Dry eye disease is one of the most common diagnoses that Christopher E. Starr, MD, FACS, encounters at the Weill Cornell Eye Associates in New York City. Even as an incredibly busy practice, Dr. Starr says it’s still the most frequent complaint. Of course it’s one that many practitioners don’t want to deal with. They may consider it boring, a nuisance, or may not even take their patients’ concerns very seriously. Dr. Starr says that’s something he’d like to see changed. The effects of dry eye can affect quality of life and in some cases even be debilitating. “We’re in a new era of ocular surface disorders and there has been newfound interest in revitalizing the field and making the disease easier to diagnose,” Dr. Starr says. “But you have to be tuned in to diagnose it; otherwise it can easily go undetected. For us, the technicians play a huge role in that,” he adds.

First Line of Defense

At Weill Cornell, techs are first in line to see the patient. It’s on their shoulders to start the discussion and to determine whether any dry eye testing should be performed. “With dry eye, because you want to get an idea of the quality and quantity of the patient’s tear and tear film, it’s critical that you do that assessment before any extensive bright lights or drops are used in the eyes,” Dr. Starr urges. “Once drops go in, you disturb that ocular surface. So, techs need to be proactive in identifying patients and starting the diagnosing process.”

Even if the patient doesn’t bring up symptoms of dry eye, the techs are trained to dig deeper in that initial conversation. “We will ask: ‘Do you ever experience any occasional blurriness, tearing, pain, itchiness, or a foreign body sensation?’” says Rose Marie Bigit, a certified ophthalmic technician at Weill Cornell. “We may also proceed with dry eye questions by asking about their medical history, such as autoimmune conditions or inflammatory skin conditions like eczema or rosacea. Some individuals are reluctant to discuss this because they feel it’s not related. It’s up to the technician to ask the right questions or observe dry skin issues, especially on the face or near the eyes.”

Starting a Conversation

Using a questionnaire is also a good way to start the dry eye conversation. Clifford L. Salinger, MD, the medical director of V.I.P. Laser Eye Center says the practice utilizes both the Standard Patient Evaluation of Eye Dryness (SPEED) and the Ocular Surface Disease Index (OSDI) questionnaires. While they do overlap a bit, Dr. Salinger finds that using both is much more comprehensive. Then the tech reviews the questionnaire with the patient. “The tech should determine the duration, the frequency, and the severity of the condition,” Dr. Salinger says. “It’s important for the doctor to know that information as he comes in because we tailor our treatment based on those three factors.”

In fact, once dry eye is detected, techs actually start the education with the patient, which saves time for the doctor. “Dry eye can be very complicated,” says Ingrid Pagan, an ophthalmic technician with V.I.P. “Patients may think it’s just that their contacts dry out their eyes or that they have something in their eye but we explain how the quality and quantity of the tear is affected. We do all of this before the doctor comes in and starts his discussion.”

Testing & Diagnosis

Early dry eye diagnosis is considered so important at the Sky Vision Center of Westlake in Westlake, Ohio, that techs are given a green light to take matters into their own hands. “Because we consider dry eye diagnosing so important, we will accept the fact that some testing may be done without getting a dry eye diagnosis and that’s an expense we’re fine with incurring,” says practice founder, Darrell E. White, MD. “We make it very clear to everyone in the office that if they start down the dry eye pathway and perform the tear osmolarity test, but discover no dry eye, we’re fine with that. We want them to feel empowered to start the process and have the confidence that nobody is going to get upset or uptight about purchasing a couple microchip cards for osmolarity that we can’t bill for.”

By being given that trust, the techs are able to do their job without hold-ups. “Dr. White knows that we can feel out who may be a candidate for dry eye and get the ball rolling. There are always those patients where you’re on the fence about testing but when in doubt, we test. Usually when we do, we find out it was a good thing we did. Some patients aren’t very symptomatic but by testing when we have suspicions, we’re often able to catch things early,” says ophthalmic technician Jennifer Fiamella.

Many practices have incorporated osmolarity testing (TearLab Osmolarity Sytem) into their routine. Dr. Starr says it fits seamlessly into his practice. “All the techs are trained on TearLab and if dry eye is suspected, will do that test before anything else in the exam,” he says. “It takes a couple of minutes to check both eyes and then they document the number in the chart so that by the time I see the patient I know what the tear osmolarity is in both eyes and based on those numbers whether or not the patient has dry eye as well as how severe it is. For me it’s a tremendous benefit that ends up saving a lot of time because I have a good idea of the diagnosis before I even walk in the door.”

Treatment & Follow-Up

There was a time when a dry eye patient would be told to try some over-the-counter drops and be sent on their way, but these days, more practices are recognizing there is tremendous opportunity to help the patient. “So many patients come through our door that have quality of life issues, saying that they no longer read or they can’t wear their contacts,” Ms. Fiamella says. “So we’ve made dry eye a priority here. There are so many new medications out there that you can really help people. You can drastically improve their lives.”

The treatment approaches vary based on the patient and the severity of the case, but Dr. Salinger says he always treats dry eye with a comprehensive approach. “A lot of doctors might say ‘try this one thing,’ but I typically have patients do multiple treatments including hot compresses and nutritional supplements as well as medication.”

The length of time until follow-up also depends on the individual case, but Dr. Salinger says, because of the potential for side effects that comes with any steroid medications, patients need to be seen back within four to five weeks to have their pressure checked by the doctor. OP