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During the webinar titled ‘Alternative Revenue Sources: Starting Up and Operating a Thriving Dry Eye Sub-speciality Post COVID-19’, Dr Wes McCann shared his views on the importance of developing a Dry Eye clinical specialty in the new Covid19 practice environment.  He provided an overview of how he has set up and continues to grow his Dry Eye practice at Central Optometry in London, Ontario, using a structured, operational approach.  Below please find the Q&A’s from the webinar with Dr McCann’s responses.

1. Would love to hear more about how Kyklos fits into an office flow outside of EHR
a. In our practice, Kyklos fits into your office and runs in parallel with your EHR. Patients are booked in your EHR and in Kyklos (to ensure you don’t have double booking in your EHR) and billing is done in your EHR (to maintain reporting for paying yourself and associates) but that is the extent of what is done in your EHR. The rest is done in Kyklos for dry eye appointments. I can see from my EHR when a patient was in for a dry eye visit, then I either refer to Kyklos for the clinical data, or I can print off a summary page from Kyklos and input that into a scans folder in the patients EHR file.

2. What is the redness scan?
a. It is a scan that is part of the Keratograph from Oculus. It grades the “redness” of the patient’s bulbar conj and a computer algorithm will give you a score. You can also, as the clinician, override that score.

3. Does your staff do all that testing listing or do you perform bottom half? I.e. lissamine and nafl and expression
a. My Staff perform: Osmolarity, InflammaDry, Redness scan (Keratograph), Vital Dyes (and photograph with the keratograph), NIKBUT, Meibography, and Lids & Lashes photography (Keratograph).

4. What do you charge for a dry eye consult?
a. We charge $268. You will have to consider what your overhead costs are and factor all that into your fees. (Consumables can run you upwards of $76 during the assessment for Osmolarity & Inflammadry. You need to consider your Chair Time Cost which can run anywhere from $70-125 for 30 min depending on where you are located [That is even before the OD is paid]). If you pay yourself or your associate OD a % of gross between 21-30% that could add between $56-$80 to your cost. So in total the COST of doing a dry eye assessment could be between $202-$281 on both extremes.

5. What test do you use to measure osmolarity
a. iPen, but I am considering switching to Tearlab when they come out with the combo MMP9/Osmolarity Device.

6. When do you use Restasis vs. Xidra
a. Restasis is my go to for chronic inflammation. + on MMP9 and depending on the level of dry eye I will Rx Lotemax Gel QID x 10 days and if a strong + on Inflammadry I will add Restasis. If the primary cause of the MGD is controlled with in office treatments we can consider removing the Restasis down the road and re-evaluate if it is still needed.

7. What is the difference between iLux/ Lipiflow?
a. Check out the manufacturer’s websites to see the differences. iLux is about ⅓ the investment of Lipiflow.

8. What dosage and frequency do you prescribe doxycycline for mild, moderate and severe cases?
a. I don’t prescribe Doxy as much anymore since I purchased my IPL. I’d rather refrain from disrupting the gut flora when possible.

9. What is the cost of the initial assessment?
a. We charge $268. You will have to consider what your overhead costs are and factor all that into your fees. (Consumables can run you upwards of $76 during the assessment for Osmolarity & Inflammadry. You need to consider your Chair Time Cost which can run anywhere from $70-125 for 30 min depending on where you are located [That is even before the OD is paid]). If you pay yourself or your associate OD a % of gross between 21-30% that could add between $56-$80 to your cost. So in total the COST of doing a dry eye assessment could be between $202-$281 on both extremes.

10. The iLux is not as soothing as the LipiFlow, what about RF and IPL.
a. IPL is painless (unless you have significant rosacea, then it feels like a small pin prick). RF feels like a warm stone massage. Both you can pretty much go back to work after. Little to no downtime.

11. what IPL brand did you purchase
a. M22 from Clarion

12. What are the platforms you can sign on that allow you to send forms to patients?
a. Kyklos will allow you to communicate with your patients for your dye eye assessments
b. For Primary Care check out Intake Q or Cognito Forms

13. What’s your treatment protocol for RF?
a. 3-4 Treatments 2-4 weeks apart.

14. what RF machine do you have as well
a. Cynosure

15. What lifestyle questionnaire do you use? Could you share it?
a. It is embedded into Kyklos. Comes with the program

16. Do you do gland expression after iLux and is it a staff member doing expression or OD
a. Part of the iLux protocol involves expression during the treatment so my staff do it. I will always check the glands after the treatment to see if more expression or further treatment is required.

17. Any views on the difference between The IPL devices E Eye and E Light?
a. Not familiar with E Eye or E Light, however, there are MANY differences in IPLs. My thoughts when purchasing a new device such as IPL, is this is a whole new field for Optometry. I want to purchase a device that has LOTS of clinical data behind it and is more or less the gold standard for treating dry eye. You can run the risk of burning a patient if you get the wrong device, and I wasn’t willing to take that risk on an unknown device or a device that has not been extensively tested in dry eye from a professional liability perspective.

