Visionaries and Educators

Just use warm compresses?

A counselor sees more to dry eye than a little heat can handle, and thus is born a practice’s center.

By K.D. Barnebey

Our practice, Specialty Eyecare Centre, is a referral-based glaucoma and anterior segment clinic. When I assumed the role of surgical counselor more than 13 years ago, it was my job to help patients decide which premium lenses to choose, answer their questions about cataract and various glaucoma procedures and, on occasion, hold a hand.

As I advised, I listened — to complaints of uncomfortable red eyes, of scratchy, gritty sensations, of morning-time conjunctival hyperemia, of uncontrolled tearing. Maybe patients talked freely because I wasn’t a doctor and therefore was considered less intimidating, or more empathetic because I had the same symptoms — regardless, I listened.

As I grew into the counselor role, gaining day-to-day experience from our ophthalmologists and technicians and more formal training through professional conferences, I began to question whether the “just put a warm compress on it” was the best relief we could offer.

And then I met Donald Korb, OD, founder of TearScience, at a conference in San Francisco in 2010.

If I had any doubt before meeting Dr. Korb that dry eye was a real problem, let alone a big one, it vanished after our chat. I was convinced we needed a dry eye center. I just had to persuade the ophthalmologists, one of whom was my husband.

BUSY, PRACTICAL CREATURES

Most of our patients have some form of ocular surface disorder, so I didn’t have to worry that our dry eye center would at least see patients. But our doctors, and I think most others, are methodical, practical creatures. Convincing them that dry eye needed to be taken seriously was just part of the issue.

They knew it was a real complaint: It was more a matter of absorbing a dry eye center into the practice. No one had taken the time to look at what potentially life-changing alternatives might be offered to our patients.

And for good reason. In our practice, one doctor sees nearly 60 patients per day; six technicians perform more than 50 tests. I couldn’t imagine asking our already burdened technicians to increase their workload. To properly address ocular surface disease, I knew our system had to change to help the doctors focus on ocular surface disease by allotting the time and attention required for each patient.

After returning from the San Francisco conference, I was able to convince some colleagues that a dry eye center was necessary. We looked at journals, dissected studies and conferred with dry eye experts. I kept rallying the cause, then, after absorbing the science behind the new technologies, my husband finally said, “yes.”

WHAT SUCCESS ENTAILS, AND FIRST STEPS

A successful dry eye center requires that everyone — physicians, nurses, technicians, billing staff — believes that dry eye is an important, unmet need to be taken and treated seriously.

It also requires that money be spent on staff training and diagnostic and therapeutic equipment.

Also, you’ve got to mix it up: What you do one year doesn’t mean you should do it the next. Offer new products, and look at new technologies. This is primarily a cash service, so you need to think retail. (And perhaps reimbursement, depending upon the diagnostic and treatment prescribed.)

As the dry eye counselor, I spend at least 45 minutes with one patient, which includes testing time. My time with the patient allows our physicians to see two to three more patients per day, giving the bottom line a significant boost.

We reserve a dedicated block on certain days of the week to schedule dry eye patients. Allowing an individualized approach to focus exclusively on patients’ often complicated, chronic and certainly progressive condition engenders trust and compassion. Patients come to us from multiple directions: glaucoma and cataract consultations; outside referrals; patient recommendations; Internet searches.

During an initial consultation, they receive a packet with brochures and information about dry eye, different treatments we provide, pretesting instructions, insurance and non-covered information, and my contact information.

HOW WE TREAT

Patient counseling starts before patients’ diagnostic visits. I call or e-mail them to tell them what to expect during the hour-long exam. The point, I say, is to try to isolate the root cause of their symptoms. All questions are answered, all costs are discussed, including the $150 out-of-pocket expense for LipiView evaluation.

Here are the highlights of the patient visit:

• At check-in, the patient pays for LipiView and any copays.

• I escort the patient to a procedure room. If the patient is new, a technician gives the patient a dry eye speed questionnaire.

• The questions on Speedi-Q, as we have aptly named it, are rated from zero to four for symptoms and the same questions rated for severity. The questions are: Are your eyes burning? Are your eyes dry? Are your eyes scratchy and gritty? Do your eyes tear?

• If the patient has not been seen for ocular surface issues in a few months, the dry eye counselor updates the patient’s questionnaire.

Next comes LipiView testing and meibography. Before I give the printouts to the physician for diagnosis, I show them to the patient. It is hard to disagree that the technology is pretty cool. The patients almost always accept their results excitedly. If accompanied, they enjoy sharing the results with friends and family, further promoting and advocating dry eye management.

Next, we travel across the hall to an exam room where we take a more comprehensive patient history along with vision, followed by an in-depth clinical examination given by the physician.

The sequence is just as important as the structures examined. First, tear film break-up time is assessed using a microfluorescein strip (label). The amount of fluid introduced to the tear film is virtually none. Meibomian glands are inspected and expression of the MG quantified in the lower eyelids. The eyelids are inspected with attention to eye margins. Vital stains are applied, including lissamine green and standard fluorescein, to inspect conjunctiva, cornea and examination of line of marks. Eyelid function is inspected for lagophthalmos before measuring tear volume. I admit we are “old school” and still screen with the Schirmer test. Tear film osmolarity could be used, although we have not added this technology.

The doctor confirms test results and concludes with his diagnosis, communicating his recommendations. We check these off on a pre-printed sheet that also includes blink exercises. LipiFlow, even though it is not covered by insurance, is often recommended.

As dry eye counselor, I step in once again to explain options, answer questions and discuss patient scheduling. At this point I discuss the products that can help: eye masks, goggles, lid scrubs, artificial tears, Omega 3 nutraceuticals. The front desk also can help with retail sales. A dry eye center’s front desk staff must have a clear understanding of all products offered and be able to answer patient questions about retail items.

A LAST WORD: HAVE NO FEAR

Practices may be afraid that patients will be unwilling to pay out of pocket for additional uncovered treatment fees. I haven’t seen this as an issue. About 80% of our patients realize improvement anywhere from around 20% to 80%, and in a matter of weeks in most cases. I never apologize for prices and am not afraid to charge patients for them.

Technology plays a big role in a dry eye center and can tell a powerful story. When patients respond to treatment and their symptoms are measurably relieved, they trust that their doctor is doing everything possible to care for them. I have found that most patients are willing to pay for quality care for their eyes. OM

Ms. Barnebey is a clinical coordinator and administrator at Specialty Eyecare Centre in Bellevue, Wash.