Proactive approach to OSD improves surgical outcomes, contact lens success

NEW YORK – Do not wait for a patient to say he or she has dry eye; assess his or her risk and symptoms and proactively explore the diagnosis, according to a presenter here at the Ocular Surface Disease and Wellness Symposium, held during Vision Expo East.

“If I go to a primary care physician, I expect them to tell me whether or not I have a certain condition,” Marc R. Bloomenstein, OD, told attendees to the symposium, which Primary Care Optometry News co-sponsored. “It’s like getting a physical for the eye.”

“Prevention is important,” Paul M. Karpecki, OD, FAAO, added. “We know because of computers and tablets that we have to get in a preventive state. When it’s later disease, it could take a lot longer to reverse it.”

When you see patients in their 20s and 30s and see that the family has lid disease, Jack Schaeffer, OD, said, you should address it.

“How many times when a patient comes in who is uncomfortable in their lenses do we switch the lens or solution when we should be looking at the ocular surface?” he asked.

The industry has advanced, providing new materials, but the dropout rate has not changed, Bloomenstein said.

“When you have a contact lens in the eye, we induce inflammation and reduce the ability to make tears,” he said. “Contact lens wear is a privilege, not a right, and it’s our duty to make sure we can sustain that, ensuring any problems are not due to the ocular surface.”

“Look at the eye first, before you consider changing the lens,” Schaeffer said. “And I don’t treat eye disease with vision insurance. All contact lens patients get a modified dry eye exam.”

Bloomenstein said his clinic conducts a thorough ocular surface evaluation prior to surgery.

“For cataract surgery it’s even more important,” he said. “A study by Trattler found that 80% of patients coming in for cataract surgery had moderate to severe dry eye. We address this in our practice.”

Bloomenstein also noted that a study conducted by TearLab showed that an eye with higher osmolarity changes the A-scan measurements.

“You can be off by a full diopter if the ocular surface is not optimized,” Karpecki added.

“Every cataract referral should get a full ocular surface disease work-up,” Schaeffer said. “Send a note to the surgeon about what you found and how you treated it. We’re trying to retain patients for a lifetime.

“In Arizona we have two or three allergy seasons,” Bloomenstein said. “Pretreating patients with prescription strength medication will end up being cheaper than waiting until the allergies get serious and trying to treat them then.”

An audience member asked how an optometrist can convince an asymptomatic patient to accept treatment.

“The minute I start to see cataracts, I discuss it with them,” Karpecki answered. “Even though they’re not symptomatic, I plant it for the future. I take the same approach with dry eye. I tell them I’m worried about their digital screen use, etc. I tell them they could lose their lashes if it’s not treated

“With an asymptomatic patient, I only get 10% to 40% of them to accept treatment,” he continued. “But it gives them permission to raise the issue next time around.”

“I relate it back to why they come to us – because their quality of vision is not right,” Bloomenstein said. “I’ll dictate, so they can hear me, that the glands look a little clogged, that I’m seeing engorgement of blood vessels. I’ll tell them this means they are not seeing as well as they should. Their eyes may not feel dry.”

“That’s a great way to approach it,” Karpecki said. “Studies show that whether it’s early, middle or severe stage dry eye, the only consistent symptom is blurred vision.”

Schaeffer said it is up to the optometrist to direct the process, to say, for example, “Mrs. Jones I need to see you next year. You’re on an antihistamine now, so we’ll want to see you a month before allergy season starts.”

“It takes work and planning,” he said.

“Most people who see an OD only think we provide glasses and contacts,” Karpecki said. “They don’t know we manage disease or provide wellness. We have questionnaires on dry eye in our reception area. Most people fill them out. It gives them something to do while they wait.” – by Nancy Hemphill, ELS, FAAO

Reference:

Schaeffer J, et al. Ocular wellness and the ocular surface: Where do we go from here? Presented at: Vision Expo East. April 14-17; New York.

Disclosures: Bloomenstein is on the speakers’ panel for Abbott Medical Optics, Alcon, Allergan, Bausch + Lomb, Better Vision Institute, BlephEx, Bruder, Macular Health and TearLab. Karpecki receives consulting fees from AcuFocus, Aerie Pharmaceuticals, Anthem, AMO, Alcon Labs, Allergan, Akorn, Bausch + Lomb/Valeant, BioTissue, Bruder Healthcare, Cambium Pharmaceuticals, Eyemaginations, Essilor, Eyes4Lives, Eye Solutions, Focus Laboratories, iCare USA, Johnson & Johnson Vision Care, OcuSoft, Freedom Meditech, Konan Medical, MacuLogix, Beaver-Visitech, Ocular Therapeutix, Reichert, Shire Pharmaceuticals, Regeneron, RySurg, Science Based Health, SightRisk, TearLab, TearScience, TLC Vision, Topcon and Vmax. He is on the speakers’ bureau for Glaukos and Oculus; has conducted research for Akorn, Allergan, Bausch + Lomb, Eleven Biotherapeutics, Fera Pharmaceuticals, Rigel Pharma and Shire; and has an ownership interest in Bruder HealthCare and TearLab. Schaeffer is a consultant for Alcon, Allergan, Bausch + Lomb, CooperVision, Essilor and Vistakon.