Dry eye disease (DED) is nearly ubiquitous, yet it is routinely underdiagnosed and chronically undertreated. Many of our colleagues continue to dabble in managing DED, recommending ocular nutritional supplements and other OTC products, while occasionally prescribing topical medications when appropriate. But what does it take to actually develop a DED clinic? Let’s investigate.

In 2012, I made a conscious decision to develop a DED clinic in my referral center practice. Here, I share the steps I took, which can be applied in any practice setting.

MAKE EDUCATION A PRIORITY

You won’t become a DED expert overnight. There really are no shortcuts here. In addition, DED is a multifactorial disease, and there is no one “playbook” that works for every patient. However, there are many more resources available to help you learn the basics. This demonstrates that we know so much more about DED than we did just a decade ago. If you have a staff member whom you’ve identified as your likely “dry eye champion,” get that person started with education right away too. Consider the following steps:

• Review the Executive Summary for TFOS DEWS II (tearfilm.org/public/TFOSDEWSII-Executive.pdf ) for a great overview of the latest thoughts on all things dry eye.
• Sign up for (and consider bringing your dry eye champion to) an intensive DED course, such as Dry Eye University, Dry Eye Boot Camp, Ocular Surface Academy, or the Twin Cities Ocular Surface Symposium. (Some of these courses will be moving online to accommodate the need for education during the COVID-19 pandemic.)
• Take the time to, at least, skim every DED article or supplement you see in trade journals and online publications.
• Connect with colleagues through social media. I’m a big fan of the OSDocs group on Facebook, for example.

DEVELOP A PROTOCOL

As with education, do not take shortcuts here. Without a solid routine, your DED clinic won’t get off the ground. I strongly suggest that the first step be the initiation of a DED survey for every patient presenting for a comprehensive eye exam. SPEED, OSD and DEQ-5 are all reasonable choices. (Find questionnaires at bit.ly/2YTVTdw .) I recommend presenting this in the following manner at check-in: “We would like you to fill out this brief questionnaire to help us understand whether you are bothered by dry eye symptoms. We’ve found this to be the most common problem we see in our practice.” This presentation sets the tone early on that DED is everywhere, and you are here to help. These patients are in your practice already.

Through telehealth, we are investigating ways to identify DED before patients even get to our office. I have found that a telehealth platform with a SPEED questionnaire embedded in the app is particularly useful for DED.

Beefing up the DED history is the next step. I like the questions that were developed from the 2014 Dry Eye Summit:

1. Do your eyes ever feel dry or uncomfortable?
2. Are you bothered by changes in your vision throughout the day?
3. Are you bothered by red eyes?
4. Do you ever feel the need to use eye drops?

The final step in the protocol is the clinical exam. I think that some of the steps from the American Society of Cataract and Refractive Surgery (ASCRS) guidelines for pre-surgical patients work quite well in a primary eye care setting. Instill some fluorescein in the eye, and perform the following:

Look at blink quality, examine for eyelid malposition and blepharitis, and assess tear film meniscus height and any corneal staining.

Push on the lower eyelid margin (central to medial) to assess meibum quality and quantity. (The ASCRS DED algorithm is “Look, Lift, Push, Pull.”)

Any significant symptoms or signs will necessitate the need for patient education and a treatment plan. Basic recommendations (level 1 therapy) regarding environmental factors, nutritional supplements and OTC lubricants/lid hygiene can be made at this initial visit. (See “Educate on DED Therapeutics,” p.24.) Provide written instructions either by print or email. Then, pre-appoint the patient for a DED evaluation.

“Wait! Didn’t we just perform an evaluation?” Not exactly.

The next visit will be focused on identifying additional risk factors, screening for symptoms of associated systemic disease, such as rheumatoid arthritis, assessing response to conservative therapy, additional diagnostic tests (often associated with reimbursement) and the consideration of more advanced therapy, such as prescription medications. This evaluation will be billed to the patient’s medical insurance. The end result of a good screening protocol is the identification of patients who are willing to listen (they’ve already told you they have a problem that needs fixing) and will benefit from therapy (that’s your job).

