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 with 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, I have prescribed PanOptx goggles for this dry-eye patient 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.

For information about a study demonstrating the successful use of PanOptx goggles as moisture chamber glasses specifically for dry eye patients, please refer to Ophthalmology Times (http://www.ophthalmologytimes.com/ophthalmologytimes/) and search for "PanOptx" to find the article "Dry Eye Patients Might Consider Moisture Chamber Glasses," dated March 15, 2004. The subsection "PanOptx Dry Eye Study" describes a study showing that PanOptx goggles can significantly reduce dry eye symptoms.

PanOptx goggles used as 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.]