Cynthia Matossian, MD, has witnessed firsthand the problem of patients who have dry eye disease (DED) and misunderstand their ophthalmologist’s instructions: 

“I handed a patient a brochure about moisture goggles that I recommended he use,” explains Dr. Matossian, a consultant who retired from private practice in 2021. “The patient returned for follow-up, complaining he didn’t notice any benefit from it. It turns out he had folded the brochure and was putting that on his eyes.”

Improper use of such non-prescription, at-home DED treatments can result in prolonged and/or worsening disease, patient frustration, treatment discontinuation and, possibly, losing faith in their ophthalmologist, stresses Dr. Matossian.

Additionally, “Patients who are not following protocol or improperly performing at-home treatments following an in-office treatment for inspissated meibomian glands are less likely to respond or be satisfied with their results,” says Alice Epitropoulos, MD, who practices at Ophthalmic Surgeons & Consultants of Ohio, in Columbus. 

Fortunately, ophthalmic professionals can play a key role in increasing the probability of the correct use of non-prescription, at-home DED treatments. How? By educating patients on practical action steps, such as the following, which are organized by treatment. 

Artificial tears

Improper application is a prevalent reason for the improper use of artificial tears, according to Dr. Epitropoulos and Darrell E. White, MD, founder of SkyVision Centers, in Westlake, Ohio. To remedy this, they recommend allied staff tell patients to:

• Tilt your head. Dr. White says he has his allied staff members instruct patients to drop the tear in the corner of the outside of their eye and then tilt their head to allow the tear to roll into the ocular surface.

• Refrigerate the tears. Dr. Epitropoulos says she has her technicians instruct patients to keep their artificial tears refrigerated, so they can feel them entering their eyes and provides a cooling sensation upon instillation.

• Aim for the eyebrow. “My allied health staff also tell patients to aim the dropper at their eyebrow, so patients are more likely to land the tear on the ocular surface,” Dr. White points out.

• Pull the lower lid. Dr. Epitropoulos points out that another technique her allied health staff use to promote proper artificial tear administration is to have patients gently pull down on the lower lid, which increases the ocular surface target area.

“If a patient is a ‘squeezer,’ or someone who just can’t open their eyes wide enough, my allied health staff is instructed to discuss the use of a spray,” Dr. Epitropoulos adds. 

Dr. Matossian offers this patient script for allied health staff to use regarding proper use: “If you hold the spray too close to your eye, the spray can be startling and uncomfortable. On the other hand, if you hold it too far away, the spray will not reach the ocular surface,” she says. “Therefore, it’s imperative you use the spray at the specific distance given in the directions, which is typically 12 to 14 inches away.”

A caveat: What one patient estimates is 12 to 14 inches is often different for another, Dr. Matossian points out. For this reason, she says she has had both allied health staff and patients demonstrate use prior to the patient’s departure from the practice. 

Warm compresses/eye masks

The interpretation of the directions “moisten” and “warm,” and the “when” of utilization often stymie proper use of warm compresses, say Lynn Girdlestone, COA, OSA, OSC, practice manager for Swedberg Eye Care, in Edmonds, WA, and Dr. Matossian, respectively. To overcome the former, Ms. Girdlestone says she and her fellow allied health staff members define these terms. 

“For ‘moisten,’ we say this means placing a washcloth under tap water and wringing it out,” she offers. “We define ‘warm’ as comfortable heat on the skin. To prevent burns, we instruct patients to test the temperature of the compress on the inside of their wrist, like they would a baby’s bottle.”

Christopher E. Starr, MD, FACS, director of Ophthalmic Education and the Fellowship Program in Cornea, Cataract & Laser Vision Correction Surgery, at Weill Cornell Medical College, New York City, notes he prefers to have his allied health staff examine the directions associated with commercially available compresses or masks, as he has seen burns from washcloths.

“The commercially available items are designed for the eyelids and come with specific heating directions, so as long as the patient follows the directions correctly, including the needed microwave power setting, they shouldn’t have to worry about burns,” he says.

When it comes to the when of use, Dr. Matossian points out that it’s not as simple as saying, “use it twice a day,” to those already on a regimen of DED treatments.

“These patients need to know, for example, whether the warm compress or eye mask should be used before or after they instill their artificial tears,” she explains. "This is where the role of the allied health staff member is so important because they can reiterate and/or go over the directions relative to each patient.”

Moisture goggles 

The big hurdle to proper use of goggles is the direction to use them at night, especially for patients with lagophthalmos, CPAP wearers, and those that have a fan in their bedroom, according to both Dr. Epitropoulos and Ms. Girdlestone. 

To rectify this, Dr. Epitropoulos has allied health staff reiterate to patients, “while you’re sleeping.”

“Typically, ophthalmologists prescribe moisture goggles for patients who have lagophthalmos, CPAP wearers and those who have a fan in their bedroom — all variables that tend to exacerbate DED,” she points out. “Because this occurs during sleep, we might assume that patients would know that ‘use them at night’ means ‘while you’re sleeping,’ but experience reveals that’s not always the case.” 

Lid scrubs

When it comes to lid scrubs, the instruction, “do them at night,” is often misinterpreted, so Ms. Girdlestone says the allied health staff should instead direct patients to “do them right before you go to sleep.”

“Allied health staff need to educate patients to do their night-time lid scrub right before bedtime, explaining that doing so rids their lids and lashes of the accumulation of invaders from the entire day,” she asserts.

Dr. Epitropoulos often has her allied staff members discuss the use of foams or wipes with patients to facilitate lid scrubs. For patients who have dexterity issues, she says she has allied health staff direct patients to gently wipe back and forth along the upper and lower lashes. Patients without dexterity issues are directed to carefully use a cotton swab, rubbing with slight pressure along the upper and the lower lashes, before gently pulling the lid down to get the inside of lid margin.

Ambient humidifiers 

Dr. Epitropoulos says that improper location, utilizing a fan during ambient humidifier use, and failure to regularly clean the humidifier are all implicated for incorrect use. “I have my allied health staff educate patients that they’ll realize benefits from the ambient humidifier if they have it in their bedroom with the door closed to trap the moisture; they don’t use a fan, which causes dryness; and they clean it regularly to prevent an accumulation of dust and such.” 

Nutritional supplements

Incorrect ocular nutritional supplementation use is largely due to taking the wrong product and ceasing use of the right product, note Drs. Matossian and White, respectively. 

To overcome the first hurdle, Dr. Matossian says allied health staff can emphasize the importance of using the product the ophthalmologist prescribed. “There is such a huge variety of ocular nutritional supplements for DED. Allied health staff can be so helpful in reiterating the importance of acquiring the specific ocular nutritional supplement the ophthalmologist prescribed for the patient and why.”

To prevent patients from ceasing use of the prescribed ocular nutritional supplement, Dr. White says staff can manage patient expectations from the outset. Specifically, it's important to impress upon them that “it could take several months for them to notice dramatic differences in their DED symptoms, so patients stick with their ocular nutritional supplement,” he says.  

The final step

Dr. Epitropoulos emphasizes that it’s essential eye-care staff ask patients if they have any questions about the specific directions provided as a means of ensuring patient comprehension. 

“When patients are invited to ask questions, they’re more likely to ask them because the invitation makes them feel comfortable to do so,” she explains. OP