Point-of-care diagnostics change the way we manage patients

In today’s clinical environment, the buzzword is “efficiency.” Eyecare professionals will continue to expand their utilization of point-of-care diagnostic testing in the future, especially in those cases where the procedures can be delegated to technicians. Gathering data is time-consuming, and physicians are best utilized as analyzers of information, not collectors of information. Additionally, in our ever-increasing evidence-based medical society, we now require more than just our basic instincts, especially when we are dealing with third-party payers. Our clinical decisions and management strategies need to be guided by science and proven technology. Point-of-care testing combines the scientific element with the convenience of same-day testing and confirmation.

A practice of distinction

Incorporating the newest technology differentiates a practice from its competitors. Let’s face it, patients love the bells and whistles; but in order to be effective, the technology must have merit and benefit to the practice as well. It is not enough to have something new or different; the technology needs to add value to the practice by providing additional information and/or diminishing the time burden on the physician.

While patients can be impressed with almost anything new, they are also very often cost-conscious and apprehensive. They want to know that the test will benefit them as well as the doctor, and that information needs to be communicated by the staff to the patients. When patients are convinced that a practice has the newest technology and that it is being used effectively to their benefit to save them time, money, or additional visits to other healthcare providers, then they are typically more than happy to proceed. And they will view the practice as unique and cutting-edge.

Diagnostic technologies leading the way

Sjö

We are just beginning to incorporate Sjö (Nicox)into our clinical care protocol for those patients who may have Sjögren’s syndrome as an underlying cause of their ocular surface dysfunction. This is truly remarkable because, in the past, our only recourse for these patients was to refer them for laboratory testing and a consultation with a rheumatologist. Because the number of patients who actually have Sjögren's is far greater than any of us may have previously expected (recent data suggests as many as 1 in 10 of patients with dry eye),¹ and dry eye patients see us first, we really are on the front line to identify these patients.

We then have the opportunity to refer the patient to the appropriate specialist for assessment, and, if necessary, care. Having the capacity to determine if a patient demonstrates the early biomarkers for Sjögren’s syndrome allows us to more efficiently manage her care from both an ocular point of view and a systemic point of view, in terms of coordinating consultations with other medical sub-disciplines. In essence, it allows us to be the gatekeepers of our patients’ overall health and welfare.

LipiView

Our institution has recently purchased and will soon begin implementing the LipiView Ocular Surface Interferometer (TearScience). LipiView may be a huge breakthrough in the assessment and management of ocular surface disease, especially evaporative dry eye and meibomian gland dysfunction. Many clinicians discuss LipiView as a device that measures lipid layer thickness, but it is much more than that. The technology gives a real-time, in-vivo view into the dynamics of the pre-ocular tear film and the patient’s blink mechanism. Once again, this added information can be obtained by a technician and reviewed by the clinician in the course of her evaluation. It lends an entirely different perspective to the battery of tests already used for our dry eye patients, and it helps to determine the best treatment strategy for dry eye patients.

A1C testing

An A1C testing meter measures glycosylated hemoglobin, which has rapidly become the standard for diabetes management because it gives an average over 3 months of blood glucose levels, as opposed to the level at the time of the test. We have had patients present with no knowledge of diabetes, but who are clearly exhibiting signs and symptoms of what we believe are diabetic retinopathy or a manifestation that is associated with it, like a retinal vascular occlusion or proliferative vitreoretinopathy. Having the capacity to identify patients who may have diabetes and then refer them to an endocrinologist and retinal specialist allows us to ensure that our patients are receiving proper care.

AdenoPlus

Our experience with AdenoPlus (Nicox) for the differential diagnosis of acute conjunctivitis has been positive. In our clinical setting, where the emphasis is on teaching, we often use this test when the signs and symptoms of a patient’s acute conjunctivitis (which may be caused by allergies, bacteria, or virus) are not clear cut or when there is a difference of opinion between the student doctor and attending physician. Given the potential ramifications of this highly contagious disease state, it is important for the clinician to be certain of the diagnosis so that proper management can be initiated. This tool can be extremely beneficial in practices that focus on primary eye care and that have a large number of contact lens patients.

Putting point-of-care tests into practice

Some of these tests can prove to have a steep learning curve; however, a review of the instructions and a conversation with the company representative helps to alleviate those potential concerns. Often, we run into problems because we assume we know how to administer the test, rather than strictly following the written protocol. Today, with training videos available via Webinars or online, it is much easier to avoid these barriers.

