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European optometrists could play key role in shared-care management of dry eye disease
Modern management of dry eye requires a more specialized primary care approach, closer follow-up and counseling for chronic cases.
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A survey carried out in the Netherlands found substantial differences in the way optometrists and general practitioners approach dry eye, raising concerns about the consistency of patient care.
The survey was sent to 1,471 general medical practitioners with a 7% response rate and 870 registered optometrists with a 17% response rate. Questions covered interpretation of symptoms, knowledge of causative factors, diagnostic means and management of dry eye.
“Almost no agreement between the optometrists and GPs was found for almost all the questions,” Mirjam van Tilborg, MSc, BOptom, FAAO, FEAOO, first author of the study, told Ocular Surgery News.
According to the survey, general practitioners diagnose dry eye on the basis of subjective complaints and clinical observation. Most of them regard dry eye as a problem mostly related to age, work or contact lens wear. Optometrists seem to be more aware that there are a number of other causes, such as low humidity environments, computer work, allergies and stress, and have a more holistic view in which different factors contribute to trigger or worsen dry eye. They know and use a range of diagnostic tests and are aware of the various therapeutic options, including punctum plugs and meibomian gland expression.
“We also found that optometrists are very interested in dry eye, and many want to specialize in this specific condition,” van Tilborg said.
A new model for shared care
In the Netherlands, dry eye patients are mostly taken care of by family doctors who give them guideline-driven tear substitutes. Only the more severe cases are referred to an ophthalmologist, who may prescribe more specific treatment and see patients again a few times thereafter.
“There is something missing there in terms of prevention, diagnosis and proper follow-up. The overall management of these patients should be reorganized, taking into account that dry eye is a highly debilitating, chronic condition that affects all aspects of daily life. How much these patients suffer, and how much could be done by prevention and regular follow-up, is grossly underestimated,” van Tilborg said.
van Tilborg is a highly specialized optometrist with a specific interest in dry eye, and she believes that optometrists could play a key role as part of a shared-care model aimed at improving the quality of patient care and optimizing resources.
“What I am thinking of is something very similar to what is already done here in the Netherlands in the shared care for diabetic patients in which the optometrists search for diabetic retinopathy in outpatient clinics. In this shared care system, the responsible GPs act as the director,” she said.
Optometrists could be involved in primary care by making a first diagnosis for all patients who report dry eye symptoms and will work together with the general practitioners. They could then refer to the ophthalmologist the more severe cases who need steroids or other prescription drugs, while taking care of the mild cases themselves.
“For many of these patients, even mild to moderate cases, the impact of dry eye on everyday life is so huge they need close follow-up, frequent counseling and guidance. This is something we could take care of, something we cannot ask the ophthalmologists to do in their practices. We could also help with severe cases by making ourselves available for whatever we can do in the follow-up,” van Tilborg said.
Prevention is another key aspect that should be empowered. More and more people are spending time in offices where artificial lighting, heating, air conditioning and long hours at the computer alter the balance of the tear film and ocular surface.
“I do think that we can take care of prevention. Some good advice on how to reduce the impact of environmental triggers, plus one or two drops a day, can help keep the mild cases mild, reduce the moderate to mild and make life better. People with dry eye experience a lot of distress and anxiety at work, and there is no care system behind them. I tell my patients I cannot cure their condition but can take care of it so that it does not interfere with their life,” van Tilborg said.
Education and awareness
Implementing education and raising awareness on dry eye are also important factors.
“I have been interested in dry eye since 1996, but nobody cared much in the beginning. Eye care practitioners were not listening to me, and many refused the idea of dry eye as a disease. But the time is ripe now for a more structured approach where we recognize dry eye as a chronic disease and work together,” she said.
With the aging of the population and the raising of retirement age, taking care of dry eye will become a growing priority.
“This cannot weigh solely on the shoulders of ophthalmologists,” van Tilborg said. “We need to define the specific competencies and tasks, and build reciprocal trust.”
“I also aim at involving occupational health care physicians and facility managers in the prevention aspects, such as taking care of temperature and humidity in the buildings,” she said.
van Tilborg is actively engaged in finding the right shared-care approach to dry eye and hopes she will be able to make a contribution regarding dry eye care in the Netherlands. – by Michela Cimberle
- For more information:
- Mirjam van Tilborg, MSc, BOptom, FAAO, FEAOO, can be reached at the University of Applied Sciences, Research Centre for Innovation of Health Care, Research Group for Demand-driven Care, Hogeschool Utrecht, Heidelberglaan 7, 3508 AA Utrecht, Netherlands; email: mirjam.vantilborg@hu.nl.
Disclosure: van Tilborg reports no relevant financial disclosures.