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Developing a dry eye clinic, part 2: The traditional dry eye practice

A three-part series explores the idea of developing a dry eye service in your practice.

In order to build a true dry eye practice, it is first necessary to make an open commitment to care for the dry eye patient. As pointed out in part 1 of this series, if you build a dry eye practice, dry eye patients will find you and they will come to your practice. In part 2, I will explore how to develop a traditional dry eye practice. The protocols for this type of practice can easily be layered onto your existing exams and can be done so without making any capital investments.

The nuts and bolts of a traditional dry eye practice are actually the building blocks on which an advanced dry eye practice is built. Every aspect of the traditional dry eye practice is a necessary part of comprehensive dry eye referral practices. Perhaps a better name than “traditional” might be “foundational.” Not unlike my beloved fitness program CrossFit, all of the individual “pieces/parts” of your new dry eye service are already in place. The magic will be in how you utilize these elements as a more effective whole, just as the magic of CrossFit is in how traditional exercises are combined in a unique fashion to more efficiently increase fitness.

Everyone in the practice should be empowered to put your dry eye protocol in motion. The driving force behind this step is patient symptoms. From the moment a patient reaches out to the practice, an effort should be made to determine if he might have symptoms of dry eye. In an ideal world, this step is never left to the last doctor to see a patient on any given visit. Once you have identified an individual as a potential dry eye patient, essentially all aspects of your traditional dry eye protocol will come into play over the course of that visit.*

Tests and examination

Once a patient is flagged, measure symptoms qualitatively and quantitatively using one of the myriad dry eye questionnaires. The simplest to use in the traditional setting is the Ocular Surface Disease Index (OSDI). Reviewing the answers to individual questions will allow you to drill down on the issues of importance for your patient, and the numerical score will give you a sense of both the overall severity of her symptoms as well as trends. Remember, for the most part your patient is not interested in corneal staining or tear break-up time, but she is interested in how she feels and sees.

There are no fancy-dancy tests to do at this point in the traditional dry eye clinic. If you are a solo doc and you do most of the technical aspects of the exam yourself, you are now off and running with the knowledge that you are looking for dry eye. If your standard patient flow protocol is designed around the concept of having the doctor only engage with the patient one time per visit (the SkyVision model), it is perfectly acceptable to allow your technician to check IOP and dilate the patient at this point. I know, the sanctity of the virgin surface and all that, but in reality what you see after checking the pressure and instilling dilating drops is still significant and actionable.

The only real decision that must be made before dilation is whether or not you will do a Schirmer test. Your protocol could direct you to the room for a pre-check (the purist’s approach), or you could have this as part of your protocol for any OSDI above a certain number. I find it much more useful to know what the pseudo-baseline tear generation is than the reflex tearing rate. Checking the Schirmer after anesthetic gives you this number. This is a measurement of tear volume or quantity; 8 mm to 10 mm and higher is normal, and anything under 6 mm is a sure indication of pathology that you will treat.

Whether or not your patient has been anesthetized or dilated, you are now at the slit lamp and ready to do the whole doctor thing. Start with a purposeful evaluation of the lids and meibomian glands. Look for telangiectatic vessels and ulceration. Can you see the individual gland orifices? Push on the lid margin and record what comes out of the meibomian glands. Normal expression should look like peanut oil; anything else is abnormal.

Next, examine the tear film itself. Is the meniscus uniformly distributed across the entire inferior aspect of the eye? Is there what you would consider a normal tear volume? There should be no debris of any kind in the tear film. Place a small amount of fluorescein dye in the inferior fornix. I like to use a fluorescein strip that has one drop of saline wash applied to the tip. Simple is better. The presence of any staining on the cornea or conjunctiva is your indication for the presence of inflammation in the traditional dry eye clinic. Ask the patient to blink and count how long it takes for a single dark “break-up” spot to appear. Do each eye individually. A normal tear break-up time is greater than 8 to 10 seconds; anything under 6 seconds is abnormal and should be treated.

