Speaker 3: Ocular surface disease—it's complex, chronic, and progressive, but rife with opportunity for the enterprising optometrist.
Jackie Garlich: The mission of this podcast is to make this condition more understandable and accessible to those interested in specializing in it. So let's get to the point. All right. Welcome to the first episode of our podcast To the Point. Um, this podcast is a place for doctors to learn more about how to treat dry eye from the basics of where to find your patients and how to market your practice and services to the more complex topics like treatment protocols from doctors at various successful dry eye practices. My name is Jackie Garlich. I'm an optometrist practicing in Boston and I am joined by my cohost, Leslie O’Dell, who is the famous dry eye guru and director of dry eye services at the Dry Eyes Centers of Pennsylvania. Um, a word on Leslie, she's been shaping the dry eye world for many years and has a thriving, dry eye patient base in Pennsylvania.
Jackie Garlich: I just bought a practice literally 2 weeks ago and I have a strong interest in treating dry eye but haven't yet developed my plan on how to grow my practice in that arena. So this is going to be an ongoing series where we start at the basics and build from there. If you are a doctor that is interested in treating dry eye and really wants to grow your dry eye patient base, you and I are in the same boat, and this podcast is for you. So, hello Leslie.
Leslie O’Dell: Hi, and congratulations on this new adventure.
Jackie Garlich: Thank you. Thanks. All right, so let's just jump right in. Leslie, where do I find patients? Where do I find my dry eye patients?
Leslie O’Dell: Well, you have a practice, right? You said you just purchased this private practice. The patients are there. Um, and one thing that I would really recommend is something that I learned or read from um, Dr. John Shepherd down in um, Virginia Eye Associates. His philosophy really makes you think about dry eye patients a little bit differently. And- and that philosophy is that everyone has dry eye and ocular surface disease walking through your practice until proven otherwise. So what does that mean? That means you're gonna treat every patient like they already have the problem and you are gonna disprove that in your exam through, you know, from one patient encounter to the next. And you're- you're gonna be, you know, very pleasantly surprised by the numbers that you see, um, of patients that you are generating for a dry eye evaluation based just on that alone.
Jackie Garlich: Yeah, I um, I, a ton of my patients have dry eye but there's this also little, so like I do meibomian gland expression just in the slit lamp on every single patient. And most patients don't look great. I don't feel like I see a lot of really healthy meibomian glands, but there's a big difference between the patients that like don't look good, meibomian gland-wise, but are actually symptomatic. So, you know, I see a lot of patients that are clinically dry eye, but a lot of them are not, [they] don't have symptoms of dry eyes. So, like, how do you handle that for a patient who's like, “No, I feel great my contacts work good, I'm doing well.” And I'm like, “Oh, there's like all this atrophy here [in the] meibomian glands.”
Leslie O’Dell: I mean, those patients can be tricky, but I almost feel like we get in our own way more than- than they are in our way. At that point, you assume they have no symptoms. But oftentimes if I treat an asymptomatic patient, like a patient that wasn't complaining, they will come back to me and say, “X, Y, or Z is better. I didn't realize it was associated with dry eye.”
So sometimes maybe the questions that we are asking them, if you have technicians that are running the tests, you know, it might not feel dry um, you know, to the patient. So sometimes I think that we're just our own obstacle when we say symptomless um, one big one would be fluctuating vision. So if you talk to patients that are on digital devices, which is most of your patients in a workday, they're going to tell you that they have some level of eye fatigue or burning or just, you know, three o'clock comes and they're rubbing their eyes and they're, you know, getting up to get a- a drink of water because they're just bothered by the way their eyes feel.
Leslie O’Dell So I think that that's a big, a big problem I had. And I would say that I do treat a lot of symptomless patients. So, first I would say, get out of your own way [laughs] and just start that conversation, right?
“So, Mrs. Jones, what I'm seeing um, today with your, meibomian glands, which are these little oil glands that express oil onto the surface of your eye and help maintain good vision throughout a workday, they aren't performing optimal, o- optimally. And in order to figure out what that means, I'd like you to return for, you know, a dry eye evaluation.”
And I do think it does require some time to have good education with the patient from the beginning. Um, and what we're doing is we're really helping to prevent those end stage patients. You know, imagine if you think of that patient the exact same way that you would think of that patient if you looked in and you saw a 0.5 cup, right? You're gonna be thinking, hmm, I need to educate this patient because they are also symptomless but are at risk for a disease.
