EYECARE Saving Boomers' Sight How ECPs Are Diagnosing and Treating Eye Diseases By Catherine Wolinski, Contributing Editor Monday, October 17, 2016 12:30 AM RELATED CONTENT The Changing Face of Dry Eye Click here to download a PDF of Saving Boomers' Sight. As Baby Boomers enter their senior years, many encounter age-related vision problems that threaten their sight. In the U.S. alone, millions of Boomers suffer from dry eye, macular degeneration, glaucoma, cataracts, intraocular lenses, retinitis pigmentosa and diabetic retinopathy. In this article, the last in Vision Monday’s three-part series about Boomer vision, titled Senior-Eyetis, eyecare professionals explain how they are treat Boomers who are fighting these potentially-blinding eye diseases and ocular conditions. The series began in VM’s August 29 issue with “Senior-Eyetis: How ECPs Are Managing Boomers’ Aging Eyes,” which discussed how ECPs are treating patients with presbyopia, night vision problems, glare sensitivity and low vision. It continued in our September 12 issue with “Getting Boomers on the Right Wavelength: How ODs Help an Aging Generation Manage UV and Blue Light,” providing a look at how patients can protect their eyes from potentially harmful radiation, both indoors and outdoors. Both features are available at VisionMonday.com. As an optometrist, perhaps you’re familiar with the scenario: a woman in her 50s or 60s in the exam room chair, complaining of redness, burning or itching in her eyes. She’s having trouble making it through the day at her desk job without visual discomfort or fatigue. Even worse, she had to steal time away from her grandson’s school play to re-apply the artificial teardrops she purchased from the drugstore and has been using, without much success, for the past few weeks. She’s suffering from dry eye, a common affliction of Baby Boomers. The chance of getting of dry eye increases with age, though other risk factors are becoming more common—patients who have undergone refractive surgery, have severe allergies, are on certain medications, or are contact lens wearers, to name a few. Prevent Blindness America estimates that approximately 6 million women and 3 million men in the U.S. suffer from moderate to severe dry eye symptoms, with women’s risk increasing with pregnancy, some birth control medications, hormone replacement therapy or menopause. Of those 9 million people who have dry eye, the National Institute of Health’s National Eye Institute estimates that 5 million are 50 years of age and over; of these, more than 3 million are women and more than one and a half million are men; and tens of millions more have less severe symptoms. As aging Boomers swell the ranks of dry eye patients, ophthalmic companies have responded with a growing assortment of treatments ranging from eye drops such as Allergan’s popular Restatis and Shire’s newly released Xiidra to warm compresses and thermal pulsation. However, the first step toward treatment often depends upon effective communication and patient education. Marguerite McDonald, MD, FACS. “It’s really interesting that conversations between patients and their eyecare practitioners don’t seem to be routine,” said Marguerite McDonald, MD, FACS, an associate of Ophthalmic Consultants of Long Island (OCLI), an 11-location network of surgical practices in New York. More than half of adults with dry eye think it’s a normal part of aging—they don’t understand there is potential for long-term damage,” she said, citing a recent Harris Poll of optometrists, ophthalmologists and U.S. adults with dry eye symptoms sponsored by Shire, a specialty biopharmaceutical company whose therapeutic areas include dry eye disease (see sidebar). Also of concern is dry eye’s effect on peoples’ work productivity, social lives, physical appearance and even self-esteem. “Based on responses from adults, their symptoms impact more than their eye health. Most reported [dry eye] symptoms impacted their ability to be in front of a screen, their hobbies, their daily activities, their job or career and their ability to work,” said Dr. McDonald, who helped advise Shire on the development of the Harris survey questionnaire.” Dr. McDonald’s concern is echoed by eyecare experts across the country. At the TearWell Advanced Dry Eye Treatment Center at the Southern College of Optometry in Memphis, Tenn., Whitney Hauser, OD and her colleagues Alan Kabat, OD, FAAO, Rachel Grant, OD and Kristina Haworth, OD, routinely observe dry eye’s effect on patients’ lifestyles. “For patients with moderate to severe dry eye, it affects their activities, their daily living and their quality of life,” said Dr. Hauser. And although a majority of patients fall within the Baby Boomer age range, Dr. Hauser said she and her colleagues have noticed a change in recent years. “We see the demographic shifting with digital device