1. Eric Botts, OD drvision@claimdoctor.net

2. Disclosures I am a member of Speakers Bureau for Valeant(B&L) and Allergan but have no financial interest in them. I am the owner of OBC Billing Specialists.

3. WHY DRY EYE?? 25 million people have dry eye 40% have no complaints Existing patients in your practice Better care equals loyal patients Huge return on investment

4. What is Dry Eye Disease? Dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface The Ocular Surface / April 2007, Vol. 5, No. 2 / www.theocularsurface.com

5. Two Types of Dry Eye Aqueous Deficient dry eye is a disorder in which the lacrimal glands fail to produce enough of the watery component of tears to maintain a healthy eye surface Evaporative dry eye may result from inflammation of the meibomian glands. These glands make the lipid of tears that slows evaporation and keeps the tears stable * The National Eye Institute (NEI)

6. What do we call it? Dry Eye Syndrome Keratoconjunctivitis Sicca Tear Film Insufficiency Dry Eye Disease Chronic Dry Eye Does it really matter?????

7. The key features of dry eye are: Decreased tear production Increased tear evaporation Incorrect composition of tears

8. Dry Eye in a Corporate Office What tools do you need How to communicate with your patient Turn key implementation in 3 steps

9. IMPLEMENT IN 3 STEPS 1. Identify 2. Diagnose 3. Treat

10. Protocol Required to Identify Set your protocol Required for lab tests (Tearlab and Inflammadry) Examples: If a patient scores above 13 on OSDI then perform Tearlab and/or Inflammadry If Keratograph 5M NIKBUT is level 1 or 2 then perform Tearlab and/or Inflammadry If patient is female above age 50 or male above 65 perform Tearlab and/or Inflammadry

11. Identify OSDI Ocular Surface Disease Index Keratograph 5M Over 35 female, over 50 male, contact lens wearer Certain medical conditions, including diabetes, rheumatoid arthritis, lupus, scleroderma, Sjogren's syndrome, thyroid disorders and vitamin A deficiency Certain medications, including antihistamines, decongestants, hormone replacement therapy, antidepressants, and drugs for high blood pressure, acne, birth control and Parkinson's disease

12. OSDI Questionnaire This 12-item questionnaire asks patients to grade and describe their ocular symptoms over a 2 to 4 week period prior to the visit. TEST is Self-administered. The booklet is given to the patient and they are asked to fill in the answers to the best of their ability. The 12 items are graded on a scale of 0 to 4. 0 is none of the time, 1 is some of the time, 2 is half of the time, 3 is most of the time and 4 is all of the time. Scoring: The OSDI score = sum of the scores for all questions answered x 100 total number of questions answered x4 The scale is from 1 to 100, with higher scores representing greater disability.

13. Scoring OSDI* 13-22 Mild and/or Episodic 23-32 Moderate, Episodic or Chronic 33-62 Severe, Frequent or Constant 63-100 Severe and/or Constant Download the APP on your smartphone *Verusa P, Profazio V, Campos EC, Performance of Tearlab Osmolarity compared to Previous Diagnostic Tests for Dry Eye Research 2010; 35(7):553-564

14. Keratograph 5M NIKBUT Meibography Tear Meniscus height Blinking rate and quality Eye redness

15. Diagnose TearLab Inflammadry Keratograph 5M Slitlamp examination Lissamine green Phenol Red Thread Test 40-50% of dry eye patients are ASYMPTOMATIC

16. What are the common complaints of Dry Eye sufferers? Excessive Tearing Gritty Feeling Tired Eyes Blurry Vision When the ocular surface is damaged or the tear film is unstable, optical quality of patient’s vision is affected* *Rolando M, Zierhut M. The Ocular Surface and Tear Film and their Dysfunction in Dry Eye Disease

17. DRY EYE Procedure Codes 92285- Keratograph/External Ocular Photography 92071- Fitting of Contact Lens for Treatment of Ocular Disease 68761- Closure of Lacrimal Punctum by Plug Initial Office Visit 92004/92014/99204/99214/99203 Follow up office visits 92012 or 99213

