A team effort to manage dry eye

The staff at The Eye Institute of West Florida Dry Eye Center of Excellence work side by side to achieve positive patient outcomes.

Steven E. Kane, MD, prepares a patient for intense pulse light therapy, assisted by Stephanie Canna, COA.

As the old proverb goes, “necessity is the mother of invention.” This is what drove Neel R. Desai, MD, to found The Dry Eye Center of Excellence at The Eye Institute of West Florida, a 43-year-old, 26-doctor, multi-specialty ophthalmology practice with six locations in the Tampa/St. Petersburg area.

“Very early on, I appreciated the effect dry eye disease (DED) was having on refractive surgery outcomes,” says Dr. Desai, a refractive cataract, cornea, and LASIK surgeon. “I recognized that so many patients had this condition. There was an unmet need for someone to treat DED in a very systematic, thoughtful way.”

Indeed. A total of 6.8% of the U.S. adult population (or more than 16 million people) has diagnosed DED, according to a study published in October 2017 issue of the American Journal of Ophthalmology.

Here, Dr. Desai, his colleagues, and staff discuss The Dry Eye Center of Excellence’s standardized approach to DED, which he says has produced happy and satisfied patients.

Kyle Wenzel, COA (right), assists Robert J. Weinstock, MD, during a patient consultation.

Tina Crevello, PA-C, uses InflammaDry to determine presence of MMP-9.

Refractive surgery candidate assessment

The practice always assesses refractive surgery patients for possible DED at their preoperative appointment, says Dr. Desai.

“We understand that DED can affect spherical power, magnitude, and axis of astigmatism measurements, making it look like there’s a refractive error that really isn’t there,” he says. “Obviously, this can have a negative effect on the refractive outcome post-surgery, so we want to identify and treat DED before surgery to give patients the best chance at a positive visual outcome.”

Robert J. Weinstock, MD, director of Cataract and Refractive Surgery at The Eye Institute of West Florida, adds that LASIK is known to disrupt ocular surface tear dynamics, placing DED patients who undergo the procedure at an even greater level of discomfort postoperatively.

Dr. Desai says diagnostic testing, with devices that include the Galilei G4 Lens Professional (Ziemer Ophthalmic Systems) and the Cassini Total Corneal Astigmatism (i-Optics), give him a “good idea” of whether the refractive surgery candidate has DED.

Should the patient reveal signs and symptoms of DED, they refer him/her to The Dry Eye Center of Excellence. The patient receives additional diagnostic testing, appropriate treatments, and an ocular surface evaluation prior to returning to the surgeon for refractive measurements and surgery, says Steven E. Kane, MD, the practice’s newest cornea and refractive cataract surgeon.

Patient empathy

Of the patients referred to the The Dry Eye Center of Excellence, several have previously visited multiple eyecare providers sans relief, says Tina Crevello, PA-C. For this reason, the practice stresses the importance of empathy toward DED patients during staff training. New hires learn that patients are very appreciative when they have someone who listens to them, makes them comfortable, educates them on what is aggravating their problem, and provides a solution.

“We want to convey, ‘I understand the symptoms that you’re having, and we’re going to try to figure out why,’” Dr. Desai says. “‘You’re not crazy for feeling this way; you’re not crazy for noticing fluctuating vision or having visual complaints. We totally understand, and we can help.’”

As a convenience to patients, The Dry Eye Center of Excellence offers dry eye disease treatment products at the front desk. Here, Michelle Rathmell, opthalmic assistant, helps a patient.

Magen Nestler, COA, uses the LipiView II diagnostic device, which includes Dynamic Meibomian Imaging.

Diagnostic testing

“Our [the staff’s] approach is always, ‘Why does this patient have DED?’” Dr. Kane says. “We pair our tests with what we are seeing. So, if a patient presents with symptoms consistent with an inflammatory process, for example, the PA may recommend sending off a panel for blood work, so we can look for Sj√∂gren’s syndrome.”

Kyle Wenzel, COA, relays why this approach to treatment is so important to The Eye Center of Excellence. “A young girl presented with complaints of symptoms of DED and some iritis issues, which was rare for a young girl, so Dr. Desai ordered a blood panel,” he says. “The panel showed she had undiagnosed sarcoidosis.”

As a result, the practice got her in touch with a rheumatologist and retina specialist to help manage the inflammatory process that was causing her symptoms, Mr. Wenzel says. “This, and other cases, have taught me that looking at someone’s DED doesn’t mean artificial tears and prescription drops are always going to fix the problem.”

The Dry Eye Center of Excellence’s PA and techs’ evaluations include blood work, fixation of lids, staining to assess corneal integrity and tear break-up time, InflammaDry (Quidel), LipiScan (J&J Vision/TearScience), and tear meniscus.

