June 2019

IN FOCUS

Dry Eye Developments
Using point-of-care and imaging testing in the office


by Ellen Stodola EyeWorld Senior Staff Writer/Meetings Editor


Testing for ocular surface inflammation with the InflammaDry
Source: Harrison Dermer

From left:
Irregular corneal staining in patient with moderate evaporative dry eye

Irregular corneal staining in a patient with Sjogren’s disease

Careful examination of lids and lashes will reveal signs of blepharitis and possible Demodex.
Source (all): Lisa Nijm, MD, JD


 

When assessing dry eye patients, physicians have a number of tests available to use in the office. The choice of which tests to use may vary depending on the practice flow, subspecialty, and other factors. Two physicians shared with EyeWorld how they approach point-of-care testing for their patients, which tests they like to use, and how they use questionnaires to treat dry eye disease.

Anat Galor, MD

Dr. Galor thinks that “questionnaires are the most relevant test we do because we’re not treating a number, we’re treating a patient.” She said she first wants to know exactly what the patient is complaining about—whether it’s pain, poor visual quality, or something else.
Dr. Galor noted that there are many different questionnaires that physicians can use. She prefers the Dry Eye Questionnaire 5 (DEQ5), which asks about dryness, discomfort, and tearing, and the Ocular Surface Disease Index (OSDI) questionnaire, which asks about pain, poor vision, and impact on function. But she doesn’t like to see a sum score and instead looks at individual responses to get a sense of specific patient complaints.
In addition, Dr. Galor said it’s important to understand what is happening on the ocular surface. “We all have our own standardized algorithms that quickly and efficiently evaluate the patient,” she said.
In the clinic, the exam starts when Dr. Galor enters the room, evaluating blink rate and noting skin abnormalities, like rosacea. She then looks at eyelid position and function, evaluating for laxity and lagophthalmos. She places a small drop of fluorescein and under the slit lamp looks for conjunctivochalasis, assesses tear breakup time, and examines the tear lake and eyelid health. It’s important to look at these parameters in a systemic way to get a sense of what’s going on.
“Your exam algorithm, including additional point-of-care tests, also depends on your goals,” Dr. Galor said. In the clinical setting, you’re trying to figure out how to best treat the patient, but in a research setting, you might be more interested in understanding the pathophysiology behind dry eye. “For example, elevated tear osmolarity is involved in the pathophysiology of dry eye, but I wouldn’t necessarily chose a treatment based on an osmolarity value,” she said. “As such, I find the test more useful in the research setting and less so in the clinical setting.”
When considering which tests to use, Dr. Galor said you need to identify what you want out of a test and what makes sense for your practice. “With dry eye, it’s not one size fits all,” she said. “My goal in using point-of-care tests is to try to understand contributors to dry eye symptoms so I can tailor therapy.” For example, if she suspects that a patient has Sjögren’s, she orders blood tests looking for early (anti-CA6, PSP, and SP-1) and late markers. Focusing on the ocular surface, Dr. Galor evaluates for ocular surface inflammation with the InflammaDry (Quidel), as a robust pink strip leads her to try an anti-inflammatory agent, such as topical cyclosporine or lifitegrast, with or without a short course of corticosteroids. Dr. Galor likes imaging the meibomian glands if she is considering a treatment to improve their health, such as LipiFlow (Johnson & Johnson Vision) and/or intense pulsed light (IPL) therapy. Significant gland dropout on imaging makes improvement with these therapies less likely and thus, she uses the findings on meibomian gland imaging to council patients prior to treatment. Dr. Galor likes the ease of the Keratograph (Oculus), as it can non-invasively quantify breakup time and tear lake height, however, these metrics can also be captured with fluorescein relatively quickly.
Overall, she incorporates point-of-care tests to make treatment decisions but doesn’t use any one value in isolation.
Regarding the extra costs that can be associated with point-of-care tests, physicians have different models for how they recover costs associated with the tests. InflammaDry and the tear osmolarity test have a CPT code, so they’re reimbursable. Imaging tests such as the Keratograph and LipiView (Johnson & Johnson Vision) are not reimbursable but can be bundled into subsequent therapy costs.
“One of the things to remember in dry eye is that there is a disconnect between symptoms and signs of disease, including point-of-care tests such as inflammation and tear osmolarity.” Dr. Galor said. “This also translates into treatment response, where improving inflammation, for example, does not always translate into improvement in symptoms.” As such, while point- of-care tests help clinicians understand what is happening on the ocular surface, it is important to inform patients that there are other aspects of dry eye that are more challenging to quantify, such as nerve function.
“Despite the availability of point-of-care tests, treating dry eye is still a bit of a trial- and-error approach, and it sometimes takes a few rounds until we find a strategy where the patient feels like his or her symptoms are adequately controlled,” she said.

