In my practice, dry eye patient volume has been increasing despite the pandemic. With growing rates of dry eye issues, patients are actively seeking out professionals who understand and can address their problem. We have a high level of demand for in-office treatments for meibomian gland dysfunction (MGD) and other forms of dry eye. But it’s not because we have discovered the magic device or perfected a strong sales pitch. Rather, I firmly believe that success in the field of dry eye starts with passion and knowledge. Only when those are present is it worth talking about what diagnostic and treatment technologies to adopt.

Dry eye is no different from any other disease. Just as with glaucoma or cataract, there is not just one typical presentation, treatment protocol or uniform response to treatment. However, unlike other diseases in ophthalmology, most of us in practice today learned relatively little about dry eye during residency. Instead, a lot of the education around dry eye has been driven by industry to support specific drugs or devices. While we can be grateful for the excellent treatments the ophthalmic industry has brought forward, it is incumbent upon physicians to develop a deeper understanding of the different forms of this disease and a solid foundation of knowledge on which to evaluate and treat patients.

ESTABLISH TESTING PROTOCOLS

The first rule of thumb in dry eye care is that you won’t find what you don’t look for. Just as every exam includes visual acuity and IOP, I believe that we need to routinely test for dry eye. In my practice, every patient completes a SPEED questionnaire and has a dry eye evaluation at the slit lamp, at a minimum. I push on the meibomian glands and evaluate the appearance of the tear film, tear meniscus, lid margin and conjunctiva. These are quick, inexpensive steps that are easy for any practice to incorporate.

Patients with any positive responses on the SPEED questionnaire or any signs of dry eye or MGD at the slit lamp are generally asked to return for a dedicated dry-eye consultation, during which we perform more extensive testing, including osmolarity (TearLab), InflammaDry MMP-9 testing (Quidel), LipiScan meibography and LipiView interferometry (Johnson & Johnson Vision) (Figure 1).

Some practices incorporate all of these tests during the initial workup before the patient sees the doctor. I like to separate them so that we can specifically address dry eye as a disease entity independent of the primary reason for the patient’s visit (more on that below). Regardless of how you choose to structure the workflow in your practice, it is important to remember that lack of symptoms does not necessarily mean lack of disease. As physicians, we are obligated to diagnose both symptomatic and asymptomatic patients.

EDUCATE THE PATIENT

While it is perfectly reasonable to delegate much of the testing to technicians or other staff members, the physician’s discussion about what these test results mean determines whether patients will accept treatment. A doctor who is dismissive, spends 2 minutes with the patient and leaves it to a patient counselor to educate and recommend treatment is not likely to inspire confidence or adherence to the treatment plan.

When I tell patients about their disease and how I propose to treat it, I often get one of two responses. Highly symptomatic patients sometimes tell me they have been suffering for years but that no one has ever explained the problem to them, much less provided a solution. These patients will be very loyal to your practice because you have now become their hero.

Those who aren’t symptomatic can be more challenging. They may question the clinical findings, claiming that their eyes “don’t feel dry.” It is still important to recommend treatment. It is all about science and education at this point. I use their own imaging and test results to educate them first, then I ask these patients, “Do you feel your blood pressure or your cholesterol?” The reality is that many silent diseases cause physiological damage without announcing themselves, especially in the early stages. The best approach is to prevent them from getting to the late state of the disease when symptoms demand more attention — but are also more challenging to reverse.

Not every ophthalmologist needs to be a dry-eye specialist. But even those who don’t wish to dedicate time personally or invest in the equipment necessary for thorough diagnosis and treatment of dry eye should take care to educate patients about the fact that they have a chronic disease requiring treatment and then make a referral to another doctor.

TREAT THE INDIVIDUAL

There is no cookie-cutter regimen for treating dry eye.

In my practice, treatment might involve LipiFlow (Johnson & Johnson Vision), TearCare (Sight Sciences, Figure 2), intense pulsed laser (IPL, Lumenis), AzaSite (azithromycin ophthalmic solution, Akorn), topical anti-inflammatory agents such as Restasis (Allergan), Cequa (Sun Pharma) or Xiidra (Novartis), punctal occlusion and other treatments — individually or in combination. My recommendations vary based on the causation of the disease in a given individual, severity of their disease, concomitant ocular, skin type, systemic conditions, age and degree of compliance.

I believe in getting the patient actively involved in their own care. For most (although not all) patients, I recommend at-home use of warm compresses, an omega-3 supplement and an effective, long-lasting, nonpreserved lubricating drop.

