Enhancing Patient Care With an Effective DED Protocol

Dry eye disease (DED) is a pervasive disease that, without the proper technology, is difficult to diagnose. Patients often come into our offices complaining of chronic pain, discomfort, and in some cases even debilitating pain, but when we look into the slit lamp the clinical signs of DED appear to be only mild. That disconnect between a patient’s symptoms and the clinical signs of DED is frustrating to both the patient and the practitioner. It becomes nearly impossible to treat a condition that you can’t properly identify.

Prescribing artificial tears, hot compresses, and lid scrubs and placing punctal plugs to alleviate DED symptoms might provide some relief to patients in the short term, but it does nothing to help us identify the underlying cause or causes of patients’ symptoms. Only when we can diagnose the source of the DED can we help patients to achieve long-lasting relief.

TECHNOLOGY IS YOUR FRIEND

In addition to subjective measurements such as the SPEED questionnaire and objective measurements such as tear breakup time (TBUT), Schirmer testing, and epithelial staining, diagnostic devices are an integral part of any DED protocol. A variety of diagnostic devices can be used to capture images of the cornea and lids, perform meibography, and do TBUT, but the best device to do them clearly, concisely, and cohesively is the Keratograph 5M (Oculus).

The Keratograph 5M is more than a corneal topographer; it also can be used to examine the meibomian glands, measure and evaluate the lipid layer, and perform noninvasive TBUT and tear meniscus height measurements. I use the Keratograph 5M to help identify the source of patients’ DED complaints and, equally important, to educate and show them the underlying causes of their symptoms.

The device’s Crystal TEAR Report makes the education process simple and effective. It includes an easy-to-understand color-coded pie chart, explanations of abbreviations and technical terms, a comprehensive presentation of the patient’s individual measurement results, and a clear explanation of the therapeutic steps and overall treatment goal. Simply stated, the Crystal TEAR Report allows me to put the story together for my patients by using their own unique images and measurements. There’s a lot of power in that.

Historically in my practice, I focused on orthokeratology (ortho-K), myopia control, and specialty contact lens fittings. What pushed me to add treatment of DED was the changing demographics of my patient base, from young families who had moved to the Myrtle Beach area during the housing boom in the early 2000s to retirees moving here in the past 10 years. Now I treat a huge number of baby boomers, and many of these patients require DED treatment.

We use the DED screening mode of the Keratograph 5M in every comprehensive eye exam we do. In total, we take four scans. The first scan measures tear meniscus height, or the quantity of liquid in the eye. The second scan is for interferometry, where I’m looking for the lipid layer and scanning for meibomian gland dysfunction. The third scan provides a redness (ie, inflammation) score. Patients with sufficient tear volume and tear quality do not have any redness because there is no reason for inflammation. The final scan is meibography of the lower lid.

THE ROLE OF EDUCATOR

Sharing the results of these scans with patients is especially powerful because it helps them to understand what’s going on inside their own eye. I can show patients, on a 32-inch flat screen in my exam room, the absence of the lipid layer in their tear film, the redness and inflammation in their eyes, the structural loss in their lower lid, and the minimal amount of lipid in their tear film (Figure). It’s not just me looking into a microscope and telling them what I see—it’s them seeing it, too. And I might be the first doctor that they’ve ever seen who not only could show them what was going on but also validate their symptoms.

The workup takes a little bit more time for my technicians, but it gives me the diagnostic data I need to identify the cause of DED and, therefore, to effectively treat patients’ symptoms. And it also allows me to take on the role of educator. The Keratograph 5M is such a powerful tool because patients can see their disease, and they can compare their images to reference images of healthy meibomian glands. This ability for patients to see their own images validates their symptoms and helps them to understand what is causing their discomfort. It also helps with patient compliance.

Once DED is detected with the Keratograph 5M, a full dry eye workup is scheduled for a subsequent visit. At that visit, we repeat the same scans with the Keratograph 5M, and we also perform meibography of the upper lids, noninvasive TBUT, staining with lissamine green dye, and fluorescein staining.

ECONOMIC IMPACT

In the past, DED therapy accounted for around 1% of my revenue. In the first 4 months after purchasing the Keratograph 5M, it accounted for 21%—and 80% of that was achieved through services alone, with no cost of goods involved. With about 75% to 80% net on these services, I make a larger profit than I would seeing vision plan patients.

More importantly, I’m making a lot of people happy. Chronic DED patients who I’ve treated for years are finally coming back happy. That’s a huge win. The clinical applications and the patient education tools of the Keratograph 5M have been a game-changer for my practice.

OTHER USES

In addition to DED analysis, the Keratograph 5M can also be used for contact lens fittings and ortho-K. The device’s topographical data is used to calculate the mathematically best-fitting contact lenses. The Keratograph 5M also simulates the fluorescein image for the chosen lens and interfaces with software design platforms for ortho-K lenses, such as the Wave Contact Lens System.

The OxiMap is also an interesting feature of the Keratograph 5M. This function provides a graphic representation of oxygen transmissibility over the entire surface of the contact lens as a function of refractive power.

While I have dabbled with other contact lens software platforms, I have more than a decade of experience designing lenses with Wave software using another topography device. I recently had the opportunity to do my first Wave ortho-K fitting with the Keratograph 5M. At the time of this writing, the patient has only worn his new contact lenses for a few days, but he is doing well so far. So, the DED diagnosis capabilities of the Keratograph 5M were my initial justification for purchasing this device, but the contact lens fitting and ortho-K functions are icing on the cake.

FUTURE OUTLOOK

Since adding DED to my armamentarium of care, my patient volume has grown enough to allow me to hire a full-time associate. Having someone to handle most of the primary care has given me the bandwidth to concentrate on specialty care.

In my 33 years of practice, providing DED care to my patients might be the single most impactful thing I’ve done. It’s put some of the fun back into what I do, and it has allowed me to make a big difference in patients’ lives. Incorporating the Keratograph 5M device into my practice has been a game-changer, and I feel better about the level of care I can provide to all my patients.