Leap these hurdles when opening a dry eye center

The potential for treating dry eye patients in an ophthalmic practice is so great that establishing a “center of excellence” makes economic sense. But does it make realistic sense?

Due to a confluence of demographics, digital device distress and increased use of prescription medications, the number of cases of dry eye is ever-rising — according to DEWS II, anywhere from 5% to 50% of populations in every nation are affected, which tallies in the millions.1 Market Scope reports that dry eye-related product sales are expected to reach $4.5 billion by 2020.2

How big of an unmet need is dry eye? If every ophthalmologist and optometrist in North America opened a dry eye center, we would still be underserving the population. Starting such a center requires not just the right tests and tools, but implementation and considerations for handling both staff and patients.3

Here’s how to overcome those hurdles.


Staff members are not mind readers — they won’t value dry eye care unless you tell them.

When talking to staff about adding a dry eye center, hit the following points, ideally at a team “launch” meeting. Get the office manager on board beforehand, so he or she can support you.

-Helping patients with dry eye will also help the practice’s bottom line.

-Due to cutbacks in Medicare and commercial insurance plans, treating dry eye can help keep the practice in the black, which will help to avoid firings or going years without granting raises.

-Dry eye patients often have multiple other diagnoses you can treat: 60% have seasonal allergies, 14% have cataracts, 48% have myopia, 4% have AMD, 3% have glaucoma and 17% have undiagnosed failing eyesight.3 These patients often see other doctors who don’t help them — if your practice does, the satisfied patients will often bring other family to your clinic.

-Controlling dry eye can also result in better clinical outcomes. Numerous peer-reviewed papers indicate the treatment of dry eye before LASIK and cataract surgery improves results.


It is helpful if at least one staff member is of a similar age as the average dry eye patient. Despite the legions of sufferers of all ages, the perimenopausal female is still the most common patient. She must feel comfortable discussing her issues. One 60-something woman told me of a trip she made to her ophthalmologist: “The young, male doctor was fine, if hurried. But the technician and a nurse, and especially the giggling office workers, were all Millennials. I didn’t go back.”

Identify an ophthalmologist or optometrist in the practice who has a rapport with this patient group, and let that person take the lead. If one isn’t available, consider a dry eye counselor.


To get patients’ attention, assure them that your practice takes dry eye seriously and is up-to-date on new treatments. Distribute a questionnaire, online or upon office arrival, to acquire information that will allow for more targeted questions during exams. A single positive answer on the psychometric questionnaire allows technicians to proceed with tear osmolarity and other testing, even before the doctor sees the patient.

In the exam room, visuals lead to more effective discussions. In each lane, we have color photos of all the dry eye OTC meds on one sheet. We circle the best ones for each patient, and explain why those are recommended. We also have as many medication samples as possible.


Patients who go out of their way to reach your practice expect extra time, so be sure to give it.

Train the front staff to red-flag someone who travels more than 50 miles. We are near JFK International Airport, so we have had many international patients, even a Middle Eastern crown prince. When patients make that kind of journey, they expect special care. Even an ophthalmologist in a remote area can get patients from a few states away after their center’s reputation grows.


Knowing where to begin can be a challenge. To start, don’t buy every toy right away; add things slowly. Start with tear osmolarity measurement, like TearLab, as hyperosmolarity is the common pathophysiologic pathway for all forms of dry eye. The capital outlay is minimal with only (at this printing) a commitment to a certain number of test cards. CMS reimburses $22.66 per test.

Then, add a new diagnostic or treatment modality every two to three months. Have at least one team meeting when you add a new modality to be sure that the technicians know how to perform the test or treatment, and that everyone in the practice — including front desk personnel — can answer basic patient questions.


Your success is shared by dry eye product companies, so let them help spread the word. They have marketing materials aplenty, from ready-to-go press releases to “ask me about dry eye” buttons and one-page announcements to slip into invoice envelopes. Don’t forget exam room posters — patients will read what’s on the wall.


Adopt a treatment algorithm. Mine is based on the Tear Film & Ocular Surface Society (TFOS) Dry Eye Workshop II and the Meibomian Gland Disease Workshop, and is heavily influenced by osmolarity measurements. (For more on DEWS II, go to page 12.) Once you grade the dry eye or meibomian gland disease (or, more usually, both), you can appropriately treat the patient.

Pay attention to the traffic flow. See how many patients can optimally be in each area at the same time, and consider where you place large diagnostic and therapeutic devices and other equipment. Do a run-through with your staff as patients.

Your staff needs to become comfortable with discussing cash payments. LipiFlow (TearScience), BlephEx (Rysurg), Oust Demodex Swabstix professional lid cleaning (OCuSOFT), EyeExpress (Holbar Medical Products) treatments, and so on are out-of-pocket expenses that can cost $150 to $975. Have your center coordinator talk to patients about how to handle out-of-pocket expenses, using programs such as CareCredit.

Look for digital device distress

Teens and 20-somethings are rapidly joining the ranks of the traditionally older dry-eyed because they stare far too long at digital devices. One of our offices is near the merchant marine academy, and we see a steady stream of 18- to 21-year-old cadets with severe dry eye. They’re otherwise healthy but can’t take their eyes off their devices — blink rate plunges from 20 per minute to three to five times per minute while looking at a digital screen.

This is a pervasive issue in our modern world. Statistics on The Vision Council’s website state that 60.5% of Americans reported symptoms of digital eye strain. More than 83% of Americans spent at least two hours a day glued to a screen, and 53.1% reported using two devices simultaneously. The challenge of digitally induced dry eye is not a problem soon to vanish, given our dependence on computers. Making matters worse, many of our patients work in buildings with forced air heating and cooling.

What can you do? Educate these patients about the following tips:

  1. The 20-20-20 rule — for every 20 minutes staring at a screen, look away at something at least 20 feet away for 20 seconds. It truly helps.
  2. Lower the screen so that the interpalpebral fissure is as small as possible, to decrease evaporative tear loss.
  3. Light a match at eye level (provided no oxygen tanks are nearby) to see if the flame flickers. If it does, close the overhead vent and/or change the orientation of the desk and seat.


The tsunami of dry eye will only get worse with the double-whammy of the digitally addicted and aging baby boomers. We can truly help our patients, and our own bottom lines, by addressing this epidemic. OM


  2. Cannady K. Dry Eye Products Market Expected to Generate $4.5 Billion by 2020. . Accessed June 26, 2017.
  3. Barkey P, Shah S, Smith Z. Giving birth to a dry eye clinic. Ophthal Manag. 2016. 20;8: 38-45. . Accessed June 26, 2017.
  4. The 2005 Gallup Survey of Dry Eye Sufferers: Summary Volume. Princeton, NJ: August 2005;1-160.
  5. The Vision Council. The 2015 Digital Eye strain Report. . Accessed August 8, 2017.

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