Just Scratching the Surface

About Just Scratching the Surface

Conversations on ocular surface disease care that address real-world clinical questions, hosted by optometrists Kaleb Abbott and Andrew Pucker with a new guest expert each episode. Updated monthly.

Publisher

Kaleb Abbott and Andrew Pucker

Category

health & fitness · science

Language

en

Explicit

No

First episode

17 Mar 2026

Latest episode

30 Sept 2026

Latest episodes

7 episodes in the feed.

1. 

   30 Sept 2026

   DEWS III Decoded: What Clinicians Need to Know

   Hosts Kaleb Abbott and Andrew Pucker welcome renowned ophthalmologist Penny Asbell to discuss the key updates from the recently published TFOS DEWS III report, the latest international consensus document on dry eye disease. The report spans over 300 pages and cites more than 1,000 references, making it extremely comprehensive but not very user-friendly for busy doctors who want to absorb the key points. Dr. Asbell—one of the authors—is here to help. The conversation begins with the updated definition of dry eye disease. While DEWS III’s version is similar to the DEWS II definition, the key change is an expanded concept of homeostasis, which now encompasses not just the tear film but also the ocular surface more broadly. The etiological factors listed include tear film instability, hyperosmolarity, ocular surface inflammation and damage and neurosensory abnormalities. Next, the three doctors unpack the OSDI-6 patient questionnaire, a streamlined six-question version of the original 12-question form. Covering symptoms, activity limitations and environmental triggers, it is scored from 0-24, with scores of four or above indicating significant dry eye. The hosts and Dr. Asbell agree it is an easy, efficient screening tool suitable for routine clinical use. The group then discusses the role of inflammation in dry eye, with Dr. Asbell noting that while DEWS III emphasizes inflammation as a key factor, her own experience, including data from the somewhat controversial NIH-funded DREAM trial, suggests it is not universal across all dry eye patients. She expresses hope that improved ocular biomarkers will eventually help clinicians better identify which patients have meaningful inflammation and would benefit most from anti-inflammatory therapies. The conversation also addresses the report’s expanded focus on eyelid abnormalities, including blink mechanics and incomplete lid closure, topics that Dr. Asbell notes were championed by dry eye guru Donald Korb decades ago. The trio share practical clinical tips for identifying nocturnal lagophthalmos, including the Korb-Blackie light test, and discuss often-overlooked causes such as blepharoplasty and Botox use. Regarding disease classification, DEWS III moves beyond the traditional aqueous-deficient vs. evaporative binary, instead organizing dry eye into three categories: tear film deficiencies, eyelid abnormalities and ocular surface abnormalities. This framework forms the basis of the DEWS III approach to treatment, providing a structure that can allow for a streamlined approach. The episode ends with thoughts on dry eye treatment, with notable discussions including semi-fluorinated alkanes (Miebo), hyaluronic acid lubricants, corticosteroids, tacrolimus ointment and regenerative therapies such as autologous serum. Dr. Asbell also raises important questions about the quality of evidence supporting certain devices and procedures, noting the difficulty of running well-controlled clinical trials in dry eye, given the highly subjective experience of patients. Relevant Articles: TFOS DEWS III Treatment Report Details Full Panoply of Interventions (https://www.reviewofoptometry.com/news/article/tfos-dews-iii-treatment-report-details-full-panoply-of-interventions) Simplifying the Diagnosis of Dry Eye Disease (https://www.reviewofoptometry.com/article/simplifying-the-diagnosis-of-dry-eye-disease) TFOS DEWS III Refines Key Diagnostic Protocols, Emphasizes Importance of Subtyping (https://www.reviewofoptometry.com/article/tfos-dews-iii-refines-key-diagnostic-protocols-emphasizes-importance-of-subtyping)

2. 

