The discussion

Dealing with dry eye in-house

As patients increasingly present with the symptoms of dry eye, OT  speaks to two practice owners about why and how they have established dry eye clinics

Raviv Sohal conducting a sight test

Patients presenting with dry eye is nothing new for practitioners. However, the frequency at which patients step through the threshold of the testing room with dry eye symptoms has risen in recent years, optometrists Ravi Sohal and Michael O’Kane agree.

This increase can be attributed to a growing ageing population, lifestyle changes, work environments and a love of screen use, they explain.

“Patients who suffer from dry eyes have been around for a long time, but historically they would have been sent off with hypromellose eye drops,” independent practice owner Mr Sohal, told OT.

Yet as education, understanding and treatment options have improved, Mr Sohal (pictured above) and Mr O’Kane felt they had the armory required to treat the condition through a specialised in-practice service.

Offering appointments

Mr Sohal introduced dry eye appointments at Blackheath Eyecare Opticians around 12 months ago because when a patient presented with dry eye symptoms, he felt more time was required to perform additional tests and communicate the findings.

“Diagnosing and then explaining the possible reasons for a patient’s dry eye and setting a personalised treatment plan can not be done properly at the end of the sight test,” he highlighted. 

While the practice does not have a dry eye clinic per se, patients are welcome to book a dry eye appointment any day of the week.

A dry eye appointment at Blackheath Eyecare Opticians costs £60, with an initial appointment lasting 40 minutes and includes tuition with support staff to ensure patients know how to use the prescribed products appropriately.

Treatments offered range from over-the-counter eye drops, eye masks, lid care products and BlephEx. However, “we will consider adding other treatments in time,” Mr Sohal confirmed.

Discussing the logistics of introducing dry eye appointments, Mr Sohal’s requirements were minimal because the practice was already accustomed to offering specialised optometry services, including PEARS, a pediatric referral service and complex contact lens fittings, he explained. However: “It needed a bit of thought as to the diagnostic tests that we would perform and how best to communicate the results,” he said.

The optometrist highlighted that staff required additional training, but pointed out that many companies that provide dry eye products offer this and his practice was assisted by Scope Ophthalmics.

"The satisfaction I had from realising that she in fact had three concurrent issues really made my day. By treating all three of her issues, she was finally symptom free"

Establishing a clinic

For Mr O’Kane, the establishment of a dry eye clinic at Specsavers Morningside where he is the director was very organic, before being officially established in 2017 when the store underwent a refurbishment and expansion. 

The expansion meant that a further 75 appointments would be available at the practice every week. Concerned that if he did not plan ahead he could have empty clinic space on his hands, Mr O’Kane began to think about how he could “ensure the investment bore fruit from the get go.”

“With the expansion planned I knew that I wanted to diversify my practice’s offering by providing the clinical services that I have always had a passion for personally – dry eye, minor ailments, ortho-k and paediatrics,” Mr O’Kane shared.

Running a practice in an area with a large over-60s population, Mr O’Kane was no stranger to patients presenting with the symptoms of dry eye. In fact, the establishment of the clinic stemmed from his experience with a patient who developed very dry eyes. “She was unresponsive to almost everything I or the GP suggested on a basic level,” Mr O’Kane explained, “so eventually I booked her in for a separate 45-minute appointment and went to town investigating her eyes. I assessed lid wiper epitheliopathy, Schirmer, FTBUT, naso-lacrimal drainage, I did McMonnies and the OSDI questionnaires, and really looked at her meibomian glands and discussed her environment and lack of humidity.”

The clinical satisfaction that Mr O’Kane got from resolving the patient’s dry eyes played a pivotal role in the establishment of the clinic. “The satisfaction I had from realising that she in fact had three concurrent issues really made my day. By treating all three of her issues, she was finally symptom free,” he said.

However, establishing the clinic officially took time and effort, Mr O’Kane admitted. “It involves patient education and introducing the conversation, which affects test times. It also means reshuffling rotas so that you don’t have too many staff on when there’s no chance of a spectacle conversion, as well as ensuring your front of house team is able to discuss the topic in an educated fashion.”

To prepare, he gained his ocular therapeutics certificate from Glasgow Caledonian University and purchased a range of equipment, including a tear lab osmolarity machine, an Oculus Keratograph 5M, a video slit lamp and a BlephEx machine. He also developed his ownn patient information leaflets.

From a clinical perspective, Mr O’Kane also spent time formulating an effective methodology of investigation. “This is important as you need to get all your results in the least invasive/condition altering manner possible so that you get a true idea of the ocular condition, without impacting the results of the next test you want to do,” he said.

The practice offers an enhanced clinical assessment prices at £35 to ascertain the cause of the dry eye, along with an itemize pricing structure of individual treatments. It also offers a better value option of set at three itemised tiers – standard (£55), gold (£115) and platinum (£195). During autumn/winter the practice runs around 20–25 appointments a month, with this reducing to between five and 10 in the spring/summer.

During the busier winter months, Mr O’Kane (pictured below) assigns a weekly dry eye clinic day, which he can promote to patients. In less busy months, patients can book a dry eye appointment for any given day, but this is capped at two a day to ensure he has variety in the clinic and that it does not affect the retail element of the business.

Michael O'Kane

Business benefits

For practice owner Mr Sohal, introducing dry eye appointments has provided the business with an additional revenue stream outside of the standard eye exam and contact lens aftercare appointments offered. He has also observed that many patients go on to join an appropriate membership scheme, “which often leads to sale of glasses and contact lenses.” 

Revealing a perhaps unexpected benefit to introducing dry eye appointments, Mr Sohal shared: “It has definitely helped our contact lens patients who would have otherwise dropped out of wearing lenses.” 

“The practice is now getting busier from recommendations from existing patients who have used the service, as well as other health care professionals,” he added.

Since establishing the clinic, Mr O’Kane acknowledges increased patient loyalty, improved professional reputation and boosted word of mouth recommendations.

Expanding on the professional reputation viewpoint, Mr O’Kane shared: “I believe that it provides a better recognition of the professional’s time and enhances the patient’s perception and value of optometry. When you do need to refer, the quality of your referral is above most of your colleagues if you can include all your findings and images, and it helps to justify why a consultant should see your patient.”

Patient benefits

Mr O’Kane feels practitioners should consider offering dry eye appointments as it enables patients’ needs to be addressed, and treating the cause rather than the symptoms is key.

“It’s tempting to treat all dry eyes the same and reiterate the generic advice of ‘Hypromellose four times a day and Lacrilube at night. Drink plenty of water and try to remember to blink.’ And while 80% of your patients’ symptoms can be rectified by this advice, rarely will you rectify their underlying problem that’s causing their symptoms,” he explained. 

“Identify the source and hopefully you can eliminate it,” he stressed. 

Encouraging practitioners to consider offering a specialist clinic in their practice, Mr Sohal concluded: “A significant portion of our patients will experience dry eye at some point in their lives. If practices are interested in expanding their optometry services then offering a dry eye service is essential to look after them.”