Article Date: 12/1/2012

DIAGNOSTIC FOCUS
diagnostic focus

Treating Acute Red Eye

Consider these benefits of point-of-care differential diagnosis.

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SCOTT HAN, O.D., F. A.A.O.

At times, a patient arrives at my practice complaining of a red, irritated eye, and the diagnosis is clear. Acute red eye patients typically have a viral or bacterial infection, dry eye or allergy-induced indications, and the patient’s medical history and clinical examination correlate with such a diagnosis.

Accurately diagnosing the cause of acute red eye is often challenging, however, as signs and symptoms associated with viral, bacterial and allergic acute red eye overlap and are often indistinguishable by empirical observation. This complicates the diagnostic process significantly and can facilitate improper treatment methods. In the past, my colleagues and I would take our best guess as to the cause of a patient’s acute red eye and attempt to treat accordingly.

Fast, accurate testing

Beginning in October, my practice has utilized a point-of-care diagnostic test, AdenoPlus (Nicox, Dallas, Texas), to aid in the differential diagnosis by either confirming the presence of, or ruling out, adenoviral conjunctivitis, a common cause of acute red eye and a condition associated with significant morbidity. (At the time of this writing, I have used the test 40 times.) Administering the test takes less than two minutes, and my technicians quickly learned the four step process:

1. “Dab and drag” the tear sample collector on the lower eyelid.

2. Snap the sample collector into the test cassette.

3. Dip the test cassette into the provided buffer for 20 seconds.

4. Read the test results.

Within 10 minutes, the test provides accurate results. (AdenoPlus demonstrated a sensitivity of 90% and a specificity of 96%.) This is a significant boon for my practice, as the test allows us to better utilize our technicians. The test is reimbursed under the CPT code 87809QW. (See “Reimbursement for the AdenoPlus Test,” page 53.)

The AdenoPlus test can yield accurate results within 10 minutes.

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A change in patient flow

Through the use of point-of-care diagnostics, my protocol for diagnosing acute red eye — and consequently, my standard of care — has evolved. When treating acute red eye patients, I can now produce a differential diagnosis as part of the initial examination. First, my staff identifies patients who may potentially have an eye infection. For example, a patient will call and say his or her eye is red, and there are no obvious causes.

When the patient arrives, we isolate the patient as soon as he or she comes into the office. Once the preliminary work is done by a technician — including the differential test — I limit the clinic’s exposure to that patient (assuming that he/she is contagious until proven otherwise), and try not to shuffle the patient around; the patient will either stay in one room or be moved to a second room where I will see him or her immediately. By the time I see the patient, I have his or her AdenoPlus test results, clinical examination and medical history in front of me. I can then immediately diagnose the patient and develop a treatment plan, confident that I am taking the right steps to treat adenovirus, if present.

Avoid unnecessary treatment

Traditionally, when a patient was diagnosed with acute red eye, my staff and I immediately started the patient on a povidone-iodine and topical wash before he or she left the office. Now, we only treat a patient in this manner if the differential diagnosis is performed and the test results are positive.

Not only are we avoiding the costs associated with treating patients who do not have adenovirus, but those patients who actually do have it are being remedied faster by receiving a first line of treatment in the office.

Additionally, my practice has been able to prescribe medication with greater confidence, largely due to diagnosing acute red eye properly in the office. I avoid a situation in which the patient returns multiple times because a condition is not improving, and I would be forced to reassess my diagnosis. With each reassessment of the diagnosis, the patient would be given a different medication that may or may not be beneficial. For instance, rather than treat based on a differential diagnosis, many eyecare specialists today hastily and erroneously prescribe acute red eye patients antibiotics. Arbitrarily prescribing antibiotics may increase the patient’s resistance to the therapy. It also drives up healthcare costs. By ruling out or confirming adenovirus at first visit, I can tailor my treatment to better suit a patient’s needs.

Reimbursement for the AdenoPlus Test:

● Obtain CLIA-waived certification for reimbursement.⋆ (For information on how to apply for certification, visit www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/.)

● Enter the CLIA-waived certification number.

● Modify the master bill to include a description of the test (infectious agent antigen detection by immunoassay with direct optical observation, adenovirus.).

● Enter the CPT code and qualifier (87809QW).

● Enter an appropriate ICD-9 code.

⋆ Facilities must obtain CLIA-waived certification for reimbursement.

Improving efficiency

I enjoy treating red eye, but from a practice management standpoint, it simply does not reimburse as well as other conditions I might treat, primarily due to the fact that before I used the AdenoPlus test, I would see the same patient with acute red eye every week for four weeks. From a reimbursement standpoint, I would be better off filling my schedule treating other conditions. By providing an accurate diagnosis the first time, I achieve the goal of better practice efficiency.

In the future, more technologies will enable eyecare specialists to diagnose and treat quickly and with greater confidence. In my own practice, AdenoPlus has proven itself an invaluable tool in reducing treatment time, costs, patient exposure to contagion and improper prescription of medication. Ultimately, I have found that embracing a protocol built around point-of-care, differential diagnosis has significantly improved my standard of care for treating acute red eye. OM

SCOTT B. HAN, O.D., F.A.A.O., IS DIRECTOR OF OPTOMETRY AND PARTNER AT THE EYE ASSOCIATES, A MULTI-SPECIALTY GROUP WITH FIVE LOCATIONS IN WEST COAST FLORIDA. HE STATES THAT HE IS A CONSULTANT/SPEAKER FOR ALLERGAN, BAUSCH+LOMB AND MERCK. HE MAY BE REACHED AT SHAN@THEEYEASSOCIATES.COM, OR SEND COMMENTS TO OPTOOMETRICMANAGEMENT@GMAIL.COM.



Optometric Management, Volume: 47 , Issue: December 2012, page(s): 52 53