   1 Sept 2026

   The Leap from Clinic to Industry

   This episode, Drs. Abbott and Pucker begin an occasional series called “Industry Insights,” welcoming guest Natalie Nguyen, OD, Senior Director of Medical Affairs at Harrow, to discuss what it’s like for optometrists to transition from clinical practice into the pharmaceutical industry. Dr. Nguyen, a Memphis native who completed her optometry degree at Southern College of Optometry, made the leap in 2022. She first learned about industry careers around 2017 through a pharmaceutical representative who introduced her to the Medical Science Liaison (MSL) role, a career path she hadn't known existed, as it was never discussed during her optometry training. She explains that her motivation to transition wasn’t burnout, as might be expected, but rather a growing curiosity about the science and strategy behind patient care—a desire to influence outcomes on a larger scale than one-on-one clinical encounters allow. A significant portion of the conversation focuses on demystifying the MSL role. Dr. Nguyen characterizes the MSL role as a scientific bridge between a pharmaceutical company and the medical community—a non-promotional position involving peer-to-peer scientific discussions with clinicians that supports medical education. An important responsibility is bringing field insights back to the company internally. The role demands significant travel (50% to 80%), a high degree of autonomy and a broad skill set that goes well beyond scientific knowledge, she explains, including relationship-building, emotional intelligence, adaptability and self-discipline. Dr. Nguyen talks candidly about the challenges of breaking into industry, sharing that she was rejected by three or four companies before landing her position at Harrow through a LinkedIn posting. She emphasizes that the field is increasingly competitive, and that a clinical background alone is no longer sufficient—candidates must find ways to differentiate themselves. Once hired at Harrow, she faced the additional challenge of being the company's first-ever medical affairs employee, essentially building the function from the ground up without formal onboarding or mentorship. Her career advanced rapidly from MSL to Field Medical Director to her current role as Senior Director of Medical Affairs, where she oversees scientific strategy, cross-functional alignment, and long-term planning within the medical affairs function. For optometrists considering a similar path, Dr. Nguyen’s key advice includes: do thorough research on the role and company, build genuine relationships through networking, find mentors early, embrace discomfort and never burn bridges in what is a surprisingly small professional community. She closes by saying that, given everything she knows now, she would make the same career leap without hesitation.

3. 

   31 Jul 2026

   Neurotrophic Keratitis: From Diagnosis to Treatment

   Kaleb Abbott and Andrew Pucker are joined by Jeff Banas, an OD from Wisconsin specializing in glaucoma and dry eye, to discuss neurotrophic keratitis (NK). The trio begin by trying to clarify what, specifically, NK is and how it develops. While classically associated with herpetic infections (HSV/HZV), the panel emphasizes that other significant causes include diabetes, ocular or neuro surgery, chronic glaucoma medication use, and severe ocular surface disease. All can damage the trigeminal nerve, leading to loss of tearing and other functions that help sustain corneal health, resulting in formation of corneal epitheliopathy or even a persistent corneal epithelial defect. Left untreated, this has the potential to progress to stromal ulceration or even perforation. A hallmark warning sign is “stain without pain”—significant corneal staining with little or no patient discomfort. This occurs because damaged nerves fail to transmit appropriate pain signals, which Dr. Abbott likens to having a non-functioning smoke detector during a fire. Dr. Banas also points to delayed healing after corneal epithelial debridement as one warning sign of incipient NK, and also describes the clinical value of the Mackie classification of NK: Stage 1: Punctate keratitis, tear film instability, reduced corneal sensitivity Stage 2: Persistent epithelial defect Stage 3: Stromal involvement, corneal thinning, neurotrophic ulcer The three ODs stress that Stage 1 is the most common, but is frequently overlooked, and that heightened awareness of early NK is critical. They emphasize the need to test corneal sensitivity with a cotton wisp or, if available, a Cochet-Bonnet esthesiometer, the gold standard in research settings (cutoff of ≤ 4.0cm indicates NK). The panel encourages all clinicians to incorporate corneal sensitivity testing, especially for dry eye patients who are unresponsive to standard treatments. Turning to treatment, the group distinguishes between supportive therapies (artificial tears, punctal occlusion, immunomodulators, warm compresses) and regenerative therapies (amniotic membranes, autologous serum drops, Oxervate) and gives pearls for effective use of each in appropriate circumstances. Prophylactic antibiotics are recommended for Stage 2 and 3 due to infection risk, but not typically for Stage 1, they note. Drs. Abbott, Pucker and Banas leave listeners with this key advice: Test corneal sensitivity. It’s simple, quick and doesn’t disrupt clinic flow. Think beyond HSV—Consider neurotrophic keratitis in any patient with corneal epitheliopathy and relevant risk factors. Don’t dismiss asymmetric staining. It may signal an underlying neurotrophic component. Treat early and aggressively to prevent progression to more severe stages. The discussion reinforces that NK is likely far more common than currently diagnosed, and earlier identification can significantly improve patient outcomes. Relevant Articles: Neurotrophic Keratitis: Hiding in Plain Sight (https://www.reviewofoptometry.com/article/neurotrophic-keratitis-hiding-in-plain-sight) Hurt Feelings (https://www.reviewofoptometry.com/article/hurt-feelings) Nerve Growth Factor Treatment May Initiate Corneal Recovery in Neurotrophic Keratitis (https://www.reviewofoptometry.com/article/nerve-growth-factor-treatment-may-initiate-corneal-recovery-in-neurotrophic-keratitis) Corneal Complications of Diabetes: What ODs Need to Know (https://www.revieweducationgroup.com/ce/corneal-complications-of-diabetes-what-ods-need-to-know)

