The most common foundational concepts of business are not difficult ones, but rather simple: Find an opportunity in the market, recognize the demand for a product or service, develop the product or service to fill the market demand, price it, market the product or service to the market segment, fulfill the demand, and repeat. This is not difficult, but it is generally expensive in the business world. It entails market research to determine the void in the market, making people aware of the void, and creating the demand—all things that generally require the expertise of a market research team, hiring marketers, and a product development team, as well as recruiting people to provide the service and evaluating supply and demand curves. It is simply exhausting.

But you know what? We all do this day in and day out in our practices already, we just don’t recognize the individual business processes that go into providing great eye care in our communities. We do every single one of those functions to some extent. What we need to do is learn how to focus those efforts in a specific way to get much better results and to help recognize true practice potential. That is why I want to count the 'Why’s' of dry eye diagnosis and treatment.

Optometry is in a unique place within the greater health care framework. We have the largest labor force and provide the vast majority of primary vision care to the 330 million people in the United States.¹ Yet we don't always recognize the potential impact we can have on patient care because we are either too busy or unaware of our capabilities—and our patients' acceptance of those capabilities—to realize what we can truly do to improve patient care in the area of dry eye.

Let’s start counting the Why’s of Dry Eye:

Understanding The Dynamics

Optometry is at the forefront of the primary eye care market. We outnumber ophthalmologists by more that two to one, and we provide the vast majority of comprehensive eye exams performed. Market control means exposure to the market and what impact we can have in influencing care for our patient base. So, we have a 'care opportunity' to present to a captured patient population who we are already seeing.

Let’s dig deeper into the patient dynamics. Patients who have symptoms of dry eye have most likely taken one of two paths. Either they have 1) looked up their symptoms online and self-diagnosed/self-treated by purchasing over-the-counter topical drops, vitamin supplements, a heat mask, etc., or 2) sought out the help of a doctor, though not necessarily an optometrist or ophthalmologist. Perhaps it was their primary care physician or family practitioner who directed them to commonly known treatments without the proper diagnostic testing to determine the cause of the problem. The bottom line is these patients know they have a problem because they experience symptoms on a daily basis, and the treatments that they have tried may not be working.

The Call For Help

Dry eye has been a very hot topic for quite some time in clinical circles. There are new and exciting approaches to identifying, diagnosing, and addressing this patient population. What we may not truly appreciate is just how many people are suffering from dry eye. More importantly, the patient demographics of this population are constantly expanding as screen use increases. Prevalence of dry eye is well established. Conservatively, by traditional definition, dry eye affects 15% of the US population.² That means for the average optometric practice having 3,500 patient encounters per year, there are at least 525 individuals in your practice each year that are suffering from dry eye.

So, there is a population of individuals in your practice who are symptomatic, have tried various therapies, and are still suffering—and they need your help.

I know what you’re thinking: that doesn't happen in my practice. I've observed that this is like the chicken and the egg dilemma. Patients claim their doctor didn’t ask any questions, so they didn’t mention their symptoms. Doctors claim the patient didn’t mention any symptoms, so they didn’t ask questions about dry eye. It doesn’t matter who is correct—what matters is that we change our approach to be proactive and ask every patient about dry eye signs and symptoms.

Incorporating Approachable Technology

Many subspecialties within eye care are equipment-intensive and require a substantial investment to get started. The beauty of having an interest in diagnosing and managing dry eye is that it doesn’t have to require a heavy front-end investment. There is quite a bit of exciting and innovative technology available to identify, diagnose, and manage this condition. You don’t need many tools to start, and you can add tools as you grow. Whether you take a low-tech or high-tech approach to this disease, the key to success lies in the fact that you have to properly identify, diagnose, and then manage patients with the condition.

While some may choose to build a dry eye specialty practice, you don’t have to. Incorporating the diagnosis and treatment of dry eye can easily be part of every practice dynamic. It can be as easy as asking the right questions to every patient. Once identified, the clinical approach you take can be as simple or complex as you want. The key here is to be prepared and have a plan for how you are going to manage your patients.

Fortunately, the low barrier to entry also applies to managing obstruction of the meibomian glands. Granted, if you are going to treat dry eye today, you are going to have to have a method to identify, diagnose, and treat meibomian gland dysfunction. This means an anterior segment camera of some sort and a thermal lid device to properly heat the lids, so that the obstruction can be cleared. In today’s world, if you’re not identifying or managing obstructive gland disease/meibomian gland obstruction, you’re not fully managing dry eye. The bottom line is that treating dry eye doesn’t require a large investment, and the sophistication of the equipment and technology you use can grow as your practice grows.

Motivation

This is probably the most difficult area to assess. Today’s world is not one where large practices succeed more than small practices, it is a world where fast, nimble practices succeed over those that procrastinate. Dry eye is prevalent, has demonstrable need from a patient perspective, and those patients are already part of your practice. Remember, most of these patients realize that they have a problem. They have self-diagnosed, self-treated, and are likely dissatisfied with the results. That is why they are seeking your expertise. You just need to optimize your patient care and practice patterns, transitioning from reactive to proactive.

