Dry Eye Technology Round-Up
By Sara Frye, OD, MPH, FAAO November 24, 2020
Dry eye is a condition that has historically been palliated, rather than treated. When a patient complained of ocular irritation, they were handed a sample of artificial tears and sent on their way. We really didn’t have any great treatments, so there wasn’t a whole lot of value in doing a more thorough assessment. Those days are long gone. We now have a range of diagnostic and treatment tools to manage this condition. Best of all, there’s always more in the pipeline!
Slit Lamp Examination
Dry eye diagnostic technologies haven’t replaced our traditional methods. Rather, they serve as an adjunct to the things we’ve always done, like a slit lamp exam. It is still very much worthwhile to assess the lids, lashes, meibomian glands, tear break-up time, corneal staining and more.
TearLab is a quick and objective point-of-care test that helps to confirm the diagnosis of dry eye and grade its severity. Using a cartridge loaded into the device, a tear sample is collected and its osmolarity measured. A number greater than 300 indicates a loss of homeostasis of the tear film. A difference of greater than 8 between the two eyes indicates tear film instability. Therefore, if the reading is > 300 or if there is an inter-eye difference of > 8, the eyes are dry. The exact value of the reading helps us to classify the dryness as mild, moderate or severe. This test is also incredibly valuable in ruling out other possible causes of irritation in the eye, such as allergic conjunctivitis, blepharitis, epithelial basement membrane dystrophy and more. TearLab is easily delegated to a technician. The 2018 Medicare reimbursement for CPT code 83861 is $22.48 per test or $44.96 per patient.
InflammaDry is another valuable point-of-care test for dry eye. It measures the levels of matrix metalloproteinase-9 (MMP-9) in the tear film. MMP-9 is an important enzyme in tissue remodeling, such as that in wound healing and bone development. It can be upregulated in dry eye, initiating a cycle of progressive inflammation. It is important to know how much of a role inflammation is playing in the dry eye patient, as it can affect treatment choices. The test may come out positive in other inflammatory conditions, such as ocular allergies; therefore, it is most useful when used in combination with other diagnostic tests, such as tear osmolarity. InflammaDry is also easily performed by a technician. The 2017 Medicare reimbursement for CPT code 83516 is $15.82 per eye or $31.64.
Meibography refers to imaging of the meibomian glands. There are various companies that offer this tool to aid in the diagnosis of meibomian gland dysfunction (MGD). Some of these are stand-alone models. Others combine meibography with other technology, such as topography. Meibography is most useful as a patient education tool. It can be used to demonstrate to patients the structural changes that are contributing to their symptoms. When patients see the truncation and atrophy of their glands, they are motivated to pursue treatment for their condition. A picture is worth a thousand words! While meibography is not currently reimbursable, it may pay for itself. This is because it leads to greater patient conversion to thermal pulsation and intense pulsed light procedures.
Anterior Segment Photography
Anterior segment photography, similar to meibography, is most helpful as a patient education tool. These photos can be used to document the patient’s condition and monitor their response to treatment. Showing a patient their lids before and after a Blephex allows them to see, with their own eyes, the value of the procedure. If there is a linkable diagnosis, such as blepharitis, photos can be billed. The 2018 Medicare reimbursement for CPT code 92285 is $21.24.
Diagnostic Tool Summary
Diagnostic devices are a great way to start out treating dry eye. With InflammaDry, TearLab and a slit lamp exam, medications and/or use punctal plugs can be prescribed. Anterior segment photography can be of value in recommending lid hygiene products that are sold in office; however, it is especially useful when paired with Blephex. Meibography is certainly best used in conjunction with a device for treatment. We will discuss the technology available for dry eye treatment next.
Thermal pulsation is a valuable treatment to unblock the meibomian glands. There are many devices now available on the market with various price points for differing budgets. After meibography is performed and reviewed with the patient, thermal pulsation can be recommended as a treatment. Despite this fact that this procedure has been on the market for many years now, it is still not reimbursed by insurance. Lipiflow and its more recent competitor, iLux, use disposable applicators; still, the sticker price for the procedure far exceeds this cost. Thermoflo doesn’t use any disposables, so there is less ongoing expense to deliver this treatment.
Intense Pulsed Light
Optima Intense Pulsed Light (IPL) is an alternative and very effective treatment for meibomian gland dysfunction. This technology has been used in dermatology for years. It’s now being used by eye care professionals as well, due to its value in treating MGD. Again, this procedure is not a reimbursable one; however, it certainly is valuable in helping patients with both the functional and cosmetic issues relating to their eyelids.
Blephex is like a dental cleaning for the eyelids. It removes the biofilm that accumulates along the lid margins. It also helps to control Demodex infestation. When used in conjunction with slit lamp photography or Blephex’s own proprietary LashCam device, patients can see their eyelids before and after the procedure. This can be a valuable tool in patient education and compliance. This procedure is not reimbursed by insurance but it does have a low overhead cost for disposable applicators.
The Right Combination of Diagnostic & Treatment Tools
With all the equipment available today, it’s easier than ever to serve patients’ dry eye needs. Patients love to see technology being used for dry eye, especially after they’ve had their complaints brushed off for so long. They want validation of their condition and treatments that work. You can offer them both.