The Dry Eye Equipment Gap: Bridging Demand and Delivery

For many years, dry eye disease was managed as a symptomatic nuisance rather than a distinct clinical entity – a bottle of lubricant drops dispensed before moving on to other pathology. That approach is no longer clinically acceptable. Updated global consensus data now describe dry eye as a multifactorial disease with a range of aetiological drivers, rather than a single disease entity.¹ As a result, screening and diagnosis rates are rising, and treatment options are expanding.

A Bigger, Better-Understood Problem

The third Tear Film and Ocular Surface Society Dry Eye Workshop (TFOS DEWS III) report, published in 2025, moves beyond the traditional subclassification of dry eye as aqueous-deficient or evaporative, adopting a more detailed approach based on aetiological drivers, with MGD identified as a primary contributor to evaporative dry eye.¹ The report also recommends standardised symptom screening, specifically the six-item Ocular Surface Disease Index (OSDI-6), rather than relying on patients to volunteer complaints they have learned to live with.¹

This shift has practical implications for what constitutes routine care. A patient who reports occasional grittiness at the end of a screen-heavy day may warrant further assessment, including assessment of meibomian gland function, rather than being managed with preservative-free tears alone and a wait-and-see approach. Dry eye management is moving from a reactive, symptom-driven model toward a proactive, structural one, and this has direct implications for the equipment and skills a practice needs to have on hand.

This new direction in dry eye care has gained traction with clinicians because lifestyle and environmental exposures are increasingly recognised as contributing factors, alongside age and other established risk factors. The TFOS Lifestyle report identifies digital device use, environmental conditions, and a range of cosmetic and pharmaceutical exposures as factors that may affect ocular surface health.² For a profession that already receives daily patient complaints about screen-related eye strain, this offers a useful basis for patient discussion around modifiable risk factors, rather than symptomatic relief alone.

Figure 1. The dry eye disease spectrum, adapted from the TFOS DEWS III consensus framework.

Interest Without Investment

Diagnosis of dry eye disease has risen substantially year on year.³ And, although recent industry survey data show a large majority of practice owners are interested in implementing in-office treatments for ocular surface disease, around half cite the cost of equipment and technology as the main barrier to doing so.³ In other words, more patients are being correctly identified as candidates for structured MGD management, but a considerable proportion of practices still have limited options to offer beyond home-based lid hygiene and preservative-free artificial tears.

This is the equipment gap: rising diagnostic confidence and patient demand set against a capital barrier that many practices, particularly smaller independent ones, find difficult to justify without a clear view of the clinical and commercial return. The hesitation is not unreasonable. IPL, radiofrequency devices and low-level light therapy (LLLT) systems represent a significant investment, in addition to staff training, clinical chair time, and implementation of protocols. The more useful question is not whether that hesitation is justified, but whether the current evidence and patient outcomes support moving past it.

The Evidence for IPL

The evidence for IPL in MGD management has evolved considerably. A 2020 Cochrane systematic review of randomised controlled trials found the certainty of evidence for IPL’s effect on dry eye symptoms and signs was low to very low. It concluded the effect of IPL on several clinical parameters remained unclear at that time.⁴

Since that review, the evidence base has matured. A 2025 systematic review and meta-analysis of randomised trials found IPL probably produces a clinically relevant reduction in dry eye symptoms compared with placebo, although its added benefit over standard care remained uncertain.⁵ IPL was recognised as a Step 2 management option in TFOS DEWS II, while TFOS DEWS III includes light-based therapies within its management approach for MGD.^1,5 The Japanese MGD Clinical Practice Guidelines report evidence of improvements in symptoms and several clinical findings with IPL, although their recommendation for implementation was qualified by its regulatory and reimbursement status in Japan.⁶

Retrospective cohort data further indicate that treatment response is not the same for everyone: patients with more active inflammatory signs, such as lid vascularity and gland plugging, tend to respond better than those with advanced, established gland dropout, although these findings do not establish that earlier intervention prevents gland dropout.

To summarise, this represents a treatment with a growing evidence base, plausible underlying mechanisms, and patient selection criteria that matter as much as the device itself. That is a more accurate position than either ‘unproven’ or ‘effective for all patients’, and it is the position worth carrying into clinical practice and patient conversations.

