Dry Eye Dx and Tx

Pearls for Prescribing Artificial Tears

BY AMBER GAUME GIANNONI, OD, FAAO

Virtually all of the patients who come to our Dry Eye Center have already experimented with using over-the-counter artificial tears (OTC-ATs). The overwhelming majority also tend to report that OTC-ATs were the only therapy ever recommended by previous practitioners, albeit with little direction regarding type or brand. Although there is often much more that we can do for our dry eye patients, in some cases OTC-ATs may be the most appropriate therapy. However, past failures can leave patients less than optimistic with your plan. What can we do in these cases to gain patients’ confidence?

Succeeding with OTC-ATs

Following are pearls for succeeding with prescribing OTC-ATs.

Educate yourself. If you haven’t kept up with the extensive artificial tear market, now is the time. Some tear supplements (e.g., oil-based ones) may be better equipped to address evaporative forms of dry eye compared to other brands (DiPascuale et al, 2004; Khanal et al, 2007; Korb et al, 2005). If you don’t know the best OTC-AT for your patients’ specific type of dry eye, you might be setting them up for unimpressive results from the beginning.

Educate patients about their dry eye condition and why a particular drop will work for them. Educated patients have more “buy-in” and are more likely to adhere to your prescribed therapy.

Recommend one specific artificial tear (unless you need one drop for daytime use and a more viscous drop for nighttime use). Practitioners often give patients multiple drop samples to “see what works best.” Unfortunately, this method does not require patients to commit to any specific drop for enough time to adequately determine whether it addresses their symptoms. Patients also tend to get confused as to which drops they’ve tried, which one worked best, and which didn’t work at all. Additionally, it promotes the misconception that all OTC-ATs are interchangeable, leading them to purchase the least expensive brand on the shelf and to question why they needed you when they could have purchased several brands on their own.

Write a prescription. Writing a prescription, even for OTC products, sends patients a strong message that you have given their disease state serious consideration and that all drops are not created equal. Additionally, written communication in your chart will eliminate the guesswork for both parties as to what was recommended or sampled in the past.

Pre-book a follow-up appointment. I believe this may be the biggest mistake that practitioners make when treating any stage of dry eye. Patients often report that past practitioners never required them to return unless they didn’t improve. This puts all decision-making into the patients’ hands (who’s the practitioner?) and sends the message that their complaints were not important enough to warrant a follow-up visit. It also incorrectly leads patients to believe that if their symptoms don’t improve, there is nothing further that you can do.

Pay attention to concurrent medications. Patients taking other topical prescriptions, such as glaucoma medications, are likely already frequently dosing with benzalkonium chloride (BAK)—a preservative known to cause corneal compromise (Baudouin and de Lunardo, 1998). These patients should be using nonpreserved artificial tears, which of course are more expensive. Again, proper patient education is paramount for compliance. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #222.

Dr. Gaume Giannoni is a clinical associate professor at the University of Houston College of Optometry and is the director of the Dry Eye Center at the University Eye Institute. She also sees patients in a private practice setting and has received authorship honoraria from Bausch + Lomb.