DEFY DRY EYE...WITH THE FOLLOWING THERAPY OPTIONS FOR AQUEOUS-DEFICIENT AND EVAPORATIVE DED P. 20 TIME TO TREAT DRY EYE DISEASE

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1 I N T H I S S E C T I O N BE THE DED DETECTIVE LEARN ABOUT THE DIAGNOSTIC TESTS THAT CAN AID YOU IN IDENTIFYING THIS CHRONIC AND BOTHERSOME CONDITION P. 16 DEFY DRY EYE......WITH THE FOLLOWING THERAPY OPTIONS FOR AQUEOUS-DEFICIENT AND EVAPORATIVE DED P. 20 STEPS TO DED CARE THESE SIX TIPS WILL ENABLE YOU TO BUILD A THRIVING DRY EYE CLINIC P. 28 TIME TO TREAT DRY EYE DISEASE Why there is an urgency to care for patients who have DED WHITNEY HAUSER, O.D., MEMPHIS, TENN. Photos courtesy of Whitney Hauser, O.D. Dry eye disease (DED) has undergone a dramatic metamorphosis over the last 20 years. Once exclusively defined as either a tear deficiency or excessive evaporation, according to the NEI, DED is now defined more specifically: Dry eye is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage and neurosensory abnormalities play etiological roles, according to the Tear Film and Ocular Surface Society s (TFOS) Dry Eye Workshop (DEWS )II. This broadened definition includes the patient s symptoms and clinical signs, such as hyperosmolarity, ocular surface inflammation and resulting ocular surface damage. Notably, neurosensory abnormalities were included, lending some potential explanation for the often encountered discordance between signs and symptoms. This definition gives license and urgency to O.D.s to serve our patients, and throughout this Practicing Medical Optometry section, we will provide you with a blueprint for how to do so. Here, we begin with a look at the condition s etiology, the key to identify- JULY 2018 OPTOMETRICMANAGEMENT.COM 13

2 PRACTICING MEDICAL OPTOMETRY ing DED patients and why you should act to find these patients. ETIOLOGY The etiology of DED is complex, and much remains to be fully elucidated. The multifactorial nature of the disease is both the origin and the result of its complexity. Some practitioners may exclusively attribute DED to inflammation, and others to meibomian gland dysfunction (MGD), but the truth likely lies The multifactorial nature of the disease is both the origin and the result of its complexity. somewhere in between with overlapping elements. Other factors, such as patient demographics (women, aging), inadequate blink mechanism, contributory ophthalmic/systemic conditions (post-surgical, autoimmune disease, rosacea), medications (antihistamines, for example, are known to cause ocular surface drying) and poor lid hygiene, also may play significant roles. It s our jobs as O.D.s to identify those causes. Drs. Vin Dang and Walt Whitley pick this up in Be the DED Detective, p.16. Note the fluorescein staining in this DED patient. THE KEY Because the condition is rarely vision threatening, but often quality-of-life compromising, the motivation to be aggressive in its treatment lies within the physician. Two basic types of motivation are intrinsic and extrinsic. An intrinsic motivation is gratifying to the doctor, such as treating the patient with an ophthalmic medication because she believes the patient will have a happier, more productive work day after initiating treatment. An extrinsic motivation is powered by a reward. For example, a doctor recommends an advanced treatment, such as thermal pulsation or intense pulsed light, for which the practice will reap a financial reward in providing symptomatic relief and sign improvement in DED patients, according to Current Eye Research and Advances in Pediatrics. Both treatments are reasonable and, thus, responsible recommendations. (See Dr. Jade Coats Defy Dry Eye, p.20.) Regardless of a doctor s motivation, initiating treatment on patients who have DED would tackle one of the largest unmet needs in all of medicine. Patients and practices both stand to benefit. (See Dr. Scott Schachter s Practical Steps to DED Care, on p.28.) WHY ACT In addition to the multifactorial nature of DED, presented in DEWS II, the condition affects more than 16 million Americans, reports the American Journal of Ophthalmology. My colleagues and I hope the following pages provide you with actionable steps to better serve these patients. DR. HAUSER provides clinical care for patients at TearWell: Advance Dry Eye Treatment Center and the Advanced Care and The Eye Center at Southern College of Optometry. She is a consultant, speaker or board member for: Akorn, Alcon, Allergan, BioTeck, BioTissue, Lumenis, NovaBay, Paragon Vision Sciences, Rysurg, TearLab, TearScience, Shire, ScienceBased Health and DryEyeCoach.com. 14 JULY 2018 OPTOMETRICMANAGEMENT.COM

3 MGD can cause the lipid layer to break down. Now Available: Preservative Free! Soothe XP helps replenish this layer. Up to 86% of patients reporting dry eye symptoms have Meibomian Gland Dysfunction (MGD). 1 MGD can cause the lipid layer to break down, which may lead to a compromised tear film. 2 Soothe XP contains Restoryl mineral oils that may benefit MGD patients by helping to restore the lipid layer, seal in moisture, and protect against tear loss. Lipid layer thickness (nm) Improved lipid layer thickness after treatment with Soothe XP 50nm 51nm 78nm } 58% Increase 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: Horwath-Winter J. Prevalence of MGD in an clinical dry eye population. ActaOphthal 2011; 89 (s248) /TM are trademarks of Bausch & Lomb Incorporated or its affliates Bausch & Lomb Incorporated. PN08785 SXP.0028.USA.18 Baseline After Leading Lubricant Eye Drop* After Soothe XP * Non-lipid containing eye drop (Systane Ultra) Lipid layer thickness (LLT) prior to and 15 minutes following a single drop of emollient or non-emollient eye drop in dry eyes with meibomian gland dysfunction. Data are the mean (±SD) LLT based on stroboscopic video color microscope (SVCM) measurements in study eyes (qualifying eye in subjects with only one qualifying eye, or the eye with the lowest LLT at baseline in subjects with two qualifying eyes). p<0.001 paired t-test for the change from baseline. p<0.001, n=35, following a single drop.