18. TearLab for Dry Eye Measurements >300 mOsm/L demonstrate loss of homeostasis A difference between eyes of 8 mOsm/L or greater indicates instability of the tear film and is a hallmark of dry eye disease

19. Scoring Tearlab MILD >295 mOsm/l MODERATE >317 mOsm/l SEVERE >330 mOsm/l

20. Inflammadry Test that detects elevated levels of MMP-9, an inflammatory marker that is consistently elevated in the tears of patients with dry eye disease

21. Non-Invasive Tear Break Up Time NIKBUT

22. Meibography

23. Corneal Evaluation

24. Phenol Red Thread Test The thread is yellow in color (acidic) and when it comes in contact with tears it changes to a light red color. No topical anesthetic is used. Insert the 3 mm folded portion of the thread into the palpebral conjunctiva of the eye 1/3 of the distance from the lateral canthus of the lower eye lid. After 15 seconds, the thread is removed and the entire wet (Red) portion is measured. A reading of less than 10 mm indicate dry eyes, less than 20 mm marginally dry eyes, and more than 20 mm normal tear volume.

25. Lissamine Green Stain

26. Lid Wiper Epitheliopathy Increased friction between conjunctiva and ocular surface Caused by reduced tear film

27. Lid Wiper Epitheliopathy What Is Lid Wiper Epitheliopathy? Varikooty et al, 2006; Varikooty et al, 2008; Varikooty et al, 2015

28. Treatment Omega 3 Artificial Tears, Gels and Ointments Restasis Punctal Plugs Topical Steroids Doxycycline/oral meds Bruder Mask/Lid Hygiene Lid Margin Debridement Lipiflow

29. Omega 3 Source in Diet Fish- Salmon, Halibut, Sardines, Tuna Eggs, Walnuts, Peanut Butter, Flaxseed, Pumpkin seeds Omega 3 Fortified Milk, Bread, Yogurt, Juice, Margarine

30. Omega 3 Supplements No more then 2000 mg per day Omega 3 1000mg per 100 lbs body weight Take with a meal, especially fatty meal with olive oil, yogurt, eggs Krill Oil versus Fish Oil Undecided, Krill oil breaks down in digestive system much faster so fish oil may be better absorbed then Krill oil CAUTION: May Cause Excessive Bleeding, check with MD if taking Coumadin, Warfarin etc

31. Artificial Tears, Gels, Ung

32. Restasis RX BID OU Increases tear production Use 3 Months before improvement occurs My Tears, My Rewards reduces cost

33. Punctal Plugs Permanent Silicone Temporary Collagen 1 WEEK 90 Day 180 Day

34. Topical Steroids Loteprednol(Lotemax) Fewer side affects Prednisolone Flourometholone Especially effective in combination with Restasis

35. Oral Antibiotics Doxycycline 50 mg Bid x 30-60 days Zithromycin (Z-Pak) 2 tablets first day, then 1 tablet x 4 days

36. Hot compresses Bruder mask 10-20 minutes twice a day

37. Lid Hygiene Lid Scrubs Cleansers Use 2-3 times per day

38. Corneal Debridement Apply lissamine green dye and use a lateral motion with the golf club spud along the line of Marx to remove the stained cells Bleph-X

39. Lipiflow LipiFlow utilizes a patented algorithm of precise heat applied to the inner eyelids and directed gentle massage to remove blockages from the meibomian glands

40. 66 YO Female Complains of dry and burning eyes Crossword puzzles and Facebook 2 hours a day

