In recent years, the transformation of the dry eye space has produced a range of quick, objective diagnostics. Ophthalmologists who worried that dry eye diagnostics would disrupt patient flow, taking up staff time and treatment time, are seeing that this is not the case. In fact, the cost of not testing is much higher in terms of both time and unhappy patients. The key is to select the diagnostics that make sense for your practice and introduce them in a way that maintains an efficient, comfortable workflow.
GET WHAT YOU NEED
Jonathan D. Solomon, MD: For cataract and refractive surgeons, dry eye is a major concern. Undiagnosed previous dry eye is a leading cause of complications and dissatisfaction after premium cataract surgery. We see a fair number of second opinions in my practice for that reason alone: well-performed surgeries with patients who are unhappy postoperatively as a result of dry eye. We must diagnose and manage dry eye to prevent unhappy outcomes, and today’s diagnostic technologies make this simpler than ever.
Sumitra S. Khandelwal, MD: Agreed. Because ophthalmologists now have several options for dry eye diagnostics, we can determine the best technologies for our data needs, price range, and available space. Some diagnostic technologies have large up-front costs, which are not balanced by reimbursements like interventional technologies are. Thankfully, we are seeing a movement toward more affordable options. Many dry eye diagnostics don’t require a lot of space and time either, so we don’t have to overwhelm technicians or crowd out rooms we could use for other purposes.
Preeya K. Gupta, MD: If I performed refractive cataract surgery without testing for and treating dry eye, I’d have refractive misses and unhappy patients. My biggest motivator in choosing a new technology is to improving our diagnostic ability so we don’t miss anything before surgery.
It is exciting to see so many new diagnostic technologies and therapies for dry eye today. I think each dry eye test has a shining moment. Meibomian gland imaging helps identify atrophy that isn’t apparent under examination, MMP-9 testing tells us if patients have markers for inflammation, and tear osmolarity testing gives us an understanding of the health of the tear film at the time of evaluation.
REVISE YOUR PROTOCOL
Dr. Khandelwal: In a perfect world, we would perform a complete dry eye exam on every patient, but it isn’t practical in a busy practice. When we introduce a new diagnostic technology, we need to review the protocol for determining who is tested and when. The standard protocol for my surgical patients involves three dry eye diagnostic tests, which allow us to identify dry eye before we perform the full workup and lens calculations. We don’t have to stop a workup because the topography indicates ocular surface problems, and patients don’t have to go through an hour of testing to find out they can’t have refractive surgery because of dry eye.
Dr. Gupta: In our protocol, the Ocular Surface Disease Index (OSDI) and the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire help us identify patients with dry eye and document their symptoms. The questionnaire score triggers more testing if needed—tear osmolarity, followed by MMP-9 testing, followed by meibomian gland imaging. The questionnaire empowers our technicians to make that decision, which has been overwhelmingly positive for technicians and doctors alike. Technicians gain ownership of this process, and doctors get better dry eye testing and save a lot of time.
Dr. Solomon: Our diagnostic protocol begins before patients even arrive. We send an email containing facts about dry eye, which gets them thinking about their eye comfort and potential causes for disruption, and then prompt them to complete an online dry eye survey. In the office, patients can also fill out a SPEED questionnaire in the reception area. Our technicians are trained to know if a patient’s answers indicate possible dry eye, but they consult me for a final decision because I want to minimize manipulation of the ocular surface. They also test all cataract and refractive patients.
FINE-TUNE YOUR WORKFLOW
Dr. Khandelwal: You need leaders in your practice who can ensure that new technologies are integrated smoothly and intelligently. We always involve our office manager and lead technician in discussions about technology from the start because we rely on them to implement these devices and use them day to day. Our office manager weighs space and time considerations, while the lead technician understands where to position new devices to give patients and technicians the smoothest path.
Dr. Solomon: Our lead technician has spearheaded the implementation of new dry eye diagnostics. Her hands-on, day-to-day experience helps her see where each technology fits into the patient encounter, which is crucial to a smooth integration process. Support comes from the top because our practice administrator and CEO have seen dry eye blossom into a major part of our practice in the past 4 years, and they want to make dry eye diagnosis more efficient and reliable.
Dr. Gupta: From the doctor’s perspective, the only change in workflow is the updated or expanded treatment based on new dry eye information. The real change in clinical flow occurs for technicians. At first, we wondered if routine dry eye testing would derail their ability to move patients quickly through the clinic, but that has not happened. All of the dry eye diagnostics we use are fast, compact, and easy to add to existing exam lanes, so introducing them has been a simple process.
