Article Date: 10/1/2011

Baby Boomers Can Boost Your Practice
booming practice

Baby Boomers Can Boost Your Practice

Exploring the challenges and opportunities of our aging patient population

Douglas K. Devries, OD

2011 is here, the year that begins the transformation of the very first baby boomers to senior citizens. The baby boomers—the generation that began in 1946 with the end of World War II and ended in 1964 with the delivery of the birth control pill—are set to hit retirement age.

While being ushered into the golden years may or may not be greeted with enthusiasm by this generation, optometrists should be ready to welcome this segment of their patient base with open arms. An estimated 77 million Americans will turn 65 in the next 18 years.1 This means 7,000 to 10,000 people each day will be celebrating their 65th birthday. This new senior population has some goals in mind as they hit their Medicare milestone—84% of people turning 65 this year plan to start talking better care of their physical health according to an AARP poll and 35% of those individuals surveyed consider this their top priority.2

How does optometry in general, and your practice specifically, help these patients fulfill their improved healthcare goals?

Owing to the fine work of the AOA, the profession has been positioned in an extremely positive manner, so we can be key providers to this segment of the population. Our practices are more prepared to accept patients with ever-increasing types of pathology. With the exception of allergic eye disease, all conditions typically handled in our practices will become more prevalent within this generation. Conditions that lead the list are ocular surface disease, glaucoma, diabetes and cataracts. It's 2011, and the question remains; have you done everything you can to build the medical side of your practice? Let's break it down by disease state to evaluate your practice's preparedness..

Ocular surface disease

Ocular surface disease could be the most common anterior segment pathology in our practices during the next decade. It's estimated that dry eye symptoms affect approximately 15% of the senior demographic. It's estimated that there are more than 20 million patients with dry eye.3 A Gallup Poll Survey of 782 dry eye patients revealed that 81% of those patients found their dry eye frustrating and 80% wished the treatment was more effective.4 The symptoms of transient blur, stinging, burning, scratchiness and redness can occur in ocular surface disease and range from mild annoyance to a debilitating inability to maintain productivity in avocation as well as occupation. The International Task Force guidelines for levels of dry eye were affirmed by the Dry Eye WorkShop (DEWS) through a panel of experts in eye care who determined various levels of severity and progression of dysfunctional tear syndrome.

Severity Level I is mild or episodic dry eye. Patients typically have mild to moderate symptoms

Severity Level II involves moderate to severe symptoms including conjunctival staining, mild punctuate staining and some visual signs such as fluctuating vision

Severity Level III has more severe symptoms and both conjunctival and corneal punctate staining which is more marked

Severity Level IV is advanced disease with severe symptoms and signs.

Modifications in your practice to provide full scope dry eye care will be primarily educational in nature, as opposed to technology intensive. Most practices have what is needed to begin treating dry eye disease, although you could add tear osmolarity testing and anterior segment photography to expand your options.

I've found that many patients display a disconnect between signs and symptoms of dry eye disease. Some patients report severe symptoms but little is seen on examination. Other patients may report only mild symptoms—or none at all—but their examination reveals moderate to severe dry eye. So, in my practice, every patient completes a short dry eye survey—regardless of the stated purpose for their visit. They're asked to identify each of following symptoms with an answer of “Never, Slight, Moderate or Severe.” The symptoms are as follows:

► Gritty or sandy sensation
► Pain or soreness
► Fluctuating vision
► Occasional tearing
► Blurred vision while reading
► Discomfort in windy conditions
► Discomfort in airconditioned areas
► Fatigue while reading

If I see that a patient is symptomatic in at least three of these areas, even if the complaints are mild or episodic, I recommend that we schedule a follow-up dry eye evaluation.

A helpful tool in developing a successful dry eye practice is the utilization of a dry eye coordinator. This individual should be someone within your practice who can assist you with dry eye evaluations and deliver the important education points that should be provided to patients during the evaluation and treatment of the disease state. The purpose of the evaluation is to determine the level of severity of the signs that correspond to the symptoms the patient has described. During the course of the dry eye evaluation, I evaluate the following:

Tear meniscus height: should be approximately 0.3 mm
Fluorescein staining: provide plenty of time to evaluate the staining because it might very well be at a micro punctate level
Tear break up time: greater than 10 seconds is considered normal
Lissamine green staining: conjunctival lissamine green staining can present in patients with mild to moderate dry eye
Expression of the meibomian glands and evaluation of lid margin disease: when lid disease is present, I treat the lids aggressively and address the dryness components
Quantification of the tear with Schirmer strips
Tear osmolarity testing: This is a possible paradigm shift that aids in the diagnosis and helps the practitioner and patient understand the progression of disease versus the success of the treatment regimen.