4. 

   1 Jul 2026

   Mucins – The Sticky Secret Protecting Your Eyes

   Mucins play an integral role in ocular surface health. They are the secret ingredient that gives the aqueous its viscosity and moisturizing properties. They entrap pathogens in the tear film to protect the eye. And they provide the glycocalyx anchor that keeps the tear film residing on the ocular surface. Dr. Tichenor explains all this and more in the no-nonsense terms you’d expect from a Midwesterner. Dr. Tichenor explains that there are two main types of mucin: free-floating and membrane-bound. The former are secreted by conjunctival goblet cells into the tear film, where they scavenge for bacteria and pollen while also providing the hydration properties of the tears. Membrane mucins, by contrast, arise from corneal and conjunctival epithelial cells and produce the glycocalyx, “kind of a shag carpet” on the ocular surface. Dr. Tichenor explains. Functionally, this creates a hydrophilic base that adheres the tear film to the eye. The three doctors then delve into clinical manifestations of these mucin properties, beginning with lissamine staining and what it signifies—dead or devitalized corneal epithelial cells that also have patches of missing glycocalyx.“Those areas are not going to be wetting very well,” Dr. Tichenor explains, “and would be very prone to infection.” The team also offers advice on how to identify the Line of Marx at the mucocutaneous junction on lissamine green staining and what it might signify, as well as the role of mucins in lid wiper epitheliopathy. Although fluorescein patterns are most often interpreted in the context of lipid layer integrity, Dr. Tichenor offers a nice clinical pearl on what they may say about the state of the glycocalyx, too: watch for the fluorescein spreading pattern across the cornea. If you see dark patches form almost immediately after a blink, “I would interpret that as areas where the glycocalyx is not functioning as well as it could.” Membrane mucins are an effective early warning system. Inflammation is widely recognized as the key driver of dry eye, and research points to mucin as a potential regulator of inflammatory cytokines, Dr. Tichenor explains. Furthermore, overproduction of mucus happens in response to an antigen on the ocular surface—a threat that needs to be eliminated. This might be a clue to mucin deficiency in, for instance, Sjögren’s Syndrome. This episode emphasizes that mucins contribute to dry eye cases in important ways that shouldn't be overlooked in favor of lipid-based mechanisms and interventions. Other mucin-mediated conditions include ocular cicatricial pemphigoid, mucus fishing syndrome, filamentary keratitis and Stevens-Johnsons Syndrome. Despite the paucity of mucin-specific treatments available in the US. Dr. Tichenor explains that some artificial tears have “mucomimetic” properties, especially those containing hyaluronic acid. The potential of topical vitamin A is also touched on, as well as two drugs available internationally: diquafosol and rebamipide. “Have mucins on your mind” as you assess dry eye and other ocular surface conditions, is Dr. Tichenor’s takeaway for the episode. Relevant articles: A Sticky Subject (https://www.reviewofoptometry.com/article/a-sticky-subject) As Smooth As Silk (https://www.reviewofoptometry.com/article/as-smooth-as-silk) Dry Eye Drop Boosts Ocular Mucins (https://www.reviewofoptometry.com/article/dry-eye-drop-boosts-ocular-mucins) Regional Conjunctival Differences in Glycocalyx Mucin Expression in Dry Eye and Normal Subjects (https://iovs.arvojournals.org/article.aspx?articleid=2793363)

5. 

