The Technician Side of The Dry Eye Workup Bruce H. Koffler, M.D. Lindsay Koffler Cassidy, COT, OSC

Overview of Dry Eye Institute Ocular surface disease patients can be very time consuming. You must have a streamlined system and work as a team in order to effectively run a dry eye institute. Consider new ways to test dry eyes Be ready to implement testing, patient education, handouts materials and patient flow Everyone must know each others roles and all roles are valued! Technicians role is to provide the doctors with the most information you can to easily asses the patients level and causes of dry eye. Use your time wisely and control the workup

The Basics Dry eye surfaces when the eye does not produce tear properly or when the tears are not of the correct consistency and evaporate to quickly.

Signs and Symptoms Key signs and symptoms include; Stinging Burning Foreign body sensation Pain and redness Contact lens discomfort and intolence Discomfort when reading or using the computer

How To Distinguish a Dry Eye Patient Dry eye presents in many different ways. Many environmental factors are also key and technical staff should always keep them in mind. Living in an area known for high or low humidity Living in places with high levels of allergens Using a ceiling fan at night Traveling more than twice a month (esp. by plane) Getting less than seven hours of sleep at night Using a computer/ tablet or reading for more than an hour a day

Additional Environmental Factors Demographics and gender also are high risk factors for dry eye. Women always more at risk than men Hormone fluctuation (including pregnancy) Menopause (pre and post) Over 40 years old Tobacco users

Lifestyle Considerations Does the patient drink more than three glasses of water a day How many servings of fish do they eat each week

Medication lists Obtain a complete list of medications. Current and maybe even past medications may be useful. Pay special attention to antihistamines, antidepressants, Beta blockers and hormone replacement therapies and GI meds. * special attention should be taken if the patient is currently being treated with any form of radiation therapy or has been in the past. Note any Omega 3 daily supplements Does the patient use a C-Pap machine at night

Surgeries All surgeries should be noted; LASIK PRK Cataract Surgery Corneal Transplants All these surgeries have high correlation to dry eye!!!

Following up Dry eye patients should generally be followed every three to six months to assess their progress Commonly treatments and medications are altered monthly by their PCP or Ophthalmologist Important to keep a list of patients with common symptoms flagged so you can let them know when new treatments are available

Get Involved!!!! Counsel patients who have high risk factors. Many dry eye symptoms can be controlled with proper hygiene. Show patient how to use products. Don’t assume that the can just figure it out. Think about possibly selling certain products that the staff has tested and likes. This improves patient compliance.

The Right Questions To Ask Your approach to the dry eye patient must be very different from the normal patient. Dry eye can be very debilitating. It can cause long term symptoms of filmy and blurry vision, foreign body sensation (maybe severe), pain in the eye and even photophobia. Listen to patients. Compassion is key to these workups.

Conversation Starters Questionnaires; Duration, Onset, Diet, Environment, Symptoms, and Diet. How long have symptoms been present? What is the frequency of symptoms? What time of the day are symptoms the worst? Does anything give relief? (tears, closing eyes, WC) Do you wake up with these symptoms Do you get a sharp pain in the middle of the night or early morning when opening you eyes? Do you use a ceiling fan or humidifier? Do you suffer from allergies?

Considerations Has the patient experienced any new lifestyle changes? (moved, death in family, stress at work) Patients that have more than one diagnosis may need to be treated first for primary diagnosis. (RCE and Dry Eye) Don’t forget some dry eye symptoms can mimic allergic conjunctivitis especially in a long allergy season. These patients will complain of itching as their #1 complaint!!!!

Dry eye Contributors Past surgeries( LASIK, Cataract, DSEK, PKP, PRK) can all result in temporary dry eye. Medications Antihistamines Diuretics Antidepressants You should counsel these patients on how these drugs contribute to dry eye *** Even Glaucoma drops can cause dry eye!!!!!!

