ALICE T. EPITROPOULOS, MD [MODERATOR]: Dry eye disease is the number one reason why patients see their eyecare practitioners.¹ And, for many patients, it’s also the root cause of unhappiness or dissatisfaction after cataract or refractive surgery.² Ocular surface disease is a great opportunity for ophthalmologists and optometrists to collaborate.

The ophthalmologists and optometrists on our panel are experts in the complexities of dry eye disease, as well as the latest diagnostic and therapeutic options for optimizing the ocular surface. Our discussion focuses on protocols and algorithms for identifying and managing dry eye disease.

Dr. Schachter, what’s the basis for your approach to diagnosis and treatment of dry eye?

SCOTT E. SCHACHTER, OD: When I first began screening patients for dry eye disease — prompted by my own experience as a LASIK patient with dry eye-related higher-order aberrations — I leaned on the first Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop (DEWS) for my guidelines.³ The expert recommendations for diagnosing, treating, and managing dry eye disease were all there. A decade later, TFOS DEWS II incorporates a wealth of new data to guide us.⁴

DR. EPITROPOULOS: Dr. Jackson, what prompted your interest in ocular surface disease?

MITCHELL A. JACKSON, MD: As a cataract refractive surgeon, I recognize how important it is to optimize the ocular surface preoperatively to ensure accurate diagnostic biometry and topography readings. Otherwise, the power of an intraocular lens implant can be off by as much as 1.00D or 1.50D,⁵ and the patient will experience fluctuating and blurred vision. Typically, I follow the TFOS DEWS II or the more disease-based CEDARS algorithm to develop my dry eye treatment plans.^4,5

Point-of-Care Tests

DR. EPITROPOULOS: Point-of-care tests are excellent tools not only to diagnose dry eye disease, but also to monitor the response to treatment over time.

Dr. Epstein, do you typically check tear osmolarity and use InflammaDry (Quidel Corporation) in your workup?

ARTHUR B. EPSTEIN, OD: I think both tests can be very helpful, but I tend to use them more for “troubleshooting” complex patients who have multifactorial disease. I believe looking at the concordance of the osmolarity and inflammatory marker assessment can be beneficial as a tear film dysfunction index. Elevated osmolarity in dry eye also serves as a surrogate for dilution. Factor in inflammatory marker levels in that context and the information becomes more valuable.

DR. EPITROPOULOS: Dr. McDonald, what is the role of inflammation in dry eye disease?

MARGUERITE B. MCDONALD, MD: Years ago, we thought dry eye was a disorder of senescence, but we now know that inflammation is involved in the etiology of both aqueous-deficient and evaporative dry eye. We cannot treat ocular surface disease without treating inflammation.

DR. EPITROPOULOS: Dr. Schachter, how do you use questionnaires or symptom surveys?

DR. SCHACHTER: We use the Standardized Patient Evaluation of Eye Dryness (SPEED) questionnaire to screen everyone in my practice. If someone scores higher than 7, my staff tests the patient with InflammaDry. A positive result shows me that inflammation is present. There’s value in that. When I tell patients that we need to start treating the inflammation before it worsens, they accept that assessment. InflammaDry is a valuable tool in my practice.

DR. JACKSON: We use a modified SPEED questionnaire that includes questions about allergies. From the patients’ responses, my technicians know what tests are required. We always include InflammaDry, the TearLab Osmolarity Test, and LipiView with Dynamic Meibomian Imaging (DMI) (Johnson & Johnson Vision TearScience) as our baseline before I see a patient. During my examination, I look for signs of autoimmune disease or other factors that might be contributing to the patient’s condition.

DR. EPSTEIN: Anyone who is serious about dry eye and ocular surface disease should have meibomian gland imaging. It’s critically important and often overlooked. One of the reasons why comanagement exists is because many of our colleagues don’t have that technology.

DR. EPITROPOULOS: Dr. McDonald, how do you proceed with your evaluation?

