Dry eye disease (DED) is a complex, multifactorial condition and is among the most common reasons we evaluate patients in our office. It can be associated with eyelid-related factors (such as meibomian gland dysfunction, lagophthalmos or ectropion), autoimmune disease, neurotrophic keratopathy, limbal stem cell deficiency, prior ocular surgeries, hormonal changes and systemic medications, among others. Consequently, treatment for DED is typically multipronged, with careful attention to tear production and quality, ocular surface inflammation, blink frequency and coverage as well as eyelid support.

It is precisely due to the multifaceted and intricate nature of this condition that an approach involving co-management is rather suitable. In this article, we discuss fundamentals of co-managing DED with our colleagues in optometry, the factors and forces that drive this pattern of care, potential models of care and possible limitations.

FACTORS DRIVING DED CO-MANAGEMENT

Demand

The Health Resources and Services Administration predicted a demand for approximately 22,000 ophthalmic surgeons in 2025 and that the quantity of ophthalmologists would be more than 6,000 physicians less than required.¹ Between 1995 and 2017, the density of ophthalmologists in the United States dropped from 6.3 per 100,000 individuals to 5.68 per 100,000, while the concentration of optometrists rose from 11.06 per 100,000 individuals to 16.16 per 100,000 from 1990 to 2017.²

Given this imbalance between supply and demand of surgical ophthalmologists, economic forces drive many physicians to prioritize surgical cases. In light of the range of medical in addition to surgical needs from patients, attempts by ophthalmologists to evaluate and manage the full range of ocular pathology may put additional strain on clinic schedules and further broaden the gap between supply and demand. Hence, sharing management of non-surgical conditions, especially dry eye, with optometrists who have a particular interest in this field works in favor of both ophthalmologist and optometrist.

Prevalence

Another factor driving increased need for co-management is the extraordinarily high prevalence of DED. At this time, approximately 16-49 million Americans experience dry eye, representing 5-15% of the population.³ Given the sheer volume of DED patients and associated clinic visits, co-management is valuable. In our practice, dry eye patients may be followed every 2-4 months initially until a comfortable regimen is identified, and then every 6-12 months thereafter for surveillance. Clinical capacity may not be able to support this demand for revisits, and dry eye patients may benefit from alternative avenues of care.

Association with refractive changes

Furthermore, the close association of dry eye with refractive shifts also supports a model of co-management with optometrists, and dry eye patients would benefit from dedicated ocular surface rehabilitation before prescribing glasses.

In addition, many patients with severe dry eye benefit from scleral or other forms of advanced contact lens technology; co-management with an optometrist with expertise and interest in contact lens fitting would streamline patient care.

CO-MANAGEMENT MODELS

Referrals

Several models of co-management for dry eye have worked well for my colleagues. One potential avenue for co-management with optometrists involves surgeon-centered referral patterns. In this model, surgeons refer patients to dry eye centers or optometrists who have a particular interest in dry eye for optimization of the ocular surface before biometry and subsequent surgery.

When surgeons recognize dry eye in patients being evaluated for cataract surgery, these patients often require multiple and frequent visits before their surface improves sufficiently to provide reliable biometry, especially in cases of patients receiving premium IOLs in whom accurate keratometry measurements are even more critical. In these cases, co-management would involve a team of dry eye specialists who work with patients on different strategies to improve the cornea. Once satisfactory results are achieved, the patients would be referred back to the surgeons for biometry and surgery.

Dry eye center

The existence of a dry eye center, or dry eye clinic, is a common feature of several proposed co-management models. Dry eye centers incorporate a range of providers, including optometrists and ophthalmologists with a specialized interest in ocular surface disease. These centers offer a one-stop location for all dry eye needs, including the full range of diagnostic, medical and procedural capabilities.

The diagnostic options for dry eye have expanded exponentially in the past decade. A simple slit lamp examination involving various stains (fluorescein, rose bengal and lissamine green) and tear-break-up time evaluation can reveal many features of the disease. Schirmer testing is also a common and easy way to quantify tear production. However, the range of diagnostic technology now includes meibomian gland imaging, meniscometry, tear film stability analysis, interferometry, tear osmolarity, tear film normalization test, ocular surface thermography and tear biomarkers (for more, see page 39).

