Eyeworld

EW FEATURE 50 Preparing for changes in ophthalmology • December 2017 AT A GLANCE • Putting more of an emphasis on dry eye in practice can help a large patient population, improve patient outcomes in other procedures, increase referrals, and be a profit source. • Efficiency is key when incorporating dry eye services into practice. • Some ophthalmologists think that optometrists are the perfect providers for delivering most dry eye diagnostics and care. by Liz Hillman EyeWorld Staff Writer Adding dry eye services addresses significant patient needs, can be a boon for business, and doesn't have to take too much time D ry eye has increasingly become a focus in oph- thalmology as it has been shown to be a signifi- cant 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. ophthalmolo- gists 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 significant- ly 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 signif- icant need in the patient commu- nity, without being a drain on your time and practice resources, said Marguerite McDonald, MD, Oph- thalmic Consultants of Long Island, Valley Stream, New York. "There is a widespread misun- derstanding 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 comor- dysfunction, because many patients coming to see you for cataract sur- gery also have dry eye," he said. One report estimates that the prevalence of diagnosed dry eye dis- ease 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. Accord- ing 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 estab- lished 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 pa- tient who positively answers one or more questions on the Standardized Patient Evaluation of Eye Dryness (SPEED) questionnaire. Tear osmo- larity, 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 Oph- thalmology 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 im- portance 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. Adopt- ing a "dry eye center of excellence" mindset is "essential to practice growth, surgical results, patient satisfaction, and business protec- tion 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 partic- ular 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 com- monplace 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. Lind- strom said, allow him and his oph- thalmic partners to delegate stable, Efficient management of dry eye practice may include closer work with optometry continued on page 52 bidities that require other surgery. It has been a huge plus for me, and for your patients, if they've been suffer- ing 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, Cincin- nati Eye Institute, Cincinnati, thinks "dry eye is one of the most neglect- ed 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 ef- ficiently, 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 under- serve the community, that's how much there is." Putting a focus on dry eye Before addressing the role optome- trists 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 prac- tice, 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 num- ber 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, Cen- ter for Excellence in Eye Care, Mi- ami, said you need to put a focus on dry eye. "If you're a cataract surgery practice, you need to become expe- rienced at identifying and treating dry eye, including meibomian gland

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