Diagnosing DED can be extremely gratifying for both the patient (by providing both an answer and subsequent treatment relief) and the optometrist (via personal fulfillment and additional practice revenue). What’s more, it’s well within the domain of the optometrist, who is the primary eye care provider.
Given that an optometrist’s day is so full, here are tips on how to simplify the management of DED.
1 SCHEDULE A SEPARATE APPOINTMENT
Once the optometrist has confirmed DED symptoms and has identified possible contributing factors (See: “Sussing Out Symptoms and Signs,” p.20), the optometrist should have the patient return for a DED diagnostic testing appointment.
In my practice, I explain to the patient that his symptoms and/or signs indicate a tear film or dry eye issue that requires special testing to make a definitive diagnosis, so we can provide him with treatment options to remediate the problem. The patient is then typically scheduled for this visit a week later. I can assure O.D.s, based on my many years of experience with this process, that patients will be very compliant with returning for the testing and, subsequently, compliant with following treatment regimens prescribed because they want symptomatic relief.
Optometrists should not perform this testing on the same day as the patient’s comprehensive, routine eye health exam because such testing takes additional time, increasing the likelihood of disrupting the appointment schedule. Something else to keep in mind: Optometrists do not receive reimbursement for DED testing during a comprehensive eye health evaluation. Lack of reimbursement is a disservice to their skills as clinicians and their practice’s revenue.
2 EMPLOY THE LATEST TECHNOLOGY
Several manufacturers have created diagnostic products for DED that provide accurate data, ease-of-use and efficiency to simplify the condition’s diagnosis. They are blink rate tests, corneal topographers, diagnostic equipment that contains biomicroscopy algorithms, inflammatory and osmolarity assessments, meibography and meibomian gland expression devices. (See “DED Diagnostic Products,” p.22.)
In my practice, we also use the Schirmer test and a tear volume device.
3 DELEGATE TESTING TO STAFF
Having technicians perform many of the tests that are part of the DED evaluation can limit the amount of time the O.D. needs to spend with the patient. It also focuses O.D.'s time on tests that the doctor needs to perform and on patient education regarding diagnosis and treatment options. (See "Getting Staff DED Ready," p.30.)
SUSSING OUT SYMPTOMS AND SIGNS
DED is an underdiagnosed condition; so optometrists should ask every patient on the patient history form, and personally at every visit, whether they experience any of the common symptoms. These may include pain, burning, tearing, foreign body sensation, blurry/fluctuating vision, tired eyes, heavy eyes, photophobia or, as some patients describe, an “awareness of their eyes.” Also, it is important to ask whether the patient experiences dry mouth, as this can indicate the need for a Sjögren’s syndrome work up and a referral to a rheumatologist for assessment of an undiagnosed autoimmune disorder, such as rheumatoid arthritis. Both conditions often occur together.
While refracting, the patient may back away from the phoropter, which can be a sign of premature TBUT, caused by MGD. Another sign of DED can be rosacea, which has close ties to both forms of DED. Some female patients who have this dermatologic condition use cover-up to hide the telangiectasias indicative of rosacea. As a result, optometrists should inquire with their female patients who wear make-up whether they are having issues with their skin.
Finally, systemic health and medication use can increase suspicion for DED, as autoimmune, allergic and mental health conditions (e.g. clinical depression) and their associated medications can play a role as underlying contributory factors. Many general practices see these patients in abundance.
TIPS FOR DISPENSING DED PRODUCTS IN-OFFICE
Dispensing DED products in-office provides patient convenience, increases the likelihood of patient compliance to the optometrist’s specific prescription and can provides an additional revenue stream for the practice.
These two action steps have enabled my DED patients to achieve symptomatic relief, while increasing my practice’s bottom line:
- Explain the value of the specific product to the patient. In my practice, we show patients videos that demonstrate the importance of specific products and their prescribed use, so the patient realizes not all DED products are created equal, precluding the likelihood of him purchasing something that “looks like” what’s been prescribed from a local retailer. The additional benefit is that the patient understands that I’m not trying to “sell” him, but “help” him.
- Schedule follow-up appointments. After providing education on “why” I’ve prescribed the use of a specific product, I instruct patients to make a follow-up appointment: “I want you to come back ____, so I can assess clinically whether the treatment is making a difference. In the interim you may begin experiencing relief, which is wonderful, but it’s essential you continue using the product as directed because the last thing I want is for the problem to ramp up again because you ceased use.”
I have found that technicians can perform inflammatory tests, tear osmolarity, Schirmer test, or a tear volume test, meibography and topography, as well as presenting patient education videos on treatment options that may be included in their management plans. (See "Tips for Dispensing DED Products In-Office," above.)
SIMPLIFY THE DED DIAGNOSIS
As outlined above, it is possible to simplify the diagnosis of DED, enabling optometrists to adhere to their appointment schedules, while providing patients with answers about their signs and symptoms and prescribing appropriate treatments for relief.
A final note: O.D.s should be sure to schedule follow-up visits with their DED patients, until these patients are comfortable and on maintenance therapy. I always go back to the initial ocular surface evaluation history and refer to the chief complaints when I assess my patients’ progress: I ask them to quantify how much improvement, percentage-wise, they have achieved. OM
DED DIAGNOSTIC PRODUCTS
→ MMP-9 Tests
- InflammaDry (Quidel)
→ Tear Osmolarity Tests
- TearLab Osmolarity System (TearLab)
- I-PEN Tear Osmolarity System (I-Med Pharma)
→ Blink Rate Tests
- BlinkCam (BlinkCam)
- iPEDA (Ophthalmic Resources)
- LipiView (Johnson & Johnson Vision)
→ Dx Equipment That Has Slit Biomicroscopy Algorithms
- OSData (Ophthalmic Resources)
→ Corneal Topographers
- Aladdin HW 3.0 (Topcon Medical Systems)
- Atlas 9000 (Zeiss)
- CA-200F Corneal Analyzer (Topcon Medical Systems)
- CA-800 Corneal Analyzer (Topcon Medical Systems)
- EasyScan (EasyScan USA)
- Galilei Dual Scheimpflug Analyzer (Ziemer Group)
- KR 7000P (Topcon Medical Systems)
- Oculus Keratograph 5M (Oculus)
- OPD Scan III (Marco)
- Orbscan III (Bausch + Lomb)
- TMS-4N (AIT Industries)
- Visionix VX110 Multi-Diagnostic Unit (AIT Industries)
- Visionix VX120 Multi-Diagnostic Unit (AIT Industries)
- Zeiss Atlas 992 (Zeiss)
- LipiScan (TearScience)
- Meibox (Box Medical Solutions)
- Oculus Keratograph 5M (Oculus, Inc.)
→ Meibomian Gland Expression Devices
- Flexx MG Expressors (OcuSci)
- Mastrota Paddle (Medi Instruments)
- Meibomian Gland Evaluator (Johnson & Johnson)
→ Tear Volume
- SMTube (OSD Care)
* This list is evolving and will be updated online.