In this article, we’ll explore the various ways dry eye and ocular surface disease (OSD) impact a comprehensive eye exam and what we can do about it to benefit both our patients and our practices.
1. Increased exam time
There is no doubt that dry eye sufferers come with a multitude of chief complaints. At times, it can be difficult to address everything during a short 15- to 20-minute exam. It’s important to keep in mind that you don’t have to! It’s common practice among practitioners to bring patients back for a medical office visit to address their dry eye complaints better.
If you prefer to address it at the routine exam, I highly recommend a patient educational handout so patients still receive a comprehensive understanding of their disease and treatment options that don’t result in you falling behind your daily schedule.
2. Multitude of complaints
I love managing OSD and glaucoma. Why? I see both diseases as interwoven puzzles that need to be delicately combed through, and only when each is pulled apart can you piece it back together.
During a routine exam, it’s important to determine the root cause as quickly as possible, but it can be difficult to tease out when multiple complaints come up. We’ve all been in situations where we ask, “Are you experiencing any itching, burning, or tearing?” to which patients respond, “Yes,” and your retort is a quizzical, “Okay… so all of those?”
Differential diagnoses for dry eye complaints
To get to the bottom of the chief complaint as efficiently as possible, I like to start with timing and duration. Morning dryness indicates nocturnal lagophthalmos, for which ointments and gels are good places to start. Further, morning itching may point to overactive staph and Demodex blepharitis (mites are more active at night).
Dryness and fluctuations in vision, especially later in the day, while watching TV, or spending time on the computer, point me to meibomian gland dysfunction (MGD). Year-round itching or peaked seasonal itching starts guiding me toward an allergic component.
With epiphora complaints, I look for signs of papillary conjunctivitis, conjunctivochalasis, MGD, and punctal stenosis. A routine eye exam is not my ideal place to fully address all complaints, but I do see it as a chance to start minimizing one or a few of the multitude of symptoms they are experiencing.
3. Contact lens comfortability and dropout
Soft contact lenses can easily exacerbate ocular surface disease. When patients begin to experience intolerance due to poor materials, improper fits, or chronic ocular surface instability, it means it’s time to pivot.
As new optometrists, we live in a time when we owe it to patients to offer the best products on the market. Hint hint: they aren’t the lenses we grew up wearing before we grew into the optometrists we are today.
Selecting contact lenses for dry eye patients
For dry eye patients, I turn towards what I refer to as the “high-performance lenses”: daily disposable soft contact lenses with silicone hydrogel materials and surface-wetting technologies that extend patient comfort and wear time.
Of the four manufacturers, I personally consider the “high-performance lenses” as follows:
- Bausch & Lomb’s Infuse (available in sphere & multifocal)
- Alcon’s Dailies Total One (available in sphere, toric, and multifocal)
- Johnson & Johnson’s Acuvue Oasys 1 day (available in sphere and toric)
- Oasys Max (available in sphere and multifocal)
- CooperVision’s MyDay (available in sphere, toric, and multifocal)
We know that dry eye is a chronic condition, and I educate patients that while daily disposable lenses can be more costly, it’s better to invest in their contact lenses and ocular surface health now so they can continue to wear them well into the future. After a trial period, most patients will certainly agree.
4. Limitations in best-corrected visual acuity
Every now and then, I have patients who can’t be refracted well due to an active dry eye flare. An early sign in the exam can be an autorefractor measurement that picks up high amounts of astigmatism or irregular astigmatism at oblique or varying axes.
On refraction, these patients often experience one to two lines of reduced best-corrected visual acuity (20/20 to 20/25 or 20/30) and poor endpoints. They may be unable to decide which is best between options or take you 10 to 30° degrees away from their original astigmatic axes. Another telltale sign is improved clarity after asking the patients to blink and then dissipation of the images as the tear film evaporates.
Identifying dry eye and OSD in routine eye exams
In these situations, I shift the exam from a “routine” to a “medical exam.” While practitioners may consider this overtly obvious, it can sometimes be disappointing for patients to hear. Admittedly, I’ve felt the creeping inkling to cave a little when I’ve heard, “But doc, I’m on my LAST set of contacts” or “I REALLY need new glasses—I was ready to order them today!”
But standing firm and educating patients on HOW holding off will benefit them is ultimately in everyone's best interest. It ultimately will result in fewer remakes and contact lens returns.
5. Billing habits
I recently conducted a poll on Instagram to understand practitioners' billing habits when it comes to medical concerns that arise during “routine eye exams.” I posed different scenarios that frequently came up and asked docs, “Who would you bill: the vision insurance or the medical insurance?”
In the case of a patient presenting for a routine exam with “secondary complaints of dry eye disease where at-home therapies may be discussed,” of the 212 people who voted, surprisingly, 122 individuals (58%) stated they would bill the exam to medical insurance, whereas 90 individuals (42%) stated they would still bill the exam to the patient’s vision insurance.
Less surprisingly, in the case of a patient presenting for a routine exam with “dry eye disease and continuation of pharmaceutical therapies (i.e., Restasis, Xiidra, Cequa, etc.)” of the 208 people that voted, 188 individuals (90%) stated they would bill the exam to medical insurance, whereas 20 individuals (10%) stated they would still bill the exam to the patient’s vision insurance.
My big takeaway from the poll is that the majority of practitioners DO recognize that dry eye impacts the routine eye exam enough to change the insurance that they bill. It makes a strong case for the practice of medical optometry and highlights the importance of billing to corresponding insurance despite increased pressure from patients' preferences and vision plans.
Conclusion
During a routine exam, my goal is not to have the final dry eye treatment plan in place but rather to establish a baseline, get patients started with at-home care, and educate patients on WHY we can’t tackle it all in one exam.
I typically bring them back in 2 to 3 months for follow-up and to dive deeper into additional assessments evaluating systemic diseases, diet and lifestyle habits, tear production, meibomian gland imaging, corneal sensitivity testing, and proparacaine testing.
