The sector has witnessed a stunning decade of research and development to treat dry eye disease, but even with this progress, Insight discovers some Australian optometrists have gone full circle with their approach to the disease.
Next year it will be a decade since the Tear Film and Ocular Surface Society (TFOS) launched Dry Eye Workshop II, a gathering of 150 global experts that represented a breakthrough in the world’s understanding and treatment of dry eye disease (DED).
That work brought a little-known condition into sharper focus for eyecare professionals and patients in Australia and around the world.
For many, DEWS II provided a vital roadmap, but almost 10 years on, a number of eyecare professionals in Australia are asking if the industry has perhaps veered off track in tackling the disease and whether it is really doing the best it can to help the sufferer in their journey.
Their thoughts, collected by Insight as part of a look into progress made on DED, appear to echo those of Dr Rolando Toyos, a world-renowned American DED expert who pioneered the use of intense pulsed light (IPL) in the treatment of the disease.
Dr Toyos, who visited Australia last year, acknowledged there are several tools eyecare professionals now have to tackle the condition. Those include state-of-the-art diagnostic devices, as well as artificial tears, eye drops and lubricants, prescription eye drops (ciclosporin), hot/cold compresses, eye lid scrubs, IPL machines, even radio technology equipment previously used in cosmetic healthcare.
These and other developments have helped many of the 700 million people around the world believed to be suffering from DED. Optometry Australia estimates that includes as much as 85% of this country’s population who have experienced it at some point, with almost one in five (18%) experiencing it frequently.
But during his Australia trip, Dr Toyos suggested that, despite the proliferation of products, the industry was still missing the bigger picture and underlying causes of DED.
“There needs to be an unlearning phase,” he said at the time. “For the paradigm shift to happen, we need a new crop of doctors trained in a new way and the older doctors to dump what they have learned previously.”
Those thoughts were supported by the eyecare professionals Insight spoke to.
They represent different parts of Australia but also different approaches to DED diagnosis and eye health, from public to private, regional and metro.
Despite those differences, they shared a common theme: the future of DED diagnosis and treatment is not necessarily about the next technological advance.
In fact, it’s quite the opposite – it’s back to the future.
It’s about looking past the latest device or pharmaceutical drops to better understand the patient in front of the professional.
It’s about gaining a better understanding of that patient’s background, environmental factors, even diet, and how these many factors might influence their DED.
It’s about something possibly even more precious to busy eyecare professionals: time. How to generate it and, possibly even more importantly, how to charge for it when issues with funding and bulk billing are so prevalent, and the nation is grappling with a cost-of-living crisis.
And it’s about taking more of a multi-factorial approach to not only diagnosis and treatment but also training for the next generation of optometrists and ophthalmologists.
Lastly, it’s about working with other medical colleagues, including GPs and dietitians, and maybe even embracing alternative therapies as part of ongoing treatments.
But the people we spoke to also agree on another important thing.
They believe that if an optometrist or ophthalmologist can take that time and open their minds to other pathways to better understand their patient, then DED represents an incredible opportunity for professionals to build long-term relationships with their patients, elevate their clinical practice, and drive commercial growth.
And that would be a sight for sore eyes – for the practice and the patient.
Forget AI – it’s about human insight
Ms Marilyn Stern, a consulting optometrist at Dry Eye WA who is a dry eye specialist with a special interest in DED, has learnt a couple of things during her career.
Firstly, that she loves Perth, even though it was never meant to be her forever home.
And secondly, that parts of the industry are not getting it right on DED.
On the former, the UNSW graduate moved to Perth in 1983 to start her career and then, when it came to considering a shift back to Sydney, discovered the jobs there had dried up, she would have to take a 25% pay cut, and also pay a third more for rent.
Decision made.
On the latter, Stern is equally forthright.
Dry eye diagnosis is not up to scratch, she believes, with professionals too quick to rush to conclusions.
“I hate to say it, but when somebody walks in and says they’ve got pain in their eyes, it’s almost automatic to say, ‘oh, it’s dry eye’, right?”
Like many others, Stern was inspired by advances made in the wake of the TFOS workshop in 2015. It laid the foundation for how DED was managed, and her eyes were opened by the possibilities on display and the opportunities to focus on what was previously a little-understood eye issue.
“I was at a conference and went through the trade section and discovered suddenly that you could do more for dry eye than we had been taught,” she says. “I saw an IPL machine and found out a little bit more about that, and thought, well, this is really interesting.”
She uses some of that advanced technology and equipment to help her diagnose and treat DED in Western Australia.
