to-the-point
To The Point
Episode 2

Point-of-Care Testing Options

Jackie and Leslie are back, and in this episode they discuss point-of-care testing options for dry eye. For those of you who are unfamiliar with or skeptical about the topic, you'll definitely want to hear what these two have to say, so don't pass up this opportunity to learn why this testing is valuable, how the results can change your treatment protocol, and how to obtain a CLIA waiver.

Jackie Garlich (00:06):Ocular surface disease. It's complex, chronic, and progressive, but rife with opportunity for the enterprising optometrist. 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.

Jackie Garlich (00:24):Today we are focusing on point of care testing options and how to obtain a CLIA waiver so that you can perform this point of care testing in your office. For those of you that aren't familiar with point of care testing or don't see the value in this, we're going to cover all of that today. So, we're covering why this testing is valuable and how the results of these tests will change your treatment protocol. My name is Jackie Garlich and I'm an optometrist practicing in Boston and I am joined by my cohost, Leslie O’Dell in the wonderful state of Pennsylvania. Hello, Leslie.

Leslie O’Dell (00:59):Hello.

Jackie Garlich (01:00):So, should we maybe just jump right into, um, in order to perform any point of care testing we have to have, the office has to have a CLIA waiver, C-L-I-A waiver? Do you wanna ... Should we just start talking about that? How you get that?

Leslie O’Dell (01:16):Sure. So, first of all, maybe back up one step and say what is point-of-care testing. So that is going to be your tear osmolarity test and then P9 tests or InflammaDry. There are other point-of-care tests that you can do in your office, which would be adenoid detector, which is very helpful when you're trying to rule out something like an EKC type of viral infection as well. So that's kind of what's getting grouped into this point-of-care testing. And what, what it is, what it's looked at, and what this CLIA waiver is, are these tests are called CLIA waived tests, and that means that they are simple laboratory procedures and exams that have an insignificant risk with erroneous results.

Leslie Odell (02:04):So what that means is just, it's giving us a piece of information to better develop a treatment plan for our patients. And so that is what the CLIA waiver means. The best way to find out the most information is through the cms.gov website, so it's cms.gov and search CLIA and you can figure out what you need to be doing to get that waiver.

Jackie Garlich (02:26):One thing I'll say is also the reps for the companies that, um, you know, Quidel that makes the InflammaDry and TearLab are actually really helpful, I think, in assisting you getting the waiver too. So they probably have information on that, that can also help if you're running into any issues with that. So, you do you know about, actually do you know anybody of any timeframe on like when you submit this application to when you can get that? Do you know how that works?

Leslie Odell (02:53):Yeah, I think it's about a 4-to-6-week period of time, and then as your renewal process, it is per location. So, if you're a multiple location, you do need to pay for that per location. And it's valid for 2 years. And the fee for the certificate, the certificate of the waiver is $150 per location, so that would be $150 per location per every 2 years. Um, but I do think it's about a 4-to-6-week period of time until you can get that.

Jackie Garlich (03:26):Okay. I—this is a for any listeners that are in Massachusetts—I learned, I tried to actually obtain, I was just telling Leslie about this, I tried to obtain my CLIA waiver for the TearLab and for InflammaDry, and I was told that we can't actually get that in the state of Massachusetts. So, I think this is the only state where you are not able to get your CLIA, they're not giving out CLIA waivers to ODs, you have to be an MD or affiliated with a hospital, of which I am neither. So that's okay. (laughs) We're gonna work on that one, that little piece there. (laughs) But this is where the, this is where the rep is really helpful 'cause they sort of guided me on this whole thing here, but yeah. (laughs)

Leslie Odell (04:11):Yeah. Yeah, definitely pushes you to explore the more politically affiliated-

Jackie Garlich (04:17):(laughs)

Leslie Odell (04:17):Parts of our profession, right?

Jackie Garlich (04:18):Abs-absolutely.

Leslie Odell (04:20):It's frustrating to, it's frustrating when you want to do something and you're limited like that.

Jackie Garlich (04:23):Yes, totally.

Leslie Odell (04:23):So, that is unfortunate because-

Jackie Garlich (04:24):Yeah.

