Dry Eye Q&A

Experts field questions regarding dry eye care

(Left to right) John Sheppard, MD, MMSc, Mitchell A. Jackson, MD, Patti Barkey, CEO, COE, Kendall Donaldson, MD, MS, and Sheetal Shah, MD

Q: Do you find that addressing dry eye has improved your patients’ satisfaction with refractive cataract surgery?

Mitchell A. Jackson, MD: Yes. Refractive cataract surgery patients need a pristine ocular surface so that preoperative diagnostic measurements, including keratometry and corneal topography, are accurate. Other-wise, the IOL power calculation and femtosecond laser astigmatism-correcting incisions can be inaccurate as well, which for premium surgery patients in particular is a disaster. As the PHACO study¹ showed, the majority of cataract surgery patients do not have symptoms of dry eye even though they have the disease. In other words, they’re not going to tell you they have dry eye, you have to look for it. Satisfaction has gone way up in terms of my outcomes because we’re paying attention to the ocular surface much more closely than we had in the past.

Kendall Donaldson, MD, MS: I agree completely. Also, patients need to understand their dry eye is a preexisting condition (identified and acknowledged before surgery), not a complication we diagnosed after surgery and potentially created with our surgical intervention.

Q: How do you motivate the recalcitrant surgeon to adopt a dry eye mentality?

Patti Barkey: We developed a standard of care that all of the doctors agreed upon. We have a provider meeting about it once a month. Doctors can voice their opinions about certain aspects of it, but at the end of the day, we do what we have agreed to do. I do a great deal of record auditing. I check to what extent the doctors are following our standard of care, for example, whether they use the SPEED questionnaire, whether they evaluate the meibomian glands, and if they are abnormal, whether something is done for the patient to take care of it. Our doctors are on board. We eliminated a doctor from the practice who wasn’t on board.

Q: Can you explain the difference between the HydroEye (ScienceBased Health) and the Dry Eye Omega Benefits (PRN) nutritional supplements? We’d like to be able to offer just one in our practice.

John Sheppard, MD, MMSc: Each of these companies has taken to heart the problem of the horrible American diet. ScienceBased health has created a carefully formulated combination gamma linolenic acid (GLA) and omega-3 product. PRN offers a patented formulation of 3:1 re-esterified EPA and DHA only. They both work beautifully. There are, however, idiosyncratic responses such as seen with glaucoma medications. We have dozens of glaucoma drops we can use, but not every one works for every patient. If HydroEye isn’t effective for a patient, Dry Eye Omega Benefits might be, and vice versa. Both are great products and address the problem for the vast majority of patients.

Dr. Jackson: Because some patients tolerate one better than the other, it’s good to have access to both products.

Dr. Donaldson: We also need to encourage patients to stick with the supplements for at least a couple of months. They shouldn’t expect instant relief. We recommend they get a supply that gives them a 3-month trial.

Q: TearScience recently changed its business model and decreased the cost of LipiFlow thermal pulsation system hardware and the treatment activators. How has that affected your pricing structure?

Dr. Sheppard: We reduced our fee by about half.

Dr. Jackson: We decreased our fee, and if a second treatment is needed within a year, the patient will get a discount. We want to make sure patients have access to the technology.

Barkey: We’re not planning to change our fee. We’ve treated a great deal of patients at our current price level and feel it would be a disservice to them. We use the treatment on 48 to 60 eyes a month. We’re going to use the extra profit for more marketing.

Dr. Donaldson: We cut our LipiFlow fee in half and we may cut it further. There were many patients who we felt could benefit from treatment but were unable to do so because of financial limitations. Now with price reductions, we can offer Lipiflow to a larger population of patients who could potentially benefit from this treatment modality.

Dr. Sheppard: We were a beta test site for the lower price and our volume shot up immediately. If this were covered by insurance, really, who wouldn’t you recommend it for? Because it’s a cash-based procedure, we look upon it just as we do refractive surgery. It’s a premium service. The counselor provides a full disclosure about what to expect. If a patient needs a second treatment in 6 to 18 months, we discount that a bit.

Q: What’s the incentive for patients to adopt the LipiFlow treatment? What’s the endpoint they’re trying to avoid in 95% of meibomian gland dysfunction cases?

Dr. Sheppard: Patients fall into one of three categories. Category one: the symptomatic patients. They’re a slam dunk because they want to feel better. Category two: the perioperative patients. They need to optimize their ocular surface for better results and safety. Category three: everyone else. When they look at the meibomian gland images you can capture with LipiView Dynamic Meibomian Imaging (DMI) (TearScience), don’t be surprised if you have a doubling or tripling of your conversion rate. And truly, the patients with damaged glands will be more motivated despite a lack of self-awareness.

Q: Do you bring patients back for the dry eye evaluation or see them within the regular flow of the clinic?

Dr. Sheppard: I try to address the dry eye in at least one way at every visit. So, I may recommend an artificial tear or a nutritional supplement, for example, during the regular visit and then bring them back for a more detailed evaluation. We have a separate schedule block for the ocular surface imaging studies, just as we do for OCT, topography, or fields, which greatly facilitates patient flow.

Sheetal Shah, MD: We try to do the same. However, it can be challenging to accommodate the necessary dry eye education during a visit that wasn’t scheduled as such, or to accurately perform some of the dry eye testing after the patient has had drops instilled. Therefore, while we try to start the patient off with something for the dry eye, we prefer separate evaluations.

Dr. Jackson: It helps to educate staff so they can identify the dry eye problem in the beginning of the workup and know what testing should be done. If we can’t accomplish everything we’d like to at that visit, we try to at least initiate some type of helpful therapy and give it about 6 weeks to work. Then we have the patient back for another diagnostic test, perhaps InflammaDry (RPS) or tear osmolarity (TearLab). When the objective test results indicate improvement, patients become more motivated to continue the existing therapy and/or use additional therapy.

Dr. Donaldson: We try to customize what we do by taking the dry eye care one step further than a patient has had elsewhere and creating a supportive partnership through the use of physician extenders, so patients feel we have spent the time and are invested in their care. Often, they are very frustrated and suffering from a lack of support and incomplete treatment of their symptoms. Dry eye is a chronic disease, so we must consider both the physiological as well as the psychological aspects of the disease process.

Barkey: Keep in mind that once you’ve been doing this for a while, you’ll have so many patients you’re working with that it’s difficult to find a schedule block to fit them all. Access is important to the patient. ■

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