Elevate your dry eye practice: tools that make a difference

The contents of this article are informational only and are not intended to be a substitute for professional medical advice, diagnosis, or treatment recommendations. This editorial presents the views and experiences of the author and does not reflect the opinions or recommendations of the publisher of Optometry 360.

By Mark Schaeffer, OD, FAAO

About 25% of patients who come to my primary eye care practice for a comprehensive exam have some form of dry eye disease (DED). Some have classic DED complaints, such as red, gritty, dry eyes, while others don’t realize that their contact lens intolerance or fluctuating vision is caused by DED. After trial and error, I finally feel like my approach to the DED workup, including a short list of effective tools, allows me to diagnose and manage DED in ways that work well for my patients and practice.

4 Simple Diagnostic Tools

Your practice doesn’t need expensive tests to screen for DED. My screening tests (1 through 3 below) are familiar to every OD. During a medical evaluation for DED, the objective tests listed in number 4 can help determine the underlying problems:

1. Phoropter: If patients have to blink between “Which is better, 1 or 2?” then I know they have ocular surface disease. I tell patients what I’m seeing and connect it back to their blurred or fluctuating vision, which makes the phoropter one of my favorite tools for educating patients about DED.
2. Questionnaire: When patients are in the chair, they often understate their symptoms (“I’m fine,” “I just have allergies,” etc.). Their responses on the questionnaire often reflect a more serious problem, including both specific symptoms and feelings of fatigue or discomfort during daily activities like reading and screen use. We have used both SPEED (Standardized Patient Evaluation of Eye Dryness) and DEQ-5 (Dry Eye Questionnaire-5) for all of our comprehensive exams.
3. Vital dye staining: Sodium fluorescein and lissamine green staining are the most important of all objective tests for DED. Using a Wratten filter to amplify staining on the corneal surface, I can see if the tear film is thick, thin, scant, or missing and if it smooths out when patients blink. Staining also reveals corneal and conjunctival damage, inflammation, exposure, and tear breakup time.
4. Your choice of objective tests: If you treat DED frequently, you might choose one or two objective tests that help reveal the underlying problems. When I have patients back for a full DED evaluation, I do meibography (LipiView II, Johnson & Johnson Vision) to learn more about meibomian gland blockage and atrophy. Without a meibographer, you can evaluate the glands by visually examining them and expressing the meibum digitally. Osmolarity (TearLab, Bausch + Lomb) tells me if the patients’ tears are functioning properly, and MMP-9 testing (InflammaDry, QuidelOrtho) shows the level of inflammation on the eye.

4 Key Treatment Tools

Once we understand the etiology of a patient’s DED, we can implement the right therapies for managing the condition. In a crowded field of options, 4 tools dominate my approach:

1. Supplements: When I see signs of DED, I want to immediately start a treatment that patients haven’t used before and then schedule them back for a complete exam. I choose supplements because most patients haven’t tried them yet (as opposed to artificial tears), they promote buy-in because they’re easy to purchase in our practice, and they help with both tear film evaporation and ocular surface inflammation. I tell patients, “When you come back next month, we’ll see how the supplements are working and look at what else we need to do to address your DED.” Patients like the idea of treating from the inside out. I educate them about the meibomian glands, explaining that when I press on the eyelids, they should release oil, but instead, it’s looking more like toothpaste. I want them to start this supplement to work on this issue from the inside, since our diets usually don’t include enough beneficial oils and anti-inflammatories. I recommend HydroEye (ScienceBased Health), a clinically proven blend of the unique anti-inflammatory omega GLA (gamma-linolenic acid), plus omega-3s and nutrient cofactors that reduce inflammation and improve the corneal surface.¹

2. Specialty pharmacies: I prescribe medications for DED inflammation, aqueous deficiency, and Demodex blepharitis. To expedite the process and help patients get drugs at a lower price with or without insurance, my practice uses specialty pharmacies like BlinkRx, PhilRx, Accredo, and a Walgreens Specialty Pharmacy in our state. In the past, I’d write a prescription, and every pharmacy would charge patients a different price. In the messy prior authorization process, staff had to get approval and call the pharmacy back, creating a logistical headache. All of this was streamlined with specialty pharmacies, which make it as easy as possible for patients to get the right drugs at affordable prices. These relationships have become almost an extension of the practice. My practice now has one point of contact for a given therapy, and the pharmacies handle prior authorizations and coupons.

3. Canalicular gel: I’ve done many punctal plugs, but Lacrifill canalicular gel (Nordic) has become my first choice because my patients get great results. The gel, made with crosslinked hyaluronic acid (HA), fills the whole puncta, helping to keep tears on the eye while eluting HA, a known ingredient that helps to lubricate, onto the surface. With Lacrifill, there’s no punctal plug sizing and no dropping the plug. It’s easy to insert, it’s reversible if necessary, and insurance covers it as punctal occlusion.
4. Interventional treatments: It’s part of our office culture to treat DED medically, so we want to alleviate patients’ burdens of self-care and compliance as much as possible. Lacrifill is one interventional therapy. We also offer several in-office treatments to help address the meibomian glands.

I’ve been doing thermal pulsation (Lipiflow, Johnson & Johnson) for a decade with great success. Direct heat and massage melt the meibum and open the meibomian glands. Low-level light therapy (Equinox with Red Mask, Essilor) stimulates collagen and elastin on the ocular surface, helps mitochondrial production, produces endogenous heat to liquify the meibum, and reduces inflammation. I express the glands after treatment. I also do intense pulsed light (Epi-C, Essilor) for meibomian gland dysfunction patients with telangiectasia to reduce inflammation and obstruction.

These treatments are easy to incorporate if you have the space, and they fit easily into our workflow—in fact, if a patient wants to do a procedure the same day rather than scheduling it for later, we can usually accommodate them without causing delays. The return on investment has been very good, and patients appreciate how these treatments reduce the work they must do every day to manage DED.

DED Today and Tomorrow

There’s never been a better time to treat DED. We have so many ways to address it, so patients can get better faster, and they no longer have to suffer. However, that doesn’t mean it’s easy. DED is a complex disease that often requires multiple therapies. But the more you do it every day, the better you get at it.

Make patients your partners in this process. Let them know that if one therapy doesn’t work, other options can still provide relief. They should see, as we do, that the pipeline of DED therapies makes the future look very promising.

Reference

1. Sheppard JD Jr, 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(10):1297-1304. doi:10.1097/ICO.0b013e318299549c

Mark Schaeffer, OD, FAAO, is Clinical Excellence Captain at MyEyeDr in Birmingham, Alabama. He is a Founding Member and Vice President of the Intrepid Eye Society. Disclosures: AbbVie, Alcon, Bausch + Lomb, Harrow, ScienceBased Health, and Tarsus.