Tapping the Dry Eye Market

Provide much-needed relief for your patients and you can turn a trickle of billings into a steady revenue stream.

BY WILLIAM B. TRATTLER, M.D.

Diagnosis and treatment of chronic dry eye disease has become an increasingly quantifiable portion of the typical ophthalmology practice in recent years. A few different reasons are responsible for the growing number of dry eye patients. With an aging population, dry eye is a more common primary and secondary reason for a visit to the eyecare provider. Additionally, as time spent in front of the computer continues to increase, so does dry eye related to a reduction in the blink rate. And, of course, dry eye continues to be common in contact lens wearers.

Although some doctors may view dry eye complaints as a nuisance that takes up chair time, I will explain in this article why dry eye patients can serve as a valuable population that can be helped by ophthalmologists and, in turn, help build an ophthalmology practice. For example, many of these dry eye patients have seen other doctors for advice, yet are still experiencing dry eye when they come to us. Once these patients experience improvement in their signs and symptoms of dry eye, I find that they can be quite grateful for the positive impact that we have made in their lives. They can also become loyal patients and valued referrers for the practice.

The Opportunity in Dry Eye

With the reduction in elective procedures, such as the recent estimated 40% dropoff in LASIK surgeries, the economic situation of today may be an opportunity to retool one's practice to be at the leading edge of dry eye management.

In particular, the effective management of dry eye patients who are undergoing cataract and refractive surgery has been shown in multiple studies to lead to better visual outcomes^1,2 and therefore superior patient satisfaction. These happy patients, who see better because of the surgical intervention along with their proper management of their ocular surface, are typically eager to share with friends and family the name of the ophthalmologist who brought this positive change about. Careful diagnosis and treatment also enables one to build an expertise that can then be used as a marketing tool to attract other patients whose dry eye has yet to be diagnosed or has been misdiagnosed and undertreated with over-the-counter eye drops. By focusing on identifying and treating dry eye patients, the additional revenues generated may be helpful in countering the reduction in revenues from elective procedures.

An Aging Population

Approximately 40% of my South Florida patient population has chronic dry eye. Many of these patients are seniors who present for evaluation for cataracts, retinal problems or glaucoma. Surprisingly, these patients frequently have dry eye present as a secondary reason for their visit. Given this, it is important to not overlook dry eye.

For example, when an elderly patient presents with vision disturbances due to a cataract, it's important to take the examination a step further to evaluate the condition of the ocular surface. If the health of the tear film is compromised, it can negatively impact visual outcomes following cataract surgery. A compromised ocular surface can lead to inaccurate keratometry readings, which can lead to an IOL power-selection error. Similarly, a dry ocular surface can lead to topographic abnormalities. I cite as an example a patient who came in to be evaluated for cataract surgery and who appeared to have forme-fruste keratoconus. However, a dry ocular surface was noted on exam and the patient was started on topical cyclosporine 0.05% (Restasis, Allergan) b.i.d. and artificial tears. The patient returned a week later with an improved tear film and more symmetrical astigmatism.

Dry eye syndrome is also widespread among glaucoma and retina patients. In particular, dry eye appears common in patients with a long history of glaucoma, as the chronic use of glaucoma medications can lead to a dysfunctional tear syndrome. Without treatment, these patients can experience a compromised ocular surface, which can be challenging to treat. So, being proactive is critical for ophthalmologists who want to provide the best possible care and stay competitive in their market.

Keep in mind that certain systemic medications, such as antidepressants or antihistamines, can have a significant drying effect. This can lead to an insufficient or unhealthy tear film, which will contribute negatively to the patient's overall ocular well-being.

Computer Vision Syndrome

I find that among my younger patients who present with visual fluctuations, photophobia and ocular burning, often times excessive screen time, whether it is from computer use or video gaming, is the mediating culprit.

The aforementioned symptoms describe computer vision syndrome (CVS), which is prevalent in all kinds of environmental and climate conditions because of the role that computers and video games play in people's lives. We now frequently treat CVS in high-school students who spend countless hours studying and researching on their computers, as well as among their less scholastically inclined counterparts who spend an equally disproportionate amount of time on social networks or playing video games. The literature shows that extended computer or video screen viewing can significantly reduce blinking frequency, which results in increased evaporation of the tear film.³ The increased evaporation leads to an increased tear breakup time, which results in dry eye signs and symptoms. Given that dry eye syndrome is progressive and worsens with age, early diagnosis and treatment can prevent the condition from becoming more serious.

Preexisting Patients

To fully address the dry eye treatment needs of one's preexisting patient population, all it takes is recognizing the likelihood of dry eye syndrome among elderly patients, surgery patients and younger patients whose lifestyle predisposes them to CVS.

We previously mentioned the importance of carefully evaluating cataract patients for dry eye symptoms. This is equally important for LASIK patients. We've long known that approximately 35% to 45% of patients who come in for LASIK will have a significant degree of dry eye. It's important to identify and treat dry eye prior to surgery, as this will lead to better visual outcomes. More importantly, being proactive in the treatment of mild-to-moderate dry eye will help reduce the risk of a patient later experiencing severe dry eye.

While LASIK is temporarily on the wane during these uncertain economic times, it will inevitably rebound when consumer confidence does. Until then, many of the patients who are LASIK candidates will continue to be contact lens wearers, many of whom will have dry eye syndrome. Diagnosing dry eye among these patients and treating them so that they will be ready for LASIK when it rebounds is another opportunity for ophthalmologists interested in growing the dry eye portion of their practice.

