I have had the opportunity, through speaking on DED throughout the United States, to get my fellow O.D.s fired up about it and, therefore, make DED screening part of their everyday practices. It is my passion. Why?

I was a spherical myope who desired LASIK. At my LASIK consult, my surgeon discovered I had higher-order aberrations. Suspecting these aberrations were due to DED, the surgeon prescribed the two-week use of an anti-inflammatory eye drop. When I returned for follow-up, “magically,” the aberrations were gone. This confirmed the surgeon’s suspicions, while giving me the epiphany that the tear layer affects vision, meaning DED is a vision disease — my bailiwick!

That day, DED became the most important disease state to identify and treat in my practice. In addition, in learning that the condition is consistently overlooked and prevalent, I knew I had to inquire about it on every one of my patients. But, how could I do it efficiently? After all, with reduced reimbursements from vision care plans, I couldn’t afford for it to take an extra 10 minutes per patient. The process had to be a streamlined, consistent and evidence-based one to benefit patients and the practice.

Here’s a look at the steps I took to accomplish this.

I EDUCATED MYSELF

1 Outside of practice, I have visited (and continue to visit) Google Scholar (https://scholar.google.com ) to find the latest research on DED. Also, I have visited the TFOS website, where their Dry Eye Workshop’s consensus of DED provides a template for making decisions.

In addition, I sought (and still seek) CE regarding the anterior segment, and I ask other thought leaders and practitioners at these events what works best in their practices when it comes to DED. Learning from actual practicing O.D.s, who understand factors, such as patient flow, staffing, prior authorization challenges and more, has been invaluable.

Further, as my DED clinic has grown, I’ve attended workshops to gain hands-on experience with the latest technologies and techniques. (Of note: In addition to benefitting patients, many of these innovations can supplement practice revenue.)

I EDUCATED STAFF

2 In knowing that staff is a critical part of practice success, I set aside time to educate them about DED.

Specifically, at lunch and learns and staff meetings before or after practice hours, I explained why identifying the condition is important (effects on vision and lifestyle), how to look for and treat it (so staff could answer patient questions) and their role in doing so (i.e. assisting in providing patient education and gathering data). There also have been occasions when I’ve taken staff with me to industry events, so they could take DED CE.

Finally, I’ve taken advantage of lunch-and-learn programs offered by industry, as they are chock-full of helpful information, making them valuable, and very well received by staff.

I INCLUDED A DED QUESTIONNAIRE

3 Along with the practice’s patient history form, I added a TFOS-validated DED symptom questionnaire. I prefer SPEED or the DEQ-5 because of the brevity required to answer the questions and interpret results.

Surveys are given at reception and scored before the patient goes to the exam area. They take less than 15 seconds to score.

I STARTED WITH BASIC TESTING

4 Once I began identifying symptomatic patients via the questionnaire, I employed efficient testing, such as fluorescein strips (O.D.), a phenol red thread test (staff) and vital dye installation (O.D.) to look for DED clinical signs. The time required for each is roughly 30 seconds, and the cost of performing such tests per patient is less than a dollar, so no significant capital outlay was required.

Start with the basics. Build patient volume before adding costly technologies. Learn to walk before you run.

With time, consider adding more diagnostics that can help refine treatment approaches, and consider offering ocular nutritional supplements and supplies, such as ocular compresses. (As a brief, yet related, aside, I recommend offering these items at a competitive price to enhance patient compliance — something needed for successful outcomes.) (See “Be the DED Detective,” p.16 and “Defy Dry Eye,” p.20.)

Before making any purchases, get a sense of patient need and the practice’s ability to support the technology (finances and device footprint). Start by creating a list of potential patients for a week, then extrapolate, and crunch the numbers. (The percentage of DED patients that would make adding new equipment a good choice depends on the specific purchase and the monthly payment of the device vs. increased income with absolute numbers.)

Next, follow the science, and look for, or ask, the manufacturers of devices to support their claims with research.

