A 45-year-old woman reported chronic foreign body sensation, redness, irritation, and fluctuating vision when reading. These are classic signs of ocular surface dysfunction. She also has chronic ocular rosacea.
The patient knows she has dry eyes. She had been using cyclosporine for 9 months and experienced mild relief. She also uses artificial tears daily, eyelid scrubs, and warm compresses.
Clinical examination revealed fine telangiectasias, and meibography showed moderate atrophy (Figure 1). I’m often surprised at what I find with meibography. It routinely changes my clinical discussion and even my management strategy, because patients who have moderate atrophy have lost at least half of their glands and should not expect one single therapy to resolve their disease. Results from meibography often lead to a candid discussion with the patient about polytherapy.
REALITY OF CHRONIC DISEASE
Dr. Gupta: One of challenges with these more complicated cases is that patients think there is a cure for MGD. Unfortunately, it is a chronic, progressive disease, and they need to understand that reality in order for them to accept advancement of therapies or polytherapy.
Dr. Matossian: That’s an important point, because patients want a cure. As eyecare providers, we need to take the time to educate patients that treatment is ongoing and some therapies may have to be repeated, perhaps annually or semi-annually. Dr. Gupta, how do you convey that message to patients?
Dr. Gupta: In the limited time I have with patients, one of my main goals is to help them understand where they are in the spectrum of the disease. The most successful doctor-patient discussion is one in which you strongly recommend the treatment strategy that you believe the patient needs. It’s not uncommon for patients to get confused. There are dozens of different options. They may have talked to a friend who had one treatment. They may have read about another treatment online. A Facebook group may have endorsed something else. You can eliminate some lengthy discussions By presenting an individualized plan for the patient.
EFFICIENT MANAGEMENT OF DIAGNOSTIC TESTS
Ms. Barkey: Dr. Gupta mentioned the importance of meibography to help make appropriate treatment decisions. I’m wondering if the other panelists have their technicians perform meibography or other tests before the physician sees a patient. In our practice, we’ve found it’s important for the physicians to have certain diagnostics in front of them when they see patients, rather than see the patient and then request the diagnostics. Scores from a SPEED form or the OSDI can prompt your staff to run certain diagnostics before you see the patient.
Dr. Matossian: Dr. Beckman, who does the testing in your practice and what tests do they perform before you see the patient?
Dr. Beckman: For a new patient, my staff performs whatever tests are appropriate based on certain triggers identified in the patient’s history. They have been educated on my protocol for dry eye evaluations and know what tests I require, whether it’s osmolarity, MMP-9, or meibography. As a rule, we try to avoid sending patients back and forth for testing during the exam.
Dr. Matossian: Dr. Gupta, what is your typical routine?
Dr. Gupta: For dry eye evaluations, my technicians obtain an osmolarity reading, MMP-9, and meibography, as these are my three foundational point-of-care tests. Having these test results upfront facilitates interpretation of the data for an accurate diagnosis.
Ms. Barkey: When a patient is scheduled for a dry eye consult, a staff member should explain in advance that the doctor will need certain diagnostic tests, some of which may not be covered by insurance. If patients are not informed of the potential for out-of-pocket costs for these necessary tests, they may decline the tests.
Dr. Matossian: An additional visit to complete the dry eye workup, will, in the end, be more costly for patients.
Dr. Gupta: There are reimbursement codes for MMP-9 and osmolarity tests, so we bill those to insurance. Some offices use a photography code for meibography and some choose to bill that separately. So for some of these diagnostics, we receive reimbursement and don’t have to pass the cost on to the patient.
Dr. Beckman: If your patient is scheduled for an eye examination and happens to mention dry eyes, you may not be able to complete all of the testing at that visit. In those situations, I perform an osmolarity test at the initial visit and then schedule a follow-up visit for further testing.
CASE COMPLEXITIES ADDRESSED
Dr. Gupta: While there are several treatment options for my patient—an oral omega supplement or a topical steroid, for example—one of the major issues is that the patient’s MGD is undertreated in the setting of chronic ocular rosacea and meibomian gland atrophy. I will spend some time explaining to the patient that the significant atrophy indicates she’s probably had this disease for a decade or more, and there are several MGD treatments to consider. Often, patients are expecting that we have something to cure their symptoms.
However, when a patient has that much atrophy, I emphasize that we need to take action to prevent the disease from progressing so we can preserve the remaining glands. That information changes the conversation for patients. Now they’re thinking about safeguarding their anatomy, and they’re less fixated on reducing symptoms. Of course, we want all of our patients to have symptom relief, but it may not be realistic with just one therapy.
The in-office treatments I offer for MGD include: the LipiFlow Thermal Pulsation System (TearScience), intense pulsed light therapy, the iLux MGD Treatment System (Alcon), micro-blepharoexfoliation, and TearCare (Sight Sciences).
Some practitioners may not be familiar with TearCare, as it was introduced earlier this year. What I like about this device is that it is customizable. Although it looks simple, there’s a lot of smart science in that little piece of tape (Figure 2).
