dry eye

The Ocular Surface in Five Minutes

With a team effort, you can optimize exam time and add a "dry eye clinic"

KELLY K. NICHOLS, O.D., M.P.H., Ph.D.

Really? A Five-minute exam? But first, understand there are many key issues to address when considering this approach. Staff support, billing and coding, intraoffice referral and most important — the actual exam, are all critical elements. Align your team to your vision and roll out the plan.

In short, adding a "dry eye clinic" to a practice can increase the bottom line both directly and indirectly (referrals), but the rollout must be well-planned and carefully orchestrated. The best run medically-oriented clinics rely on staff buy-in and well-delineated staff and doctor roles.

Where does the time go?

Of the time a patient with ocular surface disease spends in your office, 90% of it should be spent with your staff. This sounds counterintuitive because we all accept that ocular surface disease requires significant "chair time." The patient may be in the chair, but doesn't have to be with you 100% of the time. But how about five minutes of your time?

A well thought-out examination flow, consistent examination features, prepared patient education materials, and assigned staff roles will streamline the process for you and the patient.

The exam form

As the basis of your medicallyoriented ocular surface examination, develop an exam form that is the same for all ocular surface conditions. Include "add-ons" (e.g. Schirmer test, tear break-up time [TBUT], meibomian gland expression) when specific key features, are identified during the exam process. Differentiate your ocular surface assessment exam form from your routine examination form (or electronic medical records template). This will serve as a reminder to you and your staff that this exam is handled differently from routine eye care. (By joining the Ocular Surface Society of Optometry [www.ossopt.com], you can gain access to several dry eye examination forms.)

The same ocular surface assessment form can be used across disease modalities, from allergic conjunctivitis, blepharitis, to dry eye disease.

Exam elements

Critical to the ocular surface exam is the assessment of symptoms. You may consider the use of a standardized survey, such as the Ocular Surface Disease Index (OSDI) (www.restasisprofessional.com/documents/OSDI_PAD.pdf) to save time and have a consistent method of asking questions, or you may prefer a symptom interview. Critical in differentiating dry eye from anterior blepharitis may be the presence of more significant morning symptoms and burning with blepharitis, end-of-day dryness with dry eye. Itching can occur with most anterior segment conditions, so ask that patient about the severity or time course of itch to help rule out ocular allergies. Of course, it is common for dry eye, blepharitis, and allergy to overlap — especially in environments with high pollen levels or arid conditions, and in those patients who spend more time outdoors or in forced-air environments.

Ask the patient the following key questions in your assessment:

1. Do you use any over-thecounter eye products and if yes, do they work?
2. What is your worst or most noticeable symptom and when is it worst?
3. Do you have burning or eye redness in the morning?

Next, perform a thorough slit lamp examination that includes:

► assessment of the lashes for debris, flakes and collarettes
► assessment of lid abnormalities (notching)
► evaluation of the meibomian glands (orifices for blockage, ability to express glands, quality of expression)
► assessment of redness of the lid margin
► assessment of redness of the palpebral and bulbar conjunctiva
► evaluation of the conjunctiva for the presence of a papillary or follicular reaction
► evaluation of the quality of the tear film in the tear prism
► white-light and fluorescein staining assessment of the cornea
► lissamine green staining assessment of the conjunctiva
► evaluation of the anterior chamber for cells and flare
► assessment of tear production (performed the first time you see a patient who has ocular dryness/ irritation).

The ocular surface exam can be accomplished rapidly, especially if you use a check-box format on the examination form. Be sure to include an N/A box for tests not performed on a particular visit. Use a standard 0 to 4 grading scheme for tests and symptoms (e.g. 0 = patient experiences symptom none of the time, 4 = experiences symptom all of the time), as well as a staining grid for the cornea and conjunctiva (see Figure 1 below).

Figure 1. Diagram of the five corneal staining regions and six conjunctival staining regions.

The exam itself, including meibomian gland expression, should take you no more than five minutes to complete. Your staff can administer the OSDI and/or symptom interview, prepare fluorescein and lissamine green, and perform the Schirmer test (at baseline). After the exam, your staff can review the patient information sheets and your recommended management approach. Use disease specific management and education forms, and circle the appropriate management choices in front of the patient for your staff to review with the patient. Keep a copy in the patient record for review at the next follow-up visit.

Your examination should answer the following key questions:

1. Is there crusting on the eyelashes?
2. Is there redness around the meibomian glands (posterior lid margin redness)?
3. Can you express meibum (constant pressure with finger or qtip, 15 seconds (sec.), just under base of lashes)?
4. Is the meibum clear, slightly cloudy/granular, cloudy, or pasty?
5. Is there fluorescein or lissamine green (LG) staining? Reduced TBUT?
6. Is the Schirmer test ≤ 5 mm/5 min. (or phenol red thread test ≤ 9 mm/15 sec.)?

What should you document?

To illustrate the five-minute exam in a clinical setting, two cases are presented below with tips on what you should document on the basis of what you can track for worsening or improvement over time or with treatment.

