What to Do With Noncompliant Dry Eye Patients

Leslie (00:06):

Ocular Surface Disease. It's complex, chronic and progressive but rife with opportunity for the enterprising optometrist.

Jackie (00:14):

The mission of this podcast is to make this condition more understandable and accessible to those interested in specializing in it. So, let's get To the Point. All right, welcome to our final episode of the To the Point podcast for 2020. We have gone through how to start your dry eye clinic to point of care testing, to Demodex, to scleral lenses to ocular aesthetics, to IPL to at home therapies and other things I'm probably forgetting to mention. And here we are at our final episode for 2020. And there is one thing that we have not spoken much about yet. And that is the noncompliant patient. My name is Jackie Garlich, and I am joined by my co-host, Leslie O'Dell. Hello, Leslie.

Leslie (01:04):

Hi, I'm a little bit sad. It's the last one for 2020. But it's nice to see this year wrap up.

Jackie (01:10):

I know, I can be done with this year, personally. So, one thing I think we did, we really haven't covered maybe, we covered quite a bit and these 12 episodes, but one thing we haven't really talked much about is the noncompliant patient. And I want to hear you talk about this, Leslie, on how you deal with patients that are noncompliant. This is the patient that's just not following the treatments. You know, like how do you handle this patient who maybe still does come back for their dry eye follow ups, but hasn't done the x, y, or z treatment that you have laid out?

Leslie (01:47):

That can definitely be frustrating. Or the patient that started on something for one day stopped it without telling you and now they come back a month later or six weeks later, when you're expecting to, you know, kind of get to your next level of care, and you're still starting from ground zero. So that definitely is frustrating, I find that, you know, it is human nature, to struggle to start a new habit. And then it's also easy for them to fall off the rails when they start to feel better. So those are kind of the two areas that I would say can be challenging when we're dealing with, with a chronic disease like dry eye. So, the first one would be introducing a new therapy, right? So, introducing a new habit to a patient, that takes time. And so, they might be nonadherent just because they aren't remembering, you know, until they get into a habit of something that could be twice daily, or sometimes, you know, it's four times daily, or whatever that looks like. So, that's one of the challenges.

Leslie (02:52):

The second part to that challenge is a lot of times we're treating a sick eye, you know, these unhealthy tear film, this unhealthy cornea, all in to our drops that we're prescribing, causing a bit of discomfort, right? So, stinging, burning, installation site pain, we see those all as the number one or very commonly reported adverse event and a lot of the medications that we have to prescribe and even in artificial tears, right? So, we can see that stinging and burning, even with something that's supposed to be as soothing as an artificial tear. So, that really is a challenge and I think it comes back to education.

Leslie (03:36):

And whether that's something that you are doing as the provider, or if that's something that you can offset to, you know, a patient coordinator or a technician that can really champion that, in your practice save you time. Or if you have some kind of pre-formed education material that you can give to the patient that clearly spells that out, you set their expectations, they kind of know, "Okay, if it's going to sting and burn, it's not because I'm having an adverse event." W- to the patient, they would think, "Well, this is making me feel worse than, you know, what I was feeling before or maybe I'm allergic to this." And so, they would just self-discontinue. Letting them know that, that's part of the treatment and that it gets better with time I think is important.

Leslie (04:21):

The other thing I do is really make sure that they know, if they're hitting any of these obstacles to call, right? So, I’d much rather they call my office, and we can kind of tailor what's going on with their treatment than for them to suffer in silence or discontinue a therapy before it ever even was effective.

Jackie (04:41):

Yeah, I think for me the most and maybe this is true in your experience as well, but the most like difficult treatment to follow, is the warm compress, the at-home warm compress. Did you? I mean, like I'm just thinking of a patient that I saw today, and she was like, she's good with her omega's, she's adequate with drops. And she's like, "I just, I don't know, just the warm compress, I just like haven't been doing it." And I'm like, "Yeah, I hear that." I think that like, maybe we like has led to the development of these other newer warm compresses like the open eye warm compress of TearRestore.

Jackie (05:23):

I just had actually someone send me one that is a USB plug-in warm compress that has like the washable cover on the outside. So, you don't have to deal with like boiling it back to the hard state for those like, you know, button ones versus the, you know, washing it every other time or whatever. You know what I mean? Like, I mean, do you hear that with about warm compresses in particular? Or is there some other spot that seems to be a pain point for patients?

