Focus on Dry Eye

How new diagnostics help us tame the beast of dry eye

New technologies helped us improve outcomes and the bottom line.

By Brandon D. Ayres, MD

Years ago, when patients would present to me with symptoms of dry, red, irritated eyes, my colleagues and I would confirm a diagnosis based purely on a clinical examination. It was difficult to tease out the root causes of the symptoms.

More recently, however, we have seen a rapid increase in the number of easy access, point-of-care diagnostic tests we can perform in the office with minimal to no discomfort to patients. These tests allow us to pinpoint exactly what is occurring on the ocular surface, which in turn enables us to tailor our treatment.

For example, we can treat a patient's dry eye based on aqueous tear deficiency, lipid deficiency in the tear film (evaporative dry eye) or a combination of the two, which may all be managed differently. These diagnostic tests have generated greater interest in the ocular surface because we can now focus our efforts on specific problems.

Not only do these tests allow us to provide better quality care, but they can also provide a source for new revenue. Here, I describe how my clinic has incorporated four of these tests and the impact they have had on outcomes, in terms of more satisfied patients and faster resolution of symptoms, and revenue.

CLINICAL ADVANCES

Measuring tear osmolarity

For years, ophthalmologists have been searching for a marker on the ocular surface that strongly correlates with dry eye. We’ve learned tear osmolarity is one of the best markers for ocular surface health.¹ Tears high in salinity are more likely to accompany inflammation on the ocular surface.

Until the release of a tear film osmolarity diagnostic device such as the TearLab Osmolarity System (TearLab Corporation, San Diego), we did not have an easy way to measure tear osmolarity. This test is administered by collecting a few nanoliters of the patient’s tears and placing the sample in a reading device. Within 15 seconds it generates a number that correlates the patient’s tear osmolarity with the severity of his or her ocular surface disease.

A technician can perform this test before the physician enters the room. It does not change the appearance of or modify the ocular surface, and when we discuss cataract or premium lens surgery with patients, we must stress the importance of a healthy ocular surface. Pretreating the ocular surface for dry eye allows for optimal outcomes for cataract and refractive surgery.

Testing for MMP-9

Among the latest dry eye diagnostic tests is the InflammaDry Rapid Pathogen Screening (Rapid Pathogen Screening Inc., Sarasota, Fla.) tear film detector for matrix metalloproteinase 9 (MMP-9). MMP-9 is an inflammatory marker consistently elevated in the tears of patients with dry eye disease.² The tear film detector for MMP-9 is disposable and requires no additional equipment to administer or interpret results. Results are available within 10 minutes.

Combining tests

If the tear film osmolarity test shows a high score or a large disparity between the two eyes, we can then proceed with MMP-9 testing. We can use the tear film osmolarity test as a population-screening device and the tear film detector of MMP-9 as a more specific detector. If the tear film osmolarity test is positive, then we give the patient topical anti-inflammatory drops.

BENEFITS TO THE PRACTICE

Point of differentiation

These advanced diagnostic protocols set our practice apart from the field and build patients’ trust. For example, we recently implemented the point-of-care, in-office diagnostic test Sjö, (Nicox Inc., Fort Worth, Texas) for the early identification of Sjögren’s syndrome in patients with dry eye.

Diagnosing Sjögren’s syndrome in its early stages is critical, as a delay in diagnosis can lead to systemic manifestations, such as kidney dysfunction and risk of lymphoma. Research has shown a 4.7-year delay on average for positive diagnosis in the typical patient with Sjögren’s syndrome, and 3 million of the 4 million people in the United States with Sjögren’s syndrome go undiagnosed.³ Accordingly, ophthalmologists are in a unique position to diagnose Sjögren’s syndrome early because dry eye and dry mouth are often the first presenting symptoms.

Treat with confidence

Patient-pay diagnostic tests can be good revenue generators. The key to success is educating patients so they understand the true value of the tests. The positive impact that proper management and treatment of dry eye can have on a patient’s quality of life can be well worth the cost of a diagnostic test that can identify the root cause of dry eye symptoms.

We use an ocular surface interferometer, such as the LipiView, (TearScience, Morrisville, N.C.) to visualize the thickness of the lipid layer in the tear film. Identifying a lipid deficiency in the tear film is a determinant of evaporative dry eye. The ocular surface interferometer utilizes broad-spectrum white light interferometry and provides an interferometric color assessment of the tear film by specular reflection. We can show patients exactly why they are having trouble reading for extended periods or why their vision blurs when the wind blows.

We can then divide patients into two categories: evaporative dry eye or aqueous tear deficiency, which is essentially a tear-quality vs. tear-volume issue. Many patients have a combination of both. With these diagnostic tools at our disposal, we are confident in prescribing medication, recommending a warm compress twice a day, or even suggesting a thermal pulsation treatment such as LipiFlow (TearScience).

BILLING AND REIMBURSEMENT PRIMER

Tests covered by third-party payers

It is important to remember that a practice must have a Clinical Laboratory Improvement Amendments (CLIA) waiver to administer and bill for the TearLab and InflammaDry. The TearLab and Sjö tests are both reimbursable. These technologies have a high acceptance rate because patients are not concerned with any out-of-pocket costs.

Additionally, osmolarity testing can have good margins. The test cards cost $10 per eye to acquire and we are reimbursed between $16 and $22 per test card. We also utilize the test on many patients more than once, because we use it to monitor management of their ocular surface disease. We are hoping to see patients with a high tear film osmolarity slowly revert back to a normal osmolarity.

Private-pay testing

Insurance typically does not cover LipiView and InflammaDry. We explain to patients that, given their symptoms, having a diagnostic test that will allow us to ensure a correct diagnosis will benefit them. LipiView is a good source as a self-pay test, particularly if the practice owns the equipment. However, paying per-click to another institution or practice can eat into a physician’s revenue. Patients pay a fee of $75 to $100 for LipiView.

InflammaDry has recently been assigned a Medicare CPT code of 83516qw and will reimburse at around $15.75 per eye.

Patient trust

From a management perspective, our focus on ocular surface disease generates a large number of patients. Before the advent of in-office diagnostic tests, those patients were a drag on our growth and revenue. They required more time and money to treat properly. Now, we can clearly visualize the ocular surface, explain symptoms and even screen patients for concomitant conditions efficiently and profitably. Patients appreciate utilization of high-tech diagnostics during their management course because the tests help them fully understand why they are experiencing discomfort.

Most importantly, patients feel their physicians genuinely care about their overall health, which allows us to develop the best patient-physician relationship possible while growing the practice in a meaningful way. OM

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About the Author
	Brandon D. Ayres, MD, is a surgeon in the Cornea Service at Wills Eye Hospital in Philadelphia. His e-mail is bayres@willseye.org. Disclosure: Dr. Ayres has no conflicts to disclose.