Therapeutics

With new diagnostics and treatments, many are asking

Are Dry Eye Clinics the Future?

René Luthe, contributing editor

Benefit patients and your bottom line with less effort than you might think.

More and more, dry eye disease is in the news. Once considered a nuisance or afterthought, dry eye is featured in television commercials for cyclosporine ophthalmic emulsion (Restasis, Allergan) and artificial tears, and in articles in the mainstream press. So how about adding a dry eye clinic to your eye care practice? After all, dry eye isn’t going away anytime soon, Lauren Levine, of ScienceBased Health, notes. In fact, several trends are converging to create a growing demand for dry eye care: Aging baby boomers, the popularity of refractive surgery and premium IOLs, and the evergrowing number of hours people spend staring at electronic devices each day. And while creating a “dry eye clinic” may sound like a lot of work, you’ve probably already got much of the groundwork done.

No Hard Sell Required

For starters, don’t worry about having to drum up demand for dry eye services — it’s already there. Don Cushing, practice administrator at Ocala Eye, Ocala, Fla., advises anyone thinking of about focusing on dry eye services to simply check the practice’s diagnostic runs. “You’ll find 7% to 8% of patients have dry eye as documented in your computer system.” With a little more investigation, he believes that number can probably be doubled. “You don’t have to market to them, you just need a process for taking care of them,” Mr. Cushing says.

Further, these patients don’t require a hard-sell approach. Artificial tears or punctal plugs were the course of many patients who sought relief. If these did not ease symptoms, their doctor might switch them to another artificial tear, or prescribe cyclosporine, which addresses patients whose chronic dry eye was due to inflammation.

Until recently, of course, that was about all eye care specialists had to offer. But with the launch of therapies such as LipiFlow Thermal Pulsation system (TearScience, Morrisville, N.C.) and a better understanding of the role nutraceuticals can play, ophthalmologists can offer patients a variety of therapies. “With dry eye, you felt like a broken record — artificial tears, hot packs, artificial tears, hot packs,” Mr. Cushing explains. “Now there are therapies that work to alleviate these symptoms patients are having.”

And because dry eye is a chronic condition, these patients will require care for years — unlike cataract or LASIK patients. “I can imagine that some of our patients who’ve undergone LipiFlow, two years from now will call and say, ‘I need to come in for my treatment, my glands are getting clogged again and it’s coming back,” says Dale Christianson, practice administrator at Mann Eye Institute, Houston. “We don’t get game-changer treatments like this very often in ophthalmology.”

Moreover, today’s dry eye patients will eventually have cataracts and possibly glaucoma, Mr. Christianson points out. “Don’t be short-sighted: You want that patient for life.”

If you need another reason to focus on dry eye care, keep in mind that cataract and refractive surgeons cannot achieve optimal outcomes for their patients unless ocular surface disease is first treated.

So yes, practices have a strong interest in treating dry eye disease in a more intentional fashion. The good news is, creating a “dry eye clinic” does not require additional space or staff.

At a round table on dry eye clinics at this year’s American Society of Ophthalmic Administrator’s meeting, participants discussed the many forms one could take, depending on the practice’s needs and resources, reports Ms. Levine, “It doesn’t have to have four walls. It doesn’t have to have a lot of expensive equipment—it can; it depends on the scope of the practice. The practice has to figure out what it is they want to do and how to best do it, and be proactive in treating dry eye just as they would any other eye condition.”

Listen and Learn

One “must,” however, is for practices to thoroughly educate all staff — from those manning the phones to the technicians to the eye care practitioners—about the different types of dry eye and the therapies available. While you already have dry eye patients in your practice, staff probably need to learn how to better listen to their complaints, whatever the primary reason for the visit.

Patients are probably already communicating their dry eye symptoms, according to Patti Barkey, practice administrator at Bowden Eye & Associates, Jacksonville, Fla. “I’ve been in ophthalmology for about 35 years, and when doing chart audits, you would see that the patient walked in complaining of itchy, burning dry eyes; when you audited the chart, though, the primary complaint was a cataract. Well, the cataract didn’t cause the itchy dry eyes. They were here for glaucoma, or they were here for cataracts, and we were kind of just touching on their dry eye.” Teaching staff to regard those complaints as symptoms of a medical condition that warrants treatment will go a long way toward uncovering patients who will benefit from the practice’s help.

At Ms. Barkey’s practice, techs administer the SPEED Questionnaire, developed by TearScience, to all patients. “It asks a series of questions and the answers are scored,” explains Ms. Barkey. “We have added a section on allergy symptoms to the form.”

Other practices take a more low-key approach to uncovering dry-eye sufferers. Techs simply ask, after the primary reason for the visit is addressed, how the patient’s eyes are feeling. Or, Ms. Levine points out, they can ask more specific questions, such as do the patient’s eyes water? Do they burn? When does this occur?

