The logistics of integrating new diagnostics and technology into the office flow can be daunting, as can the necessity of educating not only the patients, but the office staff and the physicians themselves, on dry eye and available treatments. Addressing concerns with patients can be difficult unless everyone involved fully understands the root causes, implications, and treatment options for this widespread disease. Making dry eye an integral part of the office paradigm can ease the way into better vision for our patients.
Integrating Dry Eye Diagnosis into the Office Flow
Our understanding of the etiology and prevalence of dry eye disease (DED) has improved significantly over the past two decades, to the point that we strongly feel that caring for our patients properly must include aggressive diagnosis and management of the disease across our patient population. Likewise, if a patient has a problem they want it attended to yesterday.
Consequently, we have adapted our typical routine to include screening and diagnosis of DED for every patient that walks in the door.
Our technicians administer the SPEED questionnaire during the regular course of documenting patient history. Depending on the patient’s score, we will inform the patient that the doctor requires additional diagnostics in order to assess any dry eye issues. Insurance information is captured upon initiation of the appointment, and staff prepares each patient file with information on diagnostic testing coverage so that patients can make financially informed decisions.
If they consent, as most do, the technician will perform osmolarity testing (TearLab), testing for matrix metalloproteinase-9 (MMP-9) with InflammaDry® (RPS), a tear film analysis and meibography with LipiView® (TearScience), and scatter analysis with the HD analyzer (Visiometrics).
Many eye care providers fear that integrating dry eye diagnostics into the office may disrupt flow and increase chair time. There are also concerns that the capital outlay for a comprehensive DED diagnostic center is prohibitive. On the contrary, the majority of tests are completed quickly and by technicians, and the return on investment has more than made up for our capital outlay. What has made our practice a success is undoubtedly a comprehensive patient education program.
The Critical Importance of Education
First and foremost, physicians must become fully educated on dry eye and its multi-factorial components. No one tool will work for every patient and root causes must be addressed or therapies will not work which leads to frustrated patients and dissatisfaction with products. As the majority of patients who walk through the door will have some aspect of DED, it is imperative to have sufficient knowledge to diagnose, treat, and educate each patient.
Education of the office staff is also of critical importance as this provides consistency across the practice and reinforces recommendations that are established. This in turn improves compliance with treatment plans.
Patients must also become informed. Patients today seem to respond best to an evidence-based approach to medical care. If they understand all the aspects of their condition and care, compliance rates improve significantly. To this end, we offer multiple points of education to optimize their comprehension. Upon making the appointment, patients are directed to our website which has a wealth of information on DED and its causes and treatments. We also use the interactive patient engagement platform CheckedUp (iDoc, Inc.) which guides patients through the diagnostics, products, and disease process. A link to the interactive content is sent to the patient prior to the appointment when possible and is available in office.
At the time of the appointment, our technicians are trained and educated to introduce DED and its components to the patient. Additionally, the patient will speak to our counselor who will continue the discussion on both the disease and possible steps for treatment. The counselor does not diagnose, but can explain abnormalities versus normal pathology. She will also go over a few basic aspects of care, discuss the multi-factorial nature of this disease, explain the need for diagnostics, and provide an overview basic treatment options. The role of our counselor is crucial to minimize chair time.
Another program we have instituted to assist in patient education is our monthly dry eye waiting room education program. Essentially, we hold a mini-class in our waiting room during which we provide a detailed discussion of the disease and treatment. The atmosphere is more relaxed and many patients do research ahead of time, come prepared with questions for discussion, and leave with a much better understanding of DED, its causes, and possible treatment options.
We have found that if patients have at least a cursory knowledge of dry eye, they are more receptive, understanding, and well enough versed on the subject to ask specific questions when they meet with the doctor. This makes the doctor’s job much easier when persuading the patient to embrace the recommended treatment.
Multiple Treatment Therapies
As dry eye is a multi-factorial, chronic disease, no one treatment will completely address all symptoms. We typically approach the patient with the fact that they will be best served if we identify all the relevant contributing factors that are involved in their unique presentation and arrive at treatment plans that addresses each of those concurrently. With a targeted approach for all aspects of the disease, we can have a more meaningful impact on improving symptoms and addressing the clinical signs.
We have found dietary supplements containing omega-3 fatty acids, particularly gamma linolenic acid (GLA), to be especially beneficial for dry eye and recommend HydroEye® (ScienceBased Health). Omega-3 fatty acids are known to be anti-inflammatory, and GLA works through a unique pathway that appears to target DED symptoms specifically. Unlike other products, HydroEye has been shown in a clinical trial to have significant benefits for DED.[i] It is also well tolerated by patients as it has a smaller gel cap than other brands and is primarily plant-based. We sell it in office for our patients’ convenience or they can order it online. Recommending one product and making it readily available improves compliance and prevents our patients from ending up with alternative of unknown quality.
The immunomodulator Restasis® (cyclosporine ophthalmic emulsion, Allergan) has greatly improved our ability to treat our dry eye patients since it was approved over a decade ago, and we have also started using Xiidra® (lifitegrast ophthalmic solution, Shire), another immunomodulator that has a different mechanism of action and was approved by the FDA in 2016. In addition, we incorporate lid hygiene products such as BlephEx® (Rysurg) and recommend warm compresses for lid health. Our goal is to treat the full multi-factorial spectrum of this disease to achieve an overall healthier ocular surface and relieve the patient.
If we keep educated and elevate dry eye care to the level of rigor and discipline that we exercise in managing glaucoma, cataracts, and corneal disease, patients will be more engaged and adherent to treatment regimens and overall outcomes will improve across the board.
[i] Sheppard JD, Pflugfelder SC. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea: 2013 Oct; 32(10): 1297–1304.