Highlights from a roundtable discussion held during ASCRS 2019

Cynthia Matossian, MD: In today’s discussion of dry eye disease, we pay particular attention to the risk factors that affect women as we discuss how we diagnose and manage this chronic, progressive disease.

Let’s begin with a definition of dry eye.

Mark S. Milner, MD: I often use the term dysfunctional tear syndrome, because dry eye is not just about aqueous deficiency. It also involves poor tear quality. Newer definitions include factors such as neurosensory abnormalities and loss of homeostasis of the tear film.¹

Marguerite B. McDonald, MD: We also know that inflammation is at the heart of dry eye, whether it is aqueous deficient or evaporative.

Dr. Matossian: I agree. Inflammation is the root cause of many dry eye problems. It triggers dysregulation of the ocular surface, leading to an unstable tear film, which then initiates an inflammatory cascade and a negative spiral.

Ms. Barkey, as a practice administrator, how do you view dry eye disease?

Patti Barkey, COE, OCS: The definition of dry eye is quite broad, but I think clinicians often try to oversimplify it by treating only one specific area. Dry eye is a multifactorial disease, and to be successful, clinicians must address all of the pertinent factors with which the patient presents.

Dr. Matossian: Dr. McDonald, who is the face of dry eye in our practices today?

Dr. McDonald: I believe the perimenopausal woman is still the face of dry eye disease, although I’m seeing many young adults with severe dry eye, mostly because they cannot stop using digital devices. Studies have shown there’s a drastic reduction in blink rate when people use digital devices, and that is an issue.²

Dr. Milner: Contact lens wear is also a contributing factor. The inflammatory mediators that increase on the ocular surface with contact lens wear are similar to what we see in dry eye disease. Even refractive surgery can exacerbate dry eye disease. Young people are experiencing dry eye for a whole host of reasons, including the use of tablets, cell phones, and computers.

Ms. Barkey: I would add allergies to the list and note that some allergy medications mask dry eye symptoms. The “face” in our practice includes all ages and both genders.

Dr. Matossian: Dry eye is ubiquitous. It includes men and women of varying age groups. However, I agree that it primarily affects postmenopausal women.

SIGNS AND SYMPTOMS

Dr. Matossian: What are the typical signs and symptoms of dry eye?

Dr. Milner: The classic symptoms of dry eye include burning, irritation, grittiness, and dryness, but other symptoms are not as obvious. For instance, when patients report their vision fluctuates or becomes blurred while they’re reading or looking at a computer screen, to me, that is dry eye until proven otherwise.

Tearing is another symptom that people rarely associate with dry eye. That’s because dry eye is not simply an issue of tear quantity, but also tear quality.

Dr. McDonald: I often find that even patients with clinically significant dry eye have no symptoms. This is one reason why the metrics from meibography, matrix metalloproteinase-9 (MMP-9), and tear osmolarity tests are so valuable. I can show patients their data and explain that even though they don’t have symptoms now, they will if we don’t treat this disease.

Dr. Matossian: I absolutely agree. For patients to commit to whatever treatment we recommend, they need to know our objective. Testing is critically important.

Dr. Milner: It’s definitely challenging to keep asymptomatic patients compliant with treatment. In addition to MMP-9, tear osmolarity, and meibography, I take photographs of patients’ corneas, so I can show them the keratitis and explain how it’s damaging the ocular surface.

Dr. Matossian: Ms. Barkey, do you get pushback from patients about any of these important tests, specifically about costs and insurance coverage?

Ms. Barkey: I think every practice will encounter some pushback, particularly when patients are asymptomatic. We explain that severe dry eye doesn’t start as severe dry eye, and that many patients have no signs or symptoms initially. We emphasize that we don’t want to wait until the disease becomes severe before treating them. Even without insurance coverage, most patients agree to the testing when we explain why it’s so important. Education is the key.

CONTRIBUTING FACTORS

Dr. Matossian: What are some of the co-existing systemic diseases or conditions that contribute to dry eye disease?