4 PRACTICING MEDICAL OPTOMETRY BE THE DED DETECTIVE Learn about the diagnostic tests that can aid you in identifying this chronic and bothersome condition VIN T. DANG, O.D., F.A.A.O., BAKERSFIELD, CALIF., AND WALT WHITLEY, O.D., F.A.A.O., M.B.A., NORFOLK, VA. DED is the most prevalent medical condition we will encounter in optometric practice. 1 Because of the impact DED has on our patients quality of vision (blurriness) and life (its symptoms of foreign body sensation, photophobia, etc. distract from and hinder life s pleasures), we must be vigilant in identifying it in our patients. Also, as the TFOS DEWS II highlighted, there can be a mismatch between signs and symptoms that may be attributed by the neurosensory component of DED. Here, we discuss the importance of patient history and the diagnostic tests that can aid us in arriving at the DED diagnosis, organized by the three disease types: (1) both aqueous-deficient and evaporative DED, (2) just aqueous-deficient DED or (3) just evaporative DED. Corneal staining shows DED. PATIENT HISTORY An efficient case history is critical, as it leads you to your choices of diagnostic testing. For example, patients who have autoimmune disease (lupus, rheumatoid arthritis, etc.) are more likely to fall into the aqueous-deficient DED category. Granted, some patients may have autoimmune disease, and the systemic condition may not be diagnosed yet. Thus, asking questions about joint pain and fatigue may be beneficial and elicit a referral to their primary care doctor or rheumatologist for further assessment. If no clear path is determined based on the patient s history, you could mix and match the aqueous-deficient DED and evaporative DED diagnostics to cast a slightly wider net. For example, performing a phenol red thread test and evaluating the glands expressibility at the slit lamp can provide efficient insights, and neither require a lot of time or investment. All this said, simply playing the odds, the patient is more likely to have an evaporative type of DED. 2 BOTH The following five diagnostic tests can be used: 1. DED patient questionnaire. Organization-validated DED questionnaires (The Dry Eye Questionnaire 5 [DEQ-5], Standardized Patient Evaluation of Eye Dryness and Ocular Surface Disease Index [SPEED]) can elicit symptoms such as blurred/fluctuating vision, burning, stinging and/or watery eyes from patients who are at risk for DED, but who may not have been aware of their symptoms. For our practices, DED questionnaires are some of the best tools we utilize because they give us measurements of our patients subjective symptoms, enabling us to determine whether additional testing is warranted. Photo courtesy of Vin Dang, O.D. 16 JULY 2018 OPTOMETRICMANAGEMENT.COM

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6 PRACTICING MEDICAL OPTOMETRY 2. Vital dyes. Vital dyes enable us to measure ocular surface health. Sodium fluorescein (NaFl) highlights any break on the corneal epithelium caused by DED-induced micro-abrasion or desiccation. NaFl also can be used to measure TBUT and, thus, tear film stability. Lissamine green is effective to check for devitalized cells on the conjunctiva. 3 Patients who present with moderate conjunctival staining or mild corneal staining would be categorized as Level 2 or as having moderate DED, according to the Delphi Panel. 4 More recently, the TFOS DEWS II recommended both lissamine green and NaFl in the clinical protocol for the DED test battery. 3. Metalloproteinase-9 (MMP-9) in-office test. This point-of-care test assesses the tears for elevated levels of MMP-9, a nonspecific inflammatory marker consistently present in patients who have DED. 5 MMP-9 levels greater than 40 ng/ml are indicative of a positive test, or DED. 6 By collecting a sample of the patient s tears and placing them in a buffered solution, results are available within 10 minutes. 4. Tear osmolarity test. This measures the salt amount, or osmolarity, in tears. Osmolarity readings above 308 mosms/l or an inter-eye difference of >8 mosm are an indication of WEB EXCLUSIVE The eye care industry offers a wealth of products in the diagnosis and treatment of DED. For a regularly updated listing of products within each category mentioned, visit the online version of this article at optometricmanagement.com. mild hyperosmolarity and loss of homeostasis, which is usually indicative of DED and an unstable tear film. 7,8 A caveat: If osmolarity testing is considered, TBUT should be evaluated after it in those suspected of having evaporative DED, because the introduction of NaFl dye into the tear composition can alter the osmolarity. 5. Corneal topography. Patients suspected of having DED on topography can be identified by any abnormal spots (isolated steepening or flattening), asymmetric mean K values and irregular mires on the placido disc. In addition, this device allows for an objective measurement of the tear film, providing abnormal values <10 seconds using various technology. One instrument uses the reflection of the tear film and a computer algorithm to determine the TBUT. Another device measures it by detecting localized breaks in the tear film using infrared waves. A new player offers tear film analysis via assessing the point spread function and the TBUT. Direct fluorescein staining at the outer canthus and measurements taken between one to three seconds after instillation can be used to determined TBUT. AQUEOUS-DEFICIENT The following five diagnostic tests can be used: 1. Schirmer s Test. This test measures and quantifies tear volume via a thin absorbent strip of paper placed on to the lid margin. Tear secretion is measured on the strip after five minutes, with 15 mm or greater in tear secretion considered normal. A topical anesthetic can be given to patients to prevent reflex tearing. 2. Phenol red thread test. This is a more comfortable form of Schirmer s. It is faster and causes less reflex tearing. A simple thread is attached to the patient s lid, and the results can be obtained after 15 seconds. 3. Slit lamp biomicroscopy. This enables you to assess the tear meniscus height (TMH). You grade the inferior tear prism height as minimal, normal or excessive. The normal average TMH is 0.20 mm. Any measurement lower indicates a decreased tear volume, or aqueous-deficient DED. Several pieces of diagnostic equipment have algorithms to measure the TMH. 4. AS-OCT. Anterior segment OCT can be utilized to measure the TMH quantitatively in a noncontact, non-biased, non-invasive method. The sensitivity and specificity of TMH value with AS-OCT for DED diagnosis is 77.8% and 71.7% Sjögren s syndrome test. This test uses traditional (SS-A [RO], SS-B [La], etc.) and novel proprietary biomarkers (SP-1, IgA, IgC, IgM, etc.) to provide the Sjögren s syndrome diagnosis via an inoffice blood test or through a local lab. With earlier diagnosis, patients can be monitored for organspecific manifestations, such as interstitial pneumonitis. It is also important to be on the lookout for non-hodgkin lymphoma. 10 Common symptoms for patients who have Sjögren s syndrome include dry mouth, hyperhidrosis and dry eyes. We frequently order this test for all our DED patients. EVAPORATIVE The following three diagnostic tests can be used: 1. Meibography. A major component of evaporative DED is meibo- 18 JULY 2018 OPTOMETRICMANAGEMENT.COM

