Tailoring the dry eye conversation

Some patients may be only too aware that what they are facing is dry eye disease, but for others, the symptoms might not lead them to suspect dry eye as the issue.

With the varying types of dry eye, as well as the differing lifestyles and life-stages of patients, no two dry eye conversations are the same. OT asked three practitioners to share how they might approach a dry eye conversation in different scenarios.

Tailoring the dry eye message

...For an avid screen-user

Sarah Farrant (SF), optometrist and practice owner at Earlam and Christopher: With screen users, I usually focus on performance and comfort rather than disease terminology alone. These patients may not think they have “dry eye,” they may describe tired eyes, fluctuating vision, frontal headaches, reduced concentration, or end-of-day blur.

The message might be: ‘When we concentrate on screens, we tend to blink much less often and less completely. That means the tear film is not being refreshed as effectively, so vision can fluctuate and the eyes can feel tired or gritty.’

The advice should be practical: blink awareness, screen positioning, regular breaks, managing airflow, checking spectacle correction, treating meibomian gland dysfunction if present, and using lubricants or other therapies where clinically indicated. The Tear Film and Ocular Surface Society (TFOS) Lifestyle specifically highlights digital device use, blink changes and environmental demands as important contributors to ocular surface symptoms.

Becci Zawadzki (BZ), independent prescribing optometrist and partner at Norville Opticians, a Hakim Group independent practice: Most people now know the 20-20-20 rule. We recommend they add 20 blinks to that too. Blinking is so important and we know that when you’re using a computer or in any form of concentration, you don’t blink nearly as much as you should do. So, it’s about explaining [that] to the patient. Sometimes I will recommend setting a timer for 20 minutes on repeat.

It’s approaching all patients with the same level of conversation in history and symptoms. So as an optometrist, asking what they do for a job, the type of environment they are involved in, how many screens they use and how far away they are. But also, how do their eyes feel?

Patients might not realise what dry eye symptoms are. They will often say that their eyes feel tired. I like to explain that, for you to look at your computer screen, your eye muscles have to tense. If you imagine going to the gym and working on one muscle for the amount of time that you’re staring at a computer screen, then yes, the muscle is going to be a bit tired. Then, you’re also not blinking properly either.

We’re providing them with the knowledge of why their eyes might feel that way, so they can rest the muscles by looking out of the window and bringing in some blinks to help improve the quality of the tear film.

Kyla Black (KB), director of optical practice for Boots Opticians: Many of us spend a lot of time looking at screens, so the conversation should focus on their everyday habits and small changes that can make a meaningful difference. Prolonged screen use can contribute to dry eye because we tend to blink less completely when concentrating on a screen, which can affect the quality and stability of the tear film.

My advice to practice teams would be to ask patients about their working day and how much screen time they have, rather than simply asking whether they have dry eyes. From there, practical advice could include taking regular breaks using the 20-20-20 rule, blinking regularly, being mindful of glare, and keeping the screen at an appropriate level.

...For a patient who might be experiencing menopause

SF: For menopausal or perimenopausal patients, the message needs to be validating. Many patients do not connect hormonal change with ocular symptoms, and they may feel frustrated that their eyes have suddenly become uncomfortable, watery, gritty or contact lens intolerant.

I might say: “Hormonal changes can affect the tear film, the ocular surface and the oil-producing glands in the lids. You are not imagining it, and it is not just ageing, there are ways we can assess what is happening and support the surface of the eye.”

This group often appreciates a more holistic discussion: skin, lid margin health, rosacea, sleep, systemic medication, autoimmune history, screen use and nutrition may all be relevant. It is also important not to trivialise symptoms, because dry eye can have a major impact on quality of life.

BZ: That is one of the things we pride ourselves on because we have such a long time for appointments that we can get to know the patient. One of the first questions I will ask is: ‘How are you?’ It’s open-ended and sometimes they will just start talking and you can pick up on all the little things. Sometimes you can put two-and-two together – you’re of that age between 40-60, you’re a woman – and ask: ‘Have you spoken to your GP about how you’ve been feeling?’

