Speaker 1 (00:00): Tarsus Pharmaceuticals Incorporated applies proven science and new technology to revolutionize treatment for patients across several therapeutic categories, starting with eye care. Their lead product, XDEMVY Lotilaner Ophthalmic Solution 0.25%, is FDA approved in the United States for the treatment of Demodex blepharitis. Learn more at tarsusrx.com.

Marc Bloomenstein (00:31): Hey everybody, welcome back to Collaborative Corner: The Podcast. Have you missed me? Well, here I am. You can go back and listen to old episodes. That's what I would suggest. As I've had a little time off, I've thought about practicing, seeing patients, and just realizing one of the things that I love about our profession is that things are constantly changing. And even though I don't know everything, I know that I have colleagues that do. And so that cooperative management, the idea of doing interventional care, interventional management, looking at new devices and treatments is always amazing. And so in this podcast, I had the opportunity to talk to Dr. Brooke Messer. And Brooke is a really, really brilliant young optometrist that works at Vance Thompson Vision up in West Fargo, North Dakota. She dropped some clinical pearls, tried to challenge her a little bit, and I think you'll enjoy the conversation. So, this is a podcast with me and Dr. Messer.

(1:34): Hey, Collaborative Corner. Here we are with Dr. Brooke Messer. Brooke, why don't you tell us a little bit about yourself and where you practice?

Brooke Messer (01:41): Hi everyone. I practice in West Fargo, North Dakota, at Vance Thompson Vision. I've been there for just over six years. Prior to that, I was in private practice for almost 10 years in a specialty contact lens clinic. And now I'm doing all sorts of things, collaborating with my ophthalmologists and having a great time doing it.

Marc Bloomenstein (02:00): That's awesome. So you've had quite a storied career though. I mean, going from a private practice, so you had to deal with the business and having to actually eat what you kill and seeing patients to now working with a really esteemed and just world renowned clinic. Vance Thompson's always on the cutting edge of everything. And so, for me, talking about interventional treatment, and that seems to me– I work in a cataract and refractive surgery center. It's all I've done my whole career. And it's always been the notion that people come to those centers because (A) they feel they're getting a more thorough exam, but (B) there's this impression that they're getting cutting edge. So tell me a little bit about– I know you do certain things over there and I want to tease it out of you, but just from an interventional standpoint, starting quite simple cataract surgery or things that you guys are doing over there at Vance Thompson, what's kind of exciting?

Brooke Messer (03:04): Yeah, so the reason I joined Vance Thompson and things that still excite me is the ability to continue to expand. You're never really set in the way that we do any one thing. With interventional glaucoma, for example, MIGS devices just continue to roll out and just when you think you get your algorithm with where you like each one, something new comes and makes a splash. And so I just really like being just ready to take on whatever's new all the time. And it's happening in keratoconus, it's happening in glaucoma, corneal transplants. I mean, you name it. And that's what I really like about being at Vance Thompson. And when we talk about the collaborative care, again, we're always looking to provide the latest in research too, which is super exciting being at Vance Thompson because we have an insight into what's coming down the pipeline whether it's for Fuchs dystrophy, keratoconus, glaucoma, refractive surgery, refractive cataract.

(03:59): It's just a great place to be when there's just always new things coming down the pipeline. And we're grateful at VTV that we often get an opportunity to use those things early so that we can share our experience with others.

Marc Bloomenstein (04:14): Okay. Well, you've got a couple of people that are listening. I never underestimate my audience. Give me just an overview real quick, snapshot, 20 seconds, fast. You tell me, first and foremost, if somebody's coming in and they're on one drop for glaucoma, what are you thinking right now you guys are going to be doing as far as MIGS? Or am I making this too simple?

Brooke Messer (04:41): Well, if they're on one drop and they have glaucoma, it depends on their age. I'm going to talk to them about–

Marc Bloomenstein (04:46): Oh no, I'm sorry. Cataracts. They have cataracts.