Jackie Garlich: Yeah, that's a good point. I- I that's a good analogy. I, what I find that I do a lot is that I am, you know, seeing this dry and maybe patients are symptomatic but then I spend so much time like educating them on dry eye, what it is, what these meibomian glands are. I've got these photos and like I go, oh they're all this and then I end up running behind in clinic. So like I need to find probably a better way to really, you know, discuss this with [them] so that they know they have options, treatment options without overwhelming them but enough so that they would actually want to follow up and see what else we can do treatment-wise for them. How do you, how do you pass that out in your clinic?
Leslie O’Dell: Well and even not overwhelming yourself, right? Because that's what you're doing. You're over educating on a [crosstalk 00:06:09] exam-
Jackie Garlich: Mm-hmm [affirmative], totally yes.
Leslie O’Dell: ... and it- it does get overwhelming and it- it makes you a worse doctor for every patient that you see after that one, right?
Jackie Garlich: [laughs].
Leslie O’Dell: Because now you're just trying to catch up.
Jackie Garlich: Yes, yes.
Leslie O’Dell: So, I think what you need to do and what we all need to do is just segment it. I see it in other professions. If I go into a well visit with my primary care doctor and I have a problem, they don't actually even wanna address it. I have to come back to them oftentimes for a problem not within the realm. And I think that's what we sometimes feel bad about. You know, in our profession that we're- we're bringing the patient back too many times, but I mean, medicine does require time. And I th-, and especially our profession, it's a little bit confusing to navigate the world of vision plans and medical insurance. It makes life a whole lot easier if I find it on a routine vision patient and I say, "You're gonna come back for this dry eye evaluation."
Leslie O’Dell: Um, and I- I mean, I think our no show, no show rates are pretty low and- and you're gonna not get everyone to come back, but you know, next year you're gonna have that same conversation. And sometimes with some patients, just like anything else, it just takes them hearing it a few times to kind of start getting it. But one easy thing that you can do to sort of start the education at home is give them materials, and it's better if you have the materials branded for your own practice versus, you know, just a brochure from a company. Um, but you can use the information that is coming out of those brochures to make your own set of, um, take home papers and you say, you know, “Mrs. Jones, I wanna bring you back for that dry eye evaluation. Here, let me just give you a little bit of homework before you come in for that exam so you have some idea of, you know, what's going on.”
Leslie O’Dell: Because I think patients are surprised to learn about, they know that the computer's bad. They think more about the blue light than anything. But some of the studies now with digital devices, we just presented some work at Academy and 2 hours of digital device use is impacting the function and the structure of the meibomian glands. So right there alone, we are gonna be busy, busier than we know what to do with, you know, with our time.
Jackie Garlich: Yeah, yeah.
Leslie O’Dell: But um, the- the other big thing for you being, you know, a new practice owner in that practice is just dedicating some time to staff training. You need to surround yourself with staff that have the same vision that you do. And I can just speak to that from working in different environments, where I first started doing dry eye was in a super busy surgical practice and the texts were already completely overwhelmed. And introducing anything new was, I mean it was just painfully painful.
Jackie Garlich: [crosstalk 00:08:46] [laughs].
Leslie O’Dell: Um, but then the environment that I found that I work in now with this dry eye center, which is actually within an optometric practice, the technicians, that's front desk staff, um, the billers, like everybody was excited about something new and the support and what I've been able to achieve in- in this, you know, past 4 years has just been leaps and bounds ahead of what I was doing. You know, where I, where I started. So, first is just finding staff that share the vision and you have staff, just start training them. I mean, they're usually very eager to learn. I think that we- we do have a little bit of an advantage over an ophthalmology practice because we're not as busy.
Leslie O’Dell: Um, so the technicians seem to have a little bit different piece of work too. And that can help when you're trying to teach them something new. So getting your staff from the front desk to the technicians, to even the people in your optical all understanding about dry eye, about the treatments that you're going to offer in your practice and why it's so important is going to all, you know, they all are gonna help to champion what you're trying to achieve. So that's one thing for sure.
Jackie Garlich: Yeah, that's a good, that's a good point. How did you do that? So you start with, so what's your history at the Dry Eye Centers of Pennsylvania? Did you start there with not a strong dry eye patient base and grew it from there or how did you transform it into like what it is now?
