Discover your untapped dry eye potential

Diagnosing and treating DED helps to improve patients’ visual outcomes.

By Zack Tertel, Senior Editor

Take a look in your waiting room. The reason you should become a dry eye expert is because of those patients, and all the others you have. “Whether it’s for routine eye care, cataract surgery or LASIK, most practices have a lot of patients who are suffering from dry eye in some form,” says Preeya K. Gupta, MD.

In general, dry eye encompasses a wide variety of patients, says Dr. Gupta, assistant professor of ophthalmology at Duke Eye Center. “A lot of them have meibomian gland dysfunction [MGD]. Some of them might have aqueous deficiency and autoimmune disease.”

Testing for dry eye has improved along with modern therapies, Dr. Gupta says, so much more can be done to get patients on the path to relief. Physicians who previously dreaded dealing with dry eye should fear no more. “There are so many more things we can do to successfully alleviate dry eye, which is huge from a patient perspective.”

To increase your efforts with diagnosing and treating dry eye disease, those interviewed recommend the following.

DRY EYE DIAGNOSTICS

Start before surgery

Identifying dry eye in the early stages of the disease can save patients from unpleasantness down the road, particularly prior to surgery. Dry eye can have a significant impact on your outcomes and what the patient defines as successful surgery.

“I see a lot of patients for surgical evaluations saying, ‘I have blurry vision,’ and unless you’re looking beyond the cataract, you’re going to miss something like dry eye or MGD that is going to actually impair their vision quality after surgery,” Dr. Gupta says. “You have an opportunity to improve patients’ quality of life and improve their vision.”

Dry eye signs, such as a rapid tear break-up time and corneal staining, are common in cataract surgery patients, many of whom are often asymptomatic. The clinical appearance of fluorescein staining in dry eye includes a wide range of corneal superficial punctate epithelial erosions. In dry eyes fluorescein staining may also be seen on the conjunctival surface.¹ These signs significantly impact keratometry and topography, so you need to treat dry eye to have success with surgery and produce precise IOL calculations.² This is particularly important for the refractive or cataract patient, as untreated dry eye may impact wound healing and IOL calculations. Cataract surgery in patients with dry eye can be associated with ocular morbidity, especially in patients with connective tissue disorders.³

“It’s important to be aggressive about screening for dry eye in those patients who are trying to get a refractive outcome,” Dr. Gupta says.

Testing

Before any kind of surgery, those interviewed say you need to determine whether the patient has dry eye while conducting a clinical examination. It’s up to the clinician to go beyond determining the need for glasses or cataract surgery, and to look at signs in the ocular surface, such as corneal staining or tear break-up time, and in the meibomian glands.

“If you diagnose dry eye after surgery, they think it’s your fault,” Dr. Gupta says. “If you tell patients beforehand, it helps them to have realistic expectations. They value that you’re looking at the big picture and identifying everything that’s a problem for them.”

While many tools exist to help catch dry eye in the early stages, practices shouldn’t feel compelled to add every dry eye diagnostic test and tool right away, Dr. Gupta says. “For someone who is just starting out in the dry eye space, I think it’s very reasonable to pick one or two tests and integrate them into the practice.”

Laura Periman, MD, a cornea and refractive surgery-trained ophthalmologist in Redmond, Wash., makes sure her staff understand the Delphi Panel International Task Force guidelines for dry eye. New treatment guidelines that incorporate recent technologies are on the horizon, but for now, they follow these guidelines closely. The guidelines attach a level (one through four) based on signs and symptoms and provides appropriate treatment options. (For more on these guidelines, see http://tinyurl.com/p2ux5yf.)

Also, she recommends teaching staff to administer an Ocular Surface Disease Index (OSDI) test or the SPEED questionnaire. Staff should also be instructed to ask for a complete patient medication list (for both over the counter and prescription medications), which may contain many clues to dry eye, she says. Studies show it is probable that the duration of topical ocular therapy is relevant as a cause of dry eye, and topical BAK may be the primary factor in causing DED and ocular surface disease in a given patient.⁴ Oftentimes, Dr. Periman says her staff can recommend a less drying alternative medication to be used by the patient’s primary physician.

