Tools for a Successful Dry Eye Clinic

By: Paul M. Karpecki, OD, FAAO Clinical Director – PECAA

One of the more common questions I receive from PECAA colleagues is related to what’s specifically needed to start an effective dry eye practice. Some of the answers may seem obvious but others may surprise you.

The First Piece of Equipment

The Haag-Streit Imaging System

The question often is  posed as what’s the first piece of equipment I need to add. Although I feel osmolarity is essential, meibography is extremely valuable and if you can’t practice without expressing meibomian glands,  the answer is a slit lamp that captures images and video. My first choice would be the Haag-Streit imaging system. I’m blown away  but the resolution and quality of  imaging. And the cost may surprise you as sometimes it’s a simple upgrade to what you may already have. Other great technologies  include TelScreen and EyeFinity. A system like this pays for itself multiple times because a clinician can recall previous findings, educate patients about their condition which increases efficiency and compliance, and bill for anterior segment photography. This is a key communication tool.

Another essential tool in patient education is Rendia (previously known as Eyemaginations). By having the dry eye modules providing information to patients before, during and after the exam allows you to see many more patients per day. Patients want to understand their condition and the course of management. Patients with a good basic understanding through Rendia are better patients, easier to educate and more likely to inform friends and family. In fact studies have shown it’s not specifically time they want with the physician but rather a clear understanding their disease and next steps and knowing they were listened to and treated with respect.

Specific Dry Eye Diagnostics

Expressing meibomian glands with a Mastrota Paddle

When looking at which dry eye diagnostics are necessary the answer depends on how much you want to dedicate to building  a dry eye clinic. If you just want to manage your DED patients and refer those that are advanced or not responding, then a good history or better yet a questionnaire like the SPEED questionnaire, sodium fluorescein dye strips and a device for diagnostic meibomian gland expression may suffice (best examples I’ve witnessed are the J&J LipiScan and Oculus Keratograph meibography module or Keratograph M5). The dye will assist in measuring tear break-up time, conjunctival and corneal staining, and assessment of the tear meniscus height. Meniscus height can be a good determinant of aqueous deficient dry eye.  Expression will indicate meibomian gland dysfunction (MGD) pointing to an evaporative dry eye. The Mastrota paddle from OcuSoft is the expression tool I currently use. Simply place this titanium paddle behind the lower nasal to central eyelid and apply pressure to the outside eyelid with your thumb. You’ll  quickly see what quality meibum  is expressing. An evaporative dry eye will require hydrating compresses like the Bruder mask, lid hygiene ranging from Blephex to eyelid cleaners and inflam-mation control. Aqueous deficient dry eye requires focusing on inflammation and tear volume. Most of what’s needed to determine either of these can be achieved with a good history or questionnaire, NaFl dye and expression.

A Dedicated Dry Eye Center

If you plan to dedicate your practice or a segment of your practice to DED, then there are other items you’ll require.  For symptoms you will need more than a history as patients will provide more information via a validated questionnaire. Consider SPEED,  DEQ-5 or OSDI as potential options – I prefer the SPEED questionnaire. Point-of-Care (POC) testing is both a differentiator and  a necessity. If you are going to receive referrals you need diagnostics beyond those in general practice and osmolarity testing with TearLab is a must-have. I can unequivocally state I could not run my dry eye clinic without it and I see over 50 patients a day  with advanced dry eye and OSD per day. I see patients that complain of symptoms of dry, gritty, irritated eyes who have normal osmolarity (between 280-300 mOsmol/L and both eyes within 6 mOsmol/L), but subtle signs of what could be construed as DED. Typically these patients have been treated for dry eye for anywhere from 3 months to 5+ years and have seen numerous doctors but do not improve because the diagnosis is something other than DED. Osmolarity testing instantly tells you that.  Differential diagnosis include allergic conjunctivitis, EBMD or map dot fingerprint dystrophy, recurrent corneal erosion, limbal stem cell deficiency, blepharitis such as demodex, trigeminal dysphoria, GPC, neurotrophic keratitis, computer vision syndrome, Salzmann’s Nodular Degeneration, conjunctivochalasis, conjunctival concretions, SLK, mucin fishing syndrome, and exposure keratopathy to name a few (we’ll discuss treatment technologies like Neurolens in a future column). Plus osmolarity helps indicate improvement in the disease treatment to a much greater extend than symptoms, which often trail.1  Another valuable POC test is that of MMP-9 measurements. Patients with high osmolarity and a positive MMP-9 test point to greater inflammation treatment needs and avoidance of punctal plugs. Meibography such as LipiView or LipiScan (J&J Vision), Kerato-graph M5 (Oculus), CA-800 (Topcon), is extremely valuable and necessary for a dedicated dry eye clinic. It helps determine the severity of evaporative DED or differentiating the type of DED. I’ve seen many cases where I could not express meibum and some of those patients had ample glands and others had few glands remaining. The treatment approach would vary greatly between these two patient types.  Other vital dyes such as lissamine green are beneficial in assessing the conjunctiva for early dry eye disease or more advanced mucin deficient dry eye, but you can usually see  conjunctival staining with NaFl.  And certainly non-invasive break-up time (Visiometrics TearFilm Analyzer, Keratograph M5, Topcon CA800) is more accurate than subjective dye testing TFBUT.2 One last test: you need to assess corneal sensitivity. Far too many patients with DED have neurotrophic keratitis components. Being able to quickly assess this with something as simple as dental floss, is extremely helpful.

Final Steps

The last step is a good DED protocol as dry eye is one of the most difficult conditions to manage. My algorithm is basically made based on 4 to 5 tests: symptoms questionnaire, osmolarity, NaFl dye and expression/meibography. Clinicians initially saw DED as something of a nuisance condition similar to say chapped lips, but as doctors started working with these patients they quickly realized the complexity, variability, numerous masquerading conditions and co-morbidities make it a challenge. You must know this going into it, otherwise you’ll get frustrated and not be persistent with this wonderful area of practice. That would be a shame as is it one of the most prevalent and rewarding fields in all of medical eyecare. Just ask a DED patient who has been well diagnosed and treated.

Summary:
1. Versura P, Campos EC.  TearLab® Osmolarity System for diagnosing dry eye.  Expert Rev Mol Diagn. 2013 Mar;13(2):119-29.
2.  Mengher LS, Pandher KS, Bron AJ.  Acta Ophthalmol (Copenh). Non-invasive tear film break-up time: sensitivity and specificity. 1986 Aug;64(4):441-4.

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