Much of the diagnostic testing currently performed helps educate the patient as to the chronic and progressive nature of dry eye disease. It also helps underscore the fact that dry eye disease is multifactorial in terms of etiology, thus, there are multiple treatment modalities.

Tear osmolarity testing and anterior segment photography help patients visualize the diagnostic signs of the disease, the progression of the treatment and the corresponding improvements in lab testing and photography. Besides providing extremely valuable information on your patient's condition and progress, tear osmolarity testing and anterior segment photography also will generate additional revenue for your practice.

Dry eye disease will require reappointment for the dry eye evaluation as well as follow-up for any treatment changes you might make. If you haven't become proficient in punctal occlusion, you should consider making time to familiarize yourself with this valuable component of dry eye treatment. Once lid disease and inflammation have been controled, punctal occlusion is a very successful treatment for dry eye.

Don't overlook environmental treatments such as moisture chambers at night and barrier protection for patients who are outdoors. While nonresponsive patients can be a frustrating part of a dry eye practice, keep looking for the underlying cause of the problem—don't give up on those patients. Once you discover the underlying problem, whether it's an autoimmune disorder, nocturnal lagophthalmos or even parasitic in nature, you'll be able to help your patient—and that patient may become one of your greatest referral sources.

Comanagement—It's a New Game

By John Warren, OD

In the 19 years I've been practicing, I've seen the optometry-ophthalmology relationship make some pretty dramatic swings. From the time surgeons actively looked for referrals and to comanage cataract patients, to the advent of LASIK and surgeons direct-marketing to the general public (including my patients)—thus bypassing the patient's regular eye doctor—then back again to growing a relationship, which results in patients being educated about premium IOLs.
When cataract surgery paid much more, both the surgeon and the comanaging optometrist were well compensated for the portion of the care they provided. With current cataract reimbursements, neither is well compensated for the care and number of visits required for a “standard” cataract surgery. Hence the move by many surgeons to not only reinvigorate the referral networks they relied on for revenue in the 1990s, but also to educate and influence these optometrists to at least introduce multifocal IOLs to patients they refer for cataract surgery. And, in some cases, “presell” the technology and procedure at the time of referral.

Who Should Provide the Care?

I've been approached by many local surgeons (and a few from quite a distance) to become more aggressive in recommending multifocal IOLs as well as provide postoperative care for these patients. While multifocal IOLs can be a great choice for the right patient, for some they're not the optimal visual solution. Who knows better if a patient may be a good candidate for a multifocal IOL than the patient's current eye doctor? The obvious answer is no one. In the course of providing “routine” care to our patients, we come to know their visual demands, personal visual requirements and how they deal with any disturbances to their vision.
Anyone who has provided postoperative care to both single vision and multifocal IOL patients knows the vast differences between the two. While both types of patient need to have their postoperative healing monitored, and any excess inflammation or infection treated, the visual recovery is quite different. Not only do the multifocal IOL patients have a much more complex visual system to adapt to, they expect things to be “just right” after paying up to $4,000 more for their multifocal IOL versus a traditional single vision lens.
A multifocal IOL patient will require more postoperative visits than the single-vision and these visits will be longer and require more face-to-face time. The fee charged and paid to the comanaging doctor needs to reflect this. Implanting these lenses requires only minimally more time and expertise than a typical single vision lens, but in my opinion, it's the preoperative education on and selling of the technology and the postoperative care that require additional expertise and time.
Be sure you and the surgeons have an agreement that reflects the extra time you'll spend with these shared patients. You don't want to end up feeling like you were paid for a daily wear, singlevision, spherical contact lens fitting and but wound up providing custom RGP bitoric multifocals.
I can't suggest the fee you should charge for your services, but be sure to consider the time you'll be spending as well as the extra expertise you'll be providing by giving postoperative care for patients who select multifocal IOLs.


One of the risk factors for glaucoma is age. In most individuals, IOP will increase with the age. In 1992, the Beaver Dam Study (n = 4926) showed the overall prevalence of definite open angle glaucoma was 2.1%. The prevalence of glaucoma increased with age in adults 43 to 50 years of age and increased to 4.7% in adults 75 years of age or older.5 Remembering that about 7,000 people a day will be turning 65, the number of patients who are likely to develop glaucoma is staggering.

To adequately handle glaucoma patients, your practice will have to evolve and incorporate the best technology to diagnose, treat and manage glaucoma patients. A pachymeter, threshold visual field, posterior segment photography and OCT are pieces of equipment you should acquire. In addition, you should refine your optic nerve head evaluation and gonioscopy diagnostic skills.

