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All eye care practitioners should utilize point-of-care testing
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According to the American Academy of Ophthalmology-sponsored RAND Study completed in the 1990s, approximately 30% to 40% of both an ophthalmologist’s and optometrist’s office practice includes dealing with ocular surface issues, including dry eye disease, blepharitis, meibomian gland dysfunction and ocular allergy. If we add in the 45 million or so Americans who wear contact lenses, which always affect the ocular surface to some extent, ocular surface disease stands out as the No. 1 diagnostic and therapeutic challenge faced by the eye care practitioner.
In our practice, we are very active in external disease management with four corneal fellowship-trained ophthalmologists, two optometrists who have dedicated the majority of their practice to dry eye disease, another nine optometrists who fit contact lenses as a part of their practice, a corneal fellow and an optometric resident.
We are dedicated to providing the highest possible quality care in this area and have acquired and employed every new diagnostic and therapeutic tool available, including several so-called point-of-care tests (POCT). These include the TearLab Osmolarity System (TearLab), the LipiView ocular surface interferometer and LipiFlow thermal pulsation system (TearScience), intense pulsed light, InflammaDry (RPS), AdenoPlus (RPS/Nicox), corneal topography for tear film stability analysis and Sjö (Nicox) for Sjögren’s syndrome, and we are also currently investigating allergy testing. We are set up to pull lashes and look under immersion microscopy for Demodex, we do confocal microscopy, and of course, we perform scrapings for staining and culture using quality collaborating laboratories and pathologists. We believe, based on our training and broad clinical experience, that we are good clinical diagnosticians, as well, and utilize fluorescein, lissamine green and rose bengal staining, tear break-up time, Schirmer’s test, lid expression, and careful external and slit lamp examinations on all patients.
Nonetheless, after 42 years in ophthalmology with subspecialty training and interest in cornea and external disease, the fact remains that I continue to find the diagnosis and management of ocular surface disease to be very challenging. Many patients have more than one disease, treatment responses vary from patient to patient with the same medical regimens, and the number of patients who are misdiagnosed using history and clinical examination as the sole diagnostic tools may be as high as 50% in the typical eye care practitioner’s office. This has been proven in several well-designed clinical trials and is reinforced over and over again in newer clinical trials when clinician diagnosis is not confirmed by more sophisticated laboratory testing. For this reason, we have found the increasing number of POCT office-based diagnostics extremely useful, if not indispensable, in our everyday diagnosis and management of ocular surface disease.
In particular, tear film osmolarity has become a foundational test in our practice and is used to diagnose and screen for dry eye disease, grade disease severity and monitor response to therapy. We also prescreen surgical patients for dry eye disease with tear film osmolarity and treat preoperatively when indicated, enhancing our outcomes in refractive corneal and refractive cataract surgery.
I believe it is time for all eye care practitioners to incorporate POCT into their practices, and tear film osmolarity is a good place to start because it is easily done by ancillary personnel and has reasonable and established third-party reimbursement. The POCT diagnostics available can be expected to grow every year, with methods to measure markers such as IgE, MMP-9 and other critical cytokines, as well as additional rapid screening methods for infectious agents, all in development. POCT, along with a careful history and physical examination, is critical to every primary care physician including our internists, family physicians and pediatricians. In a few years, POCT will be as important to the eye care practitioners as it is today to the primary care physician.
Disclosure: Lindstrom has no relevant financial disclosures.