18. How do you structure your fees? Charge as you go, diagnostic and follow up separate fees and extra for treatments. Or one large package.
a. Dry Eye Assessment includes one follow up as do treatments. Treatments are, however, sold in packages.

19. Does Kyklos “speak” to any specific EMRs so that the data can be pulled in? Or do you have to entire this info twice?
a. In our practice, Kyklos fits into your office and runs in parallel with your EHR. Patients are booked in your EHR and in Kyklos (to ensure you don’t have double booking in your EHR) and billing is done in your EHR (to maintain reporting for paying yourself and associates) but that is the extent of what is done in your EHR. The rest is done in Kyklos for dry eye appointments. I can see from my EHR when a patient was in for a dry eye visit, then I either refer to Kyklos for the clinical data, or I can print off a summary page from Kyklos and input that into a scans folder in the patients EHR file.

20. Is Kyklos a subscription based program?
a. Yes

21. Is Kyklos program available for French speaking patients?
a. Yes

22. Which in office treatment is most effective in your opinion for Meibomian gland obstruction?
a. This depends on how obstructive the disease is. IPL is becoming more my first line treatment, however, if the patient has moderate obstructive MGD, they will likely benefit from both IPL first then iLux or Lipiflow. Maintenance could then be likely done with IPL.

23. When did you start Kyklos? Right from the start or later?
a. 6 Months ago. We adopted it about 6 months after we got our feet wet in dry eye, but it was really needed from a comprehensive patient management part.

24. How do we do all these treatments With COVID? Are you concerned about safety and touching patient and possible risks?
a. Our staff and ODs, when that close to the patient, are gloved, masked, in scrubs and have a face shield. IPL especially has MINIMAL manipulation of the eye except expression afterwards, however, risk with expression of the meibomian glands would be no greater than flipping the lids or evaluating the lids during anterior slit lamp exam.

25. What did you to get other docs to refer to you? ODs? GPs?
a. Talk to them, educate them and be prepared to answer questions.

26. Where to look for such a staff who has some experience and then we can build on. My biggest barrier to dry eye practice is to find a staff to sustain the specialty.
a. Don’t necessarily look for someone with the experience you need. Find the ideal PERSON and PERSONALITY and drive you want and train them from the ground up. If a qualified person falls in your lap then that’s amazing, but Millennials and Gen Xers are looking for jobs with opportunity for growth, advancement and training. If you can provide that opportunity in your practice you will get some great dedicated people.

27. Do you charge for diagnostic follow ups? If so, do you price it the same as initial testing?
a. No charge for 1st follow up (included in fees). If there are additional follow-ups after that we charge for the partial and any additional tests we are doing to cover the consumables.

28. What’s your technique for screening meibomian gland expression?
a. Cotton tip pressure on the lid against the globe or finger pressure expression against the lid against the globe. I do that on lower lids medially, centrally, and laterally. Then grade that expression.

29. How do we find out suppliers for IPL and RF?
a. IPL – Clarion
b. RF – Cynosure

30. Do you bundle treatments? Like ilux and IPL?
a. Yes

31. What fish oil do you recommend? What if they are allergic to fish?
a. PRN – they have an excellent published study to support its efficacy
b. There are some Vegan options available. Nutrasea has one, however, the dosage isn’t as high as PRN.

32. Is RF as effective as Lipiflow?
a. Clinical studies are still underway as to the efficacy of RF, however, anecdotally, I have found it to be effective.

33. Why would you use Kyklos if you have the Crystal report from Oculus
a. The metrics Kyklos provides, Patient videos, and ongoing patient engagement from home. That was something that I asked myself prior to adding Kyklos before, however, getting your patients to ‘buy in’ and stay engaged in their treatment protocol is the most difficult part. Kyklos helps with that, however, you need to use the program to its full extent.

34. Will patient’s insurance cover some of these treatments?
a. Usually have them try a health care spending account. But create a form template letter that you can give them. The more insurance companies are exposed to this the more likely they are to create an envelope of $ to dedicate to other eye care expenses such as Dry eye, VT, advanced diagnostics etc.

35. How would you structure fees of diagnostics and treatments in Ontario? Would you be able to provide examples?
a. Diagnostics – we created a dry eye assessment which encompasses most of our diagnostics. Some are included in our in office TX and follow-ups.
b. Treatments are stand-alone costs that include their one follow-up in our office.

36. Do you enter these patients DE info in your general EMR also?
a. No, if they have a dry eye exam or in office treatment or follow-up it is all in Kyklos. Everything else and billing is in our EMR