DR. MCDONALD: I do exactly what Dr. Jackson describes. If even one symptom on the SPEED questionnaire is checked off, our technicians perform the appropriate tests. When I enter the examination room, I have everything I need, and then I use my treatment ladder, which is based on TFOS DEWS II, the Meibomian Gland Workshop, and the CEDARS/ASPENS Society, which are similar and complementary.^4-6

DR. JACKSON: I like objective testing, because we often can’t convince patients that they have a problem unless we show them something objectively. If I can show patients test results that indicate inflammation is present, they understand why they need an anti-inflammatory, and they are more likely to adhere to treatment. Objective tests also enable us to monitor compliance with the prescribed therapy and motivate patients to continue their treatment. Objective testing is the key to minimizing chair time and maximizing compliance and treatment options.

DR. EPITROPOULOS: Dr. Jackson, is a dry eye evaluation part of your preoperative routine for patients who need cataract surgery?

DR. JACKSON: Patients who present for cataract surgery are coming in because they don’t see well, so their primary concern is getting their sight back. They may not realize they have dry eye disease and how the disease is affecting their vision. That’s why we perform dry eye evaluations preoperatively, and I discuss all of the test results and objective data with patients before surgery. If we wait until after surgery to tell them they have dry eye, they blame the surgery.

I usually tell patients, “We will optimize your ocular surface prior to surgery and monitor it after surgery, as well. Once you see better after cataract surgery, you will really see how dry eye has been impacting your vision.”

DR. EPSTEIN: I’m a great believer in “a picture is worth a thousand words,” particularly for educating patients. I show patients images of their meibomian glands and captures of their noninvasive tear breakup times and tear meniscus heights. These objective findings provide a platform for explaining the cause of their problems and their therapeutic options.

DR. SCHACHTER: Dr. Jackson, do you have a cut-off for who gets the SPEED questionnaire or a symptoms survey, or does everybody get one in your practice?

DR. JACKSON: Every new patient who reports blurred or fluctuating vision or has any dry eye symptomatology is asked to complete a modified SPEED questionnaire. We repeat the questionnaire periodically during treatment to assess the patients’ responses.

DR. SCHACHTER: With so many people using electronic devices for extended periods, patients with signs and symptoms of dry eye are getting younger and younger. In my practice, we provide SPEED questionnaires to younger patients, even those in their early teens. If patients are old enough to understand the questions, we ask them to complete the questionnaire.

DR. EPSTEIN: If you’re focused on ocular surface disease and dry eye, you almost have to use a questionnaire, because you’re staging treatment and looking for results over time. What’s more, many patients are symptomatic, but don’t realize it. A questionnaire brings the symptoms to the forefront and quantifies the patient’s experience.

I think many of our colleagues, both optometrists and ophthalmologists, may not recognize the value of a dry eye questionnaire, even in the general population. It is especially important in a primary eyecare practice, as it can reveal many new patients that might have been missed. I believe we’re just beginning to see the tip of the iceberg for dry eye.

Asymptomatic Patients

DR. EPITROPOULOS: I agree dry eye questionnaires are valuable in diagnosing patients with symptomatic dry eye disease. However, a high percentage of patients who have dry eye have no symptoms,⁷ so actively evaluating for signs of dry eye should be incorporated in every patient exam. Dr. McDonald, how do you look for clinical signs of dry eye in an asymptomatic patient?

DR. MCDONALD: Typically, I start the examination by expressing the meibomian glands in the middle of the lower lid. That simple maneuver with my thumb or index finger takes less than 2 seconds and provides extremely valuable information. Then, I perform staining and assess the tear lake. If I’m performing an annual dilated examination, I finish that and show the patient his or her test results. Then, I assign treatment.

Of course, if they have symptoms, the technician has already performed tear osmolarity before I even enter the exam lane. If I find that an asymptomatic patient has signs of dry eye at the slit lamp, I immediately order an osmolarity test, before using fluorescein. This score plays an important role in my decision-making ladder.

DR. EPITROPOULOS: Dr. Epstein, how do you evaluate corneal or conjunctival staining?

DR. EPSTEIN: I use fluorescein stain on every patient, and I also use lissamine green. Proper technique requires enough time for the stain to reveal surface damage. I’m also all about visual imagery, so, when appropriate, I take photographs to demonstrate the staining for the patient. I see patients specifically for dry eye, and have a suite of tests that we perform routinely. Staining certainly is among them and is very important from a diagnostic perspective.

