I simply tell them that a complete diagnostic workup is necessary to
prove to the insurance company that the insurance company should pay
for the treatment.  End of debate.

DrG

And frustrating.

A huge percentage of my patient base complains about dry eyes.

However, when informed there will be cost involved (i.e., their "well
vision" insurance does not cover the treatment/management) for the
dry-eye workup and periodic follow-ups to gauge response to treatment,
many times they balk.

Fine, then when they are told it should be covered under their medical
insurance.  They are now again disappointed because that means in
order for it to be covered under their medical insurance they have to
go back to their primary care physician.  Disappointed because they
realize this will be another appointment they will have to go to,
which may be days, weeks or months away.  This primary care physician
will probably empirically recommend artificial tears, which they've
already tried on their own (unfortunately on a "prn" basis rather than
a schedule).  And when that doesn't work, they will refer them off to
an eye care specialist under their HMO which will once again take
days, weeks or months to see.

Or they could pay fee-for-service to me, but when they are used to
paying a $5 or $10 copay for their well-vision examination, the
charges for the additional tests and follow-ups seem unreasonable to
them.  Nevermind that it is completely reasonable based on what the
majority of others in the ophthalmic community in our area charges out
of pocket for it.

Some want me to just write a prescription for RESTASIS to see if it
will work.  Or for me to just tell them what they should do.  Or just
give them some artificial tears to try.

"You just checked my eyes.  Can't you tell me if I have dry eyes and
what I should do?"

I then get to explain how dry eyes can be due to various causes such
as inadequate tear production, excessive tear drainage, poor tear
chemistry due to lid/meibomian gland disease, medications taken (e.g.,
antihistamines, BCP, beta blockers), enviornmental factors, diet, etc.
and so emperic treatment rather than targeted treatment can lead to
higher rates of failure and possibly even making the problem worse.

Some patients may need artificial tears, others RESTASIS, others need
oral antibiotics/lid hygiene, others punctal plugs, others need to
drink more water/put on flaxseed oil, others need enviornment changes,
etc. -- or combinations of the above.

There are potential side effects -- don't want to put a pregnant lady,
young child, or have a person sunbathing on tetracyclines -- and
flaxseed oil may interact with certain medications a patient is on or
medical conditions a patient has.  Or patient may have an unknown
latent drug allergy to tetracycline which be discovered.  Patients can
develop dacryocystitis from punctal plugs.

They are then told that dry eyes are many times a lifelong, chronic
condiiton, like diabetes, hypertension or asthma.  That there is no
drop, pill or shot they they can take one time and there condition is
cured; it can only be managed.

Many times they then begin to understand what is going on, decide this
is all too much work and just decide to "live" with their dry eyes.

So I just got to spend 10 minutes explaining why I won't just diagnose
and treat their dry eye for free.  Nice.

And when they come in next year, guess what their chief complaint is
again...  Dry eyes.

What do other eye doctors do?  Or am I the only one who goes through
this routinely (at least once a week)?

I'm considering putting all this information down on a handout that
the patient can read in the waiting/exam room after which the patient
can let me know what they'd like me to do.

***

This is almost as frustrating as the patient who wants us to call his
medical insurance to figure out if he can "come here" (Of course, he
can come here -- no insurance company tells you where you have to go,
they only say to whom they will reimburse.)

When asked if the patient called to check, they'll say "No", or "Yeah,
but I was on hold for 20 minutes with them and gave up."

We got a real easy way to deal with this now.  We ask them, "if they
won't cover you to come here, are you willing to pay out of pocket?"

If they say "No", then we say "Sorry, but there is no upside for us."

"If they will reimburse you to come here, we'll have you pay, bill
them as a courtesy (without verifying they will pay us) and have them
pay you directly.  Everything is OK."

"If they won't pay for the services rendered here, then we just wasted
our time calling for you.  We can't afford to have our office staff do
this.  It costs us money to pay a staff member to sit on hold for 20
minutes to discover you can't come here.  Your medical insurance is a
contract between you and the insurance company.  For medical
insurances we are familiar with, we can readily help you out.  For
ones we are not, it is your responsibility to know the particulars of
the coverage."

A symptom is something the patient feels.  A sign is something the
doctor sees.  I have seen terrible signs of dry eye and the patient had
very little awareness.  And yes, dry eye can cause corneal defects,
which predispose to corneal ulcers.

But, as with most things, there are degrees.  There are degrees of dry
eye.  They range form "sub-clinical," i.e. without signs, to "clinical"
with signs.

Without a detailed examination, it's impossible to tell where you are
on that spectrum.  The diagnosis and treatment of dry eye is one of the
most challenging clinical problems that exists.

DrG

Forgot to include something. The dry eyes with contacts is no big deal
as far as comfort is concerned, it is unwanted, but I am not sensitive
and can stand it and would much prefer to wear them. My concern is that
I believe more serious complications could result from continuing to
wear them such as corneal ulcer or cataract.. am I correct? Can I just
wear them if I can put up with them? Basically after a few days of wear
I leave them out for a few days, and repeat..

I would also add Purevision Toric to your list.  If you intend to use
soft lenses, I think you will need a toric lens for that much
astigmatism.  Purevision has a lower water content than A/V Advance and
will not show as much dimensional variation with the dry eye.

RGP?  I don't think so.  At least not the customary type that float up
and down on the cornea.  There are large format lenses on the market,
called corneascleral lenses, that cover the entire cornea.  They don't
move up and down, and tend to trap moisture in.

The bottom line is that ALL contact lens wear is made more difficult by
dry eye.  Maybe you should consider evaluation and treatment for that
first.

DrG

Been trying to figure out what I should do, will see the
ophthalmologist soon.. Here is my prescription (contacts):

OD: sphere -3.50 cyl -1.25 ax 180
OS: sphere -3.50 cyl -1.25 ax 010

I've worn soft contacts for around 7 years and recently have had dry
eyes + slight corneal impression\red ring after wearing them for a few
hours, mostly at 3 o'clock around my cornea (left eye). Since the
problems are dryness and possible lens tightness, I'm thinking to try
one (or more) of the following lenses, maybe with a larger BC:

Acuvue Oasis
Ciba 02Optix
Purevision
ProClear Compatibles
Focus N&D
Extreme H20

The Acuvue Advance I currently wear have shown a significant
improvement over previous lenses, Toric 66's, but above problems still
exist. My first thoughts are to try the Oasis, not sure they correct
astigmatism though. Full astigmatism correction is a must..

- also considering trying RPGs.
- thought about IOLs but if I am correct these are only for if you are
having cataract surgery.
- not going for Lasik.. it's too early.

Questions:
- Which above contacts should I try?
- Would RPGs fix the tightness problem?
- Does anyone know when Focus Dailies (or any dailies) will become
available in for my strength astigmatism?

Thanks