Dry eye disease (DED) is one of the most common conditions eyecare providers (ECPs) encounter day in and day out. The condition is widespread, affecting nearly 16 million people in the US,1 and is likely only going to grow due to the ever-increasing screen time associated with the ubiquitous presence of smartphones, computers, tablets, and TVs in our modern lifestyle.2
In fact, dry eye has become so pervasive that it is easy for ECPs to get caught in the trap of brushing it off and falling back on the emerging refrain “everybody has dry eye” whenever a patient presents with complaints of dryness. While this statement may be true to a certain extent, just because dry eye is common, that does not mean it is an insignificant problem for many.
As part of our practice, we have a clinic entirely dedicated to dry eye and ocular surface disease. This allows us to focus exclusively on treating dry eye stemming from numerous causes and displaying an array of presentations.
This hyper-focus has also revealed several consistent patterns—one of the most critical being that many of our dry eye patients have a significant psychological component to their condition. Accordingly, we have found that to successfully treat a patient’s dry eye, we must also address these psychological aspects.
Listen carefully to the patient
When it comes to treating DED, our maxim is “listen to the patient.” We run numerous diagnostic tests on all our dry eye and ocular surface disease patients, and while these tests provide invaluable information, the most important data we receive comes directly from the patients themselves.
We all have an innate desire to be heard and understood, and this takes on paramount importance when treating patients with dry eye who are often suffering from significant, sometimes debilitating, symptoms.
When initially talking to a patient about their condition, simple, open-ended questions tend to yield the best results by giving them ample opportunity to discuss their personal experience with dry eye.
While dry eye questionnaires and surveys can be helpful, often simply asking “How do your eyes feel?” opens the door to a more personal dialogue about their individual experience.
Not only does this make the patient feel more heard, but this often unearths critical information. For instance, if a patient responds that their eyes feel worst in the morning, but improve as the day progresses, this likely means that they are experiencing issues with nocturnal exposure.
We would then check for lagophthalmos, or a poor lid seal, and treat appropriately with either a nighttime ointment or gel. If they describe their symptoms as more itchy than dry, that suggests there may be an allergic component.
We have all heard time and time again that dry eye is a multifactorial condition with numerous underlying causes, but simply put, if you listen to your patients they will often lead you directly to the source of their problem.3 Additionally, this will ensure that you directly address the patient’s specific concerns.
For example, if a patient comes in because they can no longer wear their contact lenses due to dryness, but you never specifically discuss contact lens wear, no matter how good your treatment plan is, they may leave feeling frustrated or disappointed because their primary concern was not addressed.
It takes more than one visit to treat dry eye
This naturally segues into another important point regarding dry eye treatment: it requires time. One of the biggest mistakes ECPs make when treating dry eye is that they try to address everything in a single visit, usually during a patient’s annual comprehensive exam.
Here is a common scenario: the doctor has refracted the patient, fit a new pair of contact lenses, performed a careful slit lamp evaluation of the anterior segment, thoroughly examined the retina with fundoscopy and BIO, and now they are ready to wrap up the exam because they already have a patient waiting in the next room. But right before they exit, the patient remarks, “Doctor, my eyes always feel dry. What can I do?”
In this case, knowing that they are pressed for time, many doctors will quickly reach for a sample bottle of artificial tears, tell the patient to use them several times a day, and send them on their way. This response is understandable given the many pressures and time constraints faced by busy ECPs every day, but what actually just occurred in this exchange?
First, this encounter downplayed the importance of the problem. By lumping their dry eye in with everything else already covered in the exam and giving a bottle of artificial tears, it suggests that the drops are all that is needed and that the issue requires no further evaluation.
Second, if the brief interaction did not allow for the proper dialogue and discussion, as we just mentioned, the patient may not feel entirely heard or satisfied with the response.
The final, and perhaps most problematic outcome, is that the patient may perceive that there is nothing else that can be done for their condition.
They are left thinking, “Surely if there were other options available my doctor would have mentioned them, right?” Even though we often feel like we are helping our patients out by addressing their problems right then and there, we may actually be doing them a disservice.
A better response to this scenario is to explain that dry eye can have many different causes, and there are many excellent treatment options available, but it would be best to bring them back. That way we can have more time to thoroughly discuss and evaluate their condition and create a personalized treatment plan that addresses their specific needs.
In this case, the patient’s concerns are addressed, and the seriousness of their dry eye is validated, as opposed to being rushed or brushed aside. We will often give them a sample of artificial tears to use until their return visit, but also explain that artificial tears are more like a band-aid than a therapeutic treatment.
This way we still offer them a form of relief in that moment, but we also make them aware that there is much more that can be done to help alleviate their dry eye.
Address the psychological aspects of dry eye
Dry eye is a common problem all ECPs encounter day after day in clinical practice. However, while DED is common, it can be extremely disruptive in the lives of many.
The complex nature of dry eye and ocular surface disease and the way it impacts the quality of life of those affected creates a strong psychological component to the condition.
In our experience of managing these patients as part of our dedicated dry eye clinic, we have found that treating the psychological aspects of DED is often just as important as addressing the physical manifestations. However, to do so successfully requires time and an ability to address the patient from a holistic perspective.
Therefore, we need to take the time to listen carefully to our patient’s individual experiences with dry eye, thoroughly examine and diagnose their specific issues, provide education, and then create an individualized treatment plan.
Conclusion
Dry eye can be a challenging and disruptive disease for our patients. However, we can provide a source of hope by delivering the appropriate care grounded not only in the proper recognition, diagnosis, education, and treatment of the condition, but also in empathy and sincere concern for each patient’s physical, mental, and emotional well-being.
Arthur B. Epstein OD, FAAO, FABCO, FABCLA, DPNAP passed away far too soon on Tuesday, September 27, 2022. He was a mentor, a friend, and a pillar of the eyecare community, and he will be deeply missed. Read a tribute to Art from our CEO here.
References
- Farrand KF, Fridman M, Stillman IO, Schaumberg DA. Prevalence of Diagnosed Dry Eye Disease in the United States Among Adults Aged 18 Years and Older. Am J Ophthalmol 2017;182:90-8.
- Al-Mohtaseb Z, Schachter S, Shen Lee B, Garlich J, Trattler W. The Relationship Between Dry Eye Disease and Digital Screen Use. Clin Ophthalmol. 2021;15:3811-3820. Published 2021 Sep 10. doi:10.2147/OPTH.S321591
- Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017;15(3):276-283. doi:10.1016/j.jtos.2017.05.008
