Dry eye in the plague
Can you treat dry eye with telemedicine?
“I call on my colleagues not to become virtual doctors, but remain actual doctors using virtual technology.”
– Paula Muto, MD, FACS
This column was written on April 12, 2020. As I write, I, like all of you, am locked down in my house, locked out of my practice by a government that has declared what you and I do as nonessential. From the look of things, we may be in the exact same spot when this is published sometime in late May. How are you all doing? Are you OK? I am not going to lie — not going to work has been tough. It is getting tougher as more and more of our patients, dry eye and otherwise, reach out for help.
Dry eye disease is a chronic disease with symptoms and signs that wax and wane. How in the world are we going to take care of these patients if we cannot see them?
While I was pondering this rather existential question, I flashed back to a rather bold statement by Drs. Rolando and Melissa Toyos about point-of-care testing and DED care. To refresh everyone’s memory, Drs. Toyos took a firm position that our presently available point-of-care tests, tear osmolarity and MMP-9 activity, are unnecessary. Because they have already left behind “in the flesh” tests that many of us consider rather essential, who better to ask about how we should be caring for DED patients when we cannot actually see them?
By way of introduction, should it be necessary, Dr. Ro and Dr. Melissa are highly respected, well-known DED experts who have devoted a significant percentage of their considerable talents and practice resources to DED treatment. They are quite properly famous worldwide for a number of things, most prominently the use of intense pulsed light in the treatment of meibomian gland dysfunction and DED. My phone call intrusion was tolerated with grace and good humor. It was a pleasure to be in their company and toss around ideas about taking care of our DED patients during the COVID-19 pandemic. We talked at length about all facets of telemedicine, using both dedicated portals and MacGyvered strategies with Zoom and FaceTime (more on both in a moment).
Let me cut to the chase: Can you use telemedicine to care for DED patients? The short answer is no. Without having a slit lamp with which to examine your patient, you simply cannot provide the kind of care we all view as basic DED care. In order to do so, we must have the ability to evaluate corneal and conjunctival staining using both fluorescein and lissamine green. We need to be able to get a sense of tear break-up time. In the setting of DED and a red eye, it is important to determine if either papillae or follicles are present. None of these can be reliably determined without the use of a slit lamp. To date, there is neither an app nor a “MacGyver” solution for this.
Having said this, Dr. Ro, Dr. Melissa and I agree that there is still quite a bit of information that we can glean through the use of telemedicine. There is considerable benefit that DED doctors can provide to patients who must be seen remotely, now and in the future. The Drs. Toyos have broken down their DED patients into three groups, with slightly different approaches applied to each. In general, your requests for telemedicine visits will come from well-known, established patients, new patients who have had their DED treated elsewhere and new patients for whom everything about them is new, including their symptoms. For what it is worth, a similar approach can likely be applied to many of your non-DED patients.
As is always the case, you (or your staff) will glean the majority of information necessary to make a treatment decision by taking the patient’s history. This can be supplemented with photos taken by your patient and shared as a file on your telemedicine platform, emailed or texted to you or a staff member. Of course, your established patients will have a record; you will know their IOP, for example, and you may know whether or not they have had elevated IOP associated with topical steroids. Your history may show that a patient is having a problem that has occurred in the past, allowing you to make an educated attempt to treat without the usual objective data available.
We agreed that each practice will need to set formal guidelines about how they will address new patients of all kinds. Some will simply say that it is impossible to do so without at least one prior exam. Others, such as SkyVision and Toyos Clinic, will attempt to get enough information from a new patient with a history of DED treatment and then try to treat if possible. Some things are pretty straightforward, especially if a patient is able to send you a decent photo or if the image on the telemedicine platform has high enough resolution. Think chalazion or obviously inflamed eyelids from MGD. We have lots of low-risk/high-benefit treatments at our disposal, in both the pharmaceutical (any immunomodulator such as cyclosporine or lifitegrast) and device (the brilliant Toyos home light therapy, the “Q,” found at www.youtube.com/watch?v=9XdKt4EjvLU at the 6-minute mark) realms. These can be prescribed with a high degree of safety, even in those new patients with new problems.
What does telemedicine look like? If you are like me, Dr. Melissa and Dr. Ro, you have likely been doing Dr. MacGyver telemedicine, using ad hoc communication methods such as email, text and telephone calls, for a long time. Two things are different now. There are a number of established telemedicine platforms; we are using doxy.me. Your EMR may have a built-in option; Modernizing Medicine is one example. Secondly, CMS and insurance companies are handling telemedicine differently now. HIPAA regulations have been significantly relaxed (making Skype, FaceTime and Zoom viable options), and payment can now be expected for these services (you may need to have a commercially insured patient sign an advanced beneficiary notice). At SkyVision, we have created a protocol that mimics a physical visit (front desk check-in; tech opens visit and takes history; doctor “examines,” diagnoses and prescribes) and plan to continue to offer telemedicine visits after the lockout is lifted.
This whole COVID-19 stuff has been a bummer. Being told that what we do is nonessential stings. My Saturday morning phone call with Drs. Ro and Melissa was a ray of sunshine in a dark time. I came away from it with some good ideas about how to proceed as SkyVision telemedicine starts to remotely care for our large DED patient population. It was a delight to be in the presence of such intelligence, experience and grace.
And I really enjoyed chatting with Dr. Ro, too!
- Telemedicine: A good but incomplete answer. The Wall Street Journal. www.wsj.com/articles/telemedicine-a-good-but-incomplete-answer-11585687717. Published March 31, 2020.
- For more information:
- Darrell E. White, MD, can be reached at SkyVision Centers, 2237 Crocker Road, Suite 100, Westlake, OH 44145; email: firstname.lastname@example.org.
Disclosure: White reports he is a consultant to Allergan, Shire, Sun, Kala, Ocular Science, Rendia, TearLab, Eyevance and Omeros; is a speaker for Shire, Allergan, Omeros and Sun; and has an ownership interest in Ocular Science and Eyevance.