DETERMINE WHICH TESTS TO PERFORM, AND HOW OFTEN TO PERFORM THEM

THE DIAGNOSIS of glaucoma differs from dry eye disease (DED) because a standard of care has been established for glaucoma. This standard of care dictates that, at minimum, doctors perform tonometry, ophthalmoscopy, gonioscopy, pachymetry and perimetry to arrive at a diagnosis. Thus, we know to purchase devices that provide this testing.

As no standard of care yet exists for DED, we must determine which diagnostic tests — and there are tons — to purchase, which patients need diagnostic testing and how often to repeat it. As a result, many of our patients aren’t seen often enough, and many undergo not enough or unnecessary diagnostic testing.

Here, I discuss the consequence of this and how to prevent it.

CONSEQUENCE

After the initial diagnostic testing and initiation of topical glaucoma treatment, patients typically return for follow-up in four to six weeks. The DED follow-up is less regimented because the condition isn’t typically vision threatening, in addition to the reasons explained. Therefore, patients may be directed to return a month later, six months later or, worst of all, when symptoms worsen.

Once diagnosed with DED and a treatment is initiated, I’ve found that most patients should return for evaluation in one to three months — even if the recommendation is exclusively artificial tear use. The reason: Out of the 72% of DED patients who received that recommendation, 87% said they wished something more effective was available, reports The 2008 Gallup Study of Dry Eye Sufferers. If patients don’t get substantive relief from artificial tears and have no follow-up care pre-appointed, their risk of turning to another practitioner is high.

HOW TO PREVENT IT

The acquired baseline testing must be repeated to assess the patient’s response to treatment and, potentially, his or her compliance to treatment. That said, too little follow-up makes a patient susceptible to bouncing from a practice, and too much testing can make a doctor vulnerable to scrutiny by insurance providers.

For example, weekly osmolarity readings likely offer limited clinical relevancy and, therefore, would be difficult to justify to insurance providers. Thus, as with any medical diagnosis, timely and medically necessary testing is mandated.

FUTURE CARE

As DED diagnostics continue to mature, essential testing and timelines for those tests will be established. In fact, a standard of care for DED may be right around the corner, given the DEWS II report’s “best clinical approach” to DED, which is comprised of a screening questionnaire, TBUT, tear film osmolarity and ocular surface staining via fluorescein and lissamine green. But, until a universal protocol is elucidated, good clinical judgment serves the patient and should play within the bounds of insurance providers. OM

DR. HAUSER provides clinical care for patients at TearWell: Advance Dry Eye Treatment Center and the Advanced Care and The Eye Center at Southern College of Optometry. She is a consultant, speaker or board member for: Akorn, Alcon, Allergan, BioTeck, BioTissue, Lumenis, NovaBay, Paragon Vision Sciences, Rysurg, TearLab, TearScience, Shire, Science Based Health and DryEyeCoach.com .