In recognizing that performing cataract and refractive surgery on an unhealthy ocular surface can result in a poor post-op outcome (e.g. decreased vision), and that dry eye disease (DED) itself can cause agonizing discomfort and ocular damage, Jacksoneye, a 27-year-old Lake Villa, Ill., ophthalmology practice, has created several processes to identify and treat DED. Supporting these processes is the practice’s allied staff, says practice owner and surgeon Mitchell A. Jackson, MD.
“Without our staff, I couldn’t do anything,” he explains. “Our staff starts the dry eye evaluation and performs an extensive array of point-of-care diagnostic testing, completing the evaluation and treatment plan appropriate and customized for that patient.”
Here’s a look at these processes and the support allied staff provide.
The DED diagnosis begins with the Standardized Patient Evaluation of Eye Dryness (SPEED) questionnaire, which is part of every comprehensive eye health examination, as well as all cataract and refractive surgery pre-op evaluations. The questionnaire, designed to track the progression of dry eye symptoms, asks patients to report the frequency and severity of symptoms, such as dryness, grittiness, and irritation. (See https://bit.ly/2VZeUHE for the full questionnaire.)
Technicians report the questionnaire results to Jacksoneye doctors to ensure they don’t miss any patient’s DED, says Melissa Bollinger, OD, head of the practice’s Dry Eye Spa. “Techs issue the questionnaire to patients and inform the doctor whether the score is above a six, which indicates the patient should undergo a full array of diagnostic testing for DED,” she says.
Separate diagnostic appointments
Jacksoneye schedules separate diagnostic testing appointments for those patients identified as DED suspects.
“We need the time required to conduct the full-range of diagnostic tests, so that we can make sure these patients are put on the correct treatment path to start vs. us handing all of them artificial tear samples — which don’t work for everyone — at the end of the comprehensive exam,” asserts Dr. Bollinger.
All technicians undergo training on Jacksoneye’s various diagnostic devices. This training includes hands-on experience, watching videos and learning associated patient scripts to help the technicians properly conduct these tests and discuss them with patients.
Jacksoneye offers the following diagnostic devices:
• TearLab Osmolarity System. Technicians use the device’s Test Pen, which holds a Test Card applied to the patient’s eyelid margin, to measure osmolarity, or the salt concentration in tears. Technicians explain this to patients, noting that too much salt is a clinical sign of DED “and that the doctor can use the system to aid in identifying how severe their DED actually is,” says Shawn Wiedman, a dry eye clinic technician and scribe.
• InflammaDry (Quidel). Technicians apply a sample collector to six to eight locations on the patient’s palpebral conjunctiva to test for elevated levels of matrix metalloproteinase-9, or MMP-9. “They tell patients that this test’s purpose is to identify an inflammatory marker in tears that reveals DED,” Mr. Wiedman says.
• LipiScan Dynamic Meibomian Imager and LipiView II Ocular Surface Interferometer with Dynamic Meibomian Imaging (Johnson & Johnson Vision). For the LipiScan, technicians acquire digital images of the patient’s meibomian glands and video of their blink patterns. “We inform patients that this device is used to determine whether patients have meibomian gland dysfunction, which is a form of DED,” Mr. Wiedman says. “Showing video of incomplete blinks, in particular, is of great value to the patient — because seeing is believing — and the doctor — because it helps increase patient compliance to the prescribed treatment regimen.” Jacksoneye also uses the LipiView II device, which provides a view of the tear film’s lipid layer and blink dynamics.
• OPD-Scan III (Marco). Technicians employ this combination autorefractor, autokeratometer, corneal topographer, pupilometer and wavefront aberrometer as an additional means of collecting DED diagnostic data for Jacksoneye’s doctors. “Techs explain to patients that the device acquires images of the ocular surface, blinking, and tear quality to help the doctor identify DED,” Dr. Bollinger says.
In addition to describing and administering the diagnostic tests, technicians play a key role in reinforcing the importance of prescribed DED treatments, says Mr. Wiedman. This occurs in a few ways.
