Although by no means a new problem, anecdotal evidence suggests eye examinations where patients mention or present with dry eye symptoms are on the increase.
‘Twenty years ago, when we first started in practice, it wasn’t on our radar at all, says Lynne Fernandes, optometrist and director of Lynne Fernandes Optometrists, a group of three practices in the Bristol area.
‘Today, patients attend and tell us “I’ve got really dry eyes” or “my eyes are really watery.” Our lifestyles are changing, with longer periods of time at computers, more time spent in air-conditioned spaces and a greater awareness of the health of our eyes.’
The additional awareness of dry eye has posed something of a problem for optometrists and practices – there simply isn’t enough time as part of a standard eye test to conduct a thorough assessment, let alone work out a long-term plan for management of the condition.
Dedicated dry eye clinics benefit everyone, says Fernandes. ‘The patients are delighted because we’re making a big difference to their lives. The optometrists are happy because they’re developing their clinical skills, rather than a cycle of refractions and financially, the practitioners are actually being paid for clinical time appropriately rather than having to cross subsidise with product sales.’
The practice’s clinic has been running for eight years. Fernandes says the structure for the clinic is based around patient questionnaires recommended in the Dry Eye Workshop (DEWS II) report from the Tear Film and Ocular Surface Society (TFOS) – for pre and post patient assessment. Apart from Lissamine green to properly assess the front surface of the eye, no specific diagnostic equipment was added for the clinics, although a Medmont topographer has proven to be a valuable piece of kit for before and after tear film assessment.
Fernandes says: ‘One of the most important things is that the patient knows that they have told us their symptoms, that we’ve thoroughly assessed their eyelids and tear film, and then provided a patient management plan, so they know what we’re going to do moving forward and understand we’re treating the cause and not the symptoms – which would just be a case of prescribing eye drops.’
The practices tend to block book mornings or afternoons for dry eye clinic appointments. ‘It’s much easier to put a dry eye “hat” on for a morning or afternoon to focus completely on the condition,’ says Fernandes.
Patients attending the clinics tend to be over the age of 40 but there is also are number of younger contact lens wearers that want to get to the bottom of their dryness problems. Although many believe that the number of younger patients with dry eye is growing, Fernandes says she hasn’t seen any trends that would back that up, although there are a handful of younger patients presenting with Blepharitis.
Planning
Management plans are tailored for the severity and nature of each patient’s symptoms. ‘It might well be that we think that the eyes need to be syringed, have punctum plugs, have gland expression or even have BlephEx treatment.’
Reassessment appointments see the patients answer questionnaires once again to gauge progress, but the aim is for the least intervention possible, both for visits to the practice and for patient self-treatment at home. Patients are seen frequently at the start of a treatment programme, but this is gradually reduced as the symptoms are managed and become tolerable.
There are seven optometrists that manage the clinics across the three practices and Fernandes says the whole team gets involved with how they’re run. ‘All the optometrists get together frequently to discuss the latest evidence, review cases, update protocols. It is also a chance for our optometrists to present pieces of research they’re excited about,’ says Fernandes. What’s most important is that our patients trust us as professionals to work within our competency.
It’s this peer training aspect that’s the most important part of running a successful dry eye clinic, says Fernandes. ‘They’ve all had training in punctum plugs, syringing, gland expression and blepharitis treatment and attend conferences such as the BCLA to ensure they’re all up to speed with clinical developments.’
Successful dry eye management makes a tangible difference to people’s lives. ‘One of our optometrists, Sarah Douglas, recently saw a patient who had had watery eyes for many years and it had reached the point where she couldn’t go out anymore because her eyes were constantly watering,’ says Fernandes.
‘Simply through being in our dry eye clinic and us addressing her issues with some basic treatment, she can now go out again, and she can now wear makeup again. She’s delighted and absolutely thrilled to bits. It has made a huge impact on her life, which is marvellous.’