Dr. Karpecki’s Dream Dry Eye Clinic

What instruments and tests are best for building a dry eye subspecialty clinic?

If I could build my ‘dream’ dry eye clinic, these are some the instruments I’d want to have: 

The TearLab Osmolarity Device:  It’s a test that takes about 5-10 seconds to measure the osmolarity of a patient’s tears.  It has an almost 90% positive predictive value, which is three times more accurate than any other test including tear break-up or Schirmer’s.  It also can tell you if the topical medications you’ve chosen for the patient are working based on an improvement in osmolarity after a month’s treatment.  And having received a CLIA waiver this past month allows a reimbursement of over $46 each time it is appropriately used.  No other test is as accurate or reimburses for performing a dry eye measurement.

The iCare Tonometer: Consider a tonometer that doesn’t require drops such as fluress or anesthetic, which can affect the ocular surface and tearfilm.  The iCare tonometer is also impressive in that there is no puff of air so patient response is positive.  It also has been shown to be accurate and is portable, making it easy to use anywhere for your dry eye patients and in any lane.

TelScreen EyeRes: I don’t know of a better or more efficient way to educate patients than showing them an image or video of their own eyes.  The high resolution of this system makes capturing any image in the lane possible and it greatly increases compliance as patients know I’ll take another image at their next visit to gauge improvement.

Fluramene Dye: Nothing is more efficient than one bottle that has found a way to combine fluoresceine and lissamine green dye.  It seems to be more sensitive than each alone and it is certainly far more efficient.  Two minor things to be aware of however: it can burn certain dry eye patients and the bottle tip is a little large so practice at instilling a small drop is essential.

Eyemaginations LUMA: If there is a better patient education tool out there, I don’t know what it could be.  LUMA allows the doctor to explain the dry eye condition or any disease to a patient via images.  I can show the animations, draw on, talk about treatment and even display the patient point of view.  In 30-60 seconds I can educate a patient about dry eye and punctal plugs, for example, that used to take 3-5 minutes or more.

Topography: Topography used to cost $65,000 when first introduced and now you can obtain a topographer that does five times as much as the original and costs under six figures (e.g. the Topcon CA-200).  Topography can reveal dry eye via the patterns that are observed.  There are even topographers that measure tear film break-up time and the tear meniscus height (Oculus Keratograph).

Opt-align: This new system measures ocular alignment in about 30-60 seconds providing information such as phorias, vertical imbalances, proprioceptive disparity and the reasons for asthenopia symptoms that often mimic dry eye symptoms.  It has saved me hours and more importantly helped diagnose “dry eye” patients that really had significant ocular alignment issues; and, when treated with the prism the machine recommended, their symptoms were completely eliminated.

Specular Microscopy: There are numerous times when patients have had symptoms of contact lens intolerance that were thought to be dry eye, for example, that turned out to be endothelial issues ranging from decompensation to simple stress on the endothelial cells indicated by pleomorphism and polymegathism.  The Konan CellChek is a great machine that captures signs of early endothelial stress and readily displays below average numbers.

OM Solutions: After having all of these in place you then need a system or staff to help you manage the medical practice component including credentialing, proper coding, billing, accounts receivable, insurance verification, tracking, proper protocol, driven testing, etc.  You can outsource these activities to various companies: the most effective of which, in my experience, is OM Solutions.  With those headaches out of the way, it’s a lot easier to put the medical clinical component into optometric practice.

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