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

Simplifying the Diagnosis of Dry Eye Disease

TFOS DEWS III Refines Key Diagnostic Protocols, Emphasizes Importance of Subtyping

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.

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:

1. Test corneal sensitivity. It’s simple, quick and doesn’t disrupt clinic flow.
2. Think beyond HSV—Consider neurotrophic keratitis in any patient with corneal epitheliopathy and relevant risk factors.
3. Don’t dismiss asymmetric staining. It may signal an underlying neurotrophic component.
4. 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

Hurt Feelings

Nerve Growth Factor Treatment May Initiate Corneal Recovery in Neurotrophic Keratitis

Corneal Complications of Diabetes: What ODs Need to Know