Article Date: 2/1/2010

Targeting Ocular Surface Disease
ocular surface

Targeting Ocular Surface Disease

Boost the medical side of your practice and patient satisfaction by managing dry eye. Here's how.

DOUGLAS K. DEVRIES, O.D.,
Sparks, Nev.

J. JAMES THIMONS, O.D., F.A.A.O.,
Fairfield, Conn

The average optometric practice acquires 80% of its revenue from goods and services related to glasses and contact lenses, according to the American Optometric Association. Among practices in the top 5% income bracket, however, that figure is less than 50%, with their remaining revenue deriving from medical services.

It's not that peak earners neglect their optical sides. On the contrary, because their gross revenues double that of most practices', they make as much or more from glasses and contact lenses as average O.D.s. What these practices teach us is that growth in medical services tends to foster growth in optical services, and vice versa.

Expanding medical services has proven one of the fastest paths to growth in today's marketplace. And strengthening ocular surface disease (OSD) capabilities is an easy place to start. The condition is prevalent and under-treated, the risk low, and new equipment expenditures minimal. Below we discuss some basics on why and where to begin.

The marketplace

The National Eye Institute estimates that 15% of Americans have dry eye symptoms, and we can expect those numbers to grow as our population ages. Baby Boomers will begin reaching Medicare age next year, and roughly 40 million of them are peri- or postmenopausal women, the group with the highest incidence of dry eye.

Fewer than half of those who have dry eye symptoms have been diagnosed by a physician, according to a 2007 Gallup survey.1 A 2008 Gallup survey found that patients made numerous visits to eye care professionals in search of an effective cure, and that they may have already tried on average three brands of artificial tears. More than four-fifths somewhat agreed or strongly agreed that they wished there was something more effective to treat their condition.2

Optometry performs 72% of all eye exams, so many untreated dry eye cases can be found right in our exam chairs, although they may be there seeking primary vision care services, such as an annual checkup, new glasses or contact lenses.

A large percentage of these patients do not even realize their symptoms stem from a treatable medical condition. They may erroneously attribute them to “eyestrain or fatigue” from long hours in front of a computer, or view them as a natural consequence of aging. Such patients might neglect to mention their symptoms unless specifically asked by the practitioner or a staff member.

Additionally, with our colleagues in ophthalmology facing projected manpower shortages, a steady population of physicians will likely be increasing their surgical activities,3 leaving optometry to shoulder a greater share of the primary care duties, where the bulk of dry eye patients will probably be diagnosed and treated.

Revenue potential

With just a small investment in materials like dyes and test strips, treating dry eye can begin generating revenue almost immediately. The key is to implement this subspecialty systematically, with a clear treatment schedule that organizes the best possible care into the “medical treatment reappointment” model.

In optometry, we have a tendency to do too much in a single visit. Conversely, in the medical model, doctors discover an issue during a routine exam, and then make a second appointment to run additional tests. This model enhances patient care, keeps your practice running more efficiently and increases profits.

After recommending a follow up exam, the practitioner ends the dry eye portion of the routine exam. No additional time is spent on testing, education, treatment or management. In this way, the patient can consider how much a problem dry eye is in his or her life, and be re-appointed based on his or her individual needs.

Reimbursement levels vary depending on the region of the country, as well as the different levels of exams and decision making. Payments per visit range between $40 and $125, with an average of three to five visits yearly. Punctal occlusion, if required, could add $200 to $400. A conservative estimate of yearly revenue per dry eye patient is $350 to $550, with repeat visits likely in future years.

Diagnosis

Because the condition is so prevalent, all patients should be screened for dry eye. This is accomplished by evaluating reported symptoms and clinical tests. A simple questionnaire can help screen for symptoms. (See Table 1).

Clinical evaluation should begin at the slit lamp with a look at the tear meniscus height. It's a convenient place to start and gives an idea of the volume of tears. While there, check the cornea for filaments, scarring or neovascularization.

Always assess meibomian gland function by expressing the glands, an evaluation far too often overlooked. Meibomian gland dysfunction frequently exacerbates dry eye or is a concomitant condition. Also, keep in mind patients with meibomian gland dysfunction tend to experience their worst symptoms earlier in the day.

