To whom it may concern:

                                                              [patient's name] has been diagnosed to have a dry eye condition that results from inadequate moistening of the eye with tears due to one or more of the following conditions:

      370.33 Keratoconjunctivitis sicca
      375.15 Tear film insufficiency
710.2   Keratoconjunctivitis sicca associated with Sjogren’s disease
      Other – explanation:                                                                                

In order to preserve the moisture in the eye, a prosthetic device called moisture chamber spectacles are necessary. These custom-made spectacles have side shields that enclose the eye and prevent excessive tear evaporation. This prosthetic device is considered a therapeutic device and is not just for vision correction.

Moisture chamber spectacles are considered a therapeutic device for keratoconjunctivitis sicca or dry eye, which is a condition suffered by                                                             [patient's name]. Please afford our patient all the benefits to which he or she is entitled.


Doctor's signature:
Doctor's name:
Doctor's address:
Doctor's phone:

[Letter reproduced from: "How to Produce Moisture Chamber Eyeglasses for the Dry Eye Patient" by Hart, Dean E.; Simko, Mark; and Harris, Elaine, in the Journal of the American Optometric Association, Vol. 65., No. 7, July 1994, pp. 517-22.]