Staff Play a Key Role

Opening a dry eye clinic does not have to take up a lot of the doctor’s time. Staff are assigned patient education on dry eye, thus freeing the doctor to see more patients. “It’s not economical to spend the kind of time that it takes to help the individual really understand a chronic problem like dry eye,” Mr. Cushing notes.

At Ms. Barkey’s practice, if the Standard Patient Evaluation of Eye Dryness (SPEED) Questionnaire, which rates frequency and severity of symptoms, results in a score above a four, that patient is assigned a “dry eye counselor.” That staff member informs the patient that he or she appears to have dry eye and explains the various treatment options available once the doctor determines the type of dry eye. “We do that so the patient will understand what the doctor is talking about when he sees the patient.”

Similarly, at Mr. Cushing’s practice, if the ophthalmologist finds a constellation of symptoms indicating dry eye, he recommends an appointment for a full evaluation and education section with the practice’s “dry eye specialist.” That staff member does three things, Mr. Cushing reports. “One, she does a series of tests that includes TearScience’s LipiView and Tear Osmolarity (TearLab Corp.). Two, she explains to the patient about the range of treatment options available, and three, she then gathers all the information from the tests and ships it back to the referring ophthalmologist and schedules the follow-up appointment.”

Having a staffer dedicated to dry eye testing and education ensures that both the practice and the patient have a complete information base — the doctor on which to devise an individualized treatment plan, and the patient on which to make informed choices.

However a practice decides to proceed, Ms. Barkey emphasizes that everyone in the practice needs to be on the same page regarding education, methodology and treatment options. “It can’t be a hit-or-miss approach. It should be ‘This is what we are going to do, and if that doesn’t work, our next step is X.’ It should essentially be the same concept as a glaucoma standard of care.”

Once You Have Their Attention

Be ready for those patients who will take you up on your offer of dry-eye relief with products and services to help them. While Restasis remains a valuable tool, writing a prescription is not the only option. Again, patients first hear about their various options from the staff member who handles the patient education component of your dry eye clinic. Practice managers may consider the following treatments when analyzing options:

▪ The efficacy of nutritional supplements, as well as their ease of use, make them a must for a practice’s product offerings. Both Mr. Cushing’s and Ms. Barkey’s practices sell nutritional formulations to treat dry eye that include such nutrients as omega-3 fatty acids and antioxidants. “I’ll be candid with you, when people started telling me about nutraceuticals, I was skeptical. The next thing I know, I’m hearing from Dr. Peter Polack, a nationally recognized cornea specialist, that this stuff works. So I said, ‘Well, you’re the doctor — let’s put some on the shelf!’”

Dr. O’Dell’s practice offers an omega-3 supplement. “It seems to offer good quality, and if patients want to purchase it outside our practice, they an find it at other places.” The most difficult part about selling these nutritional supplements, Dr. O’Dell says, is educating patients as to why this brand costs more than the ones patients see at Target or Walmart.

▪ Dr. O’Dell’s practice also offers eyelid cleaner wipes for blepharitis. “These are only available through doctors,” she says.

▪ Masks or hydrating goggles, and your doctor’s preferred artificial tears are also products that can make a difference to patients, as well as to your bottom line.

▪ At Ms. Barkey’s practice, they put together dry eye bundles for patients. Those beginning dry eye treatment can buy a lid scrub, mask and a bottle of a nutritional supplement for slightly less than the products would cost sold separately.

“The front desk person presents the whole bundle and tells the patient, ‘Dr. Bowden recommended this for you today, so here it is with the instructions.’ It amazed me how eagerly patients responded, they were waiting for somebody to help them,” she says.

Patients are also reminded that the Dry Eye Counselor is available if they have any questions or need to purchase additional product prior to their next appointment.

And while some of the nutritional products can indeed be found at health food stores or online, Ms. Barkey finds that many patients prefer the convenience of buying them at the practice.

▪ Should the patient’s dry eye progress, treatments such as LipiFlow or intense pulsed light (IPL) are the “big guns” ophthalmologists can bring out for more severe cases. The cost is approximately $800 per eye and Ms. Barkey reports that people are coming in from neighboring states for the treatment, though the practice has done little external advertising.

And patients are not balking at the price, according to Mr. Christianson. “Insurance doesn’t cover LipiFlow, but it does cover the dry eye evaluations, and there’s no global period on this, so insurance does pay for the (follow-up evaluations),” he says.

Mr. Cushing says the patients at his practice who’ve undergone LipiFlow claim it delivered relief, and that the procedure was worth the price. However, he cautions, “The endgame is not to sell these things, it’s to begin with conservative treatments and inform the patient that you can progress, and if these less expensive therapies don’t work, there’s this.” The knowledge that the ultimate therapy is considerably more expensive can motivate patients to be more compliant with the “lower-level” therapies such as hot packs.

Whatever products you choose to offer your patients, Mr. Cushing says the guiding principle must be, is there evidence that the particular therapy offers real relief? “When we take that position, we do well by doing good,” he says. OP