Dry Eye Dx and Tx
Starting a Dry Eye “Center”
BY SCOTT SCHACHTER, OD, & AMBER GAUME GIANNONI, OD, FAAO
Practitioners have asked how to do more with dry eye disease in their practices. They ask if you must block off specified times to see only dry eye patients or add an exam room. But the beauty of building a dry eye practice is in its simplicity and affordability. You don’t have to build a costly center, you only need to create a reasonable protocol. Scott Schachter, OD, discusses how he accomplished this in his practice.
When I set out to manage dry eye disease on a routine basis, I knew it needed to be an efficient process to fit in with our busy practice. I looked for the most meaningful parameters that would accurately diagnose the disease, guide my treatment, and monitor the effectiveness of my plan.
My initial protocol included about half a dozen diagnostic tests, but I ultimately deemed this too time consuming and have pared it down to what I believe are the tests most effective for my practice (Table 1). You may not agree with my choices, but I encourage you to put a system in place based on what matters most to you.
|Test||What it Assesses||Time to Perform||Staff or Practitioner|
|Phenol red thread||Tear volume||15 seconds||Staff|
|Corneal staining||Surface damage/potential effect on vision||30 seconds||Practitioner|
|Lid evaluation and gland expression||Signs of meibomian gland dysfunction||30 to 60 seconds||Practitioner|
Note that patient symptoms are not a prominent part of my protocol. While assessing for symptoms is important, they often don’t match clinical signs and frequently don’t manifest consistently until the disease has progressed. I prefer to detect early disease states rather than waiting for patients to inform me.
My current protocol takes about four minutes and is conducted largely by staff. It begins with a 15-second phenol red thread test, performed on all contact lens wearers ≥ 30 years old and on any patient who complains of dry eye symptoms. If tear production is 15mm or less, or if a patient is symptomatic, my staff performs the InflammaDry test (Rapid Pathogen Screening). If the result is positive, I immediately instill fluorescein dye when the patient gets to my exam room. I don’t use an added anesthetic because it can cause staining. It is critical to wait a few minutes before assessing for staining, so I often refract patients or review images to keep the exam moving forward. I also evaluate the lids and express the meibomian glands for signs of meibomian gland dysfunction (MGD).
When a patient tests positive for ocular surface inflammation and has signs or symptoms of dry eye disease, I initiate anti-inflammatory therapy (often topical ophthalmic cyclosporine) to address the underlying mechanism. If MGD is the culprit, I also begin hot compresses and omega-3 supplementation. I schedule a follow-up exam to ensure that the treatment is effective as well.
Dry eye disease is a chronic, progressive, and underdiagnosed condition, and it affects how our patients look, feel, and see. Surely, it deserves four minutes of our time. CLS
Dr. Schachter is in a practice in Pismo Beach, CA that focuses on demodex blepharitis. He has been a Vision Source administrator since 2003. He is a consultant for Allergan and Bio-Tissue. Dr. Gaume Giannoni is a clinical associate professor at the University of Houston College of Optometry and the Co-Director/Co-Founder of the Dry Eye Center at the University Eye Institute. She also sees patients in a private practice setting and has received authorship honoraria from Bausch + Lomb.