April L. Jasper, OD, spoke with fellow optometrists Marc R. Bloomenstein, OD, Lisa M. Genovese, OD, and Justin Schweitzer, OD, in a recent podcast about the importance of proactively identifying dry eye disease in patients and how new technology, such as Reichert’s Idra Dry Eye Assessment Device and OS1000 Corneal Topographer and Dry Eye Assessment Device, helps them do that.
------------------------
APRIL L. JASPER, OD (moderator): If we were to poll an audience of optometrists and ask what percentage of their patients have dry eye, I suspect we’d hear a wide range of answers. I’ve heard anywhere from 15% to 100%. Why do you think there could be such a wide variation of answers to that question?
JUSTIN SCHWEITZER, OD: I think one reason is because many clinicians probably aren’t looking for dry eye in every patient. It just demonstrates how important it is for us to assume that everyone who walks through our doors has dry eye until proven otherwise.
MARC R. BLOOMENSTEIN, OD: That also speaks to the fact that we haven’t had a definitive way to diagnose dry eye. Many clinicians wait until patients mention problems—burning sensations, light sensitivity, or dryness—before they suspect dry eye. By waiting for those classic symptoms to emerge, they’re missing the diagnosis.
RESEARCH INFORMS DRY EYE PRACTICE
DR. JASPER: We can draw upon a significant amount of research related to dry eye, most notably reports from the Tear Film & Ocular Surface Society Dry Eye Workshop II (TFOS DEWS II).1 How does that help you when you want to discuss dry eye disease with patients?
LISA M. GENOVESE, OD: TFOS DEWS II identified dry eye disease as multifactorial,1 and that helps me explain to patients the reasons why I need data from various diagnostic tests to determine the best treatment plan for them. Multifactorial means that we have to come at dry eye from different angles. No one therapy will fix this disease.
DR. BLOOMENSTEIN: I look at TFOS DEWS II as validating what we know. The fact that the researchers include visual disturbances in the dry eye definition goes to the heart of what we do as optometrists. We’re here to help our patients get the best quality of vision.
DR. SCHWEITZER: The TFOS DEWS II report also identifies the risk factors that lead to dry eye. A questionnaire is a good tool to use to look for symptomatology, but not all patients have symptoms, so we shouldn’t base a diagnosis solely on responses to a questionnaire. Point-of-care testing is an important tool to identify patients who are asymptomatic but have risk factors.
NEW TECH FACILITATES DIAGNOSIS
DR. JASPER: How do you meet the challenge of identifying dry eye?
DR. GENOVESE: Early on, I decided that all I’d need is my stain and my brain to diagnose dry eye, and because patients want to quantify their disease, I acquired an anterior segment camera to show them their congested meibomian glands.
In recent years, diagnosing and treating dry eye has become much easier for me thanks to new technology. About two months ago, I started using the Idra Dry Eye Assessment Device from Reichert. At first, I was skeptical, because I thought I had it all figured out; but after using the Idra, I’m impressed. Not only does the system perform meibography, it evaluates all three layers of the tear film, and it presents personalized treatment recommendations based on those findings.
Idra helps me create a story for my patients. When I’m seeing loss of glands, my patient is seeing loss of glands. I can show them that their oil layer is deficient and explain that there’s one reason for that: congestion. This knowledge helps patients get on board with treating their disease.
DR. BLOOMENSTEIN: We need patients to buy into what we’re telling them, otherwise they may not adhere to the therapies we prescribe. For example, one of the best ways to get buy-in from our glaucoma patients is to show them what normal is, what abnormal is, what their pressures are, and what their target pressure should be. We haven’t had anything like that for dry eye. With this new technology, we can show patients what normal values are and why we need to take action now. I’m looking forward to using the Idra Dry Eye Assessment System in the near future.
DR. JASPER: One challenge in my practice was consistency. We’re consistent with screening for glaucoma and retina disease, but not in how we evaluate patients for dry eye—examining the meibomian glands and the tear film, for example. When I heard lectures on dry eye, diagnosis sounded so confusing. I didn’t have the technology to make it simple or fast, and I wondered how I would incorporate technology into my already busy practice. Would focusing on dry eye slow me down?
Then we acquired the Reichert/SBM OS1000, which combines corneal topography with dry eye assessment, and also includes contact lens fitting simulation software. With this technology, we can perform dry eye tests consistently in less than two minutes.
How has your approach to diagnosing dry eye changed?
DR. SCHWEITZER: My goal is always to keep things simple. Until recently, my dry eye diagnostics included a questionnaire to identify symptomatic patients and start the conversation; a slit lamp, which we all have in our clinics, to identify those who aren’t symptomatic; vital dyes for staining; and a digit, a finger, to express the glands. While this seemed adequate, something was missing, and my approach to dry eye diagnosis has evolved.
The Idra Dry Eye Assessment Device has filled that missing piece by enabling me to perform a variety of dry eye diagnostic tests. With this system, I can measure tear meniscus height, lipid layer thickness, and tear breakup time, and I also can acquire a scan of the meibomian glands. This instrument has filled two voids: number one, I’m looking at structure more often; and number two, I can educate patients more effectively with the Idra exam reports.
Before acquiring the Idra system, I had nothing to show my patients when I explained my findings. I had to trust that they were believing what I was saying. Now, they can see their test results, along with clear status indicators—red, there’s a problem; green, you’re doing great; yellow, maybe there’s an issue—and, also, what their glands look like. That’s a big advantage for educating patients.
DR. BLOOMENSTEIN: Part of the challenge in the practice where I work is that the staff is often overwhelmed with testing. How much time do these tests take?
DR. SCHWEITZER: Once your staff becomes proficient with the Idra, testing takes less than 2 minutes.
