Ohio optometrist Mile Brujic recalls the patient who made him change the way he practiced. In 2006, a female patient visited Dr. Brujic’s office for the first time, complaining she couldn’t see up close in the -1.00D single-vision glasses she was prescribed by another doctor. Dr. Brujic did a refraction and found she needed an add.
A relatively simple exam, he thought as she went out the door, until a month later when the woman returned and informed Dr. Brujic she couldn’t see out of her new prescription either. As Dr. Brujic checked her vision a second time, he noticed the patient continued to blink as she tried to focus. “I could actually see her try to sweep a fresh set of tears over her eyes,” he recalls.
It was then Dr. Brujic realized he missed the initial diagnosis. This patient, who had already gone to several doctors but was continuing to be misdiagnosed, had dry eye. He resolved to never again give a patient cause to question his clinical decisions, particularly when it involved paying out of pocket for new corrective lenses. “I made it a point then to become much more aggressive about understanding dry eye and to find the tools to help me diagnose these patients and manage them better.”
As the prevalence of dry eye continues to rise and clinical research sheds more light on the disease, Dr. Brujic and many other practitioners have invested the time and resources to become dry eye experts and build that distinction into their practices. In so doing, they offer a haven to patients who’ve gone from doctor to doctor either incorrectly diagnosed or prescribed ineffective treatments: the so-called dry eye center of excellence.
With a proliferation of such centers opening across the country, we look at the philosophy of these centers, technology needed to serve these patients, and what such dry eye centers can ultimately do for patients and the practice.
The Practice Behind the Name
The term “dry eye center of excellence” is a bit misused today, says Chuck Aldridge, OD, of Burnsville, NC. “It was originally established by one of the pharmacy companies to assist doctors in setting up dry eye centers within their practice,” he says. They had a full set of tools and guidelines, and a practice could only use that designation if certain minimum standards were met. The program became a casualty of increased pharma regulations and was abandoned. Currently, there are no real standards for use of the phrase, he adds.
Comanagement: Optometry Takes the Lead
Dry eye center experts say they are seeing a new trend: instead of referring a patient to a corneal specialist, the majority of patients are being referred in to them—and not just by fellow ODs, but by ophthalmologists as well.
“We have all the tools now to really manage these patients,” Dr. Brujic says. “The days of comanaging patients for ocular surface conditions are dwindling. What ophthalmology is really taking on is tertiary surgical care, and we are really owning everything else.”
Dr. Epstein agrees, saying that he “can’t remember the last time we referred a patient for ocular surface disease,” but now receives a rapidly increasing number of referrals from colleagues. “If you asked me this question 10 years ago, I’d say this would not be the case, but at this point, optometry has reached a level where we are managing many more complex cases because of advances in technology and growing confidence in our abilities. Optometrists are exquisitely patient-centric, and doing what’s best for our patients gives us a decided advantage.”
Dr. Karpecki estimates that 80% of his dry eye patients are referrals and he comanages them with a wide array of other doctors. “I comanage with optometrists, ophthalmologists, rheumatologists, endocrinologists, you name it,” he says. A large, cataract-oriented practice in his area sends him four or five new referrals a week. “A dry eye center can create a wonderful secondary comanagement tier involving almost every kind of specialty.”
Dr. Schaeffer considers comanagement an integral part of optometry’s future, with optometrists referring back and forth to each other. “If you are a dry eye practice that doesn’t fit scleral contact lenses, find a practitioner that does,” he advises. “If you don’t want to buy a LipiFlow machine, find a practitioner that has one. If you don’t want to have a dry eye practice, find a practitioner who is good at dry eye and you can take care of all the other patient’s needs. Working together by referring patients to each other is a sign of a higher level of optometric care.”
“Dry eye disease is something optometry should own and manage start to finish,” Dr. Aldridge says. “For optometrists who don’t want to work with the more difficult cases, this is an excellent opportunity to refer to their colleagues.”
