Where to start when setting up a dry eye clinic
Providing a clinic or specialised appointment for dry eye can provide several benefits for practices and patients. OT asks suppliers for their tips
04 December 2023
With dry eye on the rise, creating a dry eye clinic or suite of services in practice for patients with this challenge could provide a multitude of benefits.
With this in mind, he suggested: “not having a specialist clinic, or at least dedicated structured appointments for this common condition, is doing the patients and practice a disservice.”
“From a business perspective, adding a dry eye clinic in practice means happier patients, more referrals and reduced contact lens drop-out, with a completely new income stream from appointment and treatment fees, plus new product sales,” he said.
Recognising the potential opportunity is the first step to establishing a clinic, Price shared, followed by seeking assistance through a coach or mentor, “to guide the practice through the exciting adventure of setting it up.”
The practice team should also agree on a structured approach to dry eye and make information about dry eye readily available around the practice to educate patients on the symptoms.
Price noted: “It is surprising how many patients will identify themselves to practice staff, pointing to the information and saying: ‘I think this is me’.”
Assess the patient baseDr Navneet Gupta, professional education lead at Thea, suggested that assessing the potential patient base can be a useful place to start: “We recommend that customers analyse their diaries over a one-to-three-month period to identify what proportion of patients they see presenting with dry eyes.”
Quantifying these figures can help to justify any potential spend, Gupta said as, while most practices will already be equipped to offer a basic dry eye clinic: “Think about the future, because once you start, there could be a snowball effect as patient expectations are enhanced, you may want to consider specialist assessments or equipment.”
Personal levels of confidence and expertise are also key at the early stages, and considering training or upskilling might be beneficial.
“There is so much you can do to help,” Gupta said. “Drill down into the detail of the symptoms that patients are experiencing, and their lifestyle. By taking a more holistic approach, you can understand what it is about that patient that could be making them prone to dry eyes.”
"A thorough investigation and analysis of the ocular surface and tear film can then help to understand the characteristics they have,” he added. “If you can identify the type of dry eye, you can offer a more bespoke treatment and management plan for that patient.”
With the limitations of time available in a sight test, offering a more specific appointment can provide the time and focus to address dry eye fully.
When it comes to stocking treatments and solutions, Gupta recommended: “Practitioners don’t need to be anxious about knowing every product on the market. I think the most important thing is to understand the different dry eye conditions and be confident to recommend the right product(s) for each dry eye condition based on what they have used and seen real results with, and that are backed up by research evidence.”
Proactive questionsMandy Davidson, medical and professional affairs manager at Scope, suggested making a commitment to allow extra time for a dedicated dry eye assessment.
“Patients have often been struggling with symptoms of dry eye for some time before seeking advice,” Davidson said. For some, this might be a mild irritation; for others, there can be a significant impact to quality of life.
“If, as practitioners, we are able to significantly reduce or manage a patient’s symptoms, they will become advocates for not only the dry eye clinic, but the practice overall,” she said.
Achieving buy-in from the practice team is key to promoting the services to patients, with a knowledgeable team of support staff able to handle queries outside of the consulting room or understand when it is appropriate to suggest a clinical assessment.
“I started my dry eye clinics with a slit lamp and a box each of Fluorets and Lissamine Green strips, so I think we could all establish a dry eye clinic with very little financial outlay,” Davidson said.
Addressing dry eye can start with proactive questioning of possible symptoms and observing the patient for signs.
“Dry eye is a real burden for patients. As clinicians we should be on the lookout for tell-tale signs on every person who walks through our doors,” Davidson said.
“Often patients don’t consider symptoms important enough to mention so I believe that it’s vitally important to explore the common symptoms during history and symptoms,” she said, adding that including a few extra investigations during a slit lamp examination can alert practitioners to dry eye.
“We should be using every opportunity to spot signs of dry eye and these observations take only a few extra moments and can be easily assessed before starting a Volk examination.”
Confident conversationsDarren Taylor, optometrist and product training manager at Essilor Instruments UK, also emphasised the importance of developing knowledge around dry eye disease amongst the practice team, through training and CPD.
This can be followed by educating patients to “recognise the signs and symptoms they may be experiencing and understand that there is far more that can be done to manage those symptoms.”
This is also important for encouraging compliance with any dry eye management plan.
“Having confident conversations on dry eye disease with patients, promoting what you can offer on social media and getting other local practitioners such as GPs and pharmacists on board with the services and products you have at your disposal in practice is a wonderful way to start,” Taylor shared.
He noted the value of questionnaires in getting patients to “stop and think about the symptoms they might be experiencing,” and screening services, either as part of the pre-testing stage, or within the examination room.
The anterior eye
Nick Atkins of Positive Impact suggested it is key to foster “a desire and interest in helping patients complaining of even the mildest of symptoms.”
“I think the anterior eye is often seen as far less worthy of attention than the posterior eye. There is more of a focus on visual degradation due to retinal pathology, often to the detriment of the importance of the eyes’ primary refracting surfaces, the tear film, and corneal surface.”
For those at the start of their dry eye service journey, Atkins said, “simply expanding the portfolio of options they can offer patients to self-manage their condition is a step in the right direction.”
Atkins also flagged the importance of objective measures, sharing that if a practice wants to go to the “next level... accurate diagnosis is the key.”
“Dry eye is an inflammatory disease defined by a hyperosmolar tear film. Clearly being able to measure ocular surface inflammation and the osmolarity of the tear will be beneficial in ruling in and ruling out dry eye disease.”
The impact of dry eye
Davidson: Dry eye can have a profound effect on a patient’s quality of life, both physically and mentally making day-to-day activities impossible.
