Between the Blinks #009

Blink Exercise of the Week

Thinking Outside the Drop

When we think about treating aqueous deficient dry eye, most of the options that immediately come to mind involve putting something in or around the eye. Artificial tears, prescription drops, punctal occlusion, serum tears, and plenty of other treatments all have their place. Every once in a while, though, it’s worth thinking beyond the ocular surface itself.

One of the treatments I’ve incorporated for select patients with significant aqueous deficiency is oral pilocarpine. It’s certainly not something I prescribe to every aqueous deficient patient, but I’ve had some really nice results in patients with systemic autoimmune disease, particularly those dealing with significant sicca symptoms. These are often patients who aren’t just struggling with dry eyes. They’re dealing with dry mouth and other manifestations of decreased exocrine secretion at the same time.

One patient in particular had a long history of dental problems that she associated with years of significant dry mouth from her autoimmune condition. We started oral pilocarpine primarily as another way of approaching her aqueous deficiency after she had already been through plenty of the more traditional options. When she came back for follow-up, she told me about a recent visit with her dentist. Without knowing that we had started anything new, her dentist commented that her mouth looked better than it had in years.

I loved hearing that because it was a reminder that sometimes the condition we’re treating extends well beyond the few millimeters of tissue we spend most of our day looking at. Her dry eye and dry mouth weren’t two completely unrelated problems, so it made sense that a systemic treatment could potentially have benefits in both places.

That doesn’t make oral pilocarpine a catch-all treatment for aqueous deficiency. It’s a systemic medication, and with that comes systemic considerations and side effects. Increased sweating is a common one, and increased salivation is obviously part of the intended effect but can sometimes become excessive. Like any medication, patient selection, medical history, contraindications, and a conversation about potential adverse effects matter before prescribing it.

Still, I’ve had patients who had already tried what felt like everything for their dry eye and finally noticed meaningful improvement after we added it. Those experiences have made me more willing to occasionally step outside of the usual dry eye treatment algorithm and think about what else might make sense for the person sitting in front of me.

We spend a lot of time thinking about which drop, device, or procedure should come next. Sometimes the next thing worth considering isn’t another drop at all.

Practice Notes

How Much Exclusivity Is Too Much?

Non-competes are something most of us have probably encountered at some point in our careers. When I was an associate, I understood why an employer wouldn't want me leaving the practice on Friday and opening my own office next door on Monday. They spent time building that practice, developing a patient base, training me, and introducing me to their community. Asking for some reasonable protection around that investment doesn't seem particularly outrageous. Where I've always struggled is when that protection starts making it unnecessarily difficult for someone to move on with their career.

There's a pretty big difference between asking an employee not to open across the street and writing a restriction so broad that their next job requires an hour commute or moving to another city. People leave jobs. Their goals change, families move, better opportunities come along, and sometimes a workplace simply isn't the right fit anymore. I don't think leaving an employer should mean having to uproot the rest of your life.

Now that I'm on the other side and actually own a practice, I can appreciate both perspectives a little more. I understand wanting to protect something you've spent years building, especially when you're trusting an employee with your patients and your reputation. At the same time, I spent years as an employee before becoming an owner, and I haven't forgotten what it's like to be the person signing the contract.

Recently, I've started noticing a similar conversation coming up in a completely different part of my career: working with industry. As you become more involved with companies as a Key Opinion Leader, speaker, consultant, or advisor, exclusivity starts finding its way into those contracts too. In some situations, I think it makes perfect sense. If a company is paying me to stand on a stage and promote its device, it would be pretty strange for me to walk across the exhibit hall afterward and promote a directly competing device for another company. If you're asking someone to publicly represent a product, some degree of exclusivity around that specific role seems reasonable. Consulting feels different to me.

If I'm being brought in as an independent contractor to give a company my opinion, review a product, discuss clinical workflow, or help them understand how a doctor might actually use something in practice, I'm providing my expertise. Unless there's a very specific conflict involved, I don't think that should automatically give one company ownership over where else I'm allowed to provide that expertise.

In fact, part of the value of a consultant is having experience beyond a single company. Being exposed to different technologies, ideas, and approaches is often what allows someone to give useful feedback in the first place.

There is obviously nuance here. Confidential information needs to remain confidential. Genuine conflicts of interest need to be disclosed and managed. If you're being paid to publicly advocate for one product, accepting money to publicly advocate for its direct competitor at the same time is probably going to create some uncomfortable questions. None of that means every relationship needs to come with a blanket restriction on everything else you do.

I think that's the common thread between employment contracts and KOL agreements. Protecting a legitimate interest is reasonable. Trying to control someone's professional life beyond what is necessary to protect that interest is where I start to have a problem.

I've become much more comfortable reading contracts with that distinction in mind. Instead of seeing the word "exclusivity" and immediately deciding it's good or bad, I want to know exactly what I'm agreeing to be exclusive about. What product? What category? What activity? For how long? And, most importantly, does the restriction actually make sense for the relationship we're entering into?

There are times when exclusivity is part of the deal, and that's perfectly reasonable. I just don't think signing a contract should require handing someone the keys to every other professional relationship you might want to have.

Life Between the Blinks

Something Worth Capturing

I recently splurged on something I've wanted for a while and bought myself a Fujifilm X100VI. To be clear, I know very little about photography. I know there are people reading this who could probably spend an hour explaining aperture, shutter speed, ISO, and all of the things I'm currently pretending to understand. I'm starting pretty close to zero.

What I do know about myself is that I like having a project. Between running my clinic and seeing patients, speaking, consulting, advising, and writing this newsletter every week, I've started to realize that I’m happiest when I have something I'm working on. Usually several things. The problem is that nearly every project I've taken on over the last few years has somehow found its way back to optometry.

I love what I do, so that's not necessarily a bad thing. But when your career is also one of your biggest interests, it becomes pretty easy to live inside that bubble without realizing it. You work all day, come home and work on something related to work, then spend your free time talking to people you know through work. Before long, someone asks what your hobbies are and you need an uncomfortable amount of time to come up with an answer. Photography felt like an opportunity to give myself something new to learn that had absolutely nothing to do with eyes or owning a practice.

The interest actually started becoming more meaningful when I found out my parents were going to sell my childhood home. I've lived in Arizona for years now, but that house in New York is still home in a way that's difficult to explain. It's where I grew up, where so many of my memories with my family took place, and probably the one physical place I associate most with my childhood.

When I found out they were selling it, I suddenly felt this strange pressure to document everything. I wanted pictures of the rooms, the backyard, the little details nobody else would think were important. Things that probably wouldn't mean anything to the next family who lives there but mean something to me because I know what happened there. It made me realize how much of life we assume we'll remember.

We all have thousands of pictures sitting on our phones, but there's something I've started to appreciate about intentionally taking a photograph because you want to remember a particular moment. I'm sure most of the pictures I take while learning will be terrible. I'll probably mess up settings, miss shots, and take far too many pictures of things nobody else cares about. That's fine. For once, getting good at something isn't really the point.

I want pictures of my parents, my friends, and places that matter to me before they change and ordinary days that don't seem particularly important until years later when you'd give anything to experience one of them again.

So take the picture. Even if everyone complains that they don't want one. Even if nobody is dressed up and nothing particularly exciting is happening. Take pictures of your parents, your grandparents, your friends, your dogs, your house, and all of the boring moments in between. Someday, someone is going to be really glad you did.

Please enjoy some of my favorite moments I’ve captured so far.

One Last Blink

Not every moment feels important while you’re living it. Take the picture anyway. You never know which ordinary Tuesday will become something you wish you could go back to.

See you next week.

Andrew Zagelbaum, OD

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