We have an abundance of continuing education courses available to update diagnostic and therapeutic skills for managing glaucoma. Many optometrists and ophthalmologists are willing to comanage glaucoma patients with practitioners who haven't been actively managing their glaucoma patients. Acquisition and utilization of the additional testing equipment may necessitate a review of your clinic footprint. If considering a new facility, now is the time to be sure that you allow enough space to accommodate glaucoma testing equipment.

Diabetes patients

In the third quarter of 2009, the Gallup-Healthways Well-Being Index found the reported incidence of diabetes in the United States climbed to 11.3% of adults—or about 26 million Americans, up from 10.4% in the first quarter of 2008. If current trends continue, 15% of adults, or more than 37 million Americans, will be living with diabetes by the end of 2015.

Diabetes, like glaucoma, is a disease whose incidence increases with age. Diabetic patients are routinely instructed by their primary care physicians to schedule an examination to check for the presence of diabetic retinopathy on at least a yearly basis. Patients with some form of diabetic retinopathy are seen more frequently and often require regular testing to document any progression of retinopathy.

If you're considering performing routine diabetic checks and diabetic retinopathy follow-up on your patients, much of the equipment you'll utilize for your glaucoma patients also can be used to follow your diabetic patients—for example, posterior segment photography and OCT. Your gonioscopy skills will also be used in checking the angle for neovascularization.

Comanaging patients

While optometry has been participating in cataract comanagement for years, some doctors still prefer not to see their patients during the 90-day period following cataract surgery. Not only should you see your patients postoperatively, you should actively educate your patients about their IOL options. This is a valuable service for your patients, many of whom have great trust and respect you as their long-term eyecare provider. CMS has ruled that doctors may bill a patient for noncovered services that apply to premium IOLs. A premium IOL would be considered a toric, multifocal or accommodating lens. While the fees for providing postoperative care to premium IOL patients have not increased, providing and billing for noncovered services related to preoperative testing can increase. Noncovered services would include the consultation performed for a premium IOL selection as well as the following testing:

► Refraction
► Topographya
► Topography
► Pachymetry
► Contact lens fitting trial
► Wavefront testing
► Keratoplasty for enhancement
► IOL exchange

While keratoplasty for enhancement after cataract surgery or IOL exchange would not apply to you, the remaining items certainly could. Every patient receiving a premium IOL is a potential refractive surgery patient. Therefore, every patient must have a refractive surgery evaluation to make sure the cornea is stable enough to undergo a refractive surgery procedure, such as limbal relaxing incisions, PRK or LASIK.

The consultations you provide, as well as the refractive surgery evaluation, are noncovered services you can provide for your patient. Patients will appreciate your insight and guidance in the lens selection process. The surgeon, in turn, will appreciate that your shared patient is well informed.

In terms of equipment, a corneal topographer is invaluable if you plan to actively discuss and advise patients regarding premium IOLs.

If you aren't co-managing patients, it would behoove you to contact and set up a time to shadow a surgeon on a postoperative day to get acquainted with the protocols and expectations of typical surgeons and patients.

Another valuable experience is to shadow on a cataract evaluation day at the surgeon's office to hear the discussions with the patients regarding premium lenses. (See “Comanagement: It's a New Game” below).

Here come the boomers

Ready or not, 2011 is here and the baby boomers are turning 65. Optometry has evolved tremendously in the past 20 years, with the profession providing an ever-increasing amount of the medical eye care to the population.

Between 2008 and 2015 the number of inciden ces/cases of patients requiring care by an ophthalmologist is forecasted to rise 18.1%, yet the number of ophthalmologists is scheduled to increase by only 0.67%.6 The door is open and the patients are there. Will your practice be ready to let them in? OM

1. Love J. AARP Research and Strategic Analysis, December 2010.
2. St Petersburg Times, January 2011: Sources AARP Alzheimer's Association, USA Today, U.S. Census Bureau, Proximity One State demographic projection, the Centers for Medicare and Medicaid services.
3. Market Scope. Report on the Global Dry Eye Market. St. Louis, MO: Market Scope, July 2004.
4. Gallup Survery of Dry Eye Sufferes 2005 & 2008.
5. Klein BEK, Klein R, Sponsel WE, et al. Prevalence of glaucoma. Ophthalmolgy 119;99:1499-1504.
6. Demand for ophthalmic Services and Ophthalmologist – A Resource assessment. Harmon, D, Merrit, J Prepared by Market Scope April 2009.

Dr. Devries is co-founder and residency director of Eye Care Associates of Nevada, a statewide medical/surgical comanagement referral practice in Sparks, Nev.

Optometric Management, Issue: October 2011