubs, but their lids will reveal oily scurf and inspissated meibomian glands. When asked to demonstrate, although their intentions are good, they are missing the mark in most cases. We often take for granted that people know where their lid margin is and how to scrub it, but in truth, they often do not; education is key in the treatment of this form of ocular surface disease.
An effective educational campaign must be easy and readily available for the physicians and technicians to implement. Whether the technicians have iPads available at the nurses’ station, in each exam lane, or wear a uniform with big pockets to carry them around, they must have quick access without searching or they will not work it into their day.
Printed educational brochures are also very useful, if the physician or technician sits down and walks patients though the material. However, we have found the higher-tech options to be a great option that lends our practice an image of advanced technology with a high level of concern for patients. When patients understand the pathology of the disease, and then they see their tear osmolarity score decreasing and their lipid layer improving, they are more satisfied and their compliance rates are higher.
Patient understanding and compliance also tie in to patient satisfaction, loyalty, and referral rates. The population is aging and incidence of dry eye disease is increasing. If we can get patients with dry eye to be loyal and grateful to us by being the only ophthalmologist that explained their diagnosis to them and then treated it, the positive effect on the entire practice, even the surgical side, is impressive.
1. Schaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye syndrome among U.S. women. Am J Ophthalmol. 2003;136:2318-2326.
2. Schaumberg DA, Dana R, Buring JE, Sullivan DA. Prevalence of dry eye disease among U.S men. Archiv Ophthalmol. 2009;127:763-768.
Marguerite B. McDonald, MD, is clinical professor of ophthalmology at NYU, adjunct clinical professor of ophthalmology at Tulane University, and in private practice with the Ophthalmic Consultants of Long Island, Lynbrook, NY. She did not indicate any proprietary interest in the subject matter.