“The most important equipment that I have is my keratograph. It performs tear film analysing, which is a huge thing for figuring out whether it’s dry eye or not – you can take photos, you can track everything each visit – what’s happening, what’s improving, what’s not improving.”
She also conducts osmolarity tests, to measure the concentration of osmotic solution in the tear fluid, which helps determine the severity of dry eye.
But even more important than the new techniques and technology is working to build a greater, more holistic picture of the patient’s health, their circumstances, and environmental factors that may be influencing the issues with their eyes.
Forget artificial intelligence, says Stern, practitioners need to use their own intelligence and insights to create that image.
“It’s important to find out their general health, history of any eye surgeries, anything else that’s done with their eyes,” she explains.
“What are the environmental factors? Immune disease is huge, an important part of what’s causing dry eye health, gut health too. They all sort of cause a different form, it appears, of dry eye.”
Building that picture can take time in a busy practice, and time costs money.
But it is also an opportunity for private practitioners to carve out a profitable niche in a competitive industry with so many larger players.
Stern charges for the extra time she takes with her dry eye patients.
“Bulk billing is certainly good for pensioners and healthcare card holders, the ones who have serious problems, but otherwise, I believe that I am worth more than what Medicare tells me I am. So yes, I charge for it.”
She believes that extra time and aftercare work needed may not be as attractive to some of the bigger companies adopting a corporate model.
But for those who do take that time, the reward can be a better rapport with their patients.
“They do come back. Then they spread the word and that’s fabulous for getting new patients in amongst their family and friends,” Stern says.
It’s also about building a working relationship with other medical professionals. And keeping an open mind.
“Keep in touch with their GPs and let them know what’s going on. The patient may need to see an immunologist who can help get to the bottom of why this [dry eye symptoms] is happening.”
Stern recognises her views might be a little confronting for a sector constantly focused on the next big device or pharmaceutical advance.
“If you think that what I’m doing is ‘alternative medicine’, ‘alternative therapies’, well that takes a long time to be accepted in the medical and scientific communities.
“But I think more and more practitioners are going to catch on.”
Regions great for building a good rapport
One thing has Miss Jenny Kim very excited.
Radiofrequency technology. It has been used in the cosmetic health industry, to help improve skin tightness and texture. But Kim, an optometrist at the George & Matilda practice in Mudgee, NSW, has read about its applications in eyecare.
And she wants one.
The thermal technology is designed to deliver targeted bipolar radiofrequency energy to small delicate ocular zones, directly on the upper and lower lid, to address DED caused by meibomian gland dysfunction.
Kim has seen it in action, in Sydney. She’d love to get her hands on one, but it remains out of the grasp of a small optometry practice serving a regional town so far from the metropolitan centre.
For now, at least.
Knowledge about DED is also something that appears to diminish the further a person heads inland from Sydney.
Kim’s clientele is largely older and retired. As a dry eye sufferer herself, she’s passionate about the subject and has seen plenty of symptoms in her clinic that could add up to DED. But many patients are happy to put this down to older age, and a burden that must be endured.
“I’ve noticed patients in the regional areas tend to just learn to live with it,” she says. “So then every time I delve into questions about how their eyes feel, that’s when they confess, ‘oh yeah, my eyes have been itchy, but, you know, it’s okay, I just live with it all’, or ‘my eyes have been watery, I just wipe it away’.”
For those who do want help, Kim can offer preservative-free, lubricating eye drops/ointment and eye masks, as well as lid wipes or foam lid cleansers to treat blepharitis.
“Some patients are happy with that.”
Patients with more severe ailments, including Sjogren’s syndrome, might need to be prescribed with cyclosporine drops.
But for those needing access to more sophisticated equipment, treatment might mean a bit of a trip.
“There’s an IPL machine in Dubbo, which will be an hour and a half drive out,” she says, noting that her practice is hoping to get its own machine soon.
However, what the regional practice might lack in state-of-the-art DED technology, it makes up for in another important asset: time.
“The advantage of being out here in a rural region is building that rapport with patients and spending a lot of time gaining an understanding of their dry eye problem, and explaining the mechanism of their type of dry eye symptoms to help them comprehend why they are using a certain eye drop or requiring certain treatment.
“Patients appreciate this explanation and I’ve noticed it improves compliance too.
“So before you even start those treatments – diagnosing, asking the right questions and getting the right information is very important.”
For Kim, being a regional optometrist, she needs to be more flexible in finding solutions for dye eye sufferers.
