Taking the plunge into dry eye care

For a disease that once struggled for legitimacy, the rapid evolution of dry eye care in Australia has been rarkable.Now a well-established subspecialty, only a decade ago a general lack of clinical and public awareness kept dry eye on the periphery while a significant patient group suffered in silence.Today, however, an expanding body of evidence leaves little doubt over dry eye’s validity as a genuine disease. Measures vary, but it is said to impact at least 344 million people globally. In Australia, one in five adults encounter dry eye in their lifetime, and it is no longer perceived as a condition confined to older patients.Given the statistics, dry eye is a chronic condition that is reaching epidic proportions and, if left untreated, has been proven to significantly erode quality of life. Its pervasiveness can be linked to several factors including better diagnostic and treatment capabilities, the environment, technology-dependant lifestyles, or a combination of the above.Subsequently, dry eye’s newfound relevance has exposed a significant gap in the eyecare market. As such, Australia is now home to an increasing number of professionals and clinics that are making it their business.Insight spoke to Australia’s forost experts about the dry eye market, and what should be considered before opening up to this unique patient group.Dry eye’s arrivalAccording to University of Melbourne Department of Optometry and Vision Sciences senior lecturer Dr Laura Downie, several factors have converged to spark increased clinician interest in dry eye.“This likely reflects that dry eye disease is highly prevalent – affecting about one in five adults – and a chronic eye condition that falls well within the scope of optometric therapeutic care,” she said.“Over the past few years, there has also been increased global awareness about the importance of diagnosing and managing dry eye disease, particularly through the work of the Tear Film and Ocular surface Society (TFOS), and the publication of the International Dry Eye WorkShop II (DEWS II) reports in 2017.”Many consider DEWS II as one of the most critical contributions to dry eye’s acceptance as a multifactorial disease. The report involved 150 international clinical and basic research experts, including Downie, who used an evidence-based approach to also reach a consensus on some of the main aspects of the disease, and develop recommendations for diagnosis, managent and therapy.“As with all areas of practice, it is imperative that the diagnosis and managent of dry eye disease is evidence-based. It is thus essential that eyecare clinicians, particularly those who are considering establishing a clinic with a particular disease focus, are abreast with the best-available research evidence,” Downie said.“The 2017 TFOS DEWS II reports provided a comprehensive synthesis of state-of-the-art in the dry eye field,” she said, adding that there are opportunities for upskilling through postgraduate programs such as the University of Melbourne’s Specialist Certificate in the Managent of Anterior Eye Disease.As well as a strengthening body of research, dry eye diagnostics and treatment has become a multibillion-dollar industry, helping fuel even greater interest and confidence. Increased competition continues to reduce the price of more sophisticated equipment and therapies, improving accessibility.Downie said: “For example, over the past two years, there has been a 400% increase in the development pipeline for dry eye therapeutics.“As such, we expect to see the availability of a range of new dry eye therapies over the next several years, particularly those targeted to the dry eye subtypes such as aqueous-deficient and evaporative dry eye.”Given the ever-expanding body of research, a suite of new treatments and an increasing patient cohort, the market conditions may have never been better for diversification into the dry eye arena.’The learning curve is steep’For optometrists, particularly independents, offering diagnosis and all-inclusive treatment program for dry eye could be an effective way add value to a practice. However, dry eye is notoriously time-intensive and can easily evolve into a costly exercise.Because of this, according to established dry eye care practitioners, serious consideration must be given to the extent at which dry eye is incorporated into a practice, as well as the desired level of care. These factors, in turn, can help determine the level of financial investment to ensure dry eye services are viable.{{quote-A:R-W:400-I:2-Q: For example, over the past two years, there has been a 400% increase in the development pipeline for dry eye therapeutics -WHO:Laura Downie, University of Melbourne}}On recommending the best method of entry into dry eye care, established providers offered varied opinions. Some advised an ‘all or nothing’ approach, while others believed a gradual introduction is just as feasible.Dr Jim Kokkinakis, of The Eye Practice in Sydney, provides a stark reality for professionals considering the establishment of a dry eye clinic.“In my opinion it is important that you are either all in or not. This means providing all options. The reason for this is simple. There is no panacea. The arsenal you need is extensive,” he said.Kokkinakis is considered one of Australia’s leaders in dry eye care. Operating a clinic that primarily specialises in complex contact lenses and spectacle prescriptions, seven years ago he decided to sharpen his dry eye expertise.At his practice, Kokkinakis said a typical dry eye diagnostic consultation could take up to two hours. Among other things, this involves the use of the Lipiview imaging tool (meibum and blinking), meibography, non-invasive tear break up and aqueous volume.“We have also just started to implent a new technology that is not available generally yet that is an infrared scan of the mucous layer. This is something that eye practitioners have ignored as there was no simple way of assessing this,” he said.This is then followed by a customised treatment plan, which, in more severe cases, could result in the use of more sophisticated procedural-based treatments such as the LipiFlow thermal pulsation syst, intense pulsed light (IPL) therapy and the MiBoFlo device to treat meibomian gland dysfunction.“The learning curve is steep and there is not much change from $200,000. Leasing this over four years with no residual will be around $4,500 per month. You will also need extra room and a trained staff mber – about a day a week of wages. Once you factor this in you are up to about $6,000 per month before you have made one cent.”Kokkinakis added: “Specialty in anything involves a huge investment in professional development time and slowly accumulating enough clinical exposure to ocular surface disease to be able to accurately recognise the different contributors. Clinical exposure is critical as ‘one patient’s medicine can be another’s poison’.”However, Mr Willy Gunawan, of Melbourne’s Collins St Optometrists, believes significant investments may not be necessary in the immediate term.Gunawan, who introduced dry eye care to his practice in 2010, said the 2017 DEWS II report now set out clear treatment protocols, including a referral pathway. This has meant other optometrists could help ease the burden that mild to moderate cases currently place on existing dry eye clinics.“You actually don’t need fancy machines. I didn’t have th when I started out. Everyone has access to slit lamps, flourescine and lissamine green stains. The DEWS II report also mentions you need to measure the tear osmolarity, which can also be done with inexpensive equipment that costs $1000-2000,” he said.“You just start by listening. If the first few steps don’t work in accordance with DEWS II, you can then tell the patient you are going to refer th on to someone who has the equipment and tools to treat th at another level.”Gunawan added: “We can’t get all dry eye patients treated through dry eye clinics. I think everyone needs to be more engaged with these patients. It’s not just the responsibility of dry eye clinics, it’s every optometrists’ responsibility.”Ms ma Furniss is a clinical optometrist at The Dry Eye Institute. Established in 2017, it is one of Australia’s few sole dry eye treatment centres.She believes eyecare professionals should first invest and familiarise thselves with the basics in diagnostics treatment. She too identified osmolarity and lissamine green as a good starting point, as well as a Schirmer’s test and a Meibomian Gland Evaluator.“I love meibography as a tool for showing patients damage or the rate at which we should be undertaking treatment. It’s a really good piece of the puzzle. But this comes at a price,” she said.“Basic treatments such as punctal plugs are a great idea for treating mild to moderate dry eye where appropriate. If you decide to invest in the more advanced diagnostic and treatment options, then yes, you will need enough space for these machines and extra chair time with the potential cost of someone to help take these measurents if you were to get busy enough.“The technology ranges in price from a few thousand to tens of thousands but many of the basic diagnostic equipment is relatively affordable and accessible to the everyday practitioner.”