Leslie O’Dell: So we, I mean that started out much like, I think the environment that you're in right now. It was uh, actually just expanded to a two-location optometric practice and there were four ODs and one and five; one was on his way out for retirement. And, um, we decided to use one of the locations that I was gonna be spending most of my time at as the destination site. So that's where we de- dedicated more resources to invest in technologies, um, and then as I was there and building that patient. So, but the patient base was just, I'd say, you know, mostly routine. They did probably have about 30% to 40% medical practice at the time. Um, but they were heavy, you know, heavy envisioned plans for sure.
Jackie Garlich: Mm-hmm [affirmative].
Leslie O’Dell: Um, but they have, had, a- an understanding of medical optometry and we're doing a lot of like glaucoma management and you know, OCT testing and things like that. So it wasn't completely foreign like maybe in a commercial setting. Um, but the message really started with all of the doctors in our group saying, "Hey, we have this dry eye specialist." So in- in your case, that could be you and anybody that you're working with is gonna set them up in your schedule. And, I mean we have developed some protocols, so, because obviously most optometrists are more than capable of treating dry eye if they, if they have the interest. So, we have some protocols and any of the doctors in our practice now we're, now we're a three-location, eight-doctor practice so they can get started on dry eye. I traveled between two of the practices and they know when to send them to me versus you know, start a treatment themselves.
Jackie Garlich: So were you, is there ever a situation where you're some, let's say that someone comes in for their annual exam and one of their complaints is like, my eyes are dry, you know, my contacts aren't so comfortable, are you ever then like, then I'm ta- I'm talking about it, you know, like I know we want to have them back and do the whole dry eye thing, but I- I feel like it's, I'm leaving the patient hanging. If I don't like address these symptoms in the, that exam then. So, are you, when a patient comes in with like that scenario and you know, they're dry or whatever the situation is um, optically, are you ever starting treatments at this point? Do you ease into the, do you see what they're doing? I mean, this is sort of nuanced, so it's a hard, probably, question to answer, but-
Leslie O’Dell: Yeah, I'm just thinking of that as the patient [who] didn't know they had the problem until you are telling them that for the first time. So they really probably aren't doing anything. Um, you know, a lot of times in those cases you can do something, um, you can start some kind of palliative treatment. I think it's reasonable. I'm seeing this, let's get started here, but try to see them back in a timely fashion because we know that those treatments aren't going to solve the problem, right? If- if all of dry eye has inflammation at its root and you're just giving a tear, they might start to feel somewhat better. Um, but once you bring them back, and- and the other thing I was gonna say is get your CLIA waiver, right? Because the amount of doctors that do not do point of care testing and say that they are managing dry eye is still an overwhelming n- number of us.
Leslie O’Dell: So, in my mind that was, you know, that was some of the struggle, we were doing part of the point of care testing in my initial practice, but I wanted to be doing it all. And now I can't imagine doing- doing it without it. So it's not hard to get your CLIA waiver. Um, that is something that I would say to do first. And then you can start bringing in that testing once you start showing them, like, you know, when you bring them back and you start collecting this data about their tear chemistry and that, in meibography or whatever it is, and we'll get to that I'm sure in subsequent episodes. But, um, once you start to show them that now they kind of, now they are understanding more how complicated dry eye is. But, so I think it's okay to get started in that conversation.
Leslie O’Dell: And whether you wanna, you know, start with some kind of heat mask or you wanna change what they're doing with their daily routine with makeup. You know, sometimes I'll have that talk on that initial exam. Um, but some, you know, the- the artificial tears that we have, we can kinda tailor to what we think just from our exam, whether, you know, we think that they have, um, more of an evaporative dry eye or more of an aqueous dry eye. So I think it's okay to get started there. If the patient already is complaining, they might have already hit the drug store and pulled something off the shelf. So, you know, now you wanna just really try to get them back as- as promptly as you can. But I think, you know, I think you could, you- you could definitely initiate therapy.
Leslie O’Dell: I mean, I don't, I could initiate therapy. I do that sometimes without my point of care testing. If I'm seeing, you know, a lot of damage to the ocular surface. I'm not, I don't wanna wait for fear of risking. You know, again, the glaucoma analogy is always standing out in my head and I think 'cause I was trained, you know, heavy in- in glaucoma with my residency to begin with. But you know, every once in a while, you're gonna pull the trigger and treat on your first exam before you even have a pachymetry or anything because-
Jackie Garlich: Yeah true.
