Assessing the lids: as easy as PIE

When checking for OSD, remember “position, inflammation, efficiency.”

By Laura M. Periman, MD

The recent publication of the 2019 ASCRS preoperative ocular surface disease (OSD) algorithm provides eye-care professionals important guidance on best practices for identifying and managing OSD prior to surgery.¹ The in-depth clinical exam component — consisting of a “look, lift, pull, push” methodology, or LLPP — is particularly valuable, as it provides a platform for identifying a common OSD culprit: lid aggravation or failure.

Lid problems can manifest in several distinct and nuanced ways. To find these problems in your clinic, be sure to remember another abbreviation: PIE, or “position, inflammation and efficiency.”

POSITION

Although many practitioners look at inflammation first, lid position is an important starting point. The lid is a crucial biomechanical player that affects tear film quality and tear film spreading, which is important for corneal protection and homeostasis. A lid that does not operate correctly sets the stage for multiple problems that can influence and exacerbate downstream inflammatory consequences.

Performing a “snap test” to assess lid laxity and identify floppy eyelid syndrome (FES) is both simple and important. FES often manifests similarly to dry eye but requires differentiated treatment (including, in severe cases, surgical intervention).^2,3 To perform a snap test, gently pull on the upper and lower eyelids (away from the globe) by pinching and releasing. Lids that reset quickly are likely healthy.

Nocturnal lagophthalmos is a related variable worth scrutinizing. Recent research asserts that up to 79% of all symptomatic dry eye patients across diverse demographic groups face exposure to desiccating stress at night due to poor lid seal during sleep.³ I treat these cases using Eyeseals (Eye Eco), a vaulted silicone sleep mask designed to preserve moisture in dry eye and MGD patients.

Additionally, consider other positional factors, such as ocular entropion, ocular ectropion and lateral canthal dehiscence, all of which influence the lids’ mechanical performance.

INFLAMMATION

Once you assess lid position, look closely at the patient’s matrix metalloproteinase-9 inflammation load (InflammaDry, Quidel). Inflammation is associated with a wide range of etiologies, both localized and systemic.

Commonly understood culprits of lid-associated inflammation are meibomian gland dysfunction, rosacea, Demodex folliculorum and allergic conjunctivitis. Also consider lid wiper epitheliopathy, which may increase the inflammatory cytokine burden secondary to friction between the lid and ocular surface while blinking.⁴ Also, reach for your foundational therapies: omega fatty acid supplements and topical immunomodulators, like cyclosporine 0.05% (Restasis, Allergan), cyclosporine 0.09% (Cequa, Sun Ophthalmics) or lifitegrast (Xiidra, Novartis).

EFFICIENCY

Finally, considering the previous two elements of “position” and “inflammation,” think about the lids’ overall “efficiency” — the culmination of both factors. If the lid is the eye’s proverbial “windshield wiper” as recent research suggests⁵, you want to ensure that it excels at enabling tear spreading and corneal wetting.

Making the lids more efficient may require some type of intervention. If the lids are too loose, radio frequency tissue tightening can be beneficial. If the lids are too tight, mindful use of neuromodulators may help reduce excess friction in a variety of conditions (eg, filamentary keratitis,⁶ young patients with aggressive orbicularis function and post blepharoplasty patients).⁷ OM

Laura M. Periman, MD, is an ocular surface disease specialist in Seattle, Wash. Additional educational content, including a patient handout, can be found at her website, www.dryeyemaster.com . Dr. Periman is also one of the founders of www.dryeyediva.com . Contact her at dryeyemaster@gmail.com.

Dr. Periman disclosed relationships with Alcon, Allergan, Eyedetec, Eyevance, Lumenis, Novartis, ScienceBased Health, Sight Sciences, Sun Pharmaceuticals, TearLab and Visant.