use, along with medications people are taking,” Dr. Hauser said, noting that her youngest patient recently was just seven years old. “All dry eye is not all dry eye, so to speak.” Kathleen Andersen, OD, a private practitioner in Rancho Santa Margarita, Calif., also noted that the dry eye demographic is changing. “Anyone [who uses] the computer for a long time is a candidate,” she said. “Because we’re all on our devices, the blink rate slows down.” Dr. Andersen added, “It’s important to address these issues because nobody else is doing it. There’s a lot of suffering and it’s a quality of life issue for a lot of people.” Crystal Brimer, OD. Check Your Connection: Communicating About Dry Eye Crystal Brimer, OD, owner of Focus Eye Care in Wilmington, N.C., believes that communicating with Baby Boomers about dry eye and its potential symptoms is essential to eliminating this common condition. At Focus Eye Care, Dr. Brimer developed a dry eye center devoted to advanced diagnosis and treatment of the condition using advanced technology. She emphasized the importance for optometrists to conduct proper screening. “One of the main goals I have is to get optometrists to implement a screening process so we can identify dry eye patients before they come in with a list of complaints,” said Dr. Brimer, who has devoted a large portion of her career to lecturing on the topic around the world. “Because dry eye is such a progressive disease, this will allow us to treat proactively instead of reactively, and effectively change the outcomes dramatically.” At OCLI, Dr. McDonald and her associates also devote attention to dry eye with a Dry Eye Center of Excellence. A specific and easily adoptable strategy Dr. McDonald recommends is pre-screening patients with the SPEED questionnaire, developed by TearScience, a medical device company based in Morrisville, N.C. “In our practice, everybody gets the SPEED [Standard Patient Evaluation of Eye Dryness] questionnaire. It’s easy for patients to fill out and leads to a more meaningful conversation in the exam room,” she said. On the questionnaire, patients are asked to identify symptoms such as dryness, grittiness or scratchiness; soreness or irritation; burning or watering eyes; and eye fatigue by checking off boxes, as well as ranking the frequency of these symptoms. The SPEED survey is also the pre-screening strategy of choice at TearWell, which finds its brevity beneficial for both doctor and patient. “As the name implies, it doesn’t take too long,” said Dr. Hauser, noting that longer surveys and forms can be cumbersome in busy private practice settings. “It’s useful in talking to patients and getting the conversation started.” Treating Dry Eye: Beyond Drops and Warm Compresses Another approach to alleviating the recent rise in dry eye is by incorporating more advanced and targeted treatments into optometry practices. One such treatment believed by many ECPs to be more effective than the typical artificial tears and warm compress combination in treating Meibomian Gland Disease, a leading cause of dry eye, is LipiFlow, a thermal pulsation treatment developed by TearScience. Dr. Hauser said, “The problem with warm compresses is that for the heat to have an effect, it has to be so hot that it’s not tolerable to the skin. This tends not to be very effective, but is often recommended. For mild dry eye, perhaps this is beneficial, but when it’s moderate to severe, patients won’t continue [the treatment plan] and LipiFlow will give a greater outcome.” Dr. Jordan Kassalow, OD, a partner at Farkas, Kassalow, Resnick & Associates (FKR) in New York, also acknowledged warm compresses and drops as unfavorable treatments for moderate to severe dry eye, referring to them as the “Band-Aid” approach. “We use warm compresses and lid scrubs to try to get those glands to produce more and cleaner, better oils. We also do lid massages where the patient is taught how to clean the lid so the orifices of the glands are clear, allowing the oils to escape from the lids more easily and get into the tear film. But that’s all pretty simple stuff. Sometimes that all works, and sometimes it doesn’t.” Dr. Kassalow incorporates LipiFlow at his practice on a case-by-case basis. Diabetic Retinopathy: A Retinal Picture Speaks a Thousand Words Incorporating new technologies is an effective way of communicating with Boomers about a variety of conditions, according to Karen Allen, OD, owner of Premier Vision of Dallas. At Premier Vision, Dr. Allen has found that new imaging technologies have been particularly beneficial. The TearWell team, (l to r), Rachel Grant, OD; Alan Kabat, OD, FAAO; and Whitney Hauser, OD. Kristina Haworth, OD, is not pictured. “There’s been a lot of new technology coming out that’s helping with diagnosing and following disease progression. One of the big things that’s come out is OCT technology, which