My practice journey

Bundling or packaging products and services along with thorough patient education are strategies that can help you get started with comprehensively treating DED in your practice. (Image credit: Adobe Stock Photo/Ikonoklast_hh)

Whether you’re a recent graduate or have been practicing for 20-plus years, it’s not difficult to see that dry eye disease (DED) is one of, if not the, most prevalent condition affecting our patients today. Essentially, it is its own epidemic—49 million Americans with dry eyes is a pretty big deal.¹ The days of simply adjusting medication regimens and putting “Band-Aids” on a chronic condition have long passed. Although DED is nothing new, our understanding of its intricacies and how we approach treatment have changed drastically over time.

Exhausted with the seemingly never-ending cycle of prescription, follow-up, medication adjustment, follow-up, new medication addition, follow-up, and so on—all while my patients were suffering, frustrated, and searching for something more than a temporary fix—we (myself and my lifelong partner, Dr Leah Ramos) decided to go all in on hitting dry eye at its core. In doing so, we removed ourselves from primary care and dedicated close to half of our office space specifically to the diagnosis and treatment
of DED as a step toward addressing this massive need.

An early turning point was when we partnered with Lumenis—which currently has the only FDA-approved intense pulsed light device for meibomian gland dysfunction, the leading cause of DED—and committed to bring the company’s technology into our practice. We were one of the first practices in our area to implement the device, and now, years later, that one decision has blossomed into an entire med spa. This was not as much our brainchild as it was born out of demand—our patients’ demand for something they could not find elsewhere: relief. Something that would address the root cause of this often life-altering condition.

A practice within a practice

To implement a full-service DED approach, we had to create a practice within a practice, and that requires different processes, protocols, and conversations than that of a “routine” exam experience. We are not just asking, “How do your eyes feel?” We’re deep diving into their diet, nutrition, makeup habits, skin care routine, systemic health, medications, sleeping patterns—because all these things can have an impact on the meibomian glands, the health of which is a primary driver of ocular surface disease.2

When patients come in for a general, comprehensive eye exam and are identified as having DED or gland loss through meibography (all patients have meibography as part of our standard work-up), they are referred to Dr Ramos and me in our DED clinic. That is where we have the opportunity to dig deep into their history. We learn it all, including their past successes and their failures. Studies have shown that more than 80% of patients are unhappy with their current dry eye treatment and that it takes an average of 3.² visits to different offices before they find relief.^3,4 Our clinic is often the place people come when they have exhausted all the other options.

Before the advanced interventions and procedures come into play, we have our foundational therapies: improving nutrition, supporting the immune system, and providing the body what it needs to function at an optimal level. An important part of those foundational treatments is HydroEye (ScienceBased Health) with its unique anti-inflammatory fatty acid, γ-linolenic acid (GLA). This evidence-based supplement is included in every DED treatment package we offer.

Nutrition is a huge part of restoring homeostasis to the ocular surface. We’ve done the research, reviewed the data, and tried a wide variety of ω fatty acid–containing products. Yet we keep coming back to GLA as being probably one of the most important things we can put in our bodies—in balance with docosahexaenoic acid and eicosapentaenoic acid—to support corneal and overall health. We often tell our patients that we can do all these in-office procedures to reduce inflammation and improve oil quality, which will make them feel better, but if they’re not putting in their body what these glands need to function at peak levels, then we are going to be stuck in this vicious cycle for a long time.

GLA, which isn’t in our diets at any meaningful level, has been found to stimulate tear production and reduce inflammation in many types of patients with ocular surface disease.^5-11 HydroEye’s formula has been shown to improve symptoms, suppress inflammation, and maintain corneal smoothness in a randomized, controlled clinical trial in postmenopausal women.¹¹

We stress the importance of their home therapy, with the nutraceutical being a crucial component of the puzzle. I tell patients every day that home therapy is really the most important part of the treatment process. Anecdotally, we see a direct correlation between consistency in home therapy and the longevity of results from advanced treatments that are provided in the office.

A successful process

Oftentimes, doctors are so busy they find themselves dabbling in DED, so that part of their practice never really takes off. Along with some like-minded colleagues, we began an advising group that focuses exclusively on implementing ocular surface disease and aesthetics services into existing offices. Why? We talk to doctors across the country who invest significant amounts of money, sometimes $120,000 or more, on a device and then call us 6 months later and say, “We have done 3 treatments in the past 6 months and are losing money on this investment.” That is painful to hear when we know they could be doing 5 to 10 treatments a day.

We are on the front lines and understand the chaos that comes with running a practice. We also understand the excitement that comes with bringing new technology into a practice. There are a lot of logistics involved, and many doctors underestimate the complexities or simply don’t have the time to figure out how it all pieces together. Our goal with advising is to bring clarity and simplicity to this overwhelming process, resulting in increased revenues, happier patients, and less dependence on insurance, vision plans, optical sales, and traditional means of generating income.

At our practice, we have found that positioning, pricing, and packaging are important pieces of the puzzle. In our clinic, we evaluate the patient and create a treatment plan on the spot using an online platform that lists our treatments and provides immediate patient education.