Dr. McDonald: Diabetes, all of the connective tissue and autoimmune conditions, and the medicines used to treat them will trigger or exacerbate dry eye. Just being perimenopausal is another systemic condition. Those are the main categories, and they affect a high percentage of our patients with dry eye.

Dr. Milner: Along with the conditions Dr. McDonald mentions, there are common irritants, such as smoke, contact lenses, air pollution, surgery, topical medications, and makeup. Regardless of the cause, irritation leads to inflammation. Inflammation leads to tear deficiency and instability, which leads back to irritation. Any of those risk factors can enter the cycle at any time and lead to inflammation, and inflammation ultimately leads to signs and symptoms of dry eye disease.

Dr. Matossian: Let’s dig a bit deeper into the pathophysiology of dry eye. Dr. Milner, where does the cycle you describe start? How does hyperosmolarity fit in?

Dr. Milner: The cycle of inflammation is like a carousel. It doesn’t matter where you jump onto the carousel, it all ultimately leads to inflammation of the ocular surface. As I mentioned before, if your trigger is irritation, such as smoke, contact lens wear, topical glaucoma drops, and so on, that leads to inflammation and upregulation of inflammatory markers (such as ICAM-1), activation of T cells, production of cytokines, and recruitment of more T cells. This inflammation leads to tear deficiency and instability which leads to more irritation.

If the trigger is inflammation, such as rheumatoid arthritis, lupus, Sjögren’s disease, and so on, you can jump onto the carousel at that spot. And if the trigger is rosacea or menopause, you jump onto the carousel at the tear deficiency or instability point of the cycle (Figure 1). Inflammation leads to a hyperosmotic tear film, increased proteases and cytokines, and damage to the ocular surface.

ROLE OF HORMONES

Dr. Matossian: Women are more prone to dry eye, and hormones are a factor. Dr. McDonald, tell us about testosterone levels in men and women and what happens as women get older.

Dr. McDonald: Both men and women have testosterone, but women start with a much lower level than men. Over time, the levels drop for everyone. During menopause, however, a woman’s testosterone level drops below the level that’s healthy for the lacrimal glands. Certainly, we’ve all seen men with dry eye, but most patients with serious dry eye are women because of that testosterone decrease.

Dr. Matossian: Do you treat dry eye disease with testosterone drops?

Dr. McDonald: Rarely.

Dr. Matossian: I use them occasionally, as a compounded medication, after we’ve tried multiple other options for a patient.

Dr. Milner: I use a few topical compounded hormones, such as medroxyprogesterone, DHEA (dehydroepiandrosterone), and a compounded 50/50 testosterone-progesterone mix. I believe these drops have anti-inflammatory effects on the lacrimal gland and possibly the meibomian glands and goblet cells. Studies have not been performed showing significant clinical efficacy, but anecdotally, I’m seeing great results.

MAKEUP AND COSMETIC PROCEDURES

Dr. Matossian: Compared to men, although cosmetic procedures in men are on the rise, women are more likely to wear makeup and seek various beauty enhancements, such as blepharoplasty, Botox (onabotulinumtoxin A, Allergan), false eyelashes, and eyelash extensions.³ These procedures often contribute to an unstable tear film and can further exacerbate underlying ocular surface disease.

Dr. McDonald: Many of my female patients receive Botox injections, and I warn them to avoid injections in the middle of the lower eyelids, because the lack of a proper blink and meibomian pumping is deadly for people who have dry eye. I also advise my colleagues who specialize in oculoplastics to ask patients if they have dry eye, so they will know to avoid treating that area.

I advise patients who have meibomian gland disease (MGD) not to use eyeliner on the inside of the eyelid margins, because it seals off the meibomian glands.

Dr. Milner: Dr. Matossian, you recently reported on the effects of false eyelashes and extensions and other cosmetics. You noted that women who don’t remove their makeup each day have a higher SPEED score than women who do, and that false lashes and extensions carry a risk of traction alopecia of the lashes, which can lead to permanent lash loss.⁴

Dr. Matossian: Yes. That’s true. Furthermore, some products marketed for makeup removal contain chemicals, perfumes, and preservatives that can further harm the ocular surface.

