In this week’s edition we will discuss SLK, finding your spot, and social batteries.
Blink Exercise of the Week
Look Up
SLK is one of those diagnoses that is easy to remember when someone reminds you about it, and surprisingly easy to forget when you are actually in the middle of an exam.
We spend so much of a dry eye evaluation looking at the cornea, lid margins, meibomian glands, tear film, staining, and everything else we are trained to pay attention to. When you are trying to get through an exam efficiently, it is easy to forget to have the patient look down and really examine the superior bulbar conjunctiva. In the right patient, though, that extra few seconds can give you the answer you have been looking for. Superior limbic keratoconjunctivitis classically affects women between the ages of 20 and 60, and while demographics certainly don't make the diagnosis, they can at least serve as a reminder to look.
I learned that lesson as a student in a way that has stuck with me ever since. I was seeing a patient under Dr. Arthur Epstein's care and had gone through my exam without recognizing what, in retrospect, was a pretty obvious case of SLK. I still remember exactly where I was when Art told me what the patient had. He had a very matter-of-fact way about him, and there was no attempt to embarrass me or make me feel stupid for missing it. He simply looked at me and said, "This is important, you need to know this." Then we went on with our day.
It probably lasted all of ten seconds, but for whatever reason, that moment became permanently ingrained in my memory. There are certain things you learn from a textbook and remember long enough to pass an exam, and then there are things you miss on an actual patient once and never want to miss again. For me, SLK became the latter.
Since then, looking at the superior conjunctiva has become one of those small things I try to make sure I don't skip during an ocular surface exam. Have the patient look down, take a few seconds to examine the superior bulbar conjunctiva and limbus, and flip the upper lid when appropriate. I am probably even more conscious of it when the patient fits the classic demographic for SLK, but the bigger lesson for me was simply to remember that there is more to examine than what you see when the patient is looking straight ahead.
Sometimes we convince ourselves that a difficult ocular surface patient needs another test, another treatment, or a more complicated explanation. Every once in a while, the answer is sitting right in front of you. You just have to remember to look up.
Practice Notes
Find Your Spot
For a period of several months, I spent an unreasonable amount of time at the Press Coffee on 32nd Street and Shea Boulevard in Phoenix. It was right down the road from the apartment I was living in at the time, and when I needed to sit down, lock in, and actually get something done, that was where I went. I’d order a vanilla latte, find a table, open my laptop, and usually stay there much longer than anyone who purchased one coffee probably had the right to.
I’ve always found that I’m more productive when there are people around me. Sitting alone in a completely quiet room sounds like it should be the perfect environment to get work done, but somehow I’ll find twelve other things to do instead. At Press, there was always just enough going on. People talking, the espresso machine running, someone walking in and out every few minutes. When I needed a break, I could look up from my computer and people watch for a little while, which also gave me a convenient excuse to get some blink exercises in before staring at my screen again.
That particular Press also happened to become the unofficial planning headquarters for Dry Eye Center of Arizona. I would estimate that 90% of everything I could possibly plan before opening the practice was worked out at one of those tables. I spent hours figuring out equipment, pricing, vendors, insurance, paperwork, the website, patient flow, testing protocols, and all of the other things that suddenly become your responsibility when you decide it would be a good idea to open a medical practice. I’d go there with a list of ten things I needed to figure out, leave having solved eight of them, and somehow come home with a new list of fifteen.
For months, I was a regular. I’m sure the employees recognized me, although they probably had no idea that the guy who kept showing up with his laptop and ordering the same vanilla latte was trying to figure out whether opening a practice devoted entirely to dry eye was going to be the best or worst decision he had ever made. There was a lot of excitement during that period, but there was also a lot of uncertainty. I could plan every logistical detail I wanted, but there was no spreadsheet that could tell me whether patients were actually going to walk through the door once we opened.
At some point, I stopped going there all the time. The practice opened, my days became occupied by actually running the thing I had spent all those months planning, and Press went back to being a coffee shop down the street rather than my unofficial second office.
Now, whenever I drive past that location, I get this weird feeling that I have a hard time putting into words. It absolutely lights up my heart. I think about how many hours I spent sitting in there stressing about whether any of this was going to work. At the time, I was so focused on getting to the next step that I obviously wasn’t thinking about how I would eventually look back on those afternoons. I was just trying to get through my list.
