Just Scratching the Surface

Building a Dry Eye Practice

You know the story; it might even be your story. Graduate optometry school with a lot of enthusiasm—and a lot of debt. Pick up all the extra days you can just to stay afloat financially. Now you’re in the high-volume, low-reward daily grind of refraction, primary eye care and the same old conversations with patients about what astigmatism is. Hello, burnout. What to do? For Ada Noh, OD, the answer was to commit to a specialty concentration in dry eye, forgoing the trappings of routine eye care—bye-bye, phoropter!—for the intellectual stimulation of advanced care and the risks and rewards of self-employment. Dr. Noh describes her journey to specialty practice with great anecdotes about how she came to face her fears about starting cold, in an unfamiliar new city to boot. Job one was building a referral base and that meant embracing self-promotion far and wide to optometrists, ophthalmologists, other health care professions and frankly anyone else who’d hear her out. She says giving up primary care entirely rather than the half-a-loaf approach of adding a dry eye clinic to a general practice was a winning strategy, as other eyecare providers had no reason to see her as a threat. Instead, she became a resource to them. Addressing the misconception that you need to sink a lot of money into a specialty practice, Dr. Noh reassures listeners that you could start without much more than a slit lamp and a bottle of Fluress if you want. It’s the extra time and attention you give patients that often makes a decisive difference to them. She does also share her thoughts on the most helpful devices to add—notably, meibography and IPL—as you ramp up over time. Throughout the episode, Dr. Noh returns to the themes of believing in yourself and having the tenacity to take on whatever comes your way. “Don’t wait for ‘perfect’ because it’s not gonna come,” she counsels. The rewards for all this hard work and risk-taking go beyond the financial. She has more autonomy than ever before. Amazingly, Dr. Noh is about to take the plunge a second time. Having recently sold the practice she started only a few years ago, she’s moving to a bigger market and will do it all over again, beginning this fall. Stay tuned for future updates on her second (or maybe third?) act! Relevant articles worth reading: “Why Isn’t My Dry Eye Therapy Working?” [https://www.reviewofoptometry.com/article/why-isnt-my-dry-eye-therapy-working] By Ada Noh, OD Dive Into Dry Eye [https://www.reviewofoptometry.com/article/dive-into-dry-eye] With advice from Cory Lappin, OD, Hamza Shah, OD, Michelle Hessen, OD, and Erica Udell, OD Pathways to Specialization: Find–and Follow–Your Calling [https://www.reviewofoptometry.com/article/pathways-to-specialization-find-and-follow-your-calling] With advice from Kelly Cohen, OD, Emilie Seitz, OD, Rami Aboumourad, OD, Joseph Sowka, OD, Cory Lappin, OD, Marie Homa-Palladino, OD, Langis Michaud, OD, Michael Cymbor, OD, Erin Tomiyama, OD, PhD, and Diane T. Adamcyzk, OD

