Dry eye disease (DED) sufferers are estimated to be between 5% and 50% of the adult population worldwide, according to a 2020 Transparency Market Research report. With post-pandemic lifestyles increasing risk factors, such as screen-time use, it is no wonder many practices have created dry eye clinics to ensure there is specific attention given to DED patients.
Patient communication
Having the time to allow the patient to speak at length on dry eye and provide a detailed history is not always possible in general eye appointments and can leave patients feeling frustrated and unheard. However, having a dedicated clinic for the disease guarantees the extra time needed to deliver personalised treatment plans, as optometrist Gillian Bruce explains. ‘This is where dry eye clinics have the biggest opportunity,’ says Bruce, who developed the dry eye clinic at Cameron Optometry in Edinburgh.
‘There’s that cathartic moment [for the patient] when they realise that they’ve genuinely been listened to for the first time, it can be quite an emotional thing for them,’ adds Craig McArthur, optometrist and director of Peter Ivins Eye Care, who has run a dry eye clinic for 10 years. ‘I’ve honed that skill over the last 10 to 12 years, understanding how to take a holistic approach to dealing with the person and the family, rather than just the eye disease. Your communication skills have to be adapted to the severity of the dry eye. So, if it’s a patient with minor symptoms because they work on a laptop six hours a day, you’re going to deal with that slightly differently from the people that travelled 200 miles and are at the end of their tether. That “one size fits all” communication style doesn’t work.’
McArthur has learnt over time that it is important to begin the communication process with dialogue beforehand through pre-screening questions sent ahead of the appointment, such as around duration of symptoms, past DED diagnoses and treatments and what has failed. He says: ‘The more detail they’ve given you beforehand, the better you can structure that conversation in a slightly more efficient manner. You’re essentially playing detective as it’s such a multifactorial disease; for some people it’s environmental, for others it’s lifestyle, or due to underlying health conditions, or they’ve got a specific problem like a Sjögren’s patient. How you communicate will vary depending on the type of person, the reason behind the dry eye, and the severity.’
The process can differ but usually takes the path of pre-screening, an initial 60 to 90-minute appointment, treatment plan, information resources such as videos and leaflets, and a follow-up schedule and maintenance plan. Test results are given in findings reports, which includes a glossary of language explained in layman’s terms, as well as recommendations and the detailed daily treatment plan. Peter Ivins Eye Care also uses OptiMed’s Captiv8 animated information videos to better educate patients on terms and treatments, both within the consultation room and as a takeaway in a mini-customised playlist.
McArthur advises patients to bring a list of questions and a partner to appointments, particularly those on the severe end of DED. ‘If the patient is constantly borderline depressed and having work productivity issues because of the dry eye, that has an impact on the entire family. So, bringing a partner or family into the conversation and allowing them to ask questions as well as the patient is quite powerful. It allows two sets of ears to listen to what you’re explaining and they’re more likely to take home the good advice that you’re offering,’ he says.
Bruce highlights follow-up appointments as a particularly important step: ‘Explain to them it’s a chronic condition and it’s going to take time to get better. Factor it into their management that they’re going to come back to you so that then you’ve got a chance to reiterate the things you’ve said before and readdress questions and concerns.’ Follow-up schedules are dependent on the type of treatment being undergone and are customised to the individual, adds McArthur.
The best solution
Bruce believes clinics are better placed to accommodate needs than hospitals. She says: ‘It’s surprising how much psychology goes into dry eye patient communication. It’s about being compassionate and having time to actually listen. You need to really appreciate how big an issue this is for them and take it seriously because sometimes there’s a mismatch between the signs and the symptoms. With the best of intention, I don’t think hospitals are the best setting for dry eyes. They don’t really have the same amount of time, or sometimes it seems like a superficial issue in a hospital.’
Similarly, McArthur, pictured left, said dry eye clinics play an important role within the optical sector because there are an increasing number of these patients not being dealt with well within traditional optometry. He emphasises that it all comes back to time and, therefore, a longer dry eye-focused appointment is crucial, saying: ‘I’ve seen those patients that have been to several opticians, the GP and ophthalmology, that are not happy with the treatment, and the biggest factor is just having more time so you can obtain any additional tests.’
Lifestyle risks
Following the Covid-19 pandemic some trends around patient types and risks experienced within dry eye clinics have changed as binge watching TV during lockdown became common and many facets of everyday lives adapted to remote digital means. More than 80% of DED patients across all severities reported the use of digital screens, according to a 2021 dry eye patient study led by the University of Southampton.
McArthur highlights: ‘Traditionally, five to six years ago, it was mostly women over 50 that would make up about 90% of the dry eye patients that we’ve seen in the clinic, but, increasingly, I’ve seen people in their teens, 20s and 30s. I think that’s been exacerbated by the Covid-19 pandemic and the move to home schooling and working remotely. Then, there’s the proliferation of smartphone usage in tablets, laptops and gaming consoles. If you look at the cumulative number of hours people are spending on screens, it’s enormous and there’s no doubt that is having an impact on the types of patients that are popping up in the clinic.’
Emerging treatments
The global dry eye disease treatment market was valued at $5.4bn in 2019 and is anticipated to expand at a compound annual growth rate of 4% to $8.7bn by the end of 2030 due to upcoming anti-inflammatory products and technological innovations, according to the Transparency Market Research report.
McArthur has been keeping an eye on new technologies like the Rexon-Eye device, ‘which uses quantum molecular resonance, stimulating natural cellular and tissue regeneration using low-power, high-frequency electric fields,’ and the Equinox Low Level Light Therapy machines. New home products, such as dry eye-specific make-up ranges, such as Eyes Are The Story, have also emerged. He said that dual therapy lubricants, such as Hycosan Shield eye drops and Théa Pharmaceuticals’ Thealoz Duo product, have been beneficial to patients recently, adding: ‘Upwards of 80% have got an evaporative dry eye because of their lipids, so if you can get a drop that replaces the mucin layer, the aqueous layer and the lipid layer and completely becomes an artificial tear, that would be the Holy Grail.’
Are Independent Prescribing (IP) qualifications needed?
McArthur believes, technically, you don’t need to be IP qualified, but admitted it certainly helps because then you can prescribe whatever is needed on your own. ‘However, I wouldn’t let not having an IP put people off as there’s a lot you can still offer,’ he says. ‘Most of the investigations are firmly within the scope of practice for a normal optometrist. It’s only a select number of drugs that you might use as part of the treatment plan, such as topical steroids; topical antibiotics; oral antibiotics with beneficial anti-inflammatory properties like erythromycin; and in more extreme cases with drugs like cyclosporine. If you weren’t an IP, you’d have support from either an IP colleague, GP or local ophthalmologist.’
Bruce argues that while you can do a very good job of assessing dry eyes without an IP qualification, the types of eyes that come into a dry eye clinic often need a bit more than that. ‘I definitely wouldn’t want to be doing it now without an IP qualification. People will often have tried simple things before, like eye bags and lubricants, but those that reach you at a clinic often have quite significant eye disease and if you can be prescribing anti-inflammatories or antibiotics, then that’s how you’re going to help them specifically.’