Managing Dry Eye: The Need for a Short-Term Treatment (Part 2)

Whitney Hauser: Hi. I’m Dr. Whitney Hauser with Dry Eye Coach Podcast. And today I am joined by Dr. Walt Whitley. Dr. Whitley is the director of Optometric Services at Virginia Eye Consultants. And he also oversees the Dry Eye Center there with some of his colleagues. So, welcome to our program today, Walt. How are you?

Walt Whitley: I’m doing excellent. How are you, Whitney?

Whitney Hauser: I’m doing great. I’m doing great. We’re going to be talking today about educating patients about treating their dry eye disease and including a feature called flares. I’m going to kind of dive into some questions and then we’re going to get some of your perspective on how you talk to your patients about this particular aspect of dry eye disease. To kind of kick us off, why is there a need for a short-term treatment for dry eye? I mean, we have a lot of chronic therapies out there. Why do you think there’s a need for a short-term treatment for dry eye disease?

Walt Whitley: That’s a great question, Whitney. And when it comes to the need, it’s because patients are suffering. You just mentioned the word chronic. We’ve always heard about a chronic inflammatory condition that gets worse over time. However, patients, they’re suffering. What we need to do is have treatments that are available that can help provide them rapid relief. You mentioned dry eye flares. With the flares, when is this going to occur? Oftentimes patients don’t know. How often does it occur? They don’t know either. But they know it does happen. Unfortunately, some patients feel that it’s pretty, pretty common. They don’t realize that it’s actually dry eye or maybe associated with dry eye. We’re all familiar with the various symptoms with dry eye, the sandiness, burning that patients may have. We know the [1:58] is inflammation as well that leads to that chronic vicious cycle that we’ve talked about. But when it comes to the flares…

Whitney Hauser: You know…

Walt Whitley: Go ahead.

Whitney Hauser: No. You hit on a great point, Walt, and that’s, they don’t know when it’s going to happen. We don’t know when it’s going to happen. But the education component of at least talking to them about it. The fact that they’re already, probably, experiencing it and now kind of putting a name on it. If they’re not already experiencing, what might happen is really important because, by the time it’s happening, it’s hard to get into our offices, sometimes. Especially with what we’re seeing right now with COVID-19, you can’t just jump into your optometrist’s office at the drop of a hat. It takes some time. The education, I think, probably is more important than ever.

Walt Whitley: Oh, definitely. The sandiness, the grittiness, that’s what we always think of.

Whitney Hauser: Right.

Walt Whitley: But what matters to patients is looking at the quality of vision. Patients, they do experience blur, and you and I have talked about this before, that blur or fluctuations in vision is a sign of dry eye disease. If patients are suffering from that, they definitely want treatment for that. I mean, there’s numerous reasons why there’s a need for this. You mentioned chronic, once again. Chronic means long-term therapy. But when we look at compliance, yes, we can tell a patient what to do, do they do it? Yes or no. Short-term is going to be much easier than long-term management because we know the data shows that over time, patients are going to be, not necessarily compliant, but adherent and that’s what we want when it comes to our patients; them owning their condition, owning their disease state and their treatment. When we look at the adherence data, within a year, about 60% of patients may have discontinued their therapy.

Whitney Hauser: Right.

Walt Whitley: We need to get, we need shorter therapy to get in, get out, address their concerns, and take the next steps.

Whitney Hauser: What do you think maybe an ideal short-term therapy might be?

Walt Whitley: Well, something that many of us have been doing for many, many years. We have great options when it comes to dry eye therapy. We know that with the various treatment options we’re getting quicker improvement within symptomatology as well as signs in as early as two weeks and as early as a month, depending on which data you’re looking at. But we’ve been utilizing steroids for induction therapy when we first started having therapeutic treatment options for dry eye disease. One of the best ways that I like to, when I’m lecturing about this, is talking about the acute versus chronic dry eye. When we use corticosteroids and anti-inflammatories, we know we can address the inflammation right away. Of course, if you’re going to prescribe a steroid, we always want to check the pressure before we prescribe it. We also want to take a look at the nerve to make sure that they do have a healthy nerve. But I always check it before and check it when they come back, whatever you feel comfortable, whether it’s one week, two weeks, maybe even longer. Many of us, we’ve been doing that and then utilizing maybe punctal occlusion afterwards once we address the inflammatory component. Or, others, then after we address the acute inflammation, then we may go into more of the chronic therapies to help stabilize the tears.

