dry eye
Structure Your Approach to Dry Eye Management
Follow this simple plan for treating dry eye and you'll reap a happy practice and happy patients.
BY DEEPAK GUPTA, O.D., F.A.A.O., Milford, Conn.

For most of us, it's common for patients to complain of dry eye symptoms. Unfortunately, many of us overlook the fact that most insurance companies view dry eye syndrome as a medical diagnosis. In fact, many colleagues give dry eye patients several samples of artificial tears and tell them to choose whatever brand they want from the store. I, however, advocate establishing a structured approach to treatment.

As with any disease, proper management begins with proper diagnosis. Along with a patient's complaints associated with dry eyes, ask him about his environment -- specifically whether it's situated near heating and air conditioning vents. Also ask specifically about how much time he spends at a computer.

Also, be sure to ask your patient if he's taking any systemic medications such as antihistamines, antidepressants, anti-psychotics, hormone replacement therapy and oral contraceptives, which all can contribute to ocular dryness. Inquire about a history of LASIK, which severs corneal nerves and contributes to corneal surface dryness.

Lastly, ask all contact lens patients about dryness. Contact lenses have been been shown to decrease corneal sensation and disrupt the mucin layer of the tear film. Discomfort because of dryness has often been cited as the number-one reason why patients drop out of lens wear.

In addition to carefully assessing patient complaints, let's discuss a couple of objective tests you can use to help confirm your diagnosis.

Confirming your suspicions

The most common tests used in clinical practices to assess dry eye are the Schirmer test, phenol red thread test, fluorescein, rose Bengal, Lissamine green staining, tear break-up time (TBUT) and tear meniscus height measure. They're quick and easy to use; however, they lack repeatability and studies generally show a lack of association between test signs and patient-reported symptoms.

In addition to the above, some "more scientific," laboratory-based tests exist, but they're limited clinically by either cost or by difficulty in use. They are:

► Advanced Instruments, Inc. produces several models of advanced osmometers that use freezing point depression osmometry to indirectly calculate tear film osmolarity. They're fairly accurate and are reportedly quite sensitive to dry eyes.

► The Touch Tear Lactoferrin MicroAssay by Touch Scientific, Inc. measures the concentration of lactoferrin in the tears. Lactoferrin is an iron-binding protein produced by the lacrimal gland in the aqueous tears. Measuring its concentration is an indirect way of measuring tear volume.

Dry eye management pearls

Even if you prescribe over-the-counter (OTC) medications, which you will for many patients, always underscore the fact that because dry eye can develop into a serious medical condition, every patient should always return for proper follow up.

Initial full exam (code comprehensive exam). The following is the protocol when performing a complete exam on a patient complaining of dry eye symptoms:

► Document the patient's complaints and perform appropriate diagnostic tests such as TBUT, Schirmer, phenol red, rose bengal or lissamine green testing.

► If not part of the complete exam, bill this as an office visit (99212).

► Provide the patient with a sample of a low-viscosity artificial tear to determine its effectiveness. Lubricating eye drops and artificial tears are appropriate for patients who have mild dryness complaints. A nice choice here is lubricant formulations that contain "disappearing" preservatives.

► Even though lubricating eye drops are OTC, giving samples to patients is good patient management and gives the patient first-hand knowledge about the products you recommend for his disease.

► Instead of telling the patient to continue buying artificial tears at the drug store, have him return for a dry eye follow-up visit in one to two weeks. Tell the patient that artificial tears are only one way to treat dry eye and that further evaluation will reveal their effectiveness. If they don't work, you'll explore other options to help resolve the problem.

Dry eye follow-up/collagen plug insertion. Here's the protocol when performing a follow-up exam on a dry eye patient:

► If your patient received adequate relief from the artificial tears, then bill code 99212 for this visit and follow up at the next yearly exam.

