Editor's Commentary
For years I have been using the dry eye mantra, “ask, look, do something” to simplify dry eye diagnosis for clinicians. If you are just starting out in dry eye management, attending a dry eye continuing education lecture may make you think it is way too complicated. This can be the case if the lecturer has been an early adopter of all things ocular surface related.
In the context of dry eye diagnosis and management, a "back-to-basics" approach emphasizes returning to core clinical principles to improve patient outcomes, as you will read in this issue’s columns. As diagnostic tools and treatment options for dry eye disease (DED) become increasingly sophisticated, clinicians may feel pressured to adopt the latest technologies. However, like me, many dry eye aficionados advocate for a foundational strategy that prioritizes thorough patient history, symptom assessment, and basic diagnostic tests before moving to advanced testing. Your brain and your slit lamp (plus dye) are powerful tools!
This back-to-basics approach begins with understanding the patient’s lifestyle, systemic health, and environmental factors that may contribute to dry eye. Simple survey instruments like the Ocular Surface Disease Index (OSDI) or the Standardized Patient Evaluation of Eye Dryness (SPEED) survey; tear breakup time (TBUT); fluorescein staining; and thorough eyelid, lashes, and meibomian assessment remain essential for identifying tear film instability and ocular surface damage. Basic assessments, when used consistently, can guide and train clinicians toward accurate subtyping of DED—whether it’s aqueous-deficient, evaporative, or mixed.
Management, too, benefits from a back-to-basics mindset. Rather than immediately resorting to costly or invasive treatments, clinicians can start with patient education, environmental modifications, eyelid hygiene, and artificial tears tailored to the type of dry eye. Nutritional support, such as omega-3 supplementation, and addressing meibomian gland dysfunction through warm compresses or lid massage, can be effective first-line strategies. Having said this, though, it is important to ask about success with previous treatments. If any previous therapies have failed, a change is warranted. I find it common that patients have tried artificial tears or warm compresses on their own, sometimes with limited success.
Ultimately, the back-to-basics philosophy in dry eye care is about clinical clarity and patient-centered care. It ensures that, even in resource-limited settings, practitioners can deliver effective, evidence-based treatment without overcomplicating the process.
Kelly K. Nichols, OD, MPH, PhD
Editor
Clinician's Corner
Selina R. McGee, OD, FAAO
Founder of Precision Vision Edmond, Edmond, OK
The Dry Eye Office: Who Is the Right Patient for Screening?
Identifying the “right” patient for dry eye disease (DED) screening isn’t just a small part of your schedule. When it comes to DED, the right candidate for screening is every patient in your chair. Put simply, every patient should be considered to have dry eye until proven otherwise, especially since some patients fail to mention any symptoms at all. This is because dry eye disease doesn’t always present with the hallmark complaint of “dryness.” Instead, patients may describe fluctuating vision, burning, tearing, foreign body sensation, and end-of-day eye fatigue. As optometrists, we can’t just wait for our patients to recognize that their symptoms are due to DED; we must meet them where they are. That’s why every optometric office is essentially a “dry eye office,” whether you’re ready to claim that identity or not.
Start by assuming each patient has dry eye disease. This reframing ensures consistent screening and better outcomes across the board. Use a validated questionnaire at check-in to establish symptom baselines and trends. Then, ask one additional good question during the exam—something like, “How do your eyes feel at the end of the day?” or “Does your vision fluctuate while you are using digital devices?” Essentially, you want to elicit open-ended responses. One powerful question can help connect the dots so you can make a diagnosis.
The clinical exam must be geared toward detecting dry eye. Use vital dyes to assess staining patterns and tear quality. Measure tear meniscus height (TMH). Look beyond the cornea: Examine eyelid margins, express meibomian glands, and document lid function. These are not add-ons; they are essential components of comprehensive care. Dry eye doesn’t just affect comfort—it impacts vision, contact lens success, surgical outcomes, and quality of life.
This can’t be a solo effort. Ensuring that your optometric practice is one that identifies DED in every affected patient means training your entire team to recognize and manage this disease. Empower your front desk staff to distribute questionnaires and validate that these questions about common symptoms are important. Teach your technicians how to perform standardized screenings, imaging, and diagnostic testing. Train your opticians to reinforce ocular hygiene routines and support patients through the lifestyle changes that treatment often requires.
Appoint a dry eye champion—someone who “owns” the logistics, from patient communication to navigating prior authorizations and co-management. Lean heavily on your industry representatives to identify and build standard operating procedures (SOPs) and best practices. Utilize these resources; you don’t have to reinvent the wheel. Having a go-to team member elevates efficiency as well as patient satisfaction. I can’t tell you how valuable this has become in our office. If you are doing in-office procedures, train a dry eye coordinator to expand the conversation and educate patients.
