How to Create a Dry Eye Center

Transcription

1 How to Create a Dry Eye Center Whitney Hauser, OD Signal Ophthalmic Consulting Disclosures TearScience Consultant/Speaker NovaBay Speaker BioTissue - Speaker Lumenis Consultant/Speaker Shire Consultant/Speaker Allergan Consultant Akorn Consultant Paragon Biotek Consultant/Board Member TearLab Board Member 1

2 Disclosures Signal Ophthalmic Consulting Founder/Senior Consultant Advanced Ocular Care (Bryn Mawr Communications) Editorial Board Member Ocular Surface Society of Optometry Board Member Optometric Cornea Cataract Refractive Society Board Member Southern College of Optometry Assistant Professor 2

3 Prevalence in the US 3.23 million women age 50 and over 1.68 million men age 50 and over Schaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye syndrome among US women. Am J Ophthalmol. 2003;136: and Schaumberg DA, Dana R, Buring JE, Sullivan DA. Prevalence of dry eye disease among US men: estimates from the Physicians' Health Studies. Arch Ophthalmol. 2009;127:763-8.] Incidence in the US 57.4% 87.5% 16.4% Cataract Dry Eye Diabetic Retinopathy 3

4 What do you know about Dry Eye Disease? Types of Dry Eye Evaporative dry eye: Caused by meibomian gland dysfunction Leading cause of dry eye world wide Aqueous-deficient dry eye: Decreased tear production at the lacrimal gland Prevalent in autoimmune disease 4

5 Types of Dry Eye Evaporative Dry Eye = 65-86% of cases Aqueous-deficient Dry Eye = 14-20% of cases Causes of Dry Eye Symptoms Aging Lid laxity Lagophthalmous Floppy Eye Lid syndrome 5

6 Causes of Dry Eye Symptoms Gender Hormone changes or fluctuations Birth control HRT Causes of Dry Eye Symptoms Medications (Oral) Antihistamines Anti-depressants Anti-hypertensives Decongestants Certain acne drugs 6

7 Causes of Dry Eye Symptoms Medications (Ophthalmic) Glaucoma medications Allergy medications Preservative sensitivities Causes of Dry Eye Symptoms Demodex Demodex folliculorum Demodex brevis 7

8 Causes of Dry Eye Symptoms Iatragenic Causes Refractive surgery Cataract surgery Lid procedures Trauma/surgical/medical treatmentrefractive Cataract surgerylid proceduresburnsradiation therapy Causes of Dry Eye Symptoms Nutritional deficiencies Vitamin A Omega 3 8

9 Causes of Dry Eye Symptoms Systemic conditions Diabetes Thyroid disease Autoimmune disease Is the Dry Eye patient population different? 9

10 Psychology of Dry Eye 89 dry eye subjects (13 Sjogren s patients & 73 control subjects) Zung self rating anxiety scales (SAS) Zung self rating depression scales (SDS) Ocular Surface Disease Index (OSDI) Psychology of Dry Eye Anxiety and Depression scores of the DES group were significantly Higher than the control group 10

11 Psychology of Dry Eye Anxiety scores correlated with OSDI and Education level Depression scores correlated with OSDI Psychology of the Examination Change the single visit mentality Treatment is a process Individualized care 11

12 Psychology of the Examination 55 million Americans suffer from dry eye symptoms 40 million of those cases go undiagnosed 72% of patients Artificial tears only 82% of patients Demand something better 97% of patients Report condition as frustrating The Gallup Organization Inc. The 2008 Gallup Study of Dry Eye Sufferers. Princeton, NJ: Multi-Sponsor Surveys Inc; Differentiate Your Practice in the Exam 12

13 Differentiate Your Practice in the Exam Diagnostic testing Treatment options Premium care Differentiate Your Practice - Diagnostics Use of vital dyes Rose Bengal Fluorescein Lissamine Green 13

14 Differentiate Your Practice - Diagnostics Meibography & Anterior Segment Photography Oculus Keratograph Lipiview II Digital anterior segment photography Differentiate Your Practice - Diagnostics Oculus Keratograph 5M Lipiview II Meibography TF-Scan NIKBUT Meniscus Tear Height Lipid Layer Assessment TF-Dynamics Dynamic Meibomian Imaging (DMI) Lipid Layer Thickness (LLT) Blink performance 14

15 Differentiate Your Practice - Diagnostics Osmolarity Physiological marker Normal: mosml/l 1 Hyperosmolar: 308 mosm/l is a highly sensitive cut-off point that delineates a normal from a mild/moderate dry eye population 2 Inter-eye difference = hallmark of DED ( > 8 mosms/l between eyes) Differentiate Your Practice - Diagnostics InflammaDry (RPS, Sarasota, FL) Detects elevated MMP-9 in tears Useful biomarker for diagnosing, classifying and monitoring DED 15

16 Differentiate Your Practice - Diagnostics Zone-Quick Red cotton thread treated with phenolsulfonphthalein No anesthesia 5 minutes after other drops instilled May be used with contact lenses Differentiate Your Practice Basic Treatments Warming masks/moisture chamber goggles Nutraceuticals Lid hygiene products Artifical tears Punctal Plugs Educational pieces 16

