The Dry Eye Center at Ocala Eye in Florida (ocalaeye.com ), has built its reputation on caring for patients who have long suffered with dry eye disease (DED). “For a significant number of our patients, the Center is the third or fourth place they’ve visited for their condition. As a result, when they first visit our Center, they’re often depressed, frustrated, and tentative,” says Peter J. Polack, MD, FACS, who founded the Center in 2006. “We’ve been able to put these patients at ease by sharing our knowledge of the condition and by using the most up-to-date diagnostic tests and treatment. We are validating these patients’ concerns — something most of them haven’t felt elsewhere.”

Here, The Dry Eye Center at Ocala Eye’s staff provide an overview of the Center’s evaluation and management options and explain their approach to patient education.

Knowledgeable staff

Staff triage call inquiries to the practice and, when the patients present, answer DED-related questions, such as, “Why do my eyes sting?” Staff education includes:

1. In-house staff training and development. With about 150 employees, Ocala Eye has its own staff training program. In addition to COA and COT certification, the practice offers training for those technicians who are assigned to a specific doctor’s POD. This is comprised of four techs (junior and senior level) who divvy up exam room preparation, scribing, and more duties and follow the doctor throughout their day, explains Dr. Polack. “Many of us have worked alongside Dr. Polack for several years, so he has taught us a lot about DED,” notes Samantha Vertommen, The Dry Eye Center’s coordinator.
2. Vendor education. Through in-house vendor training and seminars, the staff have also learned a great deal about the importance of identifying the causes of DED, such as meibomian gland dysfunction, says Carrie Davis, a dedicated technician in Dr. Polack’s cornea POD. “The vendors keep us up to date and show us how we can explain to the patient what they’re looking at and what the results of their tests mean,” adds Ms. Vertommen.
3. Other opportunities. Much of the staff have attended DED lectures and events throughout the state and have looked to reputable online sources, such as the American Academy of Ophthalmology, for information on DED to assuage and help patients. “We feel we should have a strong knowledge of DED if we’re going to be educating patients,” says Laura Henrich, a dedicated dry eye tech.

Ms. Davis says imparting DED education is very rewarding because the techs are “connecting the dots” for patients regarding their symptoms, their form of DED, and how the prescribed treatment will benefit them. “We break all the information down in layman’s terms, such as tear deficient vs. aqueous-deficient dry eye, and patients get very relieved, excited, and then grateful that they understood and learned.”

Staff provide patients with a DED information packet that highlights what they discussed, the diagnostic tests used and a customized checklist of the prescribed interventions and how and when to use them, Ms. Davis says.

“At the end of a visit, we say to patients, ‘I know you’ve just received a lot of information at once. If you have any questions or concerns at all about what we have reviewed today, please do not hesitate to call and ask for me personally,’” adds Ms. Vertommen. “This extra level of personalized service assures patients we are invested in their care.”

Diagnostic tests

“The Center’s diagnostic tests help the doctors narrow down the specific cause of DED, which aids in providing patients with one or more treatments designed for that cause,” Ms. Henrich says. “Most patients are totally blown away by what these tests can do.”

Staff perform these tests and offer the following explanations to patients:

1. Ocular surface analysis (LipiView, J&J Vision). This device provides a measurement of the thickness of the tear film lipid layer and the patient’s blink rate.
   Explanation: “This test measures the thickness of the lipid, or oily, layer of your tear film. This is important because decreased thickness causes fast tear evaporation, or what is known as evaporative DED,” Ms. Davis says. We can also visualize the status of the meibomian glands, which is related to the tear film test, she adds.
2. Tear osmolarity test (TearLab). This device measures salt in the tears, otherwise known as osmolarity.
   Explanation: “This is going to check the watery layer of the tear film, which is made up of water and salt. If your layer has too much salt, then your DED is either due to a water deficiency in your tears or there isn’t enough oil to keep the water from evaporating,” Ms. Henrich says. “Generally, I follow up that explanation with, ‘Do you ever feel a burning or stinging sensation in your eyes?’ And the patient, wide-eyed, will reply, ‘Oh my gosh! Yes, I do!’ Now, their symptoms make more sense to them, and there is comfort in knowing they likely have aqueous-deficient DED and that we’re going to help them find relief.”
3. InflammaDry (Quidel). This identifies elevated levels of metalloproteinase-9, which is an inflammatory marker present in DED patients.
   Explanation: “This is going to test for inflammation in your tear film, which is a consistent sign of DED,” Ms. Davis says.
4. Meibography (LipiView, J&J Vision). This device uses infrared imaging to help the doctor assess for meibomian gland dysfunction, a form of evaporative DED.
   Explanation: “This is going to look at the glands in your eyelids that produce oils, which play an important role in stabilizing your tear film. If your glands all appear intact, it might indicate that they are clogged or closed up.” Ms. Henrich says. “It can also show if there is significant atrophy of the glands, another cause of insufficient oil production.” They also show patients a Meiboscale so they can see the difference between healthy glands vs. their glands and understand why a treatment, such as a warm compress regimen, is so important.

