Symptoms alone can indicate diagnosis of dry eye vs. allergy

PHILADELPHIA – Practitioners should evaluate patients for complaints of burning, itching, tearing and eye rubbing when making a differential diagnosis of allergy or dry eye. Here at the Primary Care Optometry News Symposium, PCON Editorial Board member J. James Thimons, OD, FAAO, and Ernest Bowling, OD, MS, FAAO, disseminated clinical pearls on these similar conditions.

One symptom that points the practitioner toward a diagnosis of dry eye is complaints of burning eyes that worsen as the day progresses, Dr. Thimons said at the conference. Dry eye patients are also likely to have symptoms that change based on climate, he said.

Michael D. DePaolis, OD, FAAO: PCON Editor Dr. DePaolis served as the course director and moderator for the 3-day PCON Symposium, in its sixth year. Images: Hemphill N, PCON

A practitioner should think of allergies in patients whose itching and symptoms increase with exposure to allergens, Dr. Thimons said.

The way a patient reacts to rubbing their eyes is also a valuable tool in making the differential diagnosis, Dr. Bowling added. In allergy patients, eye rubbing worsens the symptoms, whereas in dry eye patients, eye rubbing relieves symptoms.

Tearing is also a means for differentiating the two conditions, Dr. Bowling said. In allergic patients, tearing is constant, while in dry eye patients the tearing is episodic.

The condition of the lid margins should also be taken into account, Dr. Thimons said. For lid margins with crusting and collarettes, the practitioner should think dry eye, he said. For lid margins with edema and erythema, the practitioner should think allergy.

Wratten filter useful in diagnosing dry eye

Drs. Thimons and Bowling also discussed some tools for making a dry eye diagnosis. A Wratten filter can improve dry eye detection with fluorescein dye, whereas a red barrier filter enhances lissamine green staining, according to Dr. Thimons.

“If you stain someone and their symptoms are purely unilateral, look at dendrites,” Dr. Thimons said.

Dr. Thimons also discussed rose bengal and lissamine green stains, which reveal damaged areas of epithelium in both the cornea and conjunctiva. These dyes stain mucin strands and filaments that may be difficult to distinguish otherwise.

“In mild to moderate dry eye, these agents work very well,” he said.

Another useful test is the Tsubota tear film test, which measures time between blinks until vision fades, said Dr. Thimons. A time of less than 7 seconds indicates significant dry eye, and 8 to 15 seconds indicates moderate dry eye.

Dry eye and allergy: Drs. Thimons and Bowling offered pearls for differentially diagnosing dry eye and allergy. They also covered the use of nutritional supplements for treating dry eye.

Sjögren’s and lymphoma

Patients with Sjögren’s syndrome are 46 times more likely to develop lymphoma, said Dr. Bowling. He cited a study by Moutsopolous and colleagues, which found that Sjögren’s syndrome patients have an 8% to 11% incidence of lymphoma, which is 46.3% more often than those without Sjögren’s.

Secretagogues are currently the most effective treatment for Sjögren’s syndrome, Dr. Bowling said. In particular, the saliva-stimulating drug Evoxac (cevimeline HCl, Daiichi) three times a day is very useful, he said.

Side effects of nutritional supplements

The team also discussed nutritional supplementation for dry eye treatment, focusing on potential side effects resulting from the use of omega-3s. One of the biggest concerns with nutritional supplements, Dr. Thimons said, is increased gastric distress, belching and bleeding.

“You can’t use these supplements in patients who are taking drugs such as Coumadin (warfarin sodium, Bristol-Myers Squibb) Plavix (clopidogrel bisulfate, Bristol-Myers Squibb), normal dose aspirin or any other platelet agent,” he said.

Program moderator and PCON Editor Michael D. DePaolis, OD, FAAO, asked Drs. Thimons and Bowling about the assertion that the use of flaxseed could increase the risk of breast cancer. Dr. Thimons confirmed that this is true, but only when the husk of the flax is used.