Now, consider the cost of using the device. How much time does it take to get the data? Are there consumables, such as test cards? Is the data meaningful to you? Will insurance cover the cost or will the patient? Who will gather the data or use the device and when? Will patients return for testing? Due diligence is of paramount importance.

I CREATED SHORT CUTS

5 In knowing patients would need education regarding their DED diagnosis and prescribed treatments, I created handouts that include this information, rather than verbal communication, enabling me to stay on schedule. (See “Handout Example" below.)

I MARKETED THE SERVICE

6 As my primary care practice was already established, I focused on the internal marketing of screening every patient for the condition via the DED questionnaire, sending an email blast about DED’s impact on one’s quality of life and the treatments I offered for it. Also, I sent (and continue to send) email blasts regarding the addition of related technologies, as this patient base grew (and continues to grow).

If your practice is new, I recommend offering DED talks to local service clubs, donating artificial tears to first responders and getting in touch with your local news outlets to make folks aware of your practice’s DED services, and mention any new or unique technologies. Finally, use your practice’s social media channels to let your patients know that you diagnose and treat DED.

THE RESULT

Within six months of following these steps, I tripled my medical visits, while keeping my revenue-per-patient the same. (Reimbursement for medical office visits and punctal occlusion played a significant role in maintaining this revenue average.)

This occurred due to efficiency. I was able to increase patient-visit volume, but the increased medical income kept my revenue per patient high, so my gross increased. In addition, because these steps enabled efficiency, there was no need to create dedicated appointment slots for DED patients.

The bottom line: Keep it simple at first. Start identifying symptomatic patients, look for clinical signs, develop a treatment plan, and schedule a follow-up visit to monitor progress.

Oh, and about my LASIK procedure: I am happy to say that it went very well, my vision remains great, and as a result of the experience, I am also especially vigilant in looking for DED prior to patients undergoing refractive surgery. OM

Dry Eye Disease (DED) is one of the most common eye conditions in the United States. A healthy tear film is composed of 3 layers: the mucin layer, which helps spread tears evenly, the aqueous layer, which lubricates and nourishes, and the meibum layer, which helps prevent the tear film from evaporating. When any number of these layers is insufficient, Dry Eye Disease develops, resulting in any number of symptoms. These can include dryness, grittiness, burning, stinging, stickiness, light sensitivity, fluctuating vision, and watering. Below, you will find a list of treatments, some of which you will begin today. As your disease responds to treatment, your regimen will be tailored for you. 

Based on your evaluation, Dr. Schachter recommends the following treatments:
 
TARGET: OCULAR SURFACE INFLAMMATION

• Xiidra: a prescribed medication that reduces ocular surface inflammation. You will use one drop per eye twice a day. 
• Restasis: a prescribed medication that reduces ocular surface inflammation.  You will use one drop per eye twice a day.
• Steroid Eye Drops: steroid eye drops are best used for a short period of time to allow faster relief of dry eye symptoms. These drops can sometimes cause the pressure in your eye to increase; therefore we will closely monitor this while you use this drop. 
• HydroEye Supplement: these vitamins work from the inside-out to deliver a proprietary blend of gamma-lineoleic acid (GLA) and other important omegas. GLA has been shown to be effective in many peer-reviewed studies, and should reduce dry eye symptoms within two months. 