takes a scan of the back of the eye and shows on an almost cellular level what the retina is doing. If you have retinitis pigmentosa or diabetic changes, the image shows you those changes. “It is an easier technology for both doctors and patients, and it does a lot of things that fluorescein angiography doesn’t,” said Dr. Allen, referring to a common procedure in which a fluorescent dye is injected into the bloodstream to highlight blood vessels in the back of the eye to identify leaks and other issues. Dr. Allen has found OCT especially beneficial in starting conversations with diabetic patients about their vision and overall health. “By far, the most prevalent disease I see among Boomers is diabetes. What I usually do is sit and talk about their numbers like A1C, how to measure their own blood sugar, diet and exercise … see how they’re living their life and how they’re managing their diabetes personally.” She then shows patients detailed images of their eye on the spot, so they can see the changes happening in their eye. “I take a retinal photo and show them what their retina looks like, what their optic nerve looks like, show them where they may have some bleeding. They could be seeing 20/20 and have diabetic retinopathy. It’s a silent disease—they can’t tell they have it unless they look.” Even for diabetic patients who don’t have diabetic retinopathy, Dr. Allen goes through the same process. “If they don’t have diabetic retinopathy, I will Google it and show them someone who does. Showing them the picture of their own eye and showing them what’s normal and abnormal really hits home with them more than saying ‘okay, everything looks good, see you next year.’” Jordan Kassalow, OD. Age-Related Education At her California practice, Dr. Andersen takes a similar approach to treating Boomer patients, embracing new technologies to educate them about a variety of age-related diseases. “In my practice, we’ve brought in a lot of technology to screen patients’ general health because we feel that a lot of people don’t go to a primary care physical for a checkup—but they do come to their optometrist. We set up equipment in the exam room to screen for glaucoma, AMD and diabetic retinopathy at the same time,” said Dr. Andersen. “It’s amazing what you can catch with a simple screening. Once a patient sees the results on an iMac in the exam room, it’s hard for them to deny something might be wrong.” To educate Boomer patients about the risks of age-related macular degeneration, for example, Dr. Andersen and her associates show patients photos of their retinal scans and tailor their conversation techniques accordingly, even if the patient shows no signs of AMD. “If the macular screening is clean, we talk to them about risks for developing loss of vision due to lifestyle—smoking, working outside in the sun a lot—and we lead that into protecting their eyes with sunglasses and perhaps taking an ocular vitamin.” In addition to her scanning laser, which has been instrumental in detecting macular holes and numerous cases of glaucoma, Dr. Andersen said, she was also the first optometrist in the country to offer CIMT (Carotid Intima Media Thickness), an ultrasound test that detects cardiovascular disease. This treatment not only allows Dr. Andersen and her associates to locate damaged blood vessels in the retina, but to identify atherosclerosis and plaques that are potentially damaging to the heart. If she sees a problem, Dr. Andersen said she gives her patients a “report card” with nutritional information designed to educate them and help them create positive changes in their lifestyle. Karen Allen, OD. Bringing in the (Other) Experts Along with addressing all aspects of Boomers’ health, Dr. Andersen also incorporates outside expertise from other specialists, often referring patients to a dietician for nutritional help. “A lot of patients know that you can make changes in your lifestyle by changing your diet and exercise, and they might want to do it but don’t know how. A dietician can write them a treatment plan, which I find is helpful.” She also co-manages cases with primary care physicians when test results point toward other health conditions, such as hypertension, high blood pressure or macular edema, writing letters to patients’ primary care doctors regularly. Mile Brujic, OD, FAAO, a glaucoma specialist at Premier Vision Group in Bowling Green, Ohio, believes that optometrists need to embrace this form of full-scope care as the Baby Boomer generation ages. One way he does this is by treating concurrent conditions in-house (for example, a combination of glaucoma, dry eye and AMD), while also knowing when working with outside ophthalmologists is necessary. “Optometrists are going to get significantly busier as we have more opportunities to care for patients with age-related eye diseases in-house,” he said. “Ophthalmology