Dry Eye

Lessons from the Dry Eye University

Bowden Eye & Associates and Bowden Eye Services Management Organization share the tools for success in dry eye management.

BY PATTI BARKEY, COE

On July 10, ophthalmology and optometry practices gathered at EverBank Field in Jacksonville, Fla., the home of the Jacksonville Jaguars. Here, along with corporate sponsors, Bowden Eye & Associates and Bowden Eye Services Management Organization shared their experience on how to implement real dry eye care through the practice’s first Dry Eye University.

Here, I share the lessons of the Dry Eye University and explain how Bowden Eye & Associates has achieved success with dry eye care.

Meeting the patient’s needs

Bowden Eye & Associates has always focused on patient outcomes and satisfaction. We have found that today’s patients desire to stay at the forefront of technology. They want bang for their buck, so to speak. Also, they want to be “20/Happy” and comfortable with their investments, including the money they spend on health care.

Dr. Robben explains the results of the Meibography test (TearScience) to the patient. He is assisted by Allison Renn, dry eye counselor (right).PHOTOGRAPHY BY AGNES LOPEZ, POSE WELL STUDIOS

At least seven out of every 10 patients that walk through our practice doors have some level of dry eye disease. Three of those patients may be asymptomatic, as meibomian gland disease (MGD) is like a silent threat to the ocular surface. So, if we all truly want to meet the patient’s needs, each comprehensive practice must develop a way to identify, properly diagnose and treat dry eye disease. Even practices that are not comprehensive should evaluate where they want to stand when it comes to dry eye disease. (See Figure 1. “What type of dry eye practice do you want to have?” page 16.)

FIGURE 1. What type of dry eye practice do you want to have?

Tools to identify dry eye

When managing a patient who presents with a dry eye complaint, full service specialty dry eye practices must first identify the type of dry eye (meibomian gland dysfunction, aqueous deficiency, allergy-related, exposure- and contact lens-related, or blepharitis/Demodex-related). Determining the type of dry eye is the first step in the patient’s journey. The tools necessary to properly diagnose and distinguish between the types of dry eye can be compared to the tools required to diagnose glaucoma. One test, product or procedure alone cannot do the job.

At Dry Eye University, the doctors at Bowden Eye shared how they utilize tools to diagnose the patient’s type of dry eye disease and its severity. The diagnostic tools that Bowden Eye uses to properly diagnose include:

SPEED. In our practice, the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire is the initial driver of the dry eye encounter. The questionnaire evaluates both the frequency and severity of dry eye symptoms. The technician completes the form with the patient and utilizes it to determine if the patient should see a Dry Eye Counselor for education prior to the provider. Informed patients can make informed decisions about provider recommendations. Based on the symptoms, the technician will explain to the patient that, in order for the doctor to distinguish what type of dry eye the patient has, several tests will be needed. Lipid layer testing and blink assessment and meibography, along with tear osmolarity and inflammation testing, are the first diagnostics required for new patient consultations.

Allison Renn, dry eye counselor, uses a model of the eye to explain the benefits of at-home treatments. Bowden Eye carries a number of these treatments in the office.

Allergy testing. If the SPEED questionnaire identifies allergy symptoms, Bowden Eye tests for ocular allergy with a noninvasive test (Doctor’s Allergy Formula), which takes about 12 minutes to administer. This testing, which Bowden Eye performs two days a week in our office, will help the provider decide whether the patient should use antihistamines seasonally or year round.

Inflammation testing. Because inflammation is a major cause of dry eye disease, Bowden Eye uses an in-office test that detects MMP-9, an inflammatory marker that is consistently elevated in the tears of patients who have dry eye (InflammaDry, Rapid Pathogen Screening). Our practice rules out inflammation on every symptomatic dry eye patient and every surgical patient.

When the provider sees signs of dry eye but the patient appears asymptomatic, positive InflammaDry test results are useful in convincing patients of the need for treatment. My physicians are surprised frequently by the patient who, prior to surgery, appears to have a “quiet eye” yet tests positive with InflammaDry.

Lipid layer testing and blink assessment. The LipiView system (TearScience) evaluates the patient’s blink rate and measures lipid layer thickness. The lipid layer is important to keep the ocular surface smooth and comfortable. Patients who do not blink completely are often surprised by test results that demonstrate the incomplete blink. Measurements from the system give us objective “hard evidence” of MGD and further allow us to see if our treatment is improving the condition of the patient’s ocular surface.

Meibomian gland evaluations. During the slit lamp examination, Bowden Eye uses an instrument that evaluates the meibomian gland function [Korb Meibomian Gland Evaluator (MGE), TearScience]. The MGE helps determine the number of functioning glands. Expression of the glands determines whether the patient expresses oil on a full blink or if the gland expresses a thick non-oily substance. The ocular surface relies on the oil in the tears to keep it wet and smooth for the blink.

Meibography. Our physicians determine if all the patient’s meibomian glands are functioning by using meibography (Dynamic Meibomian Imaging, TearScience, available in the LipiView II system), which illuminates the glands. As the meibomian glands clog, they can become damaged. The longer they are clogged, the more damage occurs and eventually the gland structure can become atrophied. We only have the glands we are born with, once they are gone; they are gone!