Leslie (05:50):

Definitely warm compresses. I hear the same thing when patients return, "Oh, I don't know where the mask is, or I completely forgot. Or, you know, it's microwavable and I want to do it before I go to bed. But I don't have a microwave in my bedroom, and it's downstairs, and it's just inconvenient." Or they are very compliant at the beginning and then again, as their symptoms improve, they become less compliant to those treatments. But if you think about what we're doing, I always kind of step back and think about a dry eye patient and what we ask of them. We ask a lot of our dry eye patients-

Jackie (06:25):

A lot.

Leslie (06:25):

Right?

Jackie (06:25):

Yeah.

Leslie (06:26):

So, we ask them to do lid hygiene. So, we want them cleaning their lids, usually two times a day. We want them putting an artificial tear in, you know, maybe two times a day, maybe more if they're not on a therapeutic... So, in my case, I would say if I have them on a therapeutic, you know, whether it's, um, a Cyclosporin or Lifitegrast still have them supplement with tears as needed, which might be one or two times a day. But, you know, we have them using the medication two times a day as baseline. And then if they flare, we might be putting them on a drop... in addition, that's four times a day. You know, so the drop number is just overwhelming.

Leslie (07:04):

And now we want them to take 10 minutes out of their day, two times a day, not even just once a day. Two times a day to apply this heat mask and completely take themselves out of commission, right? Maybe they can make a phone call, but they certainly can't see to do work on their computer. So, I mean, we do ask a lot of these patients, anything that we can do to simplify is certainly worth considering it. One of the areas is, you know, one, one thing that we talked about was with omega three supplementation. We... there are studies that show that helps to thin the Meibum. So, doing that, and that's, you know, obviously going to be easier, it's much easier to take a vitamin than it is to spend 20 minutes warming your eyelid, right?

Leslie (07:51):

So, I think that it really is dependent on how severe that patient is, and you know, if they are motivated by their symptoms, I think you definitely get better compliance. And I do think that you have to kind of set that expectation with your patient, you know, we might be starting out your therapy with all of these steps. But as we improve, it's not going to take that much.

Leslie (08:12):

Or substituting, you know, yes, warm compresses at home, are amazing for patients when they utilize them. But that patient that's not utilizing them, you know what's happening to the status of their glands and the secretion of the glands. And that's a perfect person, person, or patient to substitute, right? Okay, so I understand your lifestyle's very busy. I, you know, I can't expect you to be doing 20 minutes of a warm compress every day. We have this meibomian gland clearing treatment that we can provide in the office, simplifies your life at home, you might have to get it done once or twice a year. But if it can keep you, you know, saving that 20 minutes a day might be worth it. And in your, in your mild to moderate MGD patients that is going to be a good substitution.

Leslie (09:04):

If you're talking about a more advanced case, though, obviously, you can't substitute it enough as treatment and just completely negate that at-home care because, you just won't get as far for your patients. But I do think that you can substitute, I do that a lot. I ha- one patient that stands out was a 26-year-old woman, who was a graphic designer with meibomian gland dysfunction. And that you know, the classic symptoms of tired eyes, blurry vision by middle of her workday and just, you know, really just not feeling great by the end of her day. All contributed to just meibomian gland dysfunction. And we talked through her options and she actually elected to have thermal pulsation, you know, ahead of a mask. And she was doing great, you know, two years post treatment without having to do anything you know, more at home.

Leslie (09:57):

So, it's really just letting their lifestyle needs kind of dictate that for sure. You know, I, I've seen that USB... actually, it was in the Sharper Image catalog, I think this year.

Jackie (10:08):

(Laughs)

Leslie (10:08):

And I was trying to figure out, you know, "Wow, that's pretty impressive." They talked about blepharitis-

Jackie (10:12):

Oh, really?

Leslie (10:13):

And this being a great treatment for blepharitis in the Sharper Image, so patients might be asking for that. You know, the, my only concern sometimes with those is, is the dry heat, you know, different than a moist heat, as far as penetrating in. You know, probably better than no heat, if you can again, get patients to do that. But I, I often just have a little bit of reservation just because I know, dry heat penetrating through the lid is less effective than our moist heat options.