Overcoming Self-Imposed Obstacles

Appropriate and improved patient care is always the motivator for adopting a more comprehensive approach to dry eye. Remember that a more comprehensive approach will have direct patient and practice benefits. However, before adding any new processes, it's worth evaluating the 'Four I’s' of new process adoption:

• Intent—Good intentions are a start, but they are not enough. Develop time-related goals to be successful. Use the SMART (Specific, Measurable, Achievable, Realistic, Time) model to begin.
• Integrate—Being able to integrate new processes into the practice is key to success. Work with your team and supplier partners to learn from their experiences about how new processes can be implemented without causing disruption.
• Implement—Implementing a plan is not an event, it is a process. That means consistent implementation with a good feedback loop to learn from your team, vendor partners, and patients. What works? What doesn’t? Learn, modify, and improve as you go.
• Impact—This is the reward after developing a great plan, integrating it successfully into your workflow, and implementing it consistently. The biggest impact may very well be how you have affected your patients’ lives by properly diagnosing and managing their dry eye, but this will also have a significant impact on reaching your practice potential. Using before and after metrics can be a useful way to measure the impact. This will help you see early on in the process what is working and what isn’t. Continual monitoring of practice metrics should be a part of your normal business routine.

CASE STUDY

Leslie O'Dell, OD, FAAO

History

A 52-year-old Caucasian female presented to the dry eye service with history of dry eyes for several years. She reported a history of intolerance to Restasis (cyclosporine 0.05%, Allergan) due to instillation site irritation and burning. Currently using Xiidra (lifitegrast, Novartis) OU BID with continued complaints of burning and eye fatigue, her symptoms were worse toward the end of the day and with prolonged computer use.

Exam

A baseline exam revealed positive symptoms of dry eye disease based on the SPEED survey. Clinical findings were significant for hyperosmolarity with an inter-eye difference > 7 mOsm, as well as a rapid tear breakup time. After making the diagnosis of dry eye disease, the meibomian glands were evaluated to determine if evaporative dry eye was present. Meibomian gland evaluation using the Meibomian Gland Evaluator (MGE) revealed a decrease in the number of glands performing optimally. For her right eye, 7/15 glands were found to be secreting clear meibum on MGE, and in the left eye, only 2/15 glands were found to have clear secretions. On LipiView II (Johnson & Johnson Vision) analysis, her lipid layer thickness was decreased at 58 nm OD and 57 nm OS.

Interestingly, although the glands were performing suboptimally, the gland structure (Figure) was quite good, showing very minimal gland atrophy with only mild segmentation noted.

Diagnosis

Based on examination, this patient was found to have predominantly evaporative dry eye disease. It was Stage 2 based on findings from her meibomian gland function of her left eye.

Treatment

I continued therapy with lifitegrast 1 gtt OU BID. Meibomain gland clearing with in-office TearCare (Sight Sciences) was recommended. The patient opted for same-day treatment. The smart lids were then placed on the outer eyelids, and the 15-minute warming treatment was initiated. Immediately following this, one drop of proparacaine was instilled OU and manual gland clearing was initiated at the slit lamp. Gland clearing was performed using the LEO method of gland clearing, and copious meibum expressed from the glands. The patient was instructed to continue her at-home heat therapy in addition to her medicated eye drops and continue use of her lipid-based artificial tears as needed. A return visit was scheduled for 1 month post-gland clearing.

Follow-up

Upon her return visit 1 month post-TearCare, this patient reported a significant improvement of symptoms. She was able to read longer into the day and use a computer with increased comfort.

Being an effective leader in your practice requires basic leadership skills to achieve the Four I’s. A good leader always strives to optimize impact for excellent patient care and practice success. Whether it is developing a new process or refining an old one, these four skills are essential to success:

1. Have a clear vision for what you want to achieve and how you are going to approach the diagnosis and management of dry eye.

2. Communicate it clearly with your entire office team. Make sure that everyone is involved in the process. Remember that your office team members have more contact time with your patients than you do, so make sure they all can identify their role in the dry eye process, as well as how they each can contribute to successful patient identification and outcomes.

3. Make it clear to your patients that dry eye identification and management is part of what you do. This can be achieved through in-office marketing tools.

4. Be proactive. Don’t get caught up in the chicken versus the egg game. You have the aptitude and ability to bring this service to a population that has the need. Engage with your patients. Ask questions, and be an attentive and active listener. Make sure that your patient base knows that you are there to help diagnose and manage their dry eye problem.

Conclusion

Patients are armed with more knowledge today than ever before, and that means you have to be more aware of what they are seeking and rise to the occasion to address their needs. Dry eye is an area of practice where patients' needs are great, and the key to recognizing your practice potential could lie with your ability to properly diagnose and manage the condition. Using tools to identify and manage meibomian gland obstruction plays a pivotal role in doing this.

Incorporating the diagnosis and management of dry eye isn’t simply a process of counting the why’s, but may be better answered by saying why not!

Indications for Use: TearCare® is indicated for the application of localized heat when the current medical community recommends the application of a warm compress to the eyelids. Such applications would include Meibomian Gland Dysfunction (MGD), Dry Eye, or Blepharitis. TearCare may not be right for everyone. Please see Instructions for Use or visit TearCare.com for Contraindications, Warnings, and Precautions.

TearCare® is a registered trademark of Sight Sciences.

SmartLids™, SmartHub™, and Clearance Assistant™ are trademarks of Sight Sciences and for use only by Sight Sciences.

© 2020 Sight Sciences, Inc. 5/20 TC-1006-US.v2