December 2017


Preparing for changes in ophthalmology
Efficient management of dry eye practice may include closer work with optometry

by Liz Hillman EyeWorld Staff Writer

Dr. Loh demonstrates using BlephEx and Meibox (Box Medical Solutions), a slit lamp mounted meibographer, on her resident.
Source: Jennifer Loh, MD

Adding dry eye services addresses significant patient needs, can be a boon for business, and doesn’t have to take too much time

Dry eye has increasingly become a focus in ophthalmology as it has been shown to be a significant burden on patients and the health system, and it can negatively affect the outcomes and patient perspectives of cataract, refractive, and other ophthalmic surgery.
According to the 2017 ASCRS Clinical Survey, U.S. ophthalmologists estimated seeing an average of 35 dry eye patients per month who were not well controlled on artificial tears. The same survey found that 91% of respondents think that mild to moderate dry eye can significantly impact patient satisfaction after cataract or refractive surgery.
Putting a dedicated emphasis on dry eye in your practice can bring in a number of new patients, enhance your referral base, and serve a significant need in the patient community, without being a drain on your time and practice resources, said Marguerite McDonald, MD, Ophthalmic Consultants of Long Island, Valley Stream, New York.
“There is a widespread misunderstanding that if you treat dry eye it’s going to ruin your surgical practice. No, it will enhance your surgical practice,” Dr. McDonald said. “You will find more and more dry eye patients who have comorbidities that require other surgery. It has been a huge plus for me, and for your patients, if they’ve been suffering for years and you’re the one who fixed them, you’re the one who got their life back in order, they will tell everyone.”
Edward Holland, MD, Cincinnati Eye Institute, Cincinnati, thinks “dry eye is one of the most neglected diseases in all of ophthalmology.” These patients take more chair time, they’re often chronic and require routine follow-up, and for the busy, high volume ophthalmologist, this can make them a challenge.
“A lot of clinicians think they’re a burden, but we shouldn’t ignore the disease,” Dr. Holland said. “We should figure out a way to take care of these diseases, and if you do it efficiently, it could be a profit center.”
One way that Dr. Holland and others interviewed for this article have been able to do that is by bringing on optometrists. And there’s room for everyone in the field to get involved.
“There is tons of dry eye out there,” Dr. McDonald said. “I’m fond of saying that there’s so much that if every ophthalmologist and optometrist in North America decided to open a ‘dry eye center of excellence,’ we would still underserve the community, that’s how much there is.”

Putting a focus on dry eye

Before addressing the role optometrists can play, let’s discuss the idea of a “dry eye center of excellence.” In general, Dr. McDonald said this might sound formal, but in her practice, it’s a reflection of the decision to put “a huge emphasis on dry eye.” That decision, she said, was made about 5 years ago due to its ability to benefit a large number of patients, due to the increasing number of publications proving that dry eye can adversely affect outcomes of other ophthalmic procedures, such as cataract surgery and laser vision correction, and because it carries little medical/legal risk.
Even if your focus is cataract surgery, William Trattler, MD, Center for Excellence in Eye Care, Miami, said you need to put a focus on dry eye. “If you’re a cataract surgery practice, you need to become experienced at identifying and treating dry eye, including meibomian gland dysfunction, because many patients coming to see you for cataract surgery also have dry eye,” he said.
One report estimates that the prevalence of diagnosed dry eye disease among U.S. adults is about 16.4 million, or 6.8% of the population.1 The prevalence of symptomatic but undiagnosed dry eye is 2.5% of the representative population. According to Market Scope, a source of data for the ophthalmic marketplace, the global dry eye treatment market is expected to reach $4.5 billion by 2021.2
If you haven’t already established dry eye as an area of focus within your practice but want to, Dr. McDonald suggested that you first identify a physician about 50 miles away who has a dry eye clinic. Ask if you and a couple of members from your staff might shadow them for a day—providing lunch that day and a gift afterward as a token of thanks—taking notes on what they offer and how they manage their dry eye patients.
In general, Dr. McDonald said practices should start performing tear osmolarity testing on any patient who positively answers one or more questions on the Standardized Patient Evaluation of Eye Dryness (SPEED) questionnaire. Tear osmolarity, she said, is the key pathway for all forms of dry eye. Once the practice becomes comfortable with this testing and answering basic questions about dry eye, you can start adding more diagnostic and therapeutic technologies to the point where you think you can adequately serve your patient base and still maintain an efficient and profitable workflow.
Jennifer Loh, MD, Loh Ophthalmology Associates, Miami, established her solo practice in May 2016. Featured prominently on her website’s home page, alongside her other ophthalmic services, is dry eye. Even before starting her own practice, Dr. Loh said she had an interest in dry eye because of the importance the ocular surface can play in achieving refractive results after cataract surgery and the number of people she could help.
Dr. Loh said that at least 25% of her patients have dry eye on a daily basis. “So many new patient consults, whether they’re referred or find me on their own, have dry eye,” she said. “Patients come in with all of these symptoms of dry eye, and we evaluate them to determine their degree of ocular surface disease/dry eye. Being the first person to spend time and talk about dry eye with patients gains their appreciation and trust, and maybe even their loyalty. Dry eye has become more common, and there’s more awareness of it, but it’s also been considered a condition that busy ophthalmologists don’t have time to address. If you can be the doctor who is able to help them, patients will be very appreciative.”
John Sheppard, MD, Virginia Eye Consultants, Norfolk, Virginia, thinks becoming a “dry eye center of excellence” is a mindset, although he noted that both TearLab (San Diego) and BioTissue (Miami) run a program for becoming one. Adopting a “dry eye center of excellence” mindset is “essential to practice growth, surgical results, patient satisfaction, and business protection with the cash flow aspect,” Dr. Sheppard said.
One important aspect of maintaining the profitability of dry eye services, he continued, is to measure and assess the efficacy and utilization of dry eye procedures by provider monthly.
“Do you want to offer a particular dry eye procedure that’s not making any money in practice? … It’s consuming time, not paying for the overhead generated by the machine itself, and failing to create a unique market niche. If you don’t measure volume, you don’t know,” Dr. Sheppard explained.