Profit or process?Careful attention needs to be given to the motivation behind establishing a dry eye clinic. While some consider it a profitable segment of their business, for others the jury is out.It can easily become an expensive undertaking; meaning costs are passed on to patients in most, if not all, cases. This dilma also appears to be contributing to a belief that some eyecare providers are inappropriately marketing or over-servicing therapies instead of adopting an evidence-based approach to treatment.Gunawan said his clinic infrequently used its most sophisticated instruments if he adhered to the DEWS II protocols.“If you push for treatment, I’m sure you can make a lot of money, but you won’t be following protocols. I believe I need to be able to defend everything I do in my managent plan, especially since we have now got an international consensus on how to manage these patients. You can’t go straight for the machines,” he said.“I don’t believe that seeing dry eye patients will be a particularly profitable venture, but it certainly will be and has been a very rewarding aspect of optometry, professionally.”For Kokkinakis, the introduction of a dry eye service was a clinical decision, more than a financial one.“I will definitely not retire because of my dry eye treatments,” he said.“I have asked myself – if I could turn back the clock, knowing what I know now, would I bother creating a dry eye practice again, the answer would be yes. My practice is mainly anterior segment disorders so having a deep understanding of ocular surface disease has complented our specialised niche.”According to Dr Nicholas Young, of the Dry Eye Centre in Victoria, despite the ever-increasing ergence of specialty clinics, there are still only a select few making dry eye their world. Dry eye accounts for the majority of his business’ revenue and, to set his practice apart, he has invested heavily in order to treat even the most complex patients.“Even some of the most internationally renowned dry eye practitioners can take up to two hours to evaluate a new patient. Medicare doesn’t even come close to runerating this duration of consultation. The practitioner needs to place a value on their time and charge accordingly. We also charge patients for all add-on procedures and treatments,” he said.Young believed too many clinics were adopting a ”cookie cutter” approach to dry eye care. He said it was important for practitioners to responsibly market their dry eye services around a holistic approach to patient care, rather than the marketing material that accompanies popular device purchases.“The latter not only fails to differentiate practices from each other, but also conveys a message to the public that dry eye treatment is as simple as pushing a button or flicking a switch, and unfortunately, in my experience, this notion couldn’t be further from the truth,” he said.“Clinics operate at different levels. I don’t think we could claim to be a leading dry eye clinic without having such a unique approach and broad range of diagnostic and treatment options. That’s mainly because many of our patients are referred to us from other health care providers, and might have already tried various other treatments.“Having said that, optometrists can obtain a lot of valuable information using a basic slit lamp and should be encouraged to brace dry eye as part of a standard consultation.”He added: “For us, it’s about sitting down with these patients, giving th a level of commitment they may not have had before, and trying to understand their condition at a new level, which often involves areas of the body roved from the eyes, including physiological issues, allergies and gastrointestinal issues.”

 View PDF Report