Between the Blinks #004

Blink Exercise of the Week

Will the Real Dry Eye Please Stand Up?

We talk about dry eye as if it’s one condition, but two patients can walk into your office with the same complaint and have very different reasons for being symptomatic. Before deciding what to treat, it helps to take a minute and ask a pretty basic question: is this primarily evaporative, aqueous deficient, or a mixture of both?

Evaporative dry eye is probably what most of us think about first, especially with how much attention meibomian gland dysfunction gets today. These are the patients where you may see poor oil quality, gland obstruction, shortened tear breakup time, incomplete blinking, or structural gland changes. Their problem isn’t necessarily that they aren’t producing enough tears. They just can’t keep the tears they have on the eye long enough.

On the other side is aqueous deficient dry eye, where there simply isn’t enough of the watery component of the tear film being produced. Looking at tear volume, the tear meniscus, staining patterns, and the rest of the clinical picture can help point you in that direction. It should also get you thinking about why the patient may be aqueous deficient, particularly when the findings are more significant than you would expect.

Of course, plenty of patients don’t fit nicely into either category. Mixed dry eye is incredibly common, and a patient can have significant MGD while also having inadequate aqueous production. That distinction matters because treating only one side of the problem may get you some improvement, but it can also leave you wondering why the patient still isn’t doing as well as you expected.

This is one of the reasons I like having multiple data points before I walk into the exam room. Tear meniscus height, non-invasive breakup time, interferometry, meibography, blink analysis, staining, and gland expression all tell me something slightly different. No single test gives me the answer, but together they help build a much better picture of what is actually happening with that patient’s tear film.

It’s easy to see MGD and immediately start thinking about how you’re going to treat the glands. Sometimes that’s exactly what the patient needs, but don’t let an obvious evaporative component distract you from looking for aqueous deficiency too. Figuring out which bucket, or buckets, your patient falls into from the beginning can make the rest of the treatment plan a lot more straightforward.

Practice Notes

Sole Searching

When I opened Dry Eye Center of Arizona, I structured the practice as a PLLC, but for tax purposes I started out as a sole proprietor. I had looked into an S-corp election from the beginning, but for where I expected the practice to be financially during its first year, I didn’t think there was much reason to rush into it.

During that first year, I wasn’t on payroll. If the practice had enough cash and I wanted to take money out, I would take an owner’s draw. The important distinction is that those draws weren’t what determined my taxable income. As a sole proprietor, I’m taxed on the net profit of the practice regardless of whether I transfer that money to my personal account or leave it sitting in the business.

My thinking was that the first year could land anywhere from around break-even to roughly what I might otherwise expect to earn as an employed optometrist. If there wasn’t going to be much profit beyond what would reasonably represent compensation for my own work, the potential payroll-tax advantage of an S-corp wasn’t especially compelling to me yet. I would have been adding payroll, another tax return, and some additional accounting complexity without necessarily getting much benefit in return.

Going into the next year, I expect that calculation to change. If the practice continues growing and its profit starts meaningfully exceeding what I could reasonably pay myself as an optometrist and practice owner, I plan to elect S-corp taxation. At that point, I would become an employee of my own company, pay myself a reasonable W-2 salary through payroll, and then have the ability to take additional money out of the business as shareholder distributions.

That distinction is where some of the potential tax savings come from. W-2 wages are subject to payroll taxes, while S-corp distributions generally are not subject to self-employment tax. You can’t just pick an artificially low salary and call everything else a distribution, though. The IRS requires shareholder-employees to receive reasonable compensation for the work they perform, and that number depends on things like your responsibilities, experience, hours worked, comparable compensation, and where the revenue of the business is actually coming from.

For a practice like mine, that last point is especially relevant because a substantial portion of the revenue is tied directly to the doctor’s work. So my goal with an S-corp isn’t to find the lowest salary I can possibly justify. It’s to pay myself a salary that reasonably reflects what I do, while recognizing that as the business grows, not every dollar of profit necessarily needs to be treated as wages.

