An interventional mindset has taken over a lot of subspecialty areas of ophthalmology, and for good reason. In glaucoma, interventional treatments like selective laser trabeculoplasty (SLT) and direct selective laser trabeculoplasty (DSLT) are now first-line therapies, trading the compliance burden and side effects of topical drops for fast, convenient, predictably effective treatment that is reimbursed—truly a win-win for patients and practices.

Similarly, in dry eye disease (DED), a proliferation of interventional treatments is now available. As someone with decades of experience doing in-office treatments for DED, the time is right for more clinicians to make the leap to an interventional approach to benefit patients and their practices.

Importantly, adopting an interventional dry eye strategy does not mean every treatment must be physician performed. Rather, it involves designing a team-based care pathway in which the trained staff and optometrists help with initial assessments and patient education on general treatment approaches, and MDs and ODs work together to deliver therapies efficiently. When structured thoughtfully, this model allows patients to access effective treatments without disrupting clinic flow while allowing physicians to practice at the top of their license.

The Burdens on Patients and Practices

The traditional approach to managing DED carries immense burdens for both patients and practices. Historically, DED treatment was all about topical therapies that patients used on their own, such as over-the-counter drops, standard prescriptions, and specialty pharmacy drops. There was very little care the clinician could provide.

That paradigm put the entirety of the treatment burden on the patient. Compliance was essential, because topical treatments are only effective when patients use them as directed, but the inconvenience, costs, and side effects decreased compliance over time. Compliance is especially difficult when patients do not feel results quickly—for example, with immunomodulatory therapies that can take weeks or months of consistent use before patients feel a difference. 

This model also presents burdens for the practice. Many patients erroneously think that when we prescribe a medication that’s expensive for them, even with insurance, there is some profit for us. But, of course, it’s just the opposite. When we open our prescription pads for a DED drug, we are increasing staff time due to the processing of electronic prescriptions, prior authorizations, formulary exemptions, and rejections. Searching for substitutions after a prescription is rejected, or when a patient tells us they can’t afford the medication, requires substantial time. For a practice of our scale, that could mean dedicating at least 1 full-time employee to these essential but often thankless tasks, when those efforts could instead be better dedicated to more productive, patient-facing benefits.

Shifting to Interventional Therapies

Clinicians who adopt an interventional mindset have a number of great treatment modalities to choose from. We have options that address obstructive meibomian gland dysfunction (MGD), evaporative disease, aqueous tear deficiency, and inflammation. Some therapies address multiple areas, which is a convenient advantage because most patients have overlapping types of DED. The following 3 treatments, in particular, have made a huge impact on our practice.

Lacrimal Occlusion With Hyaluronic Acid Gel 

I use lacrimal occlusion with hyaluronic acid (HA) gel (Lacrifill; Nordic Pharma) as first-line therapy for all types of DED, as well as for optimizing the ocular surface before cataract surgery. I tell patients, “It helps keep natural tears where they’re needed,” and it has several advantages over punctal plugs. This cross-linked HA gel conforms to the canalicular system without troublesome sizing or risk of falling out. There is also, I believe, a rejuvenating benefit to HA eluting onto the ocular surface over time. Anecdotally, we have noted significant improvement in visual acuity and higher-order aberration profiles immediately following Lacrifill placement in our patients.

Lacrimal occlusion gives us a rare instance of immediate symptomatic improvement. When patients walk out of the office already feeling better, that has a huge impact. Compliance with conventional therapies improves because topical therapies work better with puncta occluded (better contact time, bioavailability, and lubrication while HA decreases stinging from immunomodulator drops).

Injection is fast and easy for the patient and clinician, and there’s a clear reimbursement pathway using existing CPT codes for punctal occlusion. It lasts up to 6 months, and we empower the patient to determine the cadence of refills. If we need to do it the same day as a medical exam, it can be billed using 2 distinct ICD-10 codes (one for the exam and the dry eye ICD-10 for the product) and the appropriate modifier (-24).

Thermal-Activated Restorative Gland Expression Therapy

Thermal-activated restorative gland expression therapy (TARGET) is a cornerstone for DED therapy, particularly MGD and evaporative disease. The available products for TARGET in the United States include the LipiFlow Thermal Pulsation System (Johnson & Johnson Vision), the Systane iLux2 System (Alcon), and the TearCare System (Sight Sciences), which uses highly regulated thermal energy to melt and clear obstructions in the glands. Patient response has been excellent in our practice.