Leslie Odell (04:24):For the rest of the world, the point-of-care testing-

Jackie Garlich (04:25):(laughs)

Leslie Odell (04:26):When you're doing dry eye is very helpful, so I feel bad for you Jackie.

Jackie Garlich (04:31):I know, me too. That's okay, that's all right. You're, we're going to educate everyone else on point-of-care testing. So, let's actually maybe go into that. (laughs)

Leslie Odell (04:37):Good to know for the day, good to know for when the day comes that you're gonna be using it too.

Jackie Garlich (04:40):I, I'm prepared, yes. (laughs)

Leslie Odell (04:41):Yes, yeah. So easy test to run and, the best advice I have is just get your techs and your staff trained on how to do the test 'cause it frees you up a lot. Actually, I was just doing a meeting and I was gonna have to demonstrate how to do tear osmolarity and I thought, “Ooh, I probably should learn myself.” (laughs)

Jackie Garlich (04:59):(laughs)

Leslie Odell (04:59):But it was very quick to learn because my techs had done it, you know, since I've been using it for the past, uh, 5 to 6 years. So that test alone is looking at the tear volume or the uh, the water to salt concentration in the tears. It's an easy test to obtain. It's done through kind of the lateral canthus area, and it's a one eye, you know, one test per eye and the, it's read within a few seconds. So that number on your scale really goes from somewhere in the 280s, probably all the way up to close to 400 milliosmoles. And what you're looking for is a number that's around 300 with the upper limit being 308.

Leslie Odell (05:41):So that's the one thing that you want to know is what your norms are, and so 300 to 308 is what you're thinking is normal osmolarity. And then the other thing you wanna look at is any inter-eye difference that's bigger than 7 milliosmoles. So, when you see that inter-eye difference, it starts to tip you off to thinking about things like tear film instability, may be more of an evaporative dry eye. I definitely, you know, wanna make sure I'm checking the meibomian glands if I see a big spread in the patient's eyes.

Jackie Garlich (06:10):Okay. Do you do this testing, or you have your techs do this testing? So, this is like a, a patient that's coming for a dry eval, this is their follow-ups? This was when you're doing this, um, they do it like before you ever see the patient, so you have the result already ready?

Leslie Odell (06:25):Yeah. So that-

Jackie Garlich (06:25):Is that how you do it?

Leslie Odell (06:26):Yes, and that's a good, that is a good question because your sequence of dry eye testing is so very important. You can actually create a dry eye, you know, say that you're bringing someone in and you're gonna do noncontact tonometry and then you're gonna do osmolarity where you just, you're just kind of-

Jackie Garlich (06:43):Yeah.

Leslie Odell (06:43):Desiccated the tear film. So, we do have a very specific protocol when we're having a formal dry eye evaluation. So that's a patient that's scheduling for their baseline exam. We don't do anything with, um, tonometry that day unless I'm checking it in the exam room after everything is done. So the first thing that they do is actually osmolarity. Um, and you also want to guide that patient to come into your office without putting any drops in their eyes-

Jackie Garlich (07:10):Mm-hmm (affirmative).

Leslie Odell (07:11):Within 2 hours of the exam, because a teardrop or a medication drop could also, false of, you know, give you a false positive or false negative result for that matter.

Jackie Garlich (07:20):So then also contact lens wearers, they're wearing glasses and for that business?

Leslie Odell (07:24):Yeah. So, the contact lenses kind of is a little bit tricky like you are supposed to do, you're gonna get your best result when the patient is not wearing a contact lens, but I am a little bit more lenient in, with those patients. I actually like to see what that looks like when their contact lens is in place. So I, I do it with the contact lens in place a lot of times-

Jackie Garlich (07:44):Oh, you do?

Leslie Odell (07:45):Just my, you know, my own self. If they're coming in for maybe a follow-up or something, if it's a new evaluation, I probably would have them come in with glasses. But sometimes you wanna see what's happening when they're wearing the lens, right? Is the lens adding to some kind of tear film instability that, you can target the lens also while you're treating the dry eye?

