Article Date: 4/1/2001

Dry Eye Update
Long-Term Revenue
Are you taking a medical approach to treating your dry eye patients?
BY DEEPAK GUPTA, O.D., Stamford, Conn.


We're back again with part 2 of our two-part series on dry eye.  This month, we have even more new information for you.  Robert E. Prouty, O.D., F.A.A.O., answers several questions pertaining to punctal occlusion and Deepak Gupta, O.D., discusses billing issues.  We'll also share the highlights from the first ever conference on Sjögren's syndrome, plus much more.

One of the most important aspects of treating dry eye -- and one that many of my colleagues don't do -- is treat dry eye as a medical condition that requires follow-up. This rule applies even if you only prescribe artificial tears for a patient.

Another step that I've found many optometrists also overlook is punctal occlusion -- a procedure many of my patients have been quite grateful for and that has added substantial income to my practice. I discuss punctal occlusion with every dry eye patient from the beginning. This way, patients are aware of all of their options up front.


Potential Net Income from Treating
Dry Eye Patients

  Per Week Per Month Per Year
Punctal occlusion $400 $1,600 $21,000
Office visits(not related to occlusion) $90 $360 $4,500
Total income $490 $1,960 $25,500

In most cases, punctal occlusion is covered under a patient's medical insurance. But if it isn't, don't prejudge your patient's willingness to pay for it. Like any other procedure, patients will accept punctal occlusion if you successfully convey the value they'll get for their dollar. Patients come to you for help, so they're going to be more open to treatment options.

When you count office visits, plus reimbursement for both collagen and silicone plug insertions, you'll find that the average net profit per punctal occlusion is $400. I do at least one a week, which adds $21,000 in profit by the end of the year -- and I have many satisfied patients who've benefited from this procedure.

Not everyone who has dry eyes needs punctal occlusion. In fact, more than half won't by my estimates. Even so, the least symptomatic of these patients wants to find relief.

When you consider that the average office visit results in a net profit of $45, that's an extra $90 a week, or $4,500 a year.

Note that the figures in the table above merely reflect the derived income from seeing three dry eye patients a week -- only one of whom undergoes occlusion, and the other two whom you manage with lubricating drops. This table doesn't take into account factors such as patients whom you'll be able to fit with contact lenses because their dry eye problems are under control.

Insurance companies treat dry eye as a medical condition, and so should you. Your patients will appreciate you for it and will recommend you to their friends. In turn, your practice will grow as you achieve a reputation as a provider of a full range of eyecare services.

We're back again with Part 2 of our two-part series on dry eye. This month, we have even more new information for you. Robert E. Prouty, O.D., F.A.A.O., answers several questions pertaining to punctal occlusion and Deepak Gupta, O.D., discusses billing issues. We'll also share the highlights from the first ever conference on Sjögren's syndrome, plus much more.

Punctal Occlusion Tips
Advice from an expert.

Denver, Colo.

Q: Which do you occlude first, the bottom or top puncta?

Bottom. If a patient is using artificial drops six or eight times a day, that can become lifestyle prohibitive. If he's not successful with them, then I discuss punctal occlusion.

During the first visit after discussing occlusion with a patient, I insert collagen dissolvable plugs in all four puncta. Some O.D.s insert plugs in one eye and not the other or just the bottom puncta, but that makes it hard for a patient to discern which scenario provides the best relief.

I ask the patient to come back in 2 weeks after keeping a daily diary describing how his eyes feel. While the plugs are in place, the patient may not feel a benefit, but when they dissolve, I find that patients are more adamant about getting permanent plugs, which we then use inferiorly.

The type of plug I use (intracanilicular or Freeman-style silicone) depends on the patient's sinus anatomy and history. I don't use intracanilicular plugs on patients who have sinus problems. Choosing a plug is patient specific. You have to look at a patient's lid position and his sinus medical history. Only in patients who have severe dry eye (such as Sjögren's patients) will I entertain occluding the top puncta as well with the Freeman-style plugs.

Q: Are more O.D.s skipping the collagen plug step and moving straight to silicone?

I think a number of O.D.s are. They're getting comfortable with interpreting the signs and symptoms and more skilled in knowing when to insert plugs. However, we can get reimbursed for the collagen plugs, and I prefer not to skip collagen plugs because I've found them worthwhile for patients.

Also, when using the Freeman-style plugs, it's best to accurately gauge the plug size because the plugs are expensive. When it comes down to it, it's worth investing in gauging instruments to have the tools that can determine the appropriate plug size ahead of time.

