Dry Eye

How We Built Dry Eye Services that Spurred 20%+ Growth in Annual Revenue

Frank W. Bowden III, MD, the owner of the MD-OD practice where Dr. Robben and Patti Barkey, COE, work, administering a dry eye treatment. 

By Jerry L. Robben, OD, and Patti Barkey, COE

May 4, 2022

As a comprehensive surgical corneal specialty practice, we make a concerted effort to diagnose and treat dry eye disease (DED). A key way we do this is by educating patients about the need for treatment, and then making the most advanced medications and technologies available to treat their condition.

Here are the major actions we took to grow our dry eye practice.

A Huge Pool of Patients to Serve & Grow Your Practices With
Optometry practices considering adding or expanding dry eye services will recognize patients with DED are already walking through their doors. Treating the condition isn’t as much about growing a practice in terms of patient acquisition as it is about increasing the number of patient encounters and revenue per patient.

Depending on their size and level of commitment, practices can expect to see anywhere from a 5 percent to 20 percent, or more, growth in revenue by offering solutions to these patients. Consider a practice that performs 1,000 cataract surgeries with 50 percent of those patients opting for premium technology; roughly 30 percent will add a dry eye treatment to optimize their outcomes. When optometrists embrace full-scope dry eye management, it opens the door to an average of $250 increased revenue per patient encounter.

Remember, dry-eye treatments are not one-and-done. Patients require follow-up care and repeat treatments, multiplying revenue and making each DED patient an annuity. Additionally, with DED being a leading reason for contact lens failure, practices will keep a higher percentage of patients in their lenses.

As the population increases, and the number of ophthalmologists (OMDs) remains stable, this is a prime opportunity for optometry to embrace DED patients.

Offer Patients the Full Range of Treatment Options
The DED treatment market has been evolving for years. The introduction of Restasis (cyclosporine) gave us the first prescription option to offer to patients.

Then, for years, our DED tool box was limited to Restasis, punctal occlusion and simple eyelid hygiene and omega-3 supplements. However, when a treatment like LipiFlow Thermal Pulsation System  and diagnostics such as Tear Osmolarity testing and MMP-9 testing were approved, the dry eye market really took off for our practice and industry.

Taking a Multifaceted Approach to Treatment
When considering treatment offerings, practices can think in terms of categories. Using a combination of device-based strategies and therapeutics, the following aspects of DED must be addressed: inflammation, the biofilm, meibomian gland dysfunction, and ocular surface integrity and homeostasis. At Bowden Eye & Associates, we offer a comprehensive slate of therapies and procedures that include:

• Punctal occlusion (90-day plugs only)

• Prescription pharmaceuticals (ocular, oral, and now nasal)

• Nutraceuticals (HydroEye)

• Blepharoexfoliation (BlephEx)

• Meibomian gland evacuation (LipiFlow and iLux)

• Meibomian gland probing performed by ophthalmologists

• Intense pulse light or IPL (M22)

• Neurostimulation (iTear 100)

• Amniotic membrane (Prokera)

• Autologous serum tear drops (Vital Tears)

• Biologic eye drops (Regener-Eyes, StimulEyes)

You Can Start with a Small Investment
We have three gland evacuation devices because we are a teaching practice with our Dry Eye University educational programs and optometric student program, but most practices can start by adding one of these treatment options. We know that 86 percent of patients with DED have meibomian gland disease (MGD)i, therefore practices in the business of treating dry eye (and most should be) must have a gland evacuation treatment.

Determining which devices to incorporate requires research and planning. A practice could start with an investment of $25,000-$30,000 and pay for that investment quickly—the return on investment is going to be tremendous if you start to actually treat your patients. Many devices can be financed or leased with a delay in the first payment to allow you and your team to ramp up in procedures/uses.

From a diagnosis perspective, there are many low-cost ways to enter this market. Incorporating a patient questionnaire such as the Standard Patient Evaluation of Eye Dryness (SPEED) costs very little. Tear testing to identify inflammation, MMP-9 testing and tear osmolarity testing are essential—these two diagnostics alone allow us to identify DED patients. Gland evaluation will help eyecare providers quickly find patients who need treatment for MGD; this can even be done with a Q-tip. Tracking gland function can also serve as an indicator of improvement or decline. Debris from blepharitis will be observed during the standard slit-lamp evaluation.

Having a device to image the meibomian glands is the next important component of a dry eye practice. This comes with the LipiView II device, which incorporates an Ocular Surface Interferometer with Dynamic Meibomian Imaging to perform blink analysis and lipid layer thickness measurement, as well as high-quality gland imaging. We obtain these three metrics to help establish and document the patient’s story and the course of action needed, and again, track their course.

Other devices that can be used in DED diagnostics are keratometry and corneal topography devices can be implemented to obtain further information on tear film quality and breakup time. Although these devices are not primarily used for DED, they can be useful tools to help us educate patients and demonstrate the need for treatment and how they are responding.

Make Patient Success with Nutraceuticals for Dry Eye More Likely
To help patients adhere to a hygiene and nutraceutical regimen, we advise that practices make some products available in their practice. This is particularly advantageous in the setting of the pandemic with patients seeking to have as little exposure as possible. For example, patients are increasingly interested in natural options, so we recommend daily HydroEye (ScienceBased Health).

