There’s no denying that you play an invaluable role as the technician in diagnostic testing for dry eye disease (DED). The data derived from these tests set the physician up to make a proper diagnosis.

Laura M. Periman, MD, a board-certified ophthalmologist, fellowship-trained cornea and refractive surgeon, and ocular surface disease expert, who founded the Periman Eye Institute, a specialized dry eye clinic in Seattle, WA, recommends following TFOS DEWS II four steps to a dry eye diagnosis: ask the right questions (aka patient history), assess the risk factors, perform the diagnostics, categorize and treat. The first step can be delegated to the front desk.

“Engage the front desk by having them administer the questions before you call the patient back,” she says. “Choose a validated DED patient questionnaire—whether it’s DEQ-5, SPEED, or OSDI—and stick to it. It really does take the whole office leaning in to fully address the special needs of the DED patient.” (For more information on questionnaires and patient history, see OP’s previous dry eye issues at bit.ly/OPdryeye19 and bit.ly/OPdryeye18 .)

The ophthalmic technician plays a vital role in completing the second step accurately. Dr. Periman says there is a scripted sequence for diagnostic testing. She walks us through the tests that might be warranted for a DED diagnosis and offers “technique tips” for several of the tests.

Start with a vision test

Although it may seem simplistic, dry eye does impact vision, and starting the diagnostic process with a vision test is important, Dr. Periman says. It’s incredibly satisfying for both clinician and patient to return—after responding to treatment—and see vision improvements, she adds.

Test for tear osmolarity

The tear osmolarity test measures the amount of salt in the tears. A higher salt concentration in the tears can indicate inadequate tear volume. It is the vital sign of the entire tear producing system.

“The reason we check this early on, even prior to the pupil exam, is that the bright lights can create reflex tearing, which can alter the results,” Dr. Periman says. “You don’t want light sensitivity to alter the osmolarity.”

Dr. Periman’s technique tip: In performing this test, calmly ask the patient to look straight ahead, blink normally, and relax. As you come in from the temple area, tell the patient, “I’m going to grab a tiny sample of tears.” For severe dry eye patients, you may struggle in capturing the fluid. In these cases, ask them to tilt their head up and to the side, as much as the neck will allow, so that tears pool in the temporal lower lid. Place the collector delicately on the lower lid margin and use it to gently push the lid margin downward to gain a successful tear capture.

Metalloproteinase-9 (MMP-9)

This important test assesses the tears for inflammation by measuring MMP-9, an inflammatory marker often found in patients who have DED. Dr. Periman says MMP-9 is technique-sensitive; it can be easy to get a false negative.

Dr. Periman’s technique tip: Using your non-dominant hand, approach the lid from the temple (using a swab, not your finger) and touch near the lash base, rolling the lid down and away from the eye, exposing the inferior conjunctival fornix. Then, with your dominant hand, grab a tear sample with the sponge, touching the tear meniscus five times, working your way across the inferior conjunctival fornix. This needs to be repeated twice with all of the touches for a proper sample culture and to avoid those false negatives. Finally, press and hold for five seconds in the center of the inferior fornix.

Dr. Periman suggests engaging patients in the process to distract them from the annoyance. While performing the five passes, count out loud for five seconds. Patients can do anything for five seconds at a time, she says.

Sjögren’s Syndrome test

According to Dr. Periman, this test is part of an advanced work-up. It includes traditional and novel early biomarkers to provide a Sjögren’s Syndrome diagnosis through a blood test. Dr. Periman says the doctor also may want to order a Vitamin D and thyroid test at the same blood draw.

Corneal topography

Because osmolarity and dry eye can impact the patient’s topography, K measurements, and IOL calculations, dry eye is important to identify ahead of cataract surgery, says Dr. Periman.

Anterior segment OCT (AS-OCT)

Although Dr. Periman does not have AS-OCT, she says, she uses another diagnostic platform to capture data that can be acquired via AS-OCT, specifically, tear meniscus height (TMH), which is part of an advanced work-up. TMH can be a sign of dry eye; specifically, it is low in advanced dry eye cases and high in nasolacrimal duct obstructions. It also can improve with treatments.

Meibography

Dr. Periman’s office has an all-in-one system that handles topography, fluorescein staining, meibography, and more, which saves time and allows for a side-by-side comparison between eyes or between visits and can easily be uploaded to the EMR chart, she says. (Patients appreciate seeing improvements in fluorescein staining, she says.)

Fluorescein helps identify areas of tear film instability and physical changes to the ocular surface, such as punctate epitheliopathy, that are often seen in DED.

Meibography allows an eye-care professional to assess the health of the meibomian glands. The doctor can assess the presence of gland damage, drop out, or atrophy. At the slit lamp, the doctor presses on the meibomian glands and judges the expressibility of the glands and the quality of the meibum.

PICTURE THIS!

 

According to Dr. Periman, it’s always helpful to take photos with staining ahead of treatment and then again six months out. Patients often forget how bad they felt when their dry eye was at its worst—but seeing it as photographic proof can help them recommit to the treatment program. In this way, patients can physically see that it’s working. This can be key for compliance, as can going back to the questionnaire responses. Use these as a form of celebration. Remind the patient how far they’ve come.

 

Dr. Periman’s technique tip: Approach the eye from the temporal aspect, parallel with the ground. Grab the lower lid near the lash line, about two-thirds across it, and roll the swab toward yourself as you simultaneously pull the lid downward ever so slightly as this exposes the lid conjunctiva beautifully for imaging. Try to evert the eyelid in a single plane like a slice of bread and not like a jelly roll.

Schirmer’s and Phenol Red Thread tests

These tests look at tear production rate. Both measure and quantify tear production using an absorbent strip of paper placed at the lid margin. Phenol Red Thread is a more comfortable test for the patient. Schirmer’s can be performed with or without anesthetic drops. Dr. Periman advises technicians to be clear in advance of testing about which of the tests the doctor prefers.

Slit lamp biomicroscopy

According to Dr. Periman, the ophthalmic technician can greatly assist the physician in this test by having supplies ready to go. For this test, Dr. Periman uses a fluorescein strip and a lissamine green strip and stacks them. Having the strips open and set on a clean surface along with saline nearby to get those strips wet will help the doctor to streamline the process.

“As each section is evaluated for quality and expressibility of the meibomian gland, the scribe will hear things like ‘nonexpressible,’ ‘turbid meibum,’ ‘toothpaste,’ or ‘clear oil,’” says Dr. Periman. “Actually, some day you may hear ‘clear oil,’ after a patient’s successful treatments!”

Making the diagnosis

With all of the information gathered from these diagnostic tests, Dr. Periman says the physician is able to identify common dry eye contributors, categorize the dry eye problems, and recommend treatments. But, at the foundation of the treatment approach is a strategy to control inflammation.

“The technicians play such an important role in helping gather this data through diagnostic testing—or setting the physician up to perform these tests,” Dr. Periman says. “The imaging can be billable with the right coding. Work with your physician to streamline and ensure accuracy in capture, associating diagnostic codes and recording findings and interpretation.” OP