7 PRACTICING MEDICAL OPTOMETRY mian gland dysfunction (MGD). Meibography is an infrared analysis of the meibomian glands. There are two types of meibography: contact and non-contact. Contact meibography involves a direct light source to evert the lower lid and a specialized camera to image the meibomian glands. Non-contact meibography uses an infrared filter and an infrared charge-coupled device video camera to image a digitally everted eyelid. Images taken with meibography help patients to understand how the meibomian glands affect their disease. Grading for MGD structure ranges from 0, no gland loss, to 3, >67% gland loss Meibomian gland expression. After obtaining the anatomical structure of the meibomian glands, it is equally important to address the quality and quantity of meibomian gland secretions as part of the slit lamp evaluation (expression). To do so, you can use your fingers, a cotton swab or a device. The quality of the meibum expression will be graded from 0, or clear, to 3, or inspissated /toothpaste-like, indicating MGD. 12 The more advanced the characteristics and expressibility, the more progressive the diagnosis. 13 Low lipid layer thickness has been shown to be correlated with expressible meibomian glands that would suggest a higher probability for MGD Blink rate measuring device. Blinking plays an important role in resurfacing the tear film and expressing the meibum from the meibomian glands. 15 The completeness of the blink is also equally important, as a partial blink will leave the inferior part of the cornea exposed to the environment, which would lead to greater severity of DED. The normal blink rate is 15 to 17 blinks per minute, while reading or using a digital device drops our blink rate to 4.5 blinks per minute. 16 THE NEXT STEP If our diagnostic testing shows normal results or improvements, but patients are still symptomatic for DED, we may need to consider comorbidities, such as conjunctival chalasis, blepharitis, allergic conjunctivitis, epithelial membrane dystrophy or Salzmann s nodules, which all can mimic symptoms of DED. Although DED can be present with any of these mimickers, additional treatments, such as lid scrubs (See Defy Dry Eye, p.20) and/or an ocular allergy medication, may be necessary. Clinical experience matched with the diagnostic tools available in our repertoire help us make that diagnosis. Please keep these diagnostic tests in mind when you see your next DED suspect. REFERENCES 1. Farrand KF, Fridman M, Stillman IÖ, Schaumberg DA. Prevalence of Diagnosed Dry Eye Disease in the United States Among Adults Aged 18 Years and Older. Am J Ophthalmol. 2017; 182: Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012; 31: Kim J. The use of vital dyes in corneal disease. Curr Opin Ophthalmol : Behrens A, Doyle JJ, Stern L, et al. Dysfunctional tear syndrome: a Delphi approach to treatment recommendations. Cornea. 2006; 25: Acera A, Rocha G, Vecino E, Lema I, Duran JA. Inflammatory markers in the tears of patients with ocular surface disease. Ophthalmic Res. 2008; 40: Chotikavanich S, de Paiva C, Quan Li D, et al. Production and activity of matrix metalloproteinase-9 on the ocular surface increase in dysfunctional tear syndrome. Invest Ophthalmol Vis Sci. 2009; 50: Tomlinson A, Khanal S, Ramaesh K, Diaper C, McFadyen A. Tear film osmolarity: determination of a referent for dry eye diagnosis. Invest Ophthalmol Vis Sci Oct; 47: Sullivan BD, Crews LA, Sönmez B, et al. Clinical utility of objective tests for dry eye disease: variability over time and implications for clinical trials and disease management. Cornea. 2012;31: Wang CX, Liu YZ, Yuan J, Li BB, Zhou SY. Application of anterior segment optical coherence for measuring the tear meniscus height in the diagnosis of dry eye diseases. Zhonghua Yan Ke Za Zhi Jul; 45: Shen L, Suresh L, Lindemann M, et al. Novel autoantibodies in Sjögren s syndrome. Clin Immunol. 2012; 145: Arita R, Itoh K, Inoue K, Amano S. Noncontact infrared meibography to document age-related changes of the meibomian glands in a normal population. Ophthalmol. 2008; 115: Bron AJ, Benjamin L, Snibson GR. Meibomian gland disease. classification and grading of lid changes. Eye (Lond). 1991; 5 (Pt 4): Pflugfelder SC Tseng S Sanabria O, et al. Evaluation of subjective assessments and objective diagnostic tests for diagnosing tear-film disorders known to cause ocular irritation. Cornea. 1998; 17 : Finis D, Pischel N, Schrader S, Geerling G. Evaluation of lipid layer thickness measurement of the tear film as a diagnostic tool for meibomian gland dysfunction. Cornea. 2013; 32: Korb DR, Baron DF, Herman JP, et al. Tear film lipid layer thickness as a function of blinking. Cornea Jul; 13: Bentivoglio AR1, Bressman SB, Cassetta E, Carretta D, Tonali P, Albanese A. Analysis of blink rate patterns in normal subjects. Mov Disord Nov;12: DR. DANG is the director of the Ocular Surface clinic at Empire Eye and Laser Center where he also supervises 4th-year externs from three optometry schools. He has received honoraria and consulting fees from Johnson & Johnson Vision. DR. WHITLEY is the director of optometric services and oversees the dry eye clinic at Virginia Eye Consultants. In regard to diagnostic devices for DED, he has received honoraria and consulting fees from: Bausch + Lomb, Johnson & Johnson Vision and Tearlab. JULY 2018 OPTOMETRICMANAGEMENT.COM 19