41. Identify Perform Questionnaire, Tearlab, NIKBUT per protocol

42. Diagnose OSDI- 29 Tearlab- OD 332 OS 321 Keratograph NIKBUT- OD 2 OS 2 Moderate to Severe Keratoconjunctivitis Sicca

43. Treatment Mod-Severe Omega 3- 1000mg per hundred lbs body weight Non-Preserved Artificial Tears every 2 hours Positive Inflammadry- RX Restasis Negative Inflammadry- Insert Punctal Plug and/or RX Restasis RTC 1 month Punctal Plug follow up or 3 month follow up for Restasis

44. 1-3 Month Follow Up Improved No Improvement Repeat Tearlab, Inflammadry and Keratograph NIKBUT Tearlab- OD 304 OS 302 Inflammadry- neg OU NIKBUT- OD 1 OS 0 Continue current treatment plan and monitor 6 months Repeat Tearlab, Inflammadry and Keratograph NIKBUT Tearlab- OD 333 OS 327 Inflammadry- + OU NIKBUT- OD 2 OS 2 Test for Sjogrens’s Add Corticosteroid and Restasis Monitor 3 months

45. Patient Education Explain chronic nature of Dry Eye Disease Excessive tearing is symptom of dry eye Importance of Compliance Prevent corneal damage associated with severe Dry Eye Disease Set reasonable expectations for treatment plan Restasis requires 1-3 months to become effective with full compliance

46. 54 YO Male Complains of tired eyes Occasional crusting on lashes Works on laptop 3 hours a day and drives 2-4 hours a day as a salesman

47. Identify Perform Questionnaire, Tearlab, NIKBUT per protocol

48. Diagnosis OSDI- 27 Slitlamp Examination- Meibomianitis OU, Mild Corneal Staining OU Tearlab- OD 314 OS 318 Keratograph NIKBUT- OD 1 OS 1 Moderate Meibomian Gland Disease and Mild Keratoconjunctivitis Sicca

49. Treatment for Dry Eye associated with Meibomian Gland Disease Omega 3- 1000mg per hundred lbs body weight Bruder Mask BID x 10-20 minutes 50 mg Doxycyline BID x 60 days Educate patient on lid hygiene RTC 1 month to monitor

50. 1 Month Follow Up Improved No Improvement Repeat Tearlab, Inflammadry and Keratograph NIKBUT Tearlab- OD 301 OS 298 Inflammadry- neg OU NIKBUT- OD 1 OS 0 Continue current treatment and Monitor 3 months Repeat Tearlab, Inflammadry and Keratograph NIKBUT Tearlab- OD 319 OS 321 Inflammadry- + OU NIKBUT- OD 2 OS 2 Lid debridement and gland expression Continue Doxycycline RTC 1 month to monitor Lipiflow if available

51. 36 YO Female Contact lens wearer Complains of contacts being uncomfortable Has been fit in different brands Works on computer 6 hours a day

52. Identify Ask clarifying questions about chief complaint of uncomfortable contacts Since patient did not meet protocol for Tearlab, doctor now orders Keratograph and Tearlab to be performed

53. Diagnosis Tearlab OD 304 OS 314 Keratograph NIKBUT OD 1 OS 1 +1 injection OU Minimal corneal staining Mild Keratoconjunctivitis Sicca

54. Treatment Mild Omega 3- 1000mg per hundred lbs body weight Rewetting drops PRN but specifically when working up close Discuss/refit daily disposable contacts Educate patient on chronic Dry Eye Disease associated with contact lens drop out RTC 2 weeks Dry Eye follow-up

55. 2 Week Follow Up Asymptomatic No Improvement Continue current treatment RTC 6 months to monitor Repeat Tearlab and Keratograph, order Inflammadry Positive Inflammadry then RX Restasis RTC 3 mo to monitor Negative Inflammadry then consider Punctal Plugs and/or Restasis RTC 1 mo to monitor

56. What is the First Step? Develop Protocol for Lab Tests Use Questionnaire to identify Invest in Keratograph 5M Apply for CLIA waiver Order Tearlab Order Inflammadry Order Lissamine Green

57. I came, I saw, I conquered

58. Eric Botts, OD drvision@claimdoctor.net