Brooke Messer (04:49): They have cataracts and glaucoma?

Marc Bloomenstein (04:50): Yes.

Brooke Messer (04:51): Okay. So if they're on cataracts and they have glaucoma, if they don't have much for field loss, so call it pre-perimetric or mild glaucoma, I think something like trabecular bypass stents are super easy, very low impact to the patient as far as downtime, recovery, risk of bleeding into the AC or anything like that. So again, the trabecular bypass stents are super easy to use. And I suppose– do I have to remain commercially neutral here? It's not a CE lecture?

Marc Bloomenstein (05:22): No, you can bring it.

Brooke Messer (05:24): iStents, those are super easy to use. I've also really liked using things like a goniotomy, like KDB. We enjoy using things like that too. Now, if somebody was on one drop and their pressure seemed okay, but they had field loss, so it was more of a low tension or normal tension glaucoma, then we would look at pairing something up maybe like stents plus an iDose so that they're getting a two-for-one type of procedure. We're going to do two interventional glaucoma methods within the same cataract surgery. So we'd be looking at adding ECP onto a MIGS to really, again, just try and do more while we're in there and maximize the impact that we can make in one procedure.

Marc Bloomenstein (06:10): Yeah. So along those same lines, this is going to sound crazy, you tell me Brooke. There is a company that actually is developing an intraocular lens, which is infused with a sustainable release bimatoprost. You guys might actually be doing this clinical study and I find that interesting. And yet at the same time, I feel that the quality of patients’ vision shouldn't be compromised for us to be able to just put some unique opportunity to manage their glaucoma because patients are just terribly non-compliant when it comes to doing these– or non-adherent. I hate the word “compliant”. They just don't adhere to it. Yeah, I thought that was kind of interesting and yet at the same time I'm a little sus about that. Are you guys doing the light adjustable lens in your practice?

Brooke Messer (07:03): We are. Yep. I enjoy the light adjustable lens. I haven't used the LAL+ very much because of the same thing. I just feel like the LAL, we can build in that EDOF type vision without worrying about some of the compromises in vision that can come with EDOF optics. And so typically my algorithm, and again, I'm not trying to change anybody's mind here, but my algorithm is I wouldn't use it in a perfect cornea because there are so many good options for a perfect cornea outside of maybe monovision where patients are really, they have a really particular lifestyle or they need things to be at a certain distance with their monovision, then LAL is great. But when it comes to trying to build in multifocality, well, in a perfect cornea, I'm going to use one of the many excellent multifocal implants that are now available to us.

(07:55): I like using LAL in irregular, post-LASIK weird eyes where I'm not going to do any laser enhancements or anything like that. And that's what, at least in West Fargo at Vance Thompson Vision, that's where it's really fit in for us. And we have lots of patients that have had LASIK before and their epithelium is really irregular where we wouldn't want to do PRK or a flap lift or anything like that. And so the LAL works great in those patients because we compensate for a residual refractive error very easily.

Marc Bloomenstein (08:24): It's interesting because– you're way too young, but it was 1993 when Calhoun Vision right outside Pasadena was working on this lens. And it took so long to bring it to market. And back in the day, I thought it sounded just ridiculous. You could do in vivo, change somebody's refraction, and it was just like, dang. But the one thing you commented on, there are so many great options. I feel like the nomograms are so great. We have such great opportunity to basically narrow down somebody's prescription, small incision procedures using the femtosecond laser to help with the capsulotomy or even to get into the cornea. I feel that patients are so spoiled right now that I feel like the LAL kind of benefits the most for patients where they're exactly what you said. An RK patient, somebody maybe who has some form of maybe corneal irregularity that you're just describing, I think it works really nice.

(09:30): I also heard– let me give you a little scuttlebutt. I also heard that they may be partnering with Alcon to do some sort of a presbyopic lens.

Brooke Messer (09:39): I’ve also heard that.

