Cornea: Lessons learned
December 2023

by Ellen Stodola
Editorial Co-Director

Explaining the nuances of dry eye and available treatment options to patients can be a challenge, especially when it comes to asymptomatic patients. Two physicians discussed how they approach dry eye patients, how they explain the different types of dry eye, and how they talk about available treatment options.

Joseph Tauber, MD

Dr. Tauber frames his discussion on dry eye as a case where it is very important to understand exactly what is wrong. “The better you handle this conversation, the more it can enhance your practice,” he said. “It can’t be long because if you get too scientific, patients tune out, and it’s game over.” You have to tell patients something they don’t know and convince them that it relates to what’s going on with them.

Dr. Tauber said he first does an exam. “Typically, I’ve done one imaging test looking at meibomian glands,” he said. The patient may have a variety of complaints because there are many different forms of dry eye, and the initial conversation dives into those differences.

He’ll open with a discussion of how dry eye is very complicated. Many people think that dry eye simply means they don’t make enough tears, but much more common is losing tears too quickly (by evaporation). Dr. Tauber will say, “Everyone has a gland that produces tears. Water is produced, washes over the eye, and there are drains on the inside of the eyelids. We also all have oil produced from tiny glands in every lid. Every time you blink, a little oil comes out of those glands and mixes with the water. Oils prevent evaporation of the water component of tears. If there’s too little oil or it’s too thick, that’s when there is a problem, and you have too little oil in the tears and thus have excess evaporation. So for most people, they’re dry not because they’re not making enough water but because they’re losing it too quickly.”

It gets more complicated, Dr. Tauber said, because 50–70% of people who have either low water production or an oil problem also have the other problem as well. This is what Dr. Tauber calls the “double whammy,” and he said you need to define that first.

Dr. Tauber said you must control all the problems for the symptoms to be relieved. Your treatment plan must address what’s wrong for each patient, he said, adding that it’s at this point that he pauses to let the patient digest what he’s just discussed. Dr. Tauber likes to show patients their meibography and possibly do a Schirmer test to help them understand all the information he has shared.

After explaining which type of dry eye the patient has, Dr. Tauber said he will discuss the strategy for dealing with it. “I go through what I want each patient to do. For the water deficiency, this includes artificial tears, preservative-free tears, ointment at night, tear stimulants, punctal plugs, contact lenses, serum tears,” he said. “While highlighting what I want them to do, I say, ‘I want you to understand that we’re not doing every single thing that could be done,’ then I talk about excessive evaporation, where there’s some nuances of how we treat that.” For excessive evaporation, lid hygiene is number one. “No one is going to get better withou t adequate lid hygiene, and it’s all about how you teach that,” he said. “Everyone thinks that they know how to do warm compresses, but we teach a very specific technique. If they are regular and effective at doing this, they’ll be better in 2 weeks; if they’re not regular or not doing it well enough, it’s not going to work.”

It’s important to stress that there is often no cure to dry eye, but there are ways to control it. There are a variety of patient types, Dr. Tauber said, and they all process the disease differently. There are people who want the symptoms to stop and don’t care what’s wrong. Other people need to understand what’s wrong.

There are also contributing factors that Dr. Tauber said might be important to mention. A lot of evaporative dry eye is related to rosacea. You can also talk about food triggers, and he will also mention the harmful impact of oral antihistamines. “We also talk about the role of preservatives with artificial tears,” he said.

A lot of strategies start with tear supplementation, then you have a choice between tear stimulation and treating inflammation (via prescription medications) versus tear retention (plugs). “I never use temporary plugs because they’re not reliable enough to show the patient what they’re going to do,” Dr. Tauber said.

He is excited about the recent approval of Miebo (perfluorohexyloctane ophthalmic solution, Bausch + Lomb). This eye drop is a third the size of a standard eye drop, and tears can’t evaporate through it. “I think Miebo is potentially a breakthrough product because nothing does what it does, and the MGD component is present in at least 70% of dry eye patients.”

Darrell White, MD

Dr. White noted that “every single eye doctor is a dry eye doctor whether he or she knows it and if they know it, whether he or she will admit it.” In the first discussion with the patient, Dr. White said the conversation will depend on what the patient’s symptoms are and if he or she has symptoms at all. Dr. White noted that one of his treatment rules is, “You can’t make an asymptomatic patient feel better.” You start off right away knowing that you’ve got a fighting chance if they come in with symptoms, he said, and that’s the easiest place to start because you can benchmark everything that you discuss around the symptoms.