“People who grind their own flax frequently use the husk as fiber,” he said. “Husk has a high rate of estrogen compound. Women with a family history of breast cancer place themselves at a higher risk by doing this.”

Ocular side effects of systemic drugs

Nicky R. Holdeman, OD, MD, FAAO, treated symposium attendees to a discussion of popular systemic medications.

“There are more than 3 billion prescriptions written each year,” he said. “Virtually every disease entity either affects the eye or has a treatment that affects the eye.”

He recommended two yearly publications – Drug Facts and Comparisons (Wolters Kluwer Business) and Drug-Induced Ocular Side Effects (Elsevier Science and Health Division) – as excellent sources of information about many common systemic drugs.

Dr. Holdeman discussed the ocular side effects of several drugs. Hydrocodone/acetaminophen can cause miosis and blurred vision, he said. Lipitor (atorvastatin, Pfizer) may cause dry eye, and amoxicillin can cause dermatologic side effects.

The ACE [angiotensin-converting enzyme] inhibitor lisinopril can cause ocular edema and conjunctivitis, Dr. Holdeman said, and HCTZ/furosemide can cause choroidal effusion and myopia.

Atenolol/metoprolol may worsen myasthenia gravis, Dr. Holdeman said, and may also cause visual disturbances and side effects. This drug may also decrease or mask IOP, he said.

Systemic drugs and conditions: Drs. Semes and Holdeman targeted the ocular effects of systemic drugs and the signs and symptoms of Graves’ ophthalmopathy.

Signs of thyroid eye diseases

PCON Editorial Board member Leo P. Semes, OD, FAAO, joined Dr. Holdeman in a discussion of thyroid eye disease.

Dr. Holdeman covered the signs and symptoms of Graves’ ophthalmopathy (GO), in particular. “Eyelid retraction is the most common clinical feature of Graves’ ophthalmopathy,” he said.

Dr. Holdeman listed “Dr. Nick’s Top 10 Picks” – his tips for detecting and understanding this condition:

• eyelid retraction is the most common finding
• GO is the most common cause of proptosis in adults
• GO is six times more common in women
• orbitopathy is often asymmetric
• GO is associated with hyperthyroidism in 90% of patients and euthyroidism in 6%
• severity of orbitopathy does not always parallel blood work
• optic neuropathy requires urgent care
• if surgery is needed, orbital decompression should be done first
• controlling systemic thyroid does not necessarily influence the eye
• GO typically occurs in the less proptotic eye

Dr. Semes also discussed the clinical features of thyrotoxicosis, a condition that typically develops between 10 and 45 years of age, more often in women than in men. He said the skin of a patient with this condition has a moist, warm characteristic. Patients with thyrotoxicosis also may experience thyroid enlargement, onycholysis, alopecia, tremor and pretibial myxoedema. “The skin on the shins takes on an orange peel appearance,” he said.

These patients may also experience eye stare and lid lag, tachycardia/atrial fibrillation, proptosis/ophthalmoplegia, weight loss, tremulousness and muscle weakness, heat intolerance and hyperdefecation.

Dr. Semes suggested a technique for remembering the extraocular muscles involved in this condition. Using this memory device, called “I’m Leo Semes,” the first letter of each word (as well as the “m” in “I’m”) can be equated with inferior rectus (IR), medial rectus (MR), lateral rectus (LR) and superior rectus (SR).

OD’s role in evaluating, treating systemic disease

In a separate presentation, Dr. Holdeman stressed the importance of discussing systemic eye disease with patients. In addition to increasing insulin resistance, hyperglycemia, dyslipidemia, hypertension and prothrombotic and proinflammatory states, obesity increases the risk for major eye diseases such as age-related macular degeneration, dry eye, cataract and glaucoma, he said. Life expectancy could fall as much as 5 years for Americans if the frequency of obesity is not curtailed.

