Eyeworld

I JUNE 2019 | EYEWORLD | 45 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 personal- ize 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 recom- mended 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 pro- cedure 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 hon- eycomb-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. 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 bun- dled 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 treat- ment response, where improving inflammation, for example, does not always translate into im- provement 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 ade- quately 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 Stan- dardized Patient Evaluation of Eye Dryness (SPEED) questionnaire, which she has incor- porated 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, 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

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