When DED hits home
OM asked five prominent ophthalmologists: Stephanie Becker, MD; Mary Davidian, MD; Marguerite McDonald, MD; Laura Periman, MD; and Jonathan Solomon, MD, to discuss their own problems with dry eye disease and how they discuss their situation with their dry eye patients.
The conversation that ensues about dry eye disease is yet more proof that physicians are also flesh and blood: We get sick, we seek medical attention, we adhere to medical instruction. Because we were smart enough to choose ophthalmology, our knowledge base is key to our health and happiness — a base we choose to share with our patients. Hence dry eye, while it may impact us, does not define us. Please enjoy, and share your feedback with us!
— Marguerite McDonald, MD, FACS
OM: Do you discuss your dry eye problem with your patients?
Dr. Solomon: Yes, often. I find a personal touch allows for better discourse. It opens the door to a greater level of understanding. There’s stigma attached to certain medical conditions; dry eye has its share, and a lot of it is surrounded by a fair amount of misunderstanding.
I don’t have the traditional dry eye situation, but I treat myself proactively. I am candid about my management and my willingness to tailor treatment options to an individual. It is of value for me to share my approach to my eye care. I describe my situation and my symptoms.
OM: When you speak about your situation, do you find patients become more adherent?
Dr. Solomon: Whenever you describe a personal scenario, it brings the conversation down to a personal level, to become less formal. It’s between friends as opposed to someone lecturing to a subordinate. That’s important.
OM: Dr. McDonald, your thoughts?
Dr. McDonald: I don’t tell absolutely every patient, otherwise I’d be seeing three people a day. But if they have moderate to severe dry eye and they say something like, ‘Gosh, all this takes a lot of time,’ or, ‘I really hate using the gel. It gets on my pillow case.’ I’ll say, ‘You know, I have OSD too. I use ointment every night. I hate it too. But that’s the only way to feel really good in the morning.’ I will do that especially if I sense anger and noncompliance. We all wish we were 18 again and could jump into bed after brushing our teeth. Ointment at night is a mainstay if you have moderate to severe dry eye. So, I’ll talk about it if I think it will lift the person’s spirits: ‘Gosh, my doctor does this. I guess I can find the time to squirt a little lubricant in my eyes.’ Patients don’t want to be just a number. Any little thing that helps you bond really goes a long way.
I also think some people still feel dry eye is an imaginary disease like restless leg syndrome. Some doctors roll their eyes about that one because it’s the diagnosis of exclusion. ‘Oh, I saw her the other day. She complains and what’s the matter with her?’ These patients are used to doctors who blow them off. When they find one who doesn’t, who empathizes with them, they are so grateful.
Dr. Davidian: I agree. I think it helps them to know that we’re real people too. We’re not immune from any of this. We may have suffered from the same symptoms and have gotten relief. When I encourage patients to start Restasis I hear, ‘Well, is that really safe? I hate taking any drug. How do I know what side effects that’s going to have?’ I tell them, ‘I also infrequently take medications, but I have felt very comfortable taking this. There is no evidence that it gets systemically absorbed and enters your bloodstream. I feel it’s extremely safe. It has really helped me.’ When they hear that, I think it helps to encourage them to consider starting it.
I also hear, ‘Well, I just don’t have the time to do it every day. I’m too busy.’ I say, ‘Don’t think I’m any less busy than you. If you want relief, you need to be compliant. I take my Restasis, and I put it in a Dixie cup or even next to my toothbrush in the bathroom. Then, I have a visual cue because I know I’m going to brush my teeth every morning and every evening, and I’m going to see my Restasis vials there, and it’s going to trigger me to remember that I need to use it. And you need to do things like that to try and be compliant.’ I’ve made the left turn now.
I’ve also had LipiFlow treatment, and I bring that up. If I think a patient is an appropriate candidate, I tell them what my experience was like, that it was painless, that I was able to drive myself home at the end of the day in the dark after seeing 50 patients and was totally comfortable.
I also say there isn’t one magic bullet that will solve their problem overnight and make them feel better. Dry eye is, in fact, multifactorial. I think this reinforces the point that we doctors are real people who deal with all the same issues and the stresses.
I say, ‘I also have to work at it and I do multiple things on a daily basis, and you have to kind of learn how to condition yourself to accomplish certain things on a daily basis. When you do, you will feel comfortable.