DR. JACKSON: Diagnostic dry eye testing helps drive my discussions with patients. First, I explain what ocular surface disease is. I point out the oil layer, the water layer, and the tear film, then I discuss evaporative dry eye and how it relates to the use of smartphones, tablets, and computers. The discussion starts with the testing and leads me to my treatment ladder in a way that helps patients correlate the treatment I’m prescribing with their specific results.

DR. EPSTEIN: Communication is absolutely key. We need to explain this disease in a way that patients can understand and relate to their experience and symptoms. This help bond patients to our recommendations and improves compliance.

DR. SCHACHTER: When practitioners ask, “What about an asymptomatic patient?” I advise them to first make sure the patient is asymptomatic. Use a validated questionnaire rather than simply asking the patient if his eyes are dry or itchy. Even the manner in which we ask that question can downplay it. The questionnaire asks the same questions in the same manner every time. That consistency is key.

Many patients we label as asymptomatic aren’t really asymptomatic; they’re just not responding to our questions in a way that reveals the relevant symptoms. Our staff is great at helping us identify these patients during a workup by talking about blurry or fluctuating vision during pretesting.

DR. EPSTEIN: Staff should also inquire about red eyes. Many patients acknowledge that their eyes are often red. This is not only an aesthetic issue, but is often associated with meibomian gland dysfunction (MGD).

DR. EPITROPOULOS: Patients don’t always realize that fluctuations in vision and tearing are symptoms of dry eye. In fact, many of our colleagues don’t even realize these symptoms often correlate with dry eye disease.

Dr. McDonald, how do you proceed once you’ve identified dry eye in an asymptomatic patient?

DR. MCDONALD: I have a card that shows meibography of normal glands and glands with moderate and severe disease. When I identify an asymptomatic patient, I show him the image of his disease, which usually is moderate. I explain that about 50% of the people I see have moderate disease, but 100% of the people who have severe disease are so symptomatic that it becomes an enormous quality-of-life issue. These people are house prisoners. They have to close the blinds in their homes and offices, because of their light sensitivity and fluctuating vision. I explain to the patient that moderate disease will advance to the severe stage unless we treat it. That discussion usually convinces the patient that he needs treatment.

DR. EPSTEIN: Two words resonate with patients: chronic and progressive. When I explain that this is a chronic, progressive disease, and that, eventually, it’s going to catch up with them, patients are much more inclined to do something about it.

DR. JACKSON: Like Dr. McDonald, we also have a LipiScan with DMI, and I use a template to show patients mild, moderate, and severe disease, and where they fall on the spectrum. I explain that our treatment goal is to prevent their disease from progressing to an advanced stage when therapy becomes nothing but palliative.

In my opinion, the DMI is a game-changer in the MGD world, because it convinces patients to take the next step and get treated.

Therapeutic Options

DR. EPITROPOULOS: Dry eye is a multifactorial disease that is challenging to diagnose, because signs and symptoms don’t always correlate. It’s also challenging to treat, because there isn’t a one-size-fits-all solution.

Dr. Jackson, what factors do you consider when developing a treatment plan for a patient?

DR. JACKSON: Most people who come to me have been using generic over-the-counter (OTC) eye drops that are probably exacerbating their symptoms, so I have them switch to a good artificial tear, which reinforces the aqueous and/or lipid layer depending on the patient’s type of ocular surface disease. If inflammation is present, I treat it. At the same time, I start the patient on an omega-3 fatty acid supplement and warm compresses.

Based on the patient’s test results, my next step may be a LipiFlow (Johnson & Johnson Vision TearScience) treatment. Typically, I perform a BlephEx (Rysurg) treatment at the same visit, because almost all of my patients have some type of inflammatory issue. The lid margin contributes to the inflammation, and the biofilm becomes toxic to the ocular surface, releasing enzymes, such as lipase, that will degrade the oil layer of the tear film. It’s a vicious cycle. We have to attack it from all levels.

Patients may have an autoimmune disease, in which case I may choose to involve their rheumatologist or primary care physician.

DR. EPITROPOULOS: Dr. Epstein, how do you proceed with patients who exhibit evidence of aqueous deficient or evaporative dry eye disease?

