Between the Blinks #008

Blink Exercise of the Week

The Story Staining Tells Us

Corneal staining is one of those things we all look for, but I think it’s easy to get into the habit of treating it as a yes-or-no finding. There’s staining or there isn’t. Maybe we grade it, document it, and move on with the rest of the exam. The more ocular surface disease I see, though, the more attention I find myself paying to exactly where that staining is showing up.

Not all SPK means the same thing. Inferior staining may get me thinking about exposure, incomplete blinking, lid position, or something happening along the lower lid margin. Interpalpebral staining can fit nicely with tear film instability and exposure, while superior staining might send me down a completely different path. If the pattern is asymmetric or isolated to one area, I want to know why. Even the difference between corneal and conjunctival staining can add another piece to the puzzle.

The pattern becomes even more useful when it doesn’t match the diagnosis you already had in your head. If I’m treating someone for MGD and their glands are improving but the staining looks exactly the same, that makes me reconsider whether the evaporative component is really responsible for everything I’m seeing. The same goes for the patient whose staining seems way out of proportion to their symptoms, or the patient who is miserable despite having very little staining at all. Those mismatches are often where things start to get interesting.

I also think staining becomes much more valuable when you compare it over time. Rather than documenting that SPK is still present at every visit, look at whether the distribution has changed. Is there less of it? Has one area cleared while another hasn't? Does it look better even though the patient doesn't feel better yet? Those changes can tell you whether you're moving in the right direction, even when the rest of the picture isn't quite as clear.

We have access to more ocular surface technology than ever, and I obviously love having objective testing available. But there’s still a tremendous amount of information sitting right in front of us at the slit lamp. Fluorescein costs next to nothing, takes a few seconds, and can sometimes tell you more than simply whether the ocular surface is dry.

The next time you see staining, don’t just document that it’s there. Take an extra second to look at the pattern and ask yourself why it ended up there.

Practice Notes

What I Wish I Had Tracked From Day One

When I first opened my practice, there were really only a few numbers I cared about. How many patients were on the schedule, how much money came in that month, and whether there was enough sitting in the bank account to pay the bills. When you're starting from zero, those numbers feel like a pretty reasonable way to figure out whether things are moving in the right direction.

As the practice has grown, I've realized there are a lot of other things I wish I had been tracking from the beginning. One of the biggest is where every new patient came from. I knew generally which doctors were sending patients and whether someone found us through Google or word of mouth, but I wasn't nearly as consistent about documenting it as I should have been. Now that I have more referral sources, I'd love to be able to look back and see exactly how that changed month by month from the day we opened.

I also wish I had done a better job tracking new patients separately from total visits. A busy month can look great on paper, but there's a difference between growth coming from new people finding the practice and an existing patient base coming back for follow-ups. Both are important, but they tell you different things about how the practice is doing.

The same goes for treatments. In a specialty practice like mine, revenue alone doesn't tell me much about what patients are actually choosing to do. Knowing how many patients were recommended a particular treatment, how many moved forward with it, and how those numbers changed over time would have given me a much better picture of what was working. It also would have helped me recognize sooner whether a change in how we explained something to patients was actually making a difference.

There are plenty of other numbers you can track, and I think it's possible to take this way too far. I don't need a dashboard with 47 different metrics that I stare at every morning. What I want are a handful of numbers that tell me something useful about where the practice came from and where it's going.

If I could go back to day one, I'd probably start with new patients, referral source, total visits, treatment recommendations and acceptance, collections, and maybe a few basic expenses. Not because I needed another spreadsheet to worry about while trying to open a practice, but because those numbers become much more interesting once you have six months, a year, or eventually several years of history behind them.

There are plenty of things I remember about the first few months of opening my practice, but memory gets less reliable with time. I know which months felt busy and which ones felt painfully slow, but eventually I'd like to be able to look back at more than a bank statement to see how far we've come.

Life Between the Blinks

Making the Call

Moving from New York to Arizona has been one of the best decisions I’ve made, but that doesn’t mean it’s always been easy. I love the life I’ve built here, although being a five-hour flight away from most of my family is probably the part I’ll never completely get used to.

One thing I’ve made a point of doing since moving away is calling my parents every day. Sometimes we talk for a while, other times the conversation lasts a few minutes and consists mostly of what we did that day, what we had for dinner, or some random thing that probably wouldn’t sound particularly interesting to anyone else. There usually isn’t a reason for the call beyond checking in and hearing each other’s voices.

When I lived in New York, I don’t think I appreciated how easy it was to see family. You could make plans for dinner, stop by on a weekend, or know that if something came up, you weren’t very far away. Once you move across the country, those casual interactions disappear. Seeing each other requires plane tickets, planning, taking time off from work, and figuring out when everyone’s schedules line up. The phone calls became my way of keeping some of that everyday connection that distance takes away.

As life gets busier, I think it becomes surprisingly easy to go longer than we intend without talking to the people closest to us. There’s always another patient to see, an email to answer, something happening at the office, or a reason to say we’ll call tomorrow. A few days can turn into a few weeks pretty quickly if you let them.

I also know there will eventually be a point in my life when I would give just about anything to make one of these completely ordinary phone calls again. I don’t say that to be depressing, but it’s something I’ve become more aware of as I’ve gotten older. The conversations that feel routine right now probably won’t feel routine when I look back on them someday.

So I call my parents every day. Not every conversation is meaningful, and I certainly don’t have something interesting to report every afternoon. Most days, that’s actually what I like about it. They’re just a small part of my routine that keeps New York from feeling quite as far away as it actually is.

If someone came to mind while you were reading this, give them a call. You don’t need anything important to say.

One Last Blink

Life gets busy, schedules fill up, and somehow the people who matter most can end up getting whatever time is left. Make the call, plan the trip, and find the time. There will always be more work waiting for you tomorrow.

See you next week.

Andrew Zagelbaum, OD

Special thanks to our 2026 Founding Presenting Partner, Bausch + Lomb!