We can just concentrate on their eyes and think – blepharitis, great, I know what to do there. But actually, it is taking the patient as a whole person, rather than a set of eyes.

We are so knowledgeable and we do need to continually research. We know that dry eye is linked to mental health, hormones, sleep quality. All of those go around in a cycle. We need to find a way to break that cycle. Whether that is talking to the patient and giving them a bit of confidence to speak with their GP, talking to them about vitamins and backing up the research, or giving them the opportunity to have that discussion about their lifestyle as well as their eyes, because it is part of them – we can’t treat their eyes without treating the rest of them.

KB: For a patient experiencing perimenopause or menopause, it’s important to make the conversation open and reassuring. Hormonal changes during this time can affect tear production and the stability of the tear film, increasing the risk of dry eye. Symptoms can include dry, gritty, sore or burning eyes, as well as watering or intermittent blurred vision.

Practice teams should consider asking whether the patient has noticed any changes in their eye comfort alongside other changes they may be experiencing. That can help normalise the conversation and ensure dry eye isn’t simply dismissed as tiredness or part of getting older.

It’s also an opportunity for an optometrist to look at the eyelids and tear film in more detail. The meibomian glands produce the oily component of tears and can become less effective or blocked, while regular eyelid cleaning and warm compresses may help.

Primarily, advice should be individualised. If someone is experiencing persistent symptoms, an optometrist can assess their eyes and recommend an approach suited to their needs.

...For a contact lens wearer?

SF: With contact lens wearers, I try to avoid presenting dry eye as a reason they must stop using lenses. Instead, I frame it as something we need to optimise to protect comfortable wearing time.

The message might be: ‘Contact lenses sit within the tear film, so if the tear film is unstable, lenses can become uncomfortable even if the lenses themselves are a good fit. We need to look at the ocular surface, the lids, the lens material, replacement schedule and wearing pattern.’

This is particularly important because discomfort is a major reason for contact lens dropout. BCLA CLEAR and TFOS contact lens-related reports emphasise that dryness, irritation, fluctuating vision and reduced wearing time are key issues in contact lens practice, and that management should include both the lens and the ocular surface environment.

For these patients, the practice team can reinforce that they should not simply reduce wearing time silently or keep changing solutions without advice. Early intervention can make a big difference.

BZ: It’s really easy to blame dry eye on the contact lenses, but actually, they probably have dry eye anyway and it’s important to separate the two. Although contact lenses do interact with the dry eye, we still have to treat the dry eye as dry eye.

If a patient is still getting dry eyes with contact lenses, then we need to treat the dry eyes as well. We can’t just say: ‘Oh well, let’s change your contact lenses.’ We might need to add in some eye drops or do the dry eye treatments to make sure it is under control.

Technology and contact lenses have come on so much in the past five or 10, years. It’s so important that we have all availability to fit lenses that are going to suit the patients.

KB: With contact lens wearers, comfort is an important part of the conversation. I’d encourage practice teams to ask specifically about when discomfort occurs – for example, whether the lenses feel uncomfortable towards the end of the day, whether the patient’s eyes feel dry or gritty, or whether symptoms are worse during periods of prolonged screen use.

Patients should be reminded that contact lenses can become uncomfortable if worn for longer than recommended, and that glasses can be a useful alternative when lenses aren’t ideal.

Good lens hygiene is also fundamental. Patients should follow the wearing and cleaning instructions provided by their optician, remove lenses if they feel something is wrong or their vision becomes blurred, and only use eye drops that have been recommended by their optician.

For someone with persistent irritation, it’s important not to automatically assume that dry eye is the only explanation. Contact lens wear can also be associated with itchy or irritated eyes, and conditions such as blepharitis can contribute to dry eye symptoms.