Our Unique Approach to Dry Eye in Rural Georgia

Addressing an unmet need with motivation, organization, and delegation

Throughout the past 6 months, we’ve developed a dry eye clinic within our established practice. (See “North Georgia Eye at a Glance.”) We decided to do this for several reasons: 1) We know that patients want to see 20/20 or better, and quality vision requires a healthy ocular surface; 2) 50% to 75% of our patients have dry eye symptoms, so by treating them, we can, in theory, have happier and more satisfied patients; and 3) it’s a great way to step into an under-represented area of ophthalmology, improve surgical outcomes, generate revenue, and establish a niche and a referral base.

We accomplished this by per-forming scheduled dry eye evaluations 2 days per week. We see 20 to 25 patients each day, and approximately 25% of them undergo a treatment at that visit. Approximately 80% of our dry eye clinic patients are in-office referrals, meaning they were already our patients. Around 10% are self-referrals, and 10% are referred by outside eye doctors or primary care physicians. I currently work 2 days per week, and 75% of my practice is ocular surface disease. We have three technicians who rotate in and out of the clinic and one financial counselor. This approach is unique because we’re a small-scale yet full-service dry eye clinic with separate scheduled evaluation appointments, and most of our patients are internal referrals.

We have five parts to our dry eye management algorithm:

1) Identify dry eye disease

• SPEED questionnaire

• InflammaDry (RPS)

2) Diagnose dry eye disease

• LipiView (TearScience)

• Schirmer’s test

• Diagnostic expression/Korb Meibomian Gland Evaluator (TearScience)

3) Educate the patient

4) Provide financial counseling (if needed)

5) Perform treatment; establish follow-up care

• BlephEx (Rysurg)

• LipiFlow (TearScience)

• Prokera biologic corneal bandage (Bio-Tissue)

• Dry eye medications

• Dry eye product basket

The first step to carrying out the algorithm is getting patients scheduled for the dry eye evaluation. Patients being seen in our comprehensive, cornea, or retina clinics who have dry eye symptoms and are motivated to find a solution are scheduled for a dry eye evaluation during our dedicated dry eye clinic days. The dry eye appointment is a 25- to 30-minute slot. Prior to the appointment, staff call patients to advise them not to use eye drops, eye cream, or makeup in the 24 hours before testing.

During the appointment, patients have three main stops: the front desk, the diagnostic room, and the exam room. At the front desk, patients check in and out, make their payment, and, if necessary, purchase a basket of dry eye products. At check in, they receive a packet containing the SPEED questionnaire, which they begin filling out in the waiting room, explanations of dry eye disease, LipiView and LipiFlow, and a LipiFlow agreement sheet. If they sign the sheet, they receive the LipiView evaluation prior to seeing the physician. Of all the diagnostic tests we use, LipiView has been the most important because of how it helps with patient education. We don’t need to say much because they can see firsthand the damage to their meibomian glands. Also, we’ve integrated the LipiView into our electronic medical records system so we can view the results in the exam room and not have to bring patients back to the diagnostic room.

We perform the majority of the testing in the diagnostic room. When testing is complete, we usher patients to the exam room. There, they meet with the physician and undergo diagnostic gland expression. Patient education about treatment options, follow-up care ,and financial counseling also take place in the exam room.

At checkout, we sell a variety of products that are packaged in our dry eye basket, including artificial tears and lid hygiene items. This helps to ensure patients use recommended treatments. Our patients like this because in our small town, the products may not be available in all pharmacies and stores.

Three Key Points

One of the aspects of our dry eye clinic that has proved to be very important is teamwork. The technician’s contribution to the dry eye appointment is as important as the physician’s. Our technicians spend 15 to 20 minutes with each patient during which time they’re responsible for most of the diagnostic testing and starting the education process. I spend 5 to 7 minutes with each patient, and am responsible for diagnostic meibomian gland expression, reviewing test results, discussing treatment options, and continuing the education.

Sheetal Shah, MD
North Georgia Eye Clinic Gainesville, Ga.

The financial counselor is a key member of the team because she removes the doctor from the financial discussion, which we prefer.

Whenever we deal with services that aren’t covered by insurance, the question that arises is whether patients will pay out of pocket. We’ve learned the answer is “yes,” and we should never assume it will be “no.” Today’s patients want reason-based answers and they want the latest technology. I believe it’s my ethical responsibility to offer them the most relevant and up-to-date treatments regardless of what my perception of cost is.

Finally, we’ve learned that to start a dry eye practice, you don’t need a lot of personnel, resources, or materials. What you need is motivation, organization, and delegation. (See “Starting a Dry Eye Clinic.”)

If you address dry eye needs in your practice, use the resources you already have to institute a system that works for you and create a team. You can establish dry eye care, just as we did in the “Poultry Capital of the World.” ■