Jackie Garlich (08:05):Yeah. So then ... Okay, so let's talk about TearLab. Okay, so let's say that you're getting a normal TearLab reading. So a normal osmolarity, let's say it's in the 280 range and the inter-eye asymmetry is there, there isn't one really, you are then, then what are you thinking? Like, okay, this patient is complaining of what seems like dry eye, but what their tear osmolarity is normal. So then how does that change what steps you're taking?

Leslie Odell (08:32):So, that helps me in understanding that they're able. A lot of times how I'll even address that to the patient is that, say they are evaporative, a lot of times I'm thinking that that patient might still be an evaporative dry eye, so more of an oil deficient versus aqueous deficient. So, my next step would always be InflammaDry, and then my next step would be vital dye testing, and then my next step would be meibomian gland evaluation with expression. But that's usually where I find that a lot of the patients who have a lot of symptoms with normal osmolarity could be meibomian gland dysfunction.

Jackie Garlich (09:05):Hmm.

Leslie Odell (09:06):So, it kind of, you know, getting into the other point of care testing, what would matter to me then if that's normal is, are they positive or negative on InflammaDry, that would be my next kind of question before I even take a look at that patient. The other thing to think about with these tests are sometimes they help you identify the patient that thinks they have dry eye or that you thought had dry eye, but they don't. And they have those masquerading syndromes, which could be something like map-dot dystrophy, recurrent erosion, maybe even like a nocturnal lid seal type problem that you may not have been picking up on.

Jackie Garlich (09:38):So, I was thinking that TearLab was helpful or you would get an abnormal reading on TearLab if you had a, not just an aqueous but also olympia deficiency too? Was that not, do you not find that as much?

Leslie Odell (09:50):No, you will, you will.

Jackie Garlich (09:51):You will? Okay.

Leslie Odell (09:51):For sure. Mm-hmm (affirmative). It just sometimes helps me know like how long has that cycle of inflammation been spinning. So, if they're early in the disease and they have meibomian gland dysfunction, they might actually still be normal in osmolarity, but they could have still poor function because their homeostasis, they, their body can regulate better and keep the homeostasis of the tear film. So, I, it doesn't rule out my, it, it's definitely inclusive of both diseases, it doesn't tell me anything about aqueous or truly aqueous or truly evaporative, I would say.

Jackie Garlich (10:25):Okay.

Leslie Odell (10:26):The other, the other finding that I find useful is the patients that are on lots and lots of medications, you know, sometimes they're in the, you know, they're in the severe state of, of an aqueous deficiency, dry eye when they, I might see numbers up into three 380s or something like that. The other, you know, the other thing that you had mentioned earlier was how do you do that? Do you do it every time? And yeah, I do, I do osmolarity every time because it's sort of like an eye pressure to your glaucoma patient. You want to see what is changing different times of day, are the readings different? Different times of year, are the readings different? You can learn a lot about the environmental stress and challenges that your patient’s dealing with. But that's also been a lot of the negative feedback I hear from our colleagues.

Leslie Odell (11:09):You know, well that number is different every time I look at it in the variability is, you know, makes that test not reliable. But would you ever say that about intraocular pressure, right?

Jackie Garlich (11:19):(laughs) Right.

Leslie Odell (11:19):No you wouldn't. And you learn from that. If you see a big spread in your IOP, you know, six or 10 points, you're actually gonna start thinking like, "Oh, this person might be more at risk for disease." You're going to look at them more. Same is true when I see that if I am in the 290 one day and then I'm 330 the next day, I think what's changed? Is it winter? Is it low humidity? Did they have their heat on? You know, I'd try to figure out what's the environmental stimulus that might be causing more of that fluctuation.

Jackie Garlich (11:46):Okay. So if you, you use that, so you're doing it every time you've got your number. I mean, is this like a gauge for the patient too, like as a patient sort of like, “Oh, I'm 330 today versus I'm 290.” Are they into this or no? Or is this mostly just for you, like do you involve them?

Leslie Odell (12:02):They do see... I mean, I do involve them. I know that the way that the company is structured, when they train you, they really want you to kind of write it down and to end how the patient and show them on this scale. I usually just say like, you know, "Hey, things are looking better, things are getting worse." But I mean, should we give them the number? Probably same as my patients that don't know their A1C and they just say their doctors say they're okay you know? It's nice to be in control of your own health.

