To keep your practice on schedule and running smoothly while meeting your patients' dry eye needs, it is imperative to integrate meibomian gland dysfunction (MGD) treatments seamlessly into the daily workflow. The key is establishing powerful protocols and procedures.
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Establish a dry eye team to treat MGD
It all starts with establishing a highly-trained dry eye team. At my practice, the technicians are educated to be both screeners and scribes. Having found the OSDI (Ocular Surface Disease Index) or SPEED (Standard Patient Evaluation of Eye Dryness) questionnaires to be too time-consuming, we begin with a dry eye screening consisting of three chief questions to establish a baseline. However, if your practice employed a platform that would allow questionnaires to be sent and completed as a pre-visit, this would maintain efficiency.
Our practice currently opts to have the technician ask and document the answers to this trio of questions:
- How many times a day do you use artificial tears?
- We ask this, as opposed to “Do you use artificial tears?” to get a quantitative measurement to help gauge the severity of symptoms.
- Do your eyes feel tired?
- Does your vision change throughout the day?
Use accessible language when communicating with patients
We used to inquire, “Does your vision fluctuate throughout the day?” but realized when patients did not understand the meaning of the word “fluctuate,” they would simply answer “no” rather than ask to have it defined. By simplifying the language with straightforward wording, we avoid patient embarrassment and get a more accurate response.
In addition to the initial screening, my staff is empowered to do the following three point-of-care and imaging tests performed on every dry eye consult.
- Tear osmolarity: To assess instability of the tear film and the severity of ocular surface inflammation
- MMP-9 testing of the tear film: Measures matrix metalloproteinase 9, an enzyme involved in promoting inflammatory pathways
- Meibography: To visualize the morphology of meibomian glands and assess their status. The results of the tests are recorded on the patient’s card, which they will be given to refer to later.
Streamline the exam with visuals
Within the exam room are two monitors: one displaying the three screening questions and the other showing the patient’s meibography image. To begin the exam, we go over their history using these visuals and review the black and white “piano key” meibography images, explaining what they mean. Next, after handing the test strips to the patient for reference, I introduce the tear osmolarity and MMP-9 data while clarifying what the red (and lack thereof) means for their diagnosis.
I also perform a thorough slit lamp exam as well as corneal staining, using lissamine green and fluorescein, on every dry eye patient. Once all testing has been completed and analyzed, I design a customized treatment plan. I have found this method to work very efficiently and to add minimal time to the average patient chair time.
Offer on-the-spot treatment for MGD
If I deem a thermal meibomian gland treatment a viable part of their treatment plan, I proceed in one of two ways:
- Offer to do the procedure on the spot, following payment in full.
- Schedule the procedure for a future date.
This decision is dependent on the patient’s schedule and ability to pay and on how full our roster is on the given day. If you can perform a procedure without negatively impacting the clinical flow, do so. This increases the likelihood the patient will actually receive the treatment. Even when a well-meaning patient makes a future appointment, many circumstances and other financial commitments can impede their ability to show up.
Integrate MGD-based treatment protocols
Whether or not the procedure is implemented immediately also depends on the state’s scope of practice rules. In the particular states where I practice—Pennsylvania and New Jersey—intense pulse light therapy (IPL) must be performed by a physician. In addition, IPL is a more time-intensive therapy, making it harder to add to the daily schedule. Therefore, the patient schedules a future appointment to receive this treatment.
“However, with thermal pulsation therapies, in which the technician can take over the procedure at a certain point, we perform the treatment immediately after patient consent.”
The technician guides the patient through the consent form and then escorts them into the treatment area and ensures they are in the correct 45-degree chair position. At this point, I enter, administer the anesthetic drops, place the sterile activators into each eye, tape them into position, and inform the patient I will be handing them off to a very seasoned, knowledgeable technician.
I then leave the room. The technician remains and uses the remaining treatment time while the glands are heated and expressed to educate the patient on the importance of adhering to all the at-home remedies that have been prescribed.
During this time, they emphasize the importance of the sequencing of the different treatments, such as artificial tears, lid scrubs, topical medications, heated microwavable masks, as well as the optimal use of oral omega-3 supplements. This is the perfect time to inform and reinforce, as the patient is a captive audience.
Looking to the future
There are several other procedures we are now reintegrating into our armamentarium and training our staff to perform, including TearCare, BlephEx, Lipiflow, and iLux2. I will see the patient at either the beginning or end of the procedure to bolster confidence and ensure proper administration, and when possible, the treatment will be executed on the spot.
In the end, it is all about achieving the best patient results while keeping the practice running effectively and efficiently. Establishing a highly-trained staff and structured protocols is fundamental.