All patients should undergo fluorescein and lissamine green (or Rose Bengal) staining. Supravital staining takes time, but you will find it worth the effort. To screen for superior limbic keratoconjunctivitis (SLK), be sure to look above the limbus during these tests.

Tear film break up time (TBUT) is among the many diagnostic tests for dry eye. It can correlate closely to the patient's visual performance. If the TBUT is less than 7 seconds, the patient's tear film is probably unstable. In the presence of significant ocular surface disease, this test could be as low as 2 or 3 seconds. When abnormal, patients frequently complain of variable blur, especially while working at the computer.

Schirmer's test remains controversial. Some practitioners swear by it, others consider it worthless. Though it continues to be used frequently in clinical trials of dry eye, results will often vary, and it provides poor reproducibility, except in patients with advanced disease. Still, a reading of less than 5 mm may confirm a diagnosis of Sjogren's syndrome in symptomatic patients, and it is a widely accepted way to quantify tear function for your medical records from an insurance standpoint.

A new device called the Tear-Lab Osmolarity System (TearLab Corp., San Diego), which should receive FDA approval later this year, could be a valuable addition to the dry eye testing regimen. This instrument represents a growing trend in eye care and medicine in general: point of service laboratory diagnostic testing. It's a sensitive diagnostic, but sometimes slightly weak at identifying borderline disease. Its chief value lies in its utility in tracking treatment progress. As the patients' corneal health improves, that bell curve should move steadily to the left on the graph. This readout provides an accessible visual metric to both clinician and patient.

As in the diagnosis of glaucoma, it is important to remember that no one test can accurately diagnose dry eye every time. The evaluation of each case will depend on a combination of patient history, symptoms, a wide variety of diagnostic measurements, and above all, the expert opinion of the practitioner. Keep in mind that dry eye symptoms and signs very often fail to correlate. Patients with diagnostic hallmarks may be asymptomatic, but then other patients with the most persistent complaints may yield negligible clinical results.

Finally, while it helps to cast a wide diagnostic net on initial visits, subsequent exams can be greatly simplified by performing only the test that provided the most pertinent data when the diagnosis was made. This then becomes the yardstick for measuring either progression or treatment efficacy at future visits.

Treatment

The chronic, progressive nature of dry eye makes prompt treatment of the disease at its earliest possible stage critical. Once the condition reaches its severe stage, it is incredibly difficult to restore full corneal health. As clinicians who specialize in medical service, we've seen many referred patients with severe dry eye. Though much can be done to help them, their symptoms can never be completely alleviated and the quality of their lives continues to be negatively impacted.

The first step in treating mild dry eye is manipulation of environmental and nutritional factors (See “Educating Patients and Staff,” below). Next identify and treat possible underlying causes (i.e., arthritis, Sjogren's syndrome, diabetes, rosacea, etc.). Over-the-counter drugs such as antihistamines, decongestants or sleep aids can cause dry eye, as can prescription drugs such as beta blockers and anti-anxiety agents.

Patients with early mild disease may find relief by using artificial tears on a regular basis (as opposed to an as-needed basis). If patients are self medicating with an artificial tear, make sure it affords them at least an hour's relief after each instillation, and they are using it no more frequently than four times a day.

As for recommending a tear, use your best judgment. Such a wide variety of reliable over-the-counter artificial tear options exit, in our opinion it is probably unnecessary to prescribe an prescription drop in early/mild cases. We try to match the tear to the patient's problem. If the patient has a meibomian gland deficiency, a thicker tear might be most effective. If the problem is tear film deficiency, a thinner tear might be better.

