Spotlight on dry eye: Create a process, offer packages

In my practice's tertiary, referral dry eye center, we create a customized treatment plan selected from a number of therapeutic options and tailored to achieve the best outcomes for each individual patient—no matter the severity of their disease.

We use everything from device-based procedures (ie, TearCare System [SightSciences], Systane iLux [Alcon], and LipiFlow [Johnson & Johnson Vision]), to numerous prescription products (Eysuvis [loteprednol etabonate ophthalmic suspension 0.25%; Kala Pharmaceuticals], Xiidra [lifitegrast ophthalmic solution 5%; Alcon], Restasis [cyclosporine ophthalmic emulsion 0.05%; Allergan, an Abbvie Company], and Cequa [cyclosporine ophthalmic solution 0.09%; Sun Ophthalmics]), plus biologic products (ie, Regener-Eyes [Regener-Eyes LLC] and Prokera [BioTissue]), and nutritional supplements (HydroEye; ScienceBased Health).

Cultivating positive word of mouth is a major component of growing any referral-based business. We are diligent with outreach to our OD network, providing them with continuing education programs and lectures. We also make use of our practice website and social media to share information about our services, and we plan on restarting patient open houses and seminars that were suspended due to the pandemic.

Dry eye management is an integral part of our practice; we do not view it as separate because it feeds into everything else we do. All patients receive ocular surface treatments to ensure success with their cataract/refractive surgery or anything else they are here for. As part of their surgical package, for example, all of our premium IOL patients automatically receive a device-based dry eye treatment. This is scheduled when they meet with our surgery coordinator.

OBJECTIVE INFORMATION ENHANCES PATIENTS' ADHERENCE

To match patients with the right therapies as well as ensure their adherence to treatment, we start with a comprehensive diagnostic evaluation that provides us with subjective and, more importantly, objective data. For the patient's subjective vantage point, we administer a questionnaire such as the OSDI or modified SPEED. We also ask patients about their symptoms and try to determine what is most bothersome. It may be blurred or fluctuating vision or perhaps pain and foreign body sensation.

The diagnostic workup, on the other hand, leverages objective tests to obtain detailed information about the patient's underlying disease. The results of these tests give us a roadmap for therapy and give us a way to show patients what is happening on their ocular surface, with visual evidence and numerical values. In our office, these include tear testing for osmolarity and inflammation as measured by MMP-9 (TearLab and InflammaDry; Quidel), dynamic meibomian gland imaging, and the corneal analyzer OPD-Scan III (Nidek) to evaluate the mires' appearance.

Information from the objective tests helps us educate patients about their condition. When they can see evidence of their dry eye, it motivates them to adhere to our treatment recommendations. If we tell patients their tear breakup time is 2 and they have 3+ superficial punctate keratitis at the slit lamp, that does not resonate. They will have a better grasp of their situation, however, when we show them distorted mires and significantly elevated osmolarity readings that indicate the dehydrated state of the tear film. We can refer to images of the meibomian glands when we explain that they are not producing enough oil. We might use the HD Analyzer (Visiometrics) to show the objective scatter index or Cassini Technologies' honeycomb pattern to show the tear film surface disruption.

THE MORE THEY KNOW...

When patients understand what the objective tests are telling us about their condition, we can get their buy in with treatment. They will be more likely to opt for the recommended in-office interventions and stick with their nutritional and pharmaceutical regimens. We suggest HydroEye nutritional supplement as part of our patients' care package because it is backed by scientific evidence from a clinical trial and data published in peer-review journals.

The omega fatty acid gamma linolenic acid (GLA), an anti-inflammatory omega-6 shown to play an important role in modulating the inflammatory response, is the product's key ingredient. A unique omega, GLA is lacking in fish or flax and is not found at meaningful levels in our diet. GLA has been validated for improving dry eye symptoms in a variety of studies performed across a wide range of patient types.1-7 HydroEye includes other omegas and nutrient cofactors in a specific balance formulated to provide dry eye relief, an approach that offers more targeted and comprehensive support than fish oil omega-3s alone.

