Dry eye disease (DED) affects millions worldwide, causing discomfort and impairing vision. While many patients resort to over-the-counter remedies, in-office treatments offer advanced solutions that can significantly alleviate symptoms and improve their quality of life.
However, to maximize patient outcomes and satisfaction, it is crucial that ophthalmic staff take the time to clearly communicate why the patient requires in-office treatment, the options available to them, and what they can expect in terms of results. Here are the steps we take at Periman Eye Institute when educating DED patients.
Describe DED and its many causes
The first step toward effective DED treatment education is to explain to patients why in-office treatment is necessary — and in terms they can easily understand. Each patient's experience with DED is unique, so tailoring education to their specific symptoms, lifestyle, and medical history fosters better understanding and engagement.
At the Periman Eye Institute, where we specialize in treating DED and other ocular surface diseases, patient education starts pre-visit with teleconsultation and preview of consent forms and continues with the staff before the ophthalmologist even enters the room. After their exam, the MD informs patients of the likely reason(s) why they are plagued with DED, what options are available to them, and what benefits they can expect from in-office treatment.
All the information coming at them during their visit can be overwhelming, which is why they then come to the staff for a more in-depth conversation.
To begin, we explain that DED is multifactorial and that it can be caused and/or exacerbated by a variety of factors, including:
• Screen time
• Contact lens wear
• Hormonal changes
• Allergies
• Previous eye surgeries
• Smoking
• Nutrition
• Medications for unrelated conditions, such as blood pressure
• Cosmetics and skin care habits.
We also explain that inflammation is one of the biggest drivers of DED. That's why prescription medications like Restasis (cyclosporine ophthalmic emulsion 0.05%, AbbVie), Xiidra (lifitegrast ophthalmic solution 5%, Bausch + Lomb), Cequa (cyclosporine ophthalmic solution 0.09%, Sun Ophthalmics), Vevye (cyclosporine ophthalmic solution 0.1%, Harrow), and steroids that reduce inflammation are foundational treatments. But these drugs don't always fully solve the problem, and patients often don’t understand why. Taking the time to explain this helps patients grasp the relevance of in-office treatments.
Introduce the treatment options
The next step is to explain, in terms the patient can understand, their treatment option, how it works, and the risks and benefits. The most common procedures we perform for DED are microblepharoexfoliation, intense pulsed light (IPL) therapy, low-level light therapy (LLLT), and thermal meibomian gland dysfunction (MGD) treatment.
With respect to microblepharoexfoliation, we tell our patients that this treatment is much like going to the dentist for a 6-month teeth cleaning. We explain that the device works similar to an electric toothbrush and a special gel cleanser to scrub and remove dead skin cells along the lid margin. It also helps remove Demodex mite load, another common cause of DED, along the lash line. There are three major players in this space: BlephEx, Zocular Eyelid System Treatment (ZEST), and NuLids Pro.
IPL therapy is our practice workhorse in the battle against dry eye-associated MGD. It uses a device to target inflammation of the meibomian glands. This inflammation causes the glands to produce thick, turbid, abnormal oil instead of the clear, healthy oil that should look more like olive oil. It is particularly effective for patients with rosacea-related DED. We almost always treat the entire face. Patients often ask why, and we tell them it’s like weeding around a raised garden box. You don’t just weed inside the box; you weed around the box or else the box will fill up with weeds much faster. If we take care of the whole face, the inflammation will be reduced for a longer time, enabling the meibomian glands to work more effectively. Lumenis OptiLight is an FDA-approved IPL treatment for DED associated with MGD.
The thermal treatments, including LipiFlow (J&J Vision), Systane iLux (Alcon), and TearCare (Sight Sciences), target stasis and obstruction of meibomian glands, a common cause of evaporative DED. This approach applies heat and pressure to unclog blocked glands and improve the natural lipid layer of tears. Again, we use a device to warm the thickened meibum so we can express it and get the normal oils flowing again.