As eyecare professionals, we need to start educating our patients about the impact of certain cosmetic procedures, makeup, and cleansing products on the tear film and meibomian glands.

INITIAL WORKUP

Dr. Matossian: Ms. Barkey, what tests do your practitioners rely on for the initial dry eye workup?

Ms. Barkey: Meibography with LipiScan and LLT with LipiView (Johnson & Johnson Vision), MMP-9 with InflammaDry (Quidel), and tear osmolarity with the TearLab Osmolarity Test (TearLab) are valuable baseline tests, particularly for presurgical patients and for patients we’re evaluating for contact lenses. We also utilize Scatter Testing for our cataract patients with dry eye disease.

Dr. Matossian: Dr. McDonald, what basic tests do you use, and whom do you test?

Dr. McDonald: Virtually everyone who sees me, except for emergencies, has tear osmolarity and MMP-9 tests. Any patient who checks off even one symptom on the SPEED questionnaire receives those two tests before I see them. Frequently, I also request meibography. If a patient checks off no symptoms but my examination clearly shows signs of dry eye, I have our technicians perform those tests before I continue with the examination.

Dr. Matossian: Dr. Milner, who is screened for dry eye?

Dr. Milner: Dry eye is so prevalent and underdiagnosed that, ideally, dry eye screening should be done for all patients through a questionnaire or technician history. Having said that, dry eye screening should absolutely be a routine part of any presurgical workup, especially for cataract or refractive surgery patients, because a healthy ocular surface and tear film are critical for good visual outcomes.

Dr. Matossian: I agree. I recently completed a study of patients with ocular surface disease and visually significant cataracts who opted for LipiFlow thermal pulsation (Johnson & Johnson Vision) treatment before cataract surgery.⁵ Biometry, keratometry, and topography were performed before thermal pulsation and 6 weeks later. I used my second data set to calculate the IOL powers and plan for astigmatism management.

After surgery, I compared the patients’ final refractions to what they would have been had I used the pre-LipiFlow measurements. Forty percent of the time, I changed my surgical plan based on post-thermal pulsation treatment. Ninety-two percent of my outcomes were within ± 0.50D, and 88% were within ± 0.25D.

These results underscore the power of the tear film and how important it is to test for dry eye, to ask the proper questions, and to treat appropriately to achieve excellent outcomes.

Dr. Milner, what is your typical workup?

Dr. Milner: My protocol is similar to Dr. McDonald’s. The patient’s history is critical. My staff will recognize certain key words — such as fluctuating vision, tearing, and burning, as suggestive of dry eye — and they initiate a dry eye workup accordingly.

Apparently, I’m one of the few clinicians who still uses Schirmer’s tear test strips to identify aqueous deficient dry eye.

Dr. Matossian: Has anyone used the new tear function test?

Dr. McDonald: Yes. I have used the SMTube (Quidel), which has some advantages over the Schirmer’s test. Notably, it takes just 5 seconds per eye, and does not require anesthetic. Articles in peer-reviewed journals have reported this test is just as accurate in assessing tear production as the Schirmer’s test.⁶

USING METRICS TO EDUCATE

Dr. Matossian: How can we help patients, particularly those who are asymptomatic, understand that they have a chronic, progressive disease?

Ms. Barkey: The diagnostics that are available to us, such as MMP-9 and tear osmolarity, provide metrics that show patients the effects of their dry eye disease, which is particularly important for asymptomatic patients. For example, the LipiView II ocular surface interferometer (Johnson & Johnson Vision) shows patients that their eyelids aren’t closing completely, which contributes to their dry eye.

Dr. Milner: That’s a great point. I think we sometimes underestimate the importance of a decreased blink rate and incomplete blinking as a cause for dry eye.

Dr. McDonald: Metrics are definitely valuable. For example, the intensity and the speed with which the red line develops in the InflammaDry test are instructive for patients. When I explain that the red line means their eyes are inflamed, they get it.

Dr. Milner: Plus, InflammaDry is a fast and easy test for our technicians to perform. It doesn’t add time to the workup.