Leslie Odell (12:26):It's also interesting though, because sometimes as I start, start therapies, I might see hyper. So, you have to just, you know, if they were normal osmolarity and then I put him on a medication, sometimes they might actually go hyper, doesn't mean the medication's not working. It just means maybe there's, again like an environmental thing ,maybe it's just your body's way of reregulating the tears as you're in the healing process. So there's a lot of nuances to it so empowering them is good, but you also don't want to make them feel defeated if the number is too variable.

Jackie Garlich (12:57):Yeah.

Leslie Odell (12:57):So there's just kind of a little bit of a fine line in educating the patients. But, so, I do tell them, or when it does look like it's gotten worse, I'll say what's different? You know, a lot of times they'll say, you know, that they'd been working longer hours or again, the environment that they're working in is dry. We sometimes look at work in home environments for humidity levels to see where we can help that.

Jackie Garlich (13:19):So let's say that you have, what about like the range of the on the spectrum. So let's say that you have normal versus like a really high, almost 400 osmolarity reading. Oh that's the-

Leslie Odell (13:30):Are you thinking, yeah-

Jackie Garlich (13:31):Go ahead.

Leslie Odell (13:31):For, I mean, the hindsight probably seen as in the 380s personally. But, um-

Jackie Garlich (13:36):If you're, but if you're getting something higher, like are you thinking, okay, it's, this is really high, this is advanced. So, I'm going to be thinking I'm gonna do this for treatment or look at this or, you know what I mean? Like does that gauge like where your eye is kind of going?

Leslie Odell (13:52):It does, but I always am pairing it, usually with that next thing, which is MMP-9 testing. So-

Jackie Garlich (13:58):Yeah.

Leslie Odell (13:58):Looking at that protein specifically in the tears, we know that that's linked to inflammation. It can be positive or negative and there can still be inflammation. So, it's not an end-all be-all with, you know, InflammaDry testing. But it's super helpful. So, if I have a patient that is hyperosmolar and they have a positive InflammaDry, that's like an easy patient to treat. Right? You know, dry eyes, inflammatory, now you can see it. And you also can see that it's taking a toll on the homeostasis of the tears and you're hyperosmolar, which is fueling the inflammation cycle. So those patients are your easiest ones to put on a therapeutic, right? Whether it's short term wit, corticosteroid, but you definitely want to be thinking long-term with things like lifitegrast and cyclosporins. That's where those fit great.

Leslie Odell (14:50):And you watch your numbers to make sure that you're making a dent in the way that they look, right? You want to bring them down with time. But, say that you have hyperosmolarity, normal InflammaDry, I'm still going to treat that patient the same way because sometimes there is a miss, you know, the InflammaDry might not be picking up the MMP-9, sometimes it just might not yet be to that level. So anytime it's hyperosmolarity, I'm definitely treating with a therapeutic. The trickier part is when I have normal osmolarity and normal InflammaDry.

Jackie Garlich (15:23):Mm-hmm (affirmative).

Leslie Odell (15:24):You know, so normal osmolarity, normal InflammaDry, I could still have a rapid tear breakup time. I could still have meibomian gland deficiencies and I could be dealing with something totally unrelated, like we were talking about with map-dot dystrophies. The other scenario would be normal osmolarity, positive InflammaDry, and again with the therapeutics that we have, you know ... So really when you're managing dry eye, we try to make it so difficult, but it's really doesn't-

Jackie Garlich (15:49):Mm-hmm (affirmative).

Leslie Odell (15:50):Have to be.

Jackie Garlich (15:50):Right.

Leslie Odell (15:51):You know, the majority of the time, that patient needs a therapeutic. So just treating them with something that's anti-inflammatory, and again, corticosteroids are great for your short-term or maybe your flare ups, your patients that are flaring up 'cause now it's estimated that that happens maybe six times out of their year. But you need something that's going to blanket inflammation and help keep them maintaining homeostasis. And that's where we've been fortunate to have, you know, a few medications to treat.

Jackie Garlich (16:20):So, what is your treatment of choice? Like what's your corticosteroid of choice when you're doing just a short-term for your dry eye people? Are you doing Lotemax?

