Date:                                        

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 glasses or moisture chamber goggles are a medical necessity. Moisture chamber glasses or goggles are designed to 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.

Currently, commercial prescription moisture chamber goggles are not available, and no optical labs currently make custom moisture chamber goggles. Therefore, this dry-eye patient uses                                                                    [name of goggle] multi-sport glasses or swimming goggles to protect his/her eyes from air movement (both indoor and outdoor), dust, and smoke, and to create a protective moisture chamber around the eyes.

Moisture chamber goggles 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.

Sincerely,

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

[Letter adapted 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.]