More of your patients are probably complaining about it. Whether it�s because they stare at a computer screen all day, have allergies, or live and work in arid conditions, dry eye sufferers are everywhere. Treating these patients could offer your practice huge profit potential. But you may be among the many ophthalmologists who hesitate to get fully involved � even while other ophthalmologists and O.D.s are reaping the benefits of what some call the "dry eye epidemic."

Here we�ll share updated information about market potential, documentation, increased audit risks, treatment options and other issues. By reading this article, you�ll be better prepared to profit in this segment of care.

As you know, dry eye was originally the ophthalmologists� domain. The first procedures were permanent � electric cautery and later argon laser punctoplasty/canaliculoplasty. But the newer treatments for dry eye � tears, punctal and lacrimal occlusion � can be handled by O.D.s, who have incorporated these procedures into their practices with much success. In fact, in this era of reduced margins, dry eye has become a booming profit center. And because many ophthalmologists are not taking advantage of the changing dry eye climate, many patients are taking their dry eyes to optometrists.

Dr. Joseph Collins, an Arkansas ophthalmologist, says many doctors he lectures to about dry eye aren�t treating much of it in their practices.

"There�s really a need. If it�s not an epidemic, it�s close," Dr. Collins says. He noted that new treatments are effective, creating a unique practice-growing opportunity.

There are many reasons to renew your focus on dry eye:

• Baby Boomers.
As the Boomers age, so do their eyes, making for potentially millions of new dry eye sufferers. These patients are willing to work with you. They�re eager to try new treatments to help them feel better. Rid a computer-using Boomer of eye pain and he�ll likely tell his friends about the help you gave him.

• Increased awareness
. Time was when patients had never heard the term "dry eye." But with increased awareness because of media coverage, more patients realize there are treatments for this nagging problem. Also, larger ophthalmic companies are now promoting their dry eye treatments, sending their messages directly to patients.And besides the multitude of patients who may be beating a path to your door for treatment, even more will � under your direction � discover that treatment is available.

• More affordable/reversible treatments.
Patients no longer have to decide on an expensive cautery or argon laser dry eye intervention. Tears and plugs are more affordable and attractive to patients who are wary of irreversible treatments.

Identifying dry eye patients can be as easy as asking a few simple questions, such as:

• Do they use a computer?
• Are they exposed to light, pollution or do they live in a dry climate?
• Are they taking medications that could irritate their eyes, such as anti-depressants or decongestants?
• Do they suffer from a chronic illness such as rheumatoid arthritis, lupus or asthma?

Dr. Collins emphasizes the importance of asking patients if they have arthritis. "Arthritis is a common denominator," he says. "If they have arthritis, they probably have dry eye."

He also says that many of his patients know that there�s something wrong, but don�t realize it�s dry eye. When the syndrome causes the tear gland to suddenly start overproducing, sufferers tend to focus on the wetness.

"That really needs to be clarified to the public," he says.

You have to make sure someone is asking these questions � whether it�s you or your techs.

Even with these compelling reasons to treat dry eye � not the least of which is the patient benefit � many doctors are slow to increase this part of their practice. Why? Fear.

Some doctors declined to be interviewed for this article, afraid that it would put them under Medicare�s scrutiny. They were concerned that being known as someone with a large dry eye practice would make them the target of an audit.

Sue Corcoran, of Corcoran Consulting in San Bernardino, Calif., notes that the Medicare climate has changed.

"Medicare used to be friendly. If you did something out of the norm, they would say, �Maybe this is something you need to look at.� Now they don�t do that. They audit you," she said.

When a procedure is done more frequently, Medicare takes notice. Doctors tells us this has happened countless times.

"When something like punctal occlusion takes off, they start looking at the procedure," Corcoran said. "They wonder why so many more procedures are being done."

To avoid this unwanted attention from Medicare and private insurers, make sure you document everything.

"Document the therapeutic benefits of the procedure," Corcoran said. "Make sure that you show that other therapies were tried � tears, drops � and that they either didn�t work or that the patient couldn�t comply."

Part of that documentation is having the correct billing code. This is critically important to getting proper reimbursement. (See "Billing for Punctum Plugs," September 1997.)

It�s also important that you start by communicating with your patient. Take him step by step through the process, starting with a consent form that thoroughly explains treatment and what you think is the best course for him.

Dry eye doctors are using several ways to diagnose the condition � some of them new, some of them old.

• The Lactoplate.
This tests for tear lactoferrin levels. You use a paper disc to obtain a tear sample from the lower fornix. The sample is exposed to human lactoferrin antibodies, and results are available after 3 days. This test is highly specific.
• The Schirmer tear test
. You perform this test on an un-anesthetized eye. The test can irritate patients� eyes and cause tearing, so you need to be careful of a false positive.
• The Quick Zone test.
This is a variant of the Schirmer test. It takes only 15 seconds and it�s less irritating to the eye.
• Dye tests.
Several tests use dye to get results: Sodium fluorescein can help you assess tear volume. Rose Bengal dye works through advanced staining. Lissamine Green has the same staining characteristics as Rose Bengal, but it doesn�t sting, so you don�t need an anesthetic.

