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The changing face of dry eye
Who are your patients, and where do they come from?
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A long time ago in an office far, far away, every eye doctor treated dry eye. Seriously. Even retina docs. Why was that? Well, it was easy. Only one group of patients complained about it, they all had it, and there was really nothing you could do about it other than tell them to “use tears if you want.”
Remember, this was in the days of “anatomic success” and 9-mm cataract incisions. The bar was low.
Elderly patients
When I first entered practice, dry eye was a disease of the elderly. Only those patients for whom Uncle Sam was paying the bills complained of dryness. There is actually a bit of science to explain this. We have long been aware of a certain “burnout” phenomenon in basic lacrimal production. In women there is a clear association between menopause and increased dryness of all mucous membranes, and the conjunctiva is no exception. Diseases such as Parkinson’s and thyroid disease are more common as one ages, and chronic effects such as dry eye become more prominent with time.
What really set those older patients with dry eye apart was the functional aspect of their disease. What they did, how they spent their time, caused many of their symptoms. It turns out that the biggest risk factors for dry eye symptoms back in the day were paperback novels. Think about it — computers were exotic in the ’70s, ’80s and well into the ’90s. The only thing you saw on your cell phone was a phone number, if you had a cell phone at all. As I pointed out in my column on computer vision, all near tasks decrease the blink rate, what people were reading was books, and the people who had time to read books were older, retired patients.
Let me tell you, if you think it is hard to get a Millennial to give up his or her iPhone, you never tried to tell a retired Greatest Generation patient to lay off the Zane Grey.
While elderly patients remain a large and significant source population for your dry eye clinic, the first great breakthrough in our understanding of the true extent of dry eye disease came from Allergan and the market research that was done just before the initial launch of Restasis (cyclosporine ophthalmic emulsion 0.05%). This coincided with the peak of LASIK surgical volume in the U.S., and for me came along at exactly the same time that I realized that a very particular cohort of LASIK patients was not performing as expected postop. Enter SkyVision’s favorite patient, “Linda Blair” (think: Exorcist).
‘Linda Blair’
The classic dry eye archetype for the last 15 years comes from this research. Dry eye, specifically dry eye disease caused by chronic inflammation, is a disease seen in a younger cohort. Linda Blair is a woman between the ages of 35 and 55 years. She is married, has three children and spent at least 3 years in school after high school. The family income is $75,000 per year. What makes her such an important patient is that you can make her better. We all know that inflammation is the underlying cause of a majority of dry eye disease. Inflammatory dry eye can be successfully treated, so we now know we can dramatically improve Linda’s symptoms.
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The marketing mavens at Allergan discovered that Linda is a three-generation medical decision-maker; she makes the decisions for the couple, their children and both sets of parents. In the days before social media, Linda was also a connector, in touch daily with a rather large number of friends and acquaintances. She was very happy to tell any and all of her fellow dry eye sufferers about the care she received from the eye doctor who finally made her feel better. Request to Allergan: Can we have some follow-up research of all of our “Lindas,” specifically how they behave on Facebook, Instagram and other social media sites?
Every patient
Until very recently, this is pretty much where the story ended. Your dry eye patients were elderly readers and women entering mid-life. Things are a bit different now because more and more of you have started to think like a certain washed-up ex-football player who kept saying stuff such as, “The most important metric in dry eye disease is symptoms.” In fact, dry eye is second only to ametropia as a cause of visual complaints. If you listen very carefully, you quickly realize that your dry eye patients can literally be anyone who walks into your clinic.
The microchip has essentially turned every single patient over the age of 14 years into a member of the virtual Zane Grey fan club. That, and decades of declining omega-3 fatty acids in the American diet, courtesy of the USDA and its nutritional guidelines.
It is the increasingly rare individual who comes to your clinic who does not use a computer for significant portions of the workday. Compounding this “screen effect” is the now ubiquitous smartphone. Not only is it a computer, it is a computer with a relatively small screen. As if this is not bad enough, people use their smartphones to scroll through stuff such as Facebook. Scrolling intensifies the “stare reflex” of the near task, not only decreasing the frequency of blinking but the amplitude of each blink itself. One only needs to do LipiView (TearScience) on a few teenagers complaining about fluctuating vision and nighttime blur to see how effectively scrolling on a smartphone reinforces this incomplete blink phenomenon.
What does this mean for us in the clinic? Once upon a time you could be on alert for a potential dry eye issue when an older pseudophake came for an exam. We know that the typical inflammatory dry eye patient is a younger adult woman entering mid-life. There is no mistaking the issue when Linda Blair is sitting in your chair with her eyes on fire. Contemporary disease state work by Shire, Allergan and others shows strong evidence of functional dry eye disease in a much younger demographic. The combination of the modern North American diet and the omnipresence of computer screens, both at work and elsewhere, means that literally every patient is potentially having symptoms that can be traced to tear film instability.
Be alert. Be prepared. Instagram makes every one of your dry eye patients a turbo-charged connector who makes the “Linda Blair” archetype look like a loner. They will be talking about their dry eye, and they will be talking about you.
- For more information:
- Darrell E. White, MD, can be reached at SkyVision Centers, 2237 Crocker Road, Suite 100, Westlake, OH 44145; email: dwhite@healio.com.
Disclosure: White reports he is a consultant for Bausch + Lomb, Allergan, Shire and Eyemaginations; is on the speakers board for Bausch + Lomb, Allergan and Shire; and has a financial interest in TearScience.