Transcript Dry Eye Training Power Point (not recorded

Eric Botts, OD
[email protected]
Disclosures
I am a member of Speakers Bureau for
Valeant(B&L) and Allergan but have no
financial interest in them.
I am the owner of OBC Billing Specialists.
WHY DRY EYE??
 25 million people have dry eye
 40% have no complaints
 Existing patients in your practice
 Better care equals loyal patients
 Huge return on investment
What is Dry Eye Disease?
 Dry eye is a multifactorial disease of the tears
and ocular surface that results in symptoms of
discomfort, visual disturbance, and tear film
instability with potential damage to the ocular
surface. It is accompanied by increased
osmolarity of the tear film and inflammation
of the ocular surface
 The Ocular Surface / April 2007, Vol. 5, No. 2 /
www.theocularsurface.com
Two Types of Dry Eye
 Aqueous Deficient dry eye is a disorder in
which the lacrimal glands fail to produce
enough of the watery component of tears to
maintain a healthy eye surface
 Evaporative dry eye may result from
inflammation of the meibomian glands. These
glands make the lipid of tears that slows
evaporation and keeps the tears stable
*The National Eye Institute (NEI)
What do we call it?
 Dry Eye Syndrome
 Keratoconjunctivitis Sicca
 Tear Film Insufficiency
 Dry Eye Disease
 Chronic Dry Eye
 Does it really matter?????
The key features of dry eye are:
 Decreased tear production
 Increased tear evaporation
 Incorrect composition of tears
Dry Eye in a Corporate
Office
 What tools do you need
 How to communicate with your
patient
 Turn key implementation in 3 steps
IMPLEMENT IN 3 STEPS
1. Identify
2. Diagnose
3. Treat
Protocol Required to Identify
 Set your protocol
 Required for lab tests (Tearlab and Inflammadry)
 Examples:
 If a patient scores above 13 on OSDI then perform
Tearlab and/or Inflammadry
 If Keratograph 5M NIKBUT is level 1 or 2 then
perform Tearlab and/or Inflammadry
 If patient is female above age 50 or male above
65 perform Tearlab and/or Inflammadry
Identify
OSDI Ocular Surface Disease Index
Keratograph 5M
Over 35 female, over 50 male, contact lens wearer
Certain medical conditions, including diabetes,
rheumatoid arthritis, lupus, scleroderma,
Sjogren's syndrome, thyroid disorders and vitamin
A deficiency
 Certain medications, including antihistamines,
decongestants, hormone replacement therapy,
antidepressants, and drugs for high blood
pressure, acne, birth control and Parkinson's
disease




