Any Size Practice Can Create a Dry Eye Treatment Center

How a single-physician practice approaches patient management

Clifford L. Salinger, MD The Dry Eye Spa at V.I.P. Laser Eye Center

Clifford L. Salinger, MD
The Dry Eye Spa at V.I.P. Laser Eye Center

Millions of Americans suffer from dry eye, and they are some of the most frustrated individuals who come to us seeking help. Their discomfort can impact every facet of their daily lives, even the most basic activities we may take for granted. Furthermore, as more and more doctors are coming to realize, dry eye adversely affects surgical outcomes. Therefore, by systematically addressing dry eye disease in our practices, we have the opportunity to achieve better clinical outcomes, improve patient retention and referrals, and grow our practices.

We established The Dry Eye Spa^® because I wanted to create a niche, an identity among my colleagues and my patients as an Ocular Surface Disease and Dry Eye specialist. The goal was to create an environment for patients to better understand their condition and to become part of their solution. Helping to provide these individuals relief is one of the most gratifying aspects of my practice. Our experience in creating The Dry Eye Spa illustrates that it’s not only large practices with multiple doctors and numerous staff members who can create a successful dry eye center of excellence. I’ve been very successful accomplishing this as a solo practitioner, offering services from one main office location and two satellite offices, one on a weekly basis, the other monthly.

Highlighted here are some points I’ve found to be most salient in caring for this group of individuals and developing The Dry Eye Spa.

• Dry eye is multifactorial and involves concurrent, overlapping disease states.¹ The importance of identifying the underlying dysfunction(s) and assertively treating it/them cannot be overstated. Dry eye is also a progressive condition. Inadequately addressed ocular surface disease often progresses to require even more intensive and expensive treatments. Without proper treatment, the cycle of inflammation and dysfunction may cause permanent damage to the lacrimal gland and ocular surface.² When diagnosing and managing dry eye patients, it’s also important to keep in mind these three key points: that evaporative tear deficiency is the most common cause of dry eye,³ dry eye is an immune-mediated inflammatory disorder, and some degree of inflammation is present whether it’s apparent or not.⁴

• Today, we understand so much more about dry eye than in the past; we have better tools and technologies for diagnosing, managing and treating Ocular Surface Disease. Even artificial tears are much better than they used to be. Therefore, a commitment to dry eye patients requires that we use the tools available to us. For instance, I use HydroEye (ScienceBased Health), a nutritional formulation which was validated in clinical research conducted by Dr. Sheppard and colleagues.⁵ The one tool that has made the most difference in my practice is LipiFlow (TearScience) Thermal Pulsation, which addresses the root origin of evaporative dry eye disease. After one treatment with this device, along with comprehensive pre and post treatment, 85 to 90% of my patients report significant improvement in their symptoms, many at 1 month following treatment, but a significant percentage take 3 to 4 months to achieve their symptomatic improvement.

When I worked out the economics of this technology, I calculated that the breakeven point meant performing the procedure on six eyes per month. As it turned out, the equipment was paid for in 1 year because we treated nearly 200 eyes during that first 12-month period. LipiFlow and HydroEye fit nicely within the dry eye management principles to which I adhere:

• decrease tear loss

• stabilize the tear film (quality)

• protect the ocular surface

• suppress inflammation

• increase lubrication

• stimulate tear secretion (quantity)

• enhance surface healing

► Frequently, meibomian gland disease is not obvious and therefore requires active diagnosis. It’s important to thoroughly examine the lid margin for telangiectasia, quality and quantity of secretions and evidence of complete gland obstruction.

► Hyperosmolarity is the central mechanism causing ocular surface inflammation and progressive damage. With an 87% positive predictive value, tear osmolarity testing (TearLab) is the most sensitive way to diagnose and grade dry eye severity and track response to therapy.¹ In addition to the osmolarity value of each eye (>308 mOsmol/L is pathogenic), the difference between the two eyes is an important number to know. A difference of >8 mOsmol/L is a hallmark of tear film instability. This test gives us the ability to modulate therapy with a quantitative endpoint.

► Efficiency is an extremely important factor in the success of a dry eye treatment center. To bring efficiency to the process, including the diagnostic evaluation AND the patient education aspect, we use videos, a variety of printed materials and most importantly, physician extenders, our staff! In addition, TearScience, the makers of LipiFlow, have outlined a systematic approach to patient evaluation that works extremely well. It begins with a patient questionnaire; we use both the SPEED (Standard Patient Evaluation of Eye Dryness) questionnaire and the OSDI (Ocular Surface Disease Index), which gets patients (and staff members) thinking about their problem and rating the severity of their dry eye symptoms. As such, the SPEED and OSDI help determine which patients are appropriate to evaluate with the LipiView screening device, which provides an absolute measurement of the lipid layer thickness of the tear film and identifies deficiencies in the blink mechanism. We combine that with TearScience’s Meibomian Gland Evaluator — which provides a method of applying a standardized pressure equivalent to that of a normal blink to the lower eyelid while visualizing the gland secretions, which can then be graded in quality and quantity — to determine who may be a candidate for LipiFlow treatment.

Happy Patients, Happy Doctor

We all want to make our patient’s feel better, which makes them happy, and thus provides professional satisfaction in our staff and in ourselves. The Dry Eye Spa has proven to be a great way for us to make sure that happens on a daily basis. And, as we all know, happy patients refer more patients, which is still the best way to build a practice. ■

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