Cynthia Matossian, MD

Dry eye disease is ubiquitous, Dr. Matossian said. “Since a certain percentage of these patients are asymptomatic, it’s important to do some basic testing in order to be able to detect the disease earlier,” she said.
Dr. Matossian uses a version of the Standardized Patient Evaluation of Eye Dryness (SPEED) questionnaire, which she has incorporated into the history of present illness and chief complaint section of her electronic health records. “Our technicians screen patients and ask how often they’re using artificial tears, if their vision fluctuates, and/or if their eyes feel tired,” she said. If the answer is yes to any one of these, the technicians do the following three tests: InflammaDry, tear osmolarity, and LipiView.
Dr. Matossian said that the osmolarity test is usually administered first, followed by the
InflammaDry looking for MMP-9 markers. While the patients are dilating, they do the LipiView. “When I come into the exam room, the LipiView images are on a monitor so I can review them with the patient, and it’s clear if the glands are missing, dilated, or broken,” she said.
Dr. Matossian likes to use both lissamine green and fluorescein dyes. “Using the slit lamp, I look at the lid margin, meibomian gland orifices, conjunctival staining with lissamine, and the corneal staining with both dyes,” she said. “Then I have a better picture to personalize a treatment plan appropriate to the level of disease and how impacted the patient is by his or her symptoms.”
Dr. Matossian stressed that patients like to have numbers to go by. “We want to be able to ascertain whether the treatment we recommended for our patients is working, so we need objective data to see if it is,” she said.
When considering the cost of point-of-care tests, Dr. Matossian said she likens them to a primary care doctor taking the necessary steps to obtain tests for cholesterol, blood sugar, and blood pressure. “It’s our way of testing to make sure we can keep the eyes and tear film healthy for the rest of a patient’s life,” she said.
Patients may be asked to pay a substantial amount for these tests, but unless they have objective data through point-of-care testing, they may not be convinced that a disease exists. There may be pushback if an abnormal result cannot be demonstrated and is followed by asking patients to pay out of pocket for a procedure or pay monthly toward their prescription eye drops.
In terms of newer treatment options, Dr. Matossian said she has been using the surface qualifier (Cassini), which provides a honeycomb-like image of the tear film. “If the honeycombs are irregular, broken, or sections are missing, that’s an unhealthy/unstable tear film,” Dr. Matossian said, adding that she uses this technology to help “get the point across to patients.”
In the future, Dr. Matossian expects to see the combination of tear osmolarity and MMP-9 testing at the same time to make it easier for patients and to make it more streamlined for the practice and the technician.

At a glance

• In addition to tests, questionnaires can be helpful to determine a patient’s symptoms and signs and exactly how he/she is feeling.
• Some point-of-care tests may be reimbursable, while others have extra costs associated with them, so it’s important to discuss this with patients.
• With point-of-care tests, it’s important for physicians to be able to interpret the results, so an exam must be combined with the objective quantities given by the tests.

About the doctors

Anat Galor, MD
Associate professor of ophthalmology
Bascom Palmer Eye Institute
Miami VA Medical Center
Miami

Cynthia Matossian, MD
Matossian Eye Associates
Doylestown, Pennsylvania

Financial interests

Galor: Dompé
Matossian: Quidel, TearLab, Cassini, Johnson & Johnson Vision

Reference

1. Lemp MA, et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31:472–8.

Using point-of-care and imaging testing in the office Using point-of-care and imaging testing in the office
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