• Tearscope.
The Keeler-EagleVision Tearscope Plus is a non-invasive device that reflects diffused light off the cornea, backlighting the tear film. The Tearscope makes it possible to observe and measure volume of aqueous tear film, lipid layer contamination, tear prism, lipid layer spreading during blinking and break-up time.

• Osmometer.
A new device by Advanced Instruments, Inc. � the Advanced Model 3000 Nanoliter Osmometer � measures tear osmolarity. You place a single, 200-nanoliter sample into the instrument. The sample is frozen, and the instrument, directed by the accompanying computer, begins the thaw cycle. At the end of the thaw cycle, the operator stops the test and the instrument takes a reading automatically.

Dr. Collins has one of several of these units currently being tested in the United States. He lauds the scientific aspect of the machine, and says it�s less subjective than the dye tests.

Of course, dry eye treatment always starts with artificial tears. Most artificial tears work the same way, increasing the volume of tears and providing a barrier that protects the ocular surface. Tears also rinse environmental toxins from the eye and reduce the mechanical trauma of the eyelids on the eye.

When considering preserved and non-preserved tears, remember that they both have their pros and cons. The preserved tears can have a toxic effect on corneal epithelial cells. But non-preserved tears can be an expensive endeavor for the patient because they come in individual doses.

One product, TheraTears, developed by Dr. Jeffrey Gilbard, promotes healing to restore conjunctival goblet cells and corneal glycogen. TheraTears lowers tear osmolarity, which rehydrates tear film and also provides electrolyte balance.

New drops are being developed constantly. Inspire Pharmaceuticals recently signed a partnership with Santen Pharmaceutical company to develop a new product that restores the ability of ocular surface tissues to produce tears of normal composition. The compound works by activating P2Y2 receptors on the inner surface of the eyelids.

"We were very pleased to find that the P2Y2 receptor was a major coordinator of hydration at the surface of the eye," said Dr. Ben Yerxa, the key scientist on the project for Inspire. "In addition, we are unaware of any other therapeutic candidate that stimulates the production of normal tears through a pharmacological receptor-based mechanism."

Meanwhile, Allergan is developing a tolerable topical cyclosporine A solution for treatment of dry eye. The solution, which suppresses antigen-activated T lymphocytes, is expected to arrest forms of dry eye pathology at an early stage, eliminating the need for plugs in some cases.

If the tears don�t solve the dry eye problem, most ophthalmologists today opt for punctal or lacrimal plugs. These second-generation models have addressed the old complaints � difficulty with insertion and retention.

Companies introduced several dry eye products recently or have improved older ones. CIBA Vision offered its TearSaver Punctum Plug; Lacrimedics recently introduced its first punctal plug; Odyssey introduced its Parasol Punctal Occluder; EagleVision offered the EaglePlug; and FCI Ophthalmics released a new version of its Mini-Plug

In 1998, Alcon also signed a distribution agreement with Landec, a polymer company. Landec is conducting FDA trials for a procedure in which one of its polymers is injected into the lacrimal system. The heat-sensitive material is inserted as a liquid. It solidifies inside the lacrimal duct. To remove it, you�d need to raise the patient�s eyelid temperature.

In January, Lacrimedics, Inc., announced it had negotiated a patent license agreement licensing Lacrimedics technology to Landec for lacrimal occlusion. The agreement lets Landec sublicense Alcon to use the technology. Lacrimedics officials say that licensing the technology to a competitor will make the technology more available and accelerate expansion of the plug market.

Ophthalmologist Wayne H. Martin, M.D., who has a comprehensive practice in California, says today�s treatments succeed more than those in the past. He finds that drops and plugs help patients more than cautery or argon lasers.

Dr. Martin starts the patient on artificial tears, six to eight times daily. If symptoms resolve, Dr. Martin advises the patient to reduce the use of drops. If the patient returns, is using drops frequently and doesn�t feel much relief, Dr. Martin implants temporary plugs into all four ducts.

If the patient experiences temporary relief and the symptoms return shortly afterward, Dr. Martin puts permanent plugs into the lower ducts and temporary plugs into the upper. If symptoms recur, he then moves to maximum occlusion, implanting permanent plugs into the upper ducts.

Dr. Martin says he makes sure that he explains all the treatment options very carefully to the patient. That�s also an important aspect of reimbursement. You must show that all therapies have been attempted, and that the patient was aware of all treatment options.

With millions of potential sufferers and effective new treatments available, you�ll find this to be the best time to renew your dry eye efforts. And with the proper documentation, treating dry eye can be as profitable for you as it can beneficial for your patients.