Transcript The Technician Side of The Dry Eye Workup

Bruce H. Koffler, M.D.
Lindsay Koffler Cassidy, COT, OSC
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Ocular surface disease patients can be very time
consuming. You must have a streamlined system
and work as a team in order to effectively run a
dry eye institute.
Consider new ways to test dry eyes
Be ready to implement testing, patient education,
handouts materials and patient flow
Everyone must know each others roles and all
roles are valued!
Technicians role is to provide the doctors with
the most information you can to easily asses the
patients level and causes of dry eye.
Use your time wisely and control the workup
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Dry eye surfaces when the eye does not
produce tear properly or when the tears are
not of the correct consistency and evaporate
to quickly.
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Key signs and symptoms include;
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Stinging
Burning
Foreign body sensation
Pain and redness
Contact lens discomfort and intolence
Discomfort when reading or using the computer
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Dry eye presents in many different ways.
Many environmental factors are also key and
technical staff should always keep them in
mind.
– Living in an area known for high or low humidity
– Living in places with high levels of allergens
– Using a ceiling fan at night
– Traveling more than twice a month (esp. by plane)
– Getting less than seven hours of sleep at night
– Using a computer/ tablet or reading for more than
an hour a day
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Demographics and gender also are high risk
factors for dry eye.
– Women always more at risk than men
• Hormone fluctuation (including pregnancy)
• Menopause (pre and post)
– Over 40 years old
– Tobacco users
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Does the patient drink more than three
glasses of water a day
How many servings of fish do they eat each
week
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Obtain a complete list of medications. Current
and maybe even past medications may be useful.
Pay special attention to antihistamines,
antidepressants, Beta blockers and hormone
replacement therapies and GI meds.
* special attention should be taken if the patient
is currently being treated with any form of
radiation therapy or has been in the past.
Note any Omega 3 daily supplements
Does the patient use a C-Pap machine at night
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All surgeries should be noted;
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LASIK
PRK
Cataract Surgery
Corneal Transplants
All these surgeries have high correlation to
dry eye!!!
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Dry eye patients should generally be followed
every three to six months to assess their
progress
Commonly treatments and medications are
altered monthly by their PCP or
Ophthalmologist
Important to keep a list of patients with
common symptoms flagged so you can let
them know when new treatments are
available
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Counsel patients who have high risk factors.
Many dry eye symptoms can be controlled
with proper hygiene. Show patient how to use
products. Don’t assume that the can just
figure it out. Think about possibly selling
certain products that the staff has tested and
likes. This improves patient compliance.
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Your approach to the dry eye patient must be
very different from the normal patient.
Dry eye can be very debilitating. It can cause
long term symptoms of filmy and blurry
vision, foreign body sensation (maybe
severe), pain in the eye and even
photophobia.
Listen to patients. Compassion is key to these
workups.
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Questionnaires; Duration, Onset, Diet,
Environment, Symptoms, and Diet.
How long have symptoms been present?
What is the frequency of symptoms?
What time of the day are symptoms the worst?
Does anything give relief? (tears, closing eyes, WC)
Do you wake up with these symptoms
Do you get a sharp pain in the middle of the night
or early morning when opening you eyes?
◦ Do you use a ceiling fan or humidifier?
◦ Do you suffer from allergies?
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Has the patient experienced any new lifestyle
changes? (moved, death in family, stress at
work)
Patients that have more than one diagnosis
may need to be treated first for primary
diagnosis. (RCE and Dry Eye)
Don’t forget some dry eye symptoms can
mimic allergic conjunctivitis especially in a
long allergy season.
◦ These patients will complain of itching as their #1
complaint!!!!
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Past surgeries( LASIK, Cataract, DSEK, PKP,
PRK) can all result in temporary dry eye.
Medications
◦ Antihistamines
◦ Diuretics
◦ Antidepressants
 You should counsel these patients on how these drugs
contribute to dry eye
◦ *** Even Glaucoma drops can cause dry eye!!!!!!
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Questions to ask; wearing schedule, type and
brand of lens, solutions being used (never
use generics!!!) Preservatives, BAK,
Thimerosal
◦ We have seen numerous corneal inflammatory
events in our clinic due to misuse of contacts and
solutions!!!