Metabolic syndrome is initiated by obesity, then leads to insulin resistance, hyperglycemia, hyperinsulinemia, excess insulin, dyslipidemia, increased triglycerides, then hypertension, Dr. Holdeman said. Obesity is measured by calculating body mass index (BMI), with a range of 19 to 23 being considered optimal. At this point, 65% of American adults are considered to be either obese or overweight.

The obesity rates in children between 6 and 19 years old have also shown a dramatic increase, from 5% in 1964 to 20% today. An American Medical Association survey shows a 90% increase in obesity-related office visits, with $39 billion a year being spent on related diseases, he said.

The risk for developing heart disease increases by 10% for men with a BMI of greater than 23, Dr. Holdeman said. Statistics show that a majority of physicians do not discuss obesity with their patients, with 80% only recommending exercise. Each decade, 7% of muscle mass is replaced by adipose tissue, which reduces metabolism. Abdominal adipose fat increases the risk of insulin resistance, hyperlipidemia and thromboembolic events. “It is our responsibility and obligation to discuss obesity with our patients,” Dr. Holdeman said.

The risk of acquiring diabetes mellitus for those born in 2000 is 32.8% for Caucasian men and 38.5% for Caucasian women, Dr. Holdeman said. The risk for Hispanics is even greater, at 45% for males and 53% females. “Diabetes will overwhelm the health care system in the United States,” he said. “Diabetes kills more people than breast cancer and AIDS combined.”

In reaction to this rise in systemic disease, changes have been made to diagnosis criteria, he said. For example, a blood pressure of 120 mm Hg to 139 mm Hg/80 mm Hg to 89 mm Hg is considered pre-hypertension. “Physicians are not being aggressive at treating these diseases. The levels don’t have to be that high for there to be a problem,” Dr. Holdeman said.

According to the New England Journal of Medicine, “The life expectancy of the average American could drop by greater than 5 years unless efforts are made to slow the rising obesity rates,” Dr. Holdeman stated. Primary care providers should always focus on the overall health of their patients. Like the old adage for real estate, location, location, location, Dr. Holdeman recommends control of blood glucose, control of blood pressure and control of lipids.

Communication key to comanagement

During the PCON Symposium’s refractive surgery track, PCON refractive surgery columnist Jimmy Jackson, MS, OD, FAAO, and Thomas W. Samuelson, MD, supported communication and an active OD-MD comanagement relationship for the best surgical outcomes.

Dr. Jackson, who practices at InSight Laser, Golden, Colo., said his center services approximately 1,500 cases a year, with about 35% of those coming from a comanagement situation. Dr. Samuelson practices at Phillips Eye, where both comanagement and comprehensive services are offered.

“Comanagement is not our variable to control,” Dr. Samuelson said. “It is up to the optometrists and their relationship development with the patient. Comanagement can work beautifully. I am predominantly interested in surgery, so having the follow-up monitored by an OD is the best-case scenario.”

Phillips Eye offers mini-fellowships to optometrists who, in turn, are listed for comanagement referrals.

“If we all communicate, it is the best of possible worlds,” said Dr. Jackson.

Even with this type of cooperation, optometrists find themselves comanaging fewer patients, due to a smaller number of procedures annually as well as a rise in associated costs. “We are seeing a downward trend,” Dr. Jackson said. “It’s just not economically viable to base any center strictly on comanagement.”

Dr. Jackson listed several factors that are influencing the decrease in comanagement: more direct marketing, profit margins shrinking, optometrists being less aggressive at promoting laser vision correction, increased cost of malpractice carriers and legal challenges directly related to comanagement.

Dr. Jackson stressed the importance of a long, continuous history with surgeons. “The tactics that the discounters are using directly to the consumer is dodgy,” he said. “Doctors that refer to us are not financially invested.”

According to Dr. Jackson, comanagement makes sense for a number of reasons including the advice of two doctors for the price of one.

