THE ESTIMATED 30 million Americans suffering from dry eye disease (DED), including children (See “DED in Younger Patients,” p.22), according to the April 2014’s American Journal of Ophthalmology, have spawned a tremendous amount of research and innovation within both the profession and the industry.
As a result of this patient demand, we have seen a variety of diagnostic technologies and treatments come to fruition. (See “The Business Side,” p.21.)
Here, I discuss the latest diagnostic tools and therapies, so you can provide fast relief to patients.
The following tools can assist you in diagnosing the underlying etiologies of DED.
Osmolarity test. Measuring tear osmolarity (TearLab Osmolarity System, TearLab). This test is important, as healthy tears maintain a relatively stable osmolarity, whereas patients with DED may lose this balance and is indicated when the osmolarity measures greater than 308mOsml/L or the difference between the two eyes is 8mOsml/L or greater.
The financial investment of introducing this test in your practice is low. The TearLab Osmolarity System requires a CLIA number for reimbursement from CMS. (See “Implementing Lab Tests,” p.22.)
Tear inflammation test. Tear film inflammation (InflammaDry Detector, RPS), measured by the level of matrix metalloproteinase MMP-9 — a common inflammatory marker in the tear film on the ocular surface — is another useful measure in determining the underlying etiology of DED. This is displayed on the point-of-care test with a red line indicating that the MMP-9 level is 41ng/ml or greater.
Financial investment is minimal.
My office procedure is to perform the above tests on all patients who have a score of six or higher on the SPEED questionnaire. Any type of questionnaire that can be quantified will help determine the need for testing and will stimulate the conversation regarding the chosen treatment.
Gland expression. Lightly pressing on the meibomian glands with your finger tips, a cotton tip applicator or a Mastrota paddle allows for easy determination of the health of the meibum. Specifically, healthy meibum is clear and “baby-oil like.” It is easily expressed, so much so that the normal muscular contraction of the blink can be enough. Unhealthy meibum appears turbid and thickened. Diagnostic expression can be performed during virtually all exams with no real financial investment.
Meibography. Not only does it provide you with information regarding the state of the patient’s meibomian glands, but the images can have a significant educational impact on patients. Imaging of the meibomian glands has been a stimulus for patients to utilize multiple lid treatments in my practice. In my experience, patients who see what their meibomian glands look like, have greater urgency to receive treatment. Obtaining meibography will require an investment ranging from $10,000 to $20,000, but this instrument can easily pay for itself by the additional visits and procedures that it will generate. (See “Lid Margin Disease,” p.14, for a listing of meibography technology.)
The Business Side
DED is, by all accounts, an under-treated entity. That can translate into enormous opportunity for eye care professionals to provide relief to patients.
In addition, your patients receive education from direct-to-consumer DED advertising. This is an advantage to our practices because it is driving patients in to, specifically, request dry eye examinations.
Look no further than your own practices to unleash this opportunity. To do so, discuss DED symptoms with each of your patients.
When necessary (as indicated by the diagnostic measures indicated in this article), utilize meibography to educate your patients on his or her disease state and treatment options.
For your patients who have moderate to severe DED, you will ultimately see those patients more often and be utilizing more advanced treatments, such as amniotic membranes.
Some examples of the various revenue streams from focusing on DED treatment in your practice follow:
- Four visits, tears, scrubs, diagnostics = net $550 to $615
- Four visits, plugs, tears, scrubs, diagnostics = net $750 to $820
- Four visits, plugs, tears, scrubs, diagnostics, BlephEx = net $920 to $1,040
- Six visits, plugs, tears, scrubs, diagnostics, BlephEx, LipiView, LipiFlow = net $1,495 to $1,600
- Six visits, plugs, tears, scrubs, diagnostics, BlephEx, LipiView, LipiFlow, one amniotic membrane = net $2,300 to $2,600
- Six visits, plugs, tears, scrubs, diagnostics, BlephEx, LipiView, LipiFlow, two amniotic membranes = net $3,000 to $3,400
Sjö Diagnostic Test (Bausch + Lomb). This is a blood test that identifies biomarkers for Sjörgen’s syndrome, a cause of DED. The test is a valuable diagnostic tool for treatment of advanced cases of DED. Because it is a lab test the O.D. refers the patient out for, it generates no income.
Implementing Lab Tests
Implementing both osmolarity and tear inflammation tests requires a Clinical Laboratory Improvement Amendment (CLIA). This certificate, obtained from both the federal and state governments, allows a practitioner to conduct waived tests that the FDA and the CDC have determined are so simple, that there is little room for error.
The CLIA waiver allows you to perform and bill for the lab tests. Lab tests do not affect the billing of any other procedures of evaluation and management codes and are paid by insurance companies under a separate (usually lower) deductible. Both companies that create and distribute the current tests on the market will also help you become a laboratory director. Both companies also have the people and the experience to provide assistance navigating various government agencies to obtain the CLIA waiver.
