In this week’s edition, we will discuss testing over-reliance on meibography, dry eye cash pay fees, and starting passion projects.
Blink Exercise of the Week
What Meibography Can’t Tell You
I love meibography, and I use it on every new dry eye patient I see, but I think we sometimes put way too much weight on the image itself.
I've had patients with surprisingly good-looking glands who have terrible meibum, incomplete blinking, a thin lipid layer, and a tear film that falls apart almost immediately, but I’ve also seen the opposite.
It's one of the reasons I don't think meibography tells the whole story. When I'm looking at a new patient, I want to know what their glands look like, but I also want to know if they're actually working. That's where interferometry, blink analysis, tear break up time, and other forms of testing can become really helpful.
Take a look at the images below, which highlight two patients I saw back-to-back two weeks ago. Both of these patients came to my practice as new patients, and prior treatments included only over-the-counter lubricating drops.
When comparing the meibography alone of Patient A to Patient B, common sense would dictate that Patient B would have better working glands. When you look at the interferometry (lipid-analysis) of the two patients, you’ll be surprised to see that the patient with the more robust gland structure also shows lower quality oil.
This is a great example of why gland structure and function do not always tell the same story.
Patient A (Upper Lid Meibography)
Patient A (Lower Lid Meibography)
Patient A (Interferometry)
Patient B (Upper Lid Meibography)
Patient B (Lower Lid Meibography)
Patient B (Interferometry)
Adept readers will also notice the importance of everting the upper lid (especially in Patient A), which you can expect to be expanded upon in a future edition!
Practice Notes
The Cash Pay Problem Solution
When I opened my dry eye practice, one of the decisions I made was to charge separately for my dry eye testing.
This testing includes meibography of the upper and lower lids, interferometry, non-invasive TBUT, tear meniscus height, blink analysis, bulbar redness, and lid and lash photography, and corneal sensitivity all performed on high tech devices that would allow me to go over this testing with a patient directly.
I was definitely a little nervous about it at first. Would patients actually pay for testing before even seeing me? I learned very quickly that the answer is yes.
What I've come to understand is that the price isn't usually the issue. The issue is whether the patient is fully aware of what they're paying for. If you tell someone, "We're going to take some pictures and do a few dry eye tests," a testing fee may seem like an unnecessary burden.
If you explain that we're trying to figure out why they've been dealing with burning or fluctuating vision for three years despite trying every artificial tear, it starts to make a lot more sense. It has changed the way I think about cash-pay services in general.
People are much more comfortable paying for something when they understand why it matters.
Probably obvious, but it's something I've had to learn firsthand, and I haven’t looked back since.
Life Between the Blinks
The Projects You Don’t Have to Do
I had been toying with the idea of starting Between the Blinks for a while, but like a lot of ideas, it mostly lived in my head. When I brought it up to Ada, pretty quickly, the idea went from “this could be fun” to the two of us actually building it.
There’s something different about starting a project with a friend, especially when it’s something neither of you has to do. There’s no boss asking for it, no deadline hanging over your head, and no guarantee that it turns into anything. You’re doing it simply because the idea excites you.
We’ve all heard the cliché, “If you love what you do, you’ll never work a day in your life.” I don’t know if I’d go quite that far, and work is still work. I do, however, think there’s some truth buried in there. When you find projects that genuinely fuel you, the extra hours don’t feel quite as heavy.
That’s what I hope Between the Blinks becomes for us. A place to talk about the things we’re already thinking about, learning, and debating every day, while building something with a friend along the way.
One Last Blink
Find work that gives you energy back every once in a while.
See you next week.
Andrew Zagelbaum, OD