Biography: Recalde owns Lifetime Optometric, a private practice in the Central Valley of California
March 04, 2020
4 min read

BLOG: Tips for starting a dry eye practice

Biography: Recalde owns Lifetime Optometric, a private practice in the Central Valley of California
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Dry eye disease is everywhere; however, many optometrists are overlooking this opportunity to provide better care for their patients’ eye health while also adding a steady revenue source.

Let’s talk about what it takes to get started diagnosing and treating dry eye in your patients.

Initial investment

The equipment required to start testing your patients for dry eye is relatively inexpensive. We are already performing a comprehensive eye exam and can easily observe obvious symptoms such as red eyes and take a moment to closely inspect the meibomian glands. Diagnostic testing is as simple as corneal and conjunctival staining with lissamine green, checking tear breakup time and administering a dry eye questionnaire. I currently use the Standardized Patient Evaluation of Eye Dryness (SPEED) questionnaire, which helps me gauge the severity of my patients’ symptoms. These tests add little time to a comprehensive exam.

As you feel more comfortable in the dry eye realm, consider investing in technology. I use the Oculus Keratograph, which is a highly versatile imaging machine that can examine the meibomian glands, provide a noninvasive tear film breakup time, measure tear meniscus height and evaluate the lipid layer. I can also use it to do scleral fitting and topography — all in one machine. Medicare provides a modest reimbursement (about $22) for external ocular photography, which applies to meibography and corneal staining images, but the machine itself will not make you rich or pay for itself quickly. The point of making this investment is that once you identify your dry eye patients, you will eventually earn additional revenue by routinely adding more diagnostic tests to identify dry eye patients and for ongoing monitoring of previously diagnosed patients.

Another benefit of tech equipment is that patients like visuals that explain what you are talking about, and this type of technology can deliver that. If you decide to add treatment services such as LipiFlow (Johnson & Johnson) down the line, your advanced diagnostic testing will identify and feed patients to the procedure.

Build your provider network

A dry eye exam and many of the dry eye diagnostic and treatment procedures fall under the medical umbrella, so building your provider network will organically direct more patients to your practice. Becoming a Medicare provider is a definite must, since a large share of dry eye patients have reached the age of eligibility. There are also many patients who do not realize that they have a medical plan with vision coverage, or that there are certain primary eye care plans where we can bill for a medical visit.

We always offer to take a look at insurance service plans to check whether patients have vision benefits.


Reimbursables, private pay

Medicare provides us with a common denominator for estimating reimbursement rates. With our Medicare patients, we receive varying reimbursement levels for the medical visit based on the number of tests performed, external photography and the treatment plan. For patients requiring a more aggressive approach, Medicare also provides approximately $1,500 — an equitable reimbursement amount — for amniotic membrane procedures. These procedures are excellent options and can provide significant relief for many of our patients. There is an upfront cost for the membrane, but the profit margin is generally better than that of cataract surgery.

For our patients who are private pay, we add on the tear staining as an additional test and explain that it is part of the dry eye evaluation. This gives our patients a feeling of added value to what they are spending on the dry eye exam. Since it also can be difficult to get insurance coverage on dry eye prescriptions, we take care to inform our patients about need-based prescription programs offered by the makers of long-term medications such as Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan), Xiidra (lifitegrast ophthalmic solution 5%, Novartis) or Cequa (topical cyclosporine ophthalmic solution 0.09%, Sun Pharmaceutical). Patients do have to submit to a qualification process, but if they meet the criteria, they receive complimentary medication from the pharmaceutical company.

Essential treatment options

Expensive equipment is not necessary to treat most of your dry eye patients. I recommend three essential treatments as a dry eye practice starter pack.

Nutraceuticals. Artificial tears and lid hygiene treat the symptoms of dry eye from the outside in, whereas nutraceuticals treat the underlying cause from the inside out by helping our bodies to naturally produce more and higher quality tears. I personally take and recommend HydroEye (ScienceBased Health) to all my patients because it includes the unique omega GLA (gamma-linolenic acid). GLA has been found to relieve dry eye in several clinical studies, including the HydroEye clinical trial (Sheppard JD Jr., et al). HydroEye’s patented formula combines GLA, along with other omega fatty acids and key nutrient cofactors that work together to provide targeted dry eye relief.

Artificial tears. Patients often tell me they have already tried and failed on this route; however, they are usually using the wrong kind of artificial tears — such as Visine (tetrahydrozoline HCl 0.05%, Johnson & Johnson) or Clear Eyes (naphazoline HCl 0.012%, Prestige Consumer Healthcare) — which are not formulated to lubricate the eye. I always recommend a specific brand to avoid confusing my patients with too many choices, and then start them on it before they return for their dry eye evaluation. Since many insurance providers require documentation that patients tried and failed artificial tears, starting them on over-the-counter treatments makes it possible to move immediately into prescription medications without wasting the first dry eye exam.


Lid hygiene. Dysfunctional meibomian glands or bacteria are common dry eye triggers, which we treat with a routine of warm compresses, lid wipes or hypochlorous acid.

I stock all of the products that I recommend in the office. Patients love the convenience of having everything they need in one place. Plus, I can ensure my patients are getting a quality product and are not overwhelmed with the choices or tempted by inferior products.

Adding dry eye diagnostic and treatment options to your practice is relatively simple and requires little initial outlay. Dry eye disease is very prevalent, and adding just one patient each day can reap significant rewards to your bottom line.


Sheppard JD Jr, et al. Cornea. 2013;doi:10.1097/ICO.0b013e318299549c.