Ocular surface disease (OSD) is the common thread that runs through all ophthalmology specialties from cataract and refractive surgery to glaucoma, posterior segment disease, and oculoplastics. If left untreated, not only will OSD have a significant impact on comfort, vision, and long-term ocular health, but also on surgical outcomes.

Dry eye is prevalent in candidates for LASIK surgery¹ and blepharoplasty,² and one survey found that 80% of patients presenting for cataract surgery had evidence of dry eye, yet only 20% had been diagnosed.³ What’s more, any type of ocular surgery can trigger or exacerbate dry eye — cataract surgery adds one DEWS severity level and LASIK surgery adds two⁴ — complicating recovery and long-term results.

As managing senior partner of our practice, I must be mindful of the big picture and its impact on our bottom line. With decreased reimbursements, regulatory expansion, burgeoning demographics, and fewer providers, it is incumbent upon us to invest in OSD if we want to deliver state-of-the-art care and maintain our leadership position in the community.

Here, I describe how we expanded our procedures and product lines and earned the Dry Eye Center of Excellence certification, an initiative that has resulted in substantial practice growth and patient satisfaction.

Plugs and Pulses

Punctal plugs are often ignored as a viable treatment option for dry eyes, but they are useful for short-term, rapid results, and we can produce some reasonable income with permanent and temporary punctal occlusion (Figure 1). We tend to use the dissolving punctal plugs because fewer callbacks are necessary, and we can renew them every 3 to 6 months.

We use various techniques to improve meibomian gland physiology, and we have enjoyed growth in our thermal pulsation practice with LipiFlow (TearScience) (Figure 2). This must be considered a premium offering as it requires counselors and payment plans to help bring this therapy to the largest population. Our usage has doubled since a recent price reduction went into effect.

Nutritional Supplementation

We are great proponents of HydroEye (ScienceBased Health), which contains the omega fatty acid GLA, which is derived from black currant seed oil as well as omega-3s (EPA, DHA) from fish oil. Our prospective, multicenter, randomized study of patients with evaporative dry eye showed that their Ocular Surface Disease Index scores improved after using HydroEye for 6 months.⁵ Staining revealed that the HLA-DR and the CD11c inflammatory markers stabilized with the omega-3 supplement, whereas the inflammatory process continued without that intervention.

Simply delaying the aging process through supplementation produced valuable clinical insights in this first prospective analysis showing statistically significant results in a dry eye population.

Recalcitrant Dry Eye

In some recalcitrant cases in which severe OSD inhibits clarity of the central visual axis despite maximum medical therapy, we use the Prokera biologic corneal bandage (Bio-Tissue). The amniotic membrane tissue in Prokera products is preserved using the company’s proprietary processing method to ensure the tissue retains its full biologic activity. It has natural therapeutic actions that help heal damaged eye surfaces, and it imparts a wide variety of advantages over a standard bandage contact lens, including sustained growth factor delivery and superior oxygen permeability.

In a study of 40 patients treated with the Prokera biologic corneal bandage, we saw 95% improvement in fluorescein staining, 85% improvement in symptoms, and a wide variety of benefits, including normalization of MMP-9 expression in irregular surface topography.

An example of Prokera’s effect is seen in a patient who presented for cataract surgery with basement membrane dystrophy, previous laser surgery, and dry eye (Figure 3). He has higher-order coma aberrations that are extremely high and irregular keratometry readings. After placing a Prokera biologic corneal bandage for 1 week, coma was reduced significantly and keratometry readings improved. In addition, keratometry readings were markedly different, and there was a 0.5D change in the IOL prescription sphere.

Looking at the metrics for just one Prokera treatment per day ($1,200/unit), the financial impact of the procedure is clear, contributing $312,000 yearly revenue.

Combining our revenue from the therapeutics I have described thus far, we have produced a reasonable bottom line in our practice (Figure 4). Note that we use only therapeutics that have been shown to produce evidence-based improvements in outcomes, and these treatments must be managed intelligently by motivated physicians.

 

Manage Your Images

An image-management system is essential for any ophthalmology practice, and in this era of electronic health records, efficiency is paramount for those of us who feel slowed down in the office, clicking and pointing rather than talking directly to our patients. In our practice, we use the Topcon Synergy Ophthalmic Data Management System to organize all of our anterior and posterior segment images.

As we expand our product line, we must track utilization and revenue generated by each doctor. We look at which doctor is doing the most retail sales, the highest LASIK volume, and the highest premium IOL volume. If you can’t measure it, you can’t track it and change it.