In our extensive clinical experience, thermal MGD treatments are more effective after microblepharoexfoliation and IPL. As a result, we prefer to save these thermal MGD treatments until after we have used the others listed above and deem that it is necessary. When we talk to them about having glands expressed, we explain that it is not always the most comfortable experience and they might feel a little more dry the next couple days. Because thermal MGD treatments can be often uncomfortable for the patient, they require anesthetic drops. However, the goal is to express those old, turbid oils so they can fill up with fresh better oils.
LLLT (eg, Celluma, MDelite) is a gentle experience for the patient but does not reduce inflammation to the extent of IPL. We also use LLLT to heat the glands before we do manual expressions as we find them easier to express after this therapy. As a bonus, it works great to buy the doctor a little extra time because staff can give the patient that treatment while they’re waiting.
Explain treatment benefits, risks and costs
Highlighting the short- and long-term benefits of these treatments, including improved tear production, enhanced tear quality, and reduced inflammation, encourages patient compliance and satisfaction.
However, advising patients of the risks of these treatments is also important. Although they are relatively minor procedures, we require all patients to read and sign informed consent forms. After all, we are working very close to and/or on the eye itself, and corneal abrasions are possible. Is it likely? No, but it can happen.
Another issue to address is the cost of treatment. Most insurers don’t cover much, if any, in-office DED procedures. If they do, coverage varies widely, and patients must understand they need to consult their insurance providers about coverage. Our goal is to present patients with all of their options and how those treatments can help improve their situation. It’s our job to educate, and from there the patient can make an informed decision.
Set expectations
The importance of setting realistic expectations regarding treatment timelines, frequency, and anticipated outcomes cannot be overstated. Patients often want immediate relief from DED symptoms, but they should be advised that dry eye and MGD often need time as well as a multifaceted treatment approach to address their symptoms. With ZEST treatment, for example, we find that some patients start feeling relief almost immediately. However, some patients with particularly severe cases require multiple treatment sessions before experiencing a noticeable impact. For instance, IPL requires an initial series of four treatments (more in severe cases), and most patients may not notice won’t notice improvement until later in their treatment series.
Stress the importance of post-treatment home care
We impress upon patients that the success of in-office treatment relies heavily on their diligence with home care. For example, immediately post-IPL treatment, patients should be advised not to subject their face to heat from sources such as saunas, hot tubs, and even activities such as hot yoga for the rest of the day. They can get back to their routine the following day, but they should be careful to avoid excess sun exposure; we advise them to wear a hat and sunscreen every day and to keep their back to the sun. Patients should also be advised to avoid sun exposure prior to the procedure as the IPL cannot be performed on sunburned or freshly tanned skin. This includes patients using self-tanning products.
In terms of ongoing home care, we recommend that patients use lid wipes to clean their eyelash bases and eyelids and remove their makeup every night. They should be advised to refrain from using any soap or shampoo near or on the lid margins, as they can overstrip the oils produced by the meibomian glands. We always tell patients to use cleansers specially formulated for the eyes.
Patients should also be advised to avoid retinol-based face and skin creams, unless prescribed by a dermatologist for medical reasons. Retinol dries the skin and can contribute to DED. Many other face creams contain additional ingredients that can contribute to ocular surface inflammation. We instead recommend dermaceutical skin creams (eg, Epionce), some of which can help repair the barrier function of the skin, especially in patients with rosacea.
DED treatment takes a multi-pronged approach
Patients sometimes come to our clinic with an attitude of, “I want to see if this works better than what I’m doing now.” They should be advised that DED must be attacked from multiple directions in a multi-disciplinary approach. In-office procedures, such as those discussed here, work together with each other as well as with prescription medications and other over-the-counter treatments, such as allergy drops and artificial tears, to fight DED. Patients should know they can get to a better place faster when they use all these therapies together.
Educating patients on the benefits of in-office DED treatments is paramount for optimizing outcomes and improving their quality of life. By adopting tailored communication strategies and transparently addressing patient concerns, we can empower patients to make informed decisions about their eye health. OP
