Article Date: 11/1/2012

the dry eye practice

From Puddles to Oceans

My experiences provide the steps for developing a successful dry eye practice.

MICHAEL S. COOPER, O.D., Willimantic, Conn.

On any given day, I can pick out a dry eye patient a mile away. Statistics support this statement. In the United States alone, approximately 20.7 million people are affected with — and 40% experience symptoms of — this chronic disease.1,2

Once I tell the patient, “You have dry eye,” what is my next step? How do I manage him/her successfully? In addition to answering these questions, I share my journey in building a dry eye practice.

Asking for patients

When I interviewed with my current practice, I asked the doctors two questions: How many dry eye (additionally allergies and lid disease) patients does the practice see, and do they want to see them? My two colleagues, both ophthalmologists, expressed little interest in this population. However, when I subsequently gauged their interest, they were happy for me to take these patients in order to cultivate a practice within a practice, or specialty niche. (See “Table 1. Economics of Dry Eye,” page 42.)

With this nascent excitement, I thought patients would line up outside the door, and patient retention would be a piece of cake. I had the skills, knowledge and up-to-date research at my fingertips — how hard could this be? But just like a dry eye patient, the situation was frustrating and enigmatic. It would take 50+ patient encounters before I started to iron out the idiosyncrasies and get into a comfortable rhythm.

The game changer though, was a story told to me by a wise peer who changed my treatment strategy. The context of the conversation was whether the over-the-counter vs. prescription therapeutic options actually addressed the underlying chronic inflammation. It was an epiphany. The takeaway: I was waiting for progression when I should have been preventing progression in the first place with an immunomodulatory treatment, such as cyclosporine 0.05% (Restasis, Allergan), that treats inflammation.

Through the past nine to 12 months, my ocular surface disease practice has experienced impressive growth. Of the 25 to 30 patient encounters in my daily schedule, 50% to 60% are related to dry eye and either separate or concurrent allergies/lid disease. How did this critical mass explosion happen? I believe that through my own patients’ word-of-mouth referrals and internal referrals from my ophthalmology colleagues (as well as a successful therapeutic approach) an inherent trust has been created in our dry eye patients. Patients are no longer just given a bottle of artificial tears and left to fend for themselves.

Listen to “silent sufferers”

As I find more and more, dry eye patients are “silent sufferers” to the highest degree. Many think the condition is one they have to adapt to in their daily lives. In addition, a large segment of this population has told me their symptoms have either been ignored or devalued for years by medical professionals. I tell these same patients that I hear them, and they will be successfully treated in my practice.

In essence, when I utilize both passive and active listening, I empower these individuals. Patients appreciate the fact that their condition can be addressed with the proper treatment (immunomodulatory/corticosteroid/NSAID drops, punctal plugs, adjunctive-branded artificial tears, switching to daily disposable contact lenses, autologous serum, etc.) and follow up. I take time to explain the chronic inflammatory nature of dry eye and truly create a mutual covenant to facilitate trust in reference to the treatment plan. I tell each patient, “We are a team and must work together to successfully manage this chronic condition and prevent further damage.” By virtue of my conviction and confidence in treating this spectrum of ocular surface disease, my patient attrition rate is low at 5% to 10%.

Use real-world examples

I apply real-world situations to make the condition tangible for the patient. One of my best examples is how the patient’s tears are similar to an ocean’s ecosystem. I tell him/her it is a complex structure that must be kept in constant harmonious balance and when it is not, the result can be a puddle leading to a drought. The “puddle” effect can be exemplified by the fluctuations in vision and increased symptomatic irritation (foreign body sensation, redness, pain, etc.) with a possible relationship to the patient’s medications, systemic inflammatory history, age and environmental factors.3,4

Table 1. Economics of Dry Eyea,b
Type of Visit/Testing Reimbursement/Pt ($) Net Revenue ($)
Visits (New Eye Exam +3 follow-ups) 347.00 433,750
Plugs (Average of 3 motrial + Silicone) 291.00 363,750
Comorbidities (Average of Seasonal Allergies, Cataracts, AMD, Myopia, Glaucoma) 467.00 583,750
TearLab Osmolarity Test ($15/card × 4 visits) 254.40c 318,000
TOTAL 1359.40 1,699,250
aData adapted from Johns Hopkins Advanced Studies in Ophthalmology, Volume 8.7
bBased on the assumption of 1,250 dry eye patients out of 5,000 total patients/year (25% load)
cCurrent Medicare reimbursement is $46.80 for both eyes.