After receiving the diagnostic testing results, the physicians can inform patients and make recommendations regarding treatment. “I tell the patient, ‘We don’t have cures; we have treatments,’” Ms. Crevello says. “Hopefully we’ll be able to get them thinking about their eyes less, which is really what they want to hear.”

Prescribing treatments

DED treatments at The Eye Institute of West Florida are driven by both symptoms and exam results, says Dr. Kane. “Based on the severity and, of course, its underlying cause, we have levels of treatment that we can provide.”

Staff education/training

The Dry Eye Center of Excellence’s standardized approach would not be successful without staff training and education, says Dr. Weinstock. Staff undergo the following training:

  • Minilectures. Dr. Desai gives new staff members a brief lecture on DED that includes what it is and more, he says.
  • Shadowing. “New hires shadow technicians; sometimes they’ll shadow the doctors, so they can get a complete overview of how the testing is done, why it’s done and what it means, so they can educate patients,” Ms. Canna says. “We have a really good team behind us, and the doctors make sure we’re well informed.”
  • Fellowships. Ms. Crevello, who came to the practice with a background in orthopedics and emergency medicine, spent a year doing a fellowship observing doctors, reading, and attending seminars. “Once I learned more and more about the eye, I became very passionate about it,” she says. “I feel very fortunate that I’ve found something that I enjoy so much. You get a lot of satisfaction out of making these patients feel more comfortable.”
  • Monthly meetings. “All the techs who work in cornea, cataract, and refractive service meet once a month to receive a refresher on DED, including any new treatments,” Dr. Desai says.
  • Career advancement. Mr. Wenzel says the doctors are invested in the personal career goals of staff. “If you want this to be a career, if you want to learn everything, the doctors will help you, and this includes furthering your education and training outside the practice,” he says. Staff front the bill initially, but are reimbursed after they pass the training.

The doctors prescribe the following treatments (in order of severity):

  • Systane Balance (Alcon)
  • HydroEye Dry Eye Formula (ScienceBased Health)
  • Bruder dry eye mask
  • Cliradex eye & lid wipes and Light foaming cleanser
  • Ocusoft Lid Scrub and Foaming Eyelid Cleanser
  • Retaine lubricant eye drops
  • Refresh Optive Mega-3 (Allergan)
  • Restasis (Allergan)
  • Xiidra (Shire)
  • Compounded cyclosporine eye drops
  • Oral doxycycline
  • Steroid eye drop tapers
  • Punctal plugs
  • Scleral contact lenses
  • LipiFlow (J&J Vision/TearScience)
  • Intense pulsed light (IPL)
  • Autologous serum drops
  • ProKera amniotic membrane (Bio-Tissue)
  • Superficial keratectomy
  • Ocular surface reconstruction surgery. Performed when the conjunctiva and inferior fornix bunches and the tear layer is gone.

The Eye Institute of West Florida staff display empathy, appreciation, and knowledge. Here, Teri Volheim, front desk, checks in a patient at The Dry Eye Center of Excellence.

Should the prescribing doctor find the patient suffering from DED, he/she is scheduled to undergo the treatment, says Dr. Kane.

Dr. Weinstock says the doctors closely follow their DED patients. “Typically, we have these patients back in roughly two months to see how they’re doing.”

Dr. Kane adds that he doesn’t let his patients “go too long,” because he wants to see what kind of an impact the treatment is having, so he can change course if necessary.

Patient education

The Eye Institute of West Florida’s Dry Eye Center of Excellence provides patient education in several ways, says Dr. Weinstock. “Our website contains information on The Dry Eye Center of Excellence and, once in the practice, a dry eye disease pamphlet, created by Dr. Desai, is available for patients, which highlights the forms of DED and its symptoms.”

Education occurs at both the diagnosis and treatment stages. After the doctor or PA briefly explains the DED diagnosis and the prescribed treatments, the specially trained staff take over the patient education process to reinforce the treatment decision, provide additional information, and answer any questions, Mr. Wenzel says.

Dr. Desai says he and his fellow doctors urge their technicians to remind patients how long it can take to see results from a treatment so they don’t become frustrated, discouraged, and, therefore, cease the treatment before seeing results.

To aid in the treatment discussion, staff use glossy reference sheets. These sheets contain photos of the products they prescribe, circled for customization, and specific instructions on when and how to use them, says Stephanie Canna, COA. (See “Staff education/training,” p. 12.)

A welcomed side effect

Although serving an unmet need was the impetus to starting Dry Eye Center of Excellence at the Eye Institute of West Florida, the side effect has been a new gateway for patients into the practice, says Dr. Desai.

That is, by standardizing a treatment plan tailored to the patient’s specific signs and symptoms, The Dry Eye Center of Excellence has the opportunity to provide patients with a “completely different experience, one that has led to patient referrals,” says Dr. Desai. OP