As such, any practice can call itself a dry eye center of excellence. What truly sets the practice apart, however, is not the name but rather what happens inside the office, says Phoenix optometrist Art Epstein, who recently opened a dry-eye focused practice called the Dry Eye Center of Arizona. “To me, a center of excellence is a practice that devotes itself to dealing with patient problems in a specific area and serves as the last stop, the final answer, that solves the problems that in many cases have gone on for quite some time,” Dr. Epstein says.
For Dr. Brujic, a center of excellence is about a shift in philosophy, where a practitioner takes extra steps and does everything possible, starting with a thorough examination from the front to the back of the eye. “The front of the eye isn’t just the cornea,” Dr. Brujic says. “It’s the tear film and how it supports the surface of the eye.”
When a dry eye center of excellence first opens its doors, a few interesting things are going to happen, says Paul Karpecki, OD, who runs one of the largest dry eye centers in the country, at Koffler Vision Group, in Lexington, Ky.
“One, you’re going to get a good amount of new dry eye patients at your center, but you’ll also see a great deal of patients who have severe diseases—including some that aren’t dry eye per se and have confused doctors, including myself, for many years,” Dr. Karpecki says. Demodex, skin cancers of the eyelids, Sjögren’s syndrome, convergence insufficiency, conjunctivochalasis and Salzmann’s nodular degeneration are a few examples, he says.
“Working at a dry eye center of excellence really tests all your skills as an optometrist, not just your ocular surface expertise, which I think is really exciting and rewarding,” Dr. Karpecki says.
Benefit to Patients and Bottom Lines
Because dry eye is one of the most prevalent conditions an optometrist will encounter, incorporating a dry eye specialization is very important for those practitioners who want to develop a medically-oriented practice, says Jack Schaeffer, OD, of Schaeffer Eye Center in Birmingham, Ala.
And the need is obviously there. Dry eye affects an estimated 14.4% of the US population over age 40 as well as 50% of all contact lens wearers.1,2 Those numbers will only continue to increase. “If you look at it from simple demographics, the population is aging,” Dr. Epstein says. “Since we know that dry eye is prevalent in an aging population, it’s unavoidable that more of your patients will have ocular surface disease.”
Another driver of patient volume affects a younger demographic: mobile device use. Smartphones and tablets, ubiquitous among teens and 20-somethings with otherwise healthy eyes, “have an impact on blink rate,” Dr. Epstein says. Fewer blinks per minute limit the ability of meibomian glands to release oil and the lids to properly disperse it, he says, creating a cascade that results in tear film instability and, ultimately, dry eye symptoms.
This growth in patient ranks has been matched by greater attention from both researchers and clinicians. “Our understanding of dry eye and the ocular surface has increased dramatically,” Dr. Epstein says, particularly in the pathogenesis of dry eye and tear dysfunction, allowing industry to develop more targeted therapeutics.
Clinical protocols have matured as well. “Some things I do today I didn’t do routinely just three or four years ago, like meibomian gland expression,” Dr. Karpecki says. “There’s so much more we’ve learned, and it’s starting to make a difference.” There is also a sense of great accomplishment “because of the gratitude patients have” for your efforts, he says.
Of course, done effectively, a center of excellence can also generate significant revenue from exams, procedures and sales of materials such as warm compress masks, artificial tears and ocular nutritional supplements, Dr. Karpecki adds.
Increased scrutiny and regulation from insurers and the trend of declining reimbursements pose challenges to many optometrists who need to find ways to ensure patients are properly cared for and their practices can also be compensated appropriately. says Dr. Epstein. A specialization in dry eye, including some services that aren’t covered by insurance, can fill that void, he suggests.
Dry Eye Goes High Tech
Recently, new technology has offered the potential to diagnose dry eye with greater precision, and experts familiar with such tools say they have changed the way they practice and offered greater opportunities for dry eye centers.