   16 Apr 2026

   Building a Dry Eye Practice

   You know the story; it might even be your story. Graduate optometry school with a lot of enthusiasm—and a lot of debt. Pick up all the extra days you can just to stay afloat financially. Now you’re in the high-volume, low-reward daily grind of refraction, primary eye care and the same old conversations with patients about what astigmatism is. Hello, burnout. What to do? For Ada Noh, OD, the answer was to commit to a specialty concentration in dry eye, forgoing the trappings of routine eye care—bye-bye, phoropter!—for the intellectual stimulation of advanced care and the risks and rewards of self-employment. Dr. Noh describes her journey to specialty practice with great anecdotes about how she came to face her fears about starting cold, in an unfamiliar new city to boot. Job one was building a referral base and that meant embracing self-promotion far and wide to optometrists, ophthalmologists, other health care professions and frankly anyone else who’d hear her out. She says giving up primary care entirely rather than the half-a-loaf approach of adding a dry eye clinic to a general practice was a winning strategy, as other eyecare providers had no reason to see her as a threat. Instead, she became a resource to them. Addressing the misconception that you need to sink a lot of money into a specialty practice, Dr. Noh reassures listeners that you could start without much more than a slit lamp and a bottle of Fluress if you want. It’s the extra time and attention you give patients that often makes a decisive difference to them. She does also share her thoughts on the most helpful devices to add—notably, meibography and IPL—as you ramp up over time. Throughout the episode, Dr. Noh returns to the themes of believing in yourself and having the tenacity to take on whatever comes your way. “Don’t wait for ‘perfect’ because it’s not gonna come,” she counsels. The rewards for all this hard work and risk-taking go beyond the financial. She has more autonomy than ever before. Amazingly, Dr. Noh is about to take the plunge a second time. Having recently sold the practice she started only a few years ago, she’s moving to a bigger market and will do it all over again, beginning this fall. Stay tuned for future updates on her second (or maybe third?) act! Relevant articles worth reading: “Why Isn’t My Dry Eye Therapy Working?” (https://www.reviewofoptometry.com/article/why-isnt-my-dry-eye-therapy-working) By Ada Noh, OD Dive Into Dry Eye (https://www.reviewofoptometry.com/article/dive-into-dry-eye) With advice from Cory Lappin, OD, Hamza Shah, OD, Michelle Hessen, OD, and Erica Udell, OD Pathways to Specialization: Find–and Follow–Your Calling (https://www.reviewofoptometry.com/article/pathways-to-specialization-find-and-follow-your-calling) With advice from Kelly Cohen, OD, Emilie Seitz, OD, Rami Aboumourad, OD, Joseph Sowka, OD, Cory Lappin, OD, Marie Homa-Palladino, OD, Langis Michaud, OD, Michael Cymbor, OD, Erin Tomiyama, OD, PhD, and Diane T. Adamcyzk, OD

6. 

