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Take Your DED Strategy
to the Next Level
Establishing a dry eye center of excellence adds value for patients and practitioners.
By Leslie E. O’Dell, OD
P
atients with moderate to severe dry eye disease
(DED) experience consistent discomfort, and as a
result, actively seek new treatment options beyond
traditional therapies. We as eye care professionals
must use a strategic approach to treating DED because, if
left untreated, it can lead to damage to the ocular surface,
which will have an impact on the entire range of care we
provide, including cataract, glaucoma, and LASIK surgical
outcomes. This article shares the team approach my colleagues and I employ via a dry eye center of excellence at
the May Eye Care Center in Hanover, Pennsylvania.
If a routine patient complains of DED at the end of an
examination, instead of handing them artificial tears and
sending them on their way, schedule them to return for a
formal DED evaluation in the near future. This is a crucial
first step in responding to the patient’s concern and highlighting DED as a treatable, chronic condition that requires
a customized approach.
Just like other serious eye conditions, DED requires a
short-term follow-up evaluation after a course of treatment
has been enacted. A glaucoma specialist would not consider starting a new medication for a glaucoma patient and
seeing the patient back in 1 year. Even a patient receiving
a sample of artificial tears should have a follow-up visit to
determine its effectiveness and additional next steps.
ESTABLISH A TEAM APPROACH
May Eye Care is fortunate that our founder and chief
surgeon, Carl J. May Jr, MD, is passionate about bringing the
latest technology and a “big city” approach to eye care to
a relatively small town setting in central Pennsylvania. Dr.
May is aggressive in researching and investing in new testing
and treatment options that will help meet the diverse and
evolving needs of our large patient base.
In a multipractitioner practice, establishing a team
approach is a great way to maximize patient outcomes,
while strengthening the optometrist and ophthalmologist
relationship. Every member of an eye care team, from the
front desk staff to the technicians, to the optometrists to
48 Advanced ocular care May/June 2014
the surgeons, must understand that ocular surface disease is
a serious but treatable problem that needs to be addressed
for a large percentage of the patient population. Designating
a DED specialist within the practice is a valuable resource
for both patients and the other doctors at May Eye Care.
It gives patients the specialized care and attention they are
likely seeking and need. Establishing a treatment protocol
for DED patients is paramount to ensuring outcomes for
patients are maximized. In our practice, we employ a combined approach of the Delphi Panel Consensus for Dry Eye
Management and meibomian gland dysfunction (MGD)
treatment protocols. These workshops have been a much
needed next step in not only defining DED but also standardizing testing and evaluation to help further research in
the field.
We implement the Standard Patient Evaluation of Eye
Dryness (SPEED) questionnaire for every patient who visits
our practice. The SPEED questionnaire assesses the frequency and severity of patients’ DED symptoms, examines
symptoms that have occurred on the day of the visit, the
past 72 hours, and the past 3 months with only four simple
questions. If I evaluate a suspicious patient and find signs of
DED, I will further question him or her. Ironically, patients
that exhibit classic symptoms often do not attribute them
to DED. For example, eye fatigue at the end of the day is
often blamed on other causes rather than eyes drying out.
Itching is often misconstrued to be caused by allergies.
Perhaps the most common symptom, watering of the eyes,
is often the most confusing, as patients do not think their
eyes are dry when they are watering. The SPEED questionnaire helps to further confirm a diagnosis.
CUSTOM TREATMENT FOR EACH PATIENT
The more I learn about ocular surface disease and the
more patients I treat, I realize that each patient is different.
Each case is like a unique puzzle we have to put together. It
is sometimes a challenge to put together the right combination of treatments to yield the most symptom relief, but we
strive to put all the pieces in the right place.
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Vision and comfort cannot be optimized without a stable
tear film, regardless of how perfect a premium vision procedure or contact lens fit may be. A stable tear film begins
with properly working meibomian glands. We can help our
patients greatly by identifying and addressing MGD early,
before symptoms and inflammation do their damage to the
meibomian glands, lids, and the ocular surface. If symptoms
are already present, for best results, we must first address
MGD and prevent further meibomian gland deterioration.
