The long-established mind-body connection, wherein emotional and physical health are mutually entwined, is not a concept that we routinely explore in ophthalmology. However, the unique psychological features of dry eye disease (DED) are compelling reasons for physicians to view and treat the condition with a holistic mindset.
A MIND-BODY PROBLEM
DED’s effects on the body are all too familiar to eye care providers. Patients with this chronic, progressive disease often find their activities and comfort compromised by dry, gritty, burning, eyes; inflammation; and fluctuating vision. For many years, artificial tears were our only recommendation—and one we now know was insufficient to treat the disease.
DED’s effects on the mind are likely just as familiar. Affected individuals often experience frustration, anxiety, and depression. From my perspective, DED is uniquely susceptible to mind-body interaction for two primary reasons, outlined below.
No. 1: DED is ambiguous. Patients often do not get the validation they want from their doctors because DED is not a neatly packaged disease. A cataract is there one day and gone the next. An infection is treated. Glaucoma numbers go up and down. DED, however, has no gold standard test to verify the diagnosis; signs and symptoms may be classic or atypical; and it is a chronic disease with no clear beginning or end.
Adding to the ambiguity, treatment may take time to yield improvement, and that improvement can be difficult to detect. For patients who have suffered with DED long term, particularly before new tests and treatments became available, frustration is high, as the discomfort lessens temporarily but never seems to get better.
No. 2: DED fuels anxiety. The second reason I view DED as a mind-body disease is because it provides fuel for existing anxiety. In a disease of this nature, anxiety finds a unique opportunity to fill the void left by the absence of validation, objective testing, and progress markers. People who are naturally anxious struggle with the litany of failed attempts with drops, prescription drugs, and fish oils that can be costly and inconvenient without a guarantee of success.
Patients with DED are often frustrated with the process, and they feel anxious about there being no end in sight. They go from doctor to doctor, and the anxiety continues to build in the absence of validation and results.
In our profession, a common failure for DED management is to take a reductionist perspective: We see dry eye and inflammation and write a prescription. We must remember, however, that there is a person behind the eyes. The disease process occurs at tissue level, but psychological and social factors are at work. If we focus only on the ocular surface, we miss the opportunity to fully treat the disease.
A MIND-BODY SOLUTION
Taking a mind-body approach to treating DED involves not only addressing the inflammation and irritation on the ocular surface but also working to remove some of the ambiguity and anxiety associated with the disease. This involves testing that is clear and direct, therapies that inspire confidence as well as physical relief, and a social connection with a trusted doctor who understands the problem clinically and empathizes emotionally. Patients who suffer daily with DED find these measures to be encouraging—even exciting—developments.
Objectifying the disease. There is something naturally appealing about the tangibility of a diagnostic that validates the disease for patients. It gives them an understanding of what is happening and why they feel better or worse at later visits. It also validates the doctor’s commitment to a disease that has a frustrating effect on their daily lives.
The diagnostic tools available today for DED offer a long-awaited opportunity to provide patients with a picture or number that clearly pinpoints their disease. Tear osmolarity testing and point-of-care tear chemistry tests provide numbers that we can capture at baseline and at subsequent visits to measure progress. Imaging of the lid margin with meibography reveals the atrophied and blocked glands in a format that patients can easily appreciate.
Device-based therapy. Just as diagnostics reduce the ambiguity of establishing a diagnosis, therapeutic devices give patients a concrete framework within which they can understand their treatment. Unlike eye drops, which require regular patient compliance and self-motivation, devices offer a tangible, innovative look and feel as well as a schedule of treatment dates and an opportunity to be treated directly by the physician, all without the challenges of drop compliance. Patients who have gone from doctor to doctor and tried all traditional therapies—artificial tears, punctal plugs, and prescription medications—are relieved to hear a doctor explain the mechanism of action and take treatment into his or her own hands.
In my practice, I am a proponent of performing intense pulsed light (IPL) therapy for DED. IPL is different from other device options in that it may manage inflammation—the root cause of dry eye—rather than treating the downstream effects of inflammation, such as clogged meibomian glands. Without addressing the root cause, those downstream events will recur unabated.
Doctor-patient connection. When a doctor is with the patient, applying treatment, rather than spending a few minutes and writing a prescription, there is a natural cultivation of the doctor-patient relationship. Many dry eye patients have seen multiple doctors without validation, understanding, or commitment to resolving their problem. They are suffering from that lack of connection. When they make that connection with a doctor who is treating them directly, it takes the onus off them to solve their own problem, relieving their stress and reassuring them that there is hope for relief in the near future.
IPL’s impact focuses on reducing the telangiectatic vessels that harbor inflammation in the lid margin and eye area. Patients undergo four to six treatments. Subjective results vary, with some patients experiencing relief after a single treatment and others requiring the full course.
Overall, the best outcome is a patient who feels happy with his or her results. When patients feel less burning and grittiness, see less redness, use drops less often, and possibly even start wearing contact lenses again, that effect on the body is an enormous boost to the mind.