Dr. Gupta’s blog is designed to cover the latest innovations in ocular surface and MGD diagnosis and treatment from a practical, clinical perspective. Topics will range from dry eye demographics to treatment pearls and workflow tips and tricks, all focusing on real-world implementation of techniques and technologies.

BLOG: Practice blueprint: Build the structure for routine dry eye care

Screening, diagnosis and treatment for dry eye disease give patients the comfort, clear vision and targeted surgical outcomes they deserve. Eight years ago, when I was completing my training, there were few diagnostic tools for dry eye, and the primary therapies were over-the-counter drops, nutritional supplements and cyclosporine. Over the last few years, there has been an explosion of new therapies to treat dry eye and meibomian gland dysfunction. With new treatment options to offer and more patients seeking care, we developed a dry eye program with dedicated staff to not only help to provide these treatments, but also support this patient population’s needs.

Whether you want to take on dry eye on your own or with a dedicated practitioner, here’s how I recommend you get started:

Ease into it: There’s a misperception that dry eye is very time-consuming. That can be true in some complex cases, but for the vast majority of patients, you just need to make a formal process for routine screening and have treatment algorithms ready to go.

Adjust your clinical exam: You don’t have to make a large capital outlay to start diagnosing dry eye. A good clinical exam is very effective. Look at the conjunctival and corneal surfaces, expressibility of the meibomian glands and eyelid position to pinpoint the etiology.

Acquire diagnostic tests: Next, you should acquire some key diagnostic tests. Meibography (LipiView, Johnson & Johnson Vision) is very important because seeing the meibomian gland structure allows you to stage MGD according to the amount of atrophy you see. It also helps you explain MGD to patients and show them the improvement after treatment. Osmolarity testing (TearLab osmolarity test) is a reliable screening test with a high specificity. Patients with a normal osmolarity score who have symptoms of dry eye may have a masquerading condition such as conjunctivochalasis or allergic disease. MMP-9 testing (InflammaDry, Quidel) can also be valuable to identify excessive levels of inflammation on the ocular surface.

Treat underlying causes: A clinical exam and diagnostic testing can help to guide your treatment. I divide treatment broadly into two categories: anti-inflammatory therapies and treatments for MGD. These categories are complementary, not mutually exclusive, and it is important to address both MGD and chronic or episodic inflammation.

To treat the underlying inflammation of dry eye disease, we can prescribe Restasis (cyclosporine, Allergan), Xiidra (lifitegrast, Takeda) and/or intermittent topical steroids for flare-ups. For the management of MGD, there are several options to evacuate the inspissated meibum from the glands: LipiFlow (Johnson & Johnson Vision), intense pulsed light therapy (M22, Lumenis), iLux (Alcon) and TearCare (Sight Sciences).

Adjust your flow: Routine screening and new technologies don’t need to disturb patient flow. Patients who come to our practice for ocular disease or surgery don’t notice any difference in the time we spend on dry eye diagnostics. Making dry eye part of your clinical exam adds less than 1 minute, and simple point-of-care tests like tear osmolarity similarly don’t impede technician workflow. You can reserve meibography for MGD suspects or perform it as a baseline for all dry eye patients before initiating a therapy. If a patient visits for another chief complaint and you find dry eye, you can schedule more in-depth testing and treatment for a dedicated dry eye visit.

Each practice workflow differs in how they choose to offer treatments as well. For example, I perform LipiFlow treatment the same day as an initial dry eye visit if the patient is interested, but if we decide on IPL, I generally schedule that for a separate session.

Prepare for growth: Dry eye patients are everywhere, including in your practice right now. Once you start screening — especially if you include point-of-care testing that can identify disease before symptoms — your volume and demand will grow.

Build a dedicated dry eye team: At some point, my colleagues and I realized that a dedicated care team would give both dry eye patients and physicians a better experience. Who should lead the team? Choose a clinician who has an interest in ocular surface disease and is excited to take care of dry eye patients. Choose technicians who are passionate about this topic, have a caring attitude and can make personal connections with patients. It’s also important to have one or two staff members serve as points of contact for patients’ questions after they leave the office.

We’ve succeeded with a collaborative model, where multiple people care for our dry eye patients. Patients get a diagnosis and treatment while enjoying excellent continuity of care. If the need for dry eye diagnosis and treatment isn’t being met in your practice or your community, then don’t hesitate to get started and grow your dry eye practice.

 

Disclosure: Gupta reports she is a consultant to Allergan, Alcon, Bio-Tissue, Johnson & Johnson Vision, Kala, NovaBay, Oyster Point Pharmaceuticals, Ocular Science, Shire, TearLab and Zeiss.