ENCOURAGING RESULTS WITH LIPIFLOW
Prior to the US Food and Drug Administration’s approval
of LipiFlow, we would manually express the meibomian
glands for patients, which yielded temporary symptom
relief, but it was intolerable for some. In our experience,
LipiFlow provides a much more efficient and comfortable
treatment option. Heating the meibomian glands has been
a standard treatment for some time, but through years of
research conducted by Donald Korb, OD, TearScience has
established the temperature needed to liquefy secretions in
a manner that is safe for the patient.
Two-month follow-up data for 100 patients in our clinic
who received treatment with LipiFlow revealed statistically
significant improvement of symptoms, with 88% of patients
experiencing symptom relief. The number of glands secreting oil also increased by 50%, so not only are patients feeling
better, but we are also witnessing a clinical improvement.
Our success has been related to using the most advanced
technology to make the correct initial diagnosis. Follow-up
calls to patients after treatment also allow us to troubleshoot problems and modify their treatment when needed.
Epilation in both the medial and lateral canthus also helps
with symptom relief. We even have on-site allergy testing
available if needed and are excited to utilize new testing for
Sjögren syndrome (Sjö; Nicox) and the RPS InflammaDry
Detector for matrix metallopeptidase 9.
EDUCATE STAFF, patients
To develop a true center of excellence, you need buy-in and education
at all levels of the practice. It is important to have an eye care professional
eyetubeod.com/?v=odaporone
who has a passion for treating DED
because, more often than not, our subspecialist colleagues have limited interest in treating DED,
and that means that patients are not treated effectively. In
the past, patients with DED have been seen as difficult to
treat and unlikely to generate much revenue. Now that we
have techniques that work, physicians are embracing new
treatment options.
Training staff is an ongoing process that requires repeated
education sessions. All staff need to be able to convey to
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It is important to listen carefully to the patient’s symptoms. Phrases such as “discomfort upon awakening,”
“blurred vision when reading for too long,” and “tired eyes”
all stand out. Outside of the slit-lamp examination, a penlight to quickly access each patient for lagophthalmos and
lid seal, especially those with morning complaints, is helpful. At the slit lamp, I count the number of glands that are
secreting clear oil using the Meibomian Gland Evaluator
(TearScience) as well as evaluate tear breakup time and
gland atrophy. In a few seconds, with transillumination of
the lid, I can evaluate the degree of meibomian gland loss.
I also evaluate each patient for the presence of aqueousdeficient DED and ocular allergy.
For a new patient, my first approach is to either start a
new treatment method or modify the current treatment. If
inferior keratitis is noted initially on the cornea, I often prescribe AzaSite (azithromycin 1%; Akorn) once daily at bedtime. For a patient with a combination of aqueous-deficient
and evaporative DED, Restasis (cyclosporine ophthalmic
emulsion 0.05%; Allergan) twice daily for 3 to 6 weeks is a
first step in a combination treatment approach. There is still
a place for over-the-counter products, such as tear gels and
ointments, but artificial tears in general are just a palliative
course for a progressive problem. Tear gel and ointments
are very helpful for any patient with lagophthalmos for
long-term management.
If evaporative DED is present, I recommend further
evaluation with the LipiView Ocular Surface Interferometer
(TearScience) and treatment with LipiFlow (TearScience),
which uses heat and light massage to unblock obstructed
meibomian glands. As eye care providers, we have a responsibility to educate our patients about the progressive nature
of evaporative DED. If MGD is present, we need to recommend early intervention to prevent irreversible changes in
the glands. Although many patients and even some practitioners will undoubtedly have questions about the out-ofpocket costs associated with some of the new treatment
methods, it is important to lay out the pros and cons of all
treatment options and allow the patient to make his or her
own decision. Cost has not been a barrier in our practice,
even in a rural Pennsylvania setting. Our patients have seen
a great value in their treatment outcomes referring friends
and family for treatment as well.
Following LipiFlow, we contact the patient by phone several days after treatment and have them return in 2 months
and again at 10 months. My goal for patients is to reduce
their symptoms significantly. I use the SPEED survey as a
guide and work hard to keep symptom scores as low as
possible, ideally less than 8 on a scale of 0 to 28. I want my
patients to forget about their eyes and get on with their
lives. It is amazing how much of a negative impact DED has
on these patients from day to day.