Educating Patients And Staff

Screening for and treating OSD involves so much communication between doctor and patient that you might consider preparing published materials in advance. Also, a lot of routine work can be accomplished by your office staff, so plan to educate them as well.
A screening questionnaire for dry eye can be filled out by all new patients. Patients being burdened with paperwork as it is, keep this as brief as possible. We think we've narrowed it down to six pertinent questions (see Table 1, above).
Ask questions about computer use, extensive reading, caffeine consumption, contact lens wear and history of ocular surgery. Inquire whether patients have an autoimmune condition, such as lupus erythematosus, or a systemic disease such as diabetes, thyroid disease, or rheumatoid arthritis, which can also cause significant dry eye disease.
Pamphlets detailing routine procedures such as how to perform a lid scrub often come in handy. Patients retain only about 20% of what you tell them, so take-home literature provides a reminder. Some of this type of material can be downloaded for free at a website maintained by a punctal plug manufacturer: www.odysseymed.com. Patient education literature describing dry eye disease is available from a variety of different companies that allow you to personalize a message on the brochure.
Patients should also be given reminders about proper diet: More fresh vegetables; foods containing omega 3 fatty acids; 4 to 6 glasses of water a day; and limit caffeine intake. Proper environment should also be emphasized: avoid drafts and fans blowing in the face; direct automobile air conditioning away from the face; where possible wear sunglasses outdoors in dry, windy conditions; position computer monitors below eye level; and avoid smoking and secondhand smoke.
For educating staff and fellow practitioners, one of the best resources available is a study published in 2006 known as the Delphi Panel.1 This landmark study created a clinical framework for treating OSD, and its criteria for grading the disease is essential knowledge for all practitioners. Another validated tool is the Ocular Surface Disease Index (OSDI), which helps grade disease severity.
Also, take advantage of “lunch and learn” sessions offered by drug reps. These are very professional presentations sponsored by pharmaceutical companies that can help educate your staff. Having staff on board as team players is critical to implementing dry eye treatment at your practice.
1. Behrens, A, et al. Dysfunctional Tear Syndrome: A Delphi Approach to Treatment Recommendation. Cornea 2006;25:900-907.

Artificial tears will offer relief to some patients, but for those with moderate disease it is not excessive to consider first-line treatment with a prescription agent. Restasis (cyclosporine A, Allergan), twice a day, typically for six months initially, heals the underlying causes of OSD more permanently than artificial tears and presents no systemic risks. However, it is not fast-acting; the full effectiveness of the drug takes a month to six weeks to occur.

The Restasis lag time may present a challenge to compliance. You'll want to avoid patients returning to your office after a month and telling you they stopped taking the drug “because it wasn't working.” In some patients, a corticosteroid such as loteprednol etabonate may be coupled with Restasis therapy. Seldom will a patient on this drug combination return in two to six weeks without reporting some improvement in symptoms.

The downside of corticosteroids is their systemic risk, most significantly the possibility of intraocular pressure spikes. So check IOP regularly, and, after symptoms subside, taper corti-costeroids dosage over two to four weeks.

In the past, punctal occlusion may have been a first-line treatment option for cases of severe dry eye, but we now know that OSD has a auto-immune inflammatory component that must be suppressed before punctal therapy can begin. The instillation of punctal plugs too early can trap those inflammatory mediators on the surface of the eye, making it difficult to reduce symptoms.

Plugs come in several materials. Some dissolve after a few days; some last longer; others last until they are removed. Puncta can also be surgically closed (cauterized), but plugs have advanced to such an extent that this option is rarely employed today.

Also, in many cases, dry eye complicated by blepharitis may necessitate lid disease treatment, i.e. warm compress, massage, lid cleansers, etc.

For patients who fail to respond to these conventional therapies, you might consider the use an oral omega-3 fatty acid supplement or a low dose oral doxycycline or topical azithromycin to combat inflammation. Omega-3 fatty acids have been shown to be beneficial in the treatment of mild to moderate dye eye. Doxycycline inhibits inflammatory mediators, and azithromycin, though designed as an antibiotic, provides anti-inflammatory effects.

Providing medical services such as dry eye can help a practice establish and maintain a patient base that is loyal and apt to refer other patients to your door. Greater word of mouth leads to greater growth in all areas of your practice. OM

  1. The Gallup Organization, Inc. The 2007 Gallup Study of Dry Eye Sufferers. Princeton, NJ: Multi-Sponsor Surveys, Inc.; 2007.
  2. The Gallup Organization, Inc. The 2008 Gallup Study of Dry Eye Sufferers. Princeton, NJ: Multi-Sponsor Surveys, Inc.; 2008.
  3. Harmon D, Merritt J. Demand for ophthalmic services and ophthalmologistsa resource assessment. A study by Market Scope, April 2009. www.marketscope.com/index.php
Dr. Devries lectures nationally and is co-founder of Eye Care Associates of Nevada, a state-wide medical/surgical comanagement practice.
Dr. Thimons is a nationally and internationally acclaimed speaker and serves as medical director at Ophthalmic Consultants in Fairfield, Conn.


Optometric Management, Issue: February 2010