8 PRACTICING MEDICAL OPTOMETRY DEFY DRY EYE... with the following therapy options for aqueous and evaporative DED JADE COATS, O.D., FAYETTEVILLE, ARK. When it comes to the treatment of DED, the individual treatment plan varies among patients, depending on the underlying problem. Whether the signs and symptoms are worsened by an aqueous deficiency, evaporative DED, secondary to MGD, or a combination of both, it is important to be familiar with the different treatment options to tackle this progressive disease. Here, I ll take you through treatment options, based on the causation of DED. Corneal and conjunctival edema secondary to chronic contact lens overwear. AQUEOUS-DEFICIENT Aqueous-deficient DED typically can be best managed by the following treatments: Artificial Tears Ideal patients: Those who have reduced tear film stability due to aqueous-deficient and/or evaporative DED, artificial tears help provide the quality tear replacement necessary for mild, moderate and severe DED. Current formulations: Depending on the severity of ocular surface disease, a range of substances from low-viscosity drops to high-viscosity gels and ointments are offered. While preservativefree artificial tears are recommended throughout the day, ointments and gels are often used nightly for moderate to severe DED. Preservative-free artificial tears are typically preferred because they contain fewer toxic additives, such as benzalkonium chloride. For evaporative DED or prolonged dryness, a lipid-based artificial tear may be necessary to supplement the tear film with the needed oil component. events: Although a safe standalone treatment option for mild DED, sometimes artificial tears mask the symptoms of DED and can disguise the root cause of the problem. For example, contact lens wearers are often recommended an artificial tear; however, this can also, unfortunately, disguise a contact lens sensitivity or intolerance. Dosing: For symptomatic patients, artificial tears are typically recommended two to six times daily, but can safely be used as often as needed. Patients with moderate and severe aqueousdeficient DED may need additional therapies to experience maximum relief, such as in the case of Sjögren s syndrome. Cyclosporine Ideal patients: Patients who have presumed keratoconjunctivitis sicca caused by reduced lacrimal tear production due to auto-immune disorders, such as Sjögren s syndrome, can benefit. Also, patients who chronically use medicines (i.e. antihistamines, antidepressants, hormone replacement therapy, etc.) that can cause side effects, such as decreased lacrimal tear production can see results. Current formulations: As an ophthalmic emulsion, cyclosporine 0.05% is offered in both preservative-free vials and multi-dose bottles. CsA cyclosporine 0.1% is also available via a compounding pharmacy. events: The most frequently reported adverse event is temporary ocular burning, redness and tearing. 1 Dosing: Recommended twice a day with 12 hours between uses. Cyclosporine is often used in conjunction with artificial tears. It takes about 90 days for patients to experience relief. Punctal plugs Ideal patients: Patients who have aqueous deficiencies caused by Sjögren s syndrome, contact lens wear or medicines (described Photo courtesy of Jade Coats, O.D. 20 JULY 2018 OPTOMETRICMANAGEMENT.COM