Jackie (10:43):

Yeah, I think, you kind of said it earlier, but I think the most important thing that I found is really setting the expectation, because a lot of the onus is on the patient to do these dry eye treatments. And I think it's, it's much harder, obviously, in a patient, like I'm thinking of a patient that I saw a couple of weeks ago. And she, you know, was symptomatic of dryness, but she, you know, she was young, she's maybe 22 or something. And she was like, "You know, this is just like how it's always been, it's like not." Like I don't think she was that motivated to do this treatment.

Jackie (11:14):

So like, I'm like, "Here's what we're going to do X, Y, and Z." And then I see her back and she's like, "Yeah, like, haven't really done any of those things." And I was like, "Oh, I'm surprised you even came back for this appointment."

Leslie (11:24):

Well, that's what I was going to say, actually, what brought her back? You know, a lot of times that could be when the patient thinks, "Well, you know, I'm not doing those things and I'm not going to go back."

Jackie (11:34):

I know.

Leslie (11:34):

So, what did, you know, what did, well, how did that in-patient encounter look like?

Jackie (11:38):

Well, I mean, it was, it was just, I mean, it was sort of like, Oh, she's like, "Yeah, I know, I'm not really doing, I'm not doing it. Yeah, I don't know. I just, I don't know, I'm just I'm like so used to this feeling." Like it was a really sort of like, I was, it was a confusing visit, to be honest with you. I was sort of like, "What are we doing here?" like I d-, you know. I was like, well, clearly I have failed her in some way that I did not, like maybe explain well enough that like, you actually need to do these things for this to actually get better. But I think it's all, it's all perspective of the patient.

Jackie (12:09):

Like I, I mean, if this, I'm all about like, "Okay, can I just take one thing to like get whatever my problem is better or try to do it on natural or whatever." And I think if you set the stage for the patient like, "You do have to do this, this, and this for these symptoms to improve." And like relate it back to whatever their main symptom is, like, I think that's useful and finding out all right, what is their biggest symptom? Burning? Do you really hate that? Okay, here's what we have to do to like, get that to go away kind of a thing. But-

Leslie (12:35):

I mean, like I said, it can be tricky and, you know, maybe in a 22-year-old, they're not doing as much but she might be you know, wearing makeup, washing her face, you know, getting ready for the day, whatever she is, if she's going out into the world or you know, all of these things. You know, again, we're giving people a lot of things to do. And then think about that person that does wear makeup, and is, you know, in an environment where they can't just be putting tears in the middle of the day, because it causes problems for the way that they, you know, their appearance.

Leslie (13:07):

And, you know, I think that we oftentimes don't think about that when we're writing out our plans. You know, it's easy to give them, I mean, in some patients that have kind of self-medicated themselves, one lady stands out, she's was using Celluvisc 10 times a day. Celluvisc. (Laughs) And like-

Jackie (13:23):

Oh, wow.

Leslie (13:24):

... You know, but it was what... and she didn't, you know, once we got her out a better treatment path, she didn't need that, right? She actually was, we got her, I got her to the point where Celluvisc wasn't even in her daily routine. Her biggest problem was nighttime exposure, and so she was waking up already behind and never able to catch up. And then also hadn't been to a provider that talked about inflammation. So really just getting her on, actually, in that case, she was using Xiidra. Once I got her on Xiidra for a few months, and started to address her nighttime issue, she was, you know, great.

Leslie (14:03):

And for her, it was a very big social thing, she had a lot of redness and it was really starting to bother her and affect her confidence. She was going out to lunch with friends and different things. And people were always commenting on the appearance of her eyes, you know, what's wrong with you? Why do you look like this? And so, you know, it's really exciting when you can get them there, and you can get them there in not such a difficult pattern.

Leslie (14:29):

And I think that maybe, I think about it that way because everything for me always goes back to my training, which was very heavy in glaucoma management. I did a lot of research with a glaucoma specialist in the Baltimore area that was around adherence. I mean, we were doing studies with the Travatan Dosing Aid when the patient knew we were watching them. And they still were only like 70% compliant to their drops, you know, so. And that was w- the risk of blindness, you know, the upside to dry is that when you do feel bad, you're more like, if it hurts, you want to feel better.