However, even though these new technologies may help to set a practice apart, tried-and-true diagnostic tools remain an integral part of the dry eye clinic and are generally already a mainstay—though perhaps underused—in a typical practice, Dr. Brujic says. Fluorescein dye with a cobalt-blue slit lamp assessment, lissamine green and phenol red thread are just a few of the “old school” techniques that still serve ODs well in dry eye care, he says. “This is all available, and every single optometrist has this in their practice, but only a fraction may be using them regularly”
The experts agree: None of the new technologies, no matter how intuitive or sensitive, replace a good exam, starting with a patient discussion and a survey or questionnaire (see “Basic Dry Eye Questionnaire,” above). “If you listen carefully to patients, they will often tell you what their diagnosis is,” Dr. Epstein says. “For example, the patient whose dry eye or OSD is worsened by exposure at night will often say, ‘I keep drops by the side of the bed.’ One patient said if he gets up in the night, he has to feel his way to the bathroom with his eyes closed and then splash water on his face before he can open his eyes,” he elaborates. “So, the patient discussion is extremely important, just as is the slit-lamp exam and tear and ocular surface assessment.”
If a practitioner truly wants to create a dry eye center of excellence, there is an amazing amount of advanced technology available today, Dr. Schaeffer says. “We can now qualify dry eye not just by objective and subjective signs observed through the biomicroscope, but we can quantify the grading levels with the help of high tech equipment. So, now we can grade the severity of dry eye when we begin treatment, and we can more closely measure the results of our treatment.”
And, this new technology can help make a differential diagnosis. “These new devices on the market now offer the clinician a means to validate what they feel is the correct diagnosis. ‘I think this is dry eye disease, but could it be allergy?’’’ Dr. Aldridge says. “The new tests help confirm the diagnosis. And from a patient’s perspective, they can see and understand, for example, a picture of the meibomian glands or an osmolarity number, and for doctors, new technology can help them look for changes during their treatment.”
Here’s how some of the latest innovations are used in practice to refine dry eye care:
• TearLab Osmolarity System (TearLab Corporation): Tear osmolarity was recognized as an indicator of dry eye in the Dry Eye Workshop of 2007 and other studies.3-5 This device measures osmolarity of tear samples and categorizes the severity of the results. Clinicians say the device can confirm the findings of a slit-lamp exam, provide a baseline of disease severity and track the progress of treatment. “I’ve used TearLab since the start, and it’s been an awesome test,” Dr. Aldridge says. “Patients understand numbers, such as their blood pressure, blood sugar levels and cholesterol.” Sharing their tear osmolarity with them helps them to put it in perspective and understand its significance, he says.
One clinical pearl he offers is the need for doctors to understand the inherent fluctuation in the findings, particularly for abnormally high results. “This is the nature of DED,” Dr. Aldridge says. “The severity goes up and down through the day.” As the condition is treated and brought under control, the numbers begin to fall and the degree of fluctuation becomes less and less, he adds.
A New Dry Eye Resource Just One Click Away
The web-based service Ophthalmic Resources ( www.ophthalmicresources.com), which will officially be launched this fall for doctor enrollment, is an online database that will feature educational information on dry eye and ocular surface disease, in addition to providing an order and delivery service for dry eye products such as artificial tears, warm compresses, lid cleansers and ocular nutrition supplements. It essentially allows the physician to profit from the sale of OTC products based on ocular surface disease protocols, without inventory hassles or patients being confused by numerous options at a pharmacy, says Paul Karpecki, OD, the service’s clinical advisor and founder.
Doctors can custom order the items from a distributor and the products are then shipped to a patient’s home or business, which can reduce in-house stock and ensure a patient gets the exact product their doctor recommends. Stay tuned for further details.
• RPS InflammaDry Detector (Rapid Pathogen Screening): Increased matrix metalloproteinase (MMP)-9 activity has been observed in the tear fluid of dry eye patients. As such, MMP-9, a cytokine produced by epithelial cells experiencing inflammation, appears to be a reliable marker for the presence of early ocular surface disease and dry eye.6,7
The InflammaDry test detects the presence of MMP-9 in tear fluid, which can help confirm a diagnosis. Normal levels of MMP-9 in human tears range from 3ng/ml to 40ng/ml. InflammaDry identifies a level above 40ml, a critical threshold for dry eye patients, says Dr. Brujic, who incorporated the technology in his practice earlier this year. He says the test has given him better insight into what’s happening on the ocular surface, and the results have provided guidance on potential treatment options.
