To effectively manage ocular surface disease in your office, you may need to invest in a few new tools—all of which can help you better assess, diagnose and manage these patients.
One incredibly useful piece of equipment is a slit lamp that captures images and video, such as the Haag Streit imaging system, TelScreen or Eyefficient. This pays for itself multiple times over because you can recall previous findings, educate patients about their condition (which increases efficiency and compliance) and bill for anterior segment photography.
Another helpful tool in patient education is Rendia (previously known as Eyemaginations). Patients want to understand their condition and its management, and the dry eye modules provide crucial information before, during and after the exam.
Diagnostics for All
Other necessary tools depend on how much you are dedicating to dry eye disease (DED). If you are managing mild to moderate forms and referring advanced DED or non-responders, you may only need a good history or dry eye questionnaire, sodium fluorescein dye and a device for meibomian gland expression. The dye is important for measuring tear break-up time, ocular surface and corneal staining and tear meniscus height. Meniscus height in particular can be a good determinant of aqueous deficiency. Expression will indicate meibomian gland dysfunction, pointing to an evaporative form.
A Dedicated Dry Eye Center
If you plan to dedicate your practice (or a segment of it) to DED, you will need other items. For symptoms assessment, consider SPEED, DEQ-5 or OSDI as potential options.
If you are receiving referrals you need diagnostics beyond those in general practice, including osmolarity testing. I could not run my dry eye clinic without it. I see patients who complain of symptoms of dry, gritty, irritated eyes who have normal osmolarity (between 280mOsmol/L to 300mOsmol/L and both eyes within 6mOsmol/L). Typically, these patients have been treated for dry eye for months or even years with no improvement in their symptoms—because the diagnosis is not DED.
Dry eye has a laundry list of possible differential diagnoses, including allergic conjunctivitis, epithelial basement membrane dystrophy or map-dot fingerprint dystrophy, recurrent corneal erosion, limbal stem cell deficiency, Demodex, trigeminal dysphoria, giant papillary conjunctivitis, neurotrophic keratitis, computer vision syndrome and Salzmann’s nodular degeneration, to name a few.
Another valuable test is that of MMP-9 levels. Patients with high osmolarity and a positive MMP-9 test may need greater inflammation treatment and avoidance of punctal plugs.
Meibography is extremely valuable in determining the severity of evaporative DED or differentiating the type of DED. I’ve seen many cases where I could not express meibum, and meibography reveals either ample glands or few glands remaining. The treatment approach varies greatly between these two patient types.
Other vital dyes such as lissamine green are beneficial for assessing the conjunctiva for early DED or more advanced mucin deficient dry eye. And certainly noninvasive break-up time is more accurate than subjective dye testing tear film break-up time.1
Finally, you need to assess corneal sensitivity, even with something as simple as dental floss. Far too many patients with DED have neurotrophic keratitis components.
Ultimately, you need a good DED protocol, as dry eye is one of the most difficult conditions to manage. Clinicians initially saw DED as something of a nuisance condition similar to, say, chapped lips, but as doctors started working with these patients they quickly realized the complexity, variability, numerous masquerading conditions and comorbidities make it a unique condition to manage. You must understand this from the start; otherwise, you’ll get frustrated. You don’t want to miss out on incorporating one of the most prevalent and rewarding fields in all of medicine. Just ask a DED patient who has been well diagnosed and treated.
Note: Dr. Karpecki consults for companies with products and services relevant to this topic.
|1. Versura P, Campos EC. TearLab Osmolarity System for diagnosing dry eye. Expert Rev Mol Diagn. 2013 Mar;13(2):119-29.|