Trends often dictate what is offered in the marketplace. We live in a consumer-driven society and as niche markets develop in scale and penetration, new offerings are introduced, constantly stimulating a market that is easily encouraged and engaged. At times, the offerings respond to an unmet demand and more often, offerings create consumer demand. Did you know that you really and truly needed gluten-free chocolate-covered mango chips, for example? Whilst walking down the streets of my town, Paris, traditional boutiques or even – gasp – pâtisseries, are being replaced with co-working spaces, vegan restaurants or even athletic centers, all the manifestations of certain market trends. The latter is the most shocking to imagine with the cultural shift of a Parisian wearing athletic and leisure wear in public.
How is this related to ocular health? There suddenly seems to be a trend of dry eye clinics opening around the globe, and, despite the fact that they have not been mass-marketed their waiting lists are laden with patients desperate for a remedy. So the latter serves as an exception to the trend-driven offerings because, in this case, there is a genuine call-to-action for focused dry eye care and the market is responding to an unmet need, creating consumer demand.
In the ideal world, every doctor would curate an intimate relationship with a patient from birth, thereby fairly guaranteeing preemptively diagnosing dry eye symptoms, And in this still elusive fairytale world, doctors would also wield a magic wand, the quintessential tool of magicians, that could diagnose and cure a patient in one light-hearted attempt.
Life, is not, however, a chapter from Harry Potter. Broken bones are not as easy to fix as one would assume from watching Tom & Jerry cartoons. And doctors are mere humans with respective faults and limitations, who are still learning each day.
Many would agree that the ophthalmic industry needs to educate doctors more profoundly in their quest to understand, diagnose and treat dry eye and, in parallel, said industry needs to provide patients with more support, both practical and emotional. Within this context of a market need, coupled with a true optimism and desire to drive change, Dr. Etty Bitton, Associate Professor at the Ecole d’Optometrie (School of Optometry), Universite de Montreal, and Director of the dry eye clinic has proven to be an innovator in Canada.
Dr. Bitton’s perspective is a privileged one because she studied at both Canadian optometry schools – one teaches its curriculum in English and the other in French. As we are aware, with language comes a degree of cultural differentiation. Hence, Dr. Bitton has been able to note differences amongst eye doctors in Canada over the years, working to coax and merge the positive elements from this contextual duality.
The university where she teaches, Université de Montréal, École d’optométrie (University of Montreal, School of Optometry), was the first in North America to open a “dedicated” dry eye clinic within its premises. As imagined, it was both niche and quite revolutionary in 2012, a period during which dry eye barely yet deemed a disease. Dr. Bitton developed the clinic for a number of reasons, but one primary motivation was so that she could coach, encourage and influence students; in other words, teach the next generation of optometrists through practical rather than didactic teaching. In addition, she wanted the clinic to be a referral clinic, so that it could be seen as a resource for the local eye care community and not viewed as “taking patients away from practitioners.” Last, but not least, was the need to have a dedicated clinic to address patient’s need for dry eye management. Dr. Bitton views the “common thread between these goals as education for not only students, but also colleagues and patients on dry eye.
There was no marketing campaign linked to the clinic’s launch. There was not a social media explosion. There weren’t even any balloons. Yet there was a quickly growing waiting list, one that only became longer as more eye care practitioners became aware of its existence and referred their more challenging cases. As a result, the clinic quickly shifted from opening half-day, once-a-week, to two days per week. Laughing, Dr. Bitton suggested that she would be happy to offer more days if she could successfully “clone herself.” As we increasingly realize, dry eye has an impact on daily activities (reading, driving, digital device use and even ocular surgical) and as such, Dr. Bitton reflects on a casual effect: “both practitioners and patients are becoming more aware of the impact of dry eye on their quality of life and are seeking for management options, increasing the need for dry eye clinics.”