Meibomian gland dysfunction is now considered the leading cause of dry eye.8 MGD can result in inadequate release of oil needed to form the lipid layer of the tear film.8 Obstructive MGD is the most common form of MGD that results in dry eye.9 With this in mind, several products analyze the state of the meibomian gland and provide treatment to restore function.
Putting Dry Eye Education Into Practice at SCO
Dry Eye Centers of Excellence aren’t exclusive to private practice. The Southern College of Optometry recently launched TearWell Advanced Dry Eye Treatment Center, which opened its doors on July 1, 2014.
“TearWell provides our students a unique view into a premium, or concierge, practice,” says SCO associate professor Whitney Hauser, OD, TearWell’s clinical development consultant, in which the patient’s needs and satisfaction are the focus from initial greeting through the conclusion of the examination. “Our dry eye patients have often been seen by many practitioners and found little relief from their symptoms. These patients demand and deserve an individualized approach that focuses exclusively on their complicated and chronic condition.”
Dr. Alan Kabat, SCO professor and clinical care consultant states, “We pride ourselves on offering the newest and most cutting edge technology in patient care. Ours is a practice dedicated to ocular surface wellness, identifying the primary etiologies of our patients’ symptoms and outlining a progressive strategy to correct those issues.” Among the center’s core battery of testing: LipiView interferometry, tear osmolarity, infrared meibography, InflammaDry, Sjö (for those with suspected Sjögren’s syndrome), microscopic evaluation for Demodex and in-office testing for regionally specific ocular allergies. TearWell is also the first practice in the greater Memphis area to offer such innovative therapies as BlephEx and LipiFlow.
• Oculas Keratograph 5M (Oculus): This corneal topographer adds a high-resolution infrared camera to allow for meibography, and includes a suite of dry eye tests, including non-invasive tear film break-up time, ocular redness, tear meniscus height measurement and the ability to evaluate the lipid layer of the tear film. “New technology such as this has allowed me to see things I never could before,” Dr. Epstein says. “Even more importantly, it allows us to share the findings with our patients so they are seeing exactly what we are seeing, and we can document it.” Additionally, the device can objectively measure tear break-up time down to a fraction of a second, he adds.
• LipiView/LipiFlow: (TearScience): LipiView offers an objective measure of meibomian gland function. “We know that almost 90% of patients who have dry eye have primary or contributory meibomian gland dysfunction,” Dr. Epstein says. Being able to measure the thickness of the lipid layer and also the completeness of the blink is extremely important, he says. “Every time we blink, we express the glands.” He says the device measures lipid layer thickness “down to the nanometer” and is useful for documentation of baseline status and response to treatment. Patient education, too—“I show this to patients and they love getting a number, and it allows us to track their progress. It helps them understand the value of
LipiFlow, a treatment for MGD that has been nothing short of disruptive,” Dr. Epstein says. “LipiFlow has been life changing for many of my patients who have suffered for years.”
|The LipiFlow (TearScience Inc.) device used during a 12-minute, in-office dry eye treatment. It simultaneously applies heat and pulsatile pressure to the eyelids.|
The LipiFlow device allows treatment of obstructed meibomian glands by heating the eyelid surfaces and applying a pulsating force to express the glands. “The only way to treat meibomian gland disease is to get the glands working again,” Dr. Schaeffer says. “The glands need to be expressed, as they have been blocked and are not functioning.” Manual expression works to some extent, he says, but heating the glands improves the result. “LipiFlow is a procedure that places a device into the eye, heats the glands to 108°, massages the glands therefore allowing the glands to function again.”
Routine meibomian gland expression may allow optometrists to adopt a mode of care akin to the dental model of routine cleaning, Dr. Karpecki says. Patients may be open to direct payments for such care if price points reach an appropriate level, he says.
• OCT: This ever-versatile techology can assist in noninvasive assessment of tear volume by measuring tear meniscus dimensions, helping clinicians determine whether the patient experience aqueous deficient dry eye. Some OCT devices employ software specifically designed to measure the tear meniscus dimensions.
