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Are dry eye spas worth adopting?
One premium surgeon explains how his practice offers seven customized ocular surface treatment packages.
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As I embark on my 3-year anniversary of the Premium Channel column, the evolution of dry eye therapy has drastically changed since I first wrote about ocular surface disease 36 columns ago.
Ocular surface disease has taken over the term dry eye syndrome in our practices because it encompasses more than just dry eye and the various contributors to a poor tear film, and as premium surgeons, we know this can affect preoperative diagnostic accuracy and postoperative visual outcomes. As dry eye centers of excellence — a term we use to call ourselves — we provide the various diagnostic tests and evaluations to come up with a fairly clear diagnosis and treatment plan for our patient. However, the adoption of therapies such as intense pulsed light and LipiFlow (TearScience) has not been easily accepted by the general dry eye patient due to cost and no additional value after the procedure is completed. This a la carte pricing approach for treatment fails nearly every time a patient has a complaint in the early postoperative period, blaming the “LipiFlow didn’t work,” which puts us premium surgeons in a precarious situation. Many practices have taken the turn and evolved into comprehensive dry eye spas, which brings a value-added approach to the patient based on all the new diagnostics and therapeutic approaches available to us as premium surgeons.
Dry eye spa concept
Many practices have access to the most current diagnostic technologies for ocular surface evaluation, which include vital dye staining of the cornea with fluorescein and of the conjunctiva with lissamine, tear breakup time with devices such as the Keratograph 5M (Oculus), tear film stability and homeostasis with tear osmolarity (TearLab) and tear film assessment (AcuTarget HD, AcuFocus), lipid layer imaging with LipiView I and II (TearScience) and meibomian gland structure imaging (dynamic meibomian imaging, TearScience), tear film inflammatory status with measurement of MMP-9 activity with InflammaDry (RPS), Sjö blood testing of early and late immune blood titers suggestive of Sjögren’s syndrome (Bausch + Lomb), allergy skin testing (Doctor’s Allergy, Bausch + Lomb), and questionnaires such as SPEED and OSDI. Additional information on risk factors for dry eye are the patient’s age, sex, current medications being used and systemic medical conditions. Most commonly, postmenopausal women, patients on antihistamines and/or blood pressure medications, and patients with diabetes, thyroid problems, or other autoimmune conditions such as lupus and rheumatoid arthritis are the most susceptible to having an altered or abnormal ocular surface based on medical history alone. Once all of these advanced diagnostic tests have been performed and analyzed by the premium surgeon, the next step has always been the most difficult in implementing a proper therapeutic strategy, which is the basis of the dry eye spa concept.
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The entire basis of the dry eye spa is to bring value to the patient with a comprehensive acute and prevention/maintenance treatment plan that will treat the specific ocular surface disorder at hand — evaporative dry eye, aqueous deficient dry eye, ocular allergy and/or other contributors. In my practice, we have seven dry eye spa treatment packages based on patient symptoms and/or signs from the thorough diagnostic testing that is performed. Regardless of the treatment package chosen and implemented, each patient will typically follow up at 6 weeks to 3 months from the initial visit to monitor compliance and improvement of the ocular surface condition. We tailored our packages similar to what we did with femtosecond laser refractive cataract surgery and premium IOLs in terms of verbiage internally and advanced beneficiary notice requirements, as most of the treatments suggested are either over the counter or not covered by insurance.
Dry eye spa packages
We have six in-office packages and one at-home package that we provide to our patients on a customized basis based on the testing performed. At Jacksoneye, we call our packages Basic BlephEx, BlephEx Plus, Basic LipiFlow, LipiFlow Plus, LipiFlow T, Premium LipiFlow and Home Care. The packages are phrased as such so our entire ocular surface team can communicate with each other during a patient’s visit to offer the best package for his or her specific condition. They have a tiered pricing starting as low as $145 to as high as $2,250, ranging from a 3-month to 12-month all-inclusive coverage.
The OTC products include a Bruder heat mask, iLast Care/Clean (Paragon Bioteck) lid creams containing hyaluronic acid, eyelid scrubs (Cliradex, Ocusoft), eyelid foams (Ocusoft), omega GLA nutraceuticals (HydroEye, ScienceBased Health), and/or Retaine MGD (Ocusoft), Refresh Optive Advanced (Allergan), Systane Balance (Alcon) or NanoTears formulations (Altaire). Many of our internal packages include an initial LipiFlow 12-minute in-office treatment followed by quarterly BlephEx (Rysurg) maintenance treatments with tea tree oil. Some of our packages only offer BlephEx initially followed by quarterly BlephEx treatments, especially when dynamic meibomian imaging shows significant loss of meibomian glands, the latter in which LipiFlow will add little value. We currently do not offer intense pulsed light; this technology has shown to be helpful in patients with an acne rosacea type of clinical appearance, but it cannot be performed on pigmented skin, which is the only true drawback.
Once a dry eye spa package is selected for a patient, the patient will typically undergo the initial BlephEx or LipiFlow treatment that day and continue with the suggested maintenance products per the package selected by the doctor. The avoidance of an a la carte approach shows the patient our commitment to his or her overall long-term strategy to help the ocular surface improve, recover and/or stabilize.
In the end, the dry eye spa approach has been accepted well by our patient population, with much better clinical outcomes and much better profitability for the practice. Chair time has been reduced, patient expectations have been met, and the modern day dry eye armamentarium has made dry eye spas well worth adopting in our hands thus far.
- For more information:
- Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Ave., Suite L, Lake Villa, IL 60046; email: mjlaserdoc@msn.com.
Disclosure: Jackson reports he is a consultant for Bausch + Lomb, TearScience, AcuFocus, TearLab and ScienceBased Health and is a shareholder for RPS and Paragon.