Referral Streams

Marketing one's services as an ophthalmologist with an expertise in dry eye through newspaper, radio or television advertising can potentially be an effective way to attract otherwise untapped patient markets. In my case, I do not need to take that extra step because my practice generates a steady stream of word-of-mouth referrals, which is not uncommon among dry eye patients who are treated effectively. I also post information about dry eye symptoms and treatment options on my practice Web site, which potential patients often peruse prior to making an appointment to see me. Another way to generate additional streams of dry eye patients is by working with local optometrists. While many optometrists have the option of prescribing therapeutics to treat dry eye disease, an equally large number prefer to refer these patients out to physicians who have an expertise in this area.

I thoroughly enjoy treating problem dry eye patients because it is so gratifying to help them find a solution to their problem. Too often, practitioners automatically prescribe OTC or prescription-strength artificial tears and if the patient doesn't improve the result is attributed to lack of compliance rather than lack of an appropriate solution. These patients who sometimes spend years making the rounds of practitioners only to be prescribed yet another regimen of artificial tears tend to be the most grateful when I help them. The bottom line is that artificial tears cannot improve the quality of their tears, so improving the quantity is insufficient.

Effective Therapies

Topical cyclosporine 0.05% serves as a foundation for most of my patients with mild-to-moderate dry eye.

In one study, approximately 73% of patients reported improvement in their symptoms of dry eye within 5 weeks of starting therapy.⁴ For most patients with mild-to-moderate dry eye who have already been on artificial tears, topical cyclosporine works well as a first-line treatment.

It is important to examine the lids for blepharitis, which can also cause similar symptoms. If blepharitis is present, I find that topical azithromycin (AzaSite, Inspire Pharmaceuticals) q.h.s. along with warm compresses is effective in reducing the signs and symptoms of blepharitis in 3 to 4 weeks. Many patients with blepharitis have dry eye, and topical cyclosporine can work synergistically with topical azithromycin. After 3 to 4 weeks of treatment with azithromycin, I will often add or switch to topical cyclosporine. Additional treatment options include punctal plugs to raise the tear film and short courses of topical steroids to reduce inflammation and improve the health of the ocular surface.

It appears that some surgeons reserve topical cyclosporine only for patients with severe dry eye. At that point, the ocular surface is often inflamed and patients are at higher risk of experiencing burning with cyclosporine. In these cases, I will often start topical steroids and cyclosporine together, as this helps reduce inflammation and improves tolerability of cyclosporine in these eyes with a compromised ocular surface. Alternatively, I find that starting topical cyclosporine earlier on in the disease process of dry eye yields excellent results with a much lower risk of patient discomfort. Recent data supports this course of action. In an investigator-masked study of 74 patients, Rao found that dry eye disease is both progressive in nature and that topical cyclosporine can actually slow or prevent progression of the disease in comparison to artificial tear use.⁵

Evaluate Treatment Results

When dry eye patients return for their follow-up visit, I evaluate the status of the tear film and ocular surface and then review subjectively their symptom improvement. If patients have experienced moderate improvement with topical cyclosporine after the first month of treatment, I will recommend that patients continue this therapy. However, in cases when patients have not obtained significant improvement in their signs and symptoms of dry eye, I will consider adding additional therapies (topical steroids, punctal plugs) and also re-assess the lids to make sure that blepharitis is not also contributing to the dry eye condition.

Overall, a systematic approach to the treatment of dry eye can make a positive impact on a patient's life. Satisfied patients are likely to be extremely appreciative and become an advocate for the physician through word-of-mouth referrals to family and friends. Because of this dynamic, effective dry eye treatment not only builds goodwill among one's patients, it essentially can sustain and grow a practice simultaneously. OM

References

1. Ursea R, Purcell TL, Tan BU, Nalgirkar A, Lovaton ME, Ehrenhaus MR, Schanzlin DR. The effect of cyclosporine A (Restasis) on recovery of visual acuity following LASIK. J Refract Surg. 2008 May; 24(5):473-476.
2. Donnenfeld E, Roberts C, Perry H, et al. Efficacy of topical cyclosporine versus tears for improving visual outcomes following multifocal IOL implantation. Paper presented at: The ASCRS/ASOA Symposium on Cataract, IOL and Refractive Surgery; April 2006; San Diego.
3. Patel S, Henderson R, Bradley L. Effect of visual display unit use on blink rate and tear stability. Optom Vis Sci. 1991;68:888-892.
4. Trattler, W, Katsev, D, Kerney, D. Self-reported compliance with topical cyclosporine emulsion 0.05% and onset of the effects of increased tear production as assessed through patient surveys. Clinical Therapeutics. 2006 Nov;28(11):1848-1856.
5. Rao, S. Prevention of dry eye disease progression by topical cyclosporine (CsA) 0.05%. Presented at the annual meeting of the American Academy of Ophthalmology, November 2008; Atlanta.

William B. Trattler, M.D., is a corneal specialist at the Center for Excellence in Eye Care in Miami. He has received funding for research, consulting and/or speaking from Allergan, Glaukos, Advanced Medical Optics, Inspire Pharmaceuticals, ISTA Pharmaceuticals, Lenstec, Sirion Therapeutics, Aton Pharmaceuticals and Vistakon.