Keratoconjunctivitis sicca

Find out how to adopt some of the latest advances - and what's at stake if you don't.

Are you taking full advantage of the opportunity to treat dry eye patients? If you're not, your patients may be suffering more than you realize, and you could be missing out on tens of thousands of dollars in practice-building opportunities.

I'm not being an alarmist. Bear with me while I put a fresh perspective on a topic you may have read about quite a lot, but perhaps not in this manner.

Assessing the problem

How many of your patients would respond "yes" to one or more of the following questions?

* Do your eyes itch, water or burn?

* Do you ever feel a gritty sensation as though you have sand in your eyes?

* Does your vision fluctuate or become inconsistent at times?

* Do your eyes feel fatigued or tired?

* Do your eyes often seem light-sensitive?

* Do your eyes feel irritated when you're in shopping malls or large building complexes?

Most O.D.s will admit that a considerable number of their patients would answer yes to at least one of these questions. This would qualify each patient for a possible dry eye disease evaluation. Yet, clinical research shows conclusively that too few of us take advantage of this opportunity for a thorough evaluation.

Robin L. Chalmers, O.D., F.A.A.O., of Indiana University, asked 210 patients from six practices to rate the severity of their dry eye symptoms on a scale of O to 5.1 Using the same scale, their doctors were asked to rate the clinical severity of their patients' conditions. The results were not surprising, given the overlooked nature of this condition.

* 19% of patients rated their condition "severe," while the doctors rated only 9% severe.

* 36% of patients rated their condition "moderate," while the doctors rated only 20% moderate.

* 23% of patients rated their condition "mild," while the doctors rated 47% mild.

The bottom line: Patients rated their severity worse than professionals 23% to 60% of the time.

Kelly K. Nichols, O.D., M.P.H., Ph.D., F.A.A.O., and Jason J. Nichols, O.D., M.P.H., Ph.D., F.A.A.O., of The Ohio State University, studied 75 patients and found their symptoms did not correlate with clinical signs.2 Symptoms ranged from soreness (61%) to dryness (98%), but only 61% of patients were using artificial tears. The bottom line: Doctors were not treating these patients to relieve their complaints. This trend has been proven on a national basis as well.

The 2002 Gallup Study of Dry Eye Sufferers found that 77% of 501 adults surveyed reported dry eye conditions that were "very" or "somewhat" bothersome. Of those adults who sought professional care, 76% were prescribed artificial tears, and 16% received ointments. However, 74% of the patients surveyed wanted a more effective treatment than artificial tears and ointments.

Industry sources estimate 20 million Americans have had at least one symptom of dry eye disease; and lack of successful treatment for dry eye discomfort and pain is a primary reason why patients change eye doctors.

You know patients will leave your practice if they're dissatisfied with their contact lenses or eyeglasses. They'll also drop out if they feel you're not treating their dry eye symptoms. You must develop a clear, comprehensive plan to treat these patients.

Develop a focused approach

Despite the seemingly overwhelming magnitude of this problem, many eyecare professionals have taken a passive approach to dry eye treatment and management. Too often, doctors offer patients samples of several artificial tear products and tell them to buy a regular bottle of the one that works best. No further testing or follow-up care is scheduled. Why? Because most eyecare professionals don't build the necessary steps into their dry eye treatment and management cycle.

The two studies1,2 referenced in this article show that patients expect a focused treatment approach, similar to what's used for other eye diseases. You can start building the necessary steps into your dry eye treatment and management regimen by understanding the classifications of dysfunctional tear syndrome, or keratoconjunctivitis sicca (KCS), and responding appropriately. Consider the two major types of KCS and their components as shown in "Dysfunctional Tear Syndrome."

To make sure you recognize the various forms of KCS, take a more detailed history. Ask probing questions including: "What professionally prescribed or self-prescribed therapy has and hasn't been successful in relieving your dry eye symptoms in the past." Also, be sure to employ the full range of diagnostic tests, including:

* Tear volume measurement

* Tear breakup time (TBUT)

* Dyes and stains

* Tear assay

* Diagnostic collagen plugs

* Sample artificial tears as a diagnostic vehicle.

See "New Treatment Paradigm" for therapeutic options. Let's take a closer look at how to apply some of the newer approaches to diagnosis and treatment.

Inflammatory eye disease

If left untreated, inflammation eventually will reduce lacrimal gland function and allow irritating cytokines to concentrate on the ocular surface. This creates a vicious cycle of dryness leading to lower secretions, discomfort and, as a result, ongoing dryness. Patients who experience chronic inflammation symptoms may develop severe lacrimal gland damage.

How do you know if a patient has inflammatory eye disease? Look for common signs, including burning, stinging, conjunctival hyperemia, conjunctival chalasis, corneal and conjunctival staining and rapid TBUT. Once you've identified an inflammatory condition, you'll need to move to long-term treatment options to avoid potential increased intraocular pressure and other steroid-induced adverse effects. My choice is cyclosporine ophthalmic emulsion, 0.05% (Restasis) from Allergan, a nonsteroidal agent for long-term management of inflammatory dry eye syndrome.

The drops, administered twice a day, inhibit activation of inflammatory T-lymphocytes (T-cells) and induce immune cell apoptosis, stimulating lacrimal gland tear production.3

Another benefit of cyclosporine therapy is improvement of the junction between the patient's epithelial cells and the first layer of tears, the mucin layer.

Cyclosporine achieves clinically significant results in 3 to 4 months. Anecdotal evidence shows 59% of patients have experienced improvement from baseline Schirmer test scores at 6 months.