Don’t Skimp on the Education
As an optometrist who has studied dry eye and emphasized its care in his practice for the past two decades, Dr. Karpecki admits the first 17 years were challenging. “Patients often weren’t getting much better. It was another tough day at clinic.” Now, he says, it’s just the opposite. “It’s rare not to have a happy patient.”
Education was a key driver of that, he says. Over the past few years, the amount of knowledge that has been discovered about dry eye, combined with new technologies and therapies, have made a tremendous improvement in diagnosis and treatment. Understanding meibomian gland function and dysfunction, learning more about osmolarity and tear film constituents and how they correlate with real-world symptomology, researching and applying new treatments—all stem from diligent education.
That means there’s even more to learn for those who want to start a dry eye center of excellence, but myriad educational opportunities are available to do so:
• Hit the Books: Dr. Brujic suggests these three seminal points of reference to build your dry eye clinical skills: the Dry Eye Workshop 2007 (www.tearfilm.org/dewsreport/pdfs/TOS-0502-DEWS-noAds.pdf), the Meibomian Gland Dysfunction Workshop (www.tearfilm.org/mgdworkshop/) and the TFOS International Workshop on Contact Lens Discomfort (www.iovs.org/content/54/11/TFOS7.full).
• Learn From the Experts: With a wealth of information available—some of it conflicting—Dr. Karpecki suggests studying “the masters,” i.e., following the work of those whose careers have been solely or primarily centered on dry eye. “Find the doctors who’ve gone through the school of hard knocks and spent the majority of their careers in this area. Learn from what they did and look at what they’re doing now.”
• Take a Field Trip: Dr. Karpecki suggests visiting dry eye clinics to get a first-hand view of a dry eye center of excellence.
• Join a Dry Eye Organization: Dr. Schaeffer recommends becoming a part of a dry eye group, such as the Ocular Surface Society of Optometry (http://ossopt.net), which works to increase the awareness and advance the understanding and management of dry eye and ocular surface disease.
• Take a Course: All the large optometric meetings typically feature dry eye courses ranging from clinical research to practice management. Adds Dr. Schaeffer: “You need to go to the major meetings and meet with the best practitioners who will educate how to develop a dry eye center, how to improve your skills, and how to become an expert.”
Timing and Workflow
“I think to be a true center of excellence, you have to have a portion of your clinic time dedicated to dry eye,” Dr. Karpecki says. “It can’t just ‘work in’ to your general patient schedule for a given day.” Reserve a dedicated block of time to see dry eye patients exclusively, he says.
For those practitioners beginning to build a dry eye center, Dr. Karpecki suggests starting out with a half-day each week and then transitioning to a full day at the practice when you only see patients with dry eye or other ocular surface disease conditions.
Another key to building a successful dry eye clinic is staffing. Dr. Karpecki has a seasoned lead tech he refers to as his clinic’s “quarterback.” She works directly with him as his scribe when she’s not overseeing the patient flow and work-up of patients. And his lead tech will jump in and help with the work-ups if she notices the patient flow beginning to lag.
“You’ve got to have a dedicated person who takes on the role of coordinator. They too will develop expertise, same as you,” Dr. Karpecki says, but in the areas of productivity, logistics, patient education, clinical anticipation and overall problem-solving.
Eventually, you may want to have other techs whose job responsibilities shift to dry eye work-up on clinic days devoted to such care. On your dry eye day at your practice, you may need to pull a tech from your contact lens side to help as needed, he suggests.
Once you have a dedicated day to see dry eye patients and your staffing is in place, Dr. Karpecki stresses that staff needs to keep a strict eye on the sequencing of care. “Testing has to be systematic,” he says. “Once you instill the staining agent, you can no longer do osmolarity or meibomian gland expression,” for instance.
At Dr. Karpecki’s practice, a patient work-up is done in the following order:
• Patient questionnaire and
• Osmolarity testing
• Diagnostic imaging
• Meibomian gland expression
Although he hasn’t fully incorporated this yet, a new test for MMP-9 measurement would follow osmolarity testing in the lineup order, Dr. Karpecki adds.
Once the testing is complete, he reinforces the patient education by showing patients images of their eyes reflecting their dry eye or other ocular surface disease conditions, as well as animations (from Eyemaginations) that explain the condition.