However, when dealing with a chronic illness, it is also important to simplify treatment as much as possible so as not to discourage the patient. Often, patients dislike using daily chemical drops. For this reason, chronic use of topical anti-inflammatories and immunomodulators are met with resistance in compliance. It is more favorable to start patients with organic treatments, beginning with warm compresses and lubrication, dietary supplements and appropriate in-office treatments as needed. Of course, in the face of a significant inflammatory component, appropriate medications are prescribed and the reason for their use is explained to the patient. I want my patients to know that if I am recommending daily chemical eyedrops for the rest of their life, it is because there is no other good option. Ultimately, patients are more compliant with therapy if they feel that their doctor has been thoughtful about prescribing chronic medications.

ESTABLISH A CLEAR PLAN FOR FOLLOW-UP

The frequency of follow-up for dry eye patients should vary by the severity of their disease. In my practice, patients with mild disease see me once a year. Those with moderate disease see me every 6 months, and those with moderate-to-severe disease see me quarterly. More frequent visits are indicated to gauge how frequently they need to be treated or what therapies should be added when the condition is more severe.

In customizing care for my MGD patients, the majority have a LipiFlow thermal pulsation treatment once per year, but some may have it twice a year or every 2 years. If the meibomian glands are so inspissated that I don’t think thermal pulsation on its own can get the meibum flowing again, I combine it with other treatments in a series. For those with ocular rosacea, IPL is often indicated (for the qualifying skin types) in addition to other therapies to decrease inflammatory factors and promote better oil production.

ADDRESS TIMING AND COSTS

Among the most challenging situations for all of us is how to address dry eye in a patient who has presented for another reason — a cataract consult, for example. I feel strongly that dry eye should be dealt with on its own merits. Maintenance of the ocular surface in patients with chronic disease is a lifetime endeavor, while cataract surgery is a one-time event. For that reason, I don’t like to “bundle” dry eye treatment into the cataract surgery timeline or fees. It’s also a lot for patients to absorb — from both an education and a cost perspective — all at once.

Ideally, I start patients on a dry eye management plan and make sure they understand this is a chronic condition. Provided that the patient still has reasonable visual function, we can wait a few months to address the cataract. I explain to patients that they have a lot to gain by treating the ocular surface first, because that will enable us to obtain more accurate biometry measurements and achieve optimal surgical results.

But timing, too, must be customized to the patient in the chair. Recently I operated on a 45-year-old with 3+ posterior subcapsular cataracts that had progressed rapidly. The patient could not drive safely, so we really couldn’t delay cataract surgery. We proceeded with the lens surgery but also scheduled a future dry eye consultation. Sometimes I see busy technology company executives who would rather start dry eye treatment right away and schedule cataract surgery with a premium IOL. Minimizing the number of visits is a higher priority for them than spreading out the cost of treatment.

For patients with moderate or worse dry eye, I often bundle the costs of multiple dry eye treatments for the year. Dry eye is a multifactorial disease, so it makes sense to me to offer the patient a treatment package where we focus on addressing the problem with all of the technologies at our disposal that would more completely address their specific underlying conditions.

In general, treatment costs should be addressed naturally, as part of the process of educating patients about their diagnosis and treatment plan. Since insurance unfortunately doesn't cover most dry eye care, I have my staff discuss cost issues in detail. Patients often have specific questions about whether they are obligated to return every year for another treatment, how payments are scheduled, etc., that can be easily answered by my staff without wasting chair time. In fact, patients may even be more comfortable addressing cost questions to staff, as long as they are confident in my treatment recommendations.

There are lots of articles about the revenue potential of dry eye treatment. In my opinion, viewing dry eye care as simply a revenue generator is inappropriate. Dry eye is a disease, not a business opportunity. You have to have the passion to care for the patient then have the know-how to address each individual case with the appropriate treatment modalities, whether it is insurance covered or not.

CONCLUSION

No matter how complex dry eye management can be, it is also rewarding. This disease affects almost everything else we do as ophthalmologists. By treating and improving the ocular surface and tear film, we can improve our surgical success, boost patient satisfaction and help our patients see better. OM

About the Author

Lillie A. Mosaddegh, MD, is the owner of Mosaddegh Eye Institute, an anterior segment practice with three offices in San Francisco, and an executive board member of Eye Surgery Center of San Francisco. Dr Mosaddegh’s experience with the science of dry eyes spans more than two decades. Email her at DrMosaddegh@sfeyedoctors.com.

Dr. Mosaddegh reports no relevant disclosures.