Whitney Hauser: Yeah. You kind of hit on some really great points there about the differences between short-term and long-term therapy. I think, so far to date, for dry eye we’ve had a lot of advances in long-term chronic therapies. But, for me, I think, as I see patients come into the office, I think really what tends to trigger their visit, their event, is a short-term exacerbation or a flare. I mean, I do have people that return chronically for three months, six months follow-ups who are really committed to their care, in terms of dry eye. But then, I would say the majority of my patients, their trigger point for coming in is, uh oh. Something happened. I think, really, across medicine, for most of us, that’s why you come in. Something changed in how you feel, see or appear. I think you’re right. We’ve had great opportunities in chronic care for the last many years but seeing something that would be available for short-term therapy for these patients who, again, are coming because of those exacerbations.

Walt Whitley: It goes back to when we’re asking the patients the questions. How long has this been going on? If they say years, then we definitely have to set realistic expectations. Hey, we’re going to do our best, we’re going to add therapies, we’re going to, but we may not fix it in a week, a month. It may take a lot longer for us to address their condition. Setting realistic expectations for our patients. But if a patient comes in, you ask them, how long has this been going on? Oh, it started like a week or two ago. Then, as long as we rule out any infectious process, then we’re thinking more inflammatory in nature, and how can we address that for this patient.

Whitney Hauser: Yeah. Regarding dry eye flares, why are these so challenging to treat? Or what are the challenges that you think we face?

Walt Whitley: Well, it goes back to, many times, patient’s think it’s normal for them. They don’t realize it’s an issue and so they just let it go untreated. That’s where the progression comes in within the dry eye disease. Many patients have tried, they’ll go to the drugstore and get one of the various artificial tears. We know that when it comes to dryness, if we look at the TFOS DEWS II, inflammation does play a role. Homeostasis of the tears. Hyperosmolarity. Neurosensory abnormalities. Patient symptoms. Yes, we need to treat it with an anti-inflammatory. But even though we keep saying anti-inflammatory, we do have to remember there is the root cause which is the meibomian gland dysfunction which often has to be treated concurrently to get, to address patient signs and symptoms. Both short-term and long-term.

Whitney Hauser: Right. Right. Absolutely. Evaluating comprehensively for all the different elements, all that multifactorial nature that we know that goes along with dry eyes, is always important to getting to the root or root causes of what’s going on. As you’re kind of talking about the challenges, the challenges definitely are, patients tend to attribute, I think anyway, their short-term exacerbation or flares to something they did. I spent too much time on the computer. I was on an airplane. I was under a ceiling fan. There’s all these reasons why they’ve identified a trigger. Then, like you said, they tend to want to self-medicate for that by using OTC products, which may or may not alleviate the problems. Being able to kind of pro-actively talk to patients who may be at risk for having this happen and say, you know, this is something you might want to come to us for. It’s sort of a great opportunity for the practice as well.

Walt Whitley: Yeah. Well, the other difficulty there is, many patients, I mean, they don’t realize, once again, that this is a flare. They don’t come in.

Whitney Hauser: Exactly.

Walt Whitley: Then, by the time they do come in, they just want quick relief. Yes, we have other options, but patients been suffering. They want quick relief and so we need treatments that can address that.

Whitney Hauser: Right. What have you found? Are there certain times of the year, are there certain situations that your patients are particularly saying, I’m experiencing this? This is what’s happening to me. I’m having a flare, or they’re describing a flare.

Walt Whitley: I had a patient yesterday that I’ve been seeing for a while. Any of my dry eye patients I see two to three times a year, just to monitor their tear film, osmolarity, inflammation. And just their symptomatology. But what she says is, you know, this happens to me every January. She goes, right now I’m doing fine on the course of therapy that you’re doing, but whenever we put, we use steroids in January, that always seems to help. During the winter months is going to be definitely one aspect with the cold. Allergy season, whether it’s the spring, whether it’s the tree pollen or in the fall where it’s the weeds, you can get it during the summer due to grasses. The allergy we know is an inflammatory component that needs to be addressed as well. Then, environmental factors that can trigger that. The air conditioning when they’re in the car during the summer and it’s blowing in their face. Or if they’re on the computer all day long. We’ve all had that patient that says, hey, I can’t work. I can’t concentrate. I go to work but my eyes are just bugging me because they’re so dry I can’t keep them open. That can happen several times per year. Some studies may show that it can be anywhere between four to six times per year that this can occur.

