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Be a dry eye ‘resolutionary’
New Year's resolutions apply to dry eye doctors both new and old.
Well, it is that time of year again. Time to take stock of your year just passed and resolve to be even better in some particular way in the year to come. It is time for you to make your professional New Year’s resolutions. Whether you are a seasoned dry eye disease veteran or a wet-behind-the-ears rookie, allow me to make a few suggestions as you plan out how you will improve in the office in 2018.
Resolve to address DED in all of your patients. You are probably getting a bit tired of hearing this from me. Still, it is ceaselessly amazing to see the increase in the scope of DED in our North American societies. Even in a mature DED practice like SkyVision, we have been astonished to see how much more common DED has become. More than that, though, is the frequency with which we encounter really complex, severe degrees of DED. These patients are everywhere, and they are knocking on the front door of literally every kind of eye care practice there is. They need your help.
Resolve to place a bigger emphasis on your patient’s symptoms as you diagnose and treat DED. I am not going to lie: I am disappointed that DEWS II was not stronger in emphasizing the primacy of the patient’s point of view. You can do so by simply asking your whole staff to be on the lookout for phrases that should trigger a dry eye workup. Remember, the signature finding in the yet-to-be published PROOF study of DED progression is that there is a five times greater incidence of moderate to severe blurred vision in patients who suffer from DED. Test those patients for DED.
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While we are on the topic, in 2018 resolve to be a little more programmatic and objective when it comes to DED symptoms. There are a number of very good, verified questionnaires to uncover dry eye and to assign a value to symptoms. We use both the Ocular Surface Disease Index (OSDI) and the Standard Patient Evaluation of Eye Dryness (SPEED) at SkyVision, but you really only need to use just one. Authorize your staff to survey any patient who has even the mildest of symptoms. If this is already part of your routine protocol, resolve to make an attempt to dig just a bit deeper so that you miss fewer subtle cases of dry eye by asking one simple, magical question: “Do you use eye drops?” Any yes launches an evaluation.
Eye care is actually a strong leader in the use of point-of-care testing. The beginning of a new year is the perfect time to dip a toe into this very exciting area. If you do not do any of these tests, resolve to add either tear osmolarity or MMP-9 testing. There is no reason to stay on the sidelines waiting for new developments in either technology. Indeed, right now both the osmolarity test made by TearLab and the MMP-9 test from Quidel are available with business models that require a nominal commitment of capital. You can start on Jan. 2. Both companies have already resolved to bring us new and better assays, so they are doing their part, too.
Even really experienced DED docs have room to improve in ways big and small. There are so many ways to examine the DED patient that sometimes you forget something that is very helpful. For example, I had mostly forgotten how helpful lissamine green can be when you have a very symptomatic patient with an uninspiring set of exam findings. SkyVision participated in the Ocular Science micro-particulate amniotic membrane suspension study (ACE) in which lissamine green was a standard part of the protocol. In 2018, resolve to “rediscover” a simple test that you may have forgotten, such as the Schirmer test. For me, it will be the regular use of lissamine green.
A significant percentage of ophthalmic surgeons, especially cataract surgeons, have begun obtaining OCT before every cataract surgery. Why? Well, it is pretty disheartening to do a picture-perfect case only to discover that epiretinal membrane or vitreomacular traction after your patient fails to get better than 20/50 postop. Knowing that there might be subtle macular pathology before you operate allows you to prepare your patient more completely for what may come after surgery. The same thing is true for DED. If you diagnose even the subtlest dry eye preoperatively, you can initiate treatment that will make your shared postop experience more pleasant. One of your New Year’s resolutions for 2018 should be to do an OCT and test for DED on all of your preop patients.
Resolve to be a learner in 2018. I would love for you to choose DED as your topic of choice, but I think the resolve to think of yourself as a student is more important than the particular subject you choose. Pick a topic or three and throw yourself into learning something new. You might choose to learn the next logical extension of your dry eye protocol. We are adding doctors at SkyVision, and I hope that gives us a chance to learn about intense pulsed light (IPL), for example. If you already do IPL, why not take the plunge and learn about LipiFlow (TearScience). Perhaps there is something new you could pick up and try in your busiest service line. I recently spent a day in the OR using the Zepto capsulotomy unit (Mynosys Cellular Devices), my first significant change in surgical technique in almost a decade. Accepting the role of eternal student keeps you sharp.
Finally, let us all resolve to be kind. Unfailingly kind to not only our patients but also to the staff who support us so faithfully. Let us each seek opportunities to be kind to one another. Our world, however wonderful, is still one that seems to be ever more challenging. We face hardships (regulatory, tort, third-party payer, etc.) that seem arbitrary and capricious because we have done nothing to deserve them. Let us see our colleagues as the brothers and sisters that we are, and extend to one another kindness first and always.
Happy New Year.
- For more information:
- Darrell E. White, MD, can be reached at SkyVision Centers, 2237 Crocker Road, Suite 100, Westlake, OH 44145; email: dwhite@healio.com.
Disclosure: White reports he is a consultant to Allergan, Shire, Sun, Kala, Ocular Science, Rendia, TearLab, Eyevance and Omeros; is a speaker for Shire, Allergan, Omeros and Sun; and has an ownership interest in Ocular Science and Eyevance.