Leslie (15:05):

I would guess that your 22-year-old patient just was having more episodic dry eye and so she could just get through the day, and it wasn't causing tremendous, you know, problems. In that case, I would look to definitely, I mean, if the glands were part of her problem, I'm assuming they were because you went the route of a heat mask. I would definitely be talking to her about what I know you have in your practice with tear care. You know, and, and just starting that now because we know it's progressive, so maybe not at 22 is she going to commit to a treatment that's out of pocket? But maybe by the time she's 25, she will. You know when she's starting to "Oh, okay, now that one day a week is turning into two days. Now I don't even want to wear my mascara because, you know, this is really uncomfortable or it's making my eyes feel worse."

Leslie (15:54):

So sometimes it's just laying the foundation and just kind of helping them you know, make their, the best decision with time.

Jackie (16:01):

Do you have any, any input on what you do for that patient that is, you know, noticeably dry, but has no symptoms? And, you know, maybe this person is neurotrophic, but let's say that they're not. Let's just say that they don't li- well, they must be have some level of neurotrophic keratitis if they're not noticing. But let's just say, that they, you know, they feel fine, but you're noticing a ton of, you know, dryness on the cornea? How do you handle that patient any differently than you would a symptomatic patient?

Leslie (16:33):

I mean, they take a little bit more education I would say, because that you're telling them a problem that they have no idea about, right? Because they don't have the symptom. In those patients, I think doing your corneal sensitivity tests can be very helpful. Especially, you know, if you, I don't know how you're doing it, but if you use the unflavored dental floss or something, you poke them in the eye with dental floss, and they aren't feeling anything and you kind of say, you know, "You should be feeling this." That can be helpful for them to understand that.

Leslie (17:07):

The other thing I would say is any kind of imaging that you can do, you know, just like my biography speaks volumes to what people can understand about meibomian glands, and the changes that happen. If you could show a photo of a cornea or you don't have access to a camera in your clinic, you know, get mild moderate severe corneal staining photos, either on a laminated sheet or just have them up on your desktop and show them, "This is what your cornea looks like. All of these, you know, are breaks in the skin, of the surface of your eye. This is a great risk for infection, you know, those are sometimes words that I'll use, I don't, not only, not only are you not going to be seeing your best, but also you have a risk for an infection of your eyes. Especially if I have an older patient that I'm dealing with, and we need to heal that.

Leslie (18:00):

And then you know, those patients can also be challenging because as you do start healing, you know, you hope that they will regain corneal sensitivity, and they oftentimes will. So that's that patient that, let's just take, you, I mean, it would have been in Lifitegrast or Cyclosporin. But so, you put them on a therapy, going great, a month in, everything starts to burn, they think automatically that it made them worse, right? So that's again, where having them feel confident and comfortable with calling in, saves you a huge headache in the patient dropping off therapy before you see them back.

Leslie (18:38):

So, you know, my conversation to that patient would be," Mrs. Jones, you know, if you have anything even worsening of symptoms, I want to know about it." And then they will call, and my front desk can tell them you know, "This is to be expected you're 4 or 6 weeks in, we oftentimes see that just stick with it, we assure you that it's nothing, you know, to be concerned about. And let's just keep your follow up, you know, at 8 weeks with Dr. O'Dell." And then I hope that when they're in the chair, that they're continued on that therapy.

Jackie (19:06):

Yeah, I will say that I had, I do take photos and I think just showing a patient, like all their keratitis is so valuable. I had a patient actually, who told me like, "I didn't, I didn't really realize that I was dry until you show me this picture." And I feel like that that made her do all this, all this treatment. I mean, it... her symptoms weren't, are also improving, but I think the photograph speaks volumes. And you don't even really need an anterior side camera, like you can do all of this with your iPhone, get these like inexpensive adapters that you can put on your oculars. But I do think that is a really valuable tool with compliance. And I really probably don't utilize it enough. I should do it more now that we're talking about it. (Laughs)

Leslie (19:51):

(Laughs) You know, it does just become, you know, just their new normal. You know, so a person that lives... I can speak to two things that, uh, one is I have horrific allergies, but didn't know it. I mean, as a teenager in the summertime, my eyes would swell, you know, with ragweed allergies and I would, you know, be putting the cold compresses on. It was before there were any drops to save me. So, I just looked, you know, like swollen eyes for a few days. But my parents never had me get allergy testing. Then flash forward to my adulthood and one of my labs was just abnormal, like my eosinophil count was high, my doctor had this conversation like, "Either you have cancer or a parasitic infection or allergies." I'm thinking, "Huh, I'm going to hope for allergies on this one.”

