Article Date: 11/1/2012

tomorrow's dry eye practice

Ready Your Dry Eye Practice for the Future

Surefire tips to overcome the impending increase-in-patients time crunch

WILLIAM TOWNSEND, O.D., F.A.A.O., Canyon, Texas

Changes in the demographic and health profiles of the general population (America is aging), the availability of healthcare providers and the possible alterations in healthcare delivery (e.g. the Patient Protection and Affordable Care Act or a different configuration of healthcare reform, depending on this month’s presidential election outcome) will increase demands on healthcare providers, necessitating more efficient management of their practices.

“The growth and aging of the population will contribute to a 22% increase in demand for physician services between 2005 and 2020,” says The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand report, released by the U.S. Department of Health and Human Services Health Resources and Services Administration, Bureau of Health Professions. “Growth in demand will be highest among specialties that predominantly serve the elderly.”

This is particularly evident in eye care. A total of 41.3% of ophthalmologists were age 55 or older, according to a 2008 study, meaning many of them may retire during the next decade.1 In addition, from 2001 to 2011, the number of ophthalmology residents increased by 7.9%, whereas the growth in numbers of residents in other medical specialties increased by as much as 38%.2 Also, the quantity of ophthalmologists is increasing at a rate approximately half that of the general population.3

Through the past three decades, optometry has increased its number of optometry schools and scope of practice. Because we will logically and necessarily play an expanding role in the management and treatment of ocular disease, we must develop cost-effective, efficient strategies to administer in every facet of our practices. This is particularly the case when managing dry eye disease (DED), as it is a group of conditions that have an array of causes and a myriad of treatment options.

Here, I discuss how you can efficiently screen for possible DED and streamline your DED testing, management and medical coding, so you’ll be ready to best manage these patients regardless of your patient load.

Screening made easy

Patient questionnaires are both an efficient and effective means of screening for DED suspects, as the patient can fill them out without you or your staff, and answer scores influence whether the patient should undergo DED diagnostic testing.

The Diagnostic Methodology Subcommittee of the International Dry Eye Workshop (DEWS) recommends 13 symptom questionnaires based on five criteria: (1) use in randomized clinical trial, (2) tested or used in epidemiologic studies, (3) contains some psychometric testing, (4) is available and appropriate for generic, non-disease-specific dry eye populations, and (5) must have met 1 or 2 and 3 and 4.4 Some of these questionnaires: McMonnies Dry Eye Questionnaire, National Eye Institute Visual Function Questionnaire and the Dry Eye Questionnaire.

Further, the Impact of Dry Eye on Everyday Life questionnaire (IDEEL) has been validated. This is comprised of 57 items that “provide assessment of the impact of dry eye on patient dry eye-related quality of life and impact of treatment on patient outcomes in clinical trials.”5

All these questionnaires, which you can access via the Internet and easily add to your practice website for patient download prior to their appointment, work to maximize you and your staff’s time.

Streamlining objective testing

To minimize the time spent on DED diagnostic testing without sacrificing accuracy, consider implementing the following timesaving techniques:

Have staff enter patient data/obtain digital photos. External photography is a means of establishing baseline and serial photos to document and evaluate pre- and post-treatment images of the ocular surface. To save doctor time, we’ve had our technicians undergo digital camera training, enabling them to easily enter the necessary patient data into the devices we use and, in some cases, actually obtain the digital images.

Have staining formulated in sterile syringes. In recognizing that the wetting of fluorescein, lissamine green and Rose Bengal strips is not only time consuming, but also messy and yields inconsistent concentrations to the ocular surface, I have these stains formulated in sterile syringes at a compounding pharmacy. (A micro filter is attached to the tip of each syringe to prevent contamination.) One of my technicians or I depresses the plunger to instill a drop of dye onto the ocular surface. This procedure takes far less time than employing wetting strips, and the consistent concentration of testing dye on the ocular surface results in the most accurate assessment of the ocular surface and tear film break-up time.

Have staff insert the Schirmer strips. We have trained our technicians to insert the Schirmer strips in the patient’s lower cul de sac and then start a timer for five minutes. When the timer rings, the technician removes the strips, and leaves them for me to evaluate. This protocol enables me to see other patients and the technician to briefly work in other areas where he/she may be needed until the timer rings.