DR. BLOOMENSTEIN: To be able to turn toward your patient and say, “This is what I found, and this is what we need to do to manage it” is a great advantage. Do you have certain criteria to determine which patients will be tested using the Idra?
DR. GENOVESE: We use the Idra for every patient who is referred to us. It helps establish a baseline. We’ve also discussed implementing this for established patients. I’m thinking about it like a contact lens fitting or maintenance, where we’ll use it at the initial visit and then repeat it at every visit so I can monitor their status.
DR. SCHWEITZER: My approach is slightly different. Every patient we see for an evaluation prior to cataract or refractive surgery completes a Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire. If anyone scores 6 or above, my technicians automatically measure osmolarity and matrix metalloproteinase-9 (MMP-9). Now, regardless of SPEED score, we test every patient with Idra. It’s part of our pretest workup.
DR. JASPER: In our practice, anyone who wears contact lenses, anyone whose SPEED questionnaire shows they need further testing, or anyone 40 years old or older is tested with OS1000. Based on these findings, we can customize a treatment plan for each patient.
ADVANCED DIAGNOSTICS HELP TARGET TREATMENT
DR. JASPER: Dr. Schweitzer, what products and procedures are available in your practice for your dry eye patients?
DR. SCHWEITZER: We have a variety of treatments from which to choose, but what I recommend is dictated by an accurate diagnosis. In addition to prescribing pharmaceutical therapies, we also stock many items for home use or utilize a digital health platform to ship items directly to the patient. For patients who have meibomian gland dysfunction, I utilize thermal pulsation, moist heat masks, heat plus gland expression, and nutraceuticals. I also use punctal plugs, based on tear breakup time and what the tear film and the tear meniscus look like. In addition, I offer broadband light therapy.
DR. JASPER: Do you charge a global fee or individual fees for each procedure?
DR. SCHWEITZER: I charge individually. Depending on what the initial treatment is, I explain how many treatments are ahead of us and what the out-of-pocket cost will be. Again, education is key, particularly with in-office therapies. They’re not inexpensive, and they’re usually cash pay, so patients need to understand why a particular treatment is beneficial. That’s the beauty of having technology that enables us to show patients the problem. Once I explain their diagnosis, I discuss the products or procedures I’m recommending. I also discuss data associated with these therapies, because it’s important to reinforce how and why they work, and that we have good supporting data.
DR. BLOOMENSTEIN: I agree that the most important thing we can do is educate patients as to what we’re seeing and why, and what we need to do to make it better. Whatever aspect of dry eye I’m treating, I reassure patients that we have therapies to treat it. I let them know what the next step might be and the out-of-pocket expense associated with it. I like to set the patient journey, emphasizing that dry eye is a chronic condition that will worsen if not addressed.
I would add that I believe any treatments we can do in the office will be beneficial, because patients are not always adherent with home therapies.
KNOWLEDGE BOOSTS COMPLIANCE
DR. JASPER: I admit I’m not always the best patient. If I don’t understand why I should do something, I may not be as diligent as I should be. So, as a doctor, if I’m not always compliant, then it’s guaranteed that our patients are not always compliant. How does technology help you to increase your patients’ level of compliance?
DR. GENOVESE: It helps them own their disease. When we can show patients objective data, I think they’re in it with us. When I perform in-office treatments, I always say, “I’m going to do my part here, but you’re going to have some homework.”
SCHWEITZER: The symptomatic patients are the easy ones. They’re uncomfortable, and they’re going to do whatever I recommend. It’s the nonsymptomatic patients who can be difficult to convince. To be able to show them the images, to show them their glands and the green, yellow, and red indicators displayed by the Idra system, can be powerful. When they see red, they know something is wrong. Then we discuss what we can do to address it.
DR. BLOOMENSTEIN: Patients want full range of vision, whether we’re talking about contact lenses or premium IOLs. We need to be thinking about how we can prepare their ocular surface to give them the best chance of fulfilling that desire. Using a diagnostic instrument to assess patients who are not symptomatic, who don’t know they have a problem, is an effective way to convince them that they need treatment to optimize their results.
DR. GENOVESE: I agree. One of my patients had been seeing my associate for about two years, trying different contact lenses in an effort to alleviate the patient’s discomfort and dryness issues. I saw the patient this week, and I said, “How about we stop trying to fix the contact lenses right now, and let’s fix you? Let’s figure out how to make you comfortable in contact lenses for years to come.” She’s coming in next week for a full evaluation.
IN CONCLUSION
DR. JASPER: I’d like to hear everyone’s thoughts on how the product suite from Reichert—OS1000, Idra, Activa, and DEM100-DSLC200—has changed your approach to dry eye.
DR. SCHWEITZER: This new technology helps me to better educate my patients, and because of that, my patients are more likely to be compliant with the therapies I’m prescribing for them.
DR. GENOVESE: When I started treating dry eye, I thought it was such a challenge. Now, I actually have something that enables me to set a protocol and have patients on board with me. I agree that education is huge.
DR. BLOOMENSTEIN: I believe this technology validates what we know for the patient. It gives us a baseline to be able to monitor their disease and measure the impact of therapy, and it gives patients an opportunity to participate in their care.
DR. JASPER: TFOS DEWS II gave us not only a definition for dry eye disease but also a path forward with in-depth reporting on the various risk factors and manifestations of ocular surface disease. With new technology, we can do so much more. We can be consistent in how we diagnose and manage dry eye disease, and we can use the comprehensive data from our diagnostic technology to educate patients and potentially improve persistence and adherence. I think these advancements really bring it all together.
REFERENCE
1. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017;15(3):276-283.
THIS CONTENT SPONSORED BY
