Before you start building an ocular surface disease (OSD) service in your practice, ask yourself if you are genuinely interested in, passionate about, and committed to treating OSD in your practice. In my experience, those endeavoring to build an OSD service without these prerequisites face a greater risk of failure.
This article outlines my stepwise approach to building an OSD service in the practices of providers with the aforementioned characteristics.
Step No. 1: GATHER YOUR TEAM
Anyone starting an OSD service must build a team of similarly minded people to help. At least one technician and one other physician colleague in the practice must join you to serve as the foundation on which this new service can grow.
The next phase in the process is getting your practice administrator or office manager on board. This individual will play a critical role in the setup details and staff training.
Step No. 2: TRAIN YOUR STAFF
All staff members, even those in billing, need training because not all of them are familiar with point-of-care tests such as tear osmolarity and matrix metalloproteinase 9.
The billing staff needs to learn about the OSD service so that they can answer patients’ billing questions and correctly submit insurance claims to obtain appropriate reimbursement.
The front desk staff and those who answer the phones within the call centers must be educated about dry eye disease (DED) and the services the practice offers in order to better triage incoming calls based on patient complaints and described symptoms. With basic knowledge, employees are better equipped to schedule patients for a consultation with a dry eye specialist instead of another physician in the practice when appropriate.
Technicians need training on how to perform diagnostic tests for OSD and the proper questions to ask patients. Rarely do patients come into a practice and announce that they have or think that they have DED. Technicians often must ask simple yet pointed questions to elicit information that patients may not realize is relevant.
Everybody in the practice needs training, and this is not a one-time effort. I recommend a 15- to 20-minute weekly session. Ongoing training helps keep the staff’s knowledge of a rapidly evolving field up-to-date. It includes education on new products and services and addresses questions in a timely fashion.
Step No. 3: know WHAT YOU NEED TO GET STARTED
Starting an OSD service doesn’t require a lot of money. A slit lamp, two vital dyes (fluorescein and lissamine green), and a dry eye questionnaire such as the Ocular Surface Disease Index, Standard Patient Evaluation of Eye Dryness, or Symptom Assessment in Dry Eye are all you need. You can build out the service over time with offerings such as the following.
Point-of-care testing. Add point-of-care tests such as InflammaDry (Quidel) and the TearLab Osmolarity System (TearLab). The companies that manufacture these products are great resources for staff training and education.
Meibography. Devices such as the LipiScan dynamic meibomian imager and LipiView II interferometer (both from Johnson & Johnson Vision) can be used to show patients structural abnormalities in their meibomian glands that contribute to DED.
Step No. 4: Incorporate IN-OFFICE TREATMENTS
Several in-office OSD treatment options are available.
Thermal pulsation. Applying thermal energy to the meibum and meibomian glands allows impacted meibum to become more pliable and less like paste. Devices that employ this approach include LipiFlow (Johnson & Johnson Vision), iLux MGD Thermal Pulsation System (Alcon), and TearCare (Sight Sciences). With LipiFlow, thermal energy is applied automatically to heat the meibomian glands and evacuate the impacted meibum. The other technologies rely on manual expression of the meibomian glands after heating. This is achieved by compressing the iLux device or, with the TearCare, by using a stainless-steel paddle following the thermal treatment.
Intense pulsed light. This form of therapy filters light of the appropriate wavelength to allow its absorption by the targeted tissue. For the treatment of OSD, the intense pulsed light is targeted at oxyhemoglobin to address telangiectasia on the eyelids, essentially closing off the abnormal blood vessels that leak proinflammatory mediators and exacerbate inflammation on the ocular surface.
Microblepharoexfoliation. With BlephEx (BlephEx), a rotary sponge brush is moved along the lid margin of the upper and lower eyelids to remove the biofilm and scurf that may be occluding or closing off some of the orifices of the meibomian glands.
Step No. 5: Offer AT-HOME TREATMENTS
At-home treatment options include both over-the-counter, nonprescription products and prescription pharmaceutical drops. These recommendations are customized and will vary from patient to patient depending on disease severity.
Nonprescription at-home treatment options. These include the following:
- Oral supplements such as Dry Eye Omega Benefits (Physician Recommended Nutriceuticals) and HydroEye (ScienceBasedHealth)—a combination gamma-linolenic acid and omega-3 product;
- Heated moisture masks (Bruder Health);
- Devices such as NuLids (NuSight Medical), which removes biofilm and scurf buildup from the eyelids; and
- Lid cleanser sprays or wipes using ingredients such as hypochlorous acid and tea tree oil.
Prescription at-home treatment options. The iTear 100 (Olympic Ophthalmics) is a neurostimulation device that mechanically stimulates the trigeminal nerve to increase tear production. A variety of immunomodulatory agents are also available, including cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan), lifitegrast ophthalmic solution 5% (Xiidra, Novartis), cyclosporine ophthalmic solution 0.09% (Cequa, Sun Ophthalmics), and cyclosporine 0.1% ophthalmic emulsion PF (Klarity-C, ImprimisRx). Loteprednol etabonate ophthalmic suspension 0.25% (Eysuvis, Kala Pharmaceuticals) is an FDA-approved steroid for the short-term treatment of episodic DED flares. There are also multiple prescription pharmaceutical products in the pipeline (see “Ocular Surface Disease Product Roundup”).
Building an OSD service in your practice can be manageable when done in a stepwise manner. A strong, knowledgeable team can leverage various diagnostic tests and treatment modalities to address OSD, slow its progression, and enhance ocular health and comfort for your patients.