Contact Lenses and Dry Eye Questions to ask; wearing schedule, type and brand of lens, solutions being used (never use generics!!!) Preservatives, BAK, Thimerosal We have seen numerous corneal inflammatory events in our clinic due to misuse of contacts and solutions!!! In some severe cases we will use contact lenses for treatment. Bandage Contacts Scleral lenses with or without autologus serum

Systemic Diseases That Cause Dry Eye Thyroid Disease (Neurotrophic Keratitis) Diabetes (NK) Rheumatoid Arthritis (NK) Psoriasis (MGD) Rosacea (MGD) Unless the doctor manages the systemic disease the dry eye manifestation will rarely fully resolve.

Useful Dry Eye ICD 10 Codes Blepharitis H01.0 Chalazion H00.1 Hordeolum H00.0 Allergic Conjunctivitis H10.1 Corneal Dystrophy H18.5 Corneal Edema H18.20 Corneal Erosion H18.83 Diabetes Mellitus E11.9 Dry Eye H04.12 Epiphora H04.20 Keratitis H16.10 Keratoconjunctitis Sicca H16.22 Keratoconjunctitis Sjogrens M35.01 Punctate Keratitis H16.14 Rosacea L71.9 Trichiasis H02.05

Pretesting Crucial to evaluate general eye motions. Evaluate the patients blink. blink rate and completeness of blink Many patients complain of headaches as well as dry eye If patient desires a new glass prescription keep in mind that it is very difficult to refract a dry eye patient You will have a much higher success rate if you wait to refract at follow up visits when the surface is more stable!!!

Is This Truly Dry Eye Symptoms of “dry eye” can also be related to eye alignment.(burning, aching, stinging, tearing, grittiness, and irritation.we have had several patients who have complained of these symptoms but their testing was all normal. Many of these patients had been on years of dry eye therapies and we found their symptoms were alleviated by using a small amount of BI prism in their glasses. Symptoms would resolve almost immediately.

When Should The Testing Start Depending on the doctor technicians may play a very active role in patient testing. Do not diagnose the patient!!!! That is the doctor’s role In our clinic it is common for technicians to perform corneal topography, osmolarity readings and Schirmer’s tear testing when appropriate. Note: if you do not feel comfortable completing a task, always ask a fellow staff member or the doctor to explain the testing further. Everyone has to learn the first time around!!!!

Testing Continued After pre-testing the next step is for the doctor to see patient. Technicians are vital in performing further testing as ordered. Tear Meniscus Height assessment Osmolarity readings Fluorecein dye/ lissamine green dye Tear file break-up time Meibomian gland expression Schirmer’s tear testing or Phenol red thread testing Topography or wavefront testing Note: none of this testing can be done after checking IOP or instilling a drop of any kind. Take care not to compromise the results of testing!!!!!

Fun Dry Eye Equipment

Treatments You should be comfortable with the various options in treating dry eye that can range for OTC tears to prescription medications. Treatments may not be limited to drops, may include Omega-3 supplements and short term oral antibiotics Make sure to demonstrate punctal occlusion especially when patient will be using steroid drops!!!! Environmental; discontinuing ceiling fan use, lowering height of computer monitors, blink exercises, stopping antihistamines short term Increase water consumption!!!

Technicians Take Over Make sure to review doctor’s instructions This will reduce call backs!!! Be detailed Let patient know this is ocular surface disease and although chronic it can be well managed, and that you and the doctor will watch them closely. Remind them this is an “itis” (blepharitis, keratoconjunctivitis sicca) like arthritis these conditions will not go away and they may have flare ups in the future. These are inflammatory responses of the eye. You want to prepare them for future expectations. Show patients how to use warm compresses and lid scrubs effectively. As well as how to instill drops correctly. Take time to explain tapering medications correctly such as steroids.

Technician Take Over Continued Instruct patients to call if they become sensitive to any therapies. Antibiotics commonly cause symptoms of nausea, vomiting, and dizziness. Tell them to call right away if they experience any of these side effects. Remember knowledge and education are key in allowing you to develop into a more cohesive unit in you clinic. Ask your doctors with help in opportunities to further your education (shadow experienced staff in another office for example, Lunch and Learn’s internally). We love to share our knowledge and experiences!!! Technicians are essential in the dry eye clinic. Without an efficient and knowledgeable team a dry eye clinic can be time consuming frustrating. A dedicated team makes the clinic enjoyable and the patients reap the rewards!!!!!!!!!!!!

Thank you !!!!!