Leslie Odell (16:28):I use, I use a lot of Lotemax. I've been using more Flarex. In all honesty, it's really what is going to be affordable for the patient. It's really like I'm, when it comes to the corticosteroids, I'm doing more jumping through the hoops of their insurance plans than anything else. What I've seen that I don't like, and I personally don't do because of these insurance challenges, I've seen a lot of our colleagues go right to like full strength Pred Forte or prednisone Acetate 1% versus the generic. And I just still haven't been too comfortable with that because of the risk for, you know, IOP spikes and such. But when you look at the pricing, it's pretty shocking the difference-

Jackie Garlich (17:10):It is.

Leslie Odell (17:10):Between that, and sometimes what you would consider like the fluorometholone family. But the companies have been working hard, at least for our commercial patients, most of them to try to bring down the cost. And then some of them also are translating into the Medicare patients. So, that's kinda my, my go-to there. But honestly, with things like the lifitegrast family, I, in all honesty, have gotten away from a lot of steroids and I do reserve them for this idea of the flare. So, you know, some companies are looking actually to get indications for dry eye flares and they've had research that shows these six times a year that your patient flares up. And whenever I'm treating a patient, I'd send them home with that information. You know, if you're getting worse and your worse for a couple of days, it's worth a phone call because there's something that we can do instead of just feeling bad and not having an answer.

Leslie Odell (17:59):So that's really where I've kind of reserved them with things like lifitegrast. I can get symptom control so much quicker, and I can get to even corneal improvement so much quicker than past, you know, in the past. So, I feel like I've kind of given up on pre-loading with steroids a lot. Sometimes if I'm going to be doing in office procedures with, you know, meibomian gland clearing treatment, that's still where I might use them. You know, blepharitis patients, that kind of thing pre-surgery maybe. But-

Jackie Garlich (18:30):Yeah, do, where do you, well maybe we should talk about inflammatory too. So InflammaDry, you know, measuring the level of MMP-9 ,which is the inflammatory biomarker in the tears. This, when you get this reading for the InflammaDry, it's sort of like a, you know, line on this cha- on this like little pregnancy-like looking test. Are you-

Leslie Odell (18:52):Our techs, our techs like to say, “You're having baby eyeballs.” (laughs)

Jackie Garlich (18:55):(laughs)

Leslie Odell (18:55):But it is the pregnancy test of your tears, we kinda make that joke.

Jackie Garlich (19:01):Yeah that's exactly what it looks like. But if, if you, when you get these readings, you know, there's like faint lines and they're sort of a darker line, like you're like a little pregnant or a lot pregnant or whatever. Like if you, is that, that's not, what's your repeatability on that for a patient? Like are you repeating that on the follow-ups too? Like you are with TearLab or you must send the-

Leslie Odell (19:22):I am but-

Jackie Garlich (19:23):Singlet as your initial?

Leslie Odell (19:24):No, I use it initially and it is a little bit tricky and I would definitely lean on the reps there like you had said earlier, just to kind of give you a little guidance on your insurance billing before you are just doing it every time because sometimes I think that if it's not positive the first time, some of the payers might not be paying for that second time. Definitely, if it's positive one time, you need to repeat it to see if it's positive a second time. I know in our area, sometimes some of our medical assistants’ plans aren't paying, which doesn't always mean that we're not doing it. We just prepare the patient that you might have this X amount of dollars out of pocket. But, so, that's looking for that matrix metalloproteinase-9, that's that protein and it's sensitive when it's about 40 nanograms per milliliter.

Leslie Odell (20:09):So that's where you're going to get that faint pink, like, you know, barely visible line. And then as it's also the timeline that it comes out like, so if I'm getting a test within a couple minutes of a row of a collection, then I know that that's going to be a strong positive. In my chart, I document it that way, either I will say strong-positive, weak-positive. That's usually how I do. I've seen some people do like two pluses, one plus. There's definitely some work done that showed that there is this quantification of the MMP-9 testing just from the different colors of the pink line-

Jackie Garlich (20:42):Mm-hmm (affirmative).

Leslie Odell (20:43):That you know-

Jackie Garlich (20:43):Yeah.