Not all diagnostic technologies are endless revenue streams. Unfortunately, that is often a practitioner’s sole interest when deciding to implement a new technology or device. We need to consider the inherent value to our practices in terms of providing more comprehensive care and gaining the patient’s confidence and loyalty. We are all familiar with the “give a man a fish” analogy. Often, we need to make an initial investment of time and effort that may not seem to deliver immediate gratification but instead offers long-term stability and productivity.

Case presentations

Figure 1Case 1: A 48-year-old Indian male presented with complaints of blurred vision OU. He reported having difficulty seeing close when reading and sewing. He was, by trade, a tailor. His last eye examination was 9 months earlier, but he admitted that he merely had a refraction for glasses, not a comprehensive examination. His last physical examination was 20 years prior while in the military service, but he stated that he currently feels fine and is in good health.

Upon examination, his best corrected visual acuity measured 20/80 OD and 20/50 OS. His pupils were reactive but sluggish; his motilities were unrestricted. His visual fields by confrontation were accurate but with hesitation. His external eye examination was unremarkable, and his IOPs were normal at 17 mm Hg OU. His dilated examination revealed pre-retinal and intra-retinal hemorrhages with macular exudate, cotton-wool spots, and broad areas of fibroproliferative retinopathy in the posterior pole (Figures 1 and 2).

Figure 2The presumptive diagnosis was proliferative diabetic retinopathy. As this was being communicated, the patient maintained that he did not have diabetes and merely needed stronger glasses. After a discussion about blood sugar levels and diabetes often being an elusive disease, the patient agreed to undergo point-of-care testing with an A1C blood glucose monitoring system. After reading the literature and learning that a “normal” glycosylated hemoglobin level was <6.0, the patient was shocked to see his results of 12.2%, which equates roughly with an average plasma glucose level of 303 mg/dl.

After seeing it for himself, the patient became very concerned; his attitude changed immediately from one of defiance to sober acceptance. He gratefully accepted our referral to see an endocrinologist and retinal specialist that same week and kept both appointments.

Case 2: A 42-year-old African-American male presented for urgent care with a complaint of red, watery, and uncomfortable eyes OS>OD of 1 week’s duration. Shortly after the symptoms started, he was evaluated by his primary-care physician, who prescribed ciprofloxacin 0.3% QID in both eyes. The patient was concerned that his eyes and vision were growing steadily worse despite using the medication as directed.

Figure 3Upon examination, corrected acuity with habitual spectacles was OD 20/25 and OS 20/40. Pupils were equal and reactive, and motilities were unrestricted. Visual fields by confrontation were full. Biomicroscopy revealed a grossly chemotic, hyperemic, and mildly hemorrhagic conjunctiva OS>OD (Figure 3). There were fine, scattered areas of subepithelial infiltrate affecting the left cornea as well. No evidence of mucopurulent discharge or pseudomembrane was evident in either eye, and there was no preauricular lymphadenopathy.

The patient was advised that his clinical presentation combined with non-responsiveness to a broad-spectrum antibiotic indicated that he likely had either a viral conjunctivitis or a resistant bacterial infection. He was informed that a simple test could help to differentiate between the 2 conditions, and he eagerly agreed. The AdenoPlus test returned a confirmatory diagnosis of viral conjunctivitis in just over 10 minutes (Figure 4).

Figure 4The patient was relieved to learn that he would not require more aggressive antibiotic therapy and that simple supportive management with cool compresses, artificial tears, and rest would help the condition to resolve on its own. In addition, he was prescribed a mild topical corticosteroid (fluorometholone 0.1% QID) to help with comfort and to alleviate the inflammatory corneal infiltrates.

Our clinical decisions and management strategies today and going forward need to be guided much more by science and proven technology. Point-of-care diagnostic testing combines the scientific element with the convenience of same-day testing and a confirmed diagnosis so that the physician simply has to read the results, create a treatment plan, and move forward.

References

1. Liew M, Zhang M, Kim E, Akepk EK. Prevalence and predictors of Sjögren’s syndrome in a prospective cohort of patients with aqueous-deficient dry eye. Br J Ophthalmol. 2012 Dec;96(12):1498-503.