Who should take care of dry eye?
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The quick answer is, of course, everyone.
A more complete answer involves a bit of knowledge about who “everyone” is. Long-time readers of my nonsense here are aware of my backstory. Of how my personal background influenced many of my career decisions and how those early influences continue to guide me. If you do remember, I will beg your indulgence as I recount the salient parts as an introduction to these thoughts on how all three of the “O’s” of eye care, ophthalmology, optometry and opticianry, can and should play a role in treating patients with dry eye disease (DED).
As long as I can remember, my family has been surrounded by all things eyeballs. My Mom and Dad both graduated from college with degrees in what would now be industrial engineering. This being 1958, that meant that Dad would get a junior management job in manufacturing. No one was hiring women in the factories of post-WWII/Korean conflict America. Like so many other female college grads regardless of their major, Mom would become a teacher, at least until I arrived on the scene in 1960. Then, consistent with the times, Mom stayed home and managed “White Family Inc.”
My siblings and I grew up in a classic one-shop town in Southbridge, Massachusetts. Our one shop happened to be American Optical (AO), the original American entrant in the world of eye care. My Google-Fu is weak, but if memory serves, AO was one of the first couple of companies in the world to manufacture lenses, spectacle frames, diagnostic equipment and tools to make all the aforementioned. Indeed, the laboratories of AO were the site of some of the earliest experimentation and development of the laser.
All in our little Central Massachusetts burg, Southbridge.
These were the days in which every community larger than a village had a hospital and a fully kitted out assembly of medical and surgical specialists. Not that we were aware of that, of course. Jocks all, my siblings and I knew only our Zeus-like pediatrician Dr. Roy and the orthopedic guy, whose name I forget, who put our little humpty-dumpties back together again and again. I had no awareness that there was a specialty dedicated to the medical and surgical treatment of eye diseases, much less that there might be such a doctor in Southbridge. Remember, too, that this was before the “E” broke away from the “EENT,” became an “O” and formed a separate specialty.
And so it was that my life in Southbridge, a town in which no fewer than half of all workers were employed by AO, was dominated by two “O’s.” All eye doctors were optometrists, and every optometrist employed an optician who dispensed the glasses (and eventually contact lenses) that came from an optometrist’s prescription pad. AO made everything that went into the glasses you bought from your optometrist (no Pearle Vision then) that were then adjusted by his (they were all men) optician. These were all professionals who everyone looked up to.
I did not really become aware that another “O” existed until my first year of medical school.
This entire wordy lead-up is to establish my cred as a guy who entered my post-training career with none of the preconceptions and prejudices about and between ophthalmologists and optometrists in the ’80s. There were laws that delineated the scope of care for all three “O’s.” As we all know, these have evolved over the last 3 decades, partly as a result of an ongoing battle about what constitutes adequate training to handle certain aspects of eye care and, recently, as a result of ever-increasing demand for medical and surgical eye care services.
Two of the areas of increasing need and demand coalesce here in my little corner of eye care. Although I speak about DED here, I actually make my living as a cataract and refractive surgeon. Surgery of all types has always brought in more revenue than pretty much everything else combined. DED, with its exponential growth and the time I take in caring for those so afflicted, takes time away from the surgical aspects of my practice. This is not an excuse to ignore DED, to make little or no effort to either diagnose it or treat it within the context of eye surgery of any kind; I stand by my opening statement above that everyone should treat dry eye.
What I do think is that this is the place for optometrists and their professional organizations to step up and take the lead in diagnosing and treating DED. Doing so will go a long way toward increasing access to care for both DED patients and those in need of eye surgery, particularly cataract surgery. It is necessary to note that making this both an educational and business priority does not require either legislative action or the vitriol that is inevitably associated with that. Treating DED is within the established scope of practice of the overwhelming majority of ODs.
I am personally not looking for a way to stop treating DED patients; the reality in my practice is that the majority of care is being provided by one of the optometrists, especially the mild and moderate cases. At SkyVision, I see the more severe cases, and I tend to do the initial DED evaluation. Neither of these has to be the case, though; all a practice needs is an eye doctor dedicated to staying on the leading edge of DED care, and it does not matter if that doctor is an OD or an MD. What matters is a commitment to the latest and best evidence-based care, doing what is necessary to get that care to your patient, and a willingness to abandon what may have once been the “best we have right now” for something that is better, regardless of how this may impact revenue.
A perfect example of this is abandoning stuff like tea tree oil-infused lid wipes sold in the office in favor of suffering through the pain of the prior authorization process in order to get your evaporative DED patient with Demodex blepharitis on Xdemvy (lotilaner ophthalmic solution 0.25%, Tarsus Pharmaceuticals). There is no reimbursement for that — you are just a better DED doctor.
Oh, yeah, there is a third “O.” All of you opticians out there reading this — well, both of you opticians out there reading this — are probably thinking I forgot about you. Nope. I got you. From the third grade when one of you fit me with my first glasses, you have been a part of my life. How can you help your other “O’s” take care of their DED patients? Many of them suffer from photophobia brought on by DED of all types. Offer them glasses with an FL-41 tint or suggest a pair of rose-colored sunglasses (I am a big fan of the Maui Jim version). They will feel better, and they will feel better because you, the optician, took the opportunity to help treat their DED.
Remember, our DED patients only care about seeing and feeling better. They do not care whether it is an ophthalmologist, an optometrist or an optician that gets them there.
- For more information:
- Darrell E. White, MD, of SkyVision Centers in Westlake, Ohio, can be reached at dwhite@healio.com.
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