The external heating device delivers a constant temperature to melt the meibum. What’s unique about this therapy compared with others on the market is that patients can blink and keep their eyes open during therapy. A 15-minute cycle of heating is followed by manual gland expression using a proprietary forceps.
Dr. Periman: Some of my patients cannot tolerate having their eyes occluded during meibomian gland treatment. So we treat one eye at a time, leaving the other eye open because they fear claustrophobia. TearCare is a great workaround for these patients.
Dr. Matossian: Dr. Gupta, who in your practice administers in-office therapies?
Dr. Gupta: I prefer to administer new therapies myself, until I become familiar with them. At this point, almost all of the procedures I offer in my clinic are staff-driven. With the ease and flexibility of these therapies, you can determine how they best fit in your own practice.
Dr. Periman: The TearCare customizable gland expressors are so well designed that I choose not to numb the eye. Patients tolerate the treatment well without a topical anesthetic, and after gland expression they can feel the lubricity of their eye.
Dr. Matossian: Dr. Gupta, you mentioned you delegate most of these treatments to your technicians. I’d like to ask the other panelists if they delegate these types of procedures to technicians.
Ms. Barkey: At Dry Eye University, we usually recommend physicians administer some therapies, particularly those that require a significant out-of-pocket expense. I think patients appreciate the value of the therapy when the physician is involved. To be clear, the staff sets up the treatment, but the physician initiates the treatment.
Dr. Gupta: My technicians administer most treatments, but for a thermal pulsation treatment or a TearCare treatment, I apply the applicators.
Dr. Matossian: Dr. Beckman, what about you?
Dr. Beckman: I perform certain tasks, such as gland expression, and I like to affix the applicators for thermal lid treatment. My technicians do as much as they can, but there are some procedures I have to perform, such as cleaning the eyelids.
Dr. Periman: We do microblepharoexfoliation, which can be delegated. I have a skilled staff member who places the TearCare activators, starts the treatment, and brings me in just before the cycle ends, so that I can express the glands. Patients want that time with the physician, and that’s the fun part anyway. You don’t want to miss out on that. It’s very satisfying to be able to remove all of that meibum.
Dr. Matossian: You have to find the right balance to make the patient feel that you’re engaged as a physician while delegating most tasks to your technician for efficiency.
Staff as Members of the Dry Eye Team
By Patti Barkey, COE
With the various diagnostic tests and therapies now available to address dry eye disease, maintaining efficient patient flow can be challenging. Your staff can play an integral role, not only with their knowledge of the technical aspects of diagnosing and treating dry eye, but also in their interactions with patients.
How do you teach your staff to deliver a high level of care? I believe focus training in the practice is huge. We recently offered an educational program for our entire clinical staff to provide an in-depth review of some of the basics of eye care. We selected one of the many excellent books for ophthalmic professionals and reviewed the material together, chapter by chapter. We met one afternoon a week, gave presentations, and answered questions.
Feedback from both the staff as well as the physicians was extremely positive. Several of the staff were able to confidently complete their COA certifications after our program. Staff training always raises the bar as well as the staff involvement in everything your practice does.
I’d be remiss if I didn’t mention Dry Eye University. We present these educational opportunities for doctors and staff three times a year. The more your staff understands the dry eye component of your practice, the better your outcomes will be. When implementing a new treatment, teach your staff every aspect of it from the start. Your success in alleviating patients’ dry eye symptoms and avoiding the potential negative long-term effects of untreated dry eye will become their success, as well.
SUMMARY
Dr. Gupta: A key takeaway from this case is the importance of including in-office MGD treatments to care for dry eye patients. Most patients who have dry eye disease have some component of meibomian gland disease, and I think that each of the cases presented here highlight the fact that patients frequently have comorbid conditions, such as floppy eyelids or underlying keratitis. Our job is to be a detective and keep those various diagnoses in mind.
My approach to dry eye involves a checklist of signs, symptoms, possible causes, and the treatments that will be most effective. I explain to patients that this is a multifactorial disease, and that I have to determine what’s driving their symptoms. When patients understand this, you and they form a partnership and they’re willing to try the various therapies you recommend.
Chronically untreated MGD leads to meibomian gland atrophy, and that is a problem because atrophy is not reversible. We can try to improve the function of the remaining glands, but atrophy is what we are trying to avoid. The use of meibography and other diagnostics to educate patients will help them understand their anatomy and motivate them to make progress in terms of treating their disease.
Early intervention in the dry eye process is critical, regardless of which procedure or therapy you choose. Universally, I have found that when treating a patient with mild MGD I’m much more effective at improving not only the anatomic function but also the symptomatology. The longer we wait, the less of a “wow” effect the patients have. While we need prospective, longitudinal studies, I really do believe if we remove the gland obstruction, avoid stasis, and improve the flow of the oils, over time we will have less meibomian gland atrophy and less severe disease. ●
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