Leslie O’Dell: ... you just know that that patient can't go. So I think if you just use that, um, you'll- you'll be able to kind of navigate the waters a little better.
Jackie Garlich: I wanted to ask you also about like the OSDI questionnaire and when you're incorporating that into the visit, if you, if that's an initial entering form that you have patients fill out or if this is just at the, um, dry eye work-up or you know, I know you use that- that screening or that questionnaire, yeah?
Leslie O’Dell So, I think it goes back to the whole staff training and then the next step is going to be that you want to set your own standard of care, but you're not reinventing the wheel.
Fortunately, we have great resources, you know, with [inaudible 00:15:55] to work. Um, and so you can use that to set your own standard. And by doing that, it gives your staff the ability to know, um, when do I need to be doing the next thing? Um, so sometimes that might be you screen everybody to start to figure out how that looks for your practice. And I know a lot of um, other dry eye specialists and- and practices do that. They just will hand up the speed to everybody. I don't see it as too much of a paper challenge. I know some practices, that's the biggest hurdle is they feel like the patients are already overwhelmed signing new documents when they show up, whether it's HIPAA or you know, you're taking a photo that day or whatever it is that you do at check-in.
Leslie O’Dell: But I mean it is called the speed for a reason. It's not hard. Every once in a while a patient doesn't fill it out or they like only partially fill it out and that's fine. You know, it doesn't, it doesn't bother me. But then really got to figure out what your number's going to be. So speed. If you look at Dr. Korb, um, he really thinks like a speed of one you should be looking for meibomian gland dysfunction. Most practices and if you, if you look at, um, I think like Demon Duckers dry eye bootcamp, he uses five or six as his cutoff.
Leslie O’Dell: So then you have to figure out in your own practice what's gonna be your cutoff that you now are prompted to look a little further. But if you go back to that first philosophy, everybody is dry eye until you prove otherwise, you could argue that you don't even need that speed on the first visit. Um, but I definitely like having uh, a dry eye questionnaire when I'm doing my formal dry eye evaluation and then every dry eye follow-up after because it helps me know if I'm, if I'm doing my job, right?
Jackie Garlich: Right.
Leslie O’Dell: So, if you're getting worse or you're not getting better or- or you are getting better, rather, it helps just to gauge where I am in my treatment. So definitely embrace one of them. Um, OSDI makes it easy. If you have an iPad in your waiting room, you can run OSDI on everybody and it automatically just generates a number. DEQ-5, um, was spoken about with the TFOS DEWS2 as well. And that's easy five questions, you know, and it does match pretty well to speed. I've done some research using both, um, speed and DEQ-5. And if I'm, if I'm getting positive on one, I usually am positive on the other. Um, so I mean just figuring out which one works good for your, you know, your staff and the patients that you're serving. Um, if you feel like paper is overwhelming them, maybe five questions is easier.
Jackie Garlich: Yeah, yeah. I- and the five question one is the, what is a DEQ, is that what you called it?
Leslie O’Dell: Yeah. DE, yup, dry eye questionnaire.
Jackie Garlich: yeah...
Leslie O’Dell: Yep. I like that one. Um, because if you have a number of, I think it's, I forget what the upper limit is, but if you have a number of six or higher, it's, you know, you really wanna be looking for dry eye disease. And if you are over 12 on that, you should be thinking about Sjogren's, which I feel like is something, once you open the door of “I'm gonna focus on dry eye,” you're also opening the door of “I need to be making sure that I'm not just treating your eye.” And there are lots of reasons why you can have dry eye disease for, you know, autoimmune causes. And so you- you don't want to pigeonhole yourself to be just in the eye. Um, a lot of times I am the first one to be diagnosing rheumatoid arthritis or Sjogren's just based on their eye exam.
Jackie Garlich: Yeah, that's a good point. What, um, what point of care testing did you do initially? Because the other thing that I think is really valuable for a patient to see is their own meibography. So if they can see all this gland loss that they have, I think that really, um, is, you know, a stronger message than me just telling them that sort of thing. But, you know, and then I also want to get this and I want to get that. And so how do you sort of, um, how did you, what do you suggest doing for initial, you know, uh, testing equipment? What are your thoughts on that?