   16 Apr 2026

   Natural Tears vs. Artificial Tears

   With renowned dry eye expert Milton Hom, OD, as this episode’s guest, hosts Kaleb Abbott, OD, and Andrew Pucker, OD, PhD, lead a spirited discussion of so-called “artificial tears” and contact lens rewetting drops as distinct product categories. They begin by exploring whether or not FDA definitions align with the perception of clinicians and their recommendations to patients, noting that much of the terminology and categorization structure of these products stems from the original FDA product monograph (https://www.ecfr.gov/current/title-21/chapter-I/subchapter-D/part-349), which dates to 1988. Dr. Abbott argues that these categories are outdated and should rightly be combined and renamed “lubricating drops” to reflect real-world use. He also points out that there’s less than 1% similarity between artificial and human tears, as the latter contains thousands of proteins and growth factors, so the term “artificial tears” creates unrealistic expectations with patients. The conversation then turns to ingredients in tear products and their role in product selection. Dr. Hom favors drops containing hyaluronic acid when wound healing or improved contact lens comfort is needed, a trehalose-containing drop if he sees corneal staining and an emulsion-based product (mineral oil or castor oil) for evaporative dry eye. The trio are intrigued by newer products that aim to mimic natural tears by including vitamin C, vitamin B12, amino acids and other ingredients but we need to see the data supporting their efficacy. They return to the topic of the FDA monograph when discussing why Meibo is considered an artificial tear in Europe, and sold over the counter, but not in the US; its formulation doesn’t meet the FDA criteria for OTC status and so the product was developed as an Rx drug. The experts point out that Meibo has a much longer ocular surface retention time than regular artificial tears—roughly 6-8 hours vs. 30 min—and thus does perform differently. The episode ends with a discussion of how to approach patients with overlapping allergy and dry eye, and a general wrap-up on the debate over whether certain artificial tear products truly have properties that distinguish them from others. The consensus is that some indeed do but none truly replicate the natural tear film. Relevant articles worth reading: It's time to retire the terms artificial tears and rewetting drops: A call for accurate terminology and updated clinical usage in eye care (https://www.sciencedirect.com/science/article/abs/pii/S1542012425001107) By Kaleb Abbott, OD, MS, and Andrew Pucker, OD, PhD Over the counter (OTC) artificial tear drops for dry eye syndrome (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009729.pub2/full) By Andrew Pucker, OD, PhD, Sueko Ng, MHS, and Jason Nichols, OD Artificial Tears: What Matters and Why (https://www.reviewofoptometry.com/article/artificial-tears-what-matters-and-why) With advice from Jennifer S. Harthan, OD, Suzanne Sherman, OD, Cecilia Koetting, OD, and Meaghan Horton, OD Artificial Tears: Looking Beneath the Surface (https://www.reviewofcontactlenses.com/article/artificial-tears-looking-beneath-the-surface) By Mike Christensen, OD, PhD, and Tressa Larson, OD

7. 

   17 Mar 2026

   IPL Unfiltered: Separating Fact from Fiction

   Dry eye specialist Cory Lappin, OD, of Cincinnati shares insights on IPL that he’s developed from many years of performing the procedure. Dr. Lappin begins with a clear and concise explanation of how light interacts with pigment at the cellular level to “kick-start” meibocyte activity and target telangiectatic blood vessels. He addresses common misconceptions about IPL, taking care to explain that it is a non-laser and non-thermal procedure, as a way of understanding where it fits in among dry eye interventions. From there, Drs. Lappin, Abbott and Pucker discuss ideal candidates—most notably those with ocular rosacea but also many typical MGD patients—and how to discern their suitability based on Fitzpatrick skin type (https://www.msdmanuals.com/professional/multimedia/table/fitzpatrick-skin-type-classification). The trio also delves into cautions and contraindications in patients on doxycycline, those with active herpetic outbreaks, epilepsy patients, people with skin conditions like melasma and the hazards posed by eyeliner tattoos. A discussion on technique explains the three main protocols for IPL—Toyos (high fluence), Epstein (overlapping lower-fluence pulses) and Periman (full-face treatment)—and how choice of light filter can affect results. The conversation concludes with practical tips for patient education on IPL and how to establish a schedule for treatment (beginning with four sessions at a minimum) and long-term monitoring (ideally every three to six months thereafter). Dr. Lappin also gives advice for clinicians who are interested in adding IPL but apprehensive: gain confidence by thoroughly understanding it first, start with ocular rosacea patients and others likely to get great results, and don’t feel you have to sell the patient—educate, don’t attempt to “convince,” and let them decide for themselves. Relevant articles worth reading: Ocular Rosacea: How to Recognize and React (https://www.reviewofoptometry.com/article/ocular-rosacea-how-to-recognize-and-react) By Kaleb Abbott, OD, MS The Role of Intense Pulsed Light in OSD Management (https://www.reviewofoptometry.com/article/the-role-of-intense-pulsed-light-in-osd-management) By Harriette Canellos, OD, and Christina Canellos, OD When IPL Prevails (https://www.reviewofoptometry.com/article/when-ipl-prevails) Edited by Paul C. Ajamian, OD Tackle MGD with These Hands-on Interventions (https://www.reviewofoptometry.com/article/tackle-mgd-with-these-handson-interventions) By Mila Ioussifova, OD, and Hardeep Kataria, OD

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