Dry eye clinic staff provide a DED diagnosis sheet, a customizable treatment sheet and individual in-office treatment education sheets and review them with patients, says Sarah Murray, a dry eye clinic technician and scribe. (See “Jacksoneye in-office treatments.”)
• Diagnosis sheet. This sheet includes easily understood information about what, specifically, DED is.
• Treatment educational sheet. “The treatment sheet includes images of the various DED treatments, such as prescription drops and warming masks, that the doctor can circle, along with spaces for specific use instructions, facilitating patient compliance,” Mr. Wiedman explains. “Additionally, technicians scan these sheets into the patient’s chart, for fast accessibility by the doctor at follow-up appointments and for patients who may lose their treatment sheet upon leaving the practice and call us confused.”
• In-office treatment option sheets. These explain each of the practice’s options and their related payment packages. Mr. Wiedman says he and his fellow technicians use the sheets to reiterate to patients that a doctor’s prescription is based on the data provided by the diagnostic testing, so patients understand that the doctor’s motivation in prescribing an out-of-pocket pay treatment is legitimate. “We want patients to know it’s not about selling — it’s about what’s in their best interest,” he says.
Ms. Murray adds that it’s also important to help set patient expectations regarding treatment outcomes:
“Patients often have this perception of instant gratification, so we explain to them before they start a treatment that every patients’ response to a treatment can be different, and that arriving at a treatment that ultimately works can be a process of trying different treatments that must be taken as prescribed,” she says.
DED ‘spa’ treatment
One large exam room houses the aforementioned in-office treatments, a variety of streaming music — patient preference for relaxation — and dim lighting to provide patients with a spa-like atmosphere, Ms. Murray says.
“We think that it’s important to help these patients feel as comfortable as possible with the in-office treatments, especially those patients who are trying them for the first time because the unknown can be scary,” she acknowledges.
JACKSONEYE IN-OFFICE TREATMENTS
LipiFlow Thermal Pulsation System (Johnson & Johnson)
Comprised of a console and a single-use sterile cup, called an Activator, the device provides a heated massage to the eyelids to aid in unblocking the meibomian glands, so the natural production of lipids required for a stable tear film can resume. One procedure lasts roughly 12 minutes per eye. https://tearscience.com/lipiflow/
Made up of a handpiece and docking station, this in-office treatment employs a micro-sponge along the edges of the eyelids and lashes to remove scurf and debris. The treatment lasts for between 6 minutes to 8 minutes and exfoliates the eyelids. https://blephex.com/doctors/
iLux MGD Treatment System (Alcon)
This handheld device, with charging stand, applies light-based heat and compression via the iLux Smart Tip under direct visualization of the eyelids to clear blocked meibomian glands. The treatment lasts for a “matter of minutes,” the company says. http://www.tearfilm.com/ilux-device/
Additionally, the spa concept is a way to bring value to the patient by offering one of the treatment packages, says Dr. Jackson.
Jacksoneye doctors follow-up with their DED patients, at minimum, every six months, says Dr. Bollinger.
“Our approach with these patients is very similar to that of our other patients who have ocular diseases, such as AMD,” she says. “DED deserves the same attention, given that it is, indeed, a disease, it’s prevalent, and it has a negative effect on vision and ocular health.”
Technicians aid here by assisting with patient documentation, says Mr. Wiedman.
Three to four DED clinical studies tend to occur concurrently at the practice, says Maggie Sawa, COT, Jacksoneye’s clinical study coordinator. “The practice is heavily involved in DED clinical research because it’s rewarding to be able to provide access to treatment options that patients may not otherwise have, due to cost or their medical insurance,” she says. “It’s also wonderful to be part of a process that can result in patient access down the road.”
For some ophthalmology practices, DED is a road less travelled. Jacksoneye’s decision to take this road, by creating the processes mentioned above, may very well have, “made all the difference,” to borrow from poet Robert Frost, in the lives of their patients afflicted by the bothersome and chronic condition. OP