Some patients require special attention. Contact lens wearers often exhibit early signs of meibomian gland dysfunction or have demodex blepharitis, yet symptoms are brushed off as normal lens intolerance. Glaucoma patients may experience medication-induced ocular surface disease that undermines adherence. And when preparing patients for cataract surgery, preoperative tear film optimization is non-negotiable—poor ocular surface health leads to poor biometry, delayed healing, and suboptimal outcomes.
So, who’s the right patient for dry eye screening in your office? The answer is everyone. It’s not about waiting for the perfect candidate or treating the one who complains the most; it’s about creating the systems, mindset, and culture that allow you to identify and manage this disease consistently.
The takeaway is simple but powerful: No matter what kind of practice you run—primary care, contact lens, surgical co-management, or boutique optical—you’re a “dry eye practice.” At the very least, be purposeful about screening for and identifying dry eye disease. If dry eye isn’t your passion, that’s OK! Coordinate with a colleague who “lives for” diagnosing and treating this disorder and co-manage confidently. When we elevate our standard of care, we elevate the entire profession.
Research Update: Commentary on Abstract of the Week
Blair Lonsberry, MS, OD, MEd, FAAO
American Board of Optometry, Diplomate
Pacific University College of Optometry, Professor of Optometry
Traditional management of dry eye disease (DED) includes the use of lubrication drops as a means of increasing tear volume and/or potentially stabilizing the lipid layer and decreasing tear evaporation. There are multiple formulations of lubrication drops that also have variable effectiveness in DED patients. Newer advances in over-the-counter lubrication and topical prescription therapy have focused on compounds to mitigate evaporation rate.
Perfluorohexyloctane is an inert semi-fluorinated alkane that has emerged as a novel agent for lubrication drops and was approved in Europe in 2013 as a medical device for the treatment of DED. It has multiple mechanisms of action, with the primary action being to help reduce evaporation, and is a fully saturated, linear molecule consisting of hydrogenated carbon chains that confer hydrophobic properties to the molecule. Perfluorohexyloctane replaces the defective tear film lipid layer while forming a protective overlay at the tear film–air interface, significantly reducing evaporation rate. Perfluorohexyloctane solution was recently approved by the FDA in the United States for the treatment of signs and symptoms of DED.
The structural properties of the hydrocarbon chains in meibum lipids play a crucial role in maintaining tear film stability. The molecule consists of saturated hydrogenated carbon chains, which allows it to spread evenly over the tear film, whereas less saturated molecules tend to promote lipid clumping and can eventually obstruct the meibomian glands. Perfluorohexyloctane has an oxygen-carrying capacity that allows the delivery of nonreactive oxygen species to the cornea, which is critical for the health of the ocular surface.
The purpose of this study was to perform a systematic literature review of the evidence from randomized controlled trials to evaluate the efficacy and safety of perfluorohexyloctane in the treatment of DED. The literature search included the terms “perfluorohexyloctane,” “NOV03,” or “semifluorinated alkane” and “dry eye.” The initial search resulted 81articles; however, after removing duplicates and other exclusion criteria, 5 randomized clinical trials were used in the analysis. The articles were evaluated with respect to the following study variables with 2-, 4-, and 8-week follow-ups (FUs) recorded: total corneal fluorescein staining (tCFS), tear film break-up time (TFBUT), eye dryness score (EDS) assessed by a visual analogue scale (VAS), ocular burning/stinging assessed by VAS scale, Ocular Surface Disease Index (OSDI), unanesthetized Schirmer test (ST), and meibomian gland dysfunction (MGD) score.
The results of the meta-analysis indicated that statistical improvement was seen with two of the variables: tCFS and EDS. The authors concluded that perfluorohexyloctane is a safe and effective alternative for the treatment of evaporative dry eye secondary to meibomian gland dysfunction, resulting in a decrease in corneal staining and improvement of dry eye symptoms. The authors commented that more non-sponsored randomized clinical trials are necessary to fully explore the impact that perfluorohexyloctane has on the health of the ocular surface.
Abstract
Efficacy of Perfluorohexyloctane for the Treatment of Patients With Dry Eye Disease: A Meta-Analysis
Taloni A, Coco G, Pellegrini M, Scorcia V, Giannaccare G. Efficacy of perfluorohexyloctane for the treatment of patients with dry eye disease: A meta-analysis. Ophthalmic Res. 2025;68(1):41–51. doi:10.1159/000542149
INTRODUCTION: The aim of the study was to systematically review the evidence from randomized controlled trials that evaluate the efficacy and safety of perfluorohexyloctane in the treatment of dry eye disease.
METHODS: Literature search was conducted on PubMed and Scopus in April 2024 with the search strategy ("perfluorohexyloctane" or "NOV03" or "semifluorinated alkane") and "dry eye." Extension and paired-eyes study were excluded. The risk of bias was assessed using the Cochrane risk-of-bias tool. Forest plots and a summary of findings were prepared for total corneal fluorescein staining (tCFS), tear film break-up time (TFBUT), eye dryness score (EDS), and Ocular Surface Disease Index (OSDI).