Leslie Odell (20:43):You're seeing. So, I usually just go strong-positive, weak-positive and then when I see them back and retest, I see if that's any, you know, where am I on that? It did a strong go weak, did it completely go away? That's important. But it's been able to identify some, some of those other masquerade syndromes like mucus fishing syndrome. Mucus fishing syndrome is a syndrome that I, you know, learned from a cornea specialist years ago. And I thought, “I'd never heard that in school.” You know, that was not something that was top of mind for me years ago. But I have a patient, in particular, that has been through, he's on a topical, he's been through gland treatments and he will light up with lissamine and his InflammaDry was positive. Right? And I asked him, you know, are you always rubbing that eye? And show me what that looks like? And, and it was amazing what he's doing as far as local trauma, uh-

Jackie Garlich (21:32):

[crosstalk 00:21:32]-

Leslie Odell (21:32):Every day. And so, you know, for him just learning a little bit about him, I was able to teach him to stop touching his eye and stop rubbing his eye and that made a big difference then when we continued his treatment and saw him back. So, sometimes if you're, you know, if you're still positive after your adequate time of treatment, you might be questioning, well, is my treatment effective? But you might also need to ask the patient those questions. I actually oftentimes videotape how they rub their eyes. I ask them, are they eye rubbers? And then I say, show me how that looks, and it, it's frightening. I had one lady actually scratch with her fingernail her, um, bulbar conjunctiva.

Jackie Garlich (22:09):I think I, I think I saw that video. (laughs)

Leslie Odell (22:12):Yeah, it was really impressive.

Jackie Garlich (22:13):It was terrible. Yeah.

Leslie Odell (22:13):Yeah, yeah.

Jackie Garlich (22:15):So if we're talking ... So maybe I kinda don't wanna bring up the cost factor of the point of care testing because bringing, now that I own a practice, like every decision I make is now like, alright, is this good? Is this a profitable decision? Is this a good decision? Is this gonna help us in the long run? Like I, you know, obviously didn't think about that as much when I wasn't the owner. And I know point-of-care testing is, this is not going to generate a huge income for you, and, as you said in like the first episode, that's really not the point of the point-of-care testing, it's really like you're gathering all these different pieces to the puzzle. But if we, if you're thinking about entry into one of these two point-of-care testing, so InflammaDry, I think, is a cheap, like a lower cost of entry into that.

Jackie Garlich (23:05):Meaning, you're just buying those, you know, the test strips versus you're buying the whole device with TearLab. Let's say that you just have InflammaDry, that you're just starting with InflammaDry, are you, you know, you're getting either a positive or you know, strong-positive, weak-positive, or nothing. Are you then saying, okay, let's say that I just have this point-of-care testing, I don't have to TearLab yet, what am I doing for my strong-positives? Are you always starting these people on a corticosteroid or are you just going, I guess it all will depend obviously on the rest of the case, but maybe run me through your thought process on like when you see just a, let's say you didn't have osmolarity and you're just doing, you know, a TearLab or InflammaDry.

Leslie Odell (23:48):So, if I have positive InflammaDry, again, it's one piece of your exam, right? So, it would be like you're just treating glaucoma with the eye pressure, right? We're totally passed that. We need to know what the optic nerve looks like. We need to know what the visual field looks like. We want to see what the OCT looks like. All of those things. So if you have just that one piece, you need your exam. So, let's say that you have positive InflammaDry and you have, you know, meibomian gland dysfunction with some staining on the cornea or even conjunctiva tissue, definitely you're thinking of a long-term solution for that patient, right?

Leslie Odell (24:28):You wanna be doing the, again, the corticosteroids are great for improving symptoms fast, but really the medications that we have don't take that long in the big scheme of things if you're just coaching the patients. And then it comes down to costs, can you pair two medicines and are you gonna get them both through as a prior authorization? Do you have to do a step approach? All these things that we didn't have to think of before. So, in the ideal world, I'm not thinking about insurance, I keep it simple for patients, and I would go straight to lifitegrast or cyclosporine bypassing-

Jackie Garlich (25:01):Okay.

Leslie Odell (25:02):A steroid.

Jackie Garlich (25:03):Got it.