TARGET therapy is backed by data. The SAHARA¹ study is the first randomized, controlled clinical trial with a head-to-head comparison of interventional TARGET treatment (TearCare) and topical cyclosporine ophthalmic emulsion (Restasis; AbbVie). One set of patients had 2 TARGET treatments spaced 5 months apart, while topical cyclosporine patients used the drops with nearly 100% compliance for 6 months. On every objective and subjective metric (tear breakup time, staining score, meibomian gland quality score, and surveys), TearCare was equal to or better than Restasis when used diligently. Further economic analysis showed a large cost savings to the medical system for TearCare, which is why it’s under consideration for payor reimbursement.²

I have patients decide the cadence of TARGET treatment. I explain that using conventional therapies as directed at home can stretch out the benefits, and they should schedule another treatment when they start to feel things sliding downhill. If they’re diligent at home, they can get 6 months out of TearCare, but I confide that I forget my own at-home therapies, so I do Lacrifill and TearCare every 4 months for my own dry eyes. Patients come back because they like the effects of TARGET, which speaks volumes about efficacy and patients’ perception of value. 

Intense Pulsed Light Therapy

I’ve used several intense pulsed light (IPL) devices over the last 20 years and have participated in early pivotal FDA trials to gain approval for dry eye indications. IPL products currently approved for use in the United States include OptiLight IPL (Lumenis) and E-Eye (E-Swin). The latter, which I have in my practice, consists of an FDA-cleared device that uses patented Intense Regulated Pulsed Light (IRPL) to treat evaporative dry eye disease caused by MGD. Its large, ergonomically designed interface head lets me complete treatment with 10 shots. Each shot is delivered in 8 metered pulses, making the process comfortable for patients, and I’ve found it just as effective as IPL.

My protocol is to use TearCare and E-Swin together for patients with both MGD and ocular rosacea. These work synergistically, with IPL treating the source of inflammation and TearCare removing the obstructions. I schedule 1 TARGET treatment with the first IPL treatment as induction therapy, then I do monthly IPL treatments for a total of 4. Maintenance therapy consists of alternating TearCare and IPL treatments spaced 6 months apart, starting 6 months after the initial IPL series. For most patients having both of these treatments, we eventually drop immunomodulator drops, and patients do just fine with a simple home regimen of preservative-free artificial tears and warm compresses.

A Team-Based Approach to Treatment Delivery

One of the most common questions clinicians ask when considering an interventional dry eye model is who actually performs the treatments. In our practice, the physician remains responsible for diagnosis, treatment planning, and procedures that require physician-level skill, such as lacrimal occlusion with Lacrifill, TearCare targeted thermal expression, or IPL. However, many other components of interventional dry eye care can be safely and effectively delivered by a well-trained clinical team. 

Our optometrists play a central role in evaluating dry eye severity, initiating treatment pathways, and performing device-based therapies such as TearCare and IPL when appropriate. Experienced technicians assist with patient preparation, device setup, and post-treatment care. This team-based approach allows treatments to be delivered efficiently while maintaining a high standard of care. Just as importantly, it allows the physician to focus on diagnostic decision-making and surgical care while ensuring that patients receive timely treatment for their ocular surface disease.

Benefits for the Practice

Switching to an interventional approach requires the clinician’s interest, some time to educate staff, and adjustments to patient education—but it does not, notably, require a major capital investment. Lacrifill enjoys established reimbursement; the cost of the TearCare SmartHub is minimal and has a clear ROI; and IPL costs less than it used to, with the availability of devices like E-Eye. Although Lacrifill is reimbursed, patients are willing to pay out of pocket for procedures that improve their lives. Here is some more encouragement:

Interventional DED patients spend more time in the practice receiving care that’s reimbursed as well as beneficial, and they spend less time in negative interactions battling over their prescriptions. This is a win all around, with reduced staffing costs; less stress for patients related to monthly costs and wrangling with insurance; more paid treatment services for the practice; and most importantly, a number of benefits for patients in speed, efficiency, cost, and speed of onset.

Efficiency in a Busy Clinic

Because treatments are efficient, I can offer them on the fly during clinics without harming the flow, which allows patients to get started on interventional treatment immediately. I also offer maintenance treatments during dedicated, half-day blocks. This helps us maximize results by simultaneously performing TearCare, IPL, and even cross-linking procedures. No additional staff members are needed—great news in today’s challenging hiring environment. 

Clinicians often assume that adding procedural dry eye treatments will slow clinic flow, but when workflows are designed intentionally, the opposite is frequently true. Many interventional treatments are predictably brief. Lacrifill placement, for example, typically takes only a few minutes and often can be performed during the same visit as the diagnostic examination—especially for a perioperative patient. For patients requiring refills, we set aside dedicated slots in our MD's, OD's, or PA's schedule for rapid intake, informed consent, and Lacrifill placement. These slots can fill gaps between patients and other procedures to maximize clinical productivity. 

