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In integrated practices, dry eye follow-up can mirror management of glaucoma
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Significant advances in the diagnosis and treatment of patients with dry eye syndrome, or DES, have made these patients more attractive to the eye care practice, whether ophthalmic, optometric or integrated with the two practitioner groups practicing side by side.
The DES patient was for decades a relatively neglected individual, partly because the treatments available were poor, but in my opinion also because the economic models were inferior to other opportunities. Today this has changed and is continuing to change. In our group at Minnesota Eye Consultants, with six cornea fellowship-trained specialists and a cornea fellow, we have always seen a large number of patients with ocular surface disease and DES in a consultative fashion, sending the patient back to their referring doctor for long-term care once a diagnosis was confirmed and treatment plan formulated.
More recently, we ophthalmologists and the 12 optometrists who work side by side with us in the clinic have found that the DES patient who self-refers is worth capturing in the practice. We follow these patients in a similar fashion to our glaucoma patients. The frequency of follow-up varies according to the severity of the disease and stability of the treatment plan, but most patients once stable on an effective regimen are seen twice yearly, identical to our stable glaucoma patients.
In glaucoma, we will check vision and IOP, examine at the slit lamp and with fundoscopy, and on alternate 6-month visits perform either OCT of the optic nerve or a visual field. Medication use and compliance are reviewed, and once they are captured in the practice, we plan to retain these patients for a lifetime. As we all know, these glaucoma patients develop many other comorbidities, including cataract, age-related macular degeneration, diabetic retinopathy and DES. The individual visits are usually efficiently completed, and the point-of-service testing and comorbidities that require treatment make these patients attractive to the practice financially.
In an integrated eye care delivery model such as ours, many of these patients can be managed by an optometric colleague. The same is now true for the DES patient. We review the patient symptoms and adherence to therapy, check vision and IOP, perform slit lamp examination with corneal staining/tear breakup time, and at least once per year perform a dilated fundus examination. We also have point-of-service testing that is appropriate and indicated, including tear film osmolarity, MMP-9 and meibography. In select patients other testing such as topography and the Visiometrics HD Analyzer, among others, can be helpful.
In a similar fashion to glaucoma, the examination fee and appropriate testing make the DES patient attractive to the practice, and again for the integrated practice, many of these patients can be cared for by an optometric colleague. The comorbidities are similar and especially include the glaucoma patient with topical medication-induced ocular surface disease. Just like the glaucoma patient, the DES patient requires treatment for life and when well cared for is retained in the practice and serves as a source of many word-of-mouth referrals.
In addition to the effective advances in medical therapy for DES, including topical cyclosporine and lifitegrast, many DES patients now also benefit from procedural interventions. In our practice we offer, as indicated, manual lid heating, lid margin debridement and meibomian gland expression, BlephEx (BlephEx LLC), LipiFlow (Johnson & Johnson Vision), iLux (Tear Film Innovations), intense pulsed light and punctal plugs/occlusion. These treatments use FDA-approved devices and are effective for appropriate patients. In addition, they generate meaningful revenues for the provider, arguably as good as or better than selective laser trabeculoplasty for the glaucoma patient or even a YAG laser capsulotomy.
The DES patient for decades has deserved a higher priority in the ophthalmologist and optometrist office. The combination of enhanced diagnostics and therapeutics along with a patient care and reimbursement model that makes caring for them ever more lucrative has made the DES patient an attractive target for most practices. In addition, the major manufacturers have found the dry eye space an attractive one for investment, which guarantees ever better diagnostics and therapeutics in the future. Finally, after decades of neglect, the DES patient is attractive to our practices, and the clinician who treats them is properly recognized and rewarded.
Disclosure: Lindstrom reports he is a consultant for Alcon/Novartis, Allergan, Bausch + Lomb, Johnson & Johnson, TearLab and Tear Film.