Focus on Dry Eye

How to be a dry eye ‘center of excellence’

Meet the growing demand for effective and efficient testing and treatment.

By Marguerite McDonald, MD, FACS

About the Author

Marguerite McDonald, MD, FACS, is a cornea and refractive surgery specialist at Ophthalmic Consultants of Long Island in Lynbrook, N.Y.; clinical professor at NYU Langone Medical Center, New York; and adjunct clinical professor at Tulane University, New Orleans. Her e-mail is margueritemcdmd@ aol.com. Disclosures: Dr. McDonald has disclosed relationships with Bausch + Lomb, Alcon, Allergan, Oculus, Focus Laboratories, AMO-Abbott, Ocusoft, NexisVision, ORCA, Tearlab and Tearscience.

The prevalence of dry eye symptoms is evident in both the recent flourish of new diagnostic and therapeutic technologies designed to address them, and the resultant changes to our practice flow. With the changing times, we at Ophthalmic Consultants of Long Island have made the decision to become a dry eye “center of excellence.” The label does not necessarily refer to a brick-and-mortar facility or a formal designation, but instead to practice-wide approach to adopting best practices in management of dry eye disease.

This article will review the reasons to commit to becoming a dry eye center of excellence, the protocol for doing so and the resulting benefits.

WHY NOW IS THE TIME
Baby Boomers’ aging eyes

The timing to set up a dry eye center of excellence couldn’t be more perfect, for a number of reasons, one of which is the aging Baby Boomer population. The number of Americans age 65 or older is expected to more than double over the next 40 years, from 40.2 million in 2010 to 88.5 million in 2050, and Baby Boomers account for most of that increase. As the US population ages, the prevalence of age-related ocular conditions such as dry eye will increase.¹

Contributory systemic medications

Part of the reason we see so many older patients now is because medical breakthroughs are helping people live longer. However, virtually all those medications, such as antiarrhythmics, cholesterol and blood pressure-lowering agents, and anti-depressants can also cause dry eye. Also, as women age they experience more dry eye than men because of hormonal changes.²

So, more people have dry eye and are demanding solutions. Baby Boomers in particular are not willing to accept dry eye as a consequence of aging. We now have more options to offer, so the timing is perfect.

Technologies and therapies

Fortunately, we now have treatments for dry eye we did not have a few years ago. Dry eye and other ocular surface conditions have been shown to have a significant impact on quality of life.³ Now, instead of listening to patients wail and trying to get them out of our offices as quickly as we can, we now have new diagnostic and therapeutic solutions that will not only help the patient, but also benefit the practice.

DRY EYE PATIENT PROCESSING
Information and testing

In our practice, offices have abundant literature about dry eye. Educational videos are on a constant loop in the waiting area. Our technicians are equipped with iPads so patients may review specific segments. Video segments can also be added to a practice’s Web site or e-mailed directly to patients. The bottom line: Our patients are surrounded by information.

Our system is simple. First, everyone who checks in gets a short questionnaire asking about potential dry eye symptoms. It’s quite rare for anyone age 40 or older to not check off at least one symptom. When patients get into the exam lane, we first make sure they haven’t taken an artificial tear within two hours and that they haven’t just pulled out their contacts. Then, the technician takes the patient’s history and performs the TearLab Tear Osmolarity test (TearLab, San Diego). The TearLab test has been shown to have a high degree of accuracy in the diagnosis of dry eye, much higher than the other traditional tests considered, according to one study.⁴ As long the history or questionnaire results indicate some justification, we check tear osmolarity on just about everyone 40 and older and anyone with a history of dry eye or who has complaints of dry eye-like symptoms, such as itching, burning, eye fatigue or redness. We also perform the test on anybody getting any kind of ophthalmic surgery, including LASIK, PRK, cataract surgery, penetrating keratoplasty or blepharoplasty.

Course of action

Based on the history, laboratory tests and physical findings, I will take one of the following courses of action.

• For mild dry eye, I recommend artificial tears Q.I.D. A few over-the-counter alternatives are also available. Patients can even take more bottled tears, if needed, and should focus on getting their omega-3s because they are so helpful in dry eye, even in the mild stage.

• For moderate dry eye — that is, in patients with a TearLab result of 317 mOsm/L or greater — I prescribe Restasis (Allergan, Irvine, Calif.) and recommend the aforementioned therapies (an artificial tear and omega-3s).