GENERATE REVENUE THROUGH PATIENT CONVENIENCE

Make sure that your level 1 therapies, outlined above, are available to your patients at your practice for their convenience. This practice ensures they use what you want them to, which increases the likelihood of compliance, while also enhancing your practice revenue. We carry OTC supplements, microwaveable moist compresses, artificial tears, overnight protective goggles and lid hygiene products at all office locations. Patients are able to purchase the products I’ve recommended (and marked on their instruction sheet) and get started that day.

Recently, we’ve integrated an online store into our practice website. This provides patients with the option of not always having to return to our office when they require more OTC products.

An online store is easy to set up and can potentially generate a passive revenue stream.

BRING IN BOTH DIAGNOSTIC AND TREATMENT TECHNOLOGY SLOWLY

I’m a big believer in point-of-care diagnostic testing. Introduce these during your DED evaluation. Examples are:

• Tear osmolarity testing. Cost ~$10 per test/average Medicare reimbursement ~$22
• MMP-9 testing. Cost ~$8 per test/average Medicare reimbursement ~$12
• Meibography. Cost ~$5,000+ per device/average Medicare reimbursement $0

Adding tear osmolarity and MMP-9 testing provides useful data to improve decision making and to track outcomes. This streamlines the exam, while adding revenue. A CLIA waiver is required, and this will usually cost a few hundred dollars. I perform these diagnostic tests at every DED visit, as I consider them essential to successful management. These are billed to medical insurance, and reimbursement is usually straightforward.

Meibography, possibly combined with measurements of other DED markers, such as non-invasive TBUT, lipid layer thickness, etc., is a game changer: A picture really is worth a thousand words, and the ability to convert patients to an in-office procedure is simplified if you can show them an image of their glands.

Various strategies to capture a solid ROI exist. I choose to perform meibography at no charge, as I think it provides critical baseline information. However, I think it is reasonable to charge patients a nominal fee to acquire and interpret these images. Consider bundling this charge into the procedure cost if a patient elects to proceed with an in-office treatment.

DED is almost always the sequelae of meibomian gland dysfunction (MGD). I usually find myself recording both diagnoses into my EHR. My standard treatment approach generally involves addressing ocular surface inflammation, the lid biofilm and meibomian gland obstruction.

This can be achieved through a combination of level 1 therapies, prescription medication (in some cases) and in-office procedures. Adding in-office therapy is where your DED practice will really take off: These self-pay procedures are effective, well-tolerated and will need to be repeated. (For a list of in-office procedures, see “Discuss DED Diagnostics,” p.22.)

In deciding where to make an initial investment, I suggest first choosing an in-office therapy where: 1) the investment is minimal, 2) the treatment is effective for a large base of DED patients and can be efficiently integrated into the practice workflow and 3) the practice receives a reasonable fee for the service.

DELEGATE, DELEGATE, DELEGATE

Once you’ve gotten your protocol down and have some in-office procedures under your belt, plan to delegate as much as possible to your support staff.

In my practice, a technician:

• performs the DED history and point-of-care diagnostic tests;
• educates patients about OTC, prescription and in-office treatment options;
• performs microblepharoexfoliation/eyelid treatment and some steps involved in IPL and MGD treatments.

I focus my attention on connecting with the patient, interpreting the history and clinical data and developing a treatment plan. I make the hand-off to my DED champion to finish up almost everything else.

MARKET YOUR SERVICES

I’d save this step for later. The last thing you want to do is market yourself as a DED expert if you haven’t really taken the steps to get there yet. Once you’re ready, the most cost-effective way to market is through social media and your practice website. Collect patient success stories and online reviews, and share through these platforms, with the patients’ permission, of course.

YOU CAN DO IT!

I’m proud to be able to offer advanced DED services to patients throughout my community who have this chronic and bothersome condition. By taking a stepwise approach, focusing on protocols at first, I think every practice can have a successful DED clinic. OM

DR. DIERKER is the director of optometric services at Eye Surgeons of Indiana and an adjunct faculty member at the Indiana University School of Optometry. He practices consultative optometry with special interests in ocular surface disease and retinal disorders. He has developed a dedicated dry eye clinic within his practice and helps colleagues across the country in this area with “Dry Eye Boot Camp” educational programs. Additionally, he serves as president of the Indiana Optometric Association.