9 new! HARNESS EXTRA POWER FROM A NATURAL WONDER NEW TheraTears Extra Dry Eye Therapy is enhanced with trehalose for superior relief Trehalose is a natural disaccharide found in plants with moisture retention properties that help organisms survive in absence of water. In ophthalmic products, trehalose enhances active ingredients to help 1 : Protect corneal cells from desiccation Restore osmotic balance to the ocular surface Maintain the homeostasis of corneal cells DEWS ll Report The Rose of Jericho Learn about our complete line of dry eye therapy products at theratears.com Reference: 1. Jones L, Downie L, Korb D, et al. TFOS Dews ll Management and Therapy Report. The Ocular Surface Jul 2017; Akorn Consumer Health A Division of Akorn, Inc. M17-047

10 PRACTICING MEDICAL OPTOMETRY above) that decrease tear production can benefit. In addition, patients who are non-compliant with artificial tears, or those affected by dexterity issues may see relief from plugs. Current formulations: Inserting punctal plugs involves a quick non-invasive procedure that typically includes a collagen or silicone plug inserted into the lower and/or upper puncta. Often ranging from 0.4 mm to 0.8 mm, plugs help delay tear drainage and allow tears to stay in contact with the cornea for a longer duration. Collagen plugs provide a temporary solution that may help determine whether the patient is a good candidate for semipermanent silicone punctal plugs or permanent punctal cautery. Permanent punctal cautery is typically reserved for patients who have severe aqueous-deficient DED and have previously tried the temporary plugs with success. events: Although plugs can help alleviate the symptoms of aqueous-deficient DED, they do not treat the underlying problem. Rarely, punctal plugs have a small chance of causing epiphora, conjunctival epithelial erosion or pyogenic granulomas that can form if the plug migrates into the nasolacrimal duct. Dosing: Collagen plugs typically dissolve within a week; silicone plugs last three to six months. Nasal neurostimulation Ideal patients: Patients who desire an alternative, at-home DED treatment choice and who prefer a drug-free, drop-free DED treatment option can benefit. (For information on the current system, see p.50.) Current formulation: Via the nasal canal, nasal neurostimulation stimulates the trigeminal nerve to increase natural tear production. By targeting goblet cells, meibomian glands and lacrimal glands, it causes an immediate production of mucin from goblet cells, meibum from the meibomian gland, and aqueous FROM THE ARCHIVES MORE DRY EYE COVERAGE FROM OM Autologous Serum: The natural tear is loaded with mediators and proteins that create homeostasis. Read more in DED Symptom Solutions in July 2016 or ly/2sq0vsm. Mild to severe. Dr. Ami Ranani breaks down his treatment plan among patients who have mild, intermediate and severe DED in Manage Dry Eye Disease, from July 2016, available at ly/2jxb3js. How to Offer Ocular Nutritional Supplements. Dr. Douglas K. Devries takes the reader through the steps he uses to offer this therapy in his office from April s magazine, available at ly/2uopbqq. TFOS DEWS II: Guest editor Dr. Whitney Hauser has offered her in-depth analysis of the TFOS DEWS II report in her regularly occurring Dry Eye column. Published pieces appeared in January, ly/2ewvk27, and April, Search Optometricmanagement.com for dry eye disease for even more insights. from the main lacrimal gland. 2 events: The most common side effects are nasal pain, irritation post-stimulation or nose bleeds, which occurred in 5% to 10% of patients. The device cannot be used for more than 30 minutes in a 24-hour period. 2 (The device is not covered by insurance.) Dosing: Nasal neurostimulation is recommended at least twice a day for no more than three minutes per session, as needed. 2 EVAPORATIVE Evaporative DED contributes to the large majority of DED cases and can be managed by the following treatments: Hot compress/eye mask Ideal patients: Patients who have MGD can benefit. Current formulations: Eyelid warming masks heat the meibomian glands to soften the thickened meibum. Some patients opt for the hot compress alternative, which involves the bundle method, to heat several moistened cloth towels at once. This option provides a heat supply for a 10-minute treatment and eliminates time and the inconvenience of having to reheat during the treatment. events: Unless done properly with extremely hot water (>120 F) used for 10 to 15 minutes, the maximum effectivity to sufficiently allow expression isn t reached. 3 Dosing: Typically recommended nightly, but twice daily is even better. Lid scrubs and sprays Ideal patients: Patients with poor lid hygiene and/or lid margin disease can benefit. Current formulations: lid scrubs are used along the lid margin for mild to moderate an- 22 JULY 2018 OPTOMETRICMANAGEMENT.COM

11 MANAGING BACTERIA OVERPOPULATION AVENOVA IS THE MISSING PIECE IN ANY MGD DRY EYE OR BLEPHARITIS REGIMEN Avenova. Essential for all chronic management regimens. - Avenova has patient study results demonstrating bacteria load reduction on the skin around the eyes. - Avenova is pure hypochlorous acid for lid hygiene without bleach impurities. - Avenova is designed to complement all daily management regimens for patients with MGD Dry Eye and Blepharitis. AVENOVA.COM RX ONLY Essential Chronic Lid Management M