Treatment

That’s it. Four simple observations and one simple test, and you are ready to treat. Gauge the intensity of your treatment according to the severity of your patient’s symptoms. Everyone should probably receive an artificial tear recommendation as part of treatment. The sophisticated “no-brainer” tear if you want just one is Blink (Abbott Medical Optics): It is hypotonic to counteract presumed elevated osmolarity, and it supports the outer tear surface to decrease evaporation. How much or how little tear use reported on subsequent visits is a nice proxy for the effectiveness of your treatment.

There is no reason to shy away from writing prescriptions for dry eye patients in a traditional practice. We all did it for years before point-of-service tests were available. If staining is present, have your pen ready. Any sign of inflammation should prompt you to prescribe. Anything more than mild symptoms, a low tear level and/or a Schirmer under 6 mm with any degree of staining calls for Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan). A normal tear level with a rapid tear break-up time, especially in the setting of abnormal meibomian glands, is your signal to use AzaSite (azithromycin ophthalmic solution 1%, Akorn) plus standard mechanical lid therapy. It gets tricky when you have a little bit of everything: low tear volume, quick tear break-up time, staining and perhaps abnormal meibomian glands. You will have to make a judgment call on which is the primary problem: tear quantity or tear quality. In general at this point I would opt for the greatest amount of anti-inflammatory effect and prescribe Restasis.**

For years this is how dry eye was treated in the days before point-of-service testing and direct eyelid treatments. Every examination element noted is part of the foundation of dry eye care and is a necessary component of any dry eye protocol. You already do it every day. In part 3, we will finish up with the advanced dry eye clinic.

*A quick note on vision care plans for those who participate: Most of the major plans do not pay for point-of-service dry eye testing. The purpose of using your traditional/foundational dry eye protocol even on vision care patient visits is to establish the diagnosis of dry eye. All subsequent visits for diagnosis and care are then properly billed as medical encounters.

**In a traditional dry eye clinic, topical steroids are only used as an adjunct to improve Restasis initiation or as a secondary option for more serious cases.

Disclosure: White reports he is a consultant for Bausch + Lomb, Allergan, Shire and Eyemaginations and on the speakers board for Bausch + Lomb, Allergan and Shire.

In order to build a true dry eye practice, it is first necessary to make an open commitment to care for the dry eye patient. As pointed out in part 1 of this series, if you build a dry eye practice, dry eye patients will find you and they will come to your practice. In part 2, I will explore how to develop a traditional dry eye practice. The protocols for this type of practice can easily be layered onto your existing exams and can be done so without making any capital investments.

The nuts and bolts of a traditional dry eye practice are actually the building blocks on which an advanced dry eye practice is built. Every aspect of the traditional dry eye practice is a necessary part of comprehensive dry eye referral practices. Perhaps a better name than “traditional” might be “foundational.” Not unlike my beloved fitness program CrossFit, all of the individual “pieces/parts” of your new dry eye service are already in place. The magic will be in how you utilize these elements as a more effective whole, just as the magic of CrossFit is in how traditional exercises are combined in a unique fashion to more efficiently increase fitness.

Everyone in the practice should be empowered to put your dry eye protocol in motion. The driving force behind this step is patient symptoms. From the moment a patient reaches out to the practice, an effort should be made to determine if he might have symptoms of dry eye. In an ideal world, this step is never left to the last doctor to see a patient on any given visit. Once you have identified an individual as a potential dry eye patient, essentially all aspects of your traditional dry eye protocol will come into play over the course of that visit.*

Tests and examination

Once a patient is flagged, measure symptoms qualitatively and quantitatively using one of the myriad dry eye questionnaires. The simplest to use in the traditional setting is the Ocular Surface Disease Index (OSDI). Reviewing the answers to individual questions will allow you to drill down on the issues of importance for your patient, and the numerical score will give you a sense of both the overall severity of her symptoms as well as trends. Remember, for the most part your patient is not interested in corneal staining or tear break-up time, but she is interested in how she feels and sees.