OSDI Questionnaire
This 12-item questionnaire asks patients to grade and
describe their ocular symptoms over a 2 to 4 week period
prior to the visit.
TEST is Self-administered.
The booklet is given to the patient and they are asked to fill in
the answers to the best of their ability.
The 12 items are graded on a scale of 0 to 4.
 0 is none of the time,
 1 is some of the time,
 2 is half of the time,
 3 is most of the time and
 4 is all of the time.
Scoring:
The OSDI score = sum of the scores for all questions answered x 100
total number of questions answered x4
The scale is from 1 to 100, with higher scores representing greater disability.
Scoring OSDI*
 13-22
 23-32
 33-62
 63-100
Mild and/or Episodic
Moderate, Episodic or Chronic
Severe, Frequent or Constant
Severe and/or Constant
 Download the APP on your smartphone
*Verusa P, Profazio V, Campos EC, Performance of Tearlab Osmolarity
compared to Previous Diagnostic Tests for Dry Eye Research 2010;
35(7):553-564
Keratograph 5M
 NIKBUT
 Meibography
 Tear Meniscus height
 Blinking rate and quality
 Eye redness
Diagnose
 TearLab
 Inflammadry
 Keratograph 5M
 Slitlamp examination
 Lissamine green
 Phenol Red Thread Test
 40-50% of dry eye patients are
ASYMPTOMATIC
What are the common
complaints of Dry Eye
sufferers?
 Excessive Tearing
 Gritty Feeling
 Tired Eyes
Blurry Vision
When the ocular surface is damaged or the
tear film is unstable, optical quality of
patient’s vision is affected*
*Rolando M, Zierhut M. The Ocular Surface and Tear Film and their Dysfunction in Dry Eye Disease
DRY EYE Procedure Codes
 92285- Keratograph/External Ocular
Photography
 92071- Fitting of Contact Lens for
Treatment of Ocular Disease
 68761- Closure of Lacrimal Punctum by
Plug
 Initial Office Visit
92004/92014/99204/99214/99203
 Follow up office visits 92012 or 99213
TearLab for Dry Eye
 Measurements >300 mOsm/L demonstrate
loss of homeostasis
 A difference between eyes of 8 mOsm/L or
greater indicates instability of the tear film
and is a hallmark of dry eye disease
Scoring Tearlab
 MILD
>295 mOsm/l
 MODERATE >317 mOsm/l
 SEVERE
>330 mOsm/l
Inflammadry
 Test that detects elevated levels of MMP-9,
an inflammatory marker that is
consistently elevated in the tears of
patients with dry eye disease
Non-Invasive Tear Break Up Time
NIKBUT
Meibography
Corneal Evaluation
Phenol Red Thread Test
 The thread is yellow in color (acidic) and when it
comes in contact with tears it changes to a light
red color. No topical anesthetic is used. Insert the
3 mm folded portion of the thread into the
palpebral conjunctiva of the eye 1/3 of the
distance from the lateral canthus of the lower eye
lid.
 After 15 seconds, the thread is removed and the
entire wet (Red) portion is measured. A reading of
less than 10 mm indicate dry eyes, less than
20 mm marginally dry eyes, and more than 20 mm
normal tear volume.
Lissamine Green Stain
Lid Wiper Epitheliopathy
Increased friction between
conjunctiva and ocular surface
Caused by reduced tear film
Lid Wiper Epitheliopathy
 What Is Lid Wiper Epitheliopathy? Varikooty et al, 2006;
Varikooty et al, 2008; Varikooty et al, 2015
Treatment
 Omega 3
 Artificial Tears, Gels and Ointments
 Restasis
 Punctal Plugs
 Topical Steroids
 Doxycycline/oral meds
 Bruder Mask/Lid Hygiene
 Lid Margin Debridement
 Lipiflow
Omega 3 Source in Diet
 Fish- Salmon, Halibut, Sardines, Tuna
 Eggs, Walnuts, Peanut Butter, Flaxseed,
Pumpkin seeds
 Omega 3 Fortified
 Milk, Bread, Yogurt, Juice, Margarine
Omega 3 Supplements
 No more then 2000 mg per day Omega 3
 1000mg per 100 lbs body weight
 Take with a meal, especially fatty meal with
olive oil, yogurt , eggs
 Krill Oil versus Fish Oil
 Undecided, Krill oil breaks down in digestive
system much faster so fish oil may be better
absorbed then Krill oil
 CAUTION: May Cause Excessive Bleeding, check
with MD if taking Coumadin, Warfarin etc
Artificial Tears, Gels, Ung
Restasis
 RX BID OU
 Increases tear production
 Use 3 Months before improvement occurs
 My Tears, My Rewards reduces cost
Punctal Plugs
 Permanent Silicone
 Temporary Collagen
 1 WEEK
 90 Day
 180 Day
Topical Steroids
 Loteprednol(Lotemax)
 Fewer side affects
 Prednisolone
 Flourometholone
 Especially effective in combination with
Restasis
Oral Antibiotics
 Doxycycline
 50 mg Bid x 30-60 days
 Zithromycin (Z-Pak)
 2 tablets first day, then 1 tablet x 4 days
Hot compresses
 Bruder mask
 10-20 minutes twice a day
Lid Hygiene
 Lid Scrubs
 Cleansers
 Use 2-3 times per day
Corneal Debridement
 Apply lissamine green dye and use a lateral
motion with the golf club spud along the line
of Marx to remove the stained cells
 Bleph-X
Lipiflow
 LipiFlow utilizes a patented algorithm of
precise heat applied to the inner eyelids and
directed gentle massage to remove blockages
from the meibomian glands

