Eyeworld

DECEMBER 2023 | EYEWORLD | 57 C LESSONS LEARNED by Ellen Stodola Editorial Co-Director About the physicians Joseph Tauber, MD Tauber Eye Center Kansas City, Missouri Darrell White, MD Skyvision Centers Westlake, Ohio Dr. Tauber said you must control all the problems for the symptoms to be relieved. Your treatment plan must address what's wrong for each patient, he said, adding that it's at this point that he pauses to let the patient digest what he's just discussed. Dr. Tauber likes to show patients their meibography and possibly do a Schirmer test to help them understand all the information he has shared. After explaining which type of dry eye the patient has, Dr. Tauber said he will discuss the strategy for dealing with it. "I go through what I want each patient to do. For the water deficien- cy, this includes artificial tears, preservative-free tears, ointment at night, tear stimulants, punc- tal plugs, contact lenses, serum tears," he said. "While highlighting what I want them to do, I say, 'I want you to understand that we're not doing every single thing that could be done,' then I talk about excessive evaporation, where there's some nuances of how we treat that." For excessive evaporation, lid hygiene is number one. "No one is going to get better without adequate lid hygiene, and it's all about how you teach that," he said. "Everyone thinks that they know how to do warm compresses, but we teach a very specific technique. If they are reg- ular and effective at doing this, they'll be better in 2 weeks; if they're not regular or not doing it well enough, it's not going to work." It's important to stress that there is often no cure to dry eye, but there are ways to control it. There are a variety of patient types, Dr. Tauber said, and they all process the disease differently. There are people who want the symptoms to stop and don't care what's wrong. Other people need to understand what's wrong. There are also contributing factors that Dr. Tauber said might be important to mention. A lot of evaporative dry eye is related to rosacea. You can also talk about food triggers, and he will also mention the harmful impact of oral antihistamines. "We also talk about the role of preservatives with artificial tears," he said. A lot of strategies start with tear supple- mentation, then you have a choice between tear stimulation and treating inflammation (via prescription medications) versus tear retention E xplaining the nuances of dry eye and available treatment options to patients can be a challenge, especially when it comes to asymptomatic patients. Two physicians discussed how they approach dry eye patients, how they explain the different types of dry eye, and how they talk about avail- able treatment options. Joseph Tauber, MD Dr. Tauber frames his discussion on dry eye as a case where it is very important to understand exactly what is wrong. "The better you handle this conversation, the more it can enhance your practice," he said. "It can't be long because if you get too scientific, patients tune out, and it's game over." You have to tell patients something they don't know and convince them that it re- lates to what's going on with them. Dr. Tauber said he first does an exam. "Typically, I've done one imaging test looking at meibomian glands," he said. The patient may have a variety of complaints because there are many different forms of dry eye, and the initial conversation dives into those differences. He'll open with a discussion of how dry eye is very complicated. Many people think that dry eye simply means they don't make enough tears, but much more common is losing tears too quickly (by evaporation). Dr. Tauber will say, "Everyone has a gland that produces tears. Wa- ter is produced, washes over the eye, and there are drains on the inside of the eyelids. We also all have oil produced from tiny glands in every lid. Every time you blink, a little oil comes out of those glands and mixes with the water. Oils prevent evaporation of the water component of tears. If there's too little oil or it's too thick, that's when there is a problem, and you have too little oil in the tears and thus have excess evaporation. So for most people, they're dry not because they're not making enough water but because they're losing it too quickly." It gets more complicated, Dr. Tauber said, because 50–70% of people who have either low water production or an oil problem also have the other problem as well. This is what Dr. Tauber calls the "double whammy," and he said you need to define that first. Talking to dry eye patients continued on page 58

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