17 Differentiate Your Practice Advanced Treatments Meibomian gland probing Manual meibomian gland expression Microblepharoexfoliation Thermal treatments Intense Pulse Light (IPL) The Economics of Dry Eye 17

18 The Economics of Dry Eye The Economics of Dry Eye Disease 18

19 CONDITION Allergic conjunctivitis (OTHER CHRONIC ALLERGIC CONJUNCTIVITIS) Blepharitis, unspecified (includes MGD) Conjunctivochalasis Demodex folliculorum (OTHER ACARIASIS) ICD-10 H10.45 H (RUL) H (RLL) H (LUL) H (LLL) H (R) H (L) H (B) B88.0 H (RUL) Dermatochalasis H (LUL) Dry eye syndrome, tear film insufficiency (DRY EYE SYNDROME OF BILATERAL LACRIMAL GLANDS) H Epiphora due to insufficient drainage H (R) H (L) H (B) CONDITION ICD-10 Epithelial basement membrane dystrophy H18.59 Filamentary keratitis Lagophthalmos, unspecified Keratoconjunctivitis sicca Recurrent corneal erosion Stenosis of lacrimal punctum H (R) H (L) H (B) H (RUL) H (LUL) H (R) H (L) H (B) H (R) H (L) H (B) H H H

20 ANCILLARY PROCEDURES BILLABLE TO 3 RD PARTY CPT APPROXIMATE VALUE Computerized Corneal Topography $35.54 Fitting of Contact Lens to Treat Ocular Surface Disease $36.49 Visual Field - Extended $59.97 External Ocular Photography For Documentation of Medical Progress $18.63 SPECIAL CONSIDERATIONS: 1 UNILATERAL or BILATERAL - May be performed on one or both eyes, but can only be billed once. 2 UNILATERAL - If performed OU code -RT and -LT (on separate lines). 3 BILATERAL procedure; if performed on one eye only, use -52 (reduced services). 4 Medicare considers this procedure not medically necessary. 5 Post-op period applies 10 days. 9 Post-op period applies 90 days. ANCILLARY PROCEDURES BILLABLE TO 3 RD PARTY CPT APPROXIMATE VALUE InflammaDry Immunoassay for Analyte - Not infectious antibody or infectious $15.58 antigen; qualitative or semiquantitative, multiple step 2 TearLab (osmolarity) Microfluidic Analysis Utilizing an Integrated Collection and Analysis Device 2 LipiView Tear Film Imaging - Unilateral or Bilateral 1, $ T $0.00 SPECIAL CONSIDERATIONS: 1 UNILATERAL or BILATERAL - May be performed on one or both eyes, but can only be billed once. 2 UNILATERAL - If performed OU code -RT and -LT (on separate lines). 3 BILATERAL procedure; if performed on one eye only, use -52 (reduced services). 4 Medicare considers this procedure not medically necessary. 5 Post-op period applies 10 days. 9 Post-op period applies 90 days. 20

21 ANCILLARY PROCEDURES BILLABLE TO 3 RD PARTY CPT APPROXIMATE VALUE Dilation of Lacrimal Punctum, With or Without Irrigation 2, $ Probing of Lacrimal Canaliculi - With or Without Irrigation 2, $ Probing of Nasolacrimal Duct, With or Without Irrigation 2, $ Closure of Lacrimal Punctum by Plug - Each 2, $ SPECIAL CONSIDERATIONS: 1 UNILATERAL or BILATERAL - May be performed on one or both eyes, but can only be billed once. 2 UNILATERAL - If performed OU code -RT and -LT (on separate lines). 3 BILATERAL procedure; if performed on one eye only, use -52 (reduced services). 4 Medicare considers this procedure not medically necessary. 5 Post-op period applies 10 days. 9 Post-op period applies 90 days. ANCILLARY PROCEDURES BILLABLE TO 3 RD PARTY CPT APPROXIMATE VALUE Removal Corneal Epithelium w/wo Chemocauterization $74.98 Multiple Punctures of Anterior Cornea for Corneal Erosion, Tattoo 2, $ Prokera (and similar products) Placement of Amniotic Membrane on Ocular Surface - Without Sutures 2, $1, SPECIAL CONSIDERATIONS: 1 UNILATERAL or BILATERAL - May be performed on one or both eyes, but can only be billed once. 2 UNILATERAL - If performed OU code -RT and -LT (on separate lines). 3 BILATERAL procedure; if performed on one eye only, use -52 (reduced services). 4 Medicare considers this procedure not medically necessary. 5 Post-op period applies 10 days. 9 Post-op period applies 90 days. 21

22 ANCILLARY PROCEDURES NOT BILLABLE TO 3 RD PARTY CPT APPROXIMATE VALUE LipiFlow Evacuation of Meibomian Glands - Automated Using Heat and Intermittent Pressure BlephEx Microblepharoexfoliation - Automated IPL Intense Pulsed Light Therapy ThermiSmooth Thermistor-regulated Skin Tightening 0207T $800 - $2,000 N/A $100 - $250 N/A $1,000 - $2,000 N/A $1,000 - $2,000* 22