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In some severe cases we will use contact
lenses for treatment.
◦ Bandage Contacts
◦ Scleral lenses with or without autologus serum
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Thyroid Disease (Neurotrophic Keratitis)
Diabetes (NK)
Rheumatoid Arthritis (NK)
Psoriasis (MGD)
Rosacea (MGD)
Unless the doctor manages the systemic
disease the dry eye manifestation will rarely
fully resolve.
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Blepharitis H01.0
Chalazion H00.1
Hordeolum H00.0
Allergic Conjunctivitis H10.1
Corneal Dystrophy H18.5
Corneal Edema H18.20
Corneal Erosion H18.83
Diabetes Mellitus E11.9
Dry Eye H04.12
Epiphora H04.20
Keratitis H16.10
Keratoconjunctitis Sicca H16.22
Keratoconjunctitis Sjogrens M35.01
Punctate Keratitis H16.14
Rosacea L71.9
Trichiasis H02.05
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Crucial to evaluate general eye motions.
Evaluate the patients blink.
◦ blink rate and completeness of blink
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Many patients complain of headaches as well as dry
eye
◦ If patient desires a new glass prescription keep in mind that
it is very difficult to refract a dry eye patient
◦ You will have a much higher success rate if you wait to
refract at follow up visits when the surface is more stable!!!
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Symptoms of “dry eye” can also be related to
eye alignment.(burning, aching, stinging,
tearing, grittiness, and irritation.we have had
several patients who have complained of
these symptoms but their testing was all
normal. Many of these patients had been on
years of dry eye therapies and we found their
symptoms were alleviated by using a small
amount of BI prism in their glasses.
Symptoms would resolve almost immediately.
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Depending on the doctor technicians may play
a very active role in patient testing.
Do not diagnose the patient!!!! That is the
doctor’s role
In our clinic it is common for technicians to
perform corneal topography, osmolarity
readings and Schirmer’s tear testing when
appropriate.
Note: if you do not feel comfortable completing a
task, always ask a fellow staff member or the doctor
to explain the testing further. Everyone has to learn
the first time around!!!!
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After pre-testing the next step is for the doctor to
see patient. Technicians are vital in performing
further testing as ordered.
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Tear Meniscus Height assessment
Osmolarity readings
Fluorecein dye/ lissamine green dye
Tear file break-up time
Meibomian gland expression
Schirmer’s tear testing or Phenol red thread testing
Topography or wavefront testing
Note: none of this testing can be done after checking
IOP or instilling a drop of any kind. Take care not to
compromise the results of testing!!!!!
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You should be comfortable with the various options
in treating dry eye that can range for OTC tears to
prescription medications.
Treatments may not be limited to drops, may include
Omega-3 supplements and short term oral
antibiotics
Make sure to demonstrate punctal occlusion
especially when patient will be using steroid drops!!!!
Environmental; discontinuing ceiling fan use,
lowering height of computer monitors, blink
exercises, stopping antihistamines short term
Increase water consumption!!!
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Make sure to review doctor’s instructions
◦ This will reduce call backs!!! Be detailed
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Let patient know this is ocular surface disease and although
chronic it can be well managed, and that you and the doctor
will watch them closely.
Remind them this is an “itis” (blepharitis, keratoconjunctivitis
sicca) like arthritis these conditions will not go away and they
may have flare ups in the future. These are inflammatory
responses of the eye. You want to prepare them for future
expectations.
Show patients how to use warm compresses and lid scrubs
effectively. As well as how to instill drops correctly.
Take time to explain tapering medications correctly such as
steroids.
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Instruct patients to call if they become sensitive to any
therapies. Antibiotics commonly cause symptoms of nausea,
vomiting, and dizziness. Tell them to call right away if they
experience any of these side effects.
Remember knowledge and education are key in allowing you
to develop into a more cohesive unit in you clinic. Ask your
doctors with help in opportunities to further your education
(shadow experienced staff in another office for example,
Lunch and Learn’s internally).
We love to share our knowledge and experiences!!!
Technicians are essential in the dry eye clinic. Without an
efficient and knowledgeable team a dry eye clinic can be time
consuming frustrating. A dedicated team makes the clinic
enjoyable and the patients reap the rewards!!!!!!!!!!!!
Thank
you !!!!!