May/June 2014 Advanced ocular care 49
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therapeutic device for ded treatment uses thermoelectric heat
patients that there are treatment options available and that
they can link them to the resources they need. We break
the staff into small groups to home in on problem areas,
such as scheduling and how to answer questions about
billing and pricing. We have also developed a position for
a staff member to handle all dry eye phone calls, follow-up
calls, and scheduling for LipiFlow.
Taking the time to educate patients through effective
tools, such as eye models, educational videos, brochures,
and external photos and testing helps patients fully understand their treatment options and the true value of more
involved treatment options. For example, walking patients
50 Advanced ocular care May/June 2014
tocol, and other innovations. When I see a pre- or postsurgical
patient with significant meibomian gland disease, I schedule a
MiBo treatment knowing I can eat the cost if a patient cannot
or will not pay. Patients view MIBO as a true medical intervention and have asked to see my technician directly for the
treatment. I am aware of other users charging $100 to $200 a
session, often in packages of four. This covers the cost of the
unit in a few months.
I use the device as a definitive treatment for evaporative dry
eye, either alone or as a supplement to LipiFlow and/or IPL.
Preoperatively, I use it to treat LASIK and premium IOL patients
whenever there is significant meibomian gland dysfunction.
Postoperative patients with surface issues, including transplant
patients, benefit from therapy. I have used MiBo to address hordeolum with great success. I distributed questionnaires to my first 100 MiBo patients,
some who were new dry eye referrals and others who had been
treated with LipiFlow, IPL, plugs, and Restasis in my practice. At
1 month, 86% felt some level of symptom relief. I believe this
technology is an inexpensive and effective addition to any practice trying to treat the more than 23 million individuals who
suffer from DED in the United States.5
James S. Lewis, MD, is in private practice in Elkins Park,
Pennsylvania. He acknowledged no financial interest in the products or company mentioned herein. Dr. Lewis may be reached at
[email protected].
1. Toyos Clinic website. Intense Pulse Light: For Treating Dry Eye. http://www.toyosclinic.com/procedures/dry-eye-syndrome/
toyos-optimum-ipl-dry-eyes. Accessed May 12, 2014.
2. Maskin SL, Kantor K. Intraductal meibomian gland probing to restore gland functionality for obstructive meibomian gland
dysfunction. http://drmaskin.com/includes/meibomian-probing.pdf. Accessed May 12, 2014.
3. Finis D, Pischel N, Schrader S, Geerling G. Evaluation of lipid layer thickness measurement of the tear film as a diagnostic tool for
meibomian gland dysfunction. Cornea. 2013;32(12):1549-1553.
4. Korb DR, Blackie CA. Case report: a successful LipiFlow treatment of a single case of meibomian gland dysfunction and dropout.
Eye Contact Lens. 2013;39(3):e1-3.
5. The epidemiology of dry eye disease: report of the Epidemiology Subcommittee of the International Dry Eye WorkShop (2007).
Ocul Surf. 2007;5(2):93-107.
through photographs of their meibomian gland secretions
and showing them the comparison between their eyes and
healthy eyes helps to demonstrate the severity of their disease. Loss of the meibomian glands is a new important area
of education and one that can make a major difference if
addressed with the patient early on.
Early intervention is going to prove
to be a key element in successful outcomes; referring patients to a practice
with LipiFlow technology sooner will
result in better control of patients’
eyetubeod.com/?v=eetiririm
symptoms over time.
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By James S. Lewis, MD
Cataract and refractive surgeons have recognized that their
success in the OR depends on the effective management of
dry eye disease (DED). The media, once enamored with LASIK,
directs most of its attention to a so-called epidemic of DED.
The condition has cost LASIK surgeons hundreds of potential
candidates and thousands of hours of needless chair time.
Thermal punctal occlusion and later temporary and semipermanent occlusion were breakthrough techniques decades ago.
Optometry and ophthalmology quickly embraced this definitive, affordable, and effective treatment. Topical cyclosporine,
an antiinflammatory medication known for its use in high-risk
keratoplasty, was reborn as Restasis (cyclosporine ophthalmic
emulsion 0.05%; Allergan) and became the first pharmacologic
weapon against DED.
