Staying the Course with Dry Eye Treatment

October 20, 2020

5 minute read

It can be difficult to determine if a treatment plan is not being followed due to non-compliance or non-compliance.


Disclosures: White reports consulting for Allergan, Shire, Sun, Kala, Ocular Science, Rendia, TearLab, Eyevance, and Omeros; is a speaker for Shire, Allergan, Omeros and Sun; and holds a stake in Ocular Science and Eyevance.

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Have you ever had one of these days? Or weeks? Heck, have you ever had one of those months where it seems like none of your dry eye patients are following the plan you agreed to 3, 4, or 6 months ago? Of course you have.

Darrell E. White, MD

Darrell E. White

It boggles the mind, at least my mind, that so many of my DED patients return to the clinic complaining of a number of classic DED symptoms, and yet they admit that they have not treated their disease as I thought. Part of the problem is clearly a matter of adherence: there are external barriers or challenges that make it difficult to follow a treatment plan. However, even though we are not supposed to use this term and what it implies, it has become clear to me that this failure to follow a plan is sometimes a compliance issue.

Patients make an active decision to chart an alternative course despite compelling evidence that what they are doing is not working.

This is by no means a new phenomenon. Our colleagues in rheumatology, neurology or pain management would share a knowing wink with us. DED is actually a chronic pain syndrome that has a lot in common with various types of other inflammatory pain syndromes such as arthritis. Once aberrant sensory patterns become established in the central nervous system, DED appears to behave in a manner similar to fibromyalgia, another poorly understood disease marked by both chronic pain and difficult to understand behavioral patterns. understand for a treating physician.

Yet, having identified these areas of overlap, I find it useful to examine each of the “independent thinkers” and try to guess where they stand on the adherence/compliance scale. What barriers prevent them from staying on a particular treatment plan? It can be infuriating. Check that: It’s still infuriating. Whatever the reason they stopped their treatment plan, you’re looking at a huge time sinkhole for this visit. Nevertheless, to have a chance to successfully improve the symptoms of these patients, you will have to spend time at least once. Doing it in a logical, non-judgmental manner as much as possible will give you the best chance of success.

Our EMR will sometimes make it difficult to discover the most important historical details. No matter how good your techs are at taking a history, when the first paragraph on the computer is mostly about what the patient isn’t doing, you have to sit down, turn away from the screen, and do the exam on the screen. ‘Ancient. Take a moment to look at the actual symptom survey to see if there are any clues in the details that might not show up in the score. Breathe deeply; remember, you’re going to be here a while. The most important question is the first one because it will set the tone for the rest of the visit: “So, Madame Pistolacclioni, how are your eyes? Make that first inquiry about them. If your first question is about you and why your patient didn’t follow your plan, you’ll double the time it takes.

Also, you never know; sometimes your patient is not non-compliant or non-adherent. They feel really good!

No matter how long I do this, I am regularly reminded of the American (read: developed world) medical mindset. We live in a Tylenol society. If you have a headache, you take a Tylenol and in 30 minutes your headache is gone. As a company, we believe in the “cure” philosophy, especially for diseases with significant symptoms. No matter how much education you provide, some of your patients simply won’t understand the chronic nature of DED and the need for ongoing treatment. If your exam continues to show objective improvement that is consistent with symptomatic relief, your conversation has just become equal parts celebration and how can we continue to celebrate. This visit usually ends well.

Most often, this is when your patient tells you that he feels bad. They really want to blame you for that, of course. At this point in the examination, it is entirely reasonable to point out to him that he did not follow the procedure agreed upon during the previous visit and to ask him why. Your choice of therapies may indeed prove to be ineffective, but at this precise moment, neither you nor your patient have any means of determining that. Were there forces beyond their control that prevented them from following your instructions? It implies an inability to do so; they didn’t follow the program because the external barriers were seemingly insurmountable. Maybe there was an insurance coverage issue, either real (they didn’t pay their deductible) or suspected (the pharmacist gave them the list price of their immunomodulator and they left). Maybe a bottle or dropper is too difficult to use. Stuff like that. As difficult as it is to re-immerse and restart, non-adherence is usually overcome with gentle education, encouragement, and (unfortunately) completing a pre-approval.

Non-compliance is much trickier. By definition, this involves a deliberate choice on the part of your patient not to follow your recommendations. Once upon a time, “compliance” was the catch-all phrase used to describe all instances in which a patient did not follow instructions. The implication of patient choice explains the rationale for abandoning this use. However, in some cases (unfortunately common in DED and other chronic pain syndromes), patients choose not to follow a plan. Rarely, you may discover a fixable solution. For example, vegans may not even be comfortable using HydroEye (175mg fish oil per dose; ScienceBased Health), so a firm switch to intense pulsed light is an option. Non-adherent and non-compliant patients may experience drug side effects such as stinging and burning upon instillation. Both need coaching if these are mild in severity and/or short in duration.

Why does your patient not accept your treatment? It seems to me there’s something really different about thought processes when you’re in near-constant discomfort. Despair and fear seem to create mistrust. You, the doctor, cannot escape the feeling of being tested, of being judged. It seems that this visit almost always includes a discussion of why you chose a particular treatment over the one they found on WebMD. The second surprise notice might appear towards the end of the visit. I think it’s important to listen to that patient explain why they didn’t comply, and then it’s just as important to firmly restart your chosen therapy.

If you’re the first or second DED doctor they’ve seen, be prepared for them to leave your practice. It’s OK. If you’re #3 or #4 (or #7 or #10), your strong belief in the process can give them the confidence to commit to following your plan. These visits are always exhausting. Always hard. At the end of the day, always defuse. Never argue. Defend your care journey impartially and assert that the patient always has the final say. Remember that you are not the one who has the disease, you are the one who is committed to helping him overcome his symptoms. It should never be personal.

Patients don’t always follow our suggestions. Patients with DED tend to take this route more than those with other diseases such as glaucoma or macular degeneration. Determining that their deviation from plan is due to success, non-adherence, or genuine non-compliance can help you set the tone for how those very difficult office visits unfold.

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