THE OCULAR SURFACE

  low-hanging fruit

OSD: The Low-Hanging Fruit

How to identify patient suspects and diagnose a disease that is often left untreated

JEANMARIE DAVIS, O.D., F.A.A.O., FT. WORTH, TEXAS

Ocular surface disease (OSD) is highly prevalent, though it often goes undiagnosed and untreated, making it low-hanging fruit. This is because many patients who have symptoms and signs of OSD, such as blurry vision, discomfort, redness and itching, assume they are a normal part of aging or contact lens wear, so they don’t bring them up during their annual eye exam.

In addition, many eyecare practitioners do not actively ask about symptoms of OSD on patient history forms and at follow-up appointments.

The few patients who do bring up their symptoms are often instructed to use OTC lubricating drops as needed, which, in many cases, is not enough to provide proper relief and could actually worsen the condition when such drops contain certain preservatives.

Without proper diagnosis, education, treatment and follow-up, these patients often fail to improve and give up and seek help elsewhere.

The good news: OSD patients are easy to diagnose, and you have the skills and prescription rights to provide the highest quality care and improve their quality of life, all while boosting your professional credibility and growing your practice. Here’s how.

Ask probing questions

One of easiest ways to identify OSD suspects is to obtain a thorough ocular and medical history. To speed this process — and gain additional information (see below) — ask patients to fill out an intake questionnaire prior to their exam. (Use check boxes to make the process easy for both you and your patients.)

In order to determine whether the patient is an OSD suspect, the questions must be very specific.

For example, ask:

• Do your eyes get red toward the end of the day?

• Do your eyes ever feel tired? If so, when and how often?

• Do your eyes feel dry? If so, when and how often?

• Do your eyes itch? If so, when and how often?

• Do you ever feel like something is in your eye?

Also, be sure to ask about specific systemic illnesses and medications that can lead to or aggravate ocular surface disease, such as allergies and lupus, and antihistamines, among other ocular surface drying drugs, respectively.

Once in the exam room, review the questionnaire. If the patient has not checked any boxes, verbally ask, “Do your eyes ever get red, itchy or feel uncomfortable?” (In my experience, almost everyone replies, “yes.”)

For checked areas, probe the patient for further details by asking follow-up questions. For example, if the patient is a contact lens wearer, ask the patient about his or her wearing/replacement schedule and cleaning/disinfecting routine, as well as more details about symptoms.

If the patient is not a contact lens wearer, discuss his or her symptoms in more detail and ask about his or her ocular/systemic history. For example, ask questions regarding specific onset: Does the condition improve by use of any drops? (If “yes,” which ones and how often?)

These questions provide additional information and, when combined with testing, help with diagnosis and target treatment.

Use diagnostic devices

Should the patient reply with answers that lead you to suspect OSD, diagnosis can be achieved with devices you already have. They include the following:

► Biomicroscopy. Carefully examine the cornea, conjunctiva, lid margins and cornea. Look for signs of OSD, such as ocular dryness or blepharitis.

► TBUT and corneal/conjunctival staining. Fluorescein or lissamine green strips can be used to evaluate the health of the cornea, conjunctiva and tear film.

► Lid eversion and meibomian gland expression. These simple additions can provide important clinical data, such as the quality of the meibum.

All this can be done with existing basic equipment, with no additional equipment or cost to the practice. What’s more, with an ocular diagnosis, such as dry eye, blepharitis, allergy, etc., you can follow up, if appropriate, and bill medically, which can provide additional revenue.

It is important to note that if the patient presents for his/her annual eye exam and OSD is suspected, the patient should be scheduled for a follow-up appointment, at which time diagnostic testing is performed.

Something else to keep in mind: You may want to consider purchasing an anterior segment camera if you don’t already have one, as the above testing can be followed up with photos easily, if appropriate. The investment of an anterior segment camera can be minimal. However, if you are not ready to invest, you can utilize a service that comes to your practice for a fee.

Additional diagnostic investment options include, but are not limited to, the following:

• Inflammadry

• LipiView Ocular Surface Interferometer

► Oculus Keratograph

► TearLab Osmolarity System

► TearScan MicroAssay System

Ripe for the picking

The high prevalence of OSD will provide your practice with a significant amount of these patients, and they’ll be grateful for your care. In addition, by addressing this patient need, you will build credibility with your patients as a medical practitioner. This, in turn, will prompt these patients to refer friends and family to you. OM

Dr. Davis is the global head, technical, Global Performance Development for Alcon Laboratories, Inc., and a fellow of the AAO. Previously, she worked in private practice in Miami. To comment on this article, visit tinyurl.com/OMcomment.