I explain that, just one therapy will not be enough; the layered treatment approach is necessary to address the various underlying etiologies associated with their ocular surface disease. I explain that their disease, similar to a condition like high blood pressure, cannot be cured but it can be improved so that we can minimize its negative impact on their quality of life. We may do an in-office procedure on the spot, along with starting them on their prescription and nutritional regimens, or we may do an in office treatment at the next follow up. We describe for patients their individualized treatment plan that we developed based on the objective measures. Typically we see patients back in 6 weeks to evaluate their progress; we let them know that is how long it will take to see improvement and we emphasize the importance of their adherence. We must even be willing to "fire" a patient who will not commit to the treatment plan.

GETTING STARTED

It may seem overwhelming to get started managing dry eye with so many diagnostics and treatment options available, but with proper planning it does not have to be. I recommend creating a process with a stream-lined dry eye evaluation, starting small and simply with a few diagnostics. Along with the slit-lamp exam, this could include assessing tear breakup time, performing corneal staining, and imaging the meibomian glands. Get at least one device such as a corneal topographer to show patients objective signs of a dry ocular surface.

Next, develop the treatment plan and create a variety of dry eye packages for patients from as simple as a good OTC artificial tear to a full package with 3- to 6-month supply of HydroEye/TearCare single treatment/prescription for immunomodulator. Invest in at least one in-office therapeutic devices. Have a referral protocol for those patients you do not wish to treat, and consider selling products like HydroEye in the office for patients' convenience and to generate income.

CONCLUSION

Just like they would have an evaluation for cataracts, refractive surgery, keratoconus, or presbyopia, patients should receive a dry eye evaluation. The evaluation is associated with a process in terms of the accompanying diagnostic tests, treatment options, and pricing for the noncovered therapies. Be ready to explain the dry eye packages and their associated prices. Incorporating the appropriate diagnostics and treatments for dry eye to ensure comprehensive care of these patients should be a process-driven endeavor. By creating customized packages that incorporate the range of diagnostic and treatment options available, practices can simplify dry eye management and improve patients' outcomes.

Mitchell A. Jackson, MD

E: mjlaserdoc@msn.com

Jackson is the founder and CEO of Jacksoneye in Lake Villa, Illinois. He is a consultant to Alcon, Johnson & Johnson Vision, Sight Sciences, Tear Lab, Quidel, and ScienceBased Health.

References

1. Barabino S, Rolando M, Camicione P, et al. Systemic linoleic and gamma-linolenic acid therapy in dry eye syndrome with an inflammatory component. Cornea. 2003;22(2):97-101. doi: 10.1097/00003226-200303000-00002.

2. Macrì A, Giuffrida S, Amico V, et al. Effect of linoleic acid and gamma-linolenic acid on tear production, tear clearance and on the ocular surface after photorefractive keratectomy. Graefes Arch Clin Exp Ophthalmol. 2003;241(7):561-566. doi: 10.1007/s00417-003-0685-x.

3. Aragona P, Bucolo C, Spinella R, et al. Systemic Omega-6 essential fatty acid treatment and PGE1 tear content in Sjogren’s syndrome patients. Invest Ophthalmol Vis Sci. 2005;46:4474-4479. doi: 10.1167/iovs.04-1394.

4. Kokke KH, Morris JA, Lawrenson JG. Oral omega-6 essential fatty acid treatment in contact lens associated dry eye. Cont Lens Anterior Eye. 2008;31:141-146. doi: 10.1016/j.clae.2007.12.001

5. Pinna A, Piccinini P, Carta F. Effect of oral linoleic and gamma-linolenic acid on meibomian gland dysfunction. Cornea. 2007;26(3):260-4. doi: 10.1097/ICO.0b013e318033d79b.

6. Brignole-Baudouin F, Baudouin C, Aragona P, et al. A multicentre, double-masked, randomized, controlled trial assessing the effect of oral supplementation of omega-3 and omega-6 fatty acids on a conjunctival inflammatory marker in dry eye patients. Acta Ophthalmol. 2011;89(7):e591-7. doi: 10.1111/j.1755-3768.2011.02196.x.

7. Sheppard JD, Singh R, McClellan AJ, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 2013;32:1297-1304. doi: 10.1097/ICO.0b013e318299549c.