Backed by scientific evidence from a clinical trial and data published in peer-review journals, we explain to our patients the benefits of the product’s key ingredient, the omega fatty acid gamma linolenic acid (GLA). This unique anti-inflammatory omega-6 is shown to play an important role in modulating the inflammatory response and has been validated for improving dry eye symptoms in a variety of studies performed across a wide range of patient types.ii-viii

Set Up Consistent Processes for Success
Dry eye management should be a staple of eyecare practices—it is an everyday problem for patients, so it should be an everyday concern for optometrists. The condition impacts every other aspect of eyecare, from fitting contacts and prescribing glasses to LASIK to glaucoma to customized refractive cataract surgery. For our providers, it is a seamless part of their everyday exams, built into their routine. Dry eye is a practice and quality-of-care builder.

When practices are just starting out, patient encounters will take extra time as the entire team works to solidify scripts and processes. Having a standard of care in place, and ensuring everyone knows their role, will help improve efficiencies and eliminate guess work. Be flexible and adapt, when necessary, but live up to the standard you establish.

Educate Practitioners & Support Staff
Every practice should implement a system for consistent staff and provider education, with the expectation that they are improving themselves every day. For example, at Bowden Eye, we hold monthly and quarterly staff meetings in service sessions or luncheons. Our Dry Eye University program has trained practices from all over the world, laying a standard foundation of understanding that practices can implement.

Eyes On Dry Eye  is an online seminar to learn from.

Dry Eye Access is an online tutorial with training modules.

Dry Eye Coach is another well-established, online learning hub. Vendors offer training on their products, and many embrace education on overarching concepts.

Let Your Community Know You Diagnose & Treat Dry Eye
A well-created website with education, questionnaires and automated appointment booking, such as those designed by Glacial Multimedia is the best marketing tool for driving patients into your exam chair. With practices already seeing a large number of dry eye patients in their existing population, additional advertising is not necessary when just getting started. Posting signs in the office promoting OSD services is important and inexpensive.

Once the practice’s processes are established and the flow is efficient, you can consider expanding your external marketing efforts. We use Rendia, which offers direct-to-patient e-mail creation, and MDBackline, which automates conversations with patients via text and e-mails to collect information and provide customized educational material. These services require a minimal budget to get started. Taking great care of patients is the best advertising—word will get out and the branding will take care of itself.

Bottom Line: Dry Eye Diagnosis & Treatment is Needed & Can Generate Significant Profitability
Managing DED should be an essential component of any comprehensive optometry practice—it is an all-day, everyday issue for patients with implications for every aspect of eyecare. With proper planning and structure, practices can start adding revenue with a minimal investment, and patients will reap the rewards of healthier eyes and better vision.

Patti Barkey, COE, is the chief administrative officer at Bowden Eye & Associates in Jacksonville, Fla., and the Founder and Director of Dry Eye University and the creator of Dry Eye Access. She is also president-elect of the American Society of Ophthalmic Administrators.



Jerry Robben, OD, is chief optometrist and director of clinical research at Bowden Eye & Associates, and founding member of Dry Eye University and Dry Eye Access. Dr. Robben disclosed the following financial relationships: Aerie (research investigator), Allergan (speaker, consultant, research investigator), Hovione Scientia (research investigator), Johnson & Johnson Vision (speaker, consultant, research investigator), Kala Pharmaceuticals (research investigator), Novaliq (research investigator), Santen (research investigator), Sun Pharma (consultant), Takeda (Shire; speaker, consultant, research investigator), Tangible Science (speaker), Tear Solutions, Inc. (research investigator), and X-Cel Specialty Contacts (speaker).

i. Lemp MA, Crews LA, Bron AJ, et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-8. doi: 10.1097/ICO.0b013e318225415a.
ii. Barabino S, Rolando M, Camicione P, et al. Systemic linoleic and gamma-linolenic acid therapy in dry eye syndrome with an inflammatory component. Cornea. 2003;22(2):97-101. doi: 10.1097/00003226-200303000-00002.

iii. Macrì A, Giuffrida S, Amico V, et al. Effect of linoleic acid and gamma-linolenic acid on tear production, tear clearance and on the ocular surface after photorefractive keratectomy. Graefes Arch Clin Exp Ophthalmol. 2003;241(7):561-566. doi: 10.1007/s00417-003-0685-x.

iv. Aragona P, Bucolo C, Spinella R, et al. Systemic Omega-6 essential fatty acid treatment and PGE1 tear content in Sjogren’s syndrome patients. Invest Ophthalmol Vis Sci. 2005;46:4474-4479. doi: 10.1167/iovs.04-1394.

v. Kokke KH, Morris JA, Lawrenson JG. Oral omega-6 essential fatty acid treatment in contact lens associated dry eye. Cont Lens Anterior Eye. 2008;31:141-146. doi: 10.1016/j.clae.2007.12.001

vi. Pinna A, Piccinini P, Carta F. Effect of oral linoleic and gamma-linolenic acid on meibomian gland dysfunction. Cornea. 2007;26(3):260-4. doi: 10.1097/ICO.0b013e318033d79b.

vii. Brignole-Baudouin F, Baudouin C, Aragona P, et al. A multicentre, double-masked, randomized, controlled trial assessing the effect of oral supplementation of omega-3 and omega-6 fatty acids on a conjunctival inflammatory marker in dry eye patients. 2011;89(7):e591-7. doi: 10.1111/j.1755-3768.2011.02196.x.

viii. Sheppard JD, Singh R, McClellan AJ, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 2013;32:1297-1304. doi: 10.1097/ICO.0b013e318299549c.

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