allergy

Establish an Ocular Allergy Practice

Treating this widespread problem can enable you to treat other ocular diseases.

Frank Celia, Contributing Editor

For the most part, allergy in the United States is considered a systemic problem and is treated accordingly: Patients who suspect they suffer from allergies usually first visit their family practitioner, who may refer them to an allergist. These patients often end up taking an oral systemic medication, and treatment frequently ends there.

Although allergy also affects the eyes, systemic antihistamines are partially effective at alleviating ocular symptoms (e.g. itching and redness), and they have also been shown to contribute to secondary dry eye problems.^1-3 In addition, allergists and general practitioners tend to lack slit lamps, which can provide more information regarding ocular health. Further, optometrists have the ability to both identify and manage ocular surface problems.

In addition, treating ocular allergy represents a low-risk, low-overhead strategy for enhancing your practice's medical profile. “It makes a statement to patients,” says Glenn S. Corbin, O.D., of Wyomissing, PA. “They think that if this doctor can prescribe an eye drop that they have to go to the pharmacy to fill, they assume that if they have other problems you are going to be able to help them as well. Ocular allergy patients are a fairly easy way to make an entrée into more medical treatment.”

Since the public generally fails to associate optometry with the treatment of ocular allergy symptoms and with no imminent plans for a national campaign to rectify this oversight, each optometric practice must build its own allergy practice pretty much from the ground up. What follows is advice from those who've done just that.

Networking with allergists

Most thriving optometric practices have solid working relationships with local general practitioners and family physicians. To establish an ocular allergy practice, it's essential you seek and network with allergists in your area as well, says John L. Schachet, O.D., who's in private practice at Eyecare Consultants Vision Source, in Englewood, Colo. Dr. Schachet says that when he was starting out in practice, he made it a policy to contact a different local healthcare practitioner once a week and take him or her to lunch to provide education on his various diagnostic and management abilities.

“Whenever a profession overlapped with vision care, I thought it would definitely be beneficial for me to get to know some of these individuals [as doing so would lead to referrals and practice growth]…,” he explains. “I found the allergists were very open to referrals.”

The reason: Dr. Schachet says he explained to them that he had both the education and devices to identify and manage ocular surface problems. (While allergists may have headlamps or loops, nothing in their offices can match the stereoscopic view of a slit lamp.) In addition, Dr. Schachet says he told the allergists with whom he met that he had the education and proper equipment to monitor patients' intraocular pressure. (As allergists are aware that some allergy medications can cause the pupil to dilate and prompt angle-closure attacks in patients who have very narrow angles or undiagnosed angle-closure glaucoma, this skill was of particular interest.) Further, Dr. Schachet says he mentioned that referrals would be a two-way street, as he would need to refer patients to an allergist when he noted systemic disease—something not under his management jurisdiction.

Dr. Schachet says his allergy patients grew to such large numbers, that he eventually added an allergist to his practice. A friend of Dr. Schachet for more than 30 years, Gary L. Niemann, M.D., set up his practice under the same roof four years ago. In addition to lowered overhead of shared staff, the doctors say the two practices enjoy a symbiotic referral relationship.

Specifically, when ocular patients demonstrate systemic problems, Dr. Niemann can be consulted. When Dr. Niemann has a question about a drug's IOP-elevating potential, Dr. Schachet is only a corridor away.

Online marketing

The days of attracting patients through the Yellow Pages and local print newspapers are long gone. A majority of patients now seek services via the Internet. In fact, almost 60% of all U.S. adults have looked online for information regarding health topics, such as specific disease or treatment, according to a recent survey.⁴ Further, this same survey revealed that 11% of adults have consulted online rankings or reviews of doctors or other providers. The bottom line: If you're not online, you don't exist. So, if you don't already have a practice web site, get cracking, say those interviewed. (Visit www.optomeric.com/article.aspx?article=104604 for more information.)

Steven J. Gradowski, O.D., who practices privately in Omaha and sees ocular allergy patients, says he's currently in the process of increasing his practice's online presence to attract more of these, among other types of patients. The reason: Several new patients have presented for care after seeing his practice included on websites dedicated to keratoconus and corneal refractive therapy.

“Our discussions with the ‘younger’ members of our staff seem to lean toward Facebook as a vehicle to reach out to our desired patients—younger families and college types,” he notes. “Facebook offers a way to provide updated info on various new treatments for eye problems, new products and patient education.” He adds that he's also exploring ways to use Linkedin to communicate and network on a business level.

