Road Map for Success: How to Manage Dry Eye in Your Practice

When we look at the various conditions that optometrists treat, it’s impossible not to notice that dry eye disease (DED) is one of the most time-consuming and rewarding—both clinically and financially—diseases that we encounter. DED affects countless individuals, it can have a profound effect on their quality of life, and it is one of the most common reasons patients present for eye care. It’s also a condition that can be treated in an optometrist’s clinic from the time of a patient’s presentation through control of the disease. Offering higher-level services for your patients with DED will allow you to continue treating them from diagnosis to management of the disease. In 2017, when I opened my latest clinic, I decided to act on my burgeoning interest in DED and set out to establish my practice as a DED treatment destination for patients with DED and a referral destination for primary care providers, ophthalmologists, and other ODs. How can you succeed in this area as well? This article provides an overview of the lessons I learned about how to effectively manage a DED clinic while I was building my own.

HOW TO MANAGE DED

Reach for the Right Tools

To provide proper and effective DED care, you will need to be able to identify DED efficiently and early. Having the right tools at your disposal and a well-trained and empowered staff is essential for this aspect of DED care. Use the Standardized Patient Evaluation of Eye Dryness test, Ocular Surface Disease Index questionnaire, or other such forms during check-in. Doing so creates a problem-oriented approach and opens the door for you and your technicians to ask direct questions about symptoms and lifestyle issues, which will give patients confidence that you are focused on the problem for which they have come to your practice.

Examine the Patient

During the examination of a patient presenting with symptoms of DED, be alert to the signs of the disease and note difficult refraction endpoints. Pay close attention to the patient’s eyelids for evidence of telangiectasia, erythema, cicatricial irregularity, posterior blepharitis, inspissated glands, biofilm buildup, line of Marx, and lid wiper epitheliopathy. I also transilluminate the meibomian glands on every patient (even children) to evaluate gland structure.

Once DED is identified, start a conversation with the patient by reviewing the symptoms of the disease while asking the patient to confirm or deny whether he or she has experienced each one. Then, summarize your findings to ensure that the patient leaves with an understanding of DED and his or her ocular health. Provide the patient with quality references about DED and schedule a formal dry eye evaluation at a separate medical follow-up visit. Don’t rush to fit everything into a routine visit. It will not work.

Perform a DED Evaluation

Schedule an adequate amount of time to perform a proper DED evaluation. It is important to provide a compelling and thorough education for the patient so that he or she can fully understand the condition. Your goal is to ensure that the patient recognizes your treatment recommendations as necessary medical therapies. Your conversion rate from recommendations to treatment is a marker of your success. If you aren’t scheduling enough of your DED patients for therapy, the problem lies not with them but with you. Always look for ways to improve your conversion rate.

Be sure to standardize your procedure for DED visits. It is imperative to perform meibography, vital staining, and noninvasive tear breakup time at the very least. Any additional quantitative or qualitative evidence that you can demonstrate, such as tear osmolarity, Matrix metallopeptidase 9, interferometry, tear meniscus height, blink analysis, anterior segment imaging of vital staining, etc., can improve your patient’s understanding of DED.

Optimize Treatment

Proper treatment requires that you be able to identify the therapies that are best suited to each patient and to determine the optimal sequence in which to administer them. Schedule regular follow-up appointments based on the severity of the disease state to monitor patients’ conditions, assess their compliance with prescribed treatments, and explain the need for additional or alternative therapies.

In addition to standard maintenance therapies such as warm compresses, topical drops, nutraceuticals, and lid hygiene, it is important to offer some clinically appropriate procedures such as meibomian gland evacuative therapies (eg, LipiFlow, radio frequency, iLux [Alcon], and TearCare [Sight Sciences]), intense pulsed light, lid exfoliation, amniotic membranes, and scleral lenses.

If you aren’t committed to acquiring the tools necessary for treating DED, refer patients to an OD in your area who is providing these services. Your patients will be grateful.

By taking the diagnostic approach I’ve outlined above, I was able to perform 161 procedures using the LipiFlow Thermal Pulsation System (TearScience) during my practice’s first year.

Care for the Whole Patient

Many patients with DED are contact lens wearers or are candidates for cataract surgery. If you want to keep patients happy in their contact lenses or successfully convert them to recipients of premium IOLs, you must first address their DED.

Patients with DED often choose premium IOLs, and one of the
most significant causes of their dissatisfaction after cataract surgery is untreated DED.¹ It is irresponsible to refer a patient for cataract surgery without first addressing his or her ocular surface disease.

DOWN TO BUSINESS

Don’t get hung up on the financial aspect of treating DED. Be a doctor. Let the patient know that some of the treatments you have recommended are not covered by insurance. Many optometrists have no problem suggesting that a patient upgrade to more expensive frames and lenses, but they feel uncomfortable about recommending expensive fee-for-service treatments. Cataract patients who paid for premium IOLs, however, will most likely be interested in and willing to pay for prescription treatments that can improve their surgical outcomes. Be a preoperative comanager, and don’t be afraid to recommend fee-for-service treatments preoperatively to optimize a patient’s ocular surface and help maximize the postsurgical outcome.

If you sense resistance from a patient, reiterate that you are recommending the treatments that you think are best for him or her. Point to the major medical centers that provide whatever therapy it is that you are recommending and cite the latest articles and reading material about DED. You cannot force a patient to accept your recommendations. As an older, wiser OD once taught me, “Patients are entitled to their disease.” If a patient does not want to accept your recommendations or follow through with treatment, that is his or her prerogative.

GO FORTH AND TREAT DED

Many patients with DED will have seen numerous ODs and ophthalmologists prior to consulting you. Some of them will not have had success with previous treatment or, worse, will have dealt with a doctor who did not consider their symptoms to be serious enough to warrant treatment. If you are able to offer these patients a higher level of care, they are likely to be extremely grateful and may even become ambassadors for your practice.