► If your patient still complains of dry eye symptoms, consider switching to high-viscosity drops and/or lubricating ointments. These supplements last longer, but may periodically blur a patient's vision, which is why q.h.s. dosing is usually best. Perform a follow-up exam again in two to three weeks.

► Consider temporary collagen punctal plugs if the drops still don't help, or if the patient is unable to instill the drops as frequently as needed.

If you do insert punctal plugs, use the following codes:

• Bill 68761 E2 or -50 if non-Medicare (right lower puncta)
• Bill 68761 E4 or -51 if non-Medicare (left lower puncta)

► Have the patient keep track of his improvement in symptoms and return for a follow-up exam in roughly two weeks. Many patients may no longer need lubricating drops after the procedure, while others will notice a decreased dependency on them. If the collagen plugs worked, then insert silicone plugs for long-term management. To get reimbursed for both types of plug, you must wait at least 10 days between the two visits.

Collagen plug follow-up/silicone plug insertion.

► If the plugs were successful for the patient, then continue by using silicone plugs (same coding guidelines as the collagen plugs). Insurance companies consider the materials fee bundled with the procedure.

Some practitioners like to see the patient for a follow up on the silicone plugs one to two weeks after insertion. At this visit, you should make sure that the plugs are well inserted and that the patient's symptoms are better. Others will let a patient go until the next complete eye exam.

► If collagen plugs weren't successful, then discuss other options with the patient. For instance, you might recommend occluding all four puncta and implementing aggressive lubricating therapy. For patients who fall into this category, you'll want to use one of the two following options or a combination of both:

1. A short course of mild steroids (such as loteprednol etabonate 0.2% [Alrex] and loteprednol etabonate 0.5% [Lotemax]) to help manage the inflammatory nature of severe forms of chronic dry eyes. Both formulations of loteprednol do an excellent job of decreasing inflammation, but carry a reduced risk of increased IOP. Once you've gotten the inflammatory process under control, taper steroid use and initiate a long-term management program.

2. In lieu of steroids, or in addition to steroid therapy, you can write the patient a prescription for Restasis (cyclosporine ophthalmic emulsion 0.05%), which has demonstrated statistically and clinically significant relevant increases in Schirmer wetting at six months and significant improvement in conjunctival Rose Bengal staining and corneal superficial punctate keratitis (SPK). It works by reducing the cell-mediated inflammatory responses of ocular surface disease, specifically activation of T lymphocytes, and allows those cells to recover their normal activity.

One of the biggest drawbacks of Restasis is that it may take up to six months for it to take full effect. It also works best in patients who have an inflammation of the lacrimal gland, which is usually not detectable in the usual clinical setting. Instead, we must make the assumption of this inflammation in severe cases of dry eyes.

However, because you'll most likely prescribe Restasis for patients for whom other therapy has failed, your patients will be more receptive to taking a medication that may take one to three months to work. As an added bonus, by writing for an agent that needs a prescription, you underscore the legitimacy of dry eye syndrome as a potentially serious medical condition.

In many cases, you can start a patient on both the steroid and Restasis and then slowly taper the steroid after several weeks once the Restasis begins to take effect. This dual approach works best in severe cases, providing short-term relief and long-term maintenance.

If all else fails

Although many O.D.s (including myself) are reluctant to prescribe homeopathic remedies, flaxseed oil is gaining recognition for managing dry eye, as it appears to reduce T cell lymphocyte proliferation to help relieve a patient's symptoms.

For patients who have severe and refractory cases of dry eye, consider tarsorrhaphy (suturing the peripheral aspects of the eyelids together) to reduce the interpalpebral aperture. You'd also want to use this option as a short-term measure to protect a compromised ocular surface.

One way or another

If even after following the logical path to treating and managing dry eye you don't succeed, you always have other options. Start with the tried-and-true methods and if they don't meet your and your patient's expectations, move on to something else. One way or another, you're sure to find the answer.

Dr. Gupta is in private practice. You can reach him by e-mail at deegup4919@hotmail.com.