Highlights of Sjögren's Syndrome
A first-time conference drew together many specialists to increase awareness of Sjögren's syndrome.
BY KAREN RODEMICH, Associate Editor

In 1997, a national study showed that an average of 6.3 years passes from the onset of Sjögren's syndrome symptoms to an actual diagnosis. Why? According to Kathy Hammitt, immediate past president of the Sjögren's Syndrome Foundation (SSF), it's partially because many medical specialists aren't aware of Sjögren's, so they don't look for it.

Signs and Symptoms of Sjögren's

Keep these signs and symptoms in mind when talking with your dry eye patients. If you suspect a problem other than dry eye alone, ask about other symptoms, such as:

  • parotid swelling (salivary glands)
  • dry mouth
  • dryness everywhere (skin, eyes, etc.)
  • gastrointestinal problems.

Sjögren's is classified as an autoimmune exocrinopathy, which means that there's an inflammatory attack on multiple exocrine glands (glands that secrete important lubricating fluids throughout the body). Sjögren's can also result in musculoskeletal disorders and produce muscle and joint pain. It can affect the nervous system as well, especially peripheral nerves. Essentially, it can affect any organ in the body -- each patient is affected differently.

If you suspect that a patient has Sjögren's syndrome, to whom do you refer her? Rheumatologists are the main specialists who treat Sjögren's, but some immunologists and family physicians are knowledgeable enough to treat the syndrome.

Last September, a clinical conference co-hosted by the SSF and the National Institute of Dental (NID) and Craniofacial Research, National Institutes of Health (NIH) was held in Bethesda, Md. Kathy Hammitt provided highlights from this conference.

According to Hammitt, this was the first time the NIH held a clinical conference on Sjögren's syndrome. She said it was also the first time the foundation was able to get such a variety of specialists together.

Hammitt explained, "One of the ideas of the conference was to open this topic to all different kinds of specialists and allied health professionals and make them aware of the different aspects of Sjögren's." She also pointed out that what made this conference unique for the Foundation was the fact that it offered continuing education credits to all health professionals.

"We started with an overview of Sjögren's syndrome and its key signs (ocular, oral and general laboratory findings). The rest of the time was spent discussing the identification and treatment of complications and helping patients help themselves," said Hammitt.

Hammitt emphasized that optometrists were one of the Foundation's target audiences for the conference. Why? She explains, "An O.D. might see that someone has dry eyes, but 45 million people have dry eyes. It's important to get to the bottom of a patient's dry eye problem. If the O.D. is aware that it can be a sign of Sjögren's, then he can ask the patient some other questions that might lead him to believe that the patient has Sjögren's and he can refer her."

Often, patients won't come in and actually say their eyes are dry. Sometimes a patient will describe her eyes as feeling gritty, sandy, crusty, burning or irritated. If they don't know any better, they won't use terminology that makes it click in your head.

The Sjögren's Syndrome Foundation will have its annual meeting in Los Angeles this month. To find out more about the SSF, call (800) 475-6473 or visit

A New Approach to Dry Eye
New use for swim goggles.
Associate Editor

This subject looks ready for a swim, but she's keeping her eyes from drying out while playing a computer game.

Recently, Donald R. Korb, O.D., a private practitioner in Boston, began researching dry eye in computer users.

Fourteen people played Taipei on a computer for 40 minutes. All developed eye discomfort of at least grade 1 in 10 to 30 minutes. Then the same people were fitted with swimming goggles, which create an environment of periocular humidity greater than 80%. They played the game for 40 more minutes even though their eyes hurt. Within 30 minutes of wearing the goggles their eyes were comfortable.

When the patients weren't wearing the goggles and playing the computer game, their lipid layer thickness decreased from 87 nm to 65 nm. When they wore the goggles and continued playing, their lipid layers nearly doubled to 107 nm.

Practice Pearls


Freeman-style plug precautions. Getting a silicone plug into proper position is critical. After inserting a Freeman-style silicone plug, take the patient to the slit lamp to make sure that the top flange of the plug is sitting in the proper position above the punctum. When you lose a plug below the punctal opening, you have to surgically remove it, and then the patient's punctum is never the same.

Preventing post-op complaints. The number-one major complaint patients have after refractive surgery is dry eye symptoms. Warn patients prior to surgery that their symptoms will worsen for a few weeks after surgery but they won't last forever.

Try inserting collagen plugs into a patient's lower puncta prior to surgery. Put two or three plugs in each puncta so the patient gets 2 to 3 weeks of temporary occlusion.

In my opinion, every laser-assisted in situ keratomileusis (LASIK) patient should have his puncta occluded because even patients who don't suffer from preoperative dry eye may experience dry eye symptoms post-op.

Leave the top puncta open. The longer you keep a patient's own tears on the ocular surface, the better and faster his eyes will heal.

Optometric Management, Issue: April 2001