Some patients report improvement in about 1 month, typically because of the soothing properties of the oil-based emulsion that delivers the cyclosporine.

The key to treatment success is to keep patients on a maintenance regimen, mindful that patients often abandon treatment after achieving initial comfort.

Inevitably, symptoms recur. You have to effectively manage this condition long-term.

Managing severe inflammation

When prescribing cyclosporine, some patients, especially those with severe disease, will continue to experience some burning through the first 30 to 45 days. To minimize this effect, have patients use loteprednol etabonate 0.5% (Lotemax) from Bausch & Lomb concurrently - for no longer than 3 months - and taper as the inflammation subsides.

Because of the stinging - and the fact that higher concentrations of cyclosporine are used to manage corneal transplant patients - a notion persists that this treatment is not safe for the eye. I can assure you that, based on numerous studies, this is not true. Cyclosporine ophthalmic emulsion 0.05% is safe and effective for dry eyes affected by inflammatory conditions.4 The use of cyclosporine emulsion 0.05% has not produced any associated systemic toxicity to date.5

Punctal occlusion and nutrition

Punctal occlusion and nutrition still have a role in treating dry eye, provided your goal is to retain quality tears after treating inflammation.

New technologies are helping overcome many of the barriers to widespread use of plugs. Several new devices, including the FormFit from Oasis and the SmartPlug from Medennium, offer the following advantages:

* No sizing is needed.

* No dilation is needed.

* One size fits a range of puncta.

* The inventory is simplified.

* The patient can't rub the plug out.

* The plug achieves long-term fixation.

* The plug has no head; it is completely contained within the vertical punctum.

* The patient experiences no foreign body sensation.

The SmartPlug is made of thermodynamic, hydrophobic acrylic material. It can expand up to 1 mm in diameter and shrink to a minimum length of 2 mm.

The newest product in this category is the FormFit Plug, made of a hydrogel that absorbs fluid three times its own volume within 45 seconds of insertion. The FormFit fully fills the canaliculus in 10 minutes; the small-pore structure of the plug prevents absorption of bacteria, although protein deposits exist.

Nutritional therapy also plays a role in dry eye treatment. During the past 2 years, practitioners have been increasing their use of essential fatty acids (EFAs) to help control external eye inflammation. These EFAs include omega-3-alpha-linolenic acid (ALA), found in cold-water fish, walnuts and cod liver oil, and omega-6-linolenic acid (LA), found in milk, ice cream, butter, beef and other natural sources. See "Metabolic Pathways of Omega-3 and Omega-6 Fatty Acids" for a detailed breakdown.

Financial benefits of treating dry eye

Treatment and management of dry eye patients in the initial year can generate between $250 and $1,150 in professional services revenue. See "Serving Your Bottom Line" for a list of services. Ongoing care of these patients can easily produce $250 per year per patient. Practice management experts place the value of a single dry eye patient at more than $100,000 over a period of many years.

Other benefits include referrals from satisfied patients who have never been successfully treated in the past, increased patient visits that will yield eye-wear opportunities and other practice-building opportunities.

Now ask yourself: Can you afford to treat dry eye patients any differently than you treat other eye diseases?

Serving Your Bottom Line

Now that we've reviewed some of the latest treatments for dry eye, consider the financial impact treating a dry eye patient can have on your practice.

Yearly examination:

* 92004 - $129.23

* 92014 - $ 96.26

One to two office visits:

* 99213 - $ 52.68

Tear Assay:

* $18 to $20 profit per test

Nutritional supplements:

* $1.0 profit per month (BioTears)

Over-the-counter (OTC) products:

* $3 to $5 profit per month

Dilation with or without irrigation:

* 8801- $110.04 per opening

It's best not to perform the dilation on the same day as insertion. Don't include the procedure as a routine component of code 68761, shown below.

Punctal occlusion:

Collagen plugs, diagnostic mode:

* 68761-E2 100% $140.22

* 68761-E4 50% $ 70.11

Permanent plugs, treatment (after 10 day postoperative period):

* 68761-E2 100% $140.22

* 68761-E4 50% $ 70.11

Total $420.66

Your profit, after plug costs, should range from $470 to $495 per patient. You may repeat this treatment cycle if outcomes are positive (without excessive tearing) after plugging the upper puncta.

Ongoing care for dry eye can provide an additional $250 or more in revenue per year per patient. This chronic disease can have a positive effect on your bottom line if you plan correctly.

References

1. Begley CG, Chalmers RL, Mitchell GL, et. al. Characterization of ocular surface symptoms from optometric practices in North America. Cornea. 2001;6:610-618.

2. Nichols KK, Nichols JJ, Mitehell GL. The lack of association between signs and symptoms in patients with dry eye disease. Cornea. 2004;23:762-770.

3. Kunert KS, Tisdale AS, Stern ME, et al. Analysis of topical cyclosporine treatment of patients with dry eye syndrome: effect on conjunctival lymphocytes. Arch Ophthalmol. 2000;118:1489-1496.

4. Sall K, Stevenson OD, Mundorf TK, Reis BL. Two multicenter, randomized studies of the efficacy and safety of cyclosporine ophthalmic emulsion in moderate to severe dry eye disease. CsA Phase 3 Study Group. Ophthalmology. 2000;107:631-639.

5. Small DS, Acheampong A, Reis B, et al. Blood concentrations of cyclosporine a during long-term treatment with cyclosporin a ophthalmic emulsions in patients with moderate to severe dry eye disease. J Ocul Pharmacol Ther. 2002;18:411-418.

By John Lahr, O.D., F.A.A.O., Cambridge, Minn.

Copyright Boucher Communications, Inc. Oct 2005
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