NOV 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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Page 89 of 122

3 Overlapping signs and symptoms of conjunctivitis evidence of inflammation. This makes what is commonly thought to be a minor diagnostic challenge much more difficult. Fortunately, newer point-of-care objective tests can help us to start making these differentiations rapidly and easily. Some of these tests include lipid layer interferometry, noninvasive tear breakup time, and meibography. According to the DEWS report, MGD is a condition of meibomian gland obstruction, and it is the most common cause of evaporative dry eye. The MGD Workshop in 2011 similarly defined MGD as a chronic diffuse abnormality of the meibomian glands, commonly characterized by a terminal duct obstruction and/or qualitative and quantitative changes in the glandular secretion, and it may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease or dry eye disease. MGD can be broken down into low and high delivery states. The most common is the obstructive, non-cicatricial form of MGD. Conjunctivitis There are also challenges in the diagnosis and treatment of conjunctivitis. Ophthalmologists felt fairly confident about our ability to diagnose the red eye based purely on signs and symptoms until we had diagnostic tests. And like neurologists before the MRI and pediatricians before the rapid strep test, we realized that we were wrong quite often. The common signs and symptoms of conjunctivitis, such as follicles versus papillae, redness, discharge, irritation and itching, have significant overlap among the three forms: viral, bacterial, and allergic. There is similar difficulty differentiating between allergic conjunctivitis and dry eye disease. Many allergy patients have dryness symptoms, and many dry eye patients have itching as a common complaint. The most common external ocular infection is adenoviral conjunctivitis. It's the most frequent virus isolated from the conjunctiva. Up to 70% of all conjunctivitis cases are viral, and up to 90% of viral cases may be adenovirus. The significant overlap in clinical presentation among the three subtypes of acute conjunctivitis, as well as with other forms of ocular surface disease, makes an accurate diagnosis difficult when based solely on clinical exam, signs, and symptoms. It's very easy to make a diagnosis, but it's not easy to make an accurate diagnosis based solely on signs and symptoms. Better diagnostic tools Making an accurate diagnosis requires better diagnostic tools. Ideally, these newer tools should be highly sensitive and specific, with a high positive predictive value. They should provide quick, reproducible results, and they should be easy to use with minimal training. They should reduce chair time, not increase it, and they should allow patient comprehension and buy-in. The simplicity of "what's my number" is very engaging to patients. Ideally, these diagnostic tools would be reimbursable or revenue generating. Unfortunately, there are always practical issues when new technology is adopted. Practices will need to consider who will do the test. Will it be the physician's responsibility or can a technician do it? Practices will also need to consider how much training is required. Another consideration is patient flow and when the test will be done. Most dry eye-related tests should be done at the beginning of the exam before any drops go in and before any bright lights are shone in the patient's eye, potentially causing reflex tearing. The same goes for adenoviral conjunctivitis testing. These patients should be sequestered as quickly as possible to reduce the risk of contamination, and the diagnostic test should be done as early as possible. Another consideration is the office space required to incorporate a new test. Smaller tests are not much of an issue, but larger tests can create some challenges. Where will it go in the office so that it is accessible to everyone without creating congestion in the office and in the lanes? There are also HIPAA considerations when determining office placement, and some of these tests are sensitive to temperature and humidity. However, while there are a few issues to overcome, there are definite advantages to adopting this technology. A high-tech, cutting edge practice has many advantages, and you can differentiate your practice from others by adopting some of these devices. Certainly, these tests can be used effectively in marketing endeavors, but additionally, many of the companies that make these devices have doctor-locators on their websites that could drive new patients to your practice. Embracing many novel tests and technologies can enable a designation of "Dry Eye Center of Excellence" and can be a significant practice builder for many. Of course, cost issues always factor into any addition that a practice makes, and upfront fees for the device must be taken into consideration. Additionally, there is the cost of consumables, and there may also be applicable click fees. Practices will need to determine upfront whether the test will be a revenue generator, a break-even test, or a loss. Remember that just because something is reimbursed doesn't mean you're going to get reimbursed what you paid for it. However, it's important to note that even the classical tests, such as Schirmer's, staining, and tear breakup, have small costs, can take time, and technically have zero direct reimbursement. The following are some of the new diagnostic modalities for objectively assessing ocular surface disease: optical coherence tomography, wavefront aberrometry, corneal topography, tear osmolarity, inflammatory markers (MMP-9), continued on page 4

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