Device-based therapies, such as TearCare or IPL, are performed by a dedicated and trained OD who works in concert with the MD as a force multiplier. Patients may undergo treatment while the MD continues seeing surgical consultations or performing other procedures. In addition, dedicating procedural blocks—such as half-day sessions focused on interventional treatments—allows practices to perform multiple treatments efficiently in sequence. For example, a typical Friday afternoon might consist of my MD/OD team simultaneously performing dozens of TearCare and IPL procedures, Lacrifill instillations, DSLT for ocular hypertension and open angle-glaucoma, and even collagen cross-linking for keratoconus. With thoughtful scheduling and staff training, interventional DED care can integrate seamlessly into the clinic and actually improve efficiency by reducing time spent managing prescriptions, prior authorizations, and medication failures.

Patients Embrace Treatment

The interventional mindset resonates with patients because they see more immediate impact, and it relieves their at-home treatment burdens. I often hear patients say, “I’d rather come in for a 3- to 15-minute treatment once every 4 months than have to do something 10 times a day every day.” They intuitively see the economic value and, in some cases, the savings of getting periodic in-office treatments vs using drops for months or years. Patients also like that we’re trying to “get the body to do what it’s naturally designed to do” instead of trying to replicate a natural process using pharmaceuticals.

Protocols and Treatment Timeline

Standardized treatment pathways help ensure consistency while making interventional DED care easier for both patients and staff to understand. In our practice, all new dry eye patients receive comprehensive disease state education and an overview of my treatment approach from a dedicated clinically partnered OD. First-line therapies such as artificial tears and lubricants, warm compresses, and immunomodulatory therapy are discussed. Because Lacrifill has been found to be nearly universally helpful in relieving patients' symptoms regardless of their mix of aqueous tear deficiency, evaporative or MGD-related DED, or mechanical dry eye, we offer it first-line during the consultation visit. This allows patients to feel more immediate relief while awaiting benefits of topical and nutritional therapy and scheduled interventional treatments. More advanced and targeted therapies like TearCare and IPL are then introduced, discussed, and scheduled by the OD, when appropriate.

I have been performing IPL since 2008 and, in the early days, found that patients typically required 4 to 5 treatments in a series, with patients noticing appreciable impact by treatment 3. However, since integrating TearCare targeted thermal expression into the first IPL session as induction therapy, we find this acts as an accelerant to IPL efficacy and patient response. Most patients feel improvement from treatment 1, and may only need 3 to 4 treatments before moving on to treat-and-extend maintenance therapy with alternating IPL and TearCare about 4 to 6 months after the initial series is complete. We aim to empower patients to determine the cadence of these maintenance treatments, based on their symptoms, to create alignment and long-term commitment. Establishing a clear treatment trajectory helps patients understand that dry eye disease is chronic but manageable, and it allows the clinical team to deliver care in a predictable and efficient manner. We deliberately avoid "packaged" pricing, because patients may view this as sales-driven rather than as a thoughtful, patient-centric treatment plan.

Changing Refractive Cataract Surgery

The bread-and-butter surgical procedure for most of ophthalmic surgeons is cataract surgery, which has merged with the refractive world. Any time a patient presents for cataract surgery, we know chances are good they have DED, and failing to treat it before surgery means patients will not be candidates for the best lenses; they won’t get the precise biometry needed for a good outcome; and they may be dissatisfied with the outcome. If we provide interventional treatment for DED before refractive surgery, we have greater confidence in our biometry, so we can offer refractive options like advanced-technology intraocular lenses to more patients.

We always look for what’s best for the patient first, and then the practice. Interventional therapy is the perfect win-win: It’s the right thing for patient care; patients get immediate benefits; it appeals to their interventional mindset; patients have fewer treatment burdens; and the practice, providers, patients, and health care system at large can gain the economic benefits. OM

Neel R. Desai, MD, is a cornea, cataract, and refractive surgeon at The Eye Institute of West Florida in St. Petersburg, Florida. Dr. Desai reports consultancy to AbbVie, Alcon, Bausch + Lomb, Dompe, E-Swin, Harrow Health, Johnson & Johnson, Nordic Pharma, Sight Sciences, Versea, and Zeiss.

References

1. Ayres BD, Bloomenstein MR, Loh J, et al. A randomized, controlled trial comparing Tearcareand cyclosporine ophthalmic emulsion for the treatment of dry eye disease (SAHARA). Clin Ophthalmol. 2023;17:3925-3940. doi:10.2147/OPTH.S442971

2. Lighthizer N, Schwertz BK, Chester T, et al. TearCare system versus cyclosporine ophthalmic emulsion for the treatment of moderate-to-severe meibomian gland disease associated dry eye disease in the United States: a cost-utility analysis. Expert Rev Pharmacoecon Outcomes Res. 2025;25(8):1239-1247. doi:10.1080/14737167.2025.2537850