Margaret Lam BOptom
NSW president, Cornea and Contact Lens Society of Australia
Visiting lecturer, School of Optometry, UNSW
Director, theeyecarecompany Sydney NSW
A transition is underway from the commonly used term ‘compliance’, meaning submitting to the authority and directions from a medical professional, to ‘adherence’, implying greater ownership by the patient of their own care and an emphasis on shared decision-making in a patient’s management plan.
Semantic dispute aside, non-compliance is a major obstacle to the effective delivery of health care. True rates of non-compliance are hard to measure but the best estimates find that irrespective of disease, prognosis or settings, about 30-50 per cent of patients are non-compliant.1,2,3,4,5
When it comes to dry eye management, Swanson has shown that patients with dry eye disease will have a natural tendency to not adhere to a prescribed management plan from their eye-care practitioner, but will largely self-medicate according to their symptoms.6
Patients believe that non-compliance does not cause life or death consequences, yet we know that their non-compliance can exacerbate dry eye symptoms, which can lead to a debilitating, painful and severe condition.
Figure 1. Vertical breaks in the tear film are indicative of evaporative dry eye and therefore, it is worthwhile emphasising the necessity of the use of ocular lubricants
It has been shown that lower compliance can be expected in many situations: when a health condition is chronic, if the course of symptoms varies or when symptoms are not always apparent, if a regimen requires complex instructions, and when a treatment regimen requires lifestyle changes.7
Any one of these factors can produce a considerable challenge in disease management. In dry eye disease management, all of these are factors. Compounding this, the patient may sometimes simply have difficulty with fundamentally understanding their dry eye condition.
Engaging a patient with a relatable analogy is one of the keys to a successful take-home message and adherence. Having had no time to repair my car’s windscreen wiper’s pump and lubricating system for more than a year, I was often subjected to the god-awful screech of the dry windscreen wiper. I have found that is an effective analogy for dry eye.
Prescribe preservative-free ocular lubricants
It is well established that the use of ocular lubricants is useful in reducing both symptoms and clinical signs of dry eye;8 however, there is also considerable evidence on the disruptive and damaging effects on the corneal epithelium and ocular tear film of preservatives in ocular lubricants, particularly benzalkonium chloride (BAK).9,10
Newer preservatives have a slightly better safety profile but do not entirely prevent damage to the corneal epithelium.11
It has been recommended that because preservative effects disrupt the corneal epithelium at higher concentrations, use of eye-drops containing preservatives should be limited to no more than 4-6 times a day.12
Although we know preservative-free ocular lubricants represent best practice prescribing, continual use of preservative-free ocular lubricants for patients can be a considerable hindrance due to the increased cost—especially for patients who require multiple treatment types to address the causes of their dry eye syndrome.
This is where preservative-free ocular lubricants such as Hylo-Fresh (0.1% sodium hyaluronate w/v, 10 mL), and Hylo-Forte (0.2% sodium hyaluronate w/v, 10 mL) play an essential role in the management plan for dry eye patients.
Sodium hyaluronate is the active ingredient in Hylo-Fresh, which is perceived by patients to be ‘lighter’, and Hylo-Forte, which is four times more viscous and lasts longer but potentially causes blurriness on instillation. It is a naturally-occurring lubricant that is normally synthesised in the body for joint lubrication.
The continuous mono-dose (COMOD) application system, which can be challenging for patients to master initially, is innovative in that it ensures no ‘backwash’ on application and so can provide a preservative-free lubricant for up to six months from first application.
It is important to note that it is best prescribed to patients by demonstrating the COMOD pump, with its one-way delivery valve applied much like an asthma puffer. Each bottle contains 300 applications, or 150 for each eye.
This medical care model is evolving for optometry. I encourage optometrists to engage more frequently with patients in a dynamic, responsive way, which will allow for more open discussions on the importance of adherence and how it can be improved.
When patients and optometrists work with agreed management guidelines, it allows for the implementation of new treatments that can make better outcomes possible, such as preservative-free ocular lubricants.
The first step towards improved patient outcomes for those with dry eye disease is willingness on the part of the optometrist to engage and educate their patient, and a patient willing to adhere to the agreed management plan.
1. Morris LS, Schulz RM. Patient compliance: an overview. J Clin Pharm Therap 1992; 17: 183-195.
2. Sackett DL, Snow JC. The magnitude of compliance and noncompliance. In: Haynes RB, Taylor DW, Sackett DL, eds. Compliance in Health Care. Baltimore: The John Hopkins University Press 1979; 11-22.
3. Lassen LC. Patient compliance in general practice. Scand J Prim Health Care 1998; 7: 179-180.
4. Donovan JL. Patient decision making. The missing ingredient in compliance research. Int J Tech Assess Health Care 1995; 11: 443-455.
5. Griffith S. A review of the factors associated with compliance and the taking of prescribed medicines. Brit J Gen Prac 1990; 40: 114-116.
6. Swanson M. Compliance with and typical usage of artificial tears in dry eye conditions. J Am Optom Assoc 1998; 69: 10: 649-655.
7. Haynes RB, Taylor DW, Sackett DL. Compliance in health care. Baltimore, Md: Johns Hopkins University Press, 1979.
8. Moshirfar M, Pierson K, Hanamaikai K, Santiago-Caban L, Muthappan V, Passi SF. Artificial tears potpourri: a literature review. Clinical Ophthalmology 2014: 8 1419-1433.
9. Furrer P, Mayer JM, Gurny R. Ocular tolerance of preservatives and alternatives. Eur J Pharm Biopharm. 2002; 53: 3: 263-280.
10. Charnock C. Are multidose over-the-counter artificial tears adequately preserved? Cornea. 2006; 25: 4: 432-437.
11. Lazarus HM, Imperia PS, Botti RE, Mack RJ, Lass JH. An in vitro method which assesses corneal epithelial toxicity due to antineoplastic, preservative and antimicrobial agents. Lens Eye Toxic Res 1989; 6: 1-2: 59-85.
12. Asbell PA. Increasing importance of dry eye syndrome and the ideal artificial tear: consensus views from a roundtable discussion. Curr Med Res Opin 2006; 22: 11: 2149-2157.