Dr. Becker: I discuss my dry eye with my patients all the time. I let them know that I can totally relate to the dry eye issues they are having, and their concerns, since I have the same ones. I say I have the same symptoms and complaints, and the same issues with not wanting to ‘take medicine’ or ‘be a patient.’ I tell them that I have tried every single thing on myself that I would be using with them, so I ‘get it.’
Dr. Periman: I educate my patients that chronic DED (CDED) is a multi-factorial disease that deserves a multi-disciplinary approach. Particularly with more severe disease, the list of medications and home care they are required to do can be overwhelming. If patients understand the reason for each intervention, compliance and success are enhanced. Each patient is educated with a combination of technician time, physician time as well as written materials explaining each modality. Each patient leaves with an efficient one page checklist that organizes the treatments, dosing frequencies and home care.
This helps ensure accurate relay of instructions to the patient, saves on call-back questions and also saves the physician a significant amount of chair time. In our clinical experience, we have found that when the patient brings back the form in follow-up, there is a high likelihood the instructions were carefully followed and the patient has experienced improvement. The physician will give out gold stars for good compliance as a simple, fun and rewarding way to keep the patient engaged in their own care.
A minority of patients are frustrated and struggle to cope with their chronic disease. We have found this subset can benefit from objective measures, sympathetic or empathetic statements and words of hope and comfort.
For example: 1) Show the patient their diagnostic information, confirming they have a real disease; 2) I occasionally share that I also am a CDED patient and I understand their suffering; 3) I emphasize that new treatments are coming and I will not give up doing everything I can to help them. When the patient feels seen and heard, the body posture changes to a more relaxed form, they are more receptive to treatments and the therapeutic relationship flourishes. Treating the whole patient is very rewarding to me.
It’s worth the comfort. When you give that to the patient, they relax because their body posture changes and it becomes a therapeutic relationship; I love that.
OM: Please tell us how you keep adherent.
Dr. McDonald: If I stop treating myself, I instantly do worse. My eyes get red, and I start to have burning. So, my motivation is 100% staying functional, having good vision, looking normal, having nice white eyes.
Dr. Becker: I am very motivated to keep up my regimen, otherwise my eyes are miserable. I have a whole bunch of tricks to remind me to take my drops. One is the cell phone alarm.
I also leave a bottle of tears taped to my computer monitor so I remember to take them when I am working. I also leave a bottle of tears in the extra cup holder of my car to remind me to take them when I am driving, since the car’s heat and air conditioning makes my eyes feel dry.
Dr. Solomon: I never had issues with blurry vision, a primary symptom. I never had intermittent blurry vision as my primary symptom. I have perfect vision. I’ve never had surgery. I’m pre-presbyopic. That’s why it never dawned on me to think I had issues. I thought everybody woke up with a little bit of light sensitivity when they walked into the bathroom and their eyes were always a little irritated. So it’s serendipitous that I found out about my own ocular surface. Late in my training, I put a lubricating drop in my eyes and I realized that there was a degree of relief throughout the day. It was such an odd experience realizing that I had less irritation at the back of my head.
I thought, I may actually have dry eye issues. I was very aggressive. Practicing on the West Coast, everything is about quality of life and doing things to improve it. It is interesting for patients to realize that the reason we’re going about this is to try and minimize the impact on daily routine. I use oral supplements as well, and if my eyes feel irritated that’s my way of reminding myself that I need to be on my omega-3s, that I’ve got to be on my joint supplements. I get my drops in. It very much is regimented. You have to be willing to kick into that routine, which is very tough for somebody who is starting to understand the importance of medications and vitamins and so on, which is tough for Generation X.
There is a gender difference here too. I think men just don’t do it well and are compliant with some of these treatments. Women tend to do better about adherence. I use it as my canary in the coal mine. When my eyes aren’t feeling well whether right or wrong, it’s usually an indication that holistically I need to be a little bit better about improving my general health.
Dr. McDonald: I have a theory as to why men are a little less compliant. When you’re a female and your mother takes you to an Ob/Gyn when you start to menstruate, she basically says you will be going every year. The Ob/Gyn is sort of like your GP when you’re a teenager and otherwise healthy. You’re used to going to doctors and being told what to do. Men are not. The first medicine they’re put on is dry eye medication and they’re like, ‘What?” This messes with their idea of who they are. They have an idea of who they are. ‘I don’t take medicine. I’m strong. I’m healthy,’ and this really upsets them.
