Article Date: 11/1/2010

Move Your Practice Beyond Tears

Move Your Practice Beyond Tears

Today's ODs treat ocular surface disease medically.

By J. James Thimons, OD, FAAO

Management of ocular surface disease (OSD) is probably the fastest-growing medical sector in primary care optometry today. Unfortunately, it's still not the norm. Some doctors respond to patient complaints by handing out eye drop samples, while others choose to work at an entry level with OSD, choosing not to treat moderate or advanced patients who need one or more medications to maintain a healthy long-term status.

The good news is that although many clinicians have yet to tackle OSD management in their offices, the number of doctors treating the problem in all its forms has risen appreciably in the last 5 years.

While there are numerous reasons for the rise in OSD awareness and therapy, I believe the increasing number of excellent options for managing OSD, notably pharmaceutical advances that are specific to task and affordable through formulary plans, is the major factor. In addition, industry has worked to raise professional awareness and consumer branding.

When you combine these elements with current technologies that make it easier to diagnose OSD and educate patients, it's easier than ever to manage the problem. What's more, treating all levels of OSD will enhance your practice in terms of both clinical outcomes and revenue.

Abundant Treatment Options

Fifteen years ago, most ODs weren't assessing, quantifying and planning treatment for OSD because there simply weren't many treatment alternatives. Patients could take home four or five drops and pick the one they liked. Today, the quality of intervention has improved dramatically and emphasizes therapeutic measures, not just palliative care.

Options fall into four categories:

1. Tears. Looking at the first line of activity, the most important goals are to preserve the current tears and improve their quality, as well as to increase tear volume for some patients. A major step forward in medical management of OSD is the introduction of tears that not only have prolonged residence time on the cornea, but also allow patients to maintain good visual function. New-technology supplemental tears aren't the only long-lasting option. Patients with low-level OSD also can benefit from omega-3 fatty acid nutritional supplements, which are formulated specifically to improve tear quality.

2. Anti-inflammatories. When OSD is more advanced and ocular inflammation is an issue, patients may benefit from the prescription of an anti-inflammatory drop in addition to artificial tears. The Delphi Panel recommended that when patients are diagnosed at level II dry eye, the use of drugs such as cyclosporine A (Restasis, Allergan) and in more advanced cases, ester-based steroids (Lotemax, Bausch + Lomb or Alrex, Bausch + Lomb) is vital to successful management. Clinicians can tailor their approach to each patient's needs, but the key is in decreasing the inflammation and preventing progression of the disease to more advanced levels.

3. Combination drugs. Combination drugs are available for a variety of targeted OSD diagnoses and associated conditions. Combination anti-inflammatory and antibiotic medications, for example, Tobradex ST (Alcon) or Zylet (Bausch + Lomb), are best used in the management of anterior blepharitis, a commonly associated diagnosis in patients with OSD complaints. These agents, along with lid hygiene, are very effective in treating induced changes from bacteria and their associated lipases, which can affect the success of OSD therapy. These are excellent initial interventions for patients with multifactorial disease.

4. Surgical solutions. In addition to the previous three measures, mechanical management is helpful for patients with low tear volume. Punctal occlusion plays a critical role in maintaining tear volume and can be addressed with either temporary or permanent systems. Procedures such as tarsorrhaphy, amniotic membrane graft and others are available in more severe cases.

In the future, we can look forward to continued advances in treatment for specific OSD activists. For example, secretogogues may be available to stimulate mucin production. The increased specificity in how we treat OSD parallels advances in how well we can diagnose and analyze types of OSD.

Minimal Practice Changes

If you want your practice to take a more medical direction, some basic elements are important and rewarding in driving the process. The practice needs to undergo several structural and cultural changes:

Ask questions. First, your intake form needs to address OSD. Let patients answer the basic questions about dry eye in the reception area, instead of starting from scratch in the exam room. I used to have patients fill out the Ocular Surface Disease Index (OSDI), but to save time, I integrated key questions from the OSDI into our intake form. When I did, I was amazed at how many patients suffer from symptomatic dry eye.

