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Cover Focus | July/August 2020

Starting a Dry Eye Clinic

Investments in treatment technologies will be returned quickly because of the high numbers of patients who can benefit from them.

Dry eye disease (DED) is a common ocular condition that is increasing in prevalence with the aging of our society. In patients 60 years and older, up to 30% experience symptoms of DED.1 One way to fulfill the needs of this increasing segment of the population is by starting a dry eye clinic in your practice.

But there are some things you should know before undertaking such a venture. In this article, I outline five points for consideration by those who wish to start a dry eye clinic.

No. 1: It’s a win for all. Starting a dry eye clinic is one of the best things you can do for your patients, your staff, and your business. (For more on the benefits a dry eye clinic can offer, see the accompanying sidebar.)


For Patients

Especially for cataract patients, the ocular surface has an important impact on preoperative planning and the postoperative healing process.

For Staff

Staff members will get to work in and learn about a new field, which is highly motivating and rewarding.

For the Business

When patients realize the benefits of your efforts to address their dry eye disease, they will recognize they get better-than-average treatment from your practice, and they will spread your good reputation by word of mouth.

No. 2: Know the disease. One of the most important factors for the successful start of a dry eye clinic is knowledge about DED. Not only the doctors but all staff members must be well informed about symptoms, diagnostic evaluations, and treatment methods. It starts with knowledgeable staff members who can prompt patients to answer history questions when they arrive at the practice. The patient should be asked to fill out a DED questionnaire if any relevant symptoms are mentioned. The Ocular Surface Disease Index and Standard Patient Evaluation of Eye Dryness are examples of helpful questionnaires. If the patient’s score shows significant evidence of DED, the patient should be informed and diagnostic testing started.

No. 3: Use a range of diagnostic tools. There are many new technologies that are useful in the diagnosis of DED, although reliable methods such as Schirmer testing, tear breakup time, and slit-lamp examination of the lids and ocular surface are still important. More often, however, the focus of diagnosing DED is on technological methods of examination that should be present in a modern dry eye clinic.

Measurement of tear film osmolarity is one objective assessment of DED. The most widely used tool for this is the TearLab Osmolarity System (TearLab). Measurements above 300 mOsm/L indicate the presence of DED.

For evaluation of meibomian gland dysfunction (MGD), I use instruments such as the LipiView II Ocular Surface Interferometer (Johnson & Johnson Vision) or the Idra Ocular Surface Analyser (Clarion Medical Technologies). Visualization of the dysfunction can help patients to understand their disease. These instruments can also perform blink analysis, which may also aid the clinician in understanding the patient’s complaints and evaluating treatment effects.

No. 4: Fit the treatment to the diagnosis. After the diagnosis of DED, the best treatment for the patient must be selected based on the grade of the disease, and a successful DED clinic must offer every option. Good DED treatment today involves not only artificial tears or topical cyclosporine, but also therapy of the lid margin, for example with BlephEx eyelid treatment (BlephEx) or occlusion of the tear ducts with punctum plugs. If inflammation is visible, topical steroids and sometimes systemic antibiotics may be prescribed.

For MGD, therapy with a system such as the Eye-Light (Topcon) or the Tixel (Novoxel) can be helpful. The Eye-Light uses low level light therapy to simultaneously treat lower and upper eyelids with direct and indirect applications (Figure). The Tixel system uses a titanium tip designed with tiny pyramid shapes heated to high temperature (400ºC) to transfer energy to the skin around the eyes. I have incorporated both of these noninvasive treatments into my newly established dry eye clinic, and to date I have seen success in reduction of DED symptoms. Both are also well tolerated by patients.

Figure. The Eye-Light device can be used to simultaneously treat lower and upper eyelids with direct and indirect applications.

Although these instruments require an investment, they can be amortized quickly because the number of patients who can potentially benefit from the treatments is high. Also, treatments must be repeated over time to achieve a long-lasting effect, meaning patients will continue to return to your clinic for care—assuming they are pleased with their outcomes and the care they have received from you and your staff.

No. 5: DED is a chronic condition. The last important fact about establishing a successful dry eye clinic is to be aware that DED is not healed from one short period of treatment. As with other age-related diseases, most patients with DED will have symptoms to some extent over the rest of their lives. We are charged with reducing their symptoms to improve their quality of vision and quality of life. To achieve this, we must see these patients regularly. To ensure that your DED patients are not lost to follow-up, it is best to install a patient recall system, and expect to repeat treatments such as BlephEx or LipiView periodically.


If you follow these five recommendations, your dry eye clinic is bound to be a success.

1. Farrand KF, Fridman M, Stillman IO, Schaumberg DA. Prevalence of diagnosed dry eye disease in the United States among adults aged 18 years and older. Am J Ophthalmol. 2017;182:90-98.

Detlef Holland, MD
  • Cataract and refractive surgeon, nordBLICK Augenklinik Bellevue, Kiel, Germany
  • Member, CRST Europe Editorial Board
  • Holland@augenarzt-praxis.one
  • Financial disclosure: None