RESULTS: The pooled standardized mean difference (SMD) for tCFS after 8 weeks of treatment was -0.53 (95% CI: -0.68 to -0.38; p < 0.001), indicating a significant improvement in patients treated with perfluorohexyloctane. The between-study heterogeneity was moderately high (I2 = 52.0%). No significant differences in TFBUT were observed (SMD = 0.05; 95% CI: -0.16 to 0.25; p = 0.654). Regarding symptoms, patients treated with NOV03 had significantly lower EDS compared to controls (SMD = -0.49; 95% CI: -0.66 to -0.32; p < 0.001), with moderately high heterogeneity (I2 = 71.1%). Conversely, the pooled SMD of OSDI was -0.13 (95% CI: -0.43 to 0.17; p = 0.412), indicating no significant difference.
CONCLUSION: Perfluorohexyloctane is an effective and safe alternative for the treatment of evaporative dry eye disease due to MGD that can significantly reduce tCFS and eye dryness symptoms. More well-designed non-sponsored randomized clinical trials are required to investigate the impact on other ocular surface parameters.
CONFLICT OF INTEREST STATEMENT: The authors have no conflicts of interest to declare.
Coding
Ryan Ames, OD, MBA
Owner of InSight Eye Care, Oshkosh, WI
How Diagnosis and Supporting Documentation Impacts Insurance Coverage in Ocular Surface Disease
Specific and accurate diagnosis code choice is critical in coding and billing for all the medical services we provide, and clear and complete documentation is equally important. When it comes to ocular surface diseases (OSDs)—such as dry eye disease (DED), meibomian gland dysfunction (MGD), and allergic conjunctivitis—the multifactorial aspect of the disease can make choosing the best code and what is necessary for documentation confusing. Beyond guiding treatment, a precise diagnosis plays a pivotal role in securing insurance coverage for therapies and ensures patients can access the care they need without undue financial burden. This article explores how diagnosis codes and documentation can influence insurance reimbursement and treatment coverage.
Insurance coverage hinges on standardized diagnostic codes from ICD-10. For example, DED is typically coded under H04.12x. Misclassification, such as using a nonspecific code like “dry eye syndrome” (H04.12) without specifying laterality, will lead to claim denials for even just an office visit. But when it comes to more advanced procedures and treatments, the code choice can be even more important.
Similarly, distinguishing between MGD (H02.88x), allergic conjunctivitis (H10.45), and dry eye syndrome (H04.123) is critical, as treatments (eg, intense pulsed light therapy [IPL], antihistamines, punctal occlusion) and their coverage vary widely.
Diagnostic tools, including meibography, tear osmolarity testing, or inflammatory marker analysis (eg, MMP-9), can strengthen claims by objectively validating disease severity. Insurers increasingly require such documentation for costly interventions such as IPL therapy or amniotic membrane transplants. Although most third-party payors will not cover IPL, low level light therapy, or radio frequency treatment for MGD patients, some actually do. But they will require clear documentation of the condition and the testing that supports the diagnosis and treatment.
Many insurers mandate prior authorization (PA) for pharmaceuticals, such as cyclosporine (Restasis, Cequa, Vevya) or lifitegrast (Xiidra). A robust diagnostic report that details symptom persistence, failed first-line therapies, and objective signs (eg, low tear breakup time, corneal staining) is essential to justify “medical necessity.”
Coverage policies often differ by diagnosis:
- Dry eye disease: Insurers may cover artificial tears and anti-inflammatory drops under general DED codes but require prior authorization for biologics such as serum tears.
- Chronic ocular graft-vs-host disease (D89.811): Conditions like cGVHD often qualify for broader coverage, including specialty contact lenses or scleral prosthetics.
- Neurotrophic keratitis (H26.23x): This will open the doors to nerve growth factor (ie, cenegermin-bkbj [Oxervate]).
Best Practices for Clinicians
- Specificity matters: Use precise ICD-10 codes and avoid generic terms.
- Leverage diagnostic tools: Incorporate imaging and biomarker testing to substantiate claims.
- Stay updated: Regularly review insurer policies, which evolve with new evidence.
- Appeal strategically: If denied, provide supplemental data (eg, pre- and post-treatment scans) to challenge decisions.
In OSD management, diagnosis is not merely a clinical step; it is a gateway to equitable care. By aligning diagnostic accuracy with insurer requirements, clinicians can advocate effectively for their patients to ensure therapeutic success and financial accessibility. As payor landscapes shift, proactive documentation and coding precision will remain indispensable tools in bridging the gap between diagnosis and coverage.
This editorial content was supported via unrestricted sponsorship