If patients indicate that they have OSD symptoms, I follow up by asking about computer use, reading and other activities to get a clearer picture of the problem.

Follow up with clinical testing. I find that the single most helpful clinical test of OSD is supervital dye staining, which correlates most highly with symptoms in my experience. This only requires lissamine green or rose bengal stain (about $10 per month). Another important technology is the use of a Kodak Wratten filter (about $50) to see staining patterns on the eyes. Tear breakup time is informative, as well. You may also want to use Schirmer's testing equipment and strips as documentation for insurance purposes.

Train your staff. For you to succeed, your staff needs to be comfortable and well versed in your goals and services. Educate your staff about OSD. Prepare them to answer patients' questions and let patients know that the doctor can help their OSD.

Educate your patients. There's nothing like an anterior segment camera to help you show patients what's wrong with the ocular surface. After applying the supervital dye, photograph it and show it to the patient, explaining the problem and how you can resolve it. You'll be pleasantly surprised at how powerful a tool this is. Take another photo after treatment and show patients the before-and-after images to illustrate the efficacy of therapy. It adds to their enthusiasm and will encourage continued compliance. I bill for this service when appropriate, but many insurances don't cover the technology. If a patient's insurance doesn't reimburse me for it, that's fine. It's still a great practice development tool.

In the future, a very exciting technology may well change OSD testing. I've been involved with the trial of an osmolarity measuring device from Tear Lab that picks up changes in tear physiology, and I've been impressed with the correlation between symptoms and assessment outcomes that help quantify the OSD process. It will make doctors more comfortable with the diagnostic and therapeutic aspects of OSD care.

Use a Systematic Approach

The right equipment and staff training are important, but it's equally important to create a systematic approach for treating OSD. You need to be consistent in the exam, treatment, dosing rate and other aspects of the process that you can control in order to develop a sense of what works and what doesn't. A consistent approach will help you compare patient outcomes side by side and save time as well.

You wouldn't randomly dose glaucoma medications because you'd have random outcomes instead of consistent, predictable ones. Doctors who take on OSD without standardized therapeutic regimens may be frustrated when attempting to interpret the results of treatment.

I begin by assessing the patient as an entity. I examine the lids, express the meibomian glands, and stain all patients who say "yes" to OSD symptoms on the intake form. This pattern is valuable, since when I do see OSD, I've seen hundreds of "normals" against which to compare it. The question of whether to address the OSD patient at the initial visit or schedule a separate visit for that purpose is something that clinicians need to decide on their own. I typically initiate the therapeutic intervention at the time of discovery and schedule the follow-up visit for 4 to 6 weeks after treatment is started.

If patients have OSD, the next step is to quantify it in some way. I recommend using the Delphi Panel signs and symptoms grid. It shapes the medical approach by grading levels of disease that you can use to make your treatment decisions. You're already doing all the evaluation and testing that's required to use the grid, so it's simple to begin organizing your testing according to Delphi Panel guidelines.

Using the Delphi Panel grades, decide what treatments and dosing you'll employ and what patterns of clinical behavior you want patients to follow. Which drop will you try first? How long will you wait before you check for efficacy? If the drop isn't working, what's your next step? What lifestyle changes will you recommend?

Right Business Approach = Rewards

It isn't complicated to approach OSD in a way that makes sense for conserving your time and billing productively. Many patients with OSD see me two or three times per year in addition to their regular exam. Clearly, that adds volume and revenue. I tell doctors that OSD is like mortar between the bricks of the practice; in and of itself, it's not big, but it grows the practice horizontally and substantially increases the services you offer.

Many patients walk through the door of my practice because they're walking away from a previous clinician who didn't address their concerns. They want something more substantive than tears for therapy, so I solve the problem. I tell them it's the same exam that other doctors perform, but I focus my attention on the OSD symptoms. I'm approaching the ocular surface as an integral part of overall eye health, and my patients seem to understand that my philosophy benefits them.


J. James Thimons, OD, is a nationally and internationally acclaimed speaker and serves as medical director at Ophthalmic Consultants in Fairfield, Conn.

Optometric Management, Issue: November 2010