Case #1

A 65-year-old male presents for a routine examination with debris and flakes on his lashes, red lid margins and chronic symptoms, which are worse in the morning. You complete a medicallyoriented exam that day, worked up by your staff.

DOCUMENT:

► OSDI score 30 (moderate to severe)
► Worst symptoms dryness (PM), burning (AM)
► Previous unsuccessful artificial tear use
► Grade 1 collarettes and flaking O.U.
► Grade 2 telangiectatic vessels and posterior lid margin redness
► 3/8 inferior nasal meibomian glands expressed slightly cloudy to cloudy (Grade 2) meibum/15 sec.
► Grade 1 inferior corneal staining, inferior conjunctival LG staining O.U.
► TBUT 3 seconds O.U.
► Phenol red thread = 15mm/15 sec. O.U. (normal)

At follow-up, repeat those tests in which the patient had abnormal results at the previous visit. Look for the following changes:
► Improved OSDI score (a 7- to 13-point change may be clinically meaningful)
► Improved morning/evening symptoms
► Less lash debris
► Less overall lid margin redness (telangiectatic vessels may remain)
► Greater than 4/8 glands expressing, improved clarity of meibum (six to eight glands expressing mostly clear meibum = normal)
► Less staining (number of regions or overall quantity)
► Increased TBUT (a four- to five-second increase may be clinically meaningful)
► Improvement (or no change) in PRT test is optional.

Case #2

A 56-year-old post-menopausal female presents with contact lens discomfort and dryness that has been worsening over the past year. She has not changed solutions or contact lens brands within that time period. Indeed, she is a loyal patient and replaces her lenses close to the recommended schedule, if not earlier than recommended. She reports worse "evening dryness and visual blurriness" as she approaches the end of her lens wearing cycle.

DOCUMENT:

► OSDI score 22 (mild)
► Worst symptoms fluctuating vision (PM)
► No previous OTC or prescription drops
► Grade 0 collarettes and flaking O.U.
► Grade 1 telangiectatic vessels, Grade 1 posterior lid margin redness
► 4/8 inferior nasal meibomian glands expressed slightly cloudy (Grade 1) meibum/15 sec.
► Grade 1 inferior corneal staining, inferior conjunctival LG staining O.U.
► TBUT instantaneous O.U.
► PRT test = 6mm/15 sec. O.U. (abnormal)

At follow-up, repeat those tests in which the patient had abnormal results at the previous visit. Look for the following changes:

► Improved OSDI score (0 to 12 points is "normal")
► Improved evening visual clarity, increased comfortable wearing time (a two- to three-hour increase may be clinically meaningful)
► Less overall lid margin redness (may persist)
► Greater than 4/8 glands expressing, improved clarity of meibum (six to eight glands expressing mostly clear meibum = normal)
► Less staining (number of regions or overall quantity)
► Increased TBUT (a four- to five-second increase may be clinically meaningful)
► Improved PRT test — may be worthwhile to repeat, consider Sjögren's Syndrome consult if other dryness symptoms present.

Tailored management approaches

Previously, I mentioned staff review of the management plan with the patient. Educate your staff to be aware of these three factors that impact your selection of a patient management strategy:

► Patient motivation/compliance. Motivation is a significant factor in dry eye and lid disease management. Currently, artificial tears and cyclosporine A (Restasis, Allergan) are mainstay therapies for dry eye, while the combination of lid hygiene and warm compress application (with or without topical antibiotics) is currently considered within the standard of care for blepharitis.

While no good data exists on patient compliance with most therapeutic modalities, especially warm compresses, anecdotally nine of 10 clinicians would say that a patient rarely maintains non-prescription therapy for longer than two weeks (artificial tears may be an exception). It may be unrealistic to think of lid hygiene and warm compress therapy as a solitary therapy for blepharitis, especially when compliance is a significant issue with a chronic disease.

Many practitioners are using a tailored approach that includes topical antiinflammatory/ antibiotic therapy (e.g. off-label topical azithromycin) alternating with lid hygiene/warm compress therapy. Simplifying the approach will likely provide the best compliance.

► Chronicity of the presenting signs and symptoms. Although they are two different issues, the severity of a disease is often linked clinically to the chronicity. Most would agree that the longer someone has a disease, the worse the disease can be. To date, no long-term natural history studies of dry eye or blepharitis exist, so we do not know what influences the severity or chronicity, as well as the longterm response to therapy.

In ocular surface disease, initial and long-term therapies should be selected on the basis of presenting severity. A really inflamed lid or recalcitrant severe corneal staining may require initial topical steroid to quiet the ocular surface and lids so that the underlying disease etiology can be addressed.

► Mechanism of therapeutic action. When selecting a therapy, consider long-term management as well as possible prevention of progression. Lastly, the mechanism of therapeutic action should be plausible, safe and effective.

The in-service connection

Incorporating staff in-services about the therapeutic plans you are adopting will help your staff deliver and reinforce your message to your patients. Have your staff try your lid scrub and warm compress routines — or even better, find a friend, relative or patient willing to give a "therapeutic testimonial."

Keep your staff in the loop, and part of the team, in order to optimize your ocular surface disease practice. OM