Q: How do I get my dry eye clinic started? The TFOS DEWS 2 outlines a treatment algorithm that starts with addressing patient symptoms. Starting a dry eye clinic often begins with identifying the issue at hand. A good standardized questionnaire like the OSDI or SPEED Test will allow you to identify the proper patients that otherwise haven’t explained all of their eye concerns.
Q: What testing is necessary in a dry eye evaluation? Any testing conducted should be done with purpose. A clinician must ask themselves the following questions.
Why are we measuring?
What are we measuring?
Is it repeatable?
Can it be tracked for change over time?
Is the measurement sensitive enough to be meaningful?
How does it change the care delivered or dictate the care?
With the recent increase in dry eye testing that has flooded the market, another question should be “how redundant are some of these tools and do they really add value to your examination.
Q: What role does Meibography provide in addressing dry eyes? The role of Meibography is best compared to a Fundus Photo in managing glaucoma. The ultimate reason for performing Meibography is to help doctors with the following:
ETIOLOGY: Determining the root cause of the dry eyes requires a determination if the condition is an aqueous deficiency or an evaporative disorder or a combined cause. In conjunction with a good slit lamp examination, if gland drop-out is shown ion meibography, you know the etiology is an evaporative issue.
CHRONICITY: Drop out or loss of glands usually requires a chronic element. Presence of loss indicates blockages over time that have led to hypertrophy of the glands and their loss.
PROGNOSIS: With the advent of new technology for in office treatments of MGD, identifying the right patients for therapy and setting proper expectations will improve outcomes, as well as, patient satisfaction. Treating a patient with Lipiflow who has grade 4 loss of the MG will yield a much different outcome as someone who has grade 1 loss.
PATIENT COMPLIANCE: A Picture is worth a thousand words; an image of the MG drop-out will more likely spur your patient to take action with home therapy, further office visits and follow future recommendations. Functionally, they know they are not comfortable with dry eyes and you can show patients that there are actual anatomical structural changes associated with their condition. For years, dry eyes have been more of an inconvenience then an actual disease.
BASELINE: Tracking a patient over time will provide the best standard of care as we are able to see gland stability or worsening.
Q: How important is TBUT and Schirmer’s Testing? Testing always relates to its purpose. Historically, due to the lack of understanding of dry eyes, TBUT and Tear Volume measurements were something that we thought we could quantify. However, as any clinician will tell you, Schirmer’s Testing can be impacted by the nature of the testing itself. Even non-invasive TBUT measurements can lead to variations if a patient is light sensitive. TBUT (Tear Break-Up Time) doesn’t provide a concrete element of why the eyes are dry and only might tell us there is potential dryness.
It is important to note that dry eye symptoms can vary from minute to minute and measurements of clinical signs in the exam room may only provide a snapshot of a patient’s daily life. This can be a source of frustration for the practitioner who might see improvements in clinical signs that don’t correlate with patient symptoms.
Q: If not TBUT, what should I be looking for in patients? TBUT is a quick and easy qualitative test, but it does not offer any information as to the cause of tear reduction. A good slit lamp examination, history, checking for quality of meibum expression, patency of meibomian glands and Meibography to determine structural damage will provide you a significant amount of information to isolate the root cause. Instead of spending valuable clinical time confirming the presence of dry eyes, time should be dedicated towards what the cause is and how to address it. Look for the following:
Epithelial Capping: Blockage of Meibomian Ducts. Express each individual gland to determine patency
Meibum Quality: Thick inspissated meibum that is hard to express with pressure will not likely flow freely with the natural blink.
Meibography: If there is lack of expression, what is the etiology? Is it because of functional blockages or are there long-term anatomical changes and loss?
History: A good thorough health history can also identify autoimmune components that may be causing an aqueous deficiency.
Q: Which patients should I be running Meibography on? Just like retinal photography, this can be performed as a screening or as part of a problem focused examination. Screening provides advantages of identifying meibomian gland drop out in patients early on and establishing baselines. In addition, it is a patient education tool to help increase capture rate of in office therapies as well as improving patient compliance. Problem focused examinations allow for more targeted determination of root causes.
Q: What am I looking for on Meibography? Gland Shortening:
Due to chronic functional blockages where meibum cannot escape the gland, the pressure can build up and cause the glands to die out. This happens in the area distal to the exit duct as the glands furthest from the blockage have the greatest difficulty
Glands will start to balloon up due to chronic pressure build up
The pathophysiology is not fully understood but suspected to be partial blockages that cause the glands to shift from their normal position. Increased upper lid tortuosity of glands was found to relate to a higher likelihood of contact lens drop out.
Meibography provides one half of the equation on the structural issues, but a good slit lamp examination and expression of the meibum can identify blockages of the exit ductules due to epithelial capping and determine the meibum quality.
Q: What can I bill for Meibography imaging? As Meibography is a non-billable charge, you can charge privately.
Q: Is it necessary to treat dry eyes with in office therapies? Most cases of dry eyes can be treated with home therapies such as compress packs, medications, drops. In office therapies can jumpstart a patient outcome but are not necessary when getting started. Discussions with patients should focus on compliance. With severe MGD, in office therapies such as a thermal treatment and IPL can be highly beneficial.
Q: How should I target my examination? Utilizing an advanced questionnaire to identify the causes of dry eyes can really help a doctor to organize and triage their examination protocol. By establishing a systematic process, or utilizing the advanced questionnaires we have for our users, you can really hone in on the root causes of the dry eye patient.
Q: How do I get my dry eye clinic started? With a dry eye questionnaire, good case history, slit lamp and vital dyes a doctor can start a clinic right away. The TFOS DEWS II places patient symptoms as the overarching trigger to pursue further diagnostics and initiation of therapy. Utilizing standardized survey as compared to clinical signs has demonstrated a greater consistency in prevalence rates. With a qualified survey, some good detective work and systematically identifying and eliminating the risk factors propagating the vicious dry eye circle, a practitioner can significantly improve patient outcomes with less frustration. Technology is continually emerging to help doctors identify and treat the root causes of dry eyes, but it is not necessary to get started.