Establishing An In-Office Clinic

Two years ago, I established an in-office IPL dry eye clinic, alongside a broader investment in patient education, including a dedicated dry eye information resource and OSDI-based screening incorporated into routine consultations. This was not implemented because the evidence was without limitations. It was implemented because the clinical need was clear, and because the previous solution – advising symptomatic MGD patients that little more could be offered beyond drops and warm compresses – was no longer, in my view, an adequate approach to care.

In clinical practice, the greater challenge lies not in the device itself but in the systems built around it. Staff require training, not only to safely operate the platform, but to explain a multi-session treatment plan to patients unfamiliar with IPL, some of whom are hesitant about a service not covered by Medicare. Screening needs to be embedded in routine workflow, so candidates are identified consistently rather than opportunistically. Expectations should be set honestly, with patients understanding IPL as one component of a broader MGD management plan, alongside other contributing factors, such as lid hygiene and omega-3 supplementation.

This last point is significant in practice. A meaningful proportion of the patients who present to me with significant MGD are also wearing, or hoping to wear, contact lenses, including soft contact lenses and orthokeratology, where an unstable tear film and compromised lid margin health directly affect lens comfort and wear time. Addressing the ocular surface before troubleshooting lens fit in isolation has changed the outcome for several of my long-term contact lens patients who had otherwise been drifting toward discontinuing lens wear. An in-office dry eye clinic, in this sense, functions to support several other areas of practice, rather than as an isolated service.

Closing The Gap

For practices considering this investment, several factors have made a noticeable difference in my experience:

• Establish rigorous screening so the clinic has a genuine patient base from the outset,
• Train the entire clinical team, not only the treating clinician, so that referral into the clinic becomes a routine part of workflow, and
• Maintain transparency with patients about what the current evidence does and does not demonstrate.

Additionally, integrating the dry eye clinic within the existing contact lens practice has done more to drive uptake than the device itself.

The equipment gap is unlikely to close because capital suddenly becomes more available. It is more likely to close gradually, as more practices recognise that structured in-office dry eye care can be clinically justified and commercially sustainable when supported by rigorous screening and clear patient communication.

Conclusion

Dry eye disease management has moved beyond the routine dispensing of lubricant drops, and the current evidence supports that shift. The gap between practices wanting to offer in-office treatment and those actually doing so is real, but it is not permanent. It narrows with improved screening, structured staff training, and clear communication with patients about what treatments such as IPL can and cannot achieve. For practices considering in-office treatment, the question is how to build the systems required to deliver it appropriately.

Rahul Kwatra BVisSci MOptom is an optometrist at Zoom Optics in Sydney and with Eagle Eye Surgeons and Laser Vision Correction.

References 

1. Perez VL, Chen W, Sullivan DA. TFOS DEWS III: Executive summary. Am J Ophthalmol. 2026;282:135-145. doi: 10.1016/j.ajo.2025.09.035.
2. Geller M, Osayande N, Gold E. 2026 Dry eye report. Eyes on eyecare; 2026. Available at: eyesoneyecare.com/resources/2026-dry-eye-report [accessed Sep 2026].
3. Cote S, Zhang AC, Downie LE. Intense pulsed light (IPL) therapy for the treatment of meibomian gland dysfunction. Cochrane Database Syst Rev. 2020;3:CD013559. doi: 10.1002/14651858.CD013559.
4. Peira N, Mohammed Ali E, Hultcrantz M. Effectiveness and safety of intense pulsed light therapy for dry eye symptoms due to meibomian gland dysfunction: a systematic review and meta-analysis. Acta Ophthalmol. 2025;103(4):371-379. doi: 10.1111/aos.16802.
5. Arita R, Fukuoka S. Tear film and meibomian gland parameters associated with the effectiveness of intense pulsed light therapy for meibomian gland dysfunction. Sci Rep. 2025;15:35390. doi: 10.1038/s41598-025-19229-7.
6. Craig JP, Alves M, Sullivan DA. TFOS lifestyle report executive summary: A lifestyle epidemic – ocular surface disease. Ocul Surf. 2023;30:240-253. doi: 10.1016/j.jtos.2023.08.009.