This article was originally published in a sponsored newsletter.
We’ve had quite an active year here at Ocular Surface News! Our columnists covered a wide variety of topics ranging from ocular surface management of the keratoconic patient, to examining meibomian gland changes after corneal cross-linking, to the use of deep learning-assisted blink analysis and other forms of artificial intelligence in the diagnosis of dry eye disease (DED). We’ve looked at patient and physician perspectives in neuropathic ocular pain, examined roadblocks in the diagnosis and treatment of isotretinoin-related DED and tackled the issue of managing DED in underserved populations. Regarding billing and coding, we’ve dissected 92- vs. 99- coding, covered the most common dermatological conditions encountered in ophthalmic practice and how to code them properly and educated on how to express social determinants of health utilizing z-codes, along with much more. If you missed some of these informative topics, don’t fret! You can see all of our issues on Optometric Management’s website. Just click into each month’s issue and look for “Ocular Surface News” in the web exclusives or sponsored content sections!
One thing is for certain: This newsletter wouldn’t exist without our talented OSN family. Special thanks goes out to our 2024 columnists: Ryan Ames, OD, MBA; Jade Coates, OD; Jackie Garlich, OD, FAAO; Blair Lonsberry, MS, OD, MEd, FAAO; Selina McGee, OD, FAAO; Mark Schaeffer, OD; Patrick Vollmer, OD, FAAO, and co-authors and Jillian Ziemanski, OD, PhD, FAAO. Thanks to each one of you for your intriguing and educational contributions and for helping us have a stellar 12th year! An extra special thanks to our copy editor, Sarah Fackler, and of course, to my co-editor, Kelly Nichols, OD, MPH, PhD, for whom I am forever grateful.
Before you go, please read this month’s issue, which centers around environmental and occupational contributors that can exacerbate ocular surface conditions and increase dry eye symptoms. It can take considerable effort on the front end of the exam to investigate potential contributors thoroughly, as well as significant work on the back end of the exam to meticulously educate patients on how to address them effectively, but it isn’t all for naught. Many patients seek non-pharmacological and cost-effective ways to improve their symptoms beyond what you may already be doing, and environmental modification is an easy way to start. Properly “bookending” our dry eye exams is likely something we can all improve upon.
Happy Holidays from Ocular Surface News! We wish everyone a spectacular 2025!
Amber Gaume Giannoni, OD, FAAO
Editor
The Impact of Work Environments on Ocular Surface Disease
Often manifesting as dry eye disease (DED), ocular surface disease (OSD) is a condition that impacts millions of people globally. It often occurs when tear evaporation exceeds the available tear supply, leading to irritation, inflammation, and acute (then chronic) damage to the surface of the eye. While lifestyle factors and underlying health conditions play a role, the work environment can significantly influence the onset and severity of OSD. From office workers glued to screens, to health care professionals enduring long shifts, many occupations expose workers to factors that trigger or worsen dry eye symptoms. Before assessing the ocular surface quality, gaining more knowledge of a patient’s occupation may help us better understand their daily visual demands.
The Role of Digital Devices and Screen Time
One of the primary contributors to OSD in today’s work environment is the extensive use of digital devices. Professionals who spend long hours in front of computers, tablets, or smartphones are at a heightened risk for developing dry eye symptoms. Prolonged screen time leads to reduced blink rates, which is critical for maintaining a healthy tear film.1 Normally, blinking helps spread tears across the ocular surface and removes small debris. However, when individuals focus on screens, their blink frequency can drop by up to 60%, leading to insufficient tear distribution and quicker evaporation of the tear film,1 which results in common symptoms of OSD, including dry and irritated eyes, blurry vision, and discomfort.
Environmental Factors in the Workplace
In my region of the country, someone’s “work environment” could be anything from working in chicken houses, to staring at a computer for eight hours a day, to working with chemicals in a factory lab. In addition to digital device use, the physical work environment itself has the potential to significantly impact ocular health.
Offices, especially those in large buildings with centralized air conditioning and heating, can have low humidity levels. Dry air increases the rate at which tears evaporate, leading to an imbalanced tear film and causing symptoms of OSD.2,3 Additionally, air pollution–which is often prevalent in urban work environments–may introduce irritants such as particulate matter and chemicals that can aggravate the ocular surface and trigger inflammation.2,3
Workers in specific fields, such as those in laboratories, factories, or construction, may also be exposed to additional environmental hazards such as chemicals, dust, and debris, which can directly irritate the eyes and lead to more severe forms of OSD. Similarly, those who work in high-stress environments, including emergency responders and health care professionals, may experience an increase in stress hormones, which can alter tear production and exacerbate symptoms.4
Impact of Occupational Habits
Certain occupational habits also contribute to the development of OSD. People who work long shifts or overnight (e.g., in health care or security services) may face disruptions to their circadian rhythm, which can impact tear production.5 Sleep deprivation, especially, has been shown to reduce the quality and quantity of tears, making the eyes more susceptible to dryness.5
Additionally, individuals who use contact lenses for long periods during the day may find their symptoms worsened by the environmental conditions in their workplace. Extended contact lens wear combined with dry office air can reduce the lens's ability to retain moisture, leading to greater discomfort and a higher likelihood of developing OSD.