Dr. Schachet agrees that social media is a beneficial platform, as it has created profitable opportunities to stay in touch with existing patients and reach new ones. (See “Social Media Options,” below).

A caveat: While the financial bar for involvement in social media is lower than that of traditional marketing, it requires more labor on your part to do it right. Specifically, providing content for a social networking account will probably take about 10-to-15 hours of work a week, say the experts. As a result, you should probably put one employee in charge of its coordination, Dr. Schachet says.

In fact, at his practice he says he's designated one staff member to update his practice's social media accounts. These accounts include Facebook, Twitter, Yelp, Multiply, Diigo, Wordpress, Posterous and Tumblr, among others. In addition, Dr. Schachet says he contracts with a marketing firm in Colorado Springs, Colo. to make sure the content is up to par, balancing the fine line between authenticity and delivering a practical marketing message. To achieve the right mix of authenticity, fun and practicality, many experts suggest hiring an outside consultant to help set up and maintain social media accounts. Additionally, although social media is not as youth dominated as its reputation might suggest (the average Facebook member's age is 37, after all), it might not hurt to seek input from some of your young employees on its look and content to keep it fresh, says Dr. Schachet.

Although his practice's Facebook effort (www.facebook.com/EyeCareConsultants?sk=wall&filter=) is less than a year old, Dr. Schachet says a number of patients have already responded.

“When we first started, it [the popularity of the site] built quickly,” he says. “It has brought in some business we wouldn't have had otherwise.”

Keeping your eyes peeled

Be vigilant about identifying those who have undiagnosed allergies, those interviewed say. It is estimated that about a third of allergic rhinitis patients do not know they have the condition.⁵

Patients who have allergies, though don't know it, often blame their symptoms on a “recurrent cold” that occurs around the same time every year, says Dr. Corbin. “One of the critical ways to build an allergy practice is to ask the right questions,” he advises. “Ask if the patient ever experiences bouts of itching, redness and tearing. And ask them year round because you may be seeing them off-season, and they feel great.”

In addition, those who complain of ocular issues and have allergies will exhibit a papillary conjunctival reaction that is not always present in patients who have dry eye, those interviewed say. “With allergies, the patient will complain of profound itching,” says Dr. Corbin. “You can have some level of itching with dry eye, but its hallmarks are more the foreign body sensation, grittiness, discomfort and reflex tearing. And usually with allergy, there is more redness in the eye.”

In addition, these patients' lower lids may reveal dark half circles. This swelling and discoloration is indicative of allergy, say those interviewed.

Dr. Schachet says that the “allergic salute” tips him off that a child has allergies. Specifically, the “allergic salute” is when a child uses the palm of his hand to rub his nose up and down. You may even notice a crease in the child's skin under the bridge of his nose from chronic rubbing, he says. “I can't tell you how many times I've walked into the exam room and seen this [both the salute and crease],” notes Dr. Schachet. “Then I look over at the mother and ask how long her child has had allergies, and it comes as a complete shock to her.”

Educating patients

When patients present for their annual exam, let them know you have the ability to handle ocular conditions outside the realm of refractive vision care by asking them to provide both their vision and medical insurance, says Dr. Gradowski.

“Patients very often ask us what we need their medical insurance for,” he says “Then we explain that if we find any pre-existing or new medically related eye condition, we can file it under their general medical insurance.”

In addition, inquire about the current drugs patients are taking, and include the question: “Are you taking any over-the-counter (OTC) drugs, and if so, for what?” Those interviewed say this question will get many patients to divulge that they are taking OTC drugs to manage their ocular allergy symptoms, and you can use this answer as a means of educating them that you have prescription rights and can, therefore, prescribe something easier to use, more effective or safe. (See “Prescription Ocular Allergy Drugs,” below.)

Also, keep in mind that many of these patients and those patients being treated for systemic allergies are at risk for concomitant dry eye, as several OTC drugs contain preservatives that put patients at risk for this condition.

As a result, during the patient exam, be on the lookout for any signs of ocular dryness, via slit lamp exam, say those interviewed.

Dr. Schachet says it's paramount to get the message out that you have the ability to treat ocular allergy. “I think that is more important than anything else in building an allergy practice,” he says, “because you're not going to get to first base otherwise.”

The general consensus seems to be that treating ocular allergy presents less of a challenge than getting patients to understand that you can do it. But if you're willing to invest some time, forethought and creativity, it can be done. OM

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