A changing focus on dry eye
The impact of the COVID-19 pandemic on many patients’ lifestyles has shone new light on dry eye symptoms, with opportunities available for practices to meet this need
18 April 2021
Setting up a dry eye clinic has been a long-term goal for many practices, suppliers suggest – but there is still a need for more investment in this area.
While traditionally seen as an issue affecting older patients and with a female bias, Mr Atkins suggested: “It is fast becoming a problem for an ever-younger population and with more male sufferers.”
Contact lens manufacturer, Alcon, has identified two groups of patients emerging around discussions of dry eye.
In a consumer study commissioned by Alcon in December 2020, the company identified a group of patients who were not sure what to do and did very little about dry eye, nicknamed ‘considerers.’ The company suggested these patients were less anxious about their eye health and were typically relaxed shoppers.
Alcon also identified a group of patients they named ‘buyers,’ who are more anxious about their eye health and comfortable to carry on using a product.
“Both sets of patient groups blame the increase in screen time as a cause of their dry eye symptoms,” Jonathon Bench, director professional affairs international – dry eye and ocular health at Alcon, said.
Patients were also found to be blaming themselves for aggravating the issue, Mr Bench noted, believing it is something they are doing and not recognising that they have a condition.
The impact of COVID-19Practices have raised anecdotal increases in patients describing dry eye symptoms during the COVID-19 pandemic. It is thought that lifestyle changes brought about by the pandemic could link to the symptoms, such as greater amounts of time working from screens at home, or regular mask-wearing.
Mandy Davidson, optometrist and professional affairs manager at Scope Eyecare, which offers solutions for ocular surface disease and age-related macular degeneration, said: “We are all familiar with the impact of reduced blink rates associated with screen use, but this has now spread more widely as children are using screens for home schooling and for many of us have significantly increased our screen time as they have become essential for working from home.”
Any of us who wear a mask for any length of time will be aware of these symptoms, which can often extend for some time even after the mask has been removed
With social interactions also moving online, Ms Davidson suggested: “It would not be unreasonable to assume that a typical day from morning until night could involve screen hopping from one device to another.”
Mask Associated Dry Eye could also be a factor in dry eye discomfort. Ms Davidson added: “Any of us who wear a mask for any length of time will be aware of these symptoms, which can often extend for some time even after the mask has been removed.”
Alcon has also heard practices referencing an increase in conversations around dry eye, though Mr Bench added that patients do not commonly refer to the issue as ‘dry eye.’
This suggests patients are aware of a change in their ocular comfort and want to do something about it, Mr Bench said, but said: “This will most often be research-based rather than action-orientated.”
The pandemic has led to a greater awareness of dry eye symptoms, said Richard Lumley, UK and Ireland vision sales manager for solutions provider, Lumenis.
Mr Lumley suggested this awareness could grow further, with the indication that increased home-working could continue for many beyond the pandemic. He said: “In this new norm, I think we will start to see more dry eye patients coming to optometrists’ doorsteps.”
Hearing the problemSuppliers suggested that there is more opportunity for practices to grasp in the field of dry eye.
It is often patients presenting with dry eye symptoms at eye examinations that drives a need for extra investigations in order to offer advice and options, explained Scope’s Ms Davidson.
She explained: “Because dry eye is a multifactorial disease, many practitioners are realising the limitations of fully investigating dry eye as part of a routine examination and are considering inviting patients back to offer a specialist service, if first line recommendations don’t appear successful.”
The company is working with practitioners to support their learning, Ms Davidson added, “and enable them to provide help and support for patients with dry eye.”
The first lockdown allowed many independents to get off the treadmill of everyday practice business and revisit dry eye and other business differentiation and development plans
Mr Bench agreed that there is still more opportunity in this space, commenting: “As more eye care professionals are becoming engaged and aware of the impact that dry eye has on quality of life, wellbeing and of course on vision and ocular comfort, they are identifying more dry eye sufferers within their patient base.”
Over the past year, however, though people have been acknowledging their dry eye symptoms, many have been unable to visit a practice.
“This has led to great virtual consultations and perhaps us ‘hearing’ the problem better than ever before, rather than ‘seeing’ it,” Mr Bench said. “One very interesting opportunity for practices to meet the needs of dry eye sufferers is to be aware of the NHS initiative to drive dry eye into primary eye care and community as part of their plan to reduce spend on prescriptions.”
Over the past few years, Alcon has also been supporting practices through education, including CPD-style YouTube videos exploring dry eye, covering diagnosis to management and organising clinics, and with its Dry Eye Day seminars.
“We offered further support with virtual CET workshops through 2020, and are currently working on some more online and on-demand content. Watch this space,” Mr Bench hinted.
Investing in equipment“Setting up a dry eye clinic has been on many a to-do list for a number of years,” Mr Atkins commented, but suggested that a minority of practices do run the specific appointments.
“Interestingly, the first lockdown of the pandemic allowed many independents to get off the treadmill of everyday practice business and enabled them to revisit dry eye and other business differentiation and development plans,” he noted.
“While there is a glut of new technology, especially for the diagnosis of dry eye, most practitioners are still using dated investigative techniques with low specificity and sensitivity for the disease,” Mr Atkins commented.