Mitigation and Management
Given the substantial impact of work environments on OSD, several strategies can help mitigate symptoms. Simple workplace adjustments such as using humidifiers to maintain optimal humidity levels, reducing screen glare and positioning screens at or slightly below eye level to promote better blinking can all play a role.5,6 Encouraging regular breaks from screens, often following the 20-20-20 rule (taking a 20-second break every 20 minutes and looking at something 20 feet away), can help maintain tear production and reduce eye strain.6 Additionally, using artificial tears or prescription eye drops, when warranted, can help manage both acute and chronic OSD.
For individuals who work in high-risk environments, appropriate protective eyewear or face shields may be necessary to protect the eyes from irritants. Workplaces can also promote awareness of OSD, encouraging employees to seek professional eye care when necessary and incorporate eye health into overall wellness initiatives.
By implementing small changes in the work setting and promoting good eye health practices, employers and employees can work together to reduce the impact of OSD, enhancing productivity and quality of life for those affected while at work.
- Al-Mohtaseb Z, Schachter S, Shen Lee B, Garlich J, Trattler W. The relationship between dry eye disease and digital screen use. Clin Ophthalmol. 2021 Sep;15:3811-3820. doi:10.2147/OPTH.S321591
- Bazeer S, Jansonius N, Snieder H, Hammond C, Vehof J. The relationship between occupation and dry eye. Ocul Surf. 2019 Jul;17(3):484-490. doi:10.1016/j.jtos.2019.04.004
- Lin C-C, Chiu C-C, Lee P-Y, et al. The adverse effects of air pollution on the eye: a review. Int J Environ Res Public Health. 2022 Jan;19(3):1186. doi:10.3390/ijerph19031186
- Chlasta-Twardzik E, Górecka-Nitoń A, Nowińska A, Wylęgała E. The influence of work environment factors on the ocular surface in a one-year follow-up prospective clinical study. Diagnostics (Basel). 2021 Feb;11(3):392. doi:10.3390/diagnostics11030392
- Lee YB, Koh JW, Hyon JY, Wee WR, Kim JJ, Shin YJ. Sleep deprivation reduces tear secretion and impairs the tear film. Invest Ophthalmol Vis Sci. 2014 May;55(6):3525-3531. doi:10.1167/iovs.14-13881
- Sheppard AL, Wolffsohn JS. Digital eye strain: prevalence, measurement and amelioration. BMJ Open Ophthalmol. 2018 Apr;3(1):e000146. doi:10.1136/bmjophth-2018-000146
All living organisms have a circadian rhythm–the natural system of physical, mental and behavioral changes that occur in 24-hour cycles. The regulation of this biological clock is primarily based on the quantity of ambient light organisms receive, which regulates the physiology of peripheral organs through hormonal and neuronal signals. Disruptions in a “normal” circadian rhythm–such as sleep disorders–can result in a variety of physiological changes. Specifically, when alterations in normal sleep patterns affect a patient’s circadian rhythm, they may experience changes in the way their parasympathetic, sympathetic and endocrine systems control body functions, including tear production, which could ultimately affect the ocular surface and result in tear film hyperosmolarity, reduced tear break-up time (TBUT) and decreased tear secretion.
The nursing profession is well known for required night shift work. An important concern for all night shift workers is the impairment of their normal circadian rhythm because they are exposed to light signals during night hours. The current study aimed to investigate the signs and symptoms of dry eye at different times throughout the day in nurses with a relatively long history of night shift work. Most previous studies in this area were conducted on people without a history of night shift work.