INITIATING THERAPY

Dr. Matossian: Once you’ve confirmed a diagnosis of dry eye, how do you decide on initial treatment, Dr. Milner?

Dr. Milner: I treat dry eye based on diagnostic category rather than disease severity. In other words, I treat aqueous deficiency differently than I treat goblet cell deficiency, MGD, blepharitis and exposure, or partial blink.

Typically, I start with artificial tears, and, clearly, we should be using nonpreserved tears.

Dr. McDonald: Agreed. We should also keep in mind that many patients are already using a preserved glaucoma drop, which adds insult to injury.

Dr. Matossian: I often recommend a preservative-free tear. Why add a chemical that may make the situation worse?

Dr. Milner: I like FreshKote lubricant eye drops (Eyevance), because they’re preservative-free and available in a multi-dose bottle, which solves some of the issues we’ve seen with open vials that can become contaminated.

Dr. Matossian: When used 4 times a day, this multi-dose bottle lasts 5 weeks, which is economical for patients.

Dr. McDonald: I also prefer the spongy tip. Many older patients have abraded their corneas with the end of the vial.

Ms. Barkey: We stock FreshKote in our office, and patients appreciate that convenience. They will buy enough to last until their next visit.

Dr. Matossian: That’s beneficial for patients who are limited in their driving or for busy professionals who don’t have time to go to yet another place to purchase a product. I think it’s a disservice to patients if we don’t specify a type of tear or suggest a few brands of artificial tears. Patients end up staring at a shelf of literally dozens of brands at their local pharmacy. They become overwhelmed and confused. They need our professional guidance.

NEXT STEPS IN TREATMENT

Dr. Matossian: Dr. McDonald, how do you layer or stack the different treatment modalities?

Dr. McDonald: Every patient with dry eye, even those with the mildest, earliest disease, gets FreshKote tears and nutritionals (see “Testing for Omega-3s”). My scheme, which combines recommendations from CEDARS-ASPENS, the MGD Workshop, and TFOS DEWS II, relies heavily on tear osmolarity and MMP-9.^1,7,8 If tear osmolarity is 296 or greater, I recommend tears 4 times a day and oral omega-3 supplements. When osmolarity hits 317, especially with a positive MMP-9, I prescribe lifitegrast (Xiidra, Novartis) or cyclosporine (Restasis, Allergan) in addition to tears and nutritionals. At 325, I prescribe an ointment, erythromycin or bacitracin if MGD signs are present, and at 333, I order a Sjögren’s test. At 340 or higher, filamentary keratitis can be developing, and the patient needs an amniotic membrane. They may need the membrane every few months to minimize symptoms and stay functional.

When patients have a positive MMP-9, they will respond to anti-inflammatory therapy with Restasis or Xiidra. If the InflammaDry test shows a bright red line, I also prescribe a month of a steroid, a tapering dose, to break the cycle of inflammation.

Dr. Matossian: Dr. Milner, how do you proceed if artificial tears aren’t providing sufficient relief?

Dr. Milner: If patients are using tears more than 4 or 5 times a day, I prescribe Restasis or Xiidra to treat the first three categories in my algorithm: aqueous deficiency, goblet cell deficiency, and MGD (off label). In many cases, I prescribe Restasis and Xiidra concurrently, because they have different mechanisms of action, and, at least anecdotally, I believe there’s a synergistic effect, because they each work on different parts of the T-cell.

Dr. McDonald: In my practice, 20% of patients with dry eye are using both medications, because, in my opinion, one plus one equals three. In other words, these two effective treatments facilitate each other, enhancing the combined effect.

Dr. Milner: For severe inflammation, I start steroids along with Restasis and Xiidra, and for episodic dry eye, I add a steroid. Often, I start with Flarex (fluorometholone acetate, Eyevance).

Dr. Matossian: Why do you prefer Flarex?

Dr. Milner: Initial studies on ocular surface inflammation, done years ago, found that Flarex is more efficacious than FML (flurometholone alcohol) for ocular surface inflammation, and it works as well as prednisolone acetate without the potential side effects.⁹ Not only does Flarex have efficacy and a good safety profile, I find that it is often less costly than other steroids.