Leslie (20:37):

And so, I went to my first allergist, I probably was 29 and I was, I mean, it looked like I got attacked by a swarm of mosquitoes on my arm. The other guy in the room with me, his arm was completely fine, except the histamine bump and I'm thinking, "This is definitely not right." So, I learned that I was like, basically allergic to the world, but living with it. So not until I started on some therapies did I realize like, "Oh, I'm not supposed to feel this way." You know, fatigue or like maybe getting a cold more than often, you know, or more than the next person until I was better, right? Because I was just kind of in this constant inflammatory state.

Leslie (21:16):

The other thing is a little bit more embarrassing, but it's all for the greater good.

Jackie (21:23):

I love it already.

Leslie (21:23):

It's all for the greater good. So, the other one has to do with my dental care. But I did have a lapse after my son was born, I think, I, that I forgot having teeth, apparently. So, I got back to the dentist after a few years of a miss. And you know, they were doing all the fun of going to the dentist scraping your teeth and cleaning. And when I left, I thought, "Oh my gosh, my teeth are like new teeth." But I didn't feel like my mouth was dirty. I was brushing my teeth every day, you know, electric toothbrush, thinking I was doing everything right? Flossing, all those things, so and I didn't think like, "Oh, you know, I got to get to the dentist." I actually didn't even realize that I hadn't been there for as long, it was completely embarrassing.

Leslie (22:08):

But when I left, I thought, "Well, I'm never going to not go back and do that." And so, if you can get a patient, you know, to commit to a treatment with meibomian gland clearing, right? They've never had it done. They don't know how much lighter or how much easier their lids are going to glide across their eye or even you treat them with like micro exfoliation in the office to clear off debris. It's like immediately better, you know, just like those examples. They don't know that they feel bad until they realize, you know, they're not, you know, until you get them feeling better. I guess is what I'm saying.

Leslie (22:43):

But that's the trouble with chronic disease, you know, it ebbs and flows for everybody, they'll be doing great, something will pop up, because that's just what happens in life. And then, you know, the rails fall- you know, they just are completely off every therapy, and you’ve got to build them back up. You know, fortunately, we have enough, you know, treatments with everything now that, you know, we have a lot of tools that we can help them.

Leslie (23:06):

It's just the biggest thing I think I would spend time on is your education platform to the patients, and how can you simplify your time in the office, because that's more valuable than ever. Offset it to either, you know, maybe like a patient portal, something that's emailing them, a technician, a follow-up phone call, you know. What I like about some of the companies that we work with, are these wellness calls, you know. So, some of the companies actually will reach out to my patient after I get them on a product and really make sure that they're going to understand the way that works and check on them.

Leslie (23:42):

You know, that's, that's really helpful to me, because it offsets it, and it frees us up because, you know, then we can see another patient or two, which is really good for, you know, for us, and our bottom line.

Jackie (23:53):

Is there another company that's doing, I mean, I know PRN does that. But is there another company that does that?

Leslie (23:58):

Yeah, so EyeEco does that with any masks that are sold, they'll do a wellness check on your patient, which is really helpful. Because if you know, they weren't sure how to use one of the products, like they walk them through it. I think it just really helps with compliance. And they might even check up on them, you know, even a few months after. And it's, you know, not very confrontational. You know, it's, it's positioned to be helpful to the patients. So, your 22-year-old that says they're not doing it, they're not going to yell at them. They're going to say, "Oh, here's ways to remember better."

Jackie (24:34):

Yeah, okay, that sounds better. (Laughs)

Leslie (24:36):

Yeah. (Laughs) You don't want to ever do that, right? You don't want to make your patients feel bad, ever. You don't want to guilt them into the treatment either. And it doesn't sound like you do that. But, you know, we do that. I mean, we do that sometimes with glaucoma care, or "Oh, my gosh, you haven't been in for your diabetic eye exam in 6 years, you know, you could go blind." I mean, people are sometimes scared enough to come see us. I feel like, I'm not a big fan of, you know, the fear tactic, I feel like, seeing is believing.

Leslie (25:06):

My biography's been a game changer for me, in my practice, being able to show these glands, they've never seen them oftentimes before, they didn't even know they were there. You know, now, now you're telling them, they're there and they're missing, like, I need to take care of them. You know and making as many of those dental analogies as you can, are very helpful. People are familiar with dental x-rays, you know, my biography kind of resembles that even though it's not an x-ray. What we're doing with clearing the glands and treating the lids are all kind of very familiar when you think about the dental model.

