Several expert groups in the U.S. and Canada have developed dry eye disease guidelines, but their complexity has made it challenging for community ECPs to implement strategies for managing dry eye disease in their practices. The goal of the Summit was to address this unmet need and make a substantial impact in the quality and consistency of care of dry eye patients at the community level by creating easy-to-use dry eye disease recommendations.

Over the two days of the meeting, the expert attendees discussed concise, effective recommendations for identifying and managing patients with dry eye disease. The Panelists were able to identify key areas of agreement and create straightforward, easy-to-implement recommendations in the areas of screening, diagnosis, and treatment.

Recommendations aimed at community ECPs are vital, given the magnitude of dry eye disease in the U.S. and Canada. In the U.S. alone, tens of millions of Americans are estimated to have some level of dry eye disease.¹ A survey completed by more than 650 ECPs prior to the Summit indicated that many of these individuals are going undiagnosed and untreated.²

The Summit participants plan to disseminate the insights from the Summit in a set of expert recommendations, as well as numerous publications and other communications throughout 2015.

Dry Eye Summit Co-Chairs were: Marc Bloomenstein, OD, FAAO, Schwartz Laser Eye Center, Scottsdale, Arizona; Derek Cunningham, OD, FAAO, Dell Laser Consultants, Austin, Texas; Ian Benjamin Gaddie, OD, FAAO, Gaddie Eye Centers, Louisville, Kentucky; Paul Karpecki, OD, FAAO, Koffler Vision Group, Lexington, Kentucky; Scot Morris, OD, FAAO, Eye Consultants of Colorado, Conifer, Colorado; and Kelly Nichols, OD, MPH, PhD, FAAO, University of Alabama at Birmingham, Birmingham, Alabama.

1. Sullivan DA, Hammitt KM, Schaumberg DA, et al. Report of the TFOS/ARVO Symposium on global treatments for dry eye disease: an unmet need. Ocul Surf. 2012;10:108-116.
2. Data on file. 2014.

Avenova is the only eye care product to contain Neutrox, NovaBay’s pure hypochlorous acid (HOCl), which is a naturally occurring substance produced by white blood cells to fight microbial invaders. According to the company, laboratory tests show it has potent antimicrobial activity in solution yet is non-toxic to mammalian cells; it also neutralizes bacterial toxins.

Avenova was cleared by the U.S. Food and Drug Administration as a prescription medical device through the 510(k) process. As previously announced, NovaBay signed a distribution agreement with McKesson Corporation, the largest pharmaceutical distributor in North America, making Avenova available to the 45,000 pharmacies it services across the U.S. In addition, Avenova is now available to the members of the Vision Source Independent Optometry Network.

Home vs. In-Office Lid Warming

Heat therapy has been the main form of treatment for meibomian gland (MG) dysfunction for decades. Until recently, in-office therapies were not available and patients were often instructed to perform warm compresses anywhere from 5-15 minutes, once to several times per day. Some patients are told to use food products such as hard-boiled eggs, baked potatoes and uncooked rice in a sock – all very “professional” options. Commercial heat masks are now available which likely gives us a little bit more credibility when prescribing this form of therapy.

One of the main issues with home lid-warming therapy is that patients tend to do them incorrectly – the mask often isn’t hot enough or applied for long enough periods. Additionally, heat application is only ½ the necessary therapy. Melting poor quality MG secretions is important, however, if the gland contents are not evacuated, the meibum will simply harden again and reclog the gland. Many of us have started recommending lid massage to improve the effectiveness of heat therapy, however, there is at least some evidence that topographical changes can occur when force is frequently applied to a warm cornea.^1-3 Additionally, the massage must be performed immediately after warming as it only takes a very short period of time (less than one minute) for the MG to return to its normal temperature because of its rich blood supply.⁴

Another home warming device has recently entered the consumer market called Blephasteam (Thea Laboratories). Blephasteam uses a pair of goggles with disposable eye pads to deliver moist heat for a 10 minute treatment using a standard electrical outlet. It has been shown to increase MG secretions and reduce patient symptoms.^5-7

Lastly, we now also have a few in-office methods for lid warming: Intense Pulsed Light (IPL) therapy, MiBoFlo ThermoFlo (Pain Point Medical) and LipiFlow (TearScience). IPL therapy uses brief bursts of modified (off label) skin rejuvenation light to melt MG secretions. This is followed by in-office therapeutic gland expression. The MiBoFlo device offers external heat application utilizing a thermoelectric heat plate. The heat plate is massaged over the surface of the lid for approximately 12 minutes and is coupled with ultrasound gel to improve the penetration of heat into the MGs. LipiFlow is the only option for the application of heat to the internal eyelid, which is thought to be more effective due to the close proximity of the MGs to the palpebral side of the lid, as well as not having to heat them through the tarsal plate. This method also simultaneously massages the lids to evacuate MG contents while protecting the cornea from increases in temperature.

