This podcast is made possible by the support of Allergan, an AbbVie company.
With an estimated 16 million Americans suffering from dry eye disease, the need for doctors of optometry to effectively treat dry eye is great, but creating an effective strategy for dry eye treatment is not always easy. Artificial tears? Prescription eye drops? In office procedures? When do you reach for which treatments and how do you identify which patients will benefit? We sit down with Dr. Melanie Denton, owner of Salisbury Eyecare and Eyewear for this live podcast discussion.
Dr. Denton began practicing in 2009 and shares that the prevalence of dry eye in her community is skyrocketing. There’s also been a major shift in the demographics of patients affected by dry eye in her practice with younger patients experiencing more significant issues, likely associated with increased screen time. “I remember being in the dry eye clinic at Duke and most of my severe patients had Sjogrens or rheumatoid arthritis,” Dr. Denton reflects. “Now, younger patients have it, contact lens wearers struggle more to remain comfortable in their lenses, and I’m seeing more patients than ever with rosacea. People don’t use their eyes like they did even 10 years ago, and I have noticed that dry eye is EVERYWHERE and people are just dealing with it and normalizing their symptoms.”
Dr. Denton was drawn to dry eye as a specialty while completing her residency at Bascom Palmer Eye Institute in ocular disease. With retina care she could make a fantastic diagnosis, but then she would always need to refer the patient for actual treatment. “I really like that dry eye is something I can dive into and be an end-of-the-line specialist in. I don’t have to refer really at all, because I’m able to do every advanced procedure like Intense Pulse Light (IPL), thermal expression, and amniotic membranes. I just really enjoy being able to use my dry eye skills and help people.”
To diagnose dry eye in her practice, Dr. Denton uses a set protocol to screen patients to unlock the two major categories of dry eye causation: inflammation and obstruction. Her work up includes OSDI and SPEED dry eye questionnaires, InflammaDry to quantify inflammation, fluorescein staining and tear break up time, Schirmer’s test, and meibomian gland imaging. She finds that most of her patients have both inflammatory and obstructive contributors to their dry eye and both must be treated to achieve effective relief of the patient’s signs and symptoms.
Dr. Denton approaches her dry eye treatment paradigm by taking a problem-oriented approach with her patients. She is up front with patients that she cannot cure their dry eye disease, and instead focuses on setting goals for lifestyle improvement. If a patient is struggling to read comfortably for longer than 15 minutes, they set a goal of extending that time. If a patient is having to use artificial tears six times a day, they set a goal of reducing that number. By setting attainable goals, Dr. Denton helps her patients define treatment success in a realistic way.
When it comes to prescribing dry eye treatments, she has created a protocol of 3 treatment categories:
1) Habits/Hygiene: This includes drinking more water, taking nutritional supplements, daily eyelid hygiene, and avoiding direct ceiling fan or air vents. Artificial tears are a core part of Dr. Denton’s treatment plan for acute symptom relief. “I’m a huge fan of non-preserved tears,” Dr. Denton states. “One of the first things I do is switch patients from preserved to non-preserved artificial tears when I meet them.” Her go-to artificial tear recommendations include REFRESH® DIGITAL preservative free and OPTASE dry eye intense drops.
2) Prescription treatment: Immunomodulators like RESTASIS® (0.05% cyclosporine) are go-to drops in her practice for controlling inflammation. “I write a prescription for almost everyone who comes to a Dry Eye Assessment visit,” Dr. Denton shares. If patients are not experiencing relief with at home treatments like artificial tears, she is not going to waste their time with more tears but instead go straight to a medical treatment. She is careful to educate patients that these drops are not the same as over the counter tears and must be used as prescribed — twice a day every day — for them to achieve the needed results of calming underlying inflammation. This education is essential to successful patient outcomes with prescription dry eye medication: during the podcast Dr. Lyerly and Dr. Denton discuss a recent study of over 2,600 patients that found 90% of patients on prescription dry eye medication use their drops differently than how they were prescribed, and 60% of patients only use them for acute relief when they feel dry eye symptoms. In addition to immunomodulator prescription eye drops, Dr. Denton prescribes oral doxycycline for patients with ocular rosacea and oral secretagogues for patients with Sjogren’s syndrome.
3) Advanced In-Office Procedures: Dr. Denton’s practice utilizes thermal heat pulsation and IPL in office procedures to address meibomian gland obstruction and chronic inflammation. She shares a story of a patient that was recently referred to her on maximum medical therapy for glaucoma who was suffering with debilitating dry eye. She had been suffering for so long, and tried so many different dry eye treatments that she was very brusque with Dr. Denton and told her that she didn’t think she would be able to help her. “I told her to give me 6 months, and I was confident that I could help,” Dr. Denton said. Recently this patient had her fourth IPL appointment, and she hugged Dr. Denton when she came into the room. Her friends had been telling her nonstop how much better her eyes looked – less redness, less watering, and she couldn’t believe her results. That’s the kind of life-changing difference that embracing dry eye care in your practice can make!