Screening for Dry Eye Can Lead to Happier Patients

We can all agree that positive corneal staining is abnormal. We can also agree that a common cause of corneal staining is dry eye. As 77% of eyes screened for cataract surgery have positive staining,¹ it is safe to conclude that dry eye is severely undertreated by both optometrists and ophthalmologists.

You may not feel that 77% of the patients you send for cataract surgery have positive corneal staining, and you are probably better than the average eye doctor at treating dry eye. But how often do you stain the cornea?

MISSING OUT

Treating dry eye can be a practice builder. But many eye doctors look at treating dry eye as a nuisance, and the furthest they go with it is recommending artificial tears. Recognizing that eye doctors are not effectively treating this rampant condition, other health care professionals (eg, dermatologists, primary care physicians, physician assistants, nurses, etc.) are beginning to broaden their scopes of practice to include treatment of dry eye.

Are these other professions truly capable, well-equipped, and knowledgeable enough to treat dry eye? I have seen numerous conditions, including peripheral corneal degeneration, herpes simplex virus dendrites (Figure), corneal abrasion, hypopyon, subconjunctival hemorrhage, and injection secondary to latanoprost, incorrectly diagnosed as dry eye by health care professionals who are not eye doctors.

EDUCATION VERSUS EXCUSE

Why are eye doctors ignoring dry eye? First, patients don’t bring it up because they don’t know to bring it up; they have normalized the fact that their eyes are dry. Second, the legal cost of missing and not treating dry eye is much less severe than that of missing something more vision-threatening, such as a retinal detachment. However, not effectively treating dry eye can have huge consequences, not only for your patients’ satisfaction but also for your practice’s bottom line. Furthermore, contact lens patients are afraid they will be taken out of their lenses if they tell their eye doctor their eyes are dry.

My definition of education is what you tell a patient before the patient complains about what you are about to do. My definition of an excuse is what you tell the patient after the patient complains about something you have done. The education and the excuse can be the same, word for word. The difference is in the timing.

Many eye doctors say proactively treating dry eye takes too much chair time. I would argue that not proactively treating dry eye will actually take more chair time. For example, if you fit a patient with contact lenses but did not screen him or her for dry eye, that patient will likely come back for a free contact lens progress check complaining about intermittent blur or discomfort if he or she has dry eye. At that free contact lens progress check, you will likely have to perform a free dry eye evaluation because the patient will see your explanation of dry eye as your excuse regarding why the contact lenses you fit are not working.

On the other hand, if you had proactively screened this patient, identified dry eye, and begun treatment before fitting the contact lenses, it’s much easier to convert that free contact lens progress check into a reimbursable dry eye office visit, diagnostic test, and/or procedure because you had already educated that patient about dry eye.

HOW TO DO IT

If we all agree that proactively treating dry eye is good for both patient and practice, how can we screen every patient for dry eye every time? The answer is to use a survey. A survey is perfect every time. A survey never just had a bad day. A survey does not call out sick. A survey treats every patient the same every time.

The Standardized Patient Evaluation of Eye Dryness and the Dry Eye Questionnaire are two dry eye surveys commonly used in clinical practice. Some offices train their staff members to preemptively perform additional dry eye screening tests if a patient does poorly on one of these surveys.

Once the patient with dry eye is identified, treatment can begin. Remember, however, not to confuse improvement with perfection. To battle this tendency, we have developed our own survey that includes the question “Do your eyes feel perfect?” Until the answer to this question is “Yes,” we continue to prescribe (not recommend) additional dry eye treatments.

HOW TO BILL IT

Some doctors do not want to treat dry eye unless the patient is being seen under medical insurance. Regardless of who is paying for a comprehensive eye examination (vision insurance or medical insurance), the definition of a comprehensive eye examination is “an evaluation of the complete visual system.” A doctor cannot force a patient to use medical insurance if the patient wants to use vision insurance (assuming the doctor is a provider for that vision insurance).

If a patient has dry eye and wants to use vision insurance that day, we must at minimum begin some kind of dry eye treatment. Treatments can include everything from over-the-counter remedies to prescription drops to in-office out-of-pocket eyelid treatments.

If the patient needs and wants additional medical diagnostic testing (such as an external ocular photograph) and/or a medical procedure (such as punctal plugs) at a yearly examination under vision insurance, there are two options:

1. Collect both the vision and medical insurance copays and then bill the examination to vision insurance and the procedure and/or diagnostic test to medical insurance through coordination of benefits.

2. Have the patient return on another day for the medical examination (if appropriate), diagnostic test, and/or procedure.

Note that any evaluation that is done to determine the need for a surgical procedure (such as punctal plugs) is included in that surgical procedure. It may or may not be appropriate to bill an office visit the same day as a surgical procedure. In order to justify an office visit, a chief complaint and diagnosis independent of the surgical procedure are required.

DRY EYE WITH OTHER SYMPTOMS

For the dry eye patient who notices intermittent blur with contact lenses or who is experiencing other symptoms of contact lens–related dry eye, scleral lenses are an excellent option. Scleral lenses allow patients to clearly and comfortably wear contact lenses. Anecdotally, patients also report that their eyes feel less dry even after their scleral lenses are removed.

Amniotic membranes can be a great therapy for patients with more moderate to severe dry eye. In our practice we mostly use dehydrated membranes for dry eye because of patient intolerance of cryopreserved membranes. It is important to confirm with the specific medical payer whether dehydrated membranes are reimbursable. Also, some insurance companies require prior authorization.

We regularly treat ocular rosacea with oral doxycycline or azithromycin (Zithromax, Pfizer). Another off-label treatment option with which we have anecdotally had success is topical azithromycin ophthalmic solution 1% (AzaSite, Akorn). Ocular rosacea can be a precursor or trigger for meibomian gland dysfunction, so we often treat that concurrently with other lid procedures. Depending on which state you live in, many optometrists have also started using intense pulsed light therapy to treat meibomian gland dysfunction.

Cylindrical collarettes are pathognomonic for the eyelid mite Demodex. The current treatment indicated is diluted tea tree oil, but there is a potential treatment on the horizon in topical lotilaner, a veterinary drug that is currently in clinical trials for human use.

THE MORE YOU LOOK THE MORE YOU’LL FIND

Dry eye is the most common condition seen by optometrists. If you proactively screen your patients for dry eye, you will find that you have more patients experiencing this ocular surface condition than you think.

Treating dry eye offers a huge opportunity to improve not only your patients’ satisfaction but also your practice’s bottom line. New devices and medications make it more exciting than ever to treat dry eye and deliver improved patient outcomes.