12 PRACTICING MEDICAL OPTOMETRY terior blepharitis. Alternatively, lid sprays are for more moderate to severe blepharitis. events: Although these scrubs and sprays effectively remove eyelid debris and bacteria, they do not address the underlying chronic inflammation of DED. Dosing: Typically recommended twice daily. Ocular nutritional supplements Ideal patients: Those interested in an oral supplementation to increase goblet cell density, thus decreasing the incidence of DED, can benefit. Current formulations: Supplementation of omega-3 and omega-6 fatty acids help to promote anti-inflammatory activity and provide benefits to those who have inadequate tear film stability. events: Before recommending an ocular nutritional supplement, it s important to ask patients whether they are taking anticoagulants or blood thinners, as supplements with EPA may increase bleeding time. 4 Dosing: Typically recommended by mouth twice or three times a day, it commonly takes up to a month for a patient to notice effectiveness. The FDA generally considers 3 g of omega-3, EPA and DHA fatty acids, per day as safe. 5 Adequate intake of omega-6 for WEB EXCLUSIVE The eye care industry offers a wealth of products in the diagnosis and treatment of DED. For a regularly updated listing of products within each category mentioned, visit the online version of this article at optometricmanagement.com. adults, ages 19 to 50 is 17 g/day for men and 12 g per/day for women. 6 Lifitigrast Ideal patients: Post-surgical patients, contact lens wearers and patients who have mild, moderate and severe DED can benefit. Lifitigrast 5% ophthalmic solution is indicated for the treatment of the signs and symptoms of DED. Current formulation: The solution acts as an LFA-1 antagonist directly on the surface of the cornea. It is available in preservative-free vials. events: Dysgeusia, decreased VA and a temporary burning on instillation occur in 5% to 25% of patients. 7 Dosing: It is recommended twice a day with a spacing between drops of 12 hours. 7 Topical corticosteroids Ideal patients: Patients who have symptoms of moderate to severe DED and, specifically, associated inflammation that can t be controlled by cyclosporine or LFA-1 alone can benefit. Current formulations: Corticosteroids are generally used short-term to quickly manage symptoms of ocular inflammation. They often are used in conjunction with artificial tears and as a complement to other more long-term treatments. events: Long-term treatment of steroids can lead to complications, such as cataracts. Dosing: Typically, topical steroids are tapered from four times a day to once a day over the course of seven to 14 days for mild to moderate DED. Antibiotics Ideal patients: those with blepharitis and MGD can benefit. Current formulations: For most who have anterior blepharitis, topical antibiotic ointments work effectively. Oral tetracyclines are used in patients who have more severe disease. 8 events: Oral tetracyclines are not suitable for pregnant or female patients of childbearing age. 8 Sometimes, oral minocycline may be considered over doxycycline to decrease the incidence of sunburn and photosensitivity. 8 Dosing: Ointments are often recommended every day up to three times a day. Oral tetracyclines are typically recommended 50 mg to 100 mg twice a day for one to four weeks, depending on the severity of the inflammation. Meibomian gland debridement Ideal patients: Patients who have blepharitis and chronic eyelid inflammation causing a secondary evaporative DED and those who are non-compliant with lid scrubs can benefit. Current formulation: Handheld tool that removes lid debris and microbial biofilm along the lid margins. events: Some patients report a mild tickling of the lids during the use of the tool. 9 (This procedure is not currently covered by health or vision insurance.) Dosing: The cleaning procedure should be applied to the upper and lower lids, and should be repeated every four to six months, as needed. Thermal pulsation Ideal patients: Patients who have MGD can benefit. Current formulations: By providing the eyelid with a gentle heated massage, thermal pulsation devices help unblock the 24 JULY 2018 OPTOMETRICMANAGEMENT.COM

