Over the last few years, we have had a boost to our growing knowledge of dry eye disease. Like any topic with a constant influx of new and enlightening information, it’s important to remember the basics and not focus only on the new science and treatments. For me, establishing a good working relationship with my patients is key.
I find that my patients and I work better together when there is mutual respect and trust. We know that patients with dry eye are often frustrated by their condition and may have even seen providers who don’t validate their concerns. Patients need to know their doctor believes that something really is wrong, and medical care can help. It is important to explain that dry eye is a chronic, progressive disease, and even when it’s under control, patients still need to visit the doctor for maintenance therapy and/or monitoring. We want to be able to detect progression as early as possible.
As clinicians, we need to face the reality of dry eye disease as well. We can’t treat a chronic, progressive disease in one office visit or with a handful of artificial tear samples. We need to do everything we can, as early as possible, to prevent irreversible damage, including meibomian gland atrophy and corneal breakdown. We must treat dry eye aggressively and then continue a long-term partnership with patients for scheduled, continuing care. Here’s how I do it, from the initial dry eye visit to the care that helps patients stay comfortable and prevent progression for years to come.
Initial tests and therapy
Initial testing for dry eye disease helps us to not only diagnose and stage the disease, but also to establish a baseline for ongoing care. We test tear osmolarity (TearLab osmolarity test, TearLab), check for the inflammatory marker MMP-9 (InflammaDry, Quidel) and perform meibography (LipiScan, Johnson & Johnson Vision) to evaluate the meibomian glands.
If the patient’s problem is in an acute stage at the first visit, we might prescribe a topical steroid such as loteprednol to help bring down the inflammation. Other initial therapies include immunomodulators such as cyclosporine (Restasis, Allergan) or lifitegrast (Xiidra, Shire), which provide control of inflammation in the long term. Sometimes getting access to these medications can be frustrating for patients, so we have a point person in our practice to help with insurance-related issues so that patients can benefit from the excellent therapeutics we have today.
In most cases, patients with dry eye also have meibomian gland dysfunction (MGD), the underlying cause of which is obstruction of the meibomian glands. To address MGD, we often treat patients with thermal pulsation therapy (LipiFlow, Johnson & Johnson Vision), which relieves the obstruction and improves the meibum quality. The key is to restore normal function of the blocked glands. We also may use intense pulsed light (IPL) therapy (M22, Lumenis) to treat MGD and reduce telangiectasias on the eyelids, which in turn helps control inflammation. These are both out-of-pocket procedures, but we find that they can be affordable for most patients. IPL has low disposable costs, and the price of LipiFlow’s single-use activator was reduced significantly in 2019, making the procedure accessible to more people with dry eye disease. The price points for these interventions are important to me because I want to give all my patients the best care, and cost is a serious concern for patients.