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Physicians need to keep in mind the primacy of patient symptoms
It may be difficult to convince a patient who is asymptomatic that he should be treated for dry eye.
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“You can’t make an asymptomatic patient feel better.”
I wish I knew who said that first. Who among us hasn’t encountered this problem, whether it is while we are taking care of a dry eye patient or talking to an 80-year-old patient with brunescent cataracts and 20/70 vision who swears he has no trouble with his vision while driving at night. In order to have a patient on board with a treatment plan, it helps if that patient feels like he or she has a problem that needs to be solved. In a world that is increasingly driven by more and better measurements, the most important metric is sometimes patient symptoms.
Challenges present themselves when there is a disconnect between what we see clinically and what we hear from our patients.
In more traditional dry eye syndrome (DES) care protocols, a diagnosis is made primarily by exam criteria. Indeed, pretty much all of the essential elements of the seminal DEWS levels of DES severity are exam findings. With this type of system, the diagnosis, decision to treat and mode of treatment are all driven by what the doctor sees on examination or in testing. Indeed, this has been borne out in U.S. Food and Drug Administration trials for DES treatments, all of which have traditionally had primary endpoints consisting of only exam or test findings. While there is usually rather good correlation between signs, test results and symptoms, our literature is starting to fill up with reports of how frequently this is not the case. Each of us who treats DES is familiar with the equal challenges presented by the asymptomatic patient with severe signs of dryness and the patient with minimal findings who is bitterly complaining of a dry eye.
Patient symptoms
A newer diagnostic and treatment protocol that makes a patient’s symptoms more central is starting to take shape. Given the strong imperative we all face to maintain or improve the efficiency of our care in the office, the DES protocol is now typically launched before our patient first sits before us in the exam chair. The advent of more and better point-of-service tests that can be done by our technicians with results available before we enter the exam room makes it all the more important to start the process of evaluating DES as soon as possible. In order to achieve this efficiency while simultaneously providing best-in-class outcomes and patient experience, the “trigger” for starting the evaluation is patient symptoms. The FDA has begun to acknowledge this, too. Patient symptoms were one of two primary endpoints in the recently completed studies of the new DES molecule lifitegrast (Shire).
Whenever I give a talk about DES, I like to ask my audiences to share what they feel are DES symptoms. In order to create a process that misses as few treatable patients as possible, it is necessary to have a broad list of symptoms that could possibly be caused by DES, and everyone on the staff can note a symptom if it is present. Classic symptoms include burning, tearing, redness, itching, light sensitivity, scratchiness and foreign body sensation. It is important to listen carefully for visual symptoms as well, as my audiences always point out: Blurriness or fluctuating vision, especially on near or intermediate tasks, should be a tip-off that DES may be present. Be on the lookout as well for vague symptoms such as heaviness, fatigue or periorbital headaches. The most common DES symptom is also always the last one mentioned when I query my audiences, but we certainly should never miss it when a patient tells us: “My eyes are dry.” You can obtain a “measurement” of symptoms by using questionnaires such as the Ocular Surface Disease Index or Standard Patient Evaluation of Eye Dryness.
Once we acknowledge that our patient has a bothersome symptom, it is incumbent upon us to find a supportable diagnosis that explains the symptom. This is where we get to be a doctor. A careful slit lamp exam, which includes the use of some sort of vital dye (eg, fluorescein) in combination with newer point-of-service tests — TearLab Osmolarity Test (TearLab), InflammaDry (RPS) — makes it likely that we are going to be able to render an accurate diagnosis, and we are also likely to be able to use our exam results to tailor an effective first-line treatment plan. Remember, our patient has told us that there is a problem, and he or she expects something from us that will make that problem go away. A primary aspect of a DES protocol that invokes the primacy of patient symptoms is that we, the eye doctors, will address those symptoms. DES symptoms become the trigger to launch the DES evaluation and treatment. In these newer protocols, the success of treatment is at least partly dependent on how well we have alleviated those symptoms; be sure to ask about each initial symptom at follow-up examinations and have patients retake your symptom questionnaire.
The asymptomatic patient
I know what you are thinking right now. In your mind’s eye, you are seeing an asymptomatic patient at your slit lamp with a low tear film, a quick tear breakup time and some fluorescein staining. She has a dry eye. You know it. I know it. The problem, of course, is that your patient does not know it. She is totally unaware. She did not offer a single complaint that could be caused by DES, and when you ask her about specific symptoms, she denies having any problems at all. Admit it: You did your doctor thing and found a problem, and you want to treat it.
“You can’t make an asymptomatic patient feel better.”
It is difficult enough to get our patients to adhere to successful therapy that they, themselves, admit is working. We need only look at the abysmal adherence data for sight-saving glaucoma medications to realize how hard it is to keep patients on their regimen. Indeed, there are certainly times when what you see on an exam trumps your patient’s absence of symptoms. If the effects of dryness are so severe that you envision imminent harm to the health of the eye if left untreated, there is nothing to do but soldier on and do everything in your power to convince the patient that treatment is mandatory. Likewise, in the face of upcoming surgery in which you feel that a predictable increase in dryness will decrease the likelihood of a successful outcome, you must use all of your powers of persuasion in order to get your patient to accept a perioperative plan that includes DES treatment.
In the typical clinical setting, these situations are the exception rather than the rule. DES is most commonly a symptom-driven disease, and in some ways, this actually makes our lives somewhat easier. Our patients tell us there is a problem. We tell them why they have that particular problem and then offer them a solution, which is increasingly likely to solve their problem, to make their symptoms go away, with newer and ever more effective treatments. We continue to develop newer and better metrics to both diagnose DES and measure our treatment successes.
For the most part, though, the most important metric of all in DES may just be patient symptoms.