TARGET: MEIBOMIAN GLAND DISEASE

• IPL (Intense Pulsed Light): targets ocular rosacea, dry eye disease, and meibomian gland dysfunction. Treatment consists of pulses of light from ear to ear. Typically four sessions are scheduled two to four weeks apart with a maintenance treatment every six months. 
• Lipiflow, Tear Care, iLux: these state-of-the-art therapies are the most effective way to clear abnormal oil from the meibomian glands. The in-office procedure safely applies heat the glands to liquefy the hardened oil. At the same time, it massages the glands with automated, pulsing pressure to clear the poor quality oil out of the glands. Following the treatment, your glands should secrete healthier oil for eighteen months to three years after the treatment. The effect appears to last longer with sustained anti-inflammatory therapy, as prescribed by Dr. Schachter. 
• Lid Debridement: this in-office procedure is aimed at removing any blockages from the meibomian glands. Dr. Schachter will gently exfoliate the eyelids with a small tool. Research shows that this treatment alone improves dryness within one month. 
• Warm Compress: normal meibum is thin and flows easily from the meibomian glands. Heating the glands with warm compresses has been shown to keep the oil thin and easily expressed. Using a Tranquileyes xl mask for 20 minutes daily will help keep your meibum healthy. 
• Blinking: a proper, full blink spreads the tear film uniformly across the cornea and draws oil from the meibomian glands. At least four times per day, take time to fully squeeze your eyes closed for about 10 seconds at a time. 

TARGET: LOW TEAR VOLUME

• Retaine/Systane Balance/Refresh Optive Advanced: these oil-based artificial tears prevent premature evaporation of natural tears. 
• Refresh Contacts: a preserved artificial tear for use while wearing contact lenses. 
• Refresh PM Ointment: viscous lubrication that lingers on the ocular surface throughout the night. Place a rice-sized dollop on your washed fingertip, pull your lower lid away from your eye, and wipe the ointment inside your eyelid right before bed. This ointment will make your vision blurry. 
• Extended duration punctal plugs: small, dissolving inserts that are placed in the canaliculus, the duct on the edge of the edge of your eyelid that drains your tears. Over the course of about 90 days, these plugs dissolve and will need to be replaced. As your natural tear production and physiology improves, this intervention becomes unnecessary. Plugs should be avoided if you are an ocular allergy sufferer, as they trap allergens on the ocular surface. 

TARGET: LID HYGIENE 

• BlephEx: this procedure is done in-office, and aims to reduce Demodex load, bacterial overload, debris, and biofilm. Home maintenance with lid wipes will be required. 
• Cliradex: this eyelid wipe or foam is used in cases of more severe eyelid debris. The tea tree oil isolate is scientifically shown to decrease Demodex mites and bacteria at the edge of your eyelids. 
• Blephadex: this eyelid wipe is milder and can be more easily tolerated. On its own, Blephadex is not likely to reduce Demodex, but can help keep the population under control.
• We Love Eyes: this tea tree-oil based product is toxic to Demodex, anti-bacterial, and also serves as a safe, effective mascara remover.

 
TARGET: ENVIRONMENTAL CONTROL

• Desktop humidifier: creates extra air moisture at your workstation. This should be used near your desktop or wherever you spend time concentrating at a reading or computer distance. 
• Moisture Chambers: glasses and sunlasses that have a foam barrier and moisture reservoir on the inside of the frame to prevent evaporating and irritating excess airflow around your eyes. It functions like a wind jacket for your eyes, slowing down evaporative loss. These should be worn outdoors, indoors in turbulent air, while driving and while using a compute 

TARGET: FACIAL HYGIENE AND COSMETICS USAGE

• Make-up Removers: We Love Eyes- Developed by an optometrist to clean eyelids in a healthy all-natural way. Stop using store bought make up removers, which can contain chemicals that exacerbate dry eye disease. Instead, use We Love Eyes to gently massage the make-up away. Soak lids with a hot, well-wrung, microfiber cloth. Gently wipe debris away. Never expose lids to soaps, cleaners, or detergents, which strip your tear oil reserves.
• Face Wash: cleansers with tea tree oil and antibacterial effects strip oil from your skin and should be avoided. Apply and remove facial cleansers accurately and precisely with a washcloth in a circular motion, avoiding the area inside of the orbital bones. 
• Make-up Recommendations: we recommend Blinc brand mascara. This mascara is water-resistant, but easily removed with We Love Eyes.  Stick with liquid or cream based foundations, blush and eyeshadow. Avoid talc, mineral and powder based cosmetics. Use an eyeliner pencil, not liquid eyeliner. NEVER apply eyeliner to the lid margin, which blocks the oil glands.