Ms. Barkey: Prescribing a product such as Flarex is beneficial for practices because they don’t have to obtain prior authorization or get involved with appeals.

Dr. Matossian: Patients are happy, too, when we can prescribe a branded steroid product that is not so expensive.

Dr. Milner: That’s a great point. As providers, we try to avoid generic drugs if we can. There’s no generic version of Flarex. So, when we prescribe Flarex, patients get Flarex.

IN-OFFICE AND HOME THERAPIES

Dr. Matossian: What home and in-office therapies do you recommend for your patients as adjuncts to tears?

Ms. Barkey: We recommend eyelid hygiene, but we know that not all of our patients are doing it properly, if at all. For those patients, we offer BlephEx in our office. BlephEx patients attest to feeling better right away.

Dr. McDonald: We also use BlephEx for many of our patients. Immediately after BlephEx, we use thermal pulsation (LipiFlow, Johnson & Johnson Vision), because we’ve found these therapies complement each other.

A new option for eyelid cleaning at home is NuLids (NuSight Medical). The battery-powered device has a rotating tip with a soft silicone brush for exfoliation of the upper and lower eyelids.

Dr. Milner: I think it’s important to differentiate anterior and posterior blepharitis when we treat. Sponges and brushes are effective for removing lid debris associated with anterior blepharitis, and the cleansers disinfect the surface. For posterior blepharitis, I’m an advocate of the Bruder mask (Bruder Healthcare), because warm compresses cool quickly, whereas a Bruder mask heated in the microwave stays warm.

Dr. Matossian: I believe the microwaveable heated masks help with the other treatments, as well. We recommend the use of Bruder masks after thermal pulsation and after intense pulsed light therapy (IPL, Lumenis), because it seems to extend the effectiveness of those treatments. Patients find these masks to be very soothing.

Dr. Milner, do you recommend any lifestyle changes to your patients?

Dr. Milner: I counsel patients to stop smoking, to take breaks when reading, to direct air vents away from their eyes, and to lower their computer screens so they’re not looking up all the time, and exposing their inferior cornea even more.

Dr. McDonald: I advise patients to follow the 20/20/20 rule, recommended by both the American Academy of Ophthalmology and the American Academy of Optometry. Every 20 minutes, stand up for at least 20 seconds, and look at least 20 feet away. Not only is this good for circulation, it also allows the blink rate to briefly return to normal and the ciliary muscles to relax for more comfortable vision.

ASSESS TREATMENT EFFICACY

Dr. Matossian: When and how do you assess how effective your therapy is?

Dr. Milner: I think the window of opportunity for maximizing treatment benefit, regardless of the treatment, is 4 to 6 weeks. The half-life of a T cell is 70 to 90 days, and most treatments can prevent a T cell from flipping the switch on, but they can’t necessarily flip the switch off. If we bring patients back too soon and we don’t see a significant change, they may believe the treatment isn’t working. After 4 to 6 weeks, I can gauge improvement, add a therapy if necessary, and coach patients that they’re doing well, which helps them continue with treatment. If we go beyond 4 to 6 weeks, patients who do not see a complete response and don’t understand the process may stop treatment based on their presumption of a “false failure.”

Ms. Barkey: The psychology of the patient is so important. If you don’t explain how the disease process works, emphasize the need for a commitment to therapy, and show that you care and want to work together to achieve a good outcome, patients will dismiss everything you’ve started as unimportant. I’ve seen evidence in records I’ve audited where clinicians start treatment but don’t bring patients back for 6 to 8 months. By that time, patients have likely stopped therapy, if they even show up in 6 to 8 months.

Dr. Matossian: Dr. Milner, what tests do you perform at 4 to 6 weeks?

Dr. Milner: I often measure MMP-9 and tear osmolarity. Having said that, I want to point out that if the MMP-9 reading is still positive, the treatments aren’t necessarily failing. MMP-9 can decrease from 60 to 42, for example, and still be considered positive. I assure patients that a reduced MMP-9 level, even if it is still positive, means that we’re making progress.

