by Jennifer L. Stewart, OD
As optometrists, our role as primary care doctors is often overlooked. However, we are often the first line of defense for patients presenting with specific ocular complaints. For women, we can play an essential role, as many of the complaints they have are unique in that they combine the ocular surface with women specific conditions. Our role in their care may be identification, education, treatment or co-management, or any combination.
I truly enjoy my role as a primary care optometrist. I especially enjoy the connection I have with my female patients, especially when identifying issues that are caused by underlying conditions. The “aha” moment a patient has when I ask about other systemic symptoms, and the connection between other health issues and their eyes is a great moment. Patients often remark, “I had no idea my redness/dryness was related to something else!” I tell my patients the eyes are connected to the whole body, and my role as their doctor often goes beyond just their visual system. I have been able to develop wonderful connections with my patients, garner a number of referrals which serve to grow my practice, and have a large network of physicians, nurses and specialists that I co-manage with. I urge you to look beyond just the ocular complaints with your female patients and embrace your role in their primary care.
Dry Eye Disease
In recent years, there have been great advances in understanding dry eye disease (DED). It is estimated that over 30 million Americans have symptoms of DED, and only 16 million Americans have been diagnosed. Dry eye disease can vary between patients, and can include burning, tearing, foreign body sensation, stinging, grittiness, photophobia, blurred vision, tired eyes, redness and contact lens intolerance. DED is a multifactorial disease of the ocular surface that can affect visual function and quality of life. Many patients present to our offices because of the way their eyes look, or because they are unable to wear their contact lenses for as long, or at all.
For women in particular, one of the areas researched is on the effect of hormones on dry eye. I have a large dry eye practice at my primary care office, and my primary group that I work with is women. Often women have no idea that there can be a correlation between their symptoms and their changing hormone levels. This can include birth control pills, pregnancy and menopause. Part of our job as primary care doctors is educating these patients that what they are experiencing can be normal, and treatable- but first must be properly diagnosed. The relationship between DED and estrogen is not simple- researchers are looking at both low and high estrogen states, as well as levels of androgen and other sex hormones in DED.
For our patients taking oral contraceptives, including synthetic estrogen and progesterone, we must be aware that they may have an increase in DED symptoms. As research unfolds to determine why this occurs, we must continue to be aware of the possible relationship and how it affects our patients.
Our patients in the menopausal and post-menopausal age group may have increased complaints about dry eyes. This is believed to be due to the changes in balance of sex hormones. Estrogens and androgens are important in the production of the layers of the tear film, including the aqueous, mucin and lipid layer. As these hormone levels decrease, there can be tear film instability, increased tear film osmolarity, and ocular surface inflammation. While the exact relationship between sex hormone levels and clinical symptoms is unclear, we can play a large role in these patients feeling better. Prompt referral to their provider to discuss hormone replacement therapy (HRT) is one option. In our offices, we have an abundance of treatment options, including prescription and non-prescription topical and oral treatments, as well as in office therapy.
False lashes/lash extensions, make-up and other products used can affect the ocular surface and cause dryness, irritation and infection. Patients should be educated in proper cleaning techniques to prevent symptoms and infections and help keep their ocular surfaces clean.
There are several cleaning products available, including a number developed by optometrists (We Love Eyes and HEKA Clean). Patients should be instructed in proper use and care, especially in the case of lash extensions. Timely disposal of makeup, cleaners and makeup brushes should also be discussed, especially with chronic or frequent infections. Many OD’s go a step further and also discuss proper makeup, cleaners and products to be used to help with allergies or when wearing eyelash extensions. The use of high-resolution lid photography may be helpful to show patients what our lids and lashes look like so they understand the importance of proper lid hygiene.
There are a number of systemic conditions that predominantly affect women, and can drive them into your office. These include Sjogren’s disease, Grave’s Disease, thyroid eye disease, Hashimoto’s thyroiditis, lupus, and rheumatoid arthritis. We need to be aware of the roles these diseases play and communicate properly with our patients and their specialists.
Taking a thorough patient history, including current medications is key for our patients. Many women have a higher likelihood of systemic diseases that can present with ocular ramifications (see above). These diseases and conditions are often managed with medications that also need to be monitored in our offices. Prompt identification of these medications, patient education and proper communication with other practitioners shows that we are part of their medical team.
Paying careful attention to the needs of our female contact lens patients is critical. With the newest technologies in material, design and modality, contact lens dropout can be significantly decreased. Our practice utilizes the entire clariti® 1 Day contact lens family to provide our patients with clear, crisp vision at all distances. We are also excited to utilize the Biofinity® Toric Multifocal for our presbyopic patients with astigmatism. MyDay® is also a great choice for my patients who need a soft, comfortable lens with high levels of oxygen permeability and good handling.
As optometrists, we are an important part of a patient’s health team. We are often the first one that patients present to with ocular conditions stemming from systemic diseases and hormonal changes, and we are in a unique position to both manage their complaints and co-manage with their specialists. We need to be well versed on some of the challenges women face, and be ready with education, treatment and compassion when they enter our offices. I am proud of the role I serve with my female patients as part of their medical provider team, and I enjoy the relationships I have built with my knowledge, education and treatment in my office.
Jennifer Stewart, OD is a partner at Norwalk Eye Care, a 2018 Coopervision Best Practices Award Winner in Norwalk, Conn. She is also the Chief Vision Officer at Performance 20/20, a sports and performance vision training facility in Stamford, Conn. She can be contacted at firstname.lastname@example.org.
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