is going to be leaning on us a lot more, a lot of primary care is going to be taken over by optometry, and we’ve already stepped up big time,” Dr. Brujic said, noting the growing population of Baby Boomer patients in need of eyecare treatments. “I’ve been in clinical practice for 14 years. I hear people say your practice ages with you—and it certainly does—but the percent of patients I see that have medical conditions continues to increase every year as patients continue to age. It’s occupying more and more my of time.” Co-managing Cataracts and IOLs As optometrists adapt to an increase in Baby Boomer patients in their practices, many say co-managing patients with ophthalmic specialists is particularly beneficial in cases of cataracts and intraocular lenses (IOLs). At Premier Vision Group, Dr. Brujic said, optometrists work closely with the ophthalmologist who performs their patients’ cataract surgeries. “We see our patients day one after surgery out to day 90,” he said. Before surgery, Brujic said, “what’s incumbent on the optometrist is discussing IOL options. A patient may be candidate for a premium IOL versus a standard IOL, and the ophthalmologist may be meeting the patient for the first time, whereas we’ve established relationships with these individuals.” Kathleen Andersen, OD. Likewise, to co-manage cataract patients, Dr. Andersen refers to one or two surgeons in the area. “I have a good relationship with both of them. I like to talk about the latest technology of IOLs and what they could choose. I think it’s really important for optometrists to keep up with what lenses do become available—it’s important so you can explain to patients that may want to spend a little more for a special type of refractive error. As their doctor for so long, you are in the best position to recommend what’s best for them.” “A lot of times after cataract surgery, patients have complications and experience overall dissatisfaction with their treatment,” said Dr. Hauser, adding that what a patient may experience as an adverse event following surgery is oftentimes the result of an untreated ocular surface issue. “It’s ideal to identify what challenges patients are going to have prior to surgery, especially when treating presbyopic patients who are seeking multifocal intraocular lenses. For someone paying a premium price for surgery to see distance and near, expectations are going to be higher. By tackling those parts on the front end, the result will be more successful.” At FKR, Dr. Kassalow says that although his practice does not have any formal arrangements with ophthalmologists in the area, he and his associates do co-manage laser vision correction. “A lot of patients who are our patients for years choose to do laser vision correction. If person is a good candidate, then we are as comfortable recommending laser surgery as we are glasses and contact lenses. “We refer them to specialists, but do pre-operative evaluations on the day of surgery, then they go to the laser center. The day after surgery, the ophthalmologists send them back to us and we do all of the post-operative care.” Mile Brujic, OD, FAAO. Interestingly, on the surgical side, issues surrounding laser surgery for patients with refractive error has particularly surfaced with the Baby Boomers, according to Dr. McDonald at OCLI. “The Greatest Generation never wore contact lenses. Boomers frequently wear contact lenses, but will take them off and wear their glasses for their eye exam,” she said. This is problematic, she continued, because contact lenses can change the shape of the cornea, and if an ophthalmologist is unaware the patient is a contact lens wearer, false measurements may be taken, leading to inaccurate surgery. “Contacts are like a girdle—they need to be out for three to four weeks before surgery,” Dr. McDonald said. “Once in a while, someone will come in without contact lenses and you can tell they’re still unmolding. But it’s a new thing, because we’re used to operating on patients in the World War II generation, who almost never wore contacts.” Strategize, But Don’t Generalize To provide the best care possible for Baby Boomers, Dr. Brujic said, optometrists should practice age-specific strategies that are successful, but also to acknowledge that cases should not be generalized. “I used to treat individuals in different age categories very differently. Eventually I realized the more you think they’re different, the more they function similarly,” Dr. Brujic said. This is particularly the case when dealing with conversations with Boomers about their digital device use. In a personal anecdote, Dr. Brujic shared a story in which his parents, ages 67 and 69, wished to see a set of photos he had taken on a digital camera. When he offered to send them via email, his parents scoffed at the prospect: “Can’t you just share them on Facebook?”