Karen Walsh is a Clinical Scientist at the Centre for Ocular Research & Education, (CORE) with additional responsibilities focussing on the educational programmes provided by the centre. She has previously worked as a Professional Affairs Manager in the contact lens industry, and in practice in the UK. She holds a post graduate diploma in Clinical Optometry from City University, London UK, and is a Fellow of the International Association of Contact Lens Educators.
The highlight across the two days of education was a consistent focus on the ‘how’. How to take those initial steps to start focussing on dry eye management in practice, and how to then take that dry eye practice to the next level, with dedicated clinics and investment in instrumentation. Designed to meet this objective, the second day of the meeting focussed on these areas. This special edition of our clinical insight section summarises many of the tips and practice-based insights that were shared throughout the conference.
The key point to take away from this section is that it is possible to begin development of a specialist practice with some simple steps and minimal initial investment. Simply adding a symptom questionnaire to all eye examinations will uncover those patients who may benefit from further dry eye diagnosis. Ensuring then that those diagnostics are completed in a separate, dedicated appointment is the next simple change to make to the clinic schedule. This provides the time to enable full diagnosis, patient education and delivery of a treatment plan.
Getting started in the management of dry eye disease
With insights from Drs Euan McGinty and John Wilson (both private practice Nova Scotia, Canada) plus practical tips from all speaker sessions in the conference
- First point to note is that trying to add a quick ‘dry eye chat’ into the routine eye examination appointment does not work. There is not enough time, and the patient is not likely to take any advice provided on board. This sets up any treatment plan for failure, plus the fact that the additional time taken in office is not being appropriately charged for
- First steps: make the patient aware you have seen something that needs them to return for a more in-depth assessment. Do not shy away from being serious about this. More than one speaker at the conference used the phrase “I have a concern”
- Be clear on your charges for initial appointments and subsequent follow ups
- Train your staff on the new dry eye focus
- Decide if dedicated dry eye appointments are booked as part of the routine diary, or at certain times/designated days only
- Ensure you are educated and up to date on dry eye diagnosis and management options, as explained in the TFOS DEWS II report
- Ensure you have some therapies available to sell from your practice
- TIP! Without any investment you can get started with:
- Screening all patients with a questionnaire: SPEED/OSDI/DEQ-5
- Looking for homeostasis
markers:
- tear break up time (non-invasive ideal, fluorescein fine otherwise),
- ocular surface staining
- and (if available) osmolarity.
- Diagnosing type and severity of dry eye by assessing tear volume (aqueous deficiency) and health and appropriate function of the meibomian glands (evaporative)
- Educate the patient on their condition and its management
- Be realistic about improvements and timeframes
- Be encouraging
- Apply some in-office treatments if appropriate: lid cleansing and debridement, therapeutic expression, hot compresses
- Teach patient how to use their therapies
- Book a follow up appointment
Setting up a dry eye specialist practice
From ‘Anatomy of a dry eye practice’ by Dr Trevor Miranda (Private practice, Vancouver Island, BC, Canada) plus additional insights from all speaker sessions during the conference.
- Having made an initial start into more focussed dry eye practice, what does the next step in developing a more specialised dry eye clinic look like? Dr Miranda talked about his practice
- Expand from the above examples into more advanced diagnostics: osmolarity, assessment of inflammation, and meibography, along with investing in specialised in-office treatments
- Always maintain empathy and enthusiasm: patients need to understand their condition and to feel understood
- With ALL patients:
- Routine use of symptom questionnaire
- Lower lid meibography
- Use of fluorescein to check for ocular surface staining
- Make use of your technicians (if available) for: symptoms, osmolarity, inflammation, meibography, tear meniscus height, non-invasive tear break up time. Eye care practitioner follows on with more detailed lid assessment and meibum quality grading and overall diagnosis
- Can develop a standard treatment algorithm (based on TFOS DEWS II) which can help tailor treatment to particular types and severities of dry eye
- Provide a personalised treatment plan for the patient to use at home
- Treatment is often comprehensive, covering education, dietary and lifestyle changes, therapeutic gland expression (both in-office and ongoing at home), lubricants, anti-inflammatories (omega-3s, topical and oral antibiotics, short-term steroids, cyclosporine, lifitegrast)
Marketing the practice
From ‘Marketing your medical specialisation’ by Kevin Wilhelm (Co-founder Marketing 4ecps)
- Kevin covered the “ABCDE” of marketing a specialist practice:
- Advertise
- Consider balance between traditional and digital methods
- Make use of social media
- Be about it
- Develop your strategy, objectives and build your brand
- Define your market position: what do you want the practice to be known for?
- Ensure your website reflects your strategy and position
- Ensure you are known for your specialty
- Content
- Make use of video content to educate patients about dry eye, its diagnosis and treatment
- Blogs give patients access to your expertise and can be valuable
- Diagnose
- Patients don’t know what they don’t know!
- Diagnose and educate the patient on their condition
- Most important is what you do after diagnosis: how you treat and follow up
- Expertise
- Continually invest in your specialty: people and equipment
- Recognise it is a team effort
Improving patient compliance
From ‘Strategies for improving treatment compliance in dry eye patients’ by Dr Henry Reis (Private Practice, Burnaby, BC, Canada)
- Up to two-thirds of patients with chronic conditions can lapse from their treatment plans
- Reasons for poor compliance include patient-centred factors such as the doctor-patient relationship, the patient’s knowledge of their condition and therapy plan, and their ability to remember and administer their treatment. Additional factors of poor compliance relate to the choice of therapy and economic factors such as affordability.
- TIP! Look out for patients who have been given appropriate treatment who are not improving: consider if they are actually being compliant to their prescribed therapies
- TIP! Make a note of how compliant a patient is in their records: helps understand disease progression and recommendation of future treatment options
- First step is to manage patient expectations. If a patient better understands how much their treatment can achieve they are likely to continue with it
- Compliance to specific treatments (hot compresses, artificial tears) can be improved by selling them directly in your practice (rather than have the patient source from elsewhere)
- Follow up calls to patients help maintain compliance and address any questions or concerns they may have
- Direct delivery of repeat medications to the patient, with access to online and ‘by-phone’ advice may help to improve compliance