Every once in a while I’ll stop in and get a vanilla latte, and the place looks mostly the same. What’s different is that I get to sit there knowing what happened next. Dry Eye Center of Arizona isn’t a collection of ideas on my laptop anymore. I’m not wondering what opening day is going to look like or whether anyone is going to show up. I’m sitting in the same place where I worried about all of those things, except now I know how at least that part of the story turned out.
It’s funny how some random places end up becoming landmarks in your own life without you realizing it at the time. There’s nothing particularly significant about a coffee shop on the corner of 32nd Street and Shea to most people driving by it. To me, I don’t think it will ever just be a coffee shop again.
Life Between the Blinks
The Art of Doing Absolutely Nothing
If you ask me what my ideal day off looks like, there's a pretty good chance it involves absolutely no plans. I've always been a bit of a homebody, and I'm perfectly happy spending an entire day at home watching TV with my dogs, catching up on movies, or listening to an audiobook. I believe the younger generation calls this "couch rotting," which is apparently something I've been perfecting for years without realizing it. I spend so much of my week running around that having a day where I don't have to be anywhere or do anything is genuinely one of my favorite ways to spend my time.
I've always considered myself an introvert, although the older I get, the more I realize that depends entirely on the situation I'm in. Ada and I talk about this pretty frequently, particularly when we're traveling for conferences. There's a certain version of yourself that you have to turn on when you're attending a major industry event. Between lectures, meetings, dinners, and catching up with people you haven't seen in months, you can easily spend an entire day going from one conversation to the next. For the most part, I actually enjoy it. I love seeing friends, meeting new people, and having conversations that might lead to something interesting down the road. I think I'm pretty good at being social when the situation calls for it, but that doesn't mean I have an unlimited supply of energy to do it.
By the end of a particularly busy conference day, my social battery can be running dangerously low. I might have spent the last ten hours having a fantastic time, but eventually I reach a point where the thought of introducing myself to one more person sounds absolutely exhausting. It's funny because I can go from happily talking to dozens of people throughout the day to wanting nothing more than to sit in a hotel room by myself and watch a movie. I have gotten pretty good at recognizing when I’ve reached that point, and sometimes the best thing I can do is disappear for a little while.
Because of that, I've started treating breaks in my conference schedule with the same importance as meetings and dinners. If I'm going to be somewhere for three or four days, I deliberately leave myself pockets of time where absolutely nothing is planned. Maybe I'll spend an hour wandering around the exhibit hall without having anywhere specific to be or anyone I need to talk to. Maybe I'll head back to the hotel, take a nap, and come back out later for dinner. Sometimes I just want to sit somewhere with a coffee, put my headphones on, and enjoy not having to be "on" for a little while. I used to feel like I should be taking advantage of every possible opportunity at these events, especially when I was first getting involved with industry, but I've learned that packing every available minute of my schedule usually catches up with me.
There will always be another dinner invitation, another meeting, or someone you haven't had the chance to catch up with yet. I still try to make the most of these opportunities, but I've become much more comfortable declining something when I know I need a little time to myself. I'd much rather take an hour to recharge and actually enjoy the rest of my evening than spend the entire night mentally counting down the minutes until I can get back to my hotel room.
I suppose my ideal day at home and my ideal conference schedule have more in common than I originally thought. Whether I'm on the couch with my dogs watching a movie or sneaking away from a crowded exhibit hall for an afternoon nap, I really enjoy having time where nobody needs anything from me. I love the social side of my career, and I wouldn't trade the friendships and opportunities that have come from it. I've just learned that enjoying all of it sometimes requires giving myself permission to do absolutely nothing.
One Last Blink
Find your spot. Whether it’s a coffee shop, your favorite corner of the house, or somewhere entirely unexpected, having a place where you can tune out the distractions and get things done can make all the difference. And someday, you might look back at that very spot and realize just how much of your life you built there.
See you next week.
Andrew Zagelbaum, OD
Special thanks to our 2026 Founding Presenting Partner, Bausch + Lomb!