DR. EPSTEIN: About 95% of my patients have obstructive meibomian gland disease. It is the root of virtually all dry eye evil for me, and it should be treated even in patients with primary aqueous deficient disease, such as Sjögren’s syndrome.

Inflammation is often a significant element in ocular surface disease. Steroids have a role, but new drugs, such as Xiidra (lifitegrast ophthalmic solution 5%, Shire), have been helpful for managing inflammation.

I always start my conversation with new patients by saying, “You really don’t have dry eye.” Patients are often initially confused by that, because they’ve been told by everyone, including Dr. Google, that they have dry eye. I explain, “It’s not that you don’t make enough tears; it’s that your tears aren’t working properly, and all the artificial tears in the world are not going to fix the problem.” So, we have to be careful because patients tend to rely too much on artificial tears to help alleviate their symptoms.

DR. EPITROPOULOS: You mentioned the importance of clearing the biofilm. BlephEx and pure hypochlorous acid (Avenova, NovaBay) are effective treatments to reduce the overgrowth of bacteria in the biofilm that contributes to the obstruction.⁸

DR. EPSTEIN: We underestimate the role of Staphylococcus bacteria overpopulation in this disease process. Staph elaborated lipase breaks down even the most intact tear film, and that’s a major part of the dry eye process. Staph also produces significant biofilm on the lids.

Adding pure hypochlorous acid to my treatment regimen was one of those definitive moments in achieving greater success from an objective, clinical point of view, as well as from a patient’s subjective point of view. BlephEx microexfoliation is also extremely valuable in managing these patients on an ongoing basis.

DR. JACKSON: In my practice, we routinely use Avenova prior to surgery to kill the overpopulation of Staphylococcus bacteria. It’s easy for patients to use. Twice a day, they just spray it on their eyelids and wipe the excess away.

DR. EPITROPOULOS: Dr. McDonald, what is your typical treatment regimen when it comes to treating patients with dry eye disease?

DR. MCDONALD: I often use loteprednol etabonate ophthalmic gel at the beginning of treatment to break the cycle of inflammation, and if I’m starting a patient on Restasis (cyclosporine ophthalmic emulsion, Allergan) or Xiidra, it masks the stinging that accompanies the induction.

For about 7 years now, tear osmolarity has helped guide the aqueous part of my plan. For instance, for a patient with osmolarity of 317 or higher, I prescribe Restasis or Xiidra. I also prescribe an omega-3 supplement and gently preserved tears four times a day. At 325, I prescribe preservative-free tears every 2 hours while awake, a nighttime ointment, and, if there is no blepharitis, I may add punctal plugs. At 330, I order a Sjögren’s test.

I also evaluate the status of the eyelids, using diagrams and photographs from the Meibomian Gland Workshop. When patients reach Level 2, I start hot soaks and scrubs morning and evening, and erythromycin ointment at night. I like erythromycin because it’s generic, and, therefore, less costly. It treats dryness, blepharitis, and also exposure keratitis, which at least half of these patients have because they’re older and have eyelid laxity. I have patients continue that regimen for at least 6 months, then I reevaluate. For patients who cannot tolerate ointment at night due to allergies, or who have insomnia (which means they cannot tolerate the 2 hours of blurring), or who have orthopedic issues that do not allow them to instill nighttime ointments, I recommend AzaSite (azithromycin ophthalmic solution 1%, Akorn) rubbed into the eyelids b.i.d., immediately after the lid soaks and scrubs, along with Systane or Genteal Gel at night. So this one treatment — erythromycin ointment — is replaced by two products, if need be.

In my experience, when I give patients their regimen, they usually say, “Oh, wow. This is overwhelming.” To which I reply, “We can also do BlephEx combined with LipiFlow, which has been shown to be more effective than soaks and scrubs.⁹ The average person who has BlephEx and LipiFlow treatments not only has a greater chance of maintaining the health of his remaining glands for the rest of his life, but he also can jettison an average of 75% of his at-home routine.”

That explanation, combined with showing patients their meibography, usually leads patients to want BlephEx and LipiFlow.

DR. JACKSON: Our approach encompasses an acute therapy phase and a maintenance therapy phase. If there’s inflammation, we adjust the patient’s OTC formulation, add a gel or ointment, maybe recommend a humidifier at night, and address allergies during allergy season, and/or start a topical anti-inflammatory, such as Restasis or Xiidra.