Another instance is the tear gel composition itself, which I liken to a Velcro sandwich. Characteristically, the invention, by the Swiss electrical engineer George de Mestral, dovetails well with how the corneal epithelium’s microvilli “hooks and loops” into the mucin-aqueous layer with lipids rounding out the sandwich paradigm.5 My illustration of this model to a patient consists of an artist’s rendition of the tears with the cornea and lipids sandwiching the mucin and aqueous layers. The old adage still applies: Keep it simple.

Treat “family”

Finally, I treat every patient as if he/she is a member of my family. I tell patients that if they have any questions whatsoever between visits, they can call me or stop by the office for a quick chat to resolve the concern. I pride myself on being the patient’s advocate and doing whatever it takes to get him/her on the right track. If this requires a phone call to fight for a prior authorization or a call to an elderly patient to remind him/her to take their drops, we do it.

Don’t neglect staff training

As my volume has increased, I have found it paramount to train staff on the dry eye basics, follow-up protocols and answering patient questions. Front desk personnel and optometric/ophthalmic technicians have the most face time with the patient and, therefore, must have the proper skill set to elicit the correct ocular surface disease history.

In addition, I have the staff take the Ocular Surface Disease Index survey to see whether they have dry eye. The questionnaire kills two birds with one stone: It gives them a cheat sheet on what to ask patients for work-ups, and it turns them into a potential dry eye patient who can be used as a success story. Furthermore, as dental hygienists typically have pearly white teeth, optometric/ophthalmic staff members should all have healthy lids and the appearance of “white” eyes.

Think CSI and delegation

Think of the patient encounter as a “CSI” episode by allowing your technician(s) to collect all the evidence, and then you put it altogether to solve the case by the end of the episode. Although this analogy is oversimplified considering the psychological and physiological complexity of a dry eye patient, it serves a purpose in terms of delegation. For example, I explain the reasoning behind the prescribed therapeutic intervention, but I have a staff member demonstrate how to use treatments, such as drops, warm compresses and eyelid scrubs. To minimize patient confusion, the staff member dispenses written instructions, which have been approved by me and the medical director.

I cannot stress enough to completely understand what responsibilities can be delegated in your state.

A co-management approach

One of the most gratifying experiences has been the co-management relationship with my ophthalmology colleagues, which has led to an increased respect among all three of us and a seamless management of the patients who have ocular surface disease with concurrent glaucoma or retinal disease. When they uncover a dry eye patient, they encourage the patient to see me to manage the chronic disease. I have been told by patients on a regular basis that my peers told them, “You will enjoy seeing Dr. Cooper to treat this particular condition. He will take excellent care of all of you.”

In addition, I frequently reach out to local allergist, rheumatologist and ophthalmology sub-specialists to communicate the treatment plan and to pick their brains on new therapies and surgical techniques. By fostering this team approach, practices can cross pollinate and share the division of labor in a more effective manner. This exact situation has created an additional stream of new patients for me and an increase in practice revenue.

Do not let the border wars of yesteryear become your stumbling block. Keep in mind that you are acting in the patient’s best interest, not someone else’s ego.

My final preventive pitch

Marc Bloomenstein, O.D., F.A.A.O., of Scottsdale, Ariz., has written how optometrists are the fusion of therapist, detective, doctor and caregiver. With dry eye and other prospective comorbidities, we need to utilize these skills to prevent progression. In turn, you will increase your patient retention rate, net revenue and most importantly improve the patient’s quality of life. OM

1. Market Scope. Report on the Global Dry Eye Market. St. Louis, Mo. Market Scope, July 2004.

2. Multi-Sponsor Surveys, Inc. The 2005 Gallup Study of Dry Eye Sufferers: Summary Volume. Princeton, NJ: August 2005; 1-160.

3. Pflugfelder SC, Beuerman RW, Stern ME. Dry Eye and Ocular Surface Disorders. New York, NY: Marcel Dekker; 2004.

4. Wilson SE, Stulting RD. Agreement of physician treatment practices with the international task force guidelines for diagnosis and treatment of dry eye disease. Cornea. 2007 Apr; 26(3): 284-89.

5. Swiss Broadcasting Corporation. How a Swiss invention hooked the world.

6. Published January 4, 2007. (Accessed 8/25,12.)


Dr. Cooper practices in Willimantic, Conn. He is a consultant to Allergan, Inc., Epocrates, Inc., and has received past honoraria from Alcon and inVentiv Health, Inc. E-mail coopeye47@msn. com, or send comments to optometric

Optometric Management, Volume: 47 , Issue: November 2012, page(s):