The following link will download the application for the CLIA waiver from the CMS website: go.cms.gov/2s0EfGK .
(I do feel that obtaining a CLIA waiver for your practice will put your practice in a very good position going forward because there will be much more information that will be extracted from tears in the near future. The human tear has more than 1,500 proteins that could very well be biomarkers for the presence of, not only ocular, but also systemic disease. Obtaining a CLIA waiver now is just good sound practice management, in my opinion.)
Utilize the power of the pen, and write the prescriptions for the treatment of DED. While many OTC treatments are available, such as artificial tears, the base for my practice has always been to utilize a therapeutic pharmaceutical and supplement with additional treatments that will help control the underlying etiologies.
Pharmaceuticals. Cyclosporine ophthalmic emulsion, 0.05% (Restasis, Allergan) (immunosuppressive), which has been on the market for 14 years, and lifitegrast ophthalmic solution 5% (Xiidra, Shire) (LFA-1 antagonist), which became available in August, utilize different mechanisms of action to decrease inflammation. (See previous coverage on both pharmaceuticals: Restasis, April 2003, bit.ly/2s11LDH ; Xiidra, February, bit.ly/2s1cttZ .)
Ocular nutritional supplements. Omega-3 supplementation can help to decrease the inflammation associated with DED. I have found very good tolerability and compliance using an omega-6 and omega-3 combination. This is a supplement patients can use for the rest of their lives as a treatment against inflammatory dry eye.
DED in Younger Patients
In my practice, I am seeing younger and younger patients affected by DED. Meibography reveals a stunning loss of meibomian glands at earlier ages. It has been suggested that this may be a result of the dramatically increased amount of time our patients, particularly younger patients, spend on light-emitting devices. One small study showed a decrease in blink rate of five-fold when using a light emitting display, according to Optometry and Vision Science Journal, 1991. While additional research needs to be done in this area, it is alarming to think of our patients — especially our younger patients — subjected to this type of light exposure and decreased activation of the meibomian glands causing inflammation, possible occlusion and damage to their corneas. I treat younger patients aggressively, as a result of concerned parents.
I make ocular nutritional supplements available to my patients directly through the practice to increase the likelihood they’ll comply with what I recommend. (See “Ocular Nutritional Supplements,” p.27.)
Punctal occlusion. Punctal plugs block the draining of tears, providing moisture to the patient’s ocular surface. I typically recommend this treatment option once I have addressed inflammation with a therapeutic and I’ve begun to address any lid margin disease.
Ester-based steroid drops. These drops decrease the inflammation DED causes. I prescribe short-term treatment to prevent IOP increases.
Scleral contact lenses. These lenses are ideal for severe DED patients, as they contain a post-lens fluid reservoir that bathes the cornea continuously, and the lens separates the eye’s anterior surface from the posterior eyelid, protecting and promoting epithelium healing. (For more information, see “Promote Specialty Contact Lenses,” May 2016 bit.ly/2taSfLl .) (See “Contact Lens Wear and OSD,” p.23.)
Eye masks. Warm compresses can help to soften or loosen obstructions of the meibomian glands. I keep a stock of warm/moist compress masks in the office for patients. I prescribe them to patients as a baseline treatment for those who display even low levels of MGD. I recommend patients use the warm compress for 10 minutes q.d. to b.i.d., depending on severity of the lid margin disease.
Contact Lens Wear and OSD
Sufferers of ocular surface disease may be contact lens wearers. It’s important to rule it out as an underlying cause. For more, read July 2016’s “Contact Lens” column bit.ly/2sIcbFo .
Lid hygiene. Lid scrubs, wipes and foam can be an effective in-home method to help remove bacteria and clogged meibum from the glands. I prescribe and sell lid hygiene products from the office.
Amniotic membrane. Adhered to the ocular surface, an amniotic membrane promotes ocular surface healing via amniotic fluid during wear time, used about three to four days, depending on the disease state. I have found this newer technology to be extremely effective in patients who have severe DED.
Microblepharoexfoliation (MBE). MBE (BlephEx, RySurg) cleans the biofilm from the lid margins. I turn to this treatment if I don’t get sufficient results from warm compresses and lid hygiene.
Vectored thermal lid pulsation. Vectored thermal lid pulsation (LipiFlow, TearScience and MiBo Thermoflo) addresses MGD via heat and pressure to unclog the glands. This treatment is typically performed on patients who haven’t had complete success with other lid therapies. I introduce it at early stages of lid margin disease.
Patients with relief from DED come in many forms: the patient who can now wear her contact lenses longer with greater comfort; the patient who can get through his work day without fluctuating vision while looking at his computer. The opportunity lies within your practice to treat this disease — and the beneficiaries will be your patients. OM