To simplify the regimen and encourage compliance, we offer an annual dry eye spa package, which may include warm compresses, Avenova, and omega-3s, along with one or two LipiFlow treatments with BlephEx and a couple of additional BlephEx maintenance treatments. Patients come in three or four times a year for their treatments — all of our technicians are certified lid hygienists — and I might see them once or twice a year. The fact that patients pay for this package up front encourages compliance.

DR. EPSTEIN: I have a basic protocol, which I try to keep relatively simple. The foundation includes a triglyceride-based Omega 3, Avenova to the eyelids twice daily, and blink training as described by Korb.

In my experience, I’ve found that a significant number of patients, especially those who complain of greater dryness in the morning, have exposure at night, so I’m always looking for that. I don’t recommend warm compresses anymore, because by the time they get from the sink to the patient’s eye, they’ve usually cooled off. Instead, I recommend an Eye Eco heat mask. For patients with lagophthalmos, I recommend Eye Eco Silicone Shields at night. These eye masks are convenient and less obtrusive than ointment.

BlephEx is critically important every 6 months to address biofilm buildup, and many of my patients with obstruction or deficient lipid layer thickness also receive LipiFlow treatment.

DR. EPITROPOULOS: The maintenance programs that you all describe are critical to the success of thermal pulsation treatment for this chronic, progressive disease.

DR. EPSTEIN: A maintenance program keeps patients on track and gets them involved, too, which I think is important.

DR. SCHACHTER: In-office treatments, such as BlephEx and LipiFlow, help reduce the need for compliance with home therapies, such as lid scrubs and compresses, which I think can be poor.

DR. JACKSON: Many patients have the misconception that the effect of a single LipiFlow treatment gradually wears off, but studies have shown that the effect lasts about 1 year.¹¹ I explain this durability and then reinforce the importance of following the daily regimen I’ve prescribed to maintain the effect.

I also educate patients about the impact of their environment on dry eye symptoms, particularly extended periods of screen time, which exacerbates those symptoms. Then I explain the 20-20-20 rule: every 20 minutes, take a 20-second break, and look at something 20 feet away.

My staff and I provide thorough education, including blink exercises. Our dry eye spa package commits the patient to continue using Avenova and the heat mask, and to return to our office twice a year for a BlephEx treatment and annually for a LipiFlow treatment.

DR. EPSTEIN: What’s apparent from this discussion is that staff involvement is key for managing patients with ocular surface disease. I think many colleagues in traditional comprehensive practices forget that those of us in ocular surface specialty practices aren’t doing everything ourselves.

Comanagement Tips

DR. EPITROPOULOS: Some procedures, such as LipiFlow, may not be available in some offices. What sort of comanagement programs do you have for these situations?

DR. JACKSON: Most of our referring ODs have LipiScan with DMI, which enables them to qualify patients for LipiFlow. They send us a fast-track referral form, which also tells us what products the patients are already using. We perform the LipiFlow treatment, and bill patients directly. We explain the purpose of the treatment and reinforce the need to continue with the maintenance program. Patients usually follow up with their referring optometrists about 8 weeks later. We don’t split fees when comanaging LipiFlow. The optometrist will bill the patient for the preoperative and postoperative LipiFlow visits directly.

DR. SCHACHTER: Whether a referral is from an optometrist or a surgeon, I think the critical component of comanagement is to fix the problem and send the patient back to the referring doctor.

DR. EPSTEIN: I agree. We receive referrals from both ODs and MDs, and their expectation is that we’ll get the disease under control and send their patients back. All of our colleagues know that dry eye disease, particularly when it becomes more advanced, is difficult to manage and time consuming, so they appreciate our intervention.

We often work with ODs in the community, particularly those who don’t have LipiFlow and other advanced diagnostic and therapeutic devices. We tend to be more comanagement-focused with the ODs than with the MDs. Our MD colleagues usually want us to resolve the problem, so the patient can have surgery, or, in some cases, after surgery.

Raising Awareness In the Professions

DR. EPITROPOULOS: How can we do a better job communicating to our colleagues about this disease and the importance of treating it early?

