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?”

By Ada Noh, OD

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

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

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 Abbott argues that these categories are outdated and should rightly be combined and renamed “lubricating drops” to reflect real-world use.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

By Kaleb Abbott, OD, MS, and Andrew Pucker, OD, PhD

Over the counter (OTC) artificial tear drops for dry eye syndrome

• By Andrew Pucker, OD, PhD, Sueko Ng, MHS, and Jason Nichols, OD

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

By Mike Christensen, OD, PhD, and Tressa Larson, OD

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. 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

By Kaleb Abbott, OD, MS

The Role of Intense Pulsed Light in OSD Management

By Harriette Canellos, OD, and Christina Canellos, OD

When IPL Prevails

Edited by Paul C. Ajamian, OD

Tackle MGD with These Hands-on Interventions

By Mila Ioussifova, OD, and Hardeep Kataria, OD