While I’m in the exam room performing my evaluation—which takes about 45 to 60 minutes—my assistant has the online form pulled up on an iPad or computer. I make my recommendations, and the assistant will compile the plan. The patient sees this in real time as we explain everything we are prescribing. The software calculates the fees based on the treatment recommendations. We are then able to discuss our recommendations, hit “submit,” and the patient has all the details of our recommendations (and the associated fees) in their email before they even leave my exam chair. By packaging these customized treatments, patients realize they are saving a lot of money compared with doing individual treatments—and often save money in the long run versus using many traditional therapies.

No need to sell

Like many ODs (and most doctors in general), I was never a fan of discussing money with patients. The truth is that doctors don’t want to be viewed as salespeople or seen as trying to “upsell” patients on services. Because most advanced treatments are not covered by insurance, when the financial conversation comes up, many doctors are uncomfortable discussing money, which hinders the move toward the cash-based treatment arena. They have a fear of being seen as a salesperson; this was an early obstacle for me as well. Using the method described above for presenting fees has created somewhat of a safety barrier between me (as the doctor) and the patient, keeping them from feeling like I am trying to sell them something.

We don’t “sell” treatments. We make the best recommendation for that patient and their individual needs. We do this unapologetically—anything less is suboptimal patient care. By the time I’m done with my explanation of the clinical findings, patients ask me, “What’s the next step? What do I need to do?” This immediately takes me out of the sales process.

Routinely, patients ask if this is all covered by insurance. My simple answer is insurance does not cover many advanced procedures. Then I exit and allow my technician to take over. The technician reviews fees; I explain the treatment processes without using any marketing language. We let them know that if they are unable to afford some of the advanced treatments, we are not going to abandon them.

We stock all the products we recommend in the office, and although that made me a bit nervous in the beginning (again, I’ve never liked that salesy feeling), we have found that patients are actually very appreciative of the convenience. Once they have signed up for a DED treatment program, we pack up their items, and they leave with a goody bag full of all the things that they need for home therapy. More importantly, when they run out, they now come to us to order more. This is a direct result of us continuously impressing upon them the importance of ongoing home therapy.

We also utilize patient education software (Rendia) in all our exam rooms, through which we are able to send educational videos and treatment information via text or email directly to our patients. As doctors, we are naturally educators, and a huge part of what we do daily is educate. As it relates to our patients, 90% of what we do as optometrists is patient education and 10% clinical observation.

Conclusion

Comprehensively treating DED in your practice may seem like a daunting undertaking. It certainly takes planning and thought plus dedication and follow-through. But you don’t have to have every device under the sun or stock every single product available in your office to be successful. You can scale your offerings as you become more comfortable. Bundling or packaging products and services along with thorough patient education are strategies that can help you get started. The most important step is to be committed to the process that works for you.

References

1. Dana R, Meunier J, Markowitz JT, Joseph C, Siffel C. Patient-reported burden of dry eye disease in the united states: results of an online cross-sectional survey. Am J Ophthalmol. 2020;216:7-17. doi:10.1016/j.ajo.2020.03.044

2. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-478. doi:10.1097/ICO.0b013e318225415a

3. Siffel C, Hennies N, Joseph C, et al. Burden of dry eye disease in Germany: a retrospective observational study using German claims data. Acta Ophthalmol. 2020;98(4):e504-e512. doi:10.1111/aos.14300

4. Dubey A, Patel VD, Walt JG, Fox KM, Schwartz M. Treatment patterns and satisfaction in dry eye patients in real-world practice setting. Invest Ophthalmol Vis Sci. 2010;51(13):6258. Accessed November 9, 2022. https://iovs.arvojournals.org/article.aspx?articleid=2374860

5. Barabino S, Rolando M, Camicione P, et al. Systemic linoleic and gamma-linolenic acid therapy in dry eye syndrome with an inflammatory component. Cornea. 2003;22(2):97-101. doi:10.1097/00003226-200303000-00002

6. Macrì A, Giuffrida S, Amico V, Lester M, Traverso CE. Effect of linoleic acid and gamma-linolenic acid on tear production, tear clearance and on the ocular surface after photorefractive keratectomy. Graefes Arch Clin Exp Ophthalmol. 2003;241(7):561-566. doi:10.1007/s00417-003-0685-x

7. Aragona P, Bucolo C, Spinella R, Giufffrida S, Ferrerri G. Systemic omega-6 essential fatty acid treatment and PGE1 tear content in Sjögren’s syndrome patients. Invest Ophthalmol Vis Sci. 2005;46(12):4474-4479. doi:10.1167/iovs.04-1394

8. Kokke KH, Morris JA, Lawrenson JG. Oral omega-6 essential fatty acid treatment in contact lens associated dry eye. Cont Lens Anterior Eye. 2008;31(3):141-146; quiz 170. doi:10.1016/j.clae.2007.12.001

9. Pinna A, Piccinini P, Carta F. Effect of oral linoleic and gamma-linolenic acid on meibomian gland dysfunction. Cornea. 2007;26(3):260-264. doi:10.1097/ICO.0b013e318033d79b

10. Brignole-Baudouin F, Baudouin C, Aragona P, et al. A multicentre, double-masked, randomized, controlled trial assessing the effect of oral supplementation of omega-3 and omega-6 fatty acids on a conjunctival inflammatory marker in dry eye patients. Acta Ophthalmol. 2011;89(7):e591-e597. doi:10.1111/j.1755-3768.2011.02196.x

11. Sheppard JD Jr, Singh R, McClellan AJ, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 2013;32(10):1297-1304. doi:10.1097/ICO.0b013e318299549c