Dr. Robben (right) prepares a patient for the LipiFlow treatment. He is assisted by Dustin Schulze, Head Counselor at Bowden Eye.

Tear osmolarity. Tear osmolarity (TearLab) provides objective and quantitative data for diagnosis and management of dry eye patients. It helps us determine if we are properly treating patients and making headway as we work to get them comfortable. Normal osmolarity measurements let the providers know that the patient’s treatment is adequate. Abnormal osmolarity measurements alert providers that a change in treatment might be necessary. Maintaining normal osmolarity is the goal.

Sjögren’s syndrome testing. As dry eye is a symptom of Sjögren’s syndrome, Bowden Eye uses in-office testing for the disease (Sjö, Bausch+Lomb). Sjögren’s syndrome is a chronic autoimmune disease often associated with other conditions, such as rheumatoid arthritis, lupus, and scleroderma. These patients are the most difficult to manage and, if they test positive, we immediately refer them to a rheumatologist.

Treating the root cause

Presenters at the Dry Eye University explained that once the type or types of dry eye disease are diagnosed, the provider must provide treatment that addresses the root cause of the disease.

Because the multitude of products on the grocery or pharmacy store shelves can confuse patients, providers must advise them and point them in the direction of the proper product. Bowden Eye has found that patients appreciate practices that carry products for treatment. (See Figure 2. “Convenience Products Offered at Bowden” below.) This approach can lead to better patient compliance with the therapy.

FIGURE 2. Convenience products offered at Bowden

Cyclosporine (Restasis, Allergan) is the only prescription drug approved for the treatment of dry eye. Depending on the results of the patient’s tests, physicians might prescribe other drugs, including loteprednol etabonate (Lotemax, Bausch + Lomb) a corticosteroid, to reduce inflammation, azithromycin (AzaSite, Akorn), an antibiotic, to treat the lid margins or doxycycline, an oral antibiotic. Treatments offered at Bowden Eye include the following:

Blepharitis treatment. Blepharitis, a chronic inflammatory disease of the eyelids, is evident in many patients who have dry eye. Practices often recommend baby shampoo and lid scrubs, coupled with warm compresses, to treat the disease. Rather than this old school approach, Bowden suggests products such as NovaBay’s Avenova or OCuSOFT Lid Cleanser to help the patient with their lid hygiene.

In addition, Bowden Eye uses an in-office procedure that exfoliates the eyelids while removing scurf and debris (BlephEx). Bowden Eye physicians explain to patients that using lid scrubs is similar to tooth brushing — we still go to the dentist for cleanings. BlephEx treatments are much like these cleanings. A mechanical device scrubs the lids at the lash line, a deeper cleaning than the patient can do at home.

The procedure also can treat Demodex, a mite that can infest the eyelid with blepharitis, by removing the bacterial biofilm that is the mite’s food source. Demodex treatment consists of Claridex (Bio-Tissue) applications. The first application is done in the office and the patient leaves with the appropriate supply to use until the follow up visit. Our practice has seen evidence of re-infestation when Claridex isn’t used as directed by the manufacturer.

Treatments for MGD. Practices can treat MGD, the leading cause of evaporative dry eye, with several options, depending on the level of disease severity.

A biologic corneal bandage device (ProKera, Bio-Tissue) is often used to stabilize the ocular surface in patients prior to additional treatments. The bandage’s amniotic tissue contains essential, active growth factors that reduce inflammation and promote and accelerate the healing process.

Patients with MGD can benefit from mechanical expression of blocked meibomian glands (LipiFlow, TearScience). Research shows significant improvement, on average, in both the number of meibomian glands yielding clear liquid and patient-reported dry eye symptoms among patients treated with LipiFlow.

For those patients who have severe gland blockage, meibomian gland probing (Maskin Probes, Rhein Medical) is an option prior to the LipiFlow treatment. Once the procedure has opened glands and expression has started, the patient can proceed to the LipiFlow treatment.

Your next steps

Dry eye disease care can be complex. Start by sitting down with the key leaders within your organization. (See Figure 3. “Checklist for implementing dry eye care” below.) Appoint a project manager and a physician to be your champions. Plan a visit to a successful dry eye practice in your area or attend Dry Eye University where we review our entire process. In addition, investigate vendor resources. Many vendors employ staff who are dedicated to helping practices succeed.

FIGURE 3. Checklist for implementing dry eye care

Offer patients options to help their symptoms while you boost the patient, staff and provider satisfaction in your practice. Ideally, your outcomes will improve along with your bottom line. CPT codes or correlating ICD-10 codes have yet to be issued for many of the dry eye tests and treatments, and the patient pays for these out of pocket. Develop your fee schedule and teach your staff how to present these services, just as you have for refractive surgery and premium intraocular lens implants.

Your investment in a successful dry eye management program will yield results in both patient satisfaction and practice revenue. In other words, you can’t go wrong. OP

Patti Barkey, COE, is chief executive officer for Bowden Eye & Associates, Bowden Eye Services Management Organization and Eye Surgery Center of North Florida.