Jim Poggi
By Jim Poggi
What is the distributor rep’s role?
As we enter 2020, what could be more appropriate than an overview of eye testing and how lab relates to eye care and overall health? In this month’s article, I intend to explore these issues and give you some things to think about as a well-informed consultant. It should come as no surprise that the fit for lab varies dramatically between ophthalmology and primary care practices.
When it comes to ophthalmology practices, lab is usually not a front-line sales opportunity. But, there are some developments in technology that are changing the picture somewhat, especially for acute onset symptoms such as conjunctivitis and dry eye. Currently it is my experience that patients suffering from acute onset eye symptoms usually present in primary care, urgent care or retail convenience clinics. As a result, I expect that most of the new testing technology will be adopted in our core market rather than ophthalmology practices. Time will tell.
Testing needs
Where to begin? The med/surg side of things is where most of the action has been historically for us in ophthalmology practices. Since eye examination equipment, exam room equipment and accessories are typically specialty products often sold on a direct basis, the med/surg distribution business has been a limited source of products and solutions to ophthalmology practices. For the most part, the med/surg account management professional has been content to provide gloves, disposable items, some eye drops and the occasional ophthalmoscope to these clients. Our calls on these specialty practices tend to be few and far between, with focus on higher spend internal medicine and specialty practices more focused on our core product lines. I expect this trend to continue in the near term, but with some notable exceptions.
Primary care practices have very different needs for testing and treating eye problems than ophthalmology practices and are more focused on acute onset of symptoms conditions. Most of the time that primary care practices see patients with eye disease as their primary complaint, these patient visits are associated with conjunctivitis (pink eye) or dry eye. New technology is improving diagnostic capabilities for both pink eye and dry eye disorders. While we usually associate adenovirus with respiratory illness, adenovirus is also the primary reason for conjunctivitis symptoms that result from an infection.
Interestingly, primary care practices should test for pink eye for the same good reasons they test for respiratory diseases. First of all, an adenovirus infection of the eye causing pink eye can occur at the same time a patient presents with a respiratory adenovirus infection. Secondly, for both pink eye and respiratory infections, viruses are far more often the cause than bacteria. Testing for respiratory and pink eye conditions to verify whether the patient has a bacterial or viral cause makes sense from an antibiotic stewardship perspective. During the height of respiratory infection season, adenovirus infections of the eye and respiratory tract may lead to two different sources of patient symptoms and care needs. Even when it presents alone, viral causes vastly outnumber bacterial ones.
Dry eye is a very different story. It is more often a chronic condition and has a fairly wide variety of causes. Rheumatologists have known for years that dry eye can present as an early symptom of an autoimmune disease referred to as Sjogren Syndrome. Patients who present with dry eye and dry mouth will require further testing typically with autoimmune panels we commonly sell in primary care to help confirm this diagnosis. While Sjogren Syndrome may not be a disease we all think of every day, it is estimated that 3 million patients are diagnosed with it annually in the United States. It is often associated with either rheumatoid arthritis or lupus. New dry eye tests help present a broader range of lab diagnostic options to the rheumatology practice. As consultants, it pays to keep up to date with the latest developments our customers need to be aware of and to help them solve the diagnostic challenges they encounter on a daily basis.
There are other causes of dry eye as well, and they are important to diagnose accurately and on a timely basis. Chlamydia is regarded as the most common sexually transmitted infection and is asymptomatic in over 25% of men and up to 70% of women. Despite screening programs in primary care and public health, chlamydia continues to be a public health issue. Children born to a mother with previously undiagnosed chlamydia often present with dry eye and/or conjunctivitis. Symptoms of dry eye and conjunctivitis typically occur from 5 to 12 days after birth for children born with this infection. The CDC recommends chlamydia testing for infants who present with conjunctivitis symptoms within 30 days of birth. So, testing for both conditions can lead to faster more appropriate treatment.
Zika disease also presents with symptoms of conjunctivitis. For patients suspected to have been exposed to Zika virus carrying mosquitoes, it is also important to rule out Zika virus as a cause of conjunctivitis. In addition to patient history and physical, there are a number of serology and molecular tests available to diagnose Zika virus.
While ophthalmology practices and primary care practices rarely share the same patients, diabetes management is probably the best current model for ophthalmologists and primary care physicians to work collaboratively. Since diabetic retinopathy is directly related to lack of diabetic control and can lead to blindness, annual eye exams frequently include an examination of the retinal area to assess whether the retinal vasculature is being damaged by the progression of diabetes. These physical findings help to round out the clinical picture of the diabetic patient and point to the prognosis for future vision issues. On the primary care side of things, diagnosis and monitoring of glucose levels by way of hemoglobin A1c and serial glucose measurements provide the lab side of things.
As the linkage between the expanding variety of infections and eye disease and general health conditions continues to be understood, I expect there will be a new range of tests that complement diagnosis and treatment in both practice areas. Keep an eye out for new developments.