What is the biggest treatment gap in dry eye and ocular surface disease care?
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One of the biggest challenges in dry eye care has always been getting the primary eye care population interested in treating ocular surface disease.
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I have been on advisory and speaker boards for almost all of the major dry eye medications, and one question has remained the same over the years: Why do so many patients who carry a dry eye diagnosis not receive prescription therapy? When I am talking to the audience on the topic of ocular surface disease, I am usually not trying to speak to why one medication may have advantages over the other but rather to encourage practitioners to take interest in just treating ocular surface disease in general. One of the biggest misconceptions out there is that the currently available treatments for ocular surface disease are minimally effective and take too long to take effect to make it worth the time investment to treat dry eye.
The end result is that most patients with dry eye go untreated until it is severe and symptomatic enough that they end up being sent to a specialist or a dry eye center. Until eye care practitioners are willing to sit and have a conversation with their patients and feel confident that a medication prescribed will be tolerable and effective, prescription therapy will struggle. Once practitioners feel like the interventions are rapidly beneficial and tolerable, then the willingness to address dry eye prescription therapy may be more widely accepted. The conversation with the patient is not short and not always fun, but it is necessary. If you are going to have that conversation, it helps to have good options to give the patient.
That leads to the second major gap in care, which is that we need a medication that works well and is well tolerated. We have several medications for dry eye, but in the real world, there is very little wow factor to them. Most of them are relatively slow in onset, and patient self-discontinuation is fairly common. It is rare that I get a patient who calls me and tells me they feel great just a few days after starting a new medication. Most patients do improve, but it can take several weeks to months for the medication to take effect. I tend to see the most improvement in patients on the less severe end of the disease, which speaks to the benefit of treating it early. Tolerability is key in keeping these patients on long-term treatment, and burning and stinging are commonplace in some of the commonly used medications. We are still looking for a medication that works consistently and quickly for the majority of patients that is also tolerable.
Dry eye specialists have been working for a long time to get comprehensive eye care providers more interested in treating ocular surface disease earlier, and it has been an uphill battle. Making dry eye care more enjoyable and more successful is a gap that we have not yet overcome.
Lastly, many patients, especially younger patients, do not like the idea of being diagnosed with a progressive disease that requires chronic treatment. Educating patients on the chronicity of dry eye and the effectiveness of early treatment are critical if we expect patients to be compliant with treatment. By taking a more positive approach that frames medication as a health benefit vs. treating a disease, I think we can get patients to understand the process and help them be more consistent with their medication.
Brandon D. Ayres, MD, is a cornea and anterior segment specialist at Wills Eye Hospital.
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