Why Some Dry Eye Programs Thrive While Others Fail
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By Chris Wolfe | For Optometrists and Their Teams
The Slow Erosion of Optometry's Traditional Business Model
Optometry is not dying but we are being damaged as a profession. Scope continues to increase and practices continue to grow, yet even well-run practices are being slaughtered, not by one catastrophic event, but by a thousand small cuts.
Ten or fifteen years ago, many providers dismissed the idea that online retailers would meaningfully impact optical and contact lens sales. Some believed patients would always prefer to buy from their doctor. Others assumed the shift would happen slowly enough that it would not materially affect practice economics.
In some ways, they were correct. It did happen slowly.
That may actually be the problem.
Most practices did not wake up one morning to discover that half of their optical revenue had disappeared. Instead, the erosion occurred gradually:
- a patient ordered contacts online
- another purchased glasses elsewhere
- another stretched replacement schedules
- another used a vision plan discount website
- another skipped premium lens options because of inflation
Individually, these changes felt insignificant. Collectively, they fundamentally altered the financial structure of many practices.
Historically, optometry tolerated a surprising amount of under-valued clinical care because there was often a downstream financial reward attached to the encounter. Doctors could spend additional time during a comprehensive exam discussing ocular surface symptoms, reviewing systemic medications, counseling patients on contact lens discomfort, or informally managing mild disease because there was potentially a high-dollar optical or contact lens sale at the end of the visit.
In many practices, the product sale quietly subsidized the clinical inefficiency.
The problem is that the subsidy has slowly weakened while the clinical demands placed on optometrists have continued to increase.
Nowhere is this more visible than dry eye disease.
A Dry Eye Device Is Not a Dry Eye System
Dry eye is an especially interesting category because it sits at the intersection of chronic disease management, patient counseling, diagnostic testing, procedural care, and practice economics. Many doctors genuinely want to provide better ocular surface care for patients. At the same time, many practices are searching for ways to replace declining traditional revenue streams.
That combination makes dry eye extremely seductive.
Whether consciously or unconsciously, some messaging in the dry eye space resonates because it mirrors the profession’s historical reliance on high-ticket items to subsidize under-valued clinical care. The difference is that the potential subsidy has shifted from glasses and contact lenses toward procedural and device-based treatments.
To be clear, this is not an indictment of dry eye technology. Many of these devices are clinically meaningful and absolutely appropriate for the right patient. Procedures can dramatically improve quality of life. Noncovered services can be ethical, valuable, and important.
But a dry eye device is not a dry eye system. Those are two very different things.
Many optometrists purchase technology before developing the workflows necessary to support it:
- no intake screening process
- no defined diagnostic protocol
- no staff education
- no patient education pathway
- no longitudinal follow-up structure
- no billing and coding systems
- no clear understanding of which patients are actually appropriate candidates
Eventually, the device sits underutilized, the schedule becomes inefficient, and the practice concludes that “dry eye doesn’t work.”But often the issue was never the technology itself.
The issue was that the practice still viewed value as something attached to the high-dollar treatment at the end rather than the clinical expertise delivered throughout the entire disease management process.
That mindset quietly affects billing and coding behavior as well.
Many doctors continue to bundle significant medical decision-making into comprehensive examinations because that is how the profession historically operated. A patient mentions burning, fluctuating vision, redness, tearing, or contact lens intolerance during a wellness examination and the doctor naturally goes deeper:
- additional history
- meibomian gland evaluation
- treatment recommendations
- medication review
- environmental counseling
- chronic disease education
- discussion of follow-up care
Then the visit gets billed as if none of that happened or the patient gets "converted to medical" as if that actually solves the financial problem.
Guess what? It doesn't, but that is a topic for another article.
The issue is not greed. In fact, for many doctors, the opposite is true. Many optometrists are deeply uncomfortable separating medical care from the comprehensive exam because they still subconsciously associate the value of the encounter with the product purchase rather than the disease management itself.
But the economics no longer support that model.
As optical margins compress and staffing costs rise, practices become less resilient. When practices become less resilient, doctors have less time with patients, less ability to invest in technology, less ability to train staff, and less flexibility to provide high-quality care.
Eventually, patient care suffers.
This is why properly structuring disease management matters.
An anterior segment photo with meibography is a good example. Many doctors perform meaningful imaging of the ocular surface and meibomian glands during dry eye evaluations but fail to appropriately document, separate, and bill for medically necessary diagnostic testing. The missed revenue is important, but the larger issue is what the omission represents: the practice still has not fully acknowledged that chronic ocular surface disease management has value independent of whether the patient purchases an expensive procedure.
The value is not in whether the patient buys IPL, RF, LipiFlow, or any other premium treatment.
The value is in accurately diagnosing disease, creating a management plan, longitudinally monitoring the patient, and delivering the exact treatment the specific patient in front of you actually needs.
For some patients, that may absolutely include an advanced procedure.
For others, it may involve:
- allergy management
- medication changes
- home therapy
- environmental modifications
- systemic disease investigation
- prescription therapy
- nutritional counseling
- follow-up monitoring
The optometrist’s value is knowing the difference.
The Future of Optometry Is Longitudinal Disease Management
Ironically, the practices that often succeed most in dry eye are not necessarily the ones performing the highest number of procedures. They are frequently the practices with the best systems:
- efficient intake processes
- clear diagnostic pathways
- consistent patient education
- appropriate coding and documentation
- defined follow-up schedules
- trained staff
- longitudinal management protocols
In other words, they built a pillar instead of purchasing a widget.
This same principle extends far beyond dry eye. Glaucoma, myopia management, allergy, retinal disease, and specialty contact lenses all require the same shift in thinking. Optometry can no longer afford to casually absorb chronic disease management into under-valued encounters while hoping ancillary sales compensate for the difference.
The profession must become more comfortable acknowledging something that should have been true all along:
Clinical expertise has value.
Not because it leads to a product sale.
Not because it leads to a procedure.
Not because it increases revenue per patient.
But because high-quality longitudinal disease management is genuinely valuable to patients and to the healthcare system itself.
Practices that recognize this and build systems around it will likely become more resilient over time.
Practices that do not may continue to experience the same thousand cuts — slowly, quietly, and often without fully understanding why.