I liked keeping things relatively simple during year one while I figured out what the practice was actually going to produce. Now that I have a better idea of what the business looks like financially, an S-corp may make more sense for the next stage. It’s less about one structure being better than the other and more about the structure finally matching where the practice is.

A quick disclaimer: This isn’t financial or tax advice, and everyone’s practice and financial situation is going to look a little different. I’m sharing this simply to be transparent about how I approached the decision based on my own situation and where my practice stood financially at the time. If you’re opening a practice or considering a change in how your business is taxed, talk with your CPA or financial advisor about what makes the most sense for you.

Life Between the Blinks

The Letters After Our Names

A few weeks ago, I came across a negative Google review for an ophthalmology practice. The review itself wasn't what caught my attention. It was the response from the ophthalmologist, who used the opportunity to make a comment about the limitations of optometrists when it comes to managing more complex medical eye conditions.

I’ve heard some version of this argument plenty of times before, and I’ve never really understood why we’re still having it.

My own father is an ophthalmologist, and throughout my career he has been one of the biggest supporters of what I do as an optometrist. He has never treated optometry and ophthalmology as opposing sides. There are things he does that I don't do, things I do that he doesn't do, and plenty of patients who are better served because both professions exist and work together.

I see that play out every day in my own practice. More than half of my referrals come from MDs. Surgeons send me patients whose ocular surface they want optimized before or after surgery. Ophthalmologists send me complicated dry eye patients who need more time or testing than they may be able to offer in their clinic. I treat the ocular surface problem and send the patient back for the care that physician was already providing. Nobody loses the patient, and more importantly, the patient gets better care.

I've been fortunate to work alongside ophthalmologists both here in Arizona and around the country who treat me as a colleague rather than someone sitting one rung below them on some imaginary eye-care ladder. We discuss patients, ask each other questions, refer back and forth, and recognize where the other person has expertise that we don't. To me, that's how healthcare is supposed to work.

There are absolutely differences among optometrists, but I don't think that's the argument against optometry that some people think it is. There are ODs who choose to spend most of their careers focused on primary eye care and refractive correction, while others build their careers around ocular disease, specialty contact lenses, dry eye, neuro-optometry, glaucoma, or research. The letters after someone's name tell you what degree they earned. They don't tell you everything that happened in the twenty or thirty years afterward.

Dr. Art Epstein was an OD, and he became one of the people who helped push our understanding and management of ocular surface disease forward. Dr. Jacqueline Theis is an OD who has built her career around neuro-optometry, brain injury, and some incredibly complex neurologic patients. Dr. Kaleb Abbott is an OD whose work centers around complex ocular surface disease, neuropathic pain, and research within an academic medical center. Dr. Patrick Vollmer is an OD who has been heavily involved in clinical research and FDA-reviewed clinical trials. Dr. Nora Lee Cothran is an OD well known nationally for her management of patients with glaucoma.

Those were just the first five names that came to mind while I was writing this.

None of this diminishes ophthalmology. I have tremendous respect for what ophthalmologists do, and there are countless conditions and procedures where an ophthalmologist is exactly who I want caring for my patient. The same thing can be true in the other direction. There are areas where an optometrist who has spent years developing a particular niche may have considerably more experience with that specific problem than someone with a different set of letters after their name.

Maybe that's why the Google response bothered me. It wasn't because an ophthalmologist criticized optometry. It was because the attitude behind it feels so different from the way I actually experience eye care every day.

The best MDs I've worked with aren't worried about proving that they're more qualified than an OD. The best ODs I know aren't trying to prove they can replace ophthalmologists. Everyone seems much more interested in figuring out who can best help the patient sitting in front of us.

I think we're all better off when we keep it that way.

One Last Blink

As healthcare providers, the most important component of our profession is a patient’s health. Collaboration is a part of the formula that maintains that shared goal.

See you next week.

Andrew Zagelbaum, OD