Rolando Toyos, MD, released his outstanding results with
intense pulsed light (IPL), and I have confirmed its effectiveness
in my practice during the past 3 years.1 Dr. Steven Maskin’s
probing technique has brought relief to many.2 The LipiView
Ocular Surface Interferometer (TearScience), designed by
physician-scientist Donald Korb, assesses the quality of the blink
reflex and the central corneal lipid layer thickness.3 Its companion device, the LipiFlow Thermal Pulsation System, delivers pulsated heat and compression to the root cause of meibomian
gland dysfunction.4
Mike Whitehurst from Pain Point Medical showed me a
diminutive and user-friendly device called MiBoFlo. It uses a
modest amount of AC current and an embedded computer to
consistently warm a silver tab-shaped probe tip to 108˚F. This
applicator can warm, massage, and empty clogged meibomian
glands during a technician-performed 20-minute session. The
tips are removable and sterilizable, and there are no consumables.
During the past 6 months MiBo, has been updated with
newer handpieces and probe tips, an improved treatment pro-
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We also use digital photograph frames in our examination rooms that run a loop of educational messages. A specialized blog on our practice’s web site serves as a valuable
patient reference. Consider posting short, educational videos on resources such as Youtube.com or Advanced Ocular
Care’s optometry resource EyetubeOD.com explaining DED
to patients.
MARKET TO PATIENTS
Internal Marketing
As new technologies are released, we start marketing
within the practice internally, because there are many
patients who we had been seeing for years who were
not aware of all of our offerings. We knew who our DED
patients were, so it was easy for us to introduce new technologies to them. Internal marketing can be in the form
of digital picture frames with rotating messages, flyers for
promotions, and customized waiting room videos, such as
those available by Eyemaginations.
External Marketing
A DED center must have a developed brand. We link our
website to www.helpmydryeyes.com, making resources easy
to find. We hold regular patient seminars to expand public
awareness and have an active Twitter account that generates interest from patients on a regional level and from eye
care professionals on a national and even international level.
The news media has taken notice as well and is helping to educate the community on symptoms and treatment for dry eye. A local TV segment on WGAL TV has
improved awareness of new treatments in our region and
has brought in patients from more than 90 miles away.
(http://tinyurl.com/oms8k8k). A front page story in the
Sunday health section of our local paper also sparked community interest.
Thanks to our concerted marketing efforts and the interest of the community, our DED center has evolved into a
destination resource for people suffering from the disease.
REACH OUT TO OTHER SPECIALISTS
Approach subspecialties in medicine that see a large
number of DED patients, and work to develop relationships
with allergists, endocrinologists, obstetrician gynecologists,
primary care physicians, rheumatologists, and even oncologists. These doctors are often prescribing the medications
that are causing DED. I once treated an ovarian cancer
patient who received LipiFlow, and although I did not see
her for 6 months while she was undergoing cancer treatment, she returned to me and told me the treatment was
an answer to her prayers.
We have seen an influx of new patients traveling from
up to 2 hours away, and after proper treatments, many of
54 Advanced ocular care May/June 2014
them want to make the trip back for their follow-up examinations. In addition, these happy patients become positive
marketing evangelists for our practice by sharing their positive experiences with family and friends and driving referrals
of new patients.
We have also increased the number of refractive surgeries we perform. With a healthy ocular surface, many
DED patients are now interested in LASIK and respond
well postoperatively because maximum vision starts with a
stable tear film.
use the DENTAL MODEl APPROACH
Optimal DED treatment means using a dental model
approach and stressing the importance of preventive care.
Scheduling biannual examinations for DED patients to
perform simple, in-office treatments such as lid debridment
will keep the meibomian glands healthier and hopefully
decrease the loss of functioning glands.
CONCLUSION
Building a DED center of excellence takes time, effort, and
dedication to DED. Now is an exciting time, because we are
armed with a wide range of treatment options that can be
customized to each patient’s needs. DED sufferers can be
some of our most challenging patients; the symptoms of
this disease can range from annoying to debilitating. Making
these patients happy is very rewarding, but it takes a concerted effort, a plan of attack, and a well-rounded team
approach. n
Leslie E. O’Dell, OD, is a specialist in the treatment of dry eye disease at The May Eye Care
Center & Associates in Hanover, Pennsylvania. She
is a consultant to TearScience. Dr. O’Dell may be
reached at [email protected].