Diagnostic Testing

• The TearLab Osmolarity Test is the foundation of our diagnostic testing, and we test virtually everyone who walks through our door — new dry eye patients, new surgery patients, patients with post-LASIK hyperesthesia syndrome, and a wide variety of patients who have what may be symptomatically disproportionate OSD. We also use this test for punctal plug and contact lens decision analysis, as well as follow-up treatment assessments.
  Our practice performs about 50,000 TearLab Osmolarity Tests annually, which generates significant income (Figure 5). Income can be highly variable based on insurance plans, however, underscoring the importance of negotiating contracts with individual carriers. You also must be cautious about bundling and coupling procedures that may have the same diagnostic code. For example, you will receive 50% less for the second procedure if it is a punctal plug, a tear osmolarity test, or an MMP-9 test (InflammaDry, RPS).
• In addition, you must use the AdenoPlus test (RPS) in your office. It is key to diagnosing adenovirus, which may lead to central infiltrates and conjunctival scarring (Figure 6). This test is by far the best means we have of telling a patient that he has to stay home for 10 days because he is contagious. Don’t be the person who creates an epidemic in your office. The number one cause of epidemic keratoconjunctivitis is not the shipyard — these days, it is the eyecare provider’s office.
• Blepharitis remains a great concern to us, not only because of chronic recalcitrant OSD and dry eye, but also because of the potential for infection. We use LipiView and LipiScan (TearScience) in all of our offices. We find these tests produce valuable diagnostic and consultative information for patients who require intervention with the LipiFlow (TearScience) device. We use the dynamic meibomian imaging as a cash-pay or an imaging-pay situation, depending on the patient.
• Allergic conjunctivitis, which is common in children and adults, is the forgotten ocular surface disease. The Doctor’s Allergy Formula diagnostic test (Bausch + Lomb) is a noninvasive test that can be performed by a technician in your office in 2 minutes, with results available in 10 minutes. This test enables us to tailor preventive care for patients and potentially reduce medication usage. We know that we get better results with LASIK, for instance, when the patient’s allergies are controlled.^6-7 This test is convenient for patients and a good income source for the practice (Figure 7).

Practice Growth Strategies

There are four avenues toward practice growth:

1. patient acquisition
2. insurance-based business
3. cash-based business
4. value-added services

Our most effective marketing tool to acquire new patients is to engage friends and family of our patients through direct contact, such as brochures about dry eye in the clinic and conversations about this disease with anyone accompanying patients to our offices.

Opportunities for growth in insurance-based business also exist. Cigna, for example, reimburses $38 for an intermediate visit, but you can increase your income for that visit by more than 200% by performing proper diagnostic testing and providing the appropriate intervention based on degree of inflammation or hyperosmolarity readings.

The most valuable asset in your practice is doctor-provider time, so you must make the best use of it. For instance, a routine cataract surgery may generate $40 per minute for your cataract surgeon; however, treating dry eye adds value to your practice and to the patient, who will benefit from a potentially better outcome (Figure 8).

Similarly, if we evaluate our cash-based procedures, we see that a blepharoplasty can be valuable and that Botox (onabotulinumtoxinA, Allergan) is valuable, but LASIK and LipiFlow are at the top of the list for best utilization of provider time (Figure 8).

If we add combined diagnostic collections with combined therapeutic collections, we have a tremendous increase in the bottom line (Figure 9). That revenue is the equivalent of three new providers, and it was obtained entirely through internal marketing and existing — but optimized — providers.

A pharmacoeconomic analysis shows fewer visits, fewer guesses at therapy, less random therapy, empirical therapy, OTC therapy, gasoline, and work missed, for a net savings of more than $1 million to society, because we are using our analytical skills to deliver the best, most appropriate care to our patients.

Execute and Win

Several components are required to successfully execute a Dry Eye Center of Excellence. You must have a “doctor champion,” someone whom the other providers in your practice respect and to whom they will look for appropriate application of these principles. You also need leadership, an engaged administration, and an educated staff. Everyone in your practice must know where to send a dry eye patient, a LASIK patient, a Botox patient, and a premium IOL patient. You must use internal and targeted external marketing.

This is a win for all. Patients win with diagnostic accuracy and timely, appropriate treatment. Payers win because targeted therapy means fewer visits and fewer random medications. Providers win because the practice grows, and the practice wins because income is diversified. Everybody wins because this is good medicine. ■

References

1. Azuma M, Yabuta C, Fraunfelder FW, Shearer TR. Dry eye in LASIK patients. BMC Res Notes. 2014;7:420.
2. Prischmann J, Sufyan A, Ting JY, Ruffin C, Perkins SW. Dry eye symptoms and chemosis following blepharoplasty: a 10-year retrospective review of 892 cases in a single-surgeon series. JAMA Facial Plast Surg. 2013;15:39-46.
3. Trattler W, Reilly C, Goldberg D, et al. Cataract and Dry Eye: Prospective Health Assessment of Cataract Patients’ Ocular Surface Study. Poster presented at: ASCRS-ASOA Symposium & Congress; March 2011; San Diego, CA.
4. Behrens A, Doyle JJ, Stern L, et al; Dysfunctional tear syndrome study group. Dysfunctional tear syndrome: a Delphi approach to treatment recommendations. Cornea. 2006;25:900-907.
5. Sheppard JD Jr, Singh R, McClellan AJ, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 2013;31:1297-1304.
6. Bielory BP, O’Brien TP. Allergic complications with laser-assisted in-situ keratomileusis. Curr Opin Allergy Clin Immunol. 2011;11:483-491.
7. Boorstein SM, Henk HJ, Elner VM. Atopy: a patient-specific risk factor for diffuse lamellar keratitis. Ophthalmology. 2003;110(1):131-137.