The lead tech will then explain to the patient Dr. Karpecki’s tear treatment recommendation, instructions, and when they should schedule their next visit. Handouts are provided to each patient that further discuss their condition or how to appropriately apply warm compresses or take certain medications.
While the prevalence of dry eye increases and research continues to shed new light on the disease, dry eye centers of excellence may be in demand more than ever before. “The opportunities have never been greater, and the need is clearly there,” Dr. Epstein says. n
1. Moss SE, Klein R, Klein BE. Prevalance of and risk factors for dry eye syndrome. Arch Ophthalmol. 2000;118(9):1264-68
2. Scaffidi RC, Korb DR. Comparison of the efficacy of two lipid emulsion eye drops in increasing tear film lipid layer thickness. Eye Contact Lens. 2007;33:38-44.
3. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007 Apr;5(2):75-92.
4. Lemp MA, Bron AJ, et al. Tear osmolarity in the diagnosis and management of dry eye disease. Am J Ophthalmol. 2011 May;151(5):792-798.e1. doi: 10.1016/j.ajo.2010.10.032.
5. Suzuki M, Massingale ML. Tear osmolarity as a biomarker for dry eye disease severity Invest Ophthalmol Vis Sci. 2010 Sep;51(9):4557-61. doi: 10.1167/iovs.09-4596.
6. Chotikavanich S, de Paiva CS, De-Quan L, et al. Production and activity of matrix metalloproteinase-9 on the ocular surface increase in dysfunctional tear syndrome. Invest Ophthal Vis Sci. 2009, Feb 28.
7. Lam H, Bleiden L, De Paiva CS, et al. Tear cytokine profiles in dysfunctional tear syndrome. Am J Ophthalmol. 2009;147;198-206.
8. Nichols KK, Foulks GN, Bron AJ, et al. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011 Mar 30;52(4):1922-9.
9. Nelson JD, Shimazaki J, Benitez-del-Castillo JM, et al. The international workshop on meibomian gland dysfunction: report of the definition and classification subcommittee. Invest Ophthalmol Vis Sci. 2011 Mar 30;52(4):1930-7.
I Started With “Why?”
By Arthur Epstein, OD
In truth, opening a brand new practice in the current health care environment is not for the faint of heart or the insecure. Even more so, opening a practice narrowly focused on dry eye—at least from what many of my friends and colleagues have shared—bordered on downright lunacy. So why did I open a dry eye practice “cold”?
Here are the reasons why I launched the Dry Eye Center of Arizona:
• Need. Arizona is one of the driest places on earth and, with an aging population, the need for dry eye care was evident. As a result, we have literally changed people’s lives.
• Opportunity. An extensive search on the web and among local practices showed a dearth of sites that advertised dry eye care or seemed interested in building that aspect of their practice.
• Ability. When I left school, I could not even use a dilating agent or topical anesthetic. Times have changed. More than a dozen years devoted to attending every cornea clinic at a university hospital ophthalmology department, plus many years of hands-on experience and learning from some of the brightest minds in eye care, has transformed the way I practice and my skills and abilities, much as it has transformed our profession. Today, optometry owns the ocular surface!
• Passion. My interest in anterior segment disease has increasingly focused on the ocular surface. I have been immersed in dry eye and ocular surface disease and believe that the Dry Eye Center of Arizona could serve as a local and regional center for dry eye and ocular surface disease care.
• Technology. Just as the microscope expanded our knowledge and understanding of the world around us, advances in technology have elevated dry eye and ocular surface disease management to new levels. I spend more time explaining test results, treatments and prognoses than I do actual testing.
• Confidence. The Dry Eye Center of Arizona is part of Phoenix Eye Care, PLLC. I knew my wife and partner, Dr. Shannon Steinhäuser, would quickly build a large and successful primary care optometry practice, which would support the Dry Eye Center. She did, and it has.
In the end, I opened the Dry Eye Center of Arizona for all the right reasons, and I believed I could do it successfully. If your “why” is similar to mine, I encourage you to go for it.