REFERENCES

1. Starr CE, Gupta PK, Farid M, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45:669-684.
2. Sward M, Kirk C, Kumar S, et al. Lax eyelid syndrome (LES), obstructive sleep apnea (OSA), and ocular surface inflammation. Ocul Surf. 2018;16:331-336.
3. Periman LM, Sires BS. Floppy eyelid syndrome: a modified surgical technique. Ophthalmic Plast Reconstr Surg. 2002;18:370-372.
4. Korb D. Blackie C. Nau A. Prevalence of compromised Lld seal in symptomatic refractory dry eye Patients and asymptomatic patients. Invest Ophthalmol Vis Sci. 2017;58:2696.
5. Efron N, Brennan NA, Morgan PB, Wilson T. Lid wiper epitheliopathy. Prog Retin Eye Res. 2016;53:140-174.
6. Gumus K, Lee S, Yen MT, Pflugfelder SC. Botulinum toxin injection for the management of refractory filamentary keratitis. Arch Ophthalmol. 2012;130:446-450.
7. Periman LM. The everyday cost of eyelash makeup. Ophthalmol Manage. April 2019;23:38.

Patient financing enables dry eye practices to thrive

Don’t leave patients to figure out for themselves how they will pay for treatment.

By René Luthe, senior editor

With new therapies diagnostics and improved awareness among clinicians, things have been looking up for dry eye sufferers in recent years. One impediment that remains, however, is the non-covered status of many of these new tools.

“I’d say about 80% of dry eye treatment is cash pay,” says Patti Barkey, COE, chief executive officer at Bowden Eye & Associates and Eye Surgery Center of North Florida in Jacksonville, Fla. So, the practice, which has been focusing on dry eye care for 22 years, found a way to combat the problem and enable more patients to benefit from available therapies: financing.

FINANCING RELIEF

As a practice that offers premium IOLs, refractive surgery and aesthetic services, Bowden Eye has had patient financing from CareCredit in place for years, Ms. Barkey says. “It was just a natural thing to offer it for our dry eye patients.” For any service costing more than $200 — which includes LipiFlow (Johnson & Johnson Vision), iLux (Alcon), intense pulsed light (Lumenis) and TearCare (Sight Sciences) — the practice’s counselors offer the financing option first.

“It doesn’t cost patients more for the procedure to go with financing. It’s a matter of helping them fit it into their budget,” Ms. Barkey explains. “It’s easier for patients to be offered it and they can say, ‘Oh, I don’t need that, I’ll just write you a check.’ It’s just easier for a person to accept the offer than it is to ask for the option.”

Because people often think in terms of monthly installments, Ms. Barkey explains, Bowden Eye presents the treatment as a monthly payment option. “They think, ‘OK, I can fit that into my budget.’”

HOW TO APPROACH THE PATIENT

Bowden Eye introduces dry eye patients to its financing option before their first visit. When patients schedule a dry eye consult, a counselor contacts them to provide information, answer questions and direct them to the practice’s website, which details available treatments and features a “CareCredit” button for them to click on. Counselors “make patients aware then that most of these treatments are out of pocket and they can prequalify for CareCredit on our website,” says Ms. Barkey.

Once in the office, a counselor reviews the data gathered by the technician, as well as the treatments suggested by the work-up results. “The counselor will say, ‘Before you see the doctor, we’d like to educate you on some of the treatment options available to you,’” Ms. Barkey says. The counselor also reviews pricing at that point. “So, when the patient does get to the doctor, they’re not hearing about it for the first time,” Ms. Barkey says.

Ms. Barkey notes that dry eye patients tend to arrive fairly well educated about their problem. That includes being aware that they will probably need a procedure and that it will not be covered by health insurance. “So, it’s easy to prepare the patient ahead of time instead of them getting ‘sticker shock’ once they come into the office.” Pre-qualification enables patients to schedule their procedure the same day.

TAKE ACTION

Patient financing is so critical to a successful dry eye practice that Ms. Barkey presents it as part of her Dry Eye University program. Many of the new, single-provider practices and ODs who frequently make up her students do not already have financing available.

“You just can’t leave patients to try to figure out how they’re going to pay for this, who they can borrow money from,” she says. “That’s like going to the car dealer and no one there offering financing for you, leaving you to figure out how to afford it for yourself. You won’t capture or close them.”

To those practices, she recommends taking swift action to rectify the situation. “Now is the time to get it in place before you start seeing these patients, because they have to have something.” OM