Training staff

Educating staff on dry eye is a must — particularly when the staff members will conduct testing. Their interpretation and suggestions may even prompt the clinician to conduct further testing.

“Techs can help to drive identification of dry eye patients,” Dr. Gupta says. “It doesn’t have to be the doctor.”

Make sure your staff knows how to appropriately conduct individual tests so you can gather accurate data. Companies often help train staff when the practice implements its point-of-care testing, Dr. Gupta says. Along with company training, Dr. Gupta recommends occasionally holding 30- to 60-minute education seminars for your staff so that they can be empowered to explain dry eye testing and the disease process to patients.

When technicians become adept, dry eye identifiers, patients benefit. This learning also contributes to job satisfaction, Dr. Periman says. “Staff members have really been open and receptive to learning,” she says. “With the way we set up our dry eye clinic, we give the tech a lot of front-end discretion on which tests to run so they become much more involved in the patients’ care. They’re happier, and their job satisfaction is better.”

Staff members aren’t the only ones who need training and education. Dr. Periman says colleagues and mentors can also be useful resources for physicians. She recommends developing a relationship with someone who often diagnoses and treats dry eye — a medical school colleague, a lecturer or even a dry eye pharmaceutical or device representative. Dr. Periman says these resources are helpful when you need to ask questions about confusing or difficult cases.

DRY EYE TREATMENT

From basic to advanced

“To me, identifying the dryness [evolves from] an easy, simple conversation with the patient,” says Dr. Gupta. ‘We did X test, and your eyes are dry. I don’t know if you’re feeling like your eyes are dry, but this is what we’re seeing. Here are the different ways we can treat it.’”

Then, Dr. Gupta says she leaves the decision to treat to the patient, unless the dry eye is moderate or is symptomatic. If so, she strongly recommends treatment.

To set up a simple treatment strategy, Dr. Periman again recommends following the ITF guidelines. Although it may sound easy to do, only 27% of ophthalmologists reported knowing and/or regularly using these guidelines.¹

“If you’re just beginning as a practitioner, you don’t have all of these fancy toys. You still can use your head, ears and eyes. It’s still a clinical diagnosis, and just with some staining and asking a few questions you can make the diagnosis.”

When you become familiar with the different medicines, treatments and interventions you can get creative and expand your patient offerings. These therapies can relieve dry eye, especially for those looking to return to contact lens use, and they can provide the practice with a reimbursement.

TAPPING IN

Don’t fret over increased chair time

Some may fear that increasing their dry eye efforts may increase patient chair time and decrease office efficiency. Dr. Gupta says that’s not so — even if you make an aggressive push to diagnose and treat the disease.

“In the beginning, I had a preconceived idea that this would just take longer, and it actually doesn’t take a lot longer,” she says. “Think about the conversations you have with patients who keep coming back unhappy with their glasses or patients with 20/20 acuity post-LASIK who say they can’t see anything or are unhappy multifocal IOL patients ... If you identify and treat dry eye, you’ll likely be able to minimize those situations.”

Once the physician explains the diagnosis and treatment options, Dr. Gupta says the physician can move on to the next patient while a scribe or tech answers questions or helps with uncertainties about drops, tears or topical therapies.

Take action

Untreated dry eye may impact the quality of vision after a refractive, cataract or even oculoplastic procedure. Despite our impressive technologies, Dr. Periman says. “The best of the best lasers, implants and surgery done without first optimizing the refractive interface of the eye, the ocular surface, is like having a Porsche engine in a Ford Escort frame. All the patient sees is the outside, not the technology underneath. And they may think they received inferior care.”

Another positive: alleviating dry eye can increase your bottom line, says Dr. Periman.

“That is a nice, happy side effect to taking notice, taking charge and taking action in treating dry eye disease.” OM

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