CLINICAL

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The High Cost of Undiagnosed OSD

Are you prepared to pay the price for overlooking ocular surface disease?

MILE BRUJIC, O.D., BOWLING GREEN, OHIO

Do me a favor: Write (or type) the answers to the following questions, and have them at the ready.

• How much do you charge for an eye exam?

• How much do you charge for an office visit?

• What is the average cost of a pair of glasses with progressive addition lenses, anti-glare and photochromic technology in your office?

• What is the lifetime value of a patient in your practice?

Ready? Great!

Here, I share a personal experience that has prompted me to embrace identifying, educating and treating patients regarding OSD.

“Doc, I’m having trouble seeing near”

In 2006, a 42 year-old female wearing single vision glasses with a -1.00 sph OU presented as a new patient complaining of difficulty seeing near.

A comprehensive dilated ocular exam was performed. All ocular health findings were normal. Her refractive correction was a -1.00 sph OU for the distance correction with a +1.00 add.

I explained to the patient the advantages and disadvantages of a progressive lens design, and she purchased progressive addition glasses containing anti-glare coating and photochromic technology.

The patient seemed satisfied.

“I can’t see out of my new glasses!”

One month after the exam, and three weeks after she got her glasses, the patient returned.

I entered the exam room, said “hello” and asked, “What is the main reason for your visit today?”

The once pleasant woman replied in a stern and angry tone, “I can’t see out of my new glasses!”

I asked her whether the problem was with the distance or near portion, and she shot back, “Both! I can’t see clearly either in the distance or up close through my new glasses!”

Interestingly, she said her vision wasn’t worse with her new glasses vs. the old pair.

“Fluctuating vision” noted

I tested the patient’s distance VA through her new glasses OU. With some encouragement, she read the 20/20 line OU, but stopped to blink multiple times before completing the line. She asked me, “Is this normal?”

I looked at her previous exam and saw I recorded 20/20 OU, with “fluctuating vision.”

Next, I examined her patient history form. It includes questions about OSD symptoms, such as eyestrain, burning, etc., but she didn’t report any.

In noting she worked at an office using a computer, I asked how many hours a day she spends on it, and she answered, “Pretty much all day.” When I asked, “Do your eyes feel uncomfortable toward the day’s end?” she responded, “Oh no, my eyes are uncomfortable toward the end of the morning. They really get tired and strained. . . but that’s normal for me at the computer.”

I placed fluorescein on the ocular surface and viewed her eyes via a cobalt blue light with a wratten filter. I noted significant punctate epitheliopathy inferiorly, fluorescein staining on the nasal and temporal conjunctiva and a TBUT of two seconds. The diagnosis: dry eye disease (DED).

The “no-charge” quandary

We see patients at no charge who have problems with practice-purchased glasses. This visit placed me in the awkward position of having to explain that the underlying ocular surface condition that, unfortunately, wasn’t detected at her initial visit, was the issue. Fortunately, she understood.

I started the patient on the appropriate treatment plan. In a matter of months, she said she was seeing through her glasses much better and that her eyes felt more “comfortable” at work. I have managed her DED successfully since.

An important lesson

I was lucky this patient returned to, and ultimately stayed with, the practice. Had she not — the more likely scenario — she would have remained undiagnosed, seen yet another eye doctor and thought we provided the wrong prescription.

Look at your answers to the questions I posed earlier. If OSD patients go undiagnosed and assume you provided the wrong prescription, the likelihood of these patients returning to you is minimal. This can add up to a significant financial loss for your practice. (See OSD: The Numbers,” page 54.)

Have a DED protocol to ensure this doesn’t happen:

• Place fluorescein on the ocular surface at every visit.

• Put an OSD questionnaire in place.

• Incorporate point-of-care tests. OM

Dr. Brujic is a partner in Premier Vision Group in north-west Ohio. He is a consultant/advisor to various eyecare companies and has lectured on their behalf. E-mail brujic@prodigy.net, or send comments to optometricmanagement@gmail.com.