I also perform a Schirmer’s test, express the meibomian glands, and measure tear breakup time in addition to evaluating fluorescein staining. The vital dyes (rose bengal and lissamine green) are sensitive tests that will pick up conjunctival staining as well as corneal staining.

Dr. Matossian: I can’t stress enough the importance of lissamine green staining. In addition to corneal involvement, it shows staining of the conjunctiva and the mucocutaneous junction of the lower lid. Staining in those areas may indicate lid wiper epitheliopathy.

Ms. Barkey, in your practice, do you repeat InflammaDry and tear osmolarity tests?

Ms. Barkey: Yes, at every visit. If insurance won’t cover these tests, we advise patients ahead of time, emphasizing their value. Patients will pay for them.

Dr. McDonald: My follow-up regimen is diagnosis- and severity-based, typically within 4 to 6 weeks but with exceptions. For level 1 or 2 disease, I see patients at 3 months. If patients have severe disease, I see them in 1 to 2 weeks. If a patient has filamentary keratitis, and I’ve applied a PROKERA Slim corneal bandage (Bio-Tissue), follow-up is in 5 to 7 days.

All patients receive MMP-9 and tear osmolarity tests at follow-up. I perform meibography only twice a year, as I find that the glands don’t change quickly.

Ms. Barkey: We repeat meibography once a year.

Dr. Matossian: We also repeat meibography once a year, whereas tear osmolarity and InflammaDry testing is performed at all follow-up visits to assess the efficacy of the prescribed treatment.

Ms. Barkey: Any time we detect a sudden increase in a patient’s symptoms or SPEED score after an improvement was noted, we perform another InflammaDry test.

Dr. Milner: I love to repeat the SPEED test, because I believe patients who have dry eye have what I call a learned pattern of hopelessness. In other words, they’re so used to being miserable that they automatically say there’s been no improvement. When I can tell patients their SPEED score has improved from 28 to 16, the light bulb goes on as they realize that they are getting better since their symptoms are improving, and they aren’t thinking about their eyes as much.

Dr. Matossian: Sometimes patients aren’t aware of how much better they are until I ask how often they’re using their tears. If they’re using their tears only once a day, as opposed to 6 times a day, that indicates how much healthier their eyes have become.

Ms. Barkey: We had a similar experience with the TrueTear Intranasal Neurostimulation Device (Allergan). We had patients stop all artificial tears and use only the TrueTear device. When patients said they weren’t sure the treatment was working, we reminded them that they had stopped all tears.

BARRIERS TO COMPLIANCE

Dr. Matossian: What are some of the barriers to compliance with our dry eye therapies?

Dr. McDonald: For home therapies, the barrier is time. People don’t want to do soaks and scrubs in the morning when they’re flying out the door to go to work. Even retired people have busy lives. Sometimes, the barrier is financial. If you add up the cost of unit-dose tears and the co-pays for some of the medicines we prescribe, paying for therapy can be difficult for some patients.

Dr. Matossian: How can we overcome these barriers?

Dr. McDonald: The faster patients see a positive result and the more comfortable their eyes become, the more confidence they have in us and the treatments we prescribe. Of course, the metrics help. Being able to tell patients their tear osmolarity is significantly reduced and showing them an improvement in the bright red line (InflammaDry), indicating inflammation is gone, makes an enormous difference.

Dr. Milner: Another major barrier to compliance is lack of education. Often, patients don’t understand what successful therapy looks like, leading to what I call “false failures.” (See “Beware of False Failures.”)

I participated in the PERSIST Study, a retrospective chart review of Restasis failures.¹⁰ Patients were sent to the investigators after initial therapy with other doctors was deemed to have failed after less than 12 weeks of use. After restarting Restasis, 80% of the patients achieved clinical benefit. The most significant differences in the two courses of therapy were education and setting expectations.

Dr. Matossian: Contact lens wear can be another barrier to compliance with recommended treatments, including artificial tears. Eye medications and even most artificial tears require removal of the lenses before instillation or waiting 10 to 15 minutes after using the drops to insert the contact lenses.

Many patients find this inconvenient. The good news is that FreshKote lubricant eye drops are approved for use with contact lenses.