Leslie (25:39):

I think just making those parallels and, and then just doing what you did, seeing them back. And "Oh, okay, so that didn't work. Why didn't it work? Let me see if I have something else that might suit your lifestyle better." But I would say you're not giving yourself enough credit, Jackie, because I think the fact that she returned to you says you're an awesome doctor! Right?

Jackie (25:59):

Leslie, that's why we're friends.

Leslie (26:01):

(Laughs)

Jackie (26:01):

Thank you, buddy.

Leslie (26:02):

Yeah.

Jackie (26:05):

Thank you. (Laughs) Yeah. All right. So, the like main points here are education, education, education, and handouts. Do you have handouts? Do you utilize a handout?

Leslie (26:14):

Well, I'm in the works of making some.

Jackie (26:16):

Creating a handout? Do you want to see mine?

Leslie (26:18):

Yeah.

Jackie (26:18):

I'll send you mine.

Leslie (26:19):

Send me mine. I think if, we, you know, why reinvent the wheel? Share, share.

Jackie (26:23):

(Laughs)

Leslie (26:25):

All this advice I've been giving you for 2020. It's the least you can do.

Jackie (26:29):

I know, I know.

Leslie (26:29):

I'm just kidding. (Laughs)

Jackie (26:30):

(Laughs)

Leslie (26:34):

I'm kidding. I know that you Jackie are very good at creating things. I've seen some of your study guides from early on in your career.

Jackie (26:41):

(Laughs) Yeah.

Leslie (26:42):

And so, I will gladly take any patient handout that you've created.

Jackie (26:45):

Okay, expect an email from me.

Leslie (26:47):

Yes, perfect.

Jackie (26:47):

It's coming tonight. Yeah. (Laughs)

Leslie (26:48):

(Laughs)

Jackie (26:50):

All right. Any other thing we want to throw in about patient education, patient compliance? You got anything else? I feel like we've talked a lot, Leslie.

Leslie (27:01):

Yeah.

Jackie (27:02):

We got To the Point.

Leslie (27:04):

Education.

Jackie (27:05):

Right? Right. (Laughs)

Leslie (27:08):

But it's true. I mean, and again, like I said, if she didn't trust you, that particular patient, she didn't trust you, she would have done what a lot of dry eye patients do, right? Jump ship and go to the next person. So, she obviously has a lot of faith and trust in you. So, you are doing a good job. I would just keep building on it. And sometimes it does take multiple touches. So, I would also say don't defeat yourself. I did that early on too, that I would... they'd come back, they'd be off whatever I've started them on. And I'm thinking like, "Ah, like, it's like talking to a brick wall. How am I supposed to get through to you?"

Leslie (27:41):

But the more I spent time educating them and just maybe sometimes tailoring it to whatever that patient needed. I think it really helped them to understand better and "Oh, okay, this is why I have to do that." So, you know, I think just keep working at that. But you're always going to find a patient that is noncompliant. But as long as they continue to return to you... and so that's why if I'm going to start anything, I'm always going to give a follow up, right? I want a follow up appointment, in a month, 2, maybe 3 months, somewhere between 1 and 3 months. And that's part of why I want that because, especially as you're developing new habits, it's going to be hard to keep them you know, doing them.

Jackie (28:26):

Okay, Leslie. That's a- that's a wrap on 20... I almost said 2021. That's a wrap on 2020. See I'm all ready for 2020 to get out of here. This has been so fun doing this with you. I appreciate all of your expertise, all of your insights. Yeah, looking forward to collaborating with you in 2021.

Leslie (28:45):

Yeah, I can't wait. This has been a lot of fun Jackie. So again, I too am happy to wrap up 2020 but on to bigger and better things, let's hope.

Jackie (29:00):

And now for the To the Point wrap up. When managing any chronic disease, adherence is always a challenge, and dry eye disease is no exception. We expect a lot from our patients when managing dry eye. Oftentimes up to 20 minutes a day of warm, moist heat therapies; eyelid cleansing; multiple eyedrops both over the counter and prescriptive; taking blink breaks while they're working – it all adds up. Education is one of the biggest things we can do to improve adherence. Setting follow ups so we can catch nonadherence is also important. And that's a wrap on this year's To the Point.