Leslie Odell (25:03):That's me, but I, and like I said, I know that that might, but I try to keep it simple and then if, if I need to add it back, I will. But think about the adherence of glaucoma medications, right? Patients can't adhere to more than one, and that's once they, you know, more than one medication rather, their adherence rates drop. And that's for a disease that they know the end result could be blindness.

Jackie Garlich (25:30):Yeah.

Leslie Odell (25:30):Yes, dry eye feels bad, so we have that in our favor. At least there's this reminder to the patients that they gotta be using something, but at the same time, like we really make their life complicated when we give them too many steps in a day. Plus, you as the doctor, you're changing too many variables. So, I'm a, I'm a big fan of, you know, a step approach.

Jackie Garlich (25:48):The other thing is on the, from a cross perspective too, I know the reimbursements. That's something that I know you can work with the rep with. I talked with Quidel about reimbursements just for these testings, but you kind of brought up a good point whether or not the, you know, they're going to get paid for doing that testing versus letting the patient know. But again, I think, as you had said before, it's really the value that you get out of the testing and not as much like we're trying to generate an income, but more of like a, the equivalent of a chemistry and an IOP and an OCT individual field and all this.

Leslie Odell (26:24):Right. You wouldn't say like, I don't know if peer chemistry's worth it to me how much-

Jackie Garlich (26:29):Right. (laughs)

Leslie Odell (26:29):Cost and how much you're getting reimbursed. Like you wouldn't think, Hmm, I'm not sure that I, you're going to want that number because you know how valuable it is to the glaucoma patient. And that's really where we got to get things with point-of-care testing. They, it is a huge value look at new research, you know, put out by ACRs, they're saying to figure out before a patient has surgery, cataract or refractive surgery, you need to do these things. Osmolarity, InflammaDry, if they are positive on either one, now you're moving to your next step, which is like a dry eye survey and your evaluation and if they have visually significant dry eye, they are pausing surgery.

Jackie Garlich (27:07):Oh they are? Okay.

Leslie Odell (27:08):Yeah.

Jackie Garlich (27:09):Yeah.

Leslie Odell (27:09):So-

Jackie Garlich (27:09):Of course.

Leslie Odell (27:10):I mean that's what we have to do, that's what we have to do with our, you know, we have to really embrace the research that's out there. There's not just like, you know, just like OHTS did with pachymetry. I mean, imagine if you thought about that that way. How much does a pachymeter cost? I don't know.

Leslie O’Dell (27:27):(laughs) You probably don't know.

Jackie Garlich (27:27):(laughs) It came with my practice, I don't know. Yeah. Yeah. Okay. Good point.

Leslie Odell (27:30):So, I think optometry really needs to embrace it because we are kind of the gatekeeper for these patients. So that is the MD, right? ASCRS, that's now the MDs taking back over, because their research showed that when patients were coming in for cataract evaluations from us, that as high as 70% to 80% of patients had dry eye and they didn't know it. And then of those patients, sometimes 50% of them would have central corneal staining and they weren't on a therapeutic. So that really looks bad for us, right?

Jackie Garlich (28:06):Yeah.

Leslie Odell (28:06):That looks bad for us.

Jackie Garlich (28:06):Yeah.

Leslie Odell (28:07):So, now they're kind of taking charge of it saying these are what we need to do as the surgeons to ensure that our numbers are going to look good and our patients are going to have a good outcome. But it all goes back a step. If he asked me, it all goes back to the referring OD. So, if you don't have that testing, then you know, find a center that you can work with, you know, and support a local optometry, optometrist in a dry eye center of excellence and really, you know, get them that pre-surgical evaluation.

Jackie Garlich (28:43):So, now for the to the point replay. Point-of-care testing is tear osmolarity and MMP-9 through InflammaDry. You need a CLIA waiver to do point-of-care testing in your clinic. A good resource is cms.gov, as well as representatives from both of the point-of -are testing companies TearLab and Quidel. Typically, it takes about 4 to 6 weeks to obtain your waiver, and this can be renewed for 2 years per location at $150. It's best to implement staff training to increase your efficiency within your practice and also understanding the test norms help to guide your treatments when examining these patients.

4/13/2020 | 29:49