A 2021 study from the Netherlands concluded that the impact on mental health is greater if dry eye is undiagnosed, underlining the importance of clinicians proactively taking steps to address the symptoms of dry eye and make a difference to those whose lives are disrupted by dry eye disease.
Taylor: Dry eye disease can be massively debilitating to many different demographics of patients. It is up to us as professionals to educate, assess and offer the best management for our patients to keep their eyes healthy and comfortable.
Price: Dry eye disease has a significant impact on patients’ daily activities and work productivity, highlighting the broader socio-economic impact of self-reported dry eye disease.
Results of a European-wide survey involving 12,000 subjects, reported in the British Medical Journal this year, demonstrate that self-reported dry eye disease constitutes a significant burden on patients, specifically on their functional vision and overall health status.
Atkins: Chronic dry eye is a debilitating, progressive disease that causes many patients great distress and so it is an essential duty of care for optometrists to investigate and manage even the earliest of symptoms.
Gupta: Dry eye should not be underestimated. Everyone should remember that the tear film is the first surface that starts to focus light. If you haven’t got a decent tear film, we should automatically assume that is going to affect someone’s vision. Imagine having to walk around in a blur, even intermittently – that will have an impact.
Resource corner: top tips, tools and tech from our contributors
Scope: education hub, CSR and wellbeing
The Scope Education Hub is free to register and provides on-demand educational resources for clinicians. The company also provides a one day ‘Dry Eye Clinic Masterclass’ course or in-practice skills training for practitioners who want to establish a dry eye clinic.
As part of its corporate social responsibility, Scope also provides free education, support and advice for patients. This includes an annual Patient Wellbeing Webinar delivered each July to mark Dry Eye Awareness Month. Recordings are available on YouTube.
Davidson said: “In collaboration with healthcare professionals, we aim to empower and equip patients with the tools and knowledge that they need to bridge the gap between the diagnosis and management recommendations for dry eye disease.”
Essilor: data capture and tech
Essilor recommends making use of modern technology as part of a dry eye service, such as camera-based diagnostic tools.
Essilor’s Idra can quickly and accurately capture data on tear film instability and provide this in metrics that patients can understand. This can help to streamline the process of capturing diagnostic data to form a management plan.
The company has created an accompanying smart phone app for the Idra, which enables patients to monitor their symptoms at home.
Devices such as the Activa heat and massage mask and Tearstim IRPL device can then support management for evaporative dry eye conditions.
Body Doctor: research, professional bodies, and mentoring
Price described the report from the Tear Film and Ocular Surface Dry Eye Workshop II (TFOS DEWS II) as “weighty in terms of quantity and quality of information and its impact but still rightly remains the reference report.”
Industry and professional bodies are good sources of information and education, while Price also offers support for setting up clinics and service, including The Dry Eye Toolkit.
“I know it can seem overwhelming to consider what is needed, but the good news is that every piece of equipment to start [offering dry eye management] is almost certainly already in the practice,” he said.
Positive Impact: blogs and patient information
Earlier this year, Positive Impact relaunched its patient-facing website, ensuring patients can conveniently access dry eye products, while still supporting their independent practice.
The website also hosts patient information, while blogs are regularly added as new information becomes available.
Atkins pointed to the InflammaDry test and new ScoutPro portable osmolarity measuring device from Trukera Medical (formerly TearLab) for accurate and actionable data.
"For me, the future is about practitioners taking back control of their patient’s treatment and offering services such as punctum plugging, lid-cleaning with devices such as BlephEx, meibomian gland expression, and intense pulse light therapy,” he said.
Thea: patient resources, webinars and support programmes
Thea hosts a patient-centric website with information about dry eye and products. The website aims to provide simple explanations so that practitioners can signpost their patients to the site.
The Thea Academy provides education and CPD. Recent webinars include a session on menopause and dry eye, and another by optometrist Sarah Farrant discussing the management of dry eye.
The company also provides a dry eye scheme for customers considering establishing a dry eye clinic, which provides a step-by-step programme of support, modelling and marketing.
“It goes through the whole journey of thinking about it, to implementing a dry eye clinic in practice,” Gupta said.
When considering what to stock in the practice inventory, Gupta recommended looking at the different dry eye conditions: “If you’re concerned about aqueous deficiency, something like the Thealoz Duo offers the key ingredients sodium hyaluronate to lubricate the ocular surface, and Trehalose which has both bioprotection and osmoprotection properties.”
“For evaporative dry eye, if patients have got signs of reduced tear break-up time and lipid deficiency, then it’s great to arm yourself with lipid-based products to cover that. TheaLipid is a great solution for replenishing that lipid layer,” he added.
If treatment of the eye lids or meibomian glands might be beneficial, the Blepha Clean and the Blehpa EyeBag, could be useful tools in the armamentarium, while the Blephasteam device can offer an alternative treatment option for more stubborn meibomian gland dysfunction.
The lowdown on dry eye
OT and the AOP have released new resources around dry eye disease, including education and guidance.
In November, OT launched new interactive CPD with Dr Sònia Travé Huarte, titled Dry eye disease: diagnosis, subclassification and management.
The video showcases a university dry eye clinic in action, demonstrating how to investigate and diagnose dry eye disease, and how to educate and treat patients.
After watching the video, participants must answer six multiple choice questions before taking part in a discussion on OT’s dedicated LinkedIn page.
Find out more through OT’s Education Library.
The AOP has also recently released new guidance on the use of amniotic membranes (AM) to manage dry eye disease in practice.
While AM transplantation has traditionally been administered by ophthalmologists in theatre, a CE-marked product now available in the UK means this can be applied in outpatient settings.
Practitioners are required to undergo training with the manufacturer for authorisation to use the treatment.
More details on AM can be found in the AOP’s guidance, along with indications and contraindications for use, and advice on obtaining consent.