CONTROVERSY

There are some areas of controversy around co-management as it pertains to scope of practice for optometrists and ophthalmologists. With the rising comfort among optometrists for performing non-invasive eyelid and ocular surface procedures, these techniques have been increasingly shared between optometrists and ophthalmologists. Within dry eye centers, optometrists may offer an array of procedures, including intense pulsed light, thermal pulsation, punctal plug placement and amniotic membrane insertion. Many optometrists comfortably prescribe prescription dry eye therapies, including cyclosporine and lifitegrast, though fewer in my experience offer serum tears and compounded ophthalmic medications. Practitioners from these centers typically refer to a surgical ophthalmologist for more invasive procedures such as punctal cautery, tarsorrhaphy or amniotic membrane transplantation.

While many ophthalmologists feel comfortable with this setup, some feel that the performance of procedures should stay exclusively within the realm of ophthalmologists. Several arguments for this position have been put forward, including degree of training that should be required if a practitioner is performing invasive ocular surface procedures. The debate surrounding scope of practice for optometrists is an ongoing one and will likely continue to evolve as more technology is introduced in our field.

CO-MANAGEMENT PROS AND CONS

Advantages

Patients suffering from dry eye often require extensive assessments given the degree of diagnostics that may be involved, as well as the chronic nature of this disease and reassurance needed. Many physicians may feel that their clinical resources cannot support a high volume of dry eye evaluations. For this reason, specialized dry eye centers work well, as they cater to individual patients and can offer solutions tailored to their needs. These clinics, including staff and patient flow, are deliberately designed for the management of ocular surface disease.

Additionally, much of the equipment used for diagnosis and treatment of dry eye is expensive and not an economical investment for practices that do not have the space and/or volume of dry eye patients to sustain their maintenance. In this case, it is practical to consolidate dry eye patients in these specialized centers that can provide the best care in the most efficient and comprehensive manner.

Disadvantages

In the case of perioperative referral to a dry eye practice for ocular surface optimization prior to cataract surgery, patients may feel a sense of discontinuity in their medical care as they visit multiple practices and see several physicians prior to their surgery. Patients may also feel this discontinuity if they are referred from a dry eye center to a surgical practice for sutured amniotic membrane or tarsorrhaphy due to recalcitrant or severe disease.

Another potential disadvantage is that there may be considerable variation in comfort levels among optometrists in managing dry eye medications or offering particular procedures. Therefore, a single dry eye center may not be able to provide a full spectrum of medical and surgical options for patients. As such, it may be hard to establish a universally accepted model of co-management.

CONCLUSION

Co-management of DED with our optometry colleagues provides an opportunity to centralize the care of dry eye patients, while at the same time allowing ophthalmologists to decrease the gap between supply and demand in surgical ophthalmic care.

Establishment of dry eye centers offers a one-stop location that can achieve the various diagnostic, medical and procedural interventions that patients with this condition benefit from. With time, standardization of services offered at dry eye centers could allow for streamlined and efficient care of this complex and chronic disease. OM

REFERENCES

1. Department of Health & Human Services. National and Regional Projections of Supply and Demand for Surgical Specialty Practitioners: 2013-2025. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/surgical-specialty-report.pdf . Accessed March 9, 2023.
2. Feng PW, Ahluwalia A, Feng H, Adelman RA. National Trends in the United States Eye Care Workforce from 1995 to 2017. Am J Ophthalmol. 2020;218:128-135.
3. Dana R, Meunier J, Markowitz JT, Joseph C, Siffel C. Patient-Reported Burden of Dry Eye Disease in the United States: Results of an Online Cross-Sectional Survey. Am J Ophthalmol. 2020;216:7-17.

Zeba A. Syed, MD, is an assistant professor of ophthalmology at Thomas Jefferson University in Philadelphia and director of the Cornea Fellowship at Wills Eye Hospital.