Diagnostic technologies enhancing patient quality of care

Take-home

As technology continues to advance, the ability to serve patients will greatly improve. Having sophisticated tools at our disposal will make medical decisions all the more appropriate and treatment plans all the more effective.

Dr. McDonald

By Marguerite B. McDonald, MD, Special to Ophthalmology Times

New York-Recent innovations in diagnostic technology allow eye-care professionals (ECPs) to improve quality of care. Being able to diagnose disease with a higher degree of accuracy, determine treatment based on evidence, and set objective expectations for surgery are some of the many tangible benefits clinicians are seeing in recent years, as their diagnostic armamentarium grows increasingly sophisticated.

Patients recognize and appreciate being evaluated with safe, non-invasive, high-tech equipment. Accordingly, physicians have made sure to implement best-in-class diagnostic technologies for managing several diseases, including dry eye, meibomian gland dysfunction (MGD), allergic conjunctivitis, and age-related macular degeneration (AMD). These technologies have proven to set the practice apart by building patients’ confidence in their care.

Rooting out the cause of dry eye

Determining the cause of a patient’s dry eye often can be the determining factor in whether prescribed treatment can relieve symptoms and improve quality of life. The ocular manifestation of Sjögren’s syndrome-an autoimmune inflammatory disease-has typically been diagnosed as a progressive form of aqueous-deficient dry eye.

Recently, that view of the typical patient with Sjögren’s syndrome has been challenged by data suggesting that as many as 1 in 10 patients with dry eye may, in fact, have Sjögren’s syndrome.

Historically, methods for diagnosing Sjögren’s syndrome have failed to detect early cases and have a low specificity and sensitivity.

A new diagnostic test (Sjö, Nicox) combines traditional markers with three novel, proprietary biomarkers, allowing earlier detection of this serious systemic disease. The test allows physicians to diagnose Sjögren’s syndrome early and, essentially, alter the course of a patient’s health. When considering whether a patient should be tested for Sjögren’s syndrome, ECPs should not only look for early hallmark symptoms of dry eye-as well as dry eye symptoms in unusual patient demographics-but also be cognizant of patients who have difficulty speaking or swallowing, a sore or cracked tongue, dry throat and lips, halitosis, or dental decay.

Additionally, clinicians now have an ocular surface interferometer (LipiView, TearScience) to determine which patients are suffering from dry eye as a result of MGD. The device measures the absolute thickness of the tear film lipid layer by analyzing more than 1 billion data points using white light interferometry of the tear film. It also analyzes how completely the patient is blinking. Results from this test can determine which patients can benefit from treating obstructed meibomian glands with pulsating thermal lid massage (LipiFlow, TearScience).

A tactical approach to red eye

Just as getting to the bottom of dry eye is important to achieving a healthy ocular surface, properly diagnosing and managing a red eye-the presentation of which often can be difficult to diagnose empirically-is critical to ensuring the best possible outcomes for patients.

For example, it has been shown that the signs and symptoms of viral, bacterial, or allergic acute conjunctivitis can be indistinguishable and, furthermore, that ECPs make an accurate differential diagnosis for acute conjunctivitis only 50% of the time.

Accordingly, an in-office immunoassay (AdenoPlus, Nicox) enables rapid, differential diagnosis of acute conjunctivitis at the point of care. The test only takes 2 minutes to administer and provides a confirmation of adenovirus’ presence within 10 minutes.

The device itself operates much like a pregnancy test-two lines indicate a positive result, and one line equals a negative result. If the test is positive for adenovirus, ganciclovir gel (Zirgan, Bausch + Lomb), off-label use, is prescribed, effective in killing all of the serotypes of adenovirus tested so far and avoiding the unnecessary prescription of antibiotics.

If the test is negative-and allergic conjunctivitis has been ruled out via patient history and examination-then that leaves bacterial conjunctivitis, and a fluoroquinolone is prescribed. Having an objective diagnosis grounded in evidence enhances the patients’ experience, because clinicians can now inform them if they are contagious before leaving the office and determine whether they can return to work. By advising them on their contagion and sparing them from receiving an inappropriate topical therapy (usually unnecessary antibiotics), clinicians can impact their recovery process, spare relatives and friends from infection, and overall, prevent large, avoidable costs to the greater health-care system.

A new look at retinal lesions

In addition to providing best-in-class management of ocular surface disease, new advances in diagnostic technology are impacting the way clinicians approach surgery. Consider that numerous older Americans in normal health who are headed for cataract surgery have lesions indicating early AMD, but that traditionally, it has been exceedingly difficult to determine whether those lesions are clinically significant.

OCT is helpful in detecting macular lesions, but microperimetry (MAIA, CenterVue) is thus far the only way to determine if those lesions will impact postoperative vision, which would then make a patient a poor candidate for multifocal IOL implantation. Microperimetry also helps monitor the course of retinal diseases and the effectiveness of treatment.

The oldest of the baby boomer generation are undergoing cataract surgery now and could easily live another 20 or 30 years. If those patients could benefit from a multifocal IOL, then that technology should be made available to them. On the other hand, an IOL should not be implanted if the patient has retinal lesions that might cause postoperative symptoms and/or poor vision. Microperimetry is useful in measuring functional changes to the retina caused by disease.

Onboarding new technologies

To ensure successful implementation of these technologies, a physician considering implementation should consult with a colleague who has the technology he or she wants to acquire, if possible, to determine if it is a good fit for his or her practice.

Also, physicians should make it known to staff that implementation of the technology is an important aspect of providing quality care. Fortunately, many of the new diagnostic technologies available on the market today have a short-learning curve, have intuitive software, and are fail-safe.

As technology continues to advance, the ability to serve patients will greatly improve. As medical professionals, we always strive to update our knowledge base and technology offerings to provide state-of-the-art ophthalmic care. Having sophisticated tools at our disposal will make medical decisions all the more appropriate and treatment plans all the more effective.

References

1.  American Academy of Ophthalmology Preferred Practice Pattern – Dry Eye, 2011.

2. Tincani A, et al. Novel aspects of Sjögren’s Syndromein 2012. BMC Med Apr 4 2013;11:93.

3. Shen L, Suresh L, Lindemann M, et al. Novel autoantibodies in Sjögren’s syndrome. Clin Immunol. 2012;145:251-255.

4. Liew M, Zhang M, Kim E, et al. Prevalence and predictors of Sjögren’s syndrome in a prospective cohort of patients with aqueous-deficient dry eye. Br J Ophthalmol. 2012;96:1498-1503.

5. O’Brien TP, Jeng BH, McDonald M, et al. Acute conjunctivitis: truth and misconceptions. Curr Med Res Opin. 2009;25:1953-1961.

6. Leibowitz HM, Pratt MV, Flagstad IJ, et al. Human conjunctivitis. Arch Ophthalmol. 1976;94:1747-1749.

7. Stenson S, Newman R, Fedukowicz H. Laboratory studies in acute conjunctivitis. Arch Ophthalmol. 1982;100:1275-1277.

Marguerite B. McDonald, MD, is a cornea/refractive specialist with Ophthalmic Consultants of Long Island, New York, a clinical professor of ophthalmology at the NYU School of Medicine, and an adjunct clinical professor of ophthalmology at the Tulane University Health Sciences Center, New Orleans. She acknowledged no financial interest in the products or companies mentioned herein. Dr. McDonald may be reached at 516/593-7709 or margueritemcdmd@aol.com.