13 PRACTICING MEDICAL OPTOMETRY meibomian glands to resume the natural production of lipids needed for a stable tear film. events: Transient blurred vision, corneal abrasions and eyelid irritation, among others have been noted. 10 (The procedure is not covered by insurance.) Dosing: One procedure lasts about 12 minutes per eye, but both eyes are typically done simultaneously. 11 Treatment is typically every nine months as needed. 11 The other procedure is recommended for three treatments, lasting under 20 minutes, two weeks apart. 12 The results tend to be best when repeated every 12 months as needed. 12 Intense pulsed light (IPL) Ideal patients: Patients who have dilated blood vessels and telangiectasia near the eyelids and adnexa caused by ocular rosacea and/or blepharitis can benefit. Also, patients who would like an alternative dropless DED treatment can benefit. Current formulation: IPL uses non-coherent light (from visible, 515 nm to infrared spectrum, 1,200 nm), applied to the lower lid/ lateral canthal area to be absorbed by blood vessels to reduce inflammation Special eye shields should be worn for protection. events: Patients have reported that the zaps may be temporarily uncomfortable, and warmth/ redness may be experienced where the IPL is applied. IPL is currently used with caution in patients who have darker pigment, as it can cause lightening of the treated skin area. 14 Dosing: Treatment parameters can be customized based on the severity of DED and are often recommended every two to four weeks until the meibomian glands have been normalized. Once the glands have improved, maintenance treatments are suggested every six months. 14 Amniotic membrane Ideal patients: Patients who have moderate to severe DED and who have tried other therapies with minimal improvement can benefit. Current formulations: Amniotic membranes effectively and rapidly accelerate corneal healing. Offered in dehydrated and cryopreserved, both options are suture free and can be applied in-office to provide a biological bandage. events: Insurance may or may not cover the service. (For more, see Membranes p.41.) Dosing: Typically, patients wear the membrane for three to five days for mild ocular surface reconstruction or seven to 14 days for more moderate-severe DED. MULTIFACTORIAL DISEASE DED is a naturally multifactorial disease. As such, the treatments listed above may be appropriate in the treatment of a patient who exhibits signs and symptoms of both evaporate and aqueous-deficient DED. This listing is provided as a guide, but you, as the patient s doctor, in concert with the diagnostic findings, decide what treatments may be in the best interest. REFERENCES 1. Restasis Product Information. Restasis website. Restasis.com. Accessed June 5, Allergan. Patient Guide to the TrueTear intranasal tear neurostimulator. Accessed May 1, Kenrick CJ, Alloo SS. The Limitation of Applying Heat to the External Lid Surface: A Case of Recalcitrant Meibomian Gland Dysfunction. Case Rep Ophthalmol. 2017; 16: Omega-3 Supplements: In Depth. National Center for Complementary and Integrative Health website. htm. Updated May Accessed June 5, US Food and Drug Administration. Substances affirmed as generally regarded as safe. Federal Register. 1997; 62: Food and Nutrition Board, Institute of Medicine. Dietary Fats: Total Fat and Fatty Acids. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, D.C.: National Academies Press; 2002: (National Academy Press) 7. Prescribing Information for XIIDRA. Shire website. ENG.pdf Revised Dec Accessed June 5, Ezuddin NS, Alawa KA, Galor A. Therapeutic Strategies to Treat Dry Eye in an Aging Population Drugs & Aging. 2015; 32: BlephEx. Rysurg website. doctors/index.php/how-does-blephex-work.html Accessed June 5, LipiFlow Thermal Pulsation System. Johnson & Johnson Vision website. lipiflow/ Accessed June 5, Greiner JV. A Single LipiFlow Thermal Pulsation System Treatment Improves Meibomian Gland Function and Reduces Dry Eye Symptoms for 9 Months, Curr. Eye Res., 2012; 37: MiBo Thermoflo. MIBO Medical Group website. html Accessed June 5, Craig JP, Chen YH, Tunbull PR. Prospective trial of intense pulsed light for the treatment of meibomian gland dysfunction. Invest Ophthal Vis Sci. 2015; 56: Toyos R, McGill W, Briscoe, D. Intense pulsed light treatment for dry eye disease due to meibomian gland dysfunction; A 3- year retrospective study. Photomed Las Surg. 2015; DR. COATS practices at McDonald Eye Associates, an OD/ OMD multidisciplinary practice in Rogers, Ark. She dedicates the majority of her clinical practice to peri-operative surgical management, ocular disease and DED. She is both an advisor and speaker for Shire Pharmaceuticals. Also, she is an member of the AOA, the AOA Political Action Committee, the Arkansas Optometric Association s National Legislation Committee and Women in Optometry to name a few. JULY 2018 OPTOMETRICMANAGEMENT.COM 25

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16 PRACTICING MEDICAL OPTOMETRY PRACTICAL STEPS TO DED CARE These six tips will enable you to build a thriving dry eye clinic SCOTT SCHACHTER, O.D., PISMO BEACH, CALIF. Ihave had the opportunity, through speaking on DED throughout the United States, to get my fellow O.D.s fired up about it and, therefore, make DED screening part of their everyday practices. It is my passion. Why? I was a spherical myope who desired LASIK. At my LASIK consult, my surgeon discovered I had higher-order aberrations. Suspecting these aberrations were due to DED, the surgeon prescribed the two-week use of an anti-inflammatory eye drop. When I returned for follow-up, magically, the aberrations were gone. This confirmed the surgeon s suspicions, while giving me the epiphany that the tear layer affects vision, meaning DED is a vision disease my bailiwick! That day, DED became the most important disease state to identify and treat in my practice. In addition, in learning that the condition is consistently overlooked and prevalent, I knew I had to inquire about it on every one of my patients. But, how could I do it efficiently? After all, with reduced reimbursements from vision care plans, I couldn t afford for it to take an extra 10 minutes per patient. The process had to be a streamlined, consistent and evidence-based one to benefit patients and the practice. Here s a look at the steps I took to accomplish this. I EDUCATED MYSELF 1 Outside of practice, I have visited (and continue to visit) Google Scholar ( scholar.google.com) to find the latest research on DED. Also, I have visited the TFOS website, where their Dry Eye Workshop s consensus of DED provides a template for making decisions. In addition, I sought (and still seek) CE regarding the anterior segment, and I ask other thought leaders and practitioners at these events what works best in their practices when it comes to DED. Learning from actual practicing O.D.s, who understand factors, such as patient flow, staffing, prior authorization challenges and more, has been invaluable. Further, as my DED clinic has grown, I ve attended workshops to gain hands-on experience with the latest technologies and techniques. (Of note: In addition to benefitting patients, many of these innovations can supplement practice revenue.) I EDUCATED STAFF 2 In knowing that staff is a critical part of practice success, I set aside time to educate them about DED. Specifically, at lunch and learns and staff meetings before or after practice hours, I explained why identifying the condition is important (effects on vision and lifestyle), how to look for and treat it (so staff could answer patient questions) and their role in doing so (i.e. assisting in providing patient education and gathering data). There also have been occasions when I ve taken 28 JULY 2018 OPTOMETRICMANAGEMENT.COM