Bring on physician extenders

According to the 2017 ASCRS Clinical Survey, 71% of respondents employ an optometrist. Richard Lindstrom, MD, Minnesota Eye Consultants, Minneapolis, said ophthalmic practices integrated with optometrists might be commonplace today, but they weren’t several decades ago. When he went into private practice 28 years ago, he knew that he wanted to have an integrated eyecare delivery system. Minnesota Eye Consultants now has 12 optometrists within its network.
These optometrists, Dr. Lindstrom said, allow him and his ophthalmic partners to delegate stable, well-managed patients who need routine follow-up. Many dry eye patients can be delegated to optometry for treatment and follow-up as well.
Dr. Holland said Cincinnati Eye Institute has two optometrists devoted to its dry eye clinic, which it established 5 years ago.
“I usually see the dry eye patients only once. I see them on the initial consultation, lay out the treatment plan, and I rarely have to see those patients back again,” Dr. Holland said. The continued management of these patients is performed by the optometrists. “It’s made my practice more efficient. These patients have a chronic eye problem, they have loss of vision, loss of quality of life, they’re suffering, so we shouldn’t ignore them. I think we deliver higher quality care and more efficient care to my other patients by setting up a dry eye clinic within my practice.”
Dr. McDonald has technicians in her practice perform dry eye diagnostic testing, but for certain dry eye therapies, such as LipiFlow (TearScience, Morrisville, North Carolina), a thermal pulsation treatment, and BlephEx (Franklin, Tennessee), an eyelid cleaning and exfoliating treatment, she finds her patient conversion rate is higher if she tells them she’ll be performing the treatment. However, she doesn’t find they take too much time out of her day.
In addition to dry eye, several MDs who employ or work closely with optometrists collaborate in other aspects of patient care management. Dr. Holland said optometrists at Cincinnati Eye Institute perform preop workups and postop follow-up with cataract patients, monitor stable cornea transplant patients, and manage other chronic disease patients, such as medically or surgically stable glaucoma patients.
“I think if we look at the projected numbers of patients that we’re going to have to manage … there were approximately 4 million cataract surgeries done in 2017, and by 2021–22 that number is going to increase to about 7 million,” Dr. Holland said. “We’re going to have less practicing ophthalmologists due to retirement, so we are going to be overwhelmed with age-related diseases, such as cataract, glaucoma, dry eye, and macular degeneration. We have to figure out how to take care of these patients more efficiently. Like other areas of medicine, we’re leaning on physician extenders, and in ophthalmology the best choice for a physician extender is an optometrist.”
Dr. Trattler said while integrated optometrists do not yet play a role in managing patients with the sole issue of dry eye at the Center for Excellence in Eye Care, they do help manage patients with dry eye in and around cataract and refractive surgery.
Dr. Sheppard said working with optometrists, who perform all roles in his practice except for surgery, allows him and his colleagues to reserve their skills for more complex cases. “I can’t churn out dozens of well patient exams and postoperative visits all day long,” he said. “Instead, the level of pathology that all our doctors see is significantly higher than it would be otherwise.”
If a clinician wants his or her practice to get busier with the same number of hours in the day, Dr. Holland said one has to practice smartly, more efficiently, and one way to do that is by working with optometrists. On the dry eye front, Dr. McDonald said taking on these patients can snowball into a wealth of other patients.
“They might come to you for dry eye but when you make them happy, you get their cataract, you get their spouse’s cataract, you get their daughter’s LASIK. There’s a big halo effect here, even though you’re starting by treating their dry eye,” she said. EW


1. Farrand KF, et al. Prevalence of diagnosed dry eye disease in the United States among adults aged 18 years and older. Am J Ophthalmol. 2017;182:90–98.
2. 2016 Dry Eye Products Report: A Global Market Analysis for 2015 to 2012. Market Scope. December 2016.

Editors’ note: Dr. Loh has financial interests with Allergan (Dublin, Ireland), Box Medical Solutions, Johnson & Johnson Vision (Santa Ana, California), Shire (Lexington, Massachusetts), and Sun Pharmaceuticals (Mumbai, India). Dr. McDonald has financial interests with BlephEx and TearLab. Dr. Sheppard has financial interests with TearLab. Dr. Trattler has financial interests with Allergan, BlephEx, Johnson & Johnson Vision, Shire, and Sun Pharmaceuticals. Drs. Holland and Lindstrom have no financial interests related to their comments.

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Efficient management of dry eye practice may include closer work with optometry Efficient management of dry eye practice may include closer work with optometry
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