Dry Eye Disease Awareness Month: Discuss Symptoms, Treatment, and Adherence With Your Patients

Elise Kramer, OD, owner and founder of the Miami Contact Lens Institute and the Western Contact Lens Institute, spoke with Optometry 360 about Dry Eye Awareness Month and gave some tips for discussing the condition with patients.

Question:

July is Dry Eye Awareness Month. What is the importance of bringing awareness to different ocular conditions?

Elise Kramer, OD:

I think dry eye is something that many people suffer with, and it’s something actually that a lot of people don’t bring up when they go see their eye doctor annually or bi-annually or whenever they decide to go. A lot of the time, maybe it’s something that they think is normal because they’re spending so much time on screens or because they’re getting older.

But I think it’s important to bring awareness to ocular surface conditions as well as in particular dry eye because it isn’t normal. Because we have so many treatments available now and ways to discover what the underlying causes are and ways to address dry eye, it’s so important for both patients and doctors to be aware of this condition and to think of it first when seeing patients.

That means that doctors need to bring it up, that doctors need to ask the right questions in order for patients to reveal how they’re feeling and to get to the bottom of it. Especially in a contact lens practice or in a surgical practice where you are kind of messing with the ocular surface, we need to optimize that. In order to be successful with contact lenses or surgical procedures, it’s so important to optimize the ocular surface.

Question:

What are your best practices for discussing dry eye disease or ocular surface disease with your patients?

Elise Kramer, OD:

One of the main things is I like to take pictures. Photos are so important, and I think the dentists have nailed this for a long time. Now that we have infrared imaging of meibomian glands with meibography, we have slit lamp cameras, we have ways of taking photos even with our smartphones in the slit lamp.

Just vital dyes as well as meibography using imagery to show our patients what we’re seeing and to explain to them why they’re feeling the way they feel. Even if they don’t have symptoms, what can happen is if we don’t proactively address what we’re seeing. Like I said, a photo is worth a thousand words.

With photos, we’re able to really illustrate how patients are doing and what we recommend, and it’s really just a slam dunk in terms of patients being more compliant with the treatments that we recommend and being proactive themselves at home and also in the office with treatments that we recommend in order to address what we’re seeing.

Question:

How do you choose the right therapy for each patient? What individualized parameters do you consider when choosing a treatment?

Elise Kramer, OD:

Obviously the main thing is to find out the underlying cause. We can only do that with ancillary testing. Again, infrared imaging, meibography, tear film breakup time, tear meniscus, InflammaDry, and different osmolarity testing, vital dyes. With all of this information, we can find out what the underlying causes of the ocular surface condition, dry eye and figure out what the best course of treatment is.

One of the things we look at is the patient’s lifestyle. What is realistic for them to do? Because, for example, if we’re recommending a microwaveable heat mask but their travel all the time and don’t have access to a microwave, or maybe they don’t have a microwave at home, we need to take into consideration the patient’s lifestyle as well as what they have access to and what’s realistic for them. If it’s a patient that’s not too hands-on, we might aim to do more treatments in the office.

If it’s a patient that wants to do more, we can give them more things to do at home. If it’s a patient that just really wants to do it all, we can do both. Also how many drops are they also already using? If, for example, they have other ocular conditions such as glaucoma or there are contact lens where we have to be careful how many drops we’re recommending per day.

Because, for example, if they’re using contact lenses, they actually have to remove their contact lens a lot of the time to use some of the medications. Or we might aim to use a nasal spray in those conditions. It’s really figuring out what type of patient we have and what the underlying cause is and using that, all the information that we have in order to find a treatment that is realistic and will work for them.

Question:

How do you encourage treatment adherence and compliance in patients? What strategies do you employ?

Elise Kramer, OD:

Frequent follow-up is something that I’ve found help. If you’re starting a treatment like XDEMVY, lotilaner, or you’re doing something that’s new for the patient, you will follow them up. When you do have that follow-up appointment, you can check compliance and say, “What are you doing? What are you using? Do you remember that I prescribed this?”

Also, making sure that they’re using the products that you recommended and not finding a cheaper product or generic product that you didn’t recommend at their local pharmacy. Follow up is the main way. But again, back to the photos, I just think to initiate compliance and to get patients on board, photos are the best way to help them realize what they have.

Again, we’ve learned a lot from dentists on this. But following up is key in order to keep compliance, especially when you have a treatment that is successful and patients do feel a difference and you can show them. If you take images before and after, for example, vital dyes, you can see the before and after starting a treatment and it’s really amazing. Or you can see the collarettes reduced after starting lotilaner, different things like that.

Question:

What is the recommended patient follow-up cadence to ensure the condition is being adequately managed to improve symptoms and quality of life?

Elise Kramer, OD:

This is case by case. Obviously for the more mild cases, you can follow them up every 8 to 12 months. If it is a more moderate case, you might do every 4 to 6 months, and if it’s a severe case, you might do 1 to 4 months. Again, if you’re starting a new therapy, you might want to check on them sooner rather than later just to make sure that they’re not having any complications or side effects.

Also to make sure that they’re using it properly and to make sure that they actually received it. If you’re starting a new therapy, even if they’re mild, you might want to see them sooner than 8 to 12 months. But that’s a general guideline. But of course it’s case by case, patient per patient. Just see what works best for your patients and also their availability. Do they live locally? Different things like that.

Question:

What misconceptions about dry eye disease should clinicians be prepared to address in their patients?

Elise Kramer, OD:

I think that a lot of patients come in saying, “Oh, I use artificial tears.” The way I look at an artificial tears, although it’s amazing and we have so many options now, I think that it’s kind of analogous to watering a plant in the desert. If you don’t treat the environment, it’s really not going to work. It will work for the 5 to 10 minutes that the drop is instilled and then the situation goes back to where it was before.

You really have to address what is going on, what is the underlying cause of inflammation, what is the underlying cause of tear film instability, and what is the underlying cause of this interrupted homeostasis. If you figure that out, then of course artificial tears are always something I recommend, but it is not a treatment to the condition. It is a way to mitigate symptoms.

It is a way to help, but it doesn’t address an underlying cause. I think that a lot of people think dryness, artificial tears. I think we need to move away from that because although as I mentioned, it is a super helpful treatment and I recommend artificial tears to almost everyone that has dry eye, I really don’t think it’s addressing the underlying cause. Without realizing what that is, without addressing that, we’re really not doing much just by having patients use artificial tears. Again, it is a great supplement to a treatment, but it is not the only treatment in any case.