Welcome back to Dry Eye Fireside Chat. In this episode, Damon Dierker, OD, FAAO, sits down with Jaclyn Garlich, OD, FAAO, to outline how to implement dry eye screenings into comprehensive eye exams and encourage appropriate follow-ups.
According to data from the National Health and Wellness Survey, approximately 16 million Americans have been diagnosed with dry eye disease (DED)—that is conservatively 6.8% of the adult US population.1 This number approaches 30 million when you factor in underdiagnosed individuals.1
In addition, DED negatively impacts nearly all areas of eyecare—from contact lens dropout to surgical outcomes.2 This prevalence and pertinence compelled Dr. Garlich to build a dry eye specialty clinic within her primary practice in the interest of providing premium patient care. She began by adding the necessary pieces of equipment and adjusting her exam schedule to accommodate screening and treatments.
Establishing protocols for dry eye practice
Dr. Garlich notes that, during a comprehensive exam, most optometrists are already observing much of the anatomy that influences dry eye, such as lids, lashes, meibomian glands, and the ocular surface. According to Dr. Garlich, “Optometrists are probably already doing many of these things within their comprehensive exam. It's just about more intentional thinking when looking at these structures instead of quickly breezing past them.”
However, Dr. Garlich opted to add an extra element to all her exams—meibography. She states, “One other major thing that I do for every comprehensive exam is to take meibography images on everyone. At first, I was just saving that for my dry eye workups, but felt I was missing a lot of people.”
Similarly, to assess DED in his practice, Dr. Dierker screens every patient, regardless of their presenting complaint. A Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire can help to identify symptomatic patients, which further triggers a tear osmolarity test. Additional history is obtained, and the lids/ocular surface are assessed with the aid of sodium fluorescein (NaCl) dye.
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Dry Eye Treatment Plan Patient Handout
Download this patient handout (and customize as needed for your practice) to give to dry eye patients to improve patient education and optimize treatment outcomes. Patient handout courtesy of Jaclyn Garlich, OD, FAAO.
An image is worth a thousand words
After adding meibography, Dr. Garlich realized how important having a visual representation proved in patient education and compliance. “Patients really enjoy seeing those images, and it really kind of connects the dots,” she stated.
If you do not offer meibography, Dr. Garlich suggests a slit lamp photograph or even a corneal image taken with an iPhone can serve as a jumping-off point for a conversation. During this talk, she explains how what they are seeing in the image—be it meibomian gland atrophy or Demodex blepharitis—directly relates to their dry eye symptoms.
Experience has proved that patients become much more invested in their care with this visual proof.
Asking dry eye patients the right questions
Along with visual observation, fluorescein staining, and meibography, Dr. Garlich’s standard of care also includes the SPEED questionnaire as part of her practice’s intake forms. However, she understands the fear of overloading and overwhelming patients with paperwork.
If this is a concern, she notes that questions from the SPEED form can be easily incorporated into the preliminary interview. Dr. Garlich asserts that asking the right diagnostic questions is often a matter of specificity.
For example, instead of just inquiring about a patient’s vision in general, she recommends asking targeted questions such as:
- Does your vision fluctuate throughout the day?
- Can you wear your contact lenses for extended periods of time?
- Are your contacts comfortable in general?
- Do your eyes burn or feel scratchy?
Check out the Dry Eye Treatment Plan Patient Handout to improve patient education and outcomes!
Setting up a seamless schedule
Initially, Dr. Garlich attempted to fit a comprehensive exam, dry eye screening, and associated treatment into one visit but realized that was too much for a single slot. Now, during the first visit, she uses screening and imaging to determine if therapy is needed and then schedules a follow-up to administer treatment.
To further make scheduling seamless, Dr. Garlich dedicates a particular day each week to providing in-office dry eye treatments, including punctal plugs, intense pulsed light (IPL), thermal expression, and amniotic membranes. She also makes certain her staff knows that certain time slots are reserved for these therapies.
Time is the biggest barrier for dry eye care
With already challenging patient loads, many practitioners think they simply do not have the time to incorporate dry eye. Dr. Garlich found one of the most time intensive components was properly explaining the triggers and the various treatment options and therapies. To offset this, she recommends utilizing patient handouts.
In addition to saving time, this also increases the chances of patients retaining important information on the things that exacerbate dry eye (e.g., allergies, cosmetics, environment), the various therapies, and tips for success. She requests that newly diagnosed DED patients thoroughly read it before their follow-up exam.
Final thoughts
With more and more patients exhibiting DED, it is only logical that primary care practices should find a way to address dry eye and fit screenings into their comprehensive exam workflow. To do so, optometrists need not reinvent the wheel but find ways to weave the required questions and therapies into already established protocols.
Important points to remember when adding a dry eye clinic include:
- The first step is simply to be more tuned in to dry eye signs during comprehensive exams.
- Images are often the easiest way to make patients accept their condition and comply with treatment recommendations.
- Patient handouts can save valuable time in the exam room.
In closing, Dr. Dierker offered this advice: “You don’t have to start big. You can start small. But, you need to be intentional.”