Dr. Solomon: I’m glad you said it and not me.
OM: How do you keep motivated? Do you share your tips with patients?
Dr. Davidian: For me, I tried to deny that I did have a serious dry eye problem, and what finally pushed me over the edge was about a little over a year ago I started having difficulty wearing my soft contact lenses because I was so dry. I thought, ‘I can’t do surgery comfortably with glasses on.’
I started taking Restasis, tears and omega-3s and the whole gamut of treatment, and it did make a difference. As Marguerite said, when I fall behind because I go away or something happens and I get crazy busy, I feel the difference.
I’m aware of the difference, which is proof that the treatment plan, when you do it in regimented fashion, helps make a difference. And that’s what I tell my patients: I’m a real-life person and I face all those same stresses, but I can tell you I notice the difference when I fall behind and so I use these little tricks to give me visual cues.
OM: That’s so normal to be in denial. If, and when you tell your patients that, how do they react?
Dr. Davidian: They kind of nod. They’re just processing it and, ‘Uh-huh, I fought back for a long time too, it wasn’t a big deal or it wasn’t as bad as I thought it was. But now I’m really having a hard time coping. And oh, look, she has that same experience.’
OM: Dr. Periman?
Dr. Periman: I do a lot to take care of my body. Mother Nature increases the amount of maintenance work and self-care we must do as we age. I’m OK with that. The maintenance work looks different at every age and in every chronic condition. Patient compliance and success seem to improve when you can explain and link the treatment plans to an important self-care habit, like flossing and brushing your teeth.
Dr. Becker: My eyes have been really dry forever. I was absolutely in denial. And really angry about it. Even in college and medical school, I was miserable and couldn’t tolerate contact lens wear. I try to do all the right things like working out, eating healthy and have always been healthy, so this is like my Achilles’ heel.
OM: How long do you give a product to work before you switch to something else?
Dr. McDonald: If it’s an artificial tear, you’ll know within the first one or two applications if you like it or not. Whereas with something like Restasis you have to hang in for months. It really is dependent on the medicine or the therapy.
OM: So, you’re looking at this from a professional vantage point, not necessarily from the confines of the FDA approval.
Dr. McDonald: Yes. Usually FDA guidelines actually bear some resemblance to the truth, but I will go off-label if I think it’s going to help somebody and I think it’s safe, for sure.
Dr. Becker: I usually give any therapeutic regimen about six weeks — but patients have a ‘fall out’ rate faster than that when they are frustrated. So, I usually see patients after two weeks of any therapeutic change, other than starting Restasis, which I give six weeks. It takes a lot of conversation to explain to patients that these aren’t magic fixes, so they need some time. Discussing pathophysiology of dry eye is really helpful.
OM: Do you treat yourself?
Dr. McDonald: No, a colleague does.
Dr. Solomon: I have a colleague look at my eyes on a regular basis and just confirm my symptoms or lack thereof and to make sure that I’m in a place where I need to be.
Dr. Davidian: My partner looks at my eyes.
Dr. Davidian: To make sense of what we’re experiencing and what’s actually happening.
Dr. Periman: It would be disingenuous of us to not do it that way. OM
Marguerite McDonald, MD, is a cornea-refractive surgeon, Ophthalmic Consultants of Long Island, Lynbrook, NY.; clinical professor, NYU Langone Medical Center, NY; adjunct clinical professor, Tulane University, New Orleans. E-mail her at firstname.lastname@example.org.
Stephanie Becker, MD, is in private practice at Total Eye Care in Hicksville, N.Y.
Jonathan D. Solomon, MD, is in private practice at Solomon Eye Associates in Greenbelt, Md., and is a consultant to the FDA’s Ophthalmic Device Panel.
Mary Davidian, MD, is in private practice at Highland Ophthalmology Associates, New Windsor, N.Y.
Laura M. Periman, MD, is a cornea and refractive surgery-trained ophthalmologist in Redmond, Wash. Her interests in immunopatho-physiology started as a research and development associate at Immunex Corp. in the 1990s. She can be reached at email@example.com.