• For severe dry eye, which I identify as a TearLab score 325 mOsm/L or greater, I switch patients to preservative-free tears Q2h while awake and recommend the remainder of the aforementioned regimen. Any patient whom we’ve started on Restasis returns in one or two months for a screening for punctal plugs. I also recommend a liposome spray on the closed eyelids at 10 inches from the eyes Q.I.D. I instruct the patient to gently rub the spray into the lid margins — women can skip the two mid-day rubbing sessions” if they’re wearing makeup — and they will still enjoy the benefits of a more stable tear film. It is excellent for dry eye, especially evaporative dry eye, which is a comorbidity in 86% of dry eye patients.

Figure: A multitasking corneal topographer with a built-in keratometer can aid in the examination and management of multiple structures involved in dry eye. Among the different views and modalities available are: lipid layer analysis (A); meibomian gland scan (B); non-invasive, keratograph break-up time (C); tear film dynamics (D); conventional corneal topography [normal eye (E)]; and topography of pterygium (F).

The value of dry eye in the practice

It is vital for ophthalmologists to address the growing dry eye problem, not just for the health of the patient, but for the growth of the practice as well. Dry eye patient visits and charges can add an additional revenue stream. BSM Consulting provided Ophthalmic Consultants of Long Island with some conservative estimates detailed here and below. Estimated Revenue Description ■ New patient, comprehensive exam (92004) ■ 1-month follow-up exam (99213) ■ 3-month follow-up exam (99213) ■ 12-month follow-up exam (99213) Total annual revenue per patient: $354 Additional potential dry eye treatment revenue: punctal plugs (1st eye $146, 2nd eye $73), $219

Potential per patient and gross revenue from 1,500 dry eye patients

Total revenue from dry eye: $743,350

(1) Assumes 50% capture of cataract prevalence based on 2005 Gallup Study

(2) Assumes 50% capture of glaucoma prevalence based on 2005 Gallup Study

(3) Revenue rates per patient are determined as follows:

• Dry Eye assumes $354 per patient per year with various office procedures (92004 = @$144, 3 exams - 99213 = @$70).

• Cataract: Assumes bilateral cataract surgery. Revenue projection includes surgery, exam and diagnostic testing.

• Glaucoma: Assumes revenue rate per patient with POAG and no systemic disease.

• Punctal occlusion: 1st eye $146; 2nd eye $73.

PRACTICE BENEFITS
Impact on Surgery

As mentioned, becoming a dry eye center of excellence does not necessarily entail expanding to an additional, physical location. It’s more about embracing this new approach to the diagnoses and treatment of dry eye. Most comprehensive ophthalmologists are set up to scan for surgical pathologies. After all, we are surgeons.

While dry eye surgery does not exist, it’s important to note the affect of dry eye on surgical outcomes. LASIK and cataract surgery results are better when one treats the ocular surface disease first. It is far better to tell cataract or LASIK patients in advance if they have dry eyes and get them into tip-top shape before surgery than it is to try to explain their difficulties postoperatively. Biometery before cataract surgery will be more accurate if the patient has no significant, or well-controlled, ocular surface disease.

You do not need to switch the focus of the practice to embrace the dry eye center approach. Making the office a dry eye center of excellence means thinking about dry eye, actively looking for it and treating it.

What you need to acquire

Besides changing the check-in process, you are going to have to acquire new equipment. I recommend the TearLab Tear Osmolarity technology. After becoming familiar with that and incorporating it routinely in your work-ups, consider adding a multitasking corneal topographer. Theses devices can produce several different images (Figure, page 37) that help diagnose and document dry eye as well as the response to therapy.

The Lipiflow system (TearScience, Morrisville, N.C.) is another key piece. This system analyzes the tear film as well as provides a computer-controlled, pulsating thermal lid massage. The 12-minute treatment helps patients feel better for about a year while doing less of their regimen to treat dry eye meibomian gland dysfunction. These devices will help to diagnose and manage dry eye as well as increase revenue. OM

REFERENCES:

1. Alpek EK, Smith RA. Overview of age-related ocular conditions. American Journal of Managed Care. 2013;19:S67-75.

2. Schaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye syndrome among US women. American Journal of Ophthalmology. 2003;136:318-26.

3. Pouyeh B, Viteri E, Feuer W, et al. Impact of ocular surface symptoms on quality of life in a United States veterans affairs population. 2012;153:1061-1066.

4. Versura P, Profazio V, Campos EC. Performance of tear osmoloarity compared to previous diagnostic tests for dry eye diseases. Current Eye Research. 2010;35:553-564.