Prepping patients for success on therapy for their CDE

Chronic dry eye is underdiagnosed and undertreated, but careful observation, good listening skills, and proven treatment approaches can help patients achieve better vision.

Take-home message: Chronic dry eye is underdiagnosed and undertreated, but careful observation, good listening skills, and proven treatment approaches can help patients achieve better vision.


By Nancy Groves; Reviewed by Renee Bovelle, MD

Glenn Dale, MD‒ Chronic dry eye is underdiagnosed and undertreated. With the incidence rising, ophthalmologists have a duty to help their patients attain the best possible vision. Achieving this doesn’t have to be complicated or time-consuming, however, according to Renee Bovelle, MD, an ophthalmologist in private practice in Glenn Dale, MD.

In the first encounter, Dr. Bovelle asks new patients to fill out the Ocular Surface Disease Index. “I like that particular tool because it is FDA-approved and I am able to glance at it and see if they’re symptomatic,” she said.

If they are, then the possibility of a diagnosis of chronic dry eye is already on her radar.

From there, a few quick questions as the exam begins can yield more clues: how are your eyes feeling, do they get red or itchy by the end of the day, do people say your eyes look tired, do you wear contact lenses. The answers often confirm early suspicions of dry eye, although they also could suggest a different underlying cause, Dr. Bovelle said.

After instilling fluorescein, she performs an exam, checking tear break-up time (TBUT), assessing the tear meniscus, and looking for superficial punctate keratitis (SPK). IF TBUT is decreased or SPK is present, a diagnosis of dry eye is all but certain without having to spend time on additional testing. Other clues are irregular mires on topography or other presurgical diagnostic tests.

Dr. Bovelle also uses the time when patients’ eyes are dilating to educate them about dry eye. While they wait, patients watch a brief video that covers symptoms and terminology. After seeing this, patients often recognize their symptoms and are more amenable to treatment.

When Dr. Bovelle has reached a diagnosis, she prefers to use the term dysfunctional tear syndrome with her patients. If they complain of frequent tearing and watery eyes, being told that their eyes are “dry” is confusing and may ultimately affect treatment adherence.

Since all forms of chronic dry eye have an inflammatory component even if it is not expressed clinically, cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan) is a mainstay of Dr. Bovelle’s management of these cases.

She explained that it is often difficult for patients to take time off from work or make copayments, so they postpone medical visits and rely on home treatment such as over-the-counter artificial tears. Since they are still symptomatic when they come to her office, her responsibility is to offer them something more effective, such as cyclosporine.



To increase compliance, Dr. Bovelle informs patients that they may temporarily experience stinging. If patients already have pain as well as significant inflammation, she prescribes a mild steroid or nonsteroidal anti-inflammatory drug to be used concurrently for the first month.

“Usually after that month, they are able to use the Restasis alone and they are not having problems with stinging anymore,” she said.

Dr. Bovelle finds it helpful to explain the diagnosis and treatment in terms that patients can readily understand. For example, she may describe what she sees in the eye as similar to rug burn. When patients imagine what a rug burn looks like on their skin, the image helps them visualize the damage to their eyes and grasp how the treatment can relieve inflammation. This is especially important in patients who have recurrent erosion due to SPK, Dr. Bovelle said, noting that patients who make this connection tend to be the most compliant.

And with pre-surgical patients, informing them that treating their dry eye will improve the outcomes of a procedure such as cataract surgery is an effective incentive. Irregular mires on topography can lead to errors in IOL calculation.

The next step in management of chronic dry eye or dysfunctional tear syndrome is follow-up. “I have patients come back 4 to 6 weeks after prescribing Restasis because I want them to understand that this is a true disease. I’m treating them medically, and I want to see how they are progressing on the treatment,” Dr. Bovelle said.

She may suggest punctal plugs in addition to the cyclosporine, especially in patients with aqueous deficiency dry eye. Dr. Bovelle tells patients that this is similar to the function of a household drain that slows the emptying of water from a sink.

Blepharitis is often associated with chronic dry eye, Dr. Bovelle said, and, if present, must be treated concurrently. Oral agents such as high-quality fish oil or flaxseed oil supplements also can be beneficial for all chronic dry eye cases.

Dr. Bovelle also encourages patients to adopt a routine to increase compliance. For instance, it might make sense to place the cyclosporine near a toothbrush so that using drops in the morning and at night becomes attached to a daily activity. People who use preservative-free artificial tears several times during the day could keep a package on their desk at work or near a computer at home.

Once patients have noticed improvement, it’s not uncommon for them to ask how long treatment should continue. While the answer varies, Dr. Bovelle encourages patients to keep using cyclosporine or other forms of treatment just as they would continue taking medication for chronic conditions such as high blood pressure.


Renee Bovelle, MD


Dr. Bovelle is a speaker for Allergan.

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