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18 P R ACT I C I N G M E D I CA L O P TO M E T RY I INCLUDED A DED QUESTIONNAIRE 3 Along with the practice s patient history form, I added a TFOS-validated DED symptom questionnaire. I prefer SPEED or the DEQ-5 because of the brevity required to answer the questions and interpret results. Surveys are given at reception and scored before the patient goes to the exam area. They take less than 15 seconds to score. I STARTED WITH BASIC TESTING 4 Once I began identifying symptomatic patients via the questionnaire, I employed efficient testing, such as fluorescein strips (O.D.), a phenol red thread test (staff) and vital dye installation (O.D.) to look for DED clinical signs. The time required for each is roughly 30 seconds, and the cost of performing such tests per patient is less than a dollar, so no significant capital outlay was required. Start with the basics. Build patient volume before adding costly technologies. Learn to walk before you run _18 PMO_Schachter_PKSPKPKJ.indd 30 With time, consider adding more diagnostics that can help refine treatment approaches, and consider offering ocular nutritional supplements and supplies, such as ocular compresses. (As a brief, yet related, aside, I recommend offering these items at a competitive price to enhance patient compliance something needed for successful outcomes.) (See Be the DED Detective, p.16 Start with the basics. Build patient volume before adding costly technologies. Learn to walk before you run. and Defy Dry Eye, p.20.) Before making any purchases, get a sense of patient need and the practice s ability to support the technology (finances and device footprint). Start by creating a list of potential patients for a week, then extrapolate, and crunch the numbers. (The percentage of DED patients that would make adding new equipment a good choice depends on the specific purchase and the monthly payment of the device vs. increased income with absolute numbers.) Next, follow the science, and look for, or ask, the manufacturers of devices to support their claims with research. Now, consider the cost of using the device. How much time does it take to get the data? Are there consumables, such as test cards? Is the data meaningful to you? Will insurance cover the cost or will the patient? Who will gather the data or use the device and when? Will patients return for testing? Due diligence is of paramount importance. I CREATED SHORT CUTS 5 In knowing patients would need education regarding their DED diagnosis and prescribed treatments, I created handouts that include this information, rather than verbal communication, enabling me to stay on schedule. (See Handout Example, in the online version of this article.) I MARKETED THE SERVICE 6 As my primary care practice was already established, I focused on the internal marketing of screening every patient for the condition via the DED questionnaire, sending an blast about DED s impact on one s quality of life robu_s/ Taras Livyy/stock.adobe.com staff with me to industry events, so they could take DED CE. Finally, I ve taken advantage of lunch-and-learn programs offered by industry, as they are chock-full of helpful information, making them valuable, and very well received by staff. J U LY O P T O M E T R I C M A N A G E M E N T. C O M 6/21/18 9:51 AM

19 HEALTHY MEIBOMIAN GLANDS ARE THE FOUNDATION OF HEALTHY TEAR FILM, STABLE VISION AND OCULAR COMFORT 1 LipiFlow System Activator II exclusively featuring VTP technology. The efficacy of a single VTP treatment in patients with MGD and dry eye is well established, and VTP treatment has been shown to deliver a long-term treatment effect in multiple studies. 2,3 Contact us to learn more RA-VISUS-Info@ITS.JNJ.com tearscience.com 1. Nichols KK, Foulks GN, Bron AJ, et al. The International Workshop on Meibomian Gland Dysfunction: Executive Summary Investigative Ophthalmology & Visual Science, Special Issue 2011, Vol. 52, No. 4, Lane SS, DuBiner HB, Epstein RJ, et al. A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea Apr;31(4): Blackie C, Carlson AN, Korb DR. Treatment for meibomian gland dysfunction and dry eye symptoms with a single-dose vectored thermal pulsation: a review. Current Opinion in Ophthalmology. 2015; 26(4): MKT-ADV-126 A

20 PRACTICING MEDICAL OPTOMETRY and the treatments I offered for it. Also, I sent (and continue to send) blasts regarding the addition of related technologies, as this patient base grew (and continues to grow). If your practice is new, I recommend offering DED talks to local service clubs, donating artificial tears to first responders and getting in touch with your local news outlets to make folks aware of your practice s DED services, and mention any new or unique technologies. Finally, use your practice s social media channels to let your patients know that you diagnose and treat DED. THE RESULT Within six months of following these steps, I tripled my medical visits, while keeping my revenue-per-patient the same. (Reimbursement for medical office visits and punctal occlusion played a significant role in maintaining this revenue average.) This occurred due to efficiency. I was able to increase patient-visit volume, but the increased medical income kept my revenue per patient high, so my gross increased. In addition, because these steps enabled efficiency, there was no need to create dedicated appointment slots for DED patients. The bottom line: Keep it simple at first. Start identifying symptomatic patients, look for clinical signs, develop a treatment plan, and schedule a follow-up visit to monitor progress. Oh, and about my LASIK procedure: I am happy to say that it went very well, my vision remains great, and as a result of the experience, I am also especially vigilant in looking for DED prior to patients undergoing refractive surgery. DR. SCHACHTER is in private practice in Pismo Beach, Calif., with an emphasis on ocular surface disease. He is an adjunct clinical professor at Marshall B. Ketchum University and was recently named a Global Ambassador for the Tear Film and Ocular Surface Society and is the creator of Ocular Surface Academy. His disclosures: Alcon, Allergan, Bausch + Lomb, BioTissue, Lumenis, MacuLogix, Quidel, ScienceBased Health, Shire and Sight Science. [ ] Don t have access to your print copy? Want to share an article with your staff? Researching new practice purchases? Log on and find just what you need: optometricmanagement.com An interactive extension of the leading practice management information source 32 JULY 2018 OPTOMETRICMANAGEMENT.COM

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