Marc Bloomenstein (09:41): Yes, and the chief marketing officer from Tarsus, Aziz (Mottiwala), is now going over to be the new CEO for RxSight.

Brooke Messer (9:54): I also heard that.

Marc Bloomenstein (09:56): Yeah. So I mean, I'm interested to see where that company goes because to me that's a perfect example of where optometry and ophthalmology are bridged because who's doing the light delivery device? Who's doing the adjustments in your practice?

Brooke Messer (10:13): Me.

Marc Bloomenstein (10:14): Yep. For those of you who are on audio, Brooke raised her hand. Yeah, same here.

Brooke Messer (10:19): I did.

Marc Bloomenstein (10:20): Yeah, no, same here. And so it's that perfect kind of collaboration between surgery and then optometry. And so it's kind of exciting just to do. Now I'm going to ask you to role play with me a little bit. Somebody comes in and if I'm working in my practice, the practice that I bought from you, it's a private practice, I've gotten rid of all the contacts, I've changed it. It's literally now we're spinning and grinning and when people ask for things that I can't do, I just go, "You're not a good candidate. Yeah, no, sorry, sorry. No color contacts for you”.

(10:55): Somebody has a cataract and maybe they do, maybe they don't have some mild amount of ocular hypertension or not even that. It's like, what is it you think about or how do you talk to patients about cataract surgery? What's your everyday discussion you have? “Oh, you've got cataracts,” go. Now I know most of these patients already know they do and they've been referred to you because of that, but you don't take that as gospel. I'm sure you talk to them like I talk to patients, like I'm the only person in the room, the only person that matters, and everything else that was said to them didn't matter. So go.

Brooke Messer (11:37): First, we'll start off by confirming the fact that they have cataracts. So I'll do a good exam, say some nice words about their lids and all of that, talk about the back of their eye and confirm that they have nice, healthy eyes and that they're a good candidate for cataract surgery. So I like to tell them that, "Hey, your eye looks really healthy. Your lens looks like a very typical cataract, so we're going to perform a nice and safe procedure." So, I like to emphasize that cataract surgery is very safe, very low risk of complication, and that nowadays with intracameral medications and less drops postoperatively with the combination meds that we use, we can make the whole experience very streamlined for the patient. And so I like to confirm and just let them know that, hey, you can expect a nice smooth process. And then we move into the IOL technologies where I'll talk about three aspects where we can get you out of glasses for almost everything, if not 90 plus percent of your day.

(12:37): We can sometimes use glasses or we can use glasses a lot. And then we kind of dive into those options from multifocal to maybe distance LAL, toric IOLs, down to standard monofocals where they would be using their glasses. And I'll ask them, do you ever take your glasses off to read? Do you hate when your glasses fog up when you're shoveling snow outside?

Marc Bloomenstein (12:59): Oh yeah, I hate that. I hate that.

Brooke Messer (13:02): Yeah. Do they slip down your nose when you're working in the garden? I talk about, "Hey, are there pain points in your life when you're using glasses?" And if they kind of nod into those things like, "Oh, I hate my glasses or they're heavy on my nose, my nose pads make my nose sore," or whatever it is, then we talk about moving into those glasses-free options and talk about the lifestyle benefits that those can bring. And we do a lot of pre-education too of our patients, so they get information in the mail and sometimes even a phone call to pre-educate them on some of those technologies. We also use a virtual reality headset called Insight VR, and it gives them kind of the vision indoors and outdoors of what it would look like if they had a multifocal implant with halos and all.

Marc Bloomenstein (13:49): Hold on, hold on. You're telling me that you have a headset, a VR headset that can demonstrate something like an extended depth of focus lens maybe or versus a multifocal or trifocal type lens? And just so you could say, do you think you'd be able to manage with that type of vision at nighttime? Would that be worth it for you? Interesting.

Brooke Messer (14:17): So, just a little humble brag. It was designed by my surgeon.

