A look at dry eye disease management pearls from 2021

This year’s column covered a range of topics, several of which contained practical, user-friendly tips. To facilitate their use, this column serves as a “one-stop-shop” for those dry eye disease (DED) management pearls.

TOOLS TO START A DED CLINIC

We can use the slit lamp to assess corneal and conjunctival staining, allowing for the assessment of TBUT and superficial punctate keratitis. Additionally, the slit lamp can be utilized to evaluate the lids and lashes for collarettes, debris, saponification and biofilm, which indicate the presence of blepharitis, meibomian gland dysfunction (MGD) or Demodex folliculorum.

Pro tips: We should have our patients look down when we evaluate the upper lashes, as collarettes can be missed or hard to see because of redundant, overhanging lid tissue.

Additionally, we should push on the meibomian glands to grade the expression. Even more precise is meibography, which helps to identify these patients earlier and quantify MGD.

EXISTING USEFUL TREATMENT PROTOCOLS

Three treatment protocols are currently available that aid in decision making by differentiating treatment based on the severity and causality of DED:

1. TFOS Dry Eye Workshop Second Edition Protocol (see https://bit.ly/2ZKIyZ0 ).
2. ASCRS Preoperative OSD Algorithm (see bit.ly/3c38AKR ).
3. CEDARS Dysfunctional Tear Syndrome Algorithm (see bit.ly/3vD6glo ).

All three are very similar, with many overlapping areas, and I have found they are easy to follow and implement in practice.

Pro tips: We should consider in-office eyelid exfoliation, as it is a fairly inexpensive treatment that is effective in removing bacterial debris, biofilm and helps with Demodex folliculorum. Also, we should contemplate having a thermal expression device in-office, as this facilitates gland expression. Options are available at different price points, and I have discovered that many companies will work with the O.D. to demo their models.

CONTACT LENS PATIENT AWARENESS

A large reason for contact lens drop out is ocular surface disease.

Pro tips: We can follow these tips to help prevent this:

• Asses the naked eye, even if the patient doesn’t have a complaint. Be proactive, not reactive.
• Prescribe treatment(s) based on clinical findings.
• Consider prescribing a different lens storage solution.
• Keep allergy and a sensitivity to contact lenses at the top of your mind. This may require refitting patients in a different modality or lens material.

SEVERE DED TREATMENT

When all else fails for severe DED patients, we must become more aggressive in treatment. These patients usually have an underlying systemic disease, including Sjögren’s syndrome, Stevens-Johnson syndrome, neurotrophic keratitis, trigeminal neuralgia or limbal stem cell deficiency.

Pro tip: Consider topical treatments, including amniotic membranes or drops, vitamin A ointment, autologous serum drops and cenegermin-bkbj (Oxervate, Dompé). Some of these patients may even require surgical intervention, including punctal cautery, tarsorrhaphy or a conjunctival flap to cover the cornea.

COMPLYING WITH TREATMENT

What we prescribe doesn’t matter if the patient doesn’t follow directions or buy into our treatment plan. By educating patients on their condition and the consequences of them failing to intervene, they become more invested in the management of the problem.

Pro tips: I have found these three steps effective: (1) Provide evidence (“seeing is believing”); (2) educate on consequences (why this is important); (3) discuss treatments (what does it address?).

Additionally, be firm in your delivery ,and avoid being wishy-washy or indecisive, so that the patient feels confident in your treatment plan. Last, but not least, we should provide payment resources for our prescribed treatments.

MEDICAL NECESSITY = CODING

Having a dedicated coding and billing specialist in your office is well worth the investment when it comes to correct coding. 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.