This was a cross-sectional study of 40 female nurses with a history of night shift work in the last year for at least six nights per month. Using the TBUT test and ocular surface disease index (OSDI) questionnaire, each participant was evaluated four times: at the beginning of the day shift (8 am), at the end of the day shift (2 pm), at the beginning of the night shift (8 pm) and at the end of the night shift (8 am).1
The lowest rate of dry eye signs and symptoms were related to the end of the day shift (2 pm). However, even in this measurement time, 60% of the participants had dry eyes according to the TBUT (TBUT <10 s) and 70% had mild to severe dry eye according to the OSDI (scores of 13 to 100). The mean OSDI score was higher in nurses with a history of night shift work. It appears that subjects with relatively long histories of night shift work reported more dry eye signs and symptoms compared to subjects who did not work night shift hours. The authors concluded that the severity of dry eye increased after the night shift with variation over a 24-hour period. The results showed a significant correlation between the OSDI and TBUT values at the beginning and at the end of the day and night shifts. The authors recommended night shift workers receive regular ophthalmic examinations to address potential dry eye complications.1
- Bouyeh A, Hashemi H, Alizadeh Y, et al. Does long-term night shift work cause dry eye in hospital nurses? J Ophthalmic Vis Res. 2023;18(4):351–358. doi:10.18502/jovr.v18i4.14543
Does Long-Term Night Shift Work Cause Dry Eye in Hospital Nurses?
Aria Bouyeh, Hassan Hashemi, Yousef Alizadeh, Ebrahim Jafarzadehpur, Ali Mirzajani, Hadi Ostadimoghaddam, Abbasali Yekta, Abolfazl Jafarzadehpour, Arghavan Zarei, and Mehdi Khabazkhoob
J Ophthalmic Vis Res. 2023;18(4):351–358. doi:10.18502/jovr.v18i4.14543
Purpose: To determine the long-term effects of night shift work on dry eye in hospital nurses.
Methods: Each participant was evaluated four times, including at the beginning of the day shift (8 am), at the end of the day shift (2 pm), at the beginning of the night shift (8 pm), and at the end of the night shift (8 am), using the tear break-up time (TBUT) test and ocular surface disease index (OSDI) questionnaire.
Results: The results showed significant differences in the TBUT and OSDI between the end of the day shift (2 pm) (10.26, 16.61) and the end of the night shift (8 am) (6.89, 38.59) relative to each other and relative to the beginning of the day and night shifts. As for the correlation between TBUT and OSDI, a significant correlation was found at all measurement times (correlation coefficient: −0.478, −0.707, −0.556, and −0.365, respectively) (p < 0.05).
Conclusion: The results showed that the severity of dry eye increased after the night shift with variation over a 24-hr period. Moreover, a significant correlation was observed between TBUT and OSDI results at the beginning and at the end of the day and night shifts.
With dozens of ICD10 codes related to the multifactorial condition of dry eye, which should you use? Why not just code H04.123 – Dry Eye Syndrome of Bilateral Lacrimal Glands every time? Does it matter which code you pick?
These are all good questions, which is why we’re addressing them in this edition of Ocular Surface News. At the basic level, just one billable code is needed to be reimbursed for a visit. However, coding multiple comorbidities is beneficial when conveying the provided level of care to the third-party payor.
When we use the Dry Eye Syndrome (DES) code (H04.12X), we are conveying that a patient has a symptomatic disease. We have all had patients who don’t experience any dry eye symptoms even though they present with several signs of an evaporative condition. In such cases, you may appropriately use meibomian gland dysfunction (MGD; H02.88X) as a stand-alone code. In other situations when the patient is symptomatic, you could be addressing both conditions; in which case, both codes should be used. Besides being a good documentarian, the reason for coding multiple conditions comes down to accurately justifying the level of Medical Decision Making (MDM) and, ultimately, how you are reimbursed. Breaking down the entire MDM coding tree is more involved than we will get into here, but let’s hit on the “why.” I encourage you to explore the “how” on your own, if needed.
Below is an abbreviated MDM chart for reference. When we expand on the example of a patient with MGD and Dry Eye Disease (DED), we can begin to see how complete documentation can impact the level of office visit. Let’s use a hypothetical scenario of a patient who was successfully treated for chronic MGD and DED, is now stable and is being managed with a prescription medication. How would this patient “code out?”
If the doctor were to only code H04.12X Dry Eye Syndrome, they would be reporting Low for the Number of Problems Addressed (1 stable chronic illness) and Moderate for Risk (Prescription Drug Management). Low + Moderate = 99213. However, if the doctor were to more accurately convey both H04.12X and H02.88X MGD, the coding would reflect Moderate for the Number of Problems Addressed (2 or more stable chronic illnesses). The Level of Risk would remain the same at Moderate. Moderate + Moderate = 99214.
Be mindful that the purpose of this article is to guide you to accurately reflect the care that was provided so you can be properly reimbursed for the level of MDM. It is not intended to encourage stacking codes simply to justify higher coding. The key to documentation is to do it accurately and completely, then code for the care that was provided; no more, no less.