Ms. Barkey: That’s one of the reasons why our optometrists are suggesting FreshKote to their patients above everything else.

Dr. Milner: I’ve started switching to FreshKote, as well, because it’s on-label for use with contact lenses. We know that contact lens wear increases inflammatory mediators and the risk of hypoxia. We want to recommend a tear that’s approved for use with contact lenses.

Dr. Matossian: This is yet another reason why we should recommend a specific brand of tears to our patients.

BARRIERS FOR WOMEN

Dr. Matossian: Dr. McDonald, do women have additional barriers to compliance with our recommended treatment modalities?

Dr. McDonald: One hundred percent. I’ve even heard it suggested that women don’t use artificial tears as often as their doctors recommend because they don’t want to smear their makeup.

Dr. Matossian: They’re also afraid if they “wash their eyes,” they’ll lose their expensive, glued-on eyelash extensions. Unfortunately, if they stop using lid scrubs, wipes, or heated masks, their blepharitis worsens.

Dr. Milner, as a male physician, what do you say to a woman who has serious dry eye disease and is wearing eyelash extensions?

Dr. Milner: Some women may look at me as a man and say, “You don’t understand the importance of this.” My job is to help them understand the concept of inflammation, the severity of their disease, and the importance of the treatments I’m prescribing. If I’m really struggling with getting the message across, I take photographs. I love using the slit lamp camera and showing patients what I’m seeing, whether it’s a photograph of demodex or a video of what happens when I try to express their meibomian glands.

Dr. McDonald: If the eyelashes are a big issue for a patient, I’ll ask her to remove them so we can get her dry eye and blepharitis under control, which should take only 2 to 4 weeks, and then she can start Latisse (bimatoprost, Allergan). She’ll spend about the same amount of money per month as she did for the extensions, but Latisse is an FDA approved and healthy way to have long, beautiful lashes.

IMPORTANCE OF STAFF SUPPORT

Dr. Matossian: During this discussion, we’ve alluded to the importance of our staff to educate patients and reinforce our messages. How do you train your staff?

Ms. Barkey: All of our staff members are thoroughly trained in caring for dry eye patients. This training is part of our quarterly staff meetings, and recently, we completed an 8-week training program for all of our technicians. Almost all of our clinical staff members have attended Dry Eye University.

In addition, we close for 2 hours one afternoon a week when one of our physicians speaks on a specific topic. We supplement on-site group training with online courses, such as those offered by BSM Connection (bsmconnection.com ) and Dry Eye Access (dryeyeaccess.com ). We require all of our staff members to take 2 hours of education each month. We test them at the end of a course, and they’re expected to achieve a minimum score to indicate competency. Our patients expect our staff to be knowledgeable in all aspects of dry eye and for that matter, all areas of eyecare that we offer. Today’s patients are sometimes well educated, because they’ve researched online about their condition. Your staff has to at least be able to match the knowledge of the patient.

Dr. Milner: In my practice, the technicians and assistants rotate with me when they have some free time, so they can hear how I talk to patients. That’s a great way to educate staff about the disease and how I want them to explain it to patients.

Dr. Matossian: Dr. McDonald, how do you train staff?

Dr. McDonald: Ours is now the largest private practice of ophthalmology in the United States, with about 800 employees in numerous offices spanning several counties. This presents a somewhat unique challenge for staff training.

Once a month, each office has a staff meeting for 1 hour in the morning before patients arrive. Companies may request some time during a meeting to demonstrate new equipment or present new data. Also, at the beginning of the day, I’ll ask the team working with me, many of whom I have never met before, if anyone does not know how to teach soaks and scrubs, for example. Then I give a quick tutorial to anyone who needs it, because I’m going to rely on the team to teach patients how to do this after I leave the exam lane.

CONCLUSION

Dr. Matossian: Our discussion today demonstrates the truly complex nature of dry eye disease. A comprehensive treatment plan must encompass patient education, staff training, early screening and diagnosis, adding and stacking treatment modalities, and assessing the effectiveness of our treatments.

REFERENCES

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