66 YO Female
 Complains of dry and burning eyes
 Crossword puzzles and Facebook 2 hours a
day
Identify
 Perform Questionnaire, Tearlab, NIKBUT per
protocol
Diagnose
 OSDI- 29
 Tearlab- OD 332 OS 321
 Keratograph NIKBUT- OD 2 OS 2
 Moderate to Severe Keratoconjunctivitis Sicca
Treatment Mod-Severe
 Omega 3- 1000mg per hundred lbs body




weight
Non-Preserved Artificial Tears every 2 hours
Positive Inflammadry- RX Restasis
Negative Inflammadry- Insert Punctal Plug
and/or RX Restasis
RTC 1 month Punctal Plug follow up or 3
month follow up for Restasis
1-3 Month Follow Up
Improved
No Improvement
 Repeat Tearlab,
 Repeat Tearlab,
Inflammadry and
Keratograph NIKBUT
 Tearlab- OD 304 OS 302
 Inflammadry- neg OU
 NIKBUT- OD 1 OS 0
 Continue current
treatment plan and
monitor 6 months
Inflammadry and
Keratograph NIKBUT
 Tearlab- OD 333 OS 327
 Inflammadry- + OU
 NIKBUT- OD 2 OS 2
 Test for Sjogrens’s
 Add Corticosteroid and
Restasis
 Monitor 3 months
Patient Education
 Explain chronic nature of Dry Eye Disease
 Excessive tearing is symptom of dry eye
 Importance of Compliance
 Prevent corneal damage associated with
severe Dry Eye Disease
 Set reasonable expectations for treatment
plan
 Restasis requires 1-3 months to become
effective with full compliance
54 YO Male
 Complains of tired eyes
 Occasional crusting on lashes
 Works on laptop 3 hours a day and drives 2-4
hours a day as a salesman
Identify
 Perform Questionnaire, Tearlab, NIKBUT per
protocol
Diagnosis
 OSDI- 27
 Slitlamp Examination- Meibomianitis OU, Mild
Corneal Staining OU
 Tearlab- OD 314 OS 318
 Keratograph NIKBUT- OD 1 OS 1
Moderate Meibomian Gland Disease and Mild
Keratoconjunctivitis Sicca
Treatment for Dry Eye
associated with Meibomian
Gland Disease
 Omega 3- 1000mg per hundred lbs body




weight
Bruder Mask BID x 10-20 minutes
50 mg Doxycyline BID x 60 days
Educate patient on lid hygiene
RTC 1 month to monitor
1 Month Follow Up
Improved
No Improvement
 Repeat Tearlab,
 Repeat Tearlab,
Inflammadry and
Keratograph NIKBUT
 Tearlab- OD 301 OS 298
 Inflammadry- neg OU
Inflammadry and
Keratograph NIKBUT
 Tearlab- OD 319 OS 321
 Inflammadry- + OU
 NIKBUT- OD 2 OS 2
 NIKBUT- OD 1 OS 0
 Lid debridement and
 Continue current
treatment and Monitor 3
months
gland expression
 Continue Doxycycline
 RTC 1 month to monitor
 Lipiflow if available
36 YO Female
 Contact lens wearer
 Complains of contacts being uncomfortable
 Has been fit in different brands
 Works on computer 6 hours a day
Identify
 Ask clarifying questions about chief complaint
of uncomfortable contacts
 Since patient did not meet protocol for
Tearlab, doctor now orders Keratograph and
Tearlab to be performed
Diagnosis
 Tearlab OD 304 OS 314
 Keratograph NIKBUT OD 1 OS 1
 +1 injection OU
 Minimal corneal staining
 Mild Keratoconjunctivitis Sicca
Treatment Mild
 Omega 3- 1000mg per hundred lbs body




weight
Rewetting drops PRN but specifically when
working up close
Discuss/refit daily disposable contacts
Educate patient on chronic Dry Eye Disease
associated with contact lens drop out
RTC 2 weeks Dry Eye follow-up
2 Week Follow Up
Asymptomatic
No Improvement
 Continue current
 Repeat Tearlab and
treatment
 RTC 6 months to monitor
Keratograph, order
Inflammadry
 Positive Inflammadry
then RX Restasis
 RTC 3 mo to monitor
 Negative Inflammadry
then consider Punctal
Plugs and/or Restasis
 RTC 1 mo to monitor
What is the First Step?
 Develop Protocol for Lab Tests
 Use Questionnaire to identify
 Invest in Keratograph 5M
 Apply for CLIA waiver
 Order Tearlab
 Order Inflammadry
 Order Lissamine Green
I came, I saw, I conquered
Eric Botts, OD
[email protected]