Leslie O’Dell: Well, I, um, I actually had to start doing without meibography because we were one of the first centers that, um, was introduced to when, um, TearScience at the time developed the lip of you to have meibography. We actually started with that unit and all it did was look at lipid layer thickness and partial blink rates. So we were having that difficult message when the patient can't see what you're seeing. Um, and if that's the case and all you have is a transilluminator at the slit lamp, again, you're still looking and then you just would have photos to show. But once you can show the patient that, I totally agree. Um, now they see that, um, you use the messaging that, you know, we've all heard Paul Capecchi say, “I'm looking at this image and it's concerning to me, you know, and this is what we need to do about that.”
Leslie O’Dell: Um, you know, that makes a big, a big impact for the patient, but it's changing a lot. But now meibography is not point of care testing and you can have that without having your CLIA waiver. But I- I do think that osmolarity and InflammaDry, again, it's- it's just building the case for y- you, the doctor, to better understand their disease. So when you think about glaucoma, if you just had the eye pressure to treat, it makes your life a lot more, you know, difficult than if you have their OCT and you have their visual field and you have their central corneal thickness. I mean, sometimes doctors are frustrated by the reimbursement rates, but you are, you know, you're not paid for doing your Goldmann tonometry. Yup, our Goldmann tonometry, right? So we're used to doing tests that are very valuable or your pupil check that we aren't always compensated for. Um, but the- the nice part about osmolarity, the InflammaDry, um, is that you do, you know, you at least have a break-even point if not make a small profit, um, from the test.
Jackie Garlich: Yeah.
Leslie O’Dell: But that- that also shows the technicians that you have, um, that you're setting yourself apart. So I think that that's important, you know, for those, um, for- for the people that you're working with, they see that you are doing things way differently than maybe a practice they worked in before or you know, the practice that they know down the street and they, you know, they wanna be part of your vision.
Jackie Garlich: One last thing I wanna ask you before we kind of wrap, but how do, what is your opinion on the best way to market yourself as a dry eye practice, I'm getting referrals, whether it's on social media, reaching out to primary care providers. What's your, what do you, what are your tips in that department?
Leslie O’Dell: Um, I mean, Facebook is great for that because you can, um, you know, pick your target audience and, um, any kind of social media platform has made that a lot easier for you to narrow down in your own community. Um, where I am right now, they've actually been doing some billboard ads and in our area, billboards still, you know, have a big impact. So that's something that you could consider or- or print ads, but really just getting out into different groups, you know? Um, for me, I've had a lot of support actually from, um- my optometric peers, um, with maybe 25 or 30, now have sent to us at the Dry Eye Center um, of Pennsylvania, which is that, um, subspecialty focus within our group.
Leslie O’Dell: But I think it came from the years up until we launched that, that I was, you know, going out to the local meetings and talking to them or just trying to educate as much as I could. Uh, myself and my- my peers. Yeah. So I think those things are the easiest things to start doing it. And even just within your own practice, start putting little messages up in your exam lane, um, in your waiting room. You know, patients are looking at that stuff if- if you have, uh, I mean, they have some free time usually when they're waiting for you to stop talking to the patient [laughs]. I'm just kidding.
Leslie O’Dell: But the other thing I wanted to say too, um, was knowing your high-risk groups, right? So, because of all of this research that now we have to lean on, we know the high risk groups. So if you don't want to screen all of your patients, think about like age, you know, the aging female, um, your patients that are on multiple medications, the ones that have multiple disease, um, processes like diabetes or arthritis, ask your patients what their digital device consumption is. That alone, you know, is a reason for you to be looking at their meibomian glands.
Jackie Garlich: Yeah.
Leslie O’Dell: So, you know, you can definitely make it, make it easy on yourself, um, and make it fun. I mean, you like, you know, you don't want to take the best care of your patient. So, don’t, even, you know, like I said before, don't get in your own way and just let it come naturally. And- and once your passion starts to bleed through, your patients are gonna want to do what's best because they've, they feel that from what you're, you know, what your messaging is.
Jackie Garlich: All good points.
Leslie O’Dell: Let's just try a quick little to-the-point replay. So pretend that everyone walking through your door has dry eye until you prove otherwise. Get your staff involved, educate them, get them excited to wanna be part of the vision that you have. Develop your own standard of care so that you can empower your- your staff, your techs, to maybe run a test when, you know, when they know certain things that you want. Um, and then look to those high-risk groups so that you're screening them all, um, a little bit more in depth, um, when you're doing your exam and hopefully that'll help.
Jackie Garlich: Yes. Thank you, Leslie. Always a great conversation with you.
Leslie O’Dell: Good luck. And, um, hopefully we both have some exciting cases this week to share in the future.