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Optometric Management

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Treat or Refer?

There’s more than one way to ensure your patients get the dry eye care they need

Optometric Management January 1, 2017

The founder of our practice, Frank Bowden III, MD, FACS, long ago recognized the importance of treating ocular surface disease. Therefore, in addition to the comprehensive surgical and optometric care the practice provides, we also have a dry eye treatment model in place. The model addresses all of the etiologic factors that contribute to dry eye and it’s driven by diagnostic tests and the metrics they provide. As we all know, dry eye is not a simple disease, so a great deal goes into our comprehensive dry eye exam (Table 1). The good news is that today’s diagnostic tests help us to identify what’s happening in each case, guide treatment, and monitor progress. We are obtaining true medical data to help us provide the best possible care.

TABLE 1. BOWDEN EYE & ASSOCIATES’ COMPREHENSIVE DRY EYE EVALUATION
  1. HISTORY AND SYMPTOMS
    • medical history form
    • SPEED questionnaire
  2. PRE-TESTING BY TECHNICIAN
    • imaging/meibography (lipid layer thickness, partial blink, dynamic meibomian imaging)
    • tear osmolarity
    • MMP-9
  3. PATIENT SEES DRY EYE COUNSELOR FOR EDUCATION
    • counselors educate on the basics of dry eye and the treatments we recommend for most/all patients
    • counselors are able to apply the above information and predict what the physician will discuss with patient
  4. PHYSICIAN SLIT LAMP EVALUATION, INCLUDING MEIBOMIAN GLANDS
    • hyperemia/conjunctiva staining
    • corneal staining/tear break-up time
    • tear meniscus height
    • lagophthalmos
    • eyelid architecture
    • Marx’s Line
    • lid margin
    • lid wiper epitheliopathy
    • anterior segment photos
    • light microscopy to evaluate cilia for Demodex when indicated
  5. TREATMENT PLAN ESTABLISHED WITH PATIENT
    • core therapy
    • supportive therapy
  6. SECONDARY TESTING PERFORMED BY TECHNICIAN AT PHYSICIAN REQUEST
    • Sjögrens
    • antigen reaction
    • corneal topography
    • repeat previously performed tests at appropriate times
  7. APPROPRIATE FOLLOW-UP ESTABLISHED
    • Any needed or repeat testing is scheduled prior to or at the time of next follow-up

We think about dry eye the same way we think about, for example, glaucoma. There’s a standard of care to follow for glaucoma in that certain testing needs to be performed: visual fields, OCT scans, gonioscopy, pachymetry, and tonometry. If we’re not performing those tests, we’re not providing today’s standard of care and, as a result, we are putting our patients at risk. Therefore, practices that don’t provide the latest tests and treatments for dry eye need to find a way for their patients to have access to them.

THREE OPTIONS FOR PROVIDING STANDARD OF CARE

Practices have three options to choose from when it comes to ensuring their patients receive proper care for dry eye disease. They can choose to be a 1) referral-only practice, 2) shared-care practice, or 3) specialty practice.

A referral-only practice recognizes when patients could benefit from dry eye care and refers them to a specialty practice to receive that care. In this scenario, it’s important to research which nearby practice is offering top-notch, comprehensive care. Consider, too, that a referral-only practice could play an important role in educating patients.

THE FIVE Ps OF RAMPING UP A DRY EYE PRACTICE

To add a comprehensive dry eye segment to the services your practice offers, follow what we at Bowden Eye & Associates refer to as the Five Ps.

  1. People. Practice leaders develop clinical protocols, i.e., a standard of care. All staff members are trained and engaged in that standard of care.
  2. and
  3. Products and Procedures. Adopt a portfolio of tools, not just one, to accurately diagnose dry eye and treat it in all its forms.
  4. Process. Decide how patients who need care will be identified and what will happen next. At Bowden Eye & Associates, the SPEED questionnaire drives our dry eye standard of care. The technicians complete the form with the patient. From there, they can decide what to do next. For example, does the patient need an allergy test? Does the patient need meibography?
  5. Payment. Some dry eye services and products are patient-pay and others are covered by insurance. A practice that’s serious about dry eye care need not worry about that. Based on our experience, the economics will fall into place if you follow these simple steps: establish a standard of care and fee structure; identify what can and can’t be filed with third-party payers, then file accordingly; educate patients about the importance of any test or therapy; use advance beneficiary notices when appropriate; and collect fees as needed.

A shared-care practice is one that has acquired some but not all of the necessary dry eye diagnostic tests and treatments and, as such, refers patients out to receive whatever aspects of care it doesn’t yet offer. This practice may, for example, perform meibomain gland evaluation, but refer patients for thermal pulsation treatment. Or the practice may utilize one or more diagnostic testing systems with which to monitor patients before and after treatment is received elsewhere. It may also provide supportive care, such as punctal plugs and/or recommending the appropriate artificial tears. It’s important for a shared-care practice to coordinate with the referral specialty practice where it sends patients to ensure continuity of care and that patient discussions are consistent. We know firsthand at our practice that shared care works because many practices refer their patients to us. That said, relationship-building is necessary. We let our referral sources know that we don’t take their patients to our optical. We take care of the aspects of dry eye that we’re asked to address, and then we send them back to their home practice. Basically, it’s not much different from comanaging cataract surgery.

The third option is becoming a specialized dry eye practice, offering full-scope diagnostics, treatments, and products, as we do at Bowden Eye. Resources are available for practices that would like to begin moving in this direction. For instance, our team has developed Dry Eye University (dryeyeuniversity.com ) for the purpose of sharing our expweriences and keys to success. Another resource, dryeyecoach.com , was recently developed by Whitney Hauser, OD. Industry vendors are helpful as well. They’re educated and motivated to help doctors incorporate their tools and technologies into practice.

Getting on board with the dry eye revolution is absolutely doable. (See “The Five Ps of Ramping Up a Dry Eye Practice” on Page 10.) When practices really look for dry eye patients, they’re usually amazed at the number of them and how many they had been missing. The technology and techniques are obtainable, and they can create a great return on investment. They also enable practice growth and better patient care.

WE OWE IT TO OUR PATIENTS

We encourage all practices to commit to being a referral practice, a shared-care practice, or a full-scope specialty practice for dry eye to ensure patients have access to quality dry eye care. Today, we know too much about dry eye to ignore the importance of treating it. It’s a chronic disease, and patients won’t get better, they’ll get worse, if we’re content with simply masking the symptoms.

Who better to address this ubiquitous condition than optometrists? We’re first-line for ocular health care, and we have the best opportunity to educate our patients and initiate treatment. The sooner we address it, the better their future prognosis will be.

Dr. Robben is chief optometrist with Bowden Eye & Associates in Jacksonville, Fla., and an instructor in the practice’s Dry Eye University program.

Dr. Robben is chief optometrist with Bowden Eye & Associates in Jacksonville, Fla., and an instructor in the practice’s Dry Eye University program.

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