Whitney Hauser: You raise an interesting point about your patient, about noticing the sort of seasonality of it and what tends to alleviate that for her. I have sort of a tale of two patients myself. I have one patient, and I’ve seen both of these ladies for many years. One of them says winter is the worst time, winter’s terrible for me. I almost could definitely buy into that. You have increased heat in your home, decreased humidity, a lot of wind whipping around. Things like that. On the other side of the story I have one patient who says it’s summer. It’s always summer. It’s always when the air conditioning comes on, ceiling fans, air conditioning in the car, it drives me crazy. The thing that I think is unique about flares is there’s a certain degree of, perhaps, predictability about it. But then there’s the other thing about each individual patient is going to be subject to an increase in symptoms at different intervals. I think, like you said, that four to six times a year deal. I mean, we need to kind of be open minded to who is affected at what seasons, because it’s not always going to be the same group at the same time, if that makes sense.

Walt Whitney: Uh huh. Well, there’s another flare that does occur that isn’t necessarily seasonal. It’s whenever that patient wants to come in for surgery. That’s another time, you asked earlier when the need for short-term treatment.

Whitney Hauser: Right.

Walt Whitley: We need to get that surface smooth.

Whitney Hauser: Right.

Walt Whitley: The better the ocular surface is for IOL calculations is going to play a huge role within outcomes, it’s going to determine whether or not a patient’s going to be a candidate for any of the presbyopic IOL technologies, or a toric IOL. We need that stable K measurement, stable biometry, to make sure that we can give our patients the best refractive outcomes afterwards

Whitney Hauser: Absolutely. I mean, you and I both practice at surgical practices so those outcomes are kind of front of mind as patients are coming to our clinic. But equally our colleagues in primary care settings, they’re equally wanting that great outcome, right? Because where does that patient wind up going back to? It’s going back to their optometrist and everybody in the equation wants that successful lens selection and that great vision afterwards. Everyone wants a happy patient, for sure. The question, I guess, is you touched on this earlier, but I want to dive a little bit deeper. We know that the majority of patients discontinue prescriptions for dry eye medications in that first three months. You and I have been champions for continued management of chronic dry eye disease and trying to talk to our colleagues and our individual patients about it, but why do you think that struggle is happening for patients across the board?

Walt Whitley: Well, I mean, there’s several different reasons for that, whether it’s, first, I mean, just the chronic nature. If you have an acute problem, if it hurts, people are going to be more compliant. They’re going to utilize the medications that are given to them. But, once we get stabilized, if it’s not bothering them, patients may not use it. They’re like, hey. We’ve all had that patient that says, hey, my eye is still dry so I just don’t use those drops anymore, that prescription that you gave me. We know that some drops work better for some patients than others, or there may be some adverse events for some medications. It doesn’t matter what type of medication it is. I mean, if there’s an adverse event or side effect some patients may stop it whether it’s stinging or burning. But then also, cost. That’s a reality is for the patient. A short-term, talking to a patient to say, hey, you’re having a dry eye flare, we’re going to prescribe this, this drop for you. We’re going to get in and get out and we’re going to manage you that way, versus saying, hey, we’re going to put you on some other therapy that’s going to be chronic that we’re going to keep you on. How often do we get that question? How long am I going to be on my drops? When you give them forever, then they’re like what?? But if you tell them, hey, it’s short-term, we just need to use this, then they’re like, oh, okay, well, then it makes more sense to them.

Whitney Hauser: Right. Right. I mean, we live in the US. Everyone wants a fast solution to every problem, for sure. I imagine this is not unique to dry eye disease, the drop off in chronic medication. I would imagine if you look across many systemic disease processes, and ophthalmic ones as well, we see a decline in compliance with chronic medications. I know we struggle with compliance in glaucoma medication. I don’t imagine it’s unique to dry eye, but I do think some of the barriers that you listed are probably some that definitely contribute.