Marc Bloomenstein (14:21): Nice.

Brooke Messer (14:22): Yeah. So they took the bench data from the PanOptix lens and they worked with a company to recreate what the halos are like, looking at a light source, both indoors at a light above you in a dim room, and then also at oncoming headlights if you were driving at night. So then we show the patients, this is what the halo is supposed to look like based on the data from the lens. Is this something that would bother you? And interestingly, some patients of course are like, "Oh my goodness, I could never." And then there are other patients that are like, "I don't see what you're talking about."

Marc Bloomenstein (14:55): Yeah, that's awesome.

Brooke Messer (14:56): What are those halos? And it's really neat. And so a lot of our Vance Thompson Vision clinics have this set up. And so again, they're in the room, in your VR, you're sitting in your kitchen, you have a cookbook in hand and there's something on the fridge. So you can look up and see whatever is on the fridge. You can see the letters and detail on the fridge. You can look up and you can read your cookbook and then you can look up at the light and see the little halo versus having say a toric. So you can punch in how much astigmatism the patient is predicted to have postoperatively and you can say, okay, if you left your astigmatism uncorrected with a standard monofocal, here's what your distance vision would look like. If you corrected your astigmatism, here's what your vision would look like, both at distance and up close.

Brooke Messer (15:38): And it just helps them understand how does my binocularity, how does my depth perception change? How does my intermediate range change if I have these different technologies? And so our technicians walk them through that. So a lot of times, I'm spoiled, by the time I walk in the room, the patient's usually, I already have a note, the patient's leaning multifocal, the patient's leaning monofocal, and then I can come in and just further endorse their choice or educate them otherwise if they have the wrong interpretation of what their life would be like with their selected implant. And so by getting that information early to them, it definitely helps postoperatively, the handholding that comes along with some patients who weren't understanding what those halos would look like. And it makes cataract surgery, and especially when we're doing high volume multifocals, it makes it fun where many people cringe at the thought of a multifocal IOL.

Marc Bloomenstein (16:37): No, but I mean, honestly, we could just– It's so funny because I start these conversations thinking, oh my gosh, am I going to even have anything to say? What am I going to do? And I'm just like, dude, we can do this for hours because every time you mention another sentence, it's like I have questions and for my listener who's still on there, maybe they're thinking the same thing I am. One, so VR or the virtual reality, what if they're like a hand motion cataract? So if they can't see, they're not going to see, right? So, this is more– Okay, because I had a patient today who came from the VA and he literally was hand motion and I said, "Dude, how long have you had this cataract?" He goes, "Well, I went in about a year ago” and I'm like, “Dude, now you've had this cataract forever." And so, there are two things that are always reminding me to talk about cataracts, it’s that cataracts start from the minute you're born.

Marc Bloomenstein (17:28): And I think most of us as ODs, we wait until the patient has the cant’s—I can't function, I can't see street signs, I can't see the cookbooks—as opposed to talking to them about it sooner because it progresses and just letting them know where they are in this cataract journey. But you also brought up another really, really amazing point, which is utilizing your staff to help you. It's like when you talk about dry eye treatment, when you talk about patients who have worries or concerns or they're asking about specific technologies, I embolden my staff to basically take the reins because we're a team. And so, listening to you say that I think a really successful clinician is somebody who trusts their technicians and their staff to basically be onboard, and that's amazing.



Brooke Messer (18:23): Our team is excellent.

Marc Bloomenstein (18:24): Kudos. Hey, let's take a break. We’ve got to pay the bills, keep the lights on, and after we hear from our sponsor, we'll be right back. Speaker 1 (18:34): Tarsus Pharmaceuticals Incorporated applies proven science and new technology to revolutionize treatment for patients across several therapeutic categories, starting with eye care. Their lead product, XDEMVY Lotilaner Ophthalmic Solution, 0.25%, is FDA approved in the United States for the treatment of Demodex blepharitis. Learn more at tