Article

CLINICAL: CORNEA

DED Clinic Success

The key is to diagnose and treat this condition actively

Dry eye disease (DED) affects an estimated 33 million people in the US. What’s more, this number is expected to grow by 10% in the next decade, creating an even larger gap for patients needing care. Given these facts, it makes sense to consider creating a DED clinic in your practice. But, how, specifically, can you successfully do this?

I’ve found the key to accomplishing this is to actively diagnose and treat patients who have this progressive disease. And, to facilitate this, several diagnostic and in-office treatment tools are available. Also, consider going a step further by offering patients an in-office retail center. (See “Common In-Office Retail Products,”)

DIAGNOSTIC TOOLS

Common DED symptoms include dryness, burning, stinging, foreign body sensation, grittiness, blurred or fluctuating vision, redness, fatigue, itching and poor comfort with contact lenses. (Realize that some patients have become so accustomed to these symptoms, that they may not volunteer they have them, so be sure to inquire about these symptoms via a patient history form.)

Punctal occlusion after controlling inflammation
Image courtesy of Dr. Johnston

The common signs of DED include conjunctival hyperemia, conjunctival and corneal staining, decreased TBUT, increased osmolarity, increased inflammation, poor quantity and quality of meibum and meibomian gland obstruction, leading to gland atrophy. To identify the common signs, consider employing these diagnostic tools:

  • Fluorescein stain, under blue light to view corneal signs, such as staining and decreased TBUT
  • Lissamine Green and Rose Bengal stain, viewed under white light to view conjunctival signs
  • Osmolarity testing
  • Meibography
  • Lipid layer analysis using interferometry
  • Meibomian gland evaluation, analyzing the quantity and quality of meibomian gland secretions
  • MMP-9 and inflammation detection
  • Blink evaluation (blink rate and blink quality)
  • Patient questionnaires
  • Tear quantity tests, such as Schirmer’s and Phenol Red Thread test
  • Topography
  • Slit lamp photos
ICD 10
Keratoconjunctivitis Sicca, not specified as Sjögren’s H16.22-
Dry Eye Syndrome H04.12-
Sicca Syndrome (Sjögren’s syndrome) M35.0
Stenosis of lacrimal punctum H04.56
Exposure KCS H16.221

IN-OFFICE TREATMENT TOOLS

Because DED is multifactorial, oftentimes, we may need multiple shots on goal to get symptomatic breakthroughs. A vital part in achieving these breakthroughs is offering in-office treatments. Additionally, having such treatments positively separates you from other practices in your area that claim to provide DED care. Offering specialty DED treatments for your patients can help improve your patient’s quality of life as a primary benefit, with secondary benefits that include increased practice growth and cross-pollination to all areas of your practice.

A summary of these in-office treatment tools:

  • Amniotic membranes. These can help decrease inflammation and symptomatic pain from and promote healing and nerve regeneration, improving the symptoms and signs of moderate to severe DED.
  • Punctal occlusion. After inflammation has been treated and tears are produced sans inflammatory cells, this helps increase the tear reservoir, thereby offering relief.
  • Lid debridement. This can remove the bacterial biofilm that contributes to inflammation and decreased meibomian gland function.
  • Manual lid expression. This can reduce gland obstructions and improve gland secretions, providing symptomatic relief.
  • Intense pulsed light. Also known as IPL, this provides thermal heating of the glands, thereby increasing gland secretions, destroying inflammatory feeder blood vessels on the lid margin and decreasing some of the bacterial load on the lid margin.
  • Scleral contact lenses. These offer patients a reservoir of aqueous solution that bathes the cornea, giving symptomatic relief.
  • Thermal pulsation. This provides a gentle heated massage to the lids to aid in unblocking the meibomian glands, so they can produce the lipids needed for tear film stability.

COMMON IN-OFFICE RETAIL PRODUCTS

→ Artificial tears

→ Lid hygiene products

→ Warm moist heat masks

→ Nutritional supplements

→ Hyperosmotic ointments, drops

→ Sleep goggles

→ Lubricating ointments

→ Humidifiers

→ Neurostimulation device

IN-OFFICE RETAIL CENTER

Treating DED with prescription therapeutics and in-office treatments is paramount to a DED clinic, but you should also offer premium OTC products in house as a means of providing patient convenience — something they value — and insurance that patients will comply with what you’ve prescribed, enhancing clinical outcomes.

During my DED plan with the patient, I review my prescribed treatment plan and then hand them a personalized treatment summary sheet. I proceed by going over each prescribed item, educating the patient on what products can be purchased at checkout in my office. For most visits, about 90% of my patients buy two products from us. OM