Natural Tears vs. Artificial Tears

With renowned dry eye expert Milton Hom, OD, as this episode’s guest, hosts Kaleb Abbott, OD, and Andrew Pucker, OD, PhD, lead a spirited discussion of so-called “artificial tears” and contact lens rewetting drops as distinct product categories. They begin by exploring whether or not FDA definitions align with the perception of clinicians and their recommendations to patients, noting that much of the terminology and categorization structure of these products stems from the original FDA product monograph [https://www.ecfr.gov/current/title-21/chapter-I/subchapter-D/part-349], which dates to 1988. Dr. Abbott argues that these categories are outdated and should rightly be combined and renamed “lubricating drops” to reflect real-world use. He also points out that there’s less than 1% similarity between artificial and human tears, as the latter contains thousands of proteins and growth factors, so the term “artificial tears” creates unrealistic expectations with patients. The conversation then turns to ingredients in tear products and their role in product selection. Dr. Hom favors drops containing hyaluronic acid when wound healing or improved contact lens comfort is needed, a trehalose-containing drop if he sees corneal staining and an emulsion-based product (mineral oil or castor oil) for evaporative dry eye. The trio are intrigued by newer products that aim to mimic natural tears by including vitamin C, vitamin B12, amino acids and other ingredients but we need to see the data supporting their efficacy. They return to the topic of the FDA monograph when discussing why Meibo is considered an artificial tear in Europe, and sold over the counter, but not in the US; its formulation doesn’t meet the FDA criteria for OTC status and so the product was developed as an Rx drug. The experts point out that Meibo has a much longer ocular surface retention time than regular artificial tears—roughly 6-8 hours vs. 30 min—and thus does perform differently. The episode ends with a discussion of how to approach patients with overlapping allergy and dry eye, and a general wrap-up on the debate over whether certain artificial tear products truly have properties that distinguish them from others. The consensus is that some indeed do but none truly replicate the natural tear film. Relevant articles worth reading: It's time to retire the terms artificial tears and rewetting drops: A call for accurate terminology and updated clinical usage in eye care [https://www.sciencedirect.com/science/article/abs/pii/S1542012425001107] By Kaleb Abbott, OD, MS, and Andrew Pucker, OD, PhD Over the counter (OTC) artificial tear drops for dry eye syndrome [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009729.pub2/full] * By Andrew Pucker, OD, PhD, Sueko Ng, MHS, and Jason Nichols, OD Artificial Tears: What Matters and Why [https://www.reviewofoptometry.com/article/artificial-tears-what-matters-and-why] With advice from Jennifer S. Harthan, OD, Suzanne Sherman, OD, Cecilia Koetting, OD, and Meaghan Horton, OD Artificial Tears: Looking Beneath the Surface [https://www.reviewofcontactlenses.com/article/artificial-tears-looking-beneath-the-surface] By Mike Christensen, OD, PhD, and Tressa Larson, OD

IPL Unfiltered: Separating Fact from Fiction

Dry eye specialist Cory Lappin, OD, of Cincinnati shares insights on IPL that he’s developed from many years of performing the procedure. Dr. Lappin begins with a clear and concise explanation of how light interacts with pigment at the cellular level to “kick-start” meibocyte activity and target telangiectatic blood vessels. He addresses common misconceptions about IPL, taking care to explain that it is a non-laser and non-thermal procedure, as a way of understanding where it fits in among dry eye interventions. From there, Drs. Lappin, Abbott and Pucker discuss ideal candidates—most notably those with ocular rosacea but also many typical MGD patients—and how to discern their suitability based on Fitzpatrick skin type [https://www.msdmanuals.com/professional/multimedia/table/fitzpatrick-skin-type-classification]. The trio also delves into cautions and contraindications in patients on doxycycline, those with active herpetic outbreaks, epilepsy patients, people with skin conditions like melasma and the hazards posed by eyeliner tattoos. A discussion on technique explains the three main protocols for IPL—Toyos (high fluence), Epstein (overlapping lower-fluence pulses) and Periman (full-face treatment)—and how choice of light filter can affect results. The conversation concludes with practical tips for patient education on IPL and how to establish a schedule for treatment (beginning with four sessions at a minimum) and long-term monitoring (ideally every three to six months thereafter). Dr. Lappin also gives advice for clinicians who are interested in adding IPL but apprehensive: gain confidence by thoroughly understanding it first, start with ocular rosacea patients and others likely to get great results, and don’t feel you have to sell the patient—educate, don’t attempt to “convince,” and let them decide for themselves. Relevant articles worth reading: Ocular Rosacea: How to Recognize and React [https://www.reviewofoptometry.com/article/ocular-rosacea-how-to-recognize-and-react] By Kaleb Abbott, OD, MS The Role of Intense Pulsed Light in OSD Management [https://www.reviewofoptometry.com/article/the-role-of-intense-pulsed-light-in-osd-management] By Harriette Canellos, OD, and Christina Canellos, OD When IPL Prevails [https://www.reviewofoptometry.com/article/when-ipl-prevails] Edited by Paul C. Ajamian, OD Tackle MGD with These Hands-on Interventions [https://www.reviewofoptometry.com/article/tackle-mgd-with-these-handson-interventions] By Mila Ioussifova, OD, and Hardeep Kataria, OD