“There’s only so much we can help relieve their dry eye symptoms with at-home treatments, because those products only provide short term relief instead of fixing the core problem,” she says.
“IPL and radiofrequency, they can help treat the core problem, but so can nutrition and diet, and understanding their medical history and any co-existing systemic conditions, which will help you guide the treatment process needed.”
That can bring rewards for even small regional practices.
“Word of mouth is really big in this sort of community. I had a patient who came back saying, ‘Oh, my friend used those drops and I feel like those drops will help me as well. Can you see if I have dry eyes?’”
Kim is optimistic about the future of DED diagnosis and treatment.
“Science is always evolving, and there’s always newer studies coming out as well. Even with radiofrequency technology – who would have thought that something for improving skin texture would be available for dry eye treatment as well?”
Optometrists ready to take ownership of DED
Ms Varny Ganesalingam is busy. She’s frantically typing up notes on a previous patient, looking around to see where the next interruption might come from, all while being interviewed by Insight.
That’s the life of the staff optometrist and lead DED clinician at the Australian College of Optometry’s busy Carlton clinic in Melbourne. She’s one of about 20 optometrists working across a number of specialties.
The focus on dry eye at the clinic started as a trial in 2021 and then moved to bi-weekly sessions in 2022.
Patients are largely Medicare and pension-card holders, and the disadvantaged living in Victoria’s vast catchment without access to private services.
That can mean an issue with their eyes is often not their only burden.
“You’ve got patients with co-morbidities, often with a lot on their plate; they have poor health literacy and mental health issues.”
Like many others, Ganesalingam was inspired by the work on DEWS II, and in particular that of fellow New Zealander, Professor Jennifer Craig, who played a prominent role during the workshop.
“She was kind of my guru, and I ended up doing my master’s thesis under her, looking at ocular surface inflammation in the context of dry eye.”
How to put dry eye into the right context has been an ongoing piece of work for the clinic.
“When I first started, we were checking for glaucoma or diabetic retinopathy first, so dry eye was a bit of a low priority – ‘you’ve got a bit of dry eye here, have some drops and we’ll see you in six months’ time’.”
Also, diagnosing, treating and explaining DED properly took up time in a busy public health centre used by patients with complex needs. Charging for that extra time can be a challenge as well, with Medicare and bulk billing struggling to reflect the true cost of time and energy expended.
But she says the “mentality is changing” and there is a recognition now that DED does have serious impacts on quality of vision and life, and that more time spent understanding patients is important.
Another issue is a lack of top-line equipment. Ganesalingam and her team have access to an OCULUS Keratograph 5M machine for diagnosis, and a Lipiflow Thermal Pulsation device to treat meibomian gland dysfunction. But patients needing IPL treatments are told they may need to go elsewhere, although there may be funding for this in the near future – “it’s a work in progress”.
Despite all of these challenges, she believes optometrists, in particular, could take ownership for the diagnosis and treatment of DED.
“General ophthalmology seems to not be too interested in managing these patients, because it’s not something that can be surgically remedied,” she says.
Realising that opportunity needs commitment, investment in “a few pieces of kit” and understanding that it’s not just about sending the patients off with a few eye drops.
“Dry eye is multifactorial, so unless we’re coming at it from multiple angles, looking at all factors potentially feeding into their symptoms, we’re not helping them.”
Again, that’s about taking the time and asking the right questions.
It’s also about collaboration with other professionals.
“Lots of patients at our clinic have underlying conditions that provoke their dry eye, whether it’s the condition itself or the medications that they’re taking for it; you have to be in consultation with their specialists for a more holistic approach.
“It’s got to be a collaborative effort if we’re doing that kind of patient-centric care, which I think is the ideal scenario.”
That will need a change in training and also allowing optometrists to issue oral prescriptions.
“There’s two oral medications that are largely used in the dry eye space – Azithromycin and Doxycycline – both of which have been around for a long time and are unlikely to cause any major issues, especially at the sub-antimicrobial dosages prescribed in the context of dry eye, but of course the training is required for a safe roll-out of any increase in scope of practice.
“New Zealand have done it safely so I think Australia could too.”
So myriad challenges remain. But like the others interviewed by Insight, she believes that tackling DED and improving patients’ quality of life remains a great opportunity for her industry.
“I’m excited by the idea that dry eye could be an optometry area of interest.”
More reading
The Save Sight Institute Dry Eye Registry: Building the ‘big’ picture of dry eye
Re-writing the rules of dry eye management
Dr Rolando Toyos – Challenging dry eye dogma