Have staff employ anterior segment ocular coherence tomography (OCT). Specifically, the device accurately and consistently records tear meniscus values in just a few minutes and is both sensitive and specific. One study reveals the tear meniscus radius, height and cross-sectional area, as obtained by real-time OCT, were significantly smaller in aqueous tear-deficient patients vs. healthy subjects.6 Further, the researchers obtained good DED diagnostic accuracies using cutoff values for an abnormal lower tear meniscus radius (LTMR) of 182 microm and a lower tear meniscus height (LTMH) of 164 microm. The LTMR diagnostic sensitivity and specificity were 0.92 and 0.87, respectively. The LTMH diagnostic sensitivity and specificity were 0.92 and 0.90. (For information on the latest DED diagnostic devices that may also save you time, see “The New Face of Dry Eye Management” at www.optometricman articleID=107049.)

Simplifying management instructions

We typically discuss clinical findings and recommended treatments to our patients, but, studies reveal 40%-to-80% of verbal medical information provided by healthcare practitioners is forgotten immediately.7 Handouts that patients take home with them on the common DED treatments (e.g. warm compresses, lid scrubs, artificial tear use and omega-3 fatty acid supplementation) remind patients of verbal instructions, hopefully leading to better adherence to your instructions.8,9

These handouts should briefly explain, in easily understood language, the patient’s condition, the treatment regimen and the rationale for the treatment(s) prescribed. In designing these handouts remember that patients have varying levels of reading skill.10 (See “Example Handout,” page 38.)

Perfecting the code

Because correct medical coding ultimately drives payment and is often a complicated endeavor, consider sending staff to or personally attending coding education classes to create an efficient means of correctly coding for your DED services. Although many EHR systems contain built-in aids to ensure proper coding, remember that you and you alone are ultimately responsible for your coding practices.

Ready or not?

We, as optometrists, are in an excellent position to take on the aforementioned influx of patients by virtue of our skill and numbers. But without efficient strategies for managing these patients, and particularly DED patients, given the condition’s varying causes and treatments, we place ourselves at risk for failure. Therefore, I urge you to employ the tested tips discussed above, and start to think of other ways you can streamline other areas of your practice. OM

1. Lee PP, Jackson CA, Relles DA. Estimating eye care workforce supply and requirements. Ophthalmology. 1995 Dec;102(12):1964-71.

2. 2008 Physician Specialty Data. Center for Workforce Studies. November 2008. Association of American Medical Colleges. 352/data/specialtydata.pdf. (Accessed 10/2/12’)

3. Resnikoff S, Felch W, Gauthier TM, Spivey B. The number of ophthalmologists in practice and training world-wide: a growing gap despite more than 200,000 practitioners. Br J Ophthalmol 2012;96:783-87.

4. Smith JA, Albeitz J, Begley C, et al. The epidemiology of dry eye disease: Report of the Epidemiology Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007 Apr;5(2):93-107. Review.

5. Abetz L, Rajagopalan K, Mertzanis P, et al. Development and validation of the impact of dry eye on everyday life (IDEEL) questionnaire, a patient-reported outcomes (PRO) measure for the assessment of the burden of dry eye on patients. Health Qual Life Outcomes. 2011 Dec 8;9:111.

6. Shen M, Li J, Wang J, et al. Upper and lower tear menisci in the diagnosis of dry eye. Invest Ophthalmol Vis Sci. 2009 Jun;50(6):2722-6. Epub 2009 Feb 14.

7. Kessels RP, Patients’ memory for medical information. J R Soc Med. 2003 May;96(5):219-22.

8. Blinder D, Rottenberg L, Peleg M, Taicher S. Patient compliance to instructions after oral surgical procedures. Int J Oral Maxillofac Surg. 2001 Jun;30(3): 216-9.

9. Kharod BV, Johnson PB, Nesti HA, Rhee DJ. Effect of written instructions on accuracy of self-reporting medication regimen in glaucoma patients. J Glaucoma. 2006 Jun;15(3):244-7.

10. Rogers ES, Wallace LS, Weiss BD. Misperceptions of medical understanding in low-literacy patients: implications for cancer prevention. Cancer Control. 2006 Jul;13(3):225-9.


Dr. Townsend practices at Advanced Eyecare, which has multiple locations in Texas. He is a distinguished visiting clinician in Residence at the University of Houston College of Optometry and also serves as an adjunct faculty member. He is president of the Ocular Surface Society of Optometry ( E-mail him at drbill, or send comments to optometricmanagement@

Optometric Management, Volume: 47 , Issue: November 2012, page(s): 36 - 40