To whom it may concern:
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.
[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.]