Holistic approach to management

The Dry Eye Center at Ocala Eye’s dry eye management philosophy is holistic and conservative, so treatment options typically start with artificial tears and warm compresses. Also, Dr. Polack prescribes dietary changes as the first-line of treatment in most patients.

“My staff and I often ask patients what they eat during a typical day, and nine times out of 10, it’s mostly things they shouldn’t be eating — grains – particularly wheat – and foods that have a high ratio of omega 6 to omega 3 — which cause inflammation and contribute to DED,” he explains. “So, the first treatment is to educate patients on the link between their diet and the condition to get them to buy in to changing their diets. I personally discuss with patients and then have staff provide them a checklist comprised of suggested books and diets, including cutting out wheat, eating more grass-fed beef, grass-fed butter, eggs, tree nuts and other sources of omega-3s such as fish and fish oil. In many cases, patients return a couple of months later with fewer DED symptoms, less joint stiffness, lower blood sugar, decreased weight, and lower blood pressure.”

In-office treatment options

For patients who do not achieve symptomatic relief via lifestyle changes alone or for those who have more severe DED, The Dry Eye Center at Ocala Eye employs six in-office management options, many of which, staff operate and provide education on:

1. MiBo ThermoFlo. This device provides a heated massage to the lids to liquify meibum, facilitating discharge. This is performed by a dry eye tech. The doctor may also perform expression after the initial treatment to assess gland function.
   Explanation: “I am going to use a small probe that heats to a comfortable 108 degrees to gently massage your lids. This will help liquefy the oil that is clogging the glands in your lids, allowing it to easily be expressed by the doctor. The treatment will take approximately 8-12 minutes per eye. All you have to do it lay back and relax,” Ms. Vertommen says.
2. Intense Pulsed Light therapy (Lumenis). This uses a Xenon flashlamp to emit wavelengths of light to close the abnormal blood vessels that discharge inflammatory mediators, while also reducing bacterial overgrowth on the lids. The Center’s doctors operate this treatment.
   Explanation: “I’m going to place eye-shaped protective shells on your closed eyes and then the doctor will use a device that emits a very bright light to melt your meibomian gland secretions while also decreasing inflammation. In doing so, your glands will be able to express the oil necessary to protect your tears,” Ms. Davis says
3. LipiFlow (J&J Vision). This consistently emits the highest but safest heat possible to the meibomian glands via an instrument fixed to the patient’s lids, which also performs an automated program of pressure. Its purpose: To soften and express obstructed meibum
   Explanation: “This device provides a hot lid massage for 12 minutes to unclog and express your meibomian glands. Think of it as more of an advanced version of the warm compresses that you have tried,” Ms. Henrich says.
4. BlephEx (Rysurg). This cleans the edge of the lids and lashes to exfoliate and get rid of lid scurf and debris.
   Explanation: “This is basically an automatic medicated lid scrub that is going to provide a deep clean to your lids and lashes to clear the debris and crust that’s causing your blepharitis. It does not hurt, but it does tickle profusely,” Ms. Henrich says.
5. Cryopreserved amniotic membrane (Prokera, Bio-Tissue). In terms of the Ocala Dry Eye Center, this is reserved for patients who have developed conjunctival chalasis (CCh) as a result of chronic DED. CCh is a commonly overlooked cause of constant foreign body sensation and watering. Specifically, the surgeon removes the loose redundancy of the conjunctiva and replaces it with this membrane, which promotes wound healing upon resection. Doctors perform this surgery.
   Explanation: “With chronic dry eye, the membrane covering the surface of the eye (the conjunctiva) changes from firm and smooth to loose and wrinkled causing chronic irritation and constant weeping. By removing a small strip of this tissue and replacing it with a membrane harvested from umbilical cords, we can restore a nice, smooth surface to the eye again,” Dr. Polack says. He adds that staff provide a link to a video that details a case history, anatomy and everything involved in the surgery, so patients present for the procedure prepared and, therefore, at ease.
6. Maskin Meibomian Gland Intraductal Probe (Rhein Medical). This is the insertion of a wire-like instrument through the meibomian gland orifice and ductal outflow tract. Doctors employ this treatment.
   Explanation: “I’m going to apply an anesthetic to your lids, and the doctor is going to introduce a small instrument into your meibomian glands to break through any adhesions or scar tissue in attempt to open them up and allow the free flow of oil again. It’s not the most pleasant experience, but it will be done before you know it,” Ms. Henrich says.

A culture of caring

“I think what many of these patients particularly value about the Center is that their concerns are not brushed off,” explains Dr. Polack. “We listen to and work with them to get them the symptomatic relief that has evaded them.” OP