Back in 1996, I had a great, booming practice. Everything was going well. Then a patient came in with red eyes. She had already seen three eyecare providers who referred her to me. Nobody knew what was wrong. Lacking the diagnostic tests we have today, I did not know either.

Three days later, however, I knew exactly what she had — because I had it, too: severe epidemic keratoconjunctivitis. My best-corrected visual acuity was 20/80. I had severe corneal precipitates that required treatment with a steroid, causing my intraocular pressure to rise to 60 mmHg, and I developed cataracts that required surgery.

I also developed chronic, severe dry eye, to the point of needing an assistant to instill artificial tears in my eyes while performing surgery. It was a continual, long-term problem. So, not only was I motivated to start a dry eye clinic for my patients, but also to get some relief for myself.

How do you start a dry eye program? Here are some of the highlights of our process.

Educate and Organize

Our practice began with education. Key staff members attended Dry Eye University, founded by Frank W. Bowden III, MD, in Jacksonville, Fla. We also invited dry eye experts Jerry Robben, OD, and Laura M. Periman, MD, to our practice to familiarize us with this specialty. And, of course, I asked some of the leaders around the country for their recommendations for setting up a dry eye clinic.

Next we selected a lead for our dry eye clinic and developed a standard of care for diagnosing and treating dry eye.

Gain Consensus and Support

We presented our standard of care to everyone in the practice and worked diligently to ensure its adoption. The entire staff — from physicians, nurses, and technicians to front desk personnel — must be on board.

We also had meetings with our physicians to gain their support for this initiative. We emphasized that we will now be able to improve patient care well beyond the common practice of offering patients samples of various lubricant drops — an approach that is not based on scientific evidence and, in my opinion, does not inspire confidence in patients.

Initially, physicians and staff had some concerns. For example, some physicians felt that diagnosing and treating dry eye disease would be too time-consuming, taking up appointment slots needed for other patients and resulting in lost revenue. They soon realized, however, that focusing on dry eye can be a significant revenue booster by increasing doctor visits, diagnostic tests, and therapeutic modalities.

Likewise, clinical staff members were concerned that managing these patients would take up too much of their time and disrupt their schedules. As we have incorporated dry eye management into our practice, however, we have found that we are actually saving time. Patients need fewer return visits because we can address their dry eye problems efficiently, often in one visit. In addition, when we treat the ocular surface up front, patients are less likely to develop postoperative complications.

We now have a lead dry eye optometrist, a dedicated dry eye clinic day, and dry eye appointment slots, and we are following our standard of care. It took roughly a year before we were running smoothly, but the clinical staff has become quite proficient in diagnostic testing, and the speed of their workups has improved, aided by their use of the SPEED questionnaire.¹ (See “The SPEED Questionnaire for Rapid Screening” sidebar, page 11). Most importantly, we have improved patient care and satisfaction, even as we are still learning and adapting.

Key Diagnostic Tools

The LipiScan high-definition meibomian gland imager (TearScience), the LipiView II ocular surface interferometer (TearScience), and the TearLab Osmolarity System are key to diagnosing dry eye disease. What’s more, having images and measurements to share with patients helps us educate and reassure them that they actually do have a disease and are not imagining their symptoms. For example, I can show them the pink strip on the InflammaDry (RPS), which detects elevated levels of MMP-9 protein, and explain that a positive result means they have significant inflammation. From there, we discuss how I will tailor the treatment to their specific situation.

Targeted Treatments

We offer a full range of dry eye treatments. Here is an overview.

Retaine MGD ophthalmic emulsion (Ocusoft) is a preservative-free, lipid-replenishing formula that uses electrostatic attraction to stabilize the tear film and protect against moisture loss.

Oasis Tears Plus (Oasis Medical), are preservative-free, viscoadaptive, lubricating eye drops with glycerin to retain tears on the ocular surface.

We also offer the oral supplement 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. This is one of the few nutritional products that has been studied and found effective for improving dry eye symptoms.²

Avenova (NovaBay) for lid and lash hygiene is an effective adjunct for treating blepharitis. It is useful for treating pre-op patients.

The prescription medicines we use include the following:

• doxycycline
• AzaSite (azithromycin, Akorn), which is indicated for the treatment of bacterial conjunctivitis caused by susceptible isolates of various microorganisms, such as Staphylococcus aureus, Streptococcus mitis group, and Streptococcus pneumoniae
• Restasis (cyclosporine, Allergan), which is indicated for the treatment of reduced tear production owing to inflammation from dry eye disease
• Xiidra (lifitegrast, Shire), which is indicated for the treatment of dry eye disease. On a personal level, this is the product that significantly improved my dry eye condition.

We also perform LipiFlow treatments (TearScience), applying heat and pressure to the inner eyelid to safely remove gland obstructions and stagnant gland content.

Another useful adjunctive therapy is intense pulsed light (IPL, Toyos), which improves meibomian gland function, kills microorganisms, improves the signs of blepharitis, melts thick secretions, and stimulates cells and glands to function normally.

The Pellevé wrinkle reduction system (Ellman), which is used in oculoplastic surgery, has a handpiece that can be used to heat the meibomian glands to facilitate manual expression. An advantage of this treatment is that you can use it on any skin color without the risk of hyperpigmentation or scarring that sometimes occurs with IPL.

Worthy Focus with Long-term Benefits

The Hippocratic Oath states in part: “I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability.” Dry eye disease markedly decreases the quality of life for many people.

The Oath continues: “My responsibility includes these related problems, if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure.”

When you have a comprehensive dry eye program, you will prevent a legion of problems. If my dry eye had been adequately treated in 1996, for example, I would not have the scarring of the eyelids and corneas that I have now. These are just some of the long-term complications that can be prevented with prompt and effective treatment. I would strongly encourage you to adopt a dry eye program. ■

References

1. Ngo W, Situ P, Keir N, et al. Psychometric properties and validation of the Standard Patient Evaluation of Eye Dryness questionnaire. Cornea. 2013;32:1204-1210.
2. 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;32:1297-1304.