Off the Cuff: How to Fail at Treating Dry Eye Without Really Trying

I am not a big fan of telemedicine. I don’t mind it as a patient, but considering that my practice is essentially limited to dry eye and ocular surface disease, I really need to be hands on—especially with new patients. However, when an old friend emailed asking for help for one of his coworkers and the only option was telemedicine, I quickly agreed. It sounded like the patient was in pretty bad shape.

A few days later I received a text message from the 30-year-old co-worker, who introduced herself and offered a brief description of the issues she was having. She had seen five practitioners since recently relocating from California to the Southeast, and was in tears as she shared that none of the doctors were able to help her. Even worse, from her perspective, none seemed to really care.

She described being treated using a cornucopia of therapies, many that struck me as more random than logically thought out. She had little idea why she was prescribed or being treated with any of these things. Procedures like punctal occlusion were repeated despite not helping and after significant adverse reactions to earlier failed attempts.

It was easy to sense how scared she was and impossible to not feel badly for her. I reassured her and started by asking her to describe how she felt and when her symptoms were worst, the specifics of what was bothering her, and when things worsened or improved. I asked what medications she had been prescribed and what procedures she had undergone. For complex procedures like IPL, I asked her to describe the technique used in detail.

Thankfully she was a good observer and was able to communicate results of most of the testing and treatment that had been performed. None of the several anti-inflammatories used worked, suggesting that inflammation wasn’t a likely, or at least a primary, cause. She had clearly been undertreated with IPL, and many of the other approaches completely missed the mark. With this information, I spent about 15 minutes explaining the likely cause of her issues and then proposed a treatment plan.

I don’t have the space to describe the entirety of my recommendations or my rationale, but some problems were glaring. It was obvious that she had poor nocturnal lid closure. She had to pry her eyes open on waking. I recommended a non-petrolatum-, paraffin-based ointment. One of her main concerns was lid irritation, redness and swelling. I told her to stop using detergent-based lid scrubs, as they strip natural oils from the lids and periorbital skin and irritate more than help. I advised her to substitute hypochlorous acid solution sprayed onto her closed lids after gently cleansing with a wet, warm, soft washcloth.

Perhaps because she was a friend of a friend or just a patient in need, I spent a lot of time on that call. It wasn’t until the end of the conversation that I realized my impact. She said with an almost excited tone, “Dr. Epstein, you’ve spent more time with me than any other doctor I’ve seen and its obvious you actually care about me. I feel so much better. Thank you so much.”

Our skills and our knowledge vary, but the one consistent thing that helps patients is the ability to communicate that we care about them and that we give them enough time to actually be heard. Listening and caring are ultimately the foundations of clinical success.

 

 

Arthur B. Epstein, OD, FAAO Chief Medical Editor artepstein@optometricphysician.com

Want to share your perspective?
Write to Dr. Epstein at artepstein@optometricphysician.com. The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of Jobson Medical Information LLC (JMI), or any other entities or individuals.