So which therapy is better: home vs. in-office? Although in-office treatments may be considered superior to home compress therapy because of more effective heating and massage, none of these procedures are currently covered by insurance. Some patients may be willing and able to pay “out-of-pocket” and some may not. Thus, both home and in-office lid warming options remain important components of our dry eye treatment armamentarium.

1. Lam AK, Lam CH. Effect of warm compress therapy from hard-boiled eggs on corneal shape. Cornea. 2007 Feb;26(2):163-7.
2. McMonnies CW, Korb DR, Blackie CA. The role of heat in rubbing and massage-related corneal deformation. Cont Lens Anterior Eye. 2012 Aug;35(4):148-54.
3. Blackie CA, McMonnies CW, Korb DR. Warm compresses and the risks of elevated corneal temperature with massage. Cornea. 2013 Jul;32(7):e146-9.
4. Blackie CA, Solomon JD, Greiner JV, et al. Inner eyelid surface temperature as a function of warm compress methodology. Optom Vis Sci. 2008;85:675–683
5. Spiteri A, Mitra M, Menon G, Casini A, Adams D, Ricketts C, Hickling P, Fuller ET, Fuller JR. Tear lipid layer thickness and ocular comfort with a novel device in dry eye patients with and without Sjögren’s syndrome. J Fr Ophtalmol. 2007; 30 (4): 357-64
6.Pearce EI, Pentland MA, Shabbir S, McDonald ES, Ahmed K, Glyn G, Strang NC, Fuller RJ. Changes in visual acuity following Meibomian gland heat therapy. Abstract TFOSVA 2007.
7.Mitra M, Menon GJ, Casini A, Hamada S, Adams D, Ricketts C, Fuller ET, Fuller JR. Tear film lipid layer thickness and ocular comfort after meibomian therapy via latent heat with a novel device in normal subjects. Eye. 2005. 19 (6): 657-660.

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Inflammation plays a crucial role in the development and progression of dry eye disease. Two inflammatory mediators that have been found to be crucial in DED are the matrix metalloproteinases [MMP] (found to be important in the initiating and maintaining ocular surface damage) and transglutaminases [TG] (proteins regulated by cellular stress and important in the induction of cell death).

The goal of this study was to examine the expression of MMP9 and TG2 in 75 female subjects divided into three groups (15 healthy controls; 30 subjects with Sjögren syndrome (SS); and 30 subjects with meibomian gland dysfunction (MGD)). In addition, the subjects were divided into two treatment groups; one treated with saline and the other treated with saline plus topical corticosteroid eye drops (0.5% loteprednol etabonate) four times daily for 15 days. A clinical assessment was carried out and impression cytologic specimens were processed in the different forms of dry eye and noted any variations after corticosteroid treatment.

MMP9 and TG2 expression were higher in both patient groups than in controls with the SS patients demonstrating the highest levels. Corticosteroid treatment significantly reduced MMP9 and TG2 expression in both DED groups, ameliorating symptoms and signs, with a much higher percentage reduction being observed in SS.

The higher expression of MMP9 and TG2 as seen in the SS patients is thought to be secondary to the direct insult of the autoimmune disease on the cornea, while in the MGD patients the unbalanced tear film results in ocular surface damage and inflammation but at a significantly lower level than seen in SS. Corticosteroid use lowered the presence of the inflammatory mediators in both DED groups, but to a larger degree in SS patients, likely due to the direct influence of the corticosteroids on the inflammatory nature of SS.

Aragona P, Aguennouz M, Rania L, Postorino E, Sommario MS, Roszkowska AM, De Pasquale MG, Pisani A, Puzzolo D. Matrix metalloproteinase 9 and transglutaminase 2 expression at the ocular surface in patients with different forms of dry eye disease. Ophthalmology. 2015 Jan;122(1):62-71. Epub 2014 Sep 18.