Although screening for dry eye has existed for quite some time, traditionally, it has been underscored and management was limited to eye drops, coupled with a brief follow up during an annual eye examination. As a result of a compelling increase in scientific information (TFOS DEWS report, TFOS MGD report, TFOS Contact Lens Discomfort report, etc) and a movement in technological innovations (instruments and management options), doctors have more tools at their disposal for dry eye management.
Dr. Bitton expects doctors to “raise the bar” when examining dry eye in the same way that practitioners modified their clinical approach to glaucoma management. With glaucoma, if a suspicion is raised during an eye exam, the patient is typically asked to return for glaucoma-work (ie. visual fields, pachymetry, optic nerve imaging). Dr. Bitton encourages practitioners to adopt this practice for dry eye as well, having their patients return for a specific “dry eye work-up.”
Of course, this begs the question;What constitutes a dry eye work-up? Dr. Bitton demonstrates “it is no longer limited to tear film stability and looking for corneal staining, although both these parameters remain important. Advances in instrumentation have allowed us to target specific parts of the tear film, such as the lipid layer or imaging the meibomian glands to gain a better understanding of the cause of the dry eye.” So in summary, dry eye needs to be approached similarly to glaucoma, with validated tools and evidence based information.
As such, Dr. Bitton pushes fellow doctors and students to continually screen patients for dry eye during their annual visit and then create a clear follow up strategy for a dry eye work-up. She asks practitioners to reflect on these questions;
- Are you ready? Have you updated your knowledge on dry eye recently?
- Do you have the latest instrumentation for dry eye in your practice? Are you ready to invest in them? Do you know how to integrate them into your practice?
- Is your practice onboard? Does your staff/personnel know what you want for dry eye work-ups and follow ups (scheduling of appointments? Dedicated time slots? Patient information? New products?)
- Do you have validated tools? Many practitioners add a few screening questions on dry eye to their homemade questionnaires. It is time to upgrade to validated dry eye questionnaires (there are several available).
By asking questions and by being prepared, Dr. Bitton demonstrates that dry eye clinics can foster a new approach for dry eye management, one that is systematic and evidence based.
Beyond the quantitative elements associated with dry eye management, however, a certain type of personality is needed to work with dry eye patients, as many require a lot of education. Many patients have “doctor-hopped for years, self-medicated with a plethora of eye drops to no avail, and have not been compliant with recommendations.” Some practitioners argue that dry eye consumes too much chair time and is not financially feasible for their practice, but Dr. Bitton disagrees. If you structure your dry eye clinic properly and you have a patient-focused approach, they will be some of the most appreciative patients you’ve ever had and you will receive numerous word of mouth referrals, especially if you are savvy with social media!
In this light, Dr. Bitton has teamed up with doctors who are extremely empathetic, patient, and dedicated listeners who have a strong understanding of the psychology associated with symptomatic patients. Some of the challenges that practitioners face when managing dry eye can follow into some of the following categories defined by Dr. Bitton: patients who are skeptical of their diagnosis (i.e. I can’t possibly have dry eyes, if my eye is continually tearing”), ones who don’t believe that dry eye exists and “fight you on it” (i.e. It must be these new glasses. I don’t see well when I’m reading), ones who just want you to “fix” it (“there must be something you can do, I can’t continue to live like this”), or ones that fall into a depressive state as a result (I’ve stopped reading/knitting because I just can’t keep my eyes open very long”). Learning to navigate through these feelings requires patience and proper patient education of dry eye disease and its associated factors.
Collectively, on a world basis, Dr. Bitton notes, “We still have a momentous task in bringing further awareness on dry eye and how to manage this common disease. More importantly, practitioners need to relay a simple, yet important message to the public and health care agencies of who impact the tear film is on overall vision and its impact on quality of life.” She is trilled to see the trend in dry eye clinics opening up globally and asks you the following question: Now its your turn to roll up your sleeves and educate others so how will you address dry eye in your practice?
TFOS Staff Writer