“We have a one-question patient survey to see if we should be starting a dry eye evaluation; regardless of what their symptoms are, our technicians ask if they take eye drops,” he said. “It doesn’t matter what the patient thinks they’re taking the eye drop for.” Most people who take an eye drop turn out to have dry eye, Dr. White said. “The key is to not miss the opportunity to find that it’s dry eye in those classic symptoms that we all know of dry eye.”

From the patient’s point of view, Dr. White said the dry eye talk may be overwhelming. Figuring out how to communicate with them in a way that allows them to understand is important, he said.

When first looking at patients, Dr. White said he’s trying to determine if they are primarily an evaporative dry eye patient or an aqueous deficient dry eye patient. “You’re not going to be able to get through everything that they need to know and you’re probably not going to be able to get all the treatments started that they need in a single session,” he said. Patients are often skeptical from the beginning that tearing could be dryness or that the burning sensation at the end of the day or not being able to see the computer could be dryness.

For the first visit, Dr. White said his pearl is “less is more,” but he added, “We want to try to go deep on one part of it.” If you nail that and get the patient to feel a little better, when they come back, you’ve got more credibility and can expand the discussion. Continue to go back and hit the original symptoms and remind the patient that your ultimate goal is for them to feel well.

If we’re talking about a new patient, it’s a different conversation than when dealing with a referral patient, Dr. White said. “With new patients, you often are able to make a significant impact in whatever symptoms they’ve brought to the table relatively quickly,” he said. “Once again, the key is trying to figure out what’s the primary type of dry eye and going after that.”

There have been many advancements in what physicians can offer to patients. Previously, Dr. White said the physician might jump to offering steroids, and for a long time, there was only one immunomodulator (cyclosporine, Restasis, Allergan), but there have been many improvements in options. Dr. White also mentioned Miebo and said, “In Phase 3 studies on efficacy, both in terms of the signs and symptoms, it was off the charts.”

Also recently approved was XDEMVY (lotilaner, Tarsus Pharmaceuticals), to help with Demodex mite infestation. The data is very good, Dr. White said, with 95% mite eradication in the pivotal Phase 3 trial and upward of 60% of people continuing to show no signs of mite infestation a year out.

“We’ve got patients who had a lot of inflammation, which caused them to have all kinds of symptoms and signs, and they’re much better because they’re on immunomodulator therapy, but they still have some symptoms,” Dr. White said. “Our job has become easier simply because we have better widgets to put into the game,” he said.

Dr. White said he tries to put together a plan for patients that builds on fundamental things that are not particularly difficult or expensive to do. The challenge is that patients and many doctors think that artificial tears are a real therapy, he said, but with the exception of patients who have a really high tear osmolarity, artificial tears don’t do anything. With that said, he will often start with an artificial tear so he is in control of which product they’re using. This makes it easier to move on from artificial tears at subsequent visits.

If the patient has evaporative dry eye associated with MGD, we start with some fundamental things like heating their eyelids, Dr. White said, noting that there are a variety of mask options available. “I find that patients are more likely to do lid heating if it’s not quite as messy as a face cloth and the sink.” He will also discuss nutrition with patients, as well as the effects of looking at a screen all day, which prompts people to blink less frequently and less completely.

Dr. White said his practice has patients come back 6–12 weeks later. If they have a lot of signs of dryness and not too many symptoms, they will have the patient come back sooner. If they come back and they’re doing great, we’ve had a simple intervention that’s inexpensive and not particularly time consuming, he said.

“It’s the next visit for all but the disasters where we really start practicing modern medicine because when they come back, the vast majority will notice a small, relatively transient improvement in their symptoms from that building block, but now they’re aware of what the problem is and why they have it,” Dr. White said. This is the visit where we start talking about medication. “We give them a chance to learn that they have a diagnosis, we give them the chance to learn that what people think of as typical treatment doesn’t work if you have real dry eye disease.

“It’s been our experience that if we give the patient the opportunity to learn that what they have is real and that they’re not going to be able to take care of it just by going to the pharmacy and picking something up on their own, they’re much more receptive to what it’s going to take and will get on the medications that are necessary,” Dr. White said.

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About the physicians

Joseph Tauber, MD
Tauber Eye Center
Kansas City, Missouri

Darrell White, MD
Skyvision Centers
Westlake, Ohio

Relevant disclosures

Tauber: None
White: Allergan, Bausch + Lomb, Novartis, Tarsus

Contact

Tauber: jt@jteyes.com
White: dwhite2@skyvisioncenters.com