Matrix Metalloproteinase 9 and Transglutaminase 2 Expression at the Ocular Surface in Patients with Different Forms of Dry Eye Disease

Aragona P, Aguennouz M, Rania L, Postorino E, Sommario MS, Roszkowska AM, De Pasquale MG, Pisani A, Puzzolo D. Ophthalmology. 2015 Jan;122(1):62-71. Epub 2014 Sep 18.

OBJECTIVE: To evaluate the expression of matrix metalloproteinase 9 (MMP9) and transglutaminase 2 (TG2) in different forms of dry eye.

DESIGN: Case control study.

PARTICIPANTS: Seventy-five female subjects divided into 3 groups: group 1, 15 healthy controls; group 2, 30 subjects with Sjögren syndrome (SS); and group 3, 30 subjects with Meibomian gland dysfunction (MGD).

METHODS: A clinical assessment was carried out and impression cytologic specimens were processed for immunoperoxidase staining for MMP9 and TG2 and real-time polymerase chain reaction analyses were carried out for MMP9, TG2, interleukin-6, interferon-γ, B-cell lymphoma 2, and caspase 3. To study MMP9 and TG2 expression after anti-inflammatory treatment, patients were divided into 2 subgroups, one treated with saline and the other treated with saline plus topical corticosteroid eye drops (0.5% loteprednol etabonate) 4 times daily for 15 days. For statistical analysis, Student t test, Mann-Whitney U test, and Spearman's correlation coefficient were used as appropriate.

MAIN OUTCOME MEASURES: Conjunctival expression of MMP9 and TG2.

RESULTS: MMP9 and TG2 expression were higher in both patient groups than in controls (P < 0.0001). Group 2 patients showed higher expression than group 3 (P < 0.0001). The Spearman's correlation coefficient showed in group 2 a positive correlation between MMP9 and TG2 expression (ρ = 0.437; P = 0.01), but no correlation in group 3 (ρ = 0.143; P = 0.45). Corticosteroid treatment significantly reduced MMP9 and TG2 expression in both groups, ameliorating symptoms and signs. A much higher percentage reduction was observed in SS.

CONCLUSIONS: The pathogenic mechanisms of the 2 forms of dry eye give an account for the different MMP9 and TG2 expressions in the 2 groups of patients. The higher expression in SS is determined by the direct autoimmune insult to the ocular surface epithelia, whereas in MGD patients, with an epithelial damage due to an unbalanced tear secretion, the molecules expression is significantly lower, although higher than in controls. The corticosteroid treatment induced a reduction of both molecules, although higher in SS than in MGD, because of its direct inhibitory effect on inflammation.

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Coding for Meibomian Gland Expression

Since MGD has gained popularity as a clinical entity in OD’s offices, I often get asked how to code for manual meibomian gland expression and for automated meibomian gland expression (LipiFlow procedure by TearScience). Unfortunately, there is no CPT code that represents the specific procedure of meibomian gland expression, either manual or automated. That being said, the CPT does provide us a way to properly code for these procedures and to be able to charge a patient for these services.

In the case of the LipiFlow, there is a HCPCS Category III code that was created and issued by the CPT specifically for this automated procedure. The code 0207T, which is defined as “Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral”, is what you should be specifically using if you perform the LipiFlow procedure. In most cases a HCPCS Category III code is payable by the patient, even though you will have to submit the claim to the insurer with a zero balance so they can track utilization of the procedure. Please note that this code does not cover probing or manual expression of the meibomian glands.

To properly code manual expression of the meibomian glands, the CPT code 92499 (unlisted ophthalmic procedure) should be used to describe this procedure as there is no more specific code provided by the CPT. If you are submitting this to a carrier, please be aware that unlisted procedure codes generally invite additional scrutiny to help avoid abuse and waste. Also be aware that whether you are charging patient directly or submitting to a carrier, that your fee should be consistent to all patients irrespective of their coverage status.

Since neither of these is a surgical procedure, an office visit performed on the same day could also be coded, charged, and submitted for coverage. Generally a 920X2 (if you meet the definition) or an appropriate 992XX code which represents the level of history, physical exam and medical decision making actually performed. In most cases it would be a 99201 or 99212 because of the limited nature of the presenting problem.

Dry eye in an optometric practice is an extremely common condition and meibomian gland expression, whether automated or manual, is often indicated to provide patients relief from their symptoms and improve their clinical status.