DRY EYE DX AND TX
SEEING AND TREATING THE DRY EYE
KATHERINE M. MASTROTA, MS, OD
As we head into 2017, perhaps you are considering providing specialty services in dry eye/ocular surface disease/eye and eyelid wellness. A common barrier to many practitioners is the concern that their practice does not have the patient foundation to make the investment economically profitable. I assure you that ocular surface disease (OSD) management will “profit” patients in many ways that include clearer, more comfortable vision as well as enhanced productivity and overall well-being.
Which patients in your practice can benefit from your new OSD specialty? How can you identify them? Where can you find them? How can you help them? Following are my stream-of-consciousness answers.
Patients who have or are at risk for OSD (Baudouin et al, 2016) include, but are not limited to, all diabetic patients; glaucoma patients on topical or oral therapy; post-ocular surgery patients; patients who have sleep apnea/continuous positive airway pressure (CPAP) users; patients who have allergy, asthma, or atopic skin disease/dermatologic disease (especially rosacea); and all smokers (tobacco or e-cigarettes) and those exposed to second-hand smoke.
There is an association between pseudoexfoliation and dry eye. In addition, at-risk patients include all females in the menopausal/peri-menopausal age range and those on hormone therapy. Patients who have arthritis or other autoimmune disease and/or patients who see another specialty provider for any chronic disease are dry eye suspects. Also include patients who have blepharitis/meibomian gland dysfunction/basement membrane dystrophy or any corneal disease.
Add patients who have recurrent “conjunctivitis,” or patients who have had true conjunctivitis of any etiology, as well as all patients who excessively use computers/digital devices. Also include patients who wear makeup and/or contact lenses; patients who work for airlines, in hospitals, hotels, or in any environmentally controlled settings (dry heat or air conditioning) or in buildings with old ventilation systems. Patients in homes/offices with carpeting or homes/offices in the top 20 states whose air quality or allergen count is high are also prime OSD candidates. Include patients who cut grass, work around or use chemicals on a daily basis, or travel frequently. Patients who have Parkinson’s disease and incomplete blinkers fit the OSD risk profile.
I hope you are starting to see that practically every patient you encounter is at risk for OSD.
Educate your staff about OSD. Provide an educational brochure to patients and to referring primary/specialty care doctors (especially endocrinologists, allergists, and pediatricians). Use a questionnaire designed with occupation-specific, medication-specific, health-information/allergy-specific, and Ocular Surface Disease Index/Standard Patient Evaluation of Eye Dryness or other verified dry eye screening tool questions.
Use keratometry on all patients to observe the tear film/mire quality and topography to identify any other irregularity. Establish tear osmolarity, if available, on every patient as a baseline or screening. If you have it, document digital ocular redness assessment, tear meniscus height, tear stability, lipid layer thickness, and meibography on every patient. Perform eyelash rotation to identify/quantify Demodex. Eyelid photography as baseline documentation should be included in patients’ ocular surface and tear profile.
Recommend office-based lid/lid margin microblepharoexfoliation to blepharitis patients. Offer lid hygiene products, omega supplements, and occlusion products (e.g., eye masks/specialty eyewear/CPAP eye protection) in your office.
Go forth, educate, and treat. Besides the aforementioned benefits, these efforts will help ensure successful ocular surgery (including injections) with better pre-operative data and reduced infection risk. Aesthetics will be improved, contact lenses will be worn longer, and you will have happier patients. CLS
For references, please visit www.clspectrum.com/references and click on document #253.
Dr. Mastrota is Clinical Director of the Omni Eye Surgery Center for Dry Eye Specialty Care. She is a consultant or advisor to Allergan, B+L, Bio-Tissue, OcuSoft, Paragon Bioteck, and Shire and is a stock shareholder of TearLab Corporation. Contact her at firstname.lastname@example.org.