Read more from Practicing Medical Optometry:

This iteration of Practicing Medical Optometry (PMO) is part of an ongoing series focusing on medical optometry offerings of glaucoma, AMD, dry eye, and more. You can find the previous issues of this section for download here.

Additional articles in this edition include:

• Weathering the Perfect Dry Eye Disease Storm
• Determine the Root Cause of Dryness
• Heal, Clean, Calm and Protect the Ocular Surface

It’s arguably one of the most common questions optometrists ask: “How can I get started in building a dry eye disease (DED) clinic without a huge investment?” The “huge investment” part of the question implies it’s not possible, but, trust me, it is.

With an ever-changing armamentarium, it can be overwhelming to decide which devices to have in office, so here’s my advice based on my own experience.

DIAGNOSTIC BEGINNINGS

Optometrists can get started in actively diagnosing DED via a DED patient questionnaire (i.e., SPEED, OSDI) that can be given to all patients via email or at check in. (Such questionnaires can be downloaded free at bit.ly/3wFmj1F and bit.ly/3vvwQfT , respectively. Additionally, a full list of DED questionnaires can be found at bit.ly/34t6X4u .)

Next, O.D.s can use the slit lamp — a device already employed in practice — to assess corneal and conjunctival staining, looking specifically at tear break-up time and for superficial punctate keratitis (SPK). The pattern and location of the SPK tells us about possible anatomical variations to look for as well as environmental causes for the patient’s DED.

Lissamine green is approximately $36 for 100 strips, sodium fluorescein is $19 for 100 strips, and Rose Bengal strips cost $13 for 100.

Additionally, the slit lamp can be utilized to assess the lids and lashes for collarettes, debris, saponification and biofilm, which indicate the presence of blepharitis, meibomian gland dysfunction (MGD) or Demodex. (Pro tip: Optometrists should have their patients look down when they evaluate the upper lashes, as collarettes can be missed or hard to see because of redundant, overhanging lid tissue.)

The Schirmer’s test, which employs filter paper to assess tear production, can be employed to aid in DED diagnosis. Schirmer’s test strips typically cost around $40 and can contain up to 100 strips.

Finally, O.D.s can attempt to express the meibomian glands using a cotton tip applicator or meibomian gland expressor device. This helps assess for MGD by grading the meibum expressibility and quality.

Cotton tip applicators can cost up to roughly $13 for between 100 to 200. A meibomian gland expressor device can cost below $40 and can be cleaned and reused on patients.

IN-OFFICE TREATMENT BEGINNINGS

Eyelid exfoliation is a fairly inexpensive treatment that can be done in-office. Many patients’ eyelid biofilm is too dense to benefit from at-home lid cleaning at the outset, so having a deep cleaning in office makes sense. This is especially true with demodex.

Another important treatment to have in office is a thermal pulsation device. While you can perform manual expression at the slit lamp, it is not as effective, and the extra chair time is typically not reimbursable. Device options are available at different price points. Of note: I have found that many companies will work with the O.D. to demo their models.

Finally, as space allows, it is advantageous for the patient and the practice to have either in-office sales or direct shipment of DED treatments, such as lid scrubs, hypochlorous spray, heat masks, goggles and ocular nutritional supplements, for home use. O.D.s may also want to consider offering DED-friendly makeup products (see bit.ly/3yTe1oI ).

WORK YOUR WAY UP

As O.D.s starting out diagnose the condition in more and more patients, they can work their way up to purchasing state-of-the-art DED equipment, such as devices that provide information on tear osmolarity, tear quantity and ocular surface structure analysis as well as in-office lid treatments and intense pulsed light. Such technology will “wow” patients, instilling their loyalty to the practice, and further facilitate the diagnosis and treatment of DED, enabling optometrists to help and satisfy additional patients. OM

DR. KOETTING practices at Virginia Eye Consultants, and she is adjunct faculty for Pacific University, MCPHS, Salus University, Southern College of Optometry and the University of the Incarnate Word. She has received consulting fees or honorariums from Oyster Point, Glaukos, Quidel, Horizon, Ocular Therapeutix and Eyevance.