disease management

How To Treat Ocular Surface Disease

When you manage OSD like the disease state and practice annuity that it is, you can expect grateful patients and practice growth.

THOMAS P. KISLAN, O.D., STROUDSBURG, PA.

A new patient presents with a chief complaint of red, irritated eyes that are worse at end of day and fluctuating vision while using the computer or reading. The patient’s previous eyecare practitioners said the patient has “dry eyes,” recommended some over-the-counter artificial tears, which have not provided relief, and sent the patient home. My colleagues and I have built our practices from patients like this one: That is, patients who have ocular surface disease (OSD) that has not been managed aggressively enough to alleviate symptoms and signs or has gone untreated by both O.D.s and M.D.s who fail to treat it like the disease it is.

Here, I discuss how you should treat these patients to achieve practice loyalty and patient referrals for OSD, among other medical eye conditions.

1. Schedule an OSD work-up.

If you suspect OSD during the patient’s comprehensive eye exam, schedule a follow-up appointment for an OSD workup. This work-up: an OSDI or SPEED score, fluorescein and lissamine green staining of the conjunctiva and cornea, TBUT, Schirmer’s test, meibomian gland expression, atrophied gland assessment, lagophthalmos assessment, a tear osmolarity test and anterior segment photos.

Showing MGD patients blocked orifices and thick meibum makes an impression.

A separate OSD work-up not only shows patients OSD is serious, it also impresses patients, which leads to practice loyalty.

2. Explain the condition.

Discuss the specific OSD disease state. By establishing patient understanding early, he/she is more likely to comply with your instructions and follow-up visits, creating a mutually beneficial outcome.

Patient scripts for each OSD disease state:

► Aqueous deficient dry eye. “Our tears are made of three components: oil, water and mucus. Your eyes are not making enough water, which is the largest part. Are you having any other issues, such as dry skin, dry mouth or joint pain? The reason I ask is that some systemic, or body, conditions are linked with this type of dry eye.” If the patient replies “no,” I say, “Aqueous deficient dry eye is important to treat because your tears protect the surface of the eye. Lack of healthy tears can cause corneal scarring and vision loss. I’m going to prescribe ____, which should alleviate your symptoms and signs. I need you to come back [at a designated time] because I’m concerned about whether the treatment works.” (“Need” and “concerned” are very powerful in getting patients to comply with one’s directions. I learned this in a psychology class.)

If the patient answers “yes,” to the aforementioned question, schedule a Sjögren’s syndrome work-up. If the blood work comes back positive, make a referral to a rheumatologist.

► Lipid deficient dry eye/meibomian gland disease (MGD). “Your tears are made of three components: oil, water and mucus. Your eyes are not making enough of or quality of oil. That oil comes from these tiny glands in your eyelids called the meibomian glands. If these glands aren’t working properly, you don’t produce enough oil. Think of the tear film as water with an oil slick on top. That oil layer protects your tear film and prevents it from evaporating. If you don’t have a good oil layer, your tears evaporate very quickly, and this can progress to fluctuations in vision, corneal infections and scarring. I’m going to prescribe ____, which should alleviate your symptoms and signs. I need you to come back [at a designated time] because I’m concerned about whether the treatment works.”

►Anterior blepharitis. “We normally have bacteria that live around the eye. It’s called our normal flora. Every once in a while, those bacteria can get a little out of control from aging or, if our immune system is down, due to an illness. These bacteria can cause some crusting of the lids and lashes and redness of the eyes. I’m going to prescribe ____, which should alleviate your symptoms and signs. I need you to come back [at a designated time] because I’m concerned about whether the treatment works.”

► Posterior blepharitis. “Your tears are made of three components: oil, water and mucus. Your eyes are not making enough of and quality of oil. That oil comes from these tiny glands in your eyelids called the meibomian glands. Your glands are [blocked, scarred or atrophied], preventing oil production, which protects your tear film and prevents it from evaporating. I’m going to prescribe ____, which should alleviate your symptoms and signs. I need you to come back [at a designated time] because I’m concerned about whether the treatment works.”

► Allergic conjunctivitis. “We all can have sensitivities to certain things in our environment, like dust mites, which can cause hay fever, congestion and a runny nose. Such sensitivities can also affect our eyes.. Today, I’m seeing some changes in your eyes due to allergic conjunctivitis. This is what is causing your symptoms of watery, itchy eyes. I’m going to prescribe ____, which should alleviate your symptoms and signs. I need you to come back [at a designated time] because I’m concerned about whether the treatment works.”

► Bacterial conjunctivitis. “You have an infection of the eyeball. This is not pink eye, as it’s not viral. I’m going to prescribe ____, which should alleviate your symptoms and signs. I need you to come back [at a designated time] because I’m concerned about whether the treatment works.”

► Viral conjunctivitis. “You have an infection in the front of the eye. It comes from a virus that makes the eyes red and itchy, and it can cause some mucus discharge. I’m going to prescribe ____, which should alleviate your symptoms and signs. I need you to come back [at a designated time] because I’m concerned whether the treatment is working.”

Also, explain to these patients that, just as the condition didn’t get this bad overnight, it is not going to get 100% better overnight. Use anterior segment photos to educate the patient on his/her condition. I use the slit lamp’s video camera to show MGD patients gland expression.

3. Discuss treatments.

Tell the patient you can provide treatments that exceed OTC artificial tears, and explain the specific purpose of these treatments, so the patient sees the value in them and complies with them. A brief review of these treatments: broad-spectrum antibiotics, corticosteroids, cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan), lid scrubs, LipiFlow (Tear-Science), macrolide antibiotics, omega-3 fatty acid supplementation and a topical antibiotic/steroid combination.

Keeping patients

Treat OSD as the serious condition it is by scheduling an OSD work-up, educating patients on their form of OSD and discussing the latest treatment options. Doing so results in grateful patients who are yours for life (who refer their family and friends) and a growth in the medical portion of your practice — something crucial to the sustainability of our practices. OM

Dr. Kislan is the founder and medical director of three private practices in Pennsylvania, where he specializes in routine eye care, refractive surgery co-management and the treatment and management of ocular diseases, such as cataracts, glaucoma, dry eye disease, diabetic retinopathy and AMD. Also, he lectures nationally, is involved in clinical research, hosts a local monthly cable TV show called Eye Care Today and is a consultant for Allergan, AMO, PRN and Pfizer pharmaceuticals. E-mail him at foreeyes@ptd.net, or send comments to optometricmanagement@gmail.com.