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This is How to Start a Dry Eye Practice and Why Your Patients Will Love You For It


Dry Eye Syndrome (DES) is a growing area of optometric care, and not treating it can cost your patients and your business.

Can you afford to not treat a condition that affects approximately 9 million people a year?

You already have the training to do so, now it is time to implement it!

The healthcare system is not going to help your profitability, and we need to provide medical services to differentiate ourselves. Ocular surface disease affects a majority of the patients already in your practice, and addressing it will not only help your business, but more importantly, it helps your patients.

How To Get Started

The first step is to make a decision to becoming a dry eye expert.

That decision requires making a commitment to look for signs of DES during your clinical examination, and deciding to start a treatment regimen for affected patients. How to treat is a more complicated answer, but the answers are out there!

Use your colleagues as resources.

There are several publications every month addressing the topic of Dry Eye, and treatment options.

My go-to’s include:

  • Review of Optometry
  • Ocular Surface News by Optometric Management
  • Social media outlets like ODs on Facebook and ODs For Ocular Surface Disease

Some of the best advice I can give you, is to just start treating, and learn from experience.

What To Do

If you see signs of ocular inflammation or lid disease during a routine encounter, inform the patient of your findings, and advise you need to further testing.

I typically start patients on OTC treatment at this point, including artificial tears, omega 3 supplements, and lid hygiene as needed. A majority of DES has been noted to be caused by MGD, thus I recommend lipid based artificial tears.

Systane Balance and Soothe XP are both lipid based lubricating drops that are excellent choices for patients. Retaine MGD and Refresh Advanced are preservative free lipid based drops, which are a better options for patients using artificial tears several times a day.

Omega 3 supplements vary widely across OTC formulas. I typically recommend between 1000-2000 mg of EPA/DHA omega 3 concentration per day for patients.

Having an in office supplement can insure patients get the proper omega 3 dosage, and can boost your office revenue.

I advised that this will start addressing the issues, and we will investigate the problem further at the medical visit, and alter/add treatment protocol as needed.

This does several things.

You have addressed that there is a medical issue, and that it needs a separate visit to be assessed and treated. You have given the patient a simple treatment plant to start, and advised further more aggressive treatment may be needed. You have also done this with minimal additional chair time on the routine visit.

Ocular surface disease is a multifactorial disease process affecting several different tissues. A more thorough slit lamp evaluation, with vital dyes, lid expression, and photography may be warranted. This takes time and should be done separate from a routine evaluation, and you should be reimbursed accordingly for that time.

How To Test

When the patient returns for the medical evaluation, this is the time to be a detective.

Look at the entire anterior segment from lids to cornea. The use of vital dyes is extremely important, as well as the lid margins.

Lissamine green is my dye of choice for conjunctival staining, and Fluorescein for corneal staining.

Objective measurements such as tear osmolarity (TearLab) or MMP-9 detectors (InflammaDry, Rapid Pathogen Screening, Inc.) are excellent diagnostic tools. These values are also helpful for patients to track improvement with treatment. Having a number that shows the patient that something is not normal solidifies your diagnosis in their mind.

Also, as the saying goes, seeing is believing.

Anterior segment photography is extremely helpful in eliciting a response from patients. If they see the problem, they understand it, and are more willing to do something about it.

Follow Up Schedule

Once a more aggressive treatment protocol is initiated, it shows the patient that you are with them in this fight against this disease.

Schedule regular follow ups to track progress of the treatment and compliance.

Once I see staining of any kind (conjunctival, corneal), that patient is already a moderate DES patient. I will start them on Restasis, in addition to a 2-4 week course of soft steroid therapy (lotemax gel bid to qid OU).

Depending on amount of corneal staining and symptoms, I typically will insert punctal plugs (6 month temporary) or 3-7 day treatment with amniotic membrane.

I will also address any MGD component at this time as well. That can vary from omega 3 supplements, lid scrubs, Azasite, doxycycline, or more recently, I’ve been utilizing a 5 day course of Azithromycin.

Lipiflow thermal pulsation treatment is the only FDA approved treatment for Meibomian Gland Dysfunction, and is a great option for MGD patients as well.

You have just started a treatment that is likely changing their daily routine. It is imperative to track their compliance and show them effects of this treatment. This shows your patients that you care about their ocular health, are taking time to ensure the treatment is effective, and being proactive in addressing this issue.

The more you care about the problem, the more they will as well.  This will also grow your business exponentially.

The Practice Management Aspect

This once “routine exam” now provided 2-3 additional medical office visits, with additional testing, and possibly special procedures.

Starting the patient on more simplistic treatments at the initial visit is important.

Most medical insurances require failure of more modest treatment before they will approve the use of more aggressive treatment options (i.e punctal plugs). This also shows the patient, that OTC treatments alone are not going to be effective.

Once additional therapy is added, it warrants a further follow-up to check for effectiveness. These additional visits are imperative in properly managing DES. It builds patient rapport, shows your commitment to treating DES, and also helps your revenue stream.

This patient is more likely to continue care with you because you were the first to diagnose this issue, the first to do something about it, and more importantly, the first to care enough to treat it.

You have just created a loyal patient to your practice, who is also more likely to refer you to others.  That is the start of growing a loyal patient base!

DES affects millions of people, and more importantly if affects a large percentage of your patient population right now!  You can be a better doctor and better business owner by addressing this disease, and you already have the tools to do it!

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About Anith Pillai

Anith Pillai
UHCO graduate Anterior segment disease and specialty contact lens evaluations Co-owner of Evolutionary Eye Care


  1. Van Kochkarian

    Very informative primer Dr. Pillai. My office recently started down the path of improving our dry eye protocol and I am seeking some information. I wanted to know what specific punctal plugs (brand and sizes) you recommend. (preferably ones that come pre-loaded) . I have also been looking for a 6-month collagen plug, but the closest I find are 3 months max. I am also intrigued that you are using a 5 day course of azithromycin rather than the usual long term doxy. Are you seeing similar results with your new treatment plan as compared to other long-term plans?

  2. Matthew Ward

    Dr. Pillai is a fantastic colleague and eye care professional. I am in the process of purchasing my own clinic,and Anith has been a great resource all things private practice. I communicate with him regularly and he is always willing to help. I’m certain over the years Dr. Pillai will be found right at the top with doctors like Dr. Karpecki and Dr. Epstein when it comes to dry eye management. Thank you Dr. Pillai for sharing your expertise!

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