Walt Whitley: Gosh! You just mentioned glaucoma. I mean, glaucoma, they don’t feel glaucoma. We’re telling them to do a treatment. They feel the dry eye and we’re still having the issues with it. But that’s where it comes back to one of the things that you and I often talk about, is going to be the education at every opportunity. Whether it’s the technician re-emphasizing the importance of their condition, whether we’re doing, this is your disease, you have dry eye disease. This is how we’re going to manage it. This is what you need to do for it. And this is how we’re going to give you the best possible vision.

Whitney Hauser: Well, and you kind of hit on my final question which is, what’s the best way to educate patients about flares? I mean, you kind of mentioned drawing in staff members into the equation. Because we do want to create a compliant environment for them. Do you have any pearls or takeaways in educating patients about this?

Walt Whitley: Well, when the patients are suffering and coming to us, it’s easy. Because they’re already coming to us for a problem. And so, just letting them know that dry eye is, inflammation does play a role. Yes, we did mention there’s going to be a meibomian gland component. But from the TFOS DEWS II, 80%of dry eye, you have to treat both. That means you still need an anti-inflammatory. We need to get in with a medication that can treat the acute, active inflammation. We need to address the symptoms. I mean, that’s what patients are suffering from.

Whitney Hauser: Right.

Walt Whitley: They want something, a therapeutic treatment, that’s going to give them quick relief but then also improve the signs. That’s what we care about as doctors. We often see the patients that, they feel fine, but you look at their surface and it looks like a mine field. We say, hey, we know you’re feeling good, but this is what I’m seeing. It looks like coarse sandpaper. We need to improve your vision. You’re mentioning that you’re having the fluctuations or blurred vision, this is what we need to do to give you the best vision.

Whitney Hauser: Yeah.

Walt Whitley: I mean, that’s a sense of what I go over with the patients.

Whitney Hauser: For me is, I’m kind of looking forward. I’m thinking I want to really educate my chronic patients who are not having a problem. I think that’s really going to be where I want to focus a lot of my flare education on the people that are not actively having the problem. Because I want them to know I’m a resource to them. Because it’s inevitable, almost, that it happens in people that have that chronic inflammatory condition. We’re going to see that uptick in symptomatology, and I want them to know to circle back and come to my office. With dry eye disease patients, they tend to have a higher turn rate than some of our other disease processes and they bounce from practitioner to practitioner. I think some of that I predict to be driven a little bit by these acute exacerbations because they’re like, okay, why, you know, I saw Dr. Smith and I got started on this therapy and then I had this uptick in symptoms. Well, maybe I don’t need to go back to Dr. Smith. Maybe I need to try Dr. Jones. What I often tell my patients about changes that they experience, and really flare can be one of these, is that it’s like we work a puzzle together in terms of dry eye and we may find all the puzzle pieces go together and we get a completed puzzle, and then three months, six months, a year later, it’s like someone shook the puzzle and the pieces are ajar and they’re not in the right locations anymore. Really, that’s almost like what happens with a flare. We’ve got to go back in and rework that puzzle. I want those chronic patients to know this is an expected event and then what course of action to take afterwards.

Walt Whitley: I definitely agree. The education part when I tell the patient, I’m going to see you back in, let’s say, six months or they’re controlled at the time, but I’ve been following them for a couple years if not longer already. That’s why I always, when they come back, I’m doing one of those symptom questionnaires, which I utilize the SPEED, and then I’m utilizing either osmolarity or InflammaDry just to let them know, hey, we want to make sure that this is addressed, not short-term, but long-term as well. If you have a flare, what we can do about it. That’s why I’m bringing you back.

Whitney Hauser: Right.

Walt Whitley: If they have dry eye, many patients they get it and they’ll come back every single time.

Whitney Hauser: Exactly. Exactly. Well, that was a great discussion, Walt. I really appreciate your time today. I definitely brought, I’m going to be bringing home some pearls from our discussion. I thank you for your time.

Walt Whitley: Well, thank you.

Whitney Hauser: I’d like to thank our audience for joining us as well. Thanks for joining Dry Eye Coach Podcast. We’ll be bringing more to Eye Tube soon.

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Managing Dry Eye: The Need for a Short-Term Treatment (Part 2)