For optometrists who are committed to having comanagement as a part of their practice, he reiterated the essentials for success: be well informed and an expert; be active and proactive with your referrals; expect no center to try hard to get the patient back to you; aggressively promote your laser vision correction expertise internally and externally; and leverage your clout, as centers are always looking for referrals.

Refractive surgery and comanagement: Drs. Jackson and Samuelson addressed refractive surgery comanagement as well as the future of refractive surgery.

LASIK will continue its popularity

Drs. Jackson and Samuelson also discussed the popularity of various refractive surgery procedures, saying LASIK will most likely continue its dominance. “LASIK has the instant ‘wow’ factor that makes it more likely for patients to immediately communicate their positive experience with the surgery to family and friends,” Dr. Jackson said.

Surface ablation is challenging LASIK’s stronghold by making a comeback as a viable surgical choice due to the decreased likelihood of epithelial growth. It is particularly good for thin corneas, dry eye, epithelial basement membrane disease and post-radial keratotomy. The small spot scanning technology makes it a viable option for treating postoperative eyes, according to Dr. Jackson.

“Some people believe surface ablation is better because of the quality of optics,” Dr. Samuelson said. “Epithelial cells are never the same after LASIK.”

The drawbacks, increased healing time and pain, keep photorefractive keratectomy at less than 5% of U.S. laser vision correction procedures annually.

Multifocals and IOLs are now being viewed as an excellent alternative for the increasing numbers of presbyopes, Dr. Samuelson said. “For presbyopes who can tolerate monovision, these options can be used as a niche product, not a primary procedure,” he said. “You can tell the patient to reasonably expect improvement of two vision zones, with improvement of all three being considered gravy.”

Incorporating the newest in wavefront platforms improves patient outcomes, increases profitability and maintains the practice’s leading edge status, according to Dr. Jackson.

“We took the decision about whether or not to use custom procedures out of the hands of the patients,” Dr. Samuelson added. “We decide what is best for them by using custom only.”

Good records key to coding success

Coding and reimbursement: Dr. Brownlow, PCON’s resident coding expert, shared pearls from his columns with the audience.

In a final presentation on coding and reimbursement, PCON columnist and Editorial Board member Charles B. Brownlow, OD, FAAO, told attendees that providing excellent health care is at the heart of the coding process. “The bill that was passed in 1997 that introduced these codes was liberating, but it hasn’t been well accepted by the medical world,” he said. “Unfortunately, there are many ODs who haven’t even read the codes.”

Dr. Brownlow recommends basing patient care on the following principles: find out the patient’s needs, keep good records and choose codes correctly. In particular, he stresses accurate recording of the reason for visit.

“Even though insurers are predominantly interested in the diagnosis, you must have a reason for the visit to be reimbursed by Medicare standards,” Dr. Brownlow explained. “Even if a patient presents with blurred vision and nothing is diagnosed, it is still legitimate by Medicare standards as long as the correct reason for the visit code is used.”

Dr. Brownlow listed a number of caveats for providing health care: find out why the patients is in the office; design the history and physical examination to match the patient’s needs; complete the history and examination; record all appropriate information on the patient’s record; make the diagnosis and list management options; and choose the code(s) to report your services to the patient and payer.

On the topic of the patient’s visit, Dr. Brownlow reiterated the importance of finding out the specific reason for the visit, the history of present illness, and review of the systems and family medical history. “Do what the patient needs, keep good records and choose codes correctly,” he said.

The 99000 codes are based upon patient medical history, physical exam and medical decision-making, he said. Specifically, the physical exam now comprises 12 elements that include evaluation of 10 ocular and two psychiatric elements.

Dr. Brownlow recommends developing your own protocols for common conditions such as chronic open-angle glaucoma, keratoconjunctivitis sicca, posterior vitreous detachment, keratoconus and diabetic checks. “Never compromise your quality of care to accommodate a carrier,” he said.

Codes for Optometry is revised annually and can be purchased through the American Optometric Association by calling (800) 365-2219 or by visiting their Web site: www.aoa.org.