He outlined a need for practices to invest in the latest instrumentation and software for an accurate diagnosis of dry eye, suggesting there is a first mover advantage available to those practices who do.
Positive Impact is developing a portfolio of dry eye diagnostic tools, treatment and management options to serve practices in this area. Mr Atkins said: “The advantage of being a distributor is it enables us to scour the globe in search of the best new and differentiated products in each dry eye product category. These are often patented and always innovative technologies.”
Lisa Evans, director of optical supplier Hanson Instruments, suggested it can be challenging to gain compliance from patients with certain dry eye treatments, such as eye drops or eye bags, that can take time and effort.
“When you think that people with dry eye are getting younger and younger, you’re just not going to get that happening on a regular basis,” she said.
With a variety of products and treatments available to address the condition, Ms Evans said investing in equipment to provide treatments such as low-level laser light therapy could differentiate a practice.
As this treatment is non-invasive, it also does not need to be carried out by the optometrist, Ms Evans explained, adding that this could be a positive for practices with spare rooms, or that don’t have an optometrist practising every day, enabling patients to attend for treatments and generating income.
Suggesting the sector is on a “cusp,” Ms Evans said: “I think today it seems to be the more forward-thinking practices that are seeing the opportunity and the benefits. We’ve been talking about dry eye for years, but it has been heating up in the last couple of years.”
The company is supporting practices with ambitions of setting up dry eye clinics through a partnership with The ADP Consultancy.
The first thing to help this is more and greater conversations – listening to what the patient is feeling, asking more questions to better understand, to then be able to make great recommendations
Lumenis’ Mr Lumley suggests that it is still an early stage for alternative treatments to dry eye in primary care. Intense pulsed light (IPL) has been clinically acknowledged to deliver controlled positive results for dry eye and is a registered alternative method of treatment.
Practices have not yet had the time to fully investigate this alternative treatment, Mr Lumley suggests. “But now, optometrists are seeing that with IPL treatment, they can treat dry eye as a first-stage treatment process,” he added.
This is something the company is aiming to address through its work with optometrists. Earlier this year, Lumenis told OT that the company has rolled out a pilot programme to deliver training to optometrists in the UK around the treatment and its Optima IPL product.
Mr Lumley added: “Lumenis is taking the lead to educate optometrists and ophthalmologists to actively promote awareness to new clients and existing patients by supporting them with marketing material to deliver the message of IPL treatment as a primary option.”
The way aheadConsidering what is next for dry eye management and treatment, suppliers suggested that there is no one-way ahead, with many suggesting continuing education and communication are key.
Ms Davidson shared: “I think educating patients and practitioners on what the patient can do for themselves, in the way of diet and lifestyle for example, to promote a healthy tear film would be a good start.”
For Alcon, it also begins with communication. Mr Bench said: “The first thing to help this is more and greater conversations – listening to what the patient is feeling, asking more questions to better understand, to then be able to make great recommendations.”
There is still space for more diagnostic instrumentation to complement those available in practices, Mr Bench noted, adding: “We hope to share more in this area in the future.”
Investing in new technology will be important for the development of dry eye clinics, and particularly for practices looking to expand their services.
Ms Evans suggests that many of the tools for addressing dry eye are already available, noting “practices can do most things to do with dry eye on the equipment they already have.”
However, a starting point that practices could consider is equipment to image the meibomian glands. She suggests: “That gives a measure, and if optometrists then use the treatment system, it can measure the effectiveness of the treatments and show the patient what is going on.”
Positive Impact’s Mr Atkins suggested that some practices are using “less than reliable tests and techniques that consume chair time and don’t give a definitive answer.”
“What we do know is that tear film osmolarity is the only definitive measure to know for sure whether a patient has dry eye or not,” he explained, adding that solutions such as TearLab can quickly gather this data.
Mr Atkins added: “The future of diagnosis is actually here today.”
Dry eye in three parts with Professor James Wolffsohn
1 The prevalence of dry eye disease currently in the UKOur most recent study in the UK, which examined 282 people matching the general population profile against the Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop II criteria, found a reverence of 36.2% – so a little more than one in three in the UK have dry eye disease (DED). Female sex, systemic/ocular health conditions, short sleep duration, and prolonged outdoor leisure time were significant DED risk factors.
2 The impact of COVID-19 for dry eye symptomsMasks force exhaled air across the ocular surface which will increase evaporation and can cause dry eye, especially in those with pre-existing ocular surface disease from lots of screen time (due to less and partial blinking). Long-term, the increase of screen time could conceivably increase the prevalence of dry eye. Optometrists could screen for this and open up conversations by having patients complete a standard dry eye questionnaire prior to the consultation.
3 Approaches to dry eye following the TFOS DEWS II reportI think the TFOS DEWS II report is slowly changing clinical diagnosis and management of dry eye in primary care in the UK. The main focus now is to better inform the choice of the most effective treatment based on baseline measures; such as a 2021 paper by Jennifer Craig et al which indicates that symptoms will improve within a month of artificial tear use if they will at all. This allows for better communication to patients about the need for compliance during this period and practitioner knowledge to modify treatment after this period if the patient has not had a marked improvement.