February 13, 2017
3 min read

Dry eye: Emphasis on treatment, not testing

Melissa Toyos, MD, FACS, explains the reasons why her practice stopped testing for dry eye.

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Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.

In January, I discussed the need for multiple tear osmolarity tests to gain the true benefit from dry eye testing. This month, Melissa Toyos, MD, FACS, takes another viewpoint. She no longer relies on dry eye testing. In this column, she will explain her strategy. We hope you enjoy the discussion.

Kenneth A. Beckman, MD, FACS

I recently stopped all conversational traffic in an ophthalmology meeting I was attending by announcing that I was no longer offering dry eye testing in our clinics. After years of investigating and utilizing the multitude of currently available dry eye tests, I finally decided that the best choice was to “go bare” — back to the old standards of relying on the patient’s subjective complaints paired with my slit lamp exam. And just like in those nightmares, there were a few uncomfortable moments in which everyone simply turned and stared at me. But I held my ground because I have my reasons: time, energy and money.

Melissa Toyos


Almost every one of the new dry eye tests is faster and less invasive than what we used to do: Schirmer’s. But if a test does not change my diagnosis or treatment, does it matter if it is faster? None of the currently available methods for testing — Schirmer’s, validated questionnaires, tear osmolarity, tear breakup time, Sjö, MMP-9 — are definitive. Because they are non-definitive and each may reflect a different quality of dry eye, none of us can decide which test is the most important. Our confusion has also affected the FDA and its standards for dry eye medication approval. Even though the tests are faster, they do not add to my diagnosis or treatment, so any time they take up is wasted time. Until there is something like a pregnancy test for dry eye, I am sticking to my original plan.


The numbers on my technicians’ Fitbits went through the roof when we adopted TearLab. Whatever time and energy we saved by not performing Schirmer’s was chewed up and then some by the back and forth running from patient to docking station, and back again if the sample was not sufficient. Docking stations in each room helped, but having a numeric value to attach to dry eye became less useful when the generated number did not support the patient’s experience or exam. I spent a Schirmer’s test worth of time and then some trying to rationalize the discrepancy. My Fitbit numbers went up as I began backpedaling, trying to explain treatment plans to my patients in part based on numbers that did not make sense.


The final straw was money. My practice’s reimbursements for dry eye testing, which admittedly can vary wildly between insurance plans and geographic regions, were regularly less than the cost of the test. We did not have the time, resources or inclinations to figure out which patients could or could not receive testing. Beyond that, our private practice is significantly comprised of patients paying out of pocket for their dry eye care, and we are acutely sensitive to providing value to our patients.


In the end, I base my treatment decisions on the patients’ symptoms and on a thorough slit lamp exam with staining. Dry eye testing often supported but never changed my decisions. Obamacare is on the chopping block, but high-deductible insurance plans and out-of-pocket costs for patients are here to stay. The best use of our patients’ resources is to give them an accurate diagnosis and a treatment that will make a noticeable difference in their dry eye disease. For our patients, that may be fish oil, a prescription for an eye drop, intense pulsed light therapy or specialty serum tears. There is no value in spending money on a battery of tests that tell patients what they (and you) likely already know — that they have dry eyes — instead of on something that could help them mitigate or cure the problem.

You will be interested to know that after I explained my rationale in the meeting, other ophthalmologists raised their hands to say that they too were either not using dry eye testing in the office or were planning to stop offering it. One day there may be a better dry eye test that is more impactful in my decision making. Until that day arrives, my patients, my technicians and I are freer. My clinics run more smoothly, we have fewer reimbursement hassles from insurance, and my patients are happier because they are using their money to address the problem, not just test it to death.

Disclosure: Toyos reports she is a speaker, consultant and does research for Shire; does research for Kala; is a consultant and does research for PRN Omega; and is a consultant for Magellan PRP. Her husband, Rolando Toyos, MD, invented IPL.