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As ocular surface disease (OSD) becomes increasingly prevalent among the general population, it also becomes less predictable. In the digital age, OSD is becoming more widespread across all genders and ages.1 Given the widespread prevalence of OSD and its plethora of symptoms, patients with OSD are inevitably going to be sitting in your exam lanes weekly, perhaps daily.
Eye care practitioners have a duty to diagnose, educate, and treat patients experiencing OSD. But in order to treat them we must find them first, and then we must find ways to keep patients coming back and complying with their treatment regimens. This article explains some of the ways I try to do these things in my own practice. I hope some of these pointers will be helpful for other eye care practitioners with similar patient populations.
HOW DO I START?
OSD is present in our established patients, but how do we find it? I have identified an overabundance of OSD patients in my practice using a limited set of tools: a simple question, a short survey, various dyes, the slit lamp, and compassion.
Finding OSD patients can start with a single question: “Does your vision fluctuate?”
TO THE POINT
When optometrists manage OSD, conversation is key. Engage your patients with a detailed questionnaire to determine the presence and severity of OSD, and explain to them in detail how their disease is manifesting.
This is the most common symptom of OSD. To the trained professional, fluctuating vision, a sandy or gritty sensation in the eyes, and habitual use of over-the-counter artificial tears may seem like glaring signs of OSD. However, these symptoms are obvious flags to us only because of our extensive training. Asking this single question can help you easily begin to uncover OSD in your patients and demonstrate to them that you are listening to and addressing their concerns.
WHEN THE ANSWER IS YES
When the answer to that first critical question is yes, I ask patients to fill out a questionnaire that consists of 12 simple yes-or-no questions (see Questionnaire for Identifying Ocular Surface Disease below). Although I strongly believe that other validated surveys may provide more definitive scores that can serve as benchmarks, in my initial encounters I target simplicity. At this point in the process, my simple survey allows me to make a sound judgment regarding whether or not OSD should be discussed further with the patient.
From here, finding OSD is a textbook process. I proceed by looking at staining patterns and examining meibomian gland structure and function.
DON’T STOP THERE
Patient education is crucial to foster compliance with treatment and follow-up regimens. The goal in educating patients about OSD is to make them feel engaged and encourage them to act diligently with their treatment regimens. This leads to symptomatic relief of their OSD and minimizes risk of dropout from treatment.
It is easiest for patients to accept the presence of OSD if you help them to visualize their sick eyes. A “selfie” of the eye can be golden. For example, anterior segment photographs of staining patterns can show patients their “dry sores.” Or a LipiScan (TearScience) high-definition image can show patients their own structural meibomian gland dysfunction (MGD). These means of visualization make it personal and easy for patients to see the disruptions and anatomic problems in their own eyes. They also give patients a starting point and a frame of reference to compare against at their follow-up appointments.
BREAKING IT DOWN
We know that OSD can stem from more than one mechanism. Consider having this discussion with your patient to explain the complex situation on the ocular surface:
“Tears are made up of two major components: water and oil. You need both of these to maintain clear and comfortable vision. The watery layer is the substance, while the oil holds the tears onto the eye, preventing them from evaporating or running down your face.”
In a patient with MGD, you might explain:
“What happens when you leave a cup of water on your kitchen counter? It evaporates. That is why we need the oil. The oil comes from glands along the border of your lids that are activated by a blink. Every time you blink, oil comes out of these glands, and your eyelid sweeps the oil across the eye. On average, humans are supposed to blink 10,000 times each day, but, due to increased time in front of computer screens and smartphones, many of us are actually blinking only about 4,000 times per day. That’s less than half of how often we’re supposed to be blinking. Additionally, many of those blinks are incomplete, meaning the oil glands are not activated.2
Our oil glands follow a use-it-or-lose-it policy. After a period of decreased use, they start to deteriorate and die. After we lose them, they do not grow back. That’s why it is so important that we do something about it before the condition worsens.
I am seeing signs that there is not enough oil on your eyes. You either don’t have enough glands making oil, or the oil is getting thick and stagnant. When it doesn’t move often enough, the oil turns into a buttery substance, which does not flow freely through your glands. Here’s what your meibomian glands look like.” (At this point, you should show your patient Figure 1.)
In an aqueous-deficient patient, the conversation might go more like this:
“We need enough liquid in our tears to coat the front surface of our eye. When we don’t have enough liquid, even with blinking, some areas of the front of the eye develop dry patches, or what I call ‘dry sores.’ Here is a picture of the front of your eye.” (At this point, you should show your patient an image of corneal staining.)
TRUST THE PROCESS
This is the process I have implemented as daily routine in my patient care. In just 6 months at my current practice, this process has uncovered a large OSD demographic, and we are in the beginning stages of developing an eye wellness center that is focused around OSD.
I find this topic especially compelling, as these symptomatic patients are affected daily. Simply listening to them sometimes provides some comfort, and working with these patients to get their inflammatory disease under control is greatly rewarding when they start feeling relief from their symptoms.
Finding and treating OSD patients has been incredibly engaging and rewarding for me. I hope it can be for you as well.
1. Moss SE, Klein R, Klein BE. Incidence of dry eye in an older population. Arch Ophthalmol. 2004;122(3):369-373.
2. Hirota M, Uozato H, Kawamorita T, et al. Effect of incomplete blinking on tear film stability. Optom Vis Sci. 2013;90(7):650-657.
Ada Noh, OD
• private practice, Optic One Family Eye Care of Cinnaminson and Bellmawr Eye Care, both in N.J.
• financial interest: none acknowledged
• 856-786-1616; firstname.lastname@example.org