There are no fancy-dancy tests to do at this point in the traditional dry eye clinic. If you are a solo doc and you do most of the technical aspects of the exam yourself, you are now off and running with the knowledge that you are looking for dry eye. If your standard patient flow protocol is designed around the concept of having the doctor only engage with the patient one time per visit (the SkyVision model), it is perfectly acceptable to allow your technician to check IOP and dilate the patient at this point. I know, the sanctity of the virgin surface and all that, but in reality what you see after checking the pressure and instilling dilating drops is still significant and actionable.

The only real decision that must be made before dilation is whether or not you will do a Schirmer test. Your protocol could direct you to the room for a pre-check (the purist’s approach), or you could have this as part of your protocol for any OSDI above a certain number. I find it much more useful to know what the pseudo-baseline tear generation is than the reflex tearing rate. Checking the Schirmer after anesthetic gives you this number. This is a measurement of tear volume or quantity; 8 mm to 10 mm and higher is normal, and anything under 6 mm is a sure indication of pathology that you will treat.

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Whether or not your patient has been anesthetized or dilated, you are now at the slit lamp and ready to do the whole doctor thing. Start with a purposeful evaluation of the lids and meibomian glands. Look for telangiectatic vessels and ulceration. Can you see the individual gland orifices? Push on the lid margin and record what comes out of the meibomian glands. Normal expression should look like peanut oil; anything else is abnormal.

Next, examine the tear film itself. Is the meniscus uniformly distributed across the entire inferior aspect of the eye? Is there what you would consider a normal tear volume? There should be no debris of any kind in the tear film. Place a small amount of fluorescein dye in the inferior fornix. I like to use a fluorescein strip that has one drop of saline wash applied to the tip. Simple is better. The presence of any staining on the cornea or conjunctiva is your indication for the presence of inflammation in the traditional dry eye clinic. Ask the patient to blink and count how long it takes for a single dark “break-up” spot to appear. Do each eye individually. A normal tear break-up time is greater than 8 to 10 seconds; anything under 6 seconds is abnormal and should be treated.

Treatment

That’s it. Four simple observations and one simple test, and you are ready to treat. Gauge the intensity of your treatment according to the severity of your patient’s symptoms. Everyone should probably receive an artificial tear recommendation as part of treatment. The sophisticated “no-brainer” tear if you want just one is Blink (Abbott Medical Optics): It is hypotonic to counteract presumed elevated osmolarity, and it supports the outer tear surface to decrease evaporation. How much or how little tear use reported on subsequent visits is a nice proxy for the effectiveness of your treatment.

There is no reason to shy away from writing prescriptions for dry eye patients in a traditional practice. We all did it for years before point-of-service tests were available. If staining is present, have your pen ready. Any sign of inflammation should prompt you to prescribe. Anything more than mild symptoms, a low tear level and/or a Schirmer under 6 mm with any degree of staining calls for Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan). A normal tear level with a rapid tear break-up time, especially in the setting of abnormal meibomian glands, is your signal to use AzaSite (azithromycin ophthalmic solution 1%, Akorn) plus standard mechanical lid therapy. It gets tricky when you have a little bit of everything: low tear volume, quick tear break-up time, staining and perhaps abnormal meibomian glands. You will have to make a judgment call on which is the primary problem: tear quantity or tear quality. In general at this point I would opt for the greatest amount of anti-inflammatory effect and prescribe Restasis.**

For years this is how dry eye was treated in the days before point-of-service testing and direct eyelid treatments. Every examination element noted is part of the foundation of dry eye care and is a necessary component of any dry eye protocol. You already do it every day. In part 3, we will finish up with the advanced dry eye clinic.

*A quick note on vision care plans for those who participate: Most of the major plans do not pay for point-of-service dry eye testing. The purpose of using your traditional/foundational dry eye protocol even on vision care patient visits is to establish the diagnosis of dry eye. All subsequent visits for diagnosis and care are then properly billed as medical encounters.

**In a traditional dry eye clinic, topical steroids are only used as an adjunct to improve Restasis initiation or as a secondary option for more serious cases.

Disclosure: White reports he is a consultant for Bausch + Lomb, Allergan, Shire and Eyemaginations and on the speakers board for Bausch + Lomb, Allergan and Shire.