DR. MCDONALD: In a word, education. Everyone learns in a different way. Some people take in information best when they hear it, so they like to listen to podcasts. Others are more visual. A third group likes to read. I think we just have to keep singing from the same page in the hymnal.

Our view of ocular surface disease has changed over the years from when we thought it was just part of aging and we couldn’t do anything about it. It keeps evolving, and we have to keep sharing with each other and with our colleagues.

DR. EPSTEIN: Ocular surface disease provides a great opportunity for optometry and ophthalmology to collaborate. Our shared interest in dry eye has created common ground where we can work together; this has clearly benefited patients.

DR. SCHACHTER: Social media is another effective means to communicate among ourselves and with our patients. Personally, I like to share research. For example, investigators in Korea found that the incidence of dry eye in adolescents dropped from 100% to 0% after they gave up their smartphones for 1 month.¹² We have to recognize that we’re asking more of our eyes than ever as we stare at screens all day. As eyecare professionals, it’s our job to improve quality of life. If we don’t intervene earlier in the group of children who are growing up with iPads, often starting at age 3, we could be seeing problems down the road. Everyone should be familiar with the current research.

DR. JACKSON: I agree, and I would go a step further. I think it’s time for eyecare professionals, maybe working with our professional societies, to get involved and work with companies, such as Apple, to increase awareness of the potential for vision problems, including dry eye disease. This is probably the next step, the next level of education, because the devices aren’t going away.

Creating a Center of Excellence

DR. EPITROPOULOS: Dr. McDonald, what advice would you give to eyecare professionals looking to develop a dry eye center of excellence in their practices?

DR. MCDONALD: First, you must get your staff on board. Explain how it will help grow the practice, and how that success will make it easier for you to give them bonuses and raises.

Then, arrange to visit a dry eye center of excellence with your office manager and your top technician. Choose a practice that’s far enough away that they aren’t threatened by you as a competitor, but close enough that you can drive there and back in a day. Have lunch catered by their favorite deli. Listen, observe, and take notes. What you can learn in that day is incalculable. It’s worth doing.

Once your practice is ready, start simply with marketing tools that cost pennies, such as “Ask Me About Dry Eye” buttons for all of the technicians. Many of the companies in the dry eye space are more than willing to provide marketing materials, because our success is their success. Place posters in the lobby and on the back door of each examination lane. Include an announcement about your dry eye center of excellence with all invoices.

DR. EPITROPOULOS: Dr. Jackson, do you have any recommendations for internal marketing as well patient education?

DR. JACKSON: We use interactive digital screens (CheckedUp). That’s our next level of marketing and education internally, once a patient is referred. Patients can click on various topics and learn more about dry eye and treatments, such as LipiFlow and BlephEx. My technicians may choose a topic, based on what I will be discussing with a patient.

DR. EPITROPOULOS: Dr. Epstein, what type of marketing have you found to be most effective?

Dr. Epstein: For me, it was our web presence. Early on, many of our patients found us through a web search. Today, I find that most new patients have gone through our entire website before their appointment. Patients with dry eye are oddly Internet savvy, even those whom you wouldn’t expect to be. Some elderly patients actually have recited passages from my website. So, our website has been very helpful, and I think it is for any practice focusing on dry eye.

DR. EPITROPOULOS: Dr. McDonald, if there were a “dry eye center of excellence starter kit,” what would it contain?

DR. MCDONALD: Start with the TearLab Osmolarity Test and InflammaDry. They are inexpensive, and they give you a great deal of information. You can get your foot in the door without a huge capital investment. You should be well versed on DEWS and the various treatment algorithms. Very soon after that, you can start adding in-office therapeutic technologies, such as LipiFlow and BlephEx.

After about a year or even 6 months, you may want to return to the dry eye center of excellence you first visited. You will see and hear things you didn’t notice the first time, because you were so overwhelmed.

As you’re building your reputation as a dry eye specialist, you’ll start seeing every manifestation of the disease, and you’ll add to your dry eye toolbox accordingly.

A dry eye center of excellence can be rewarding and profitable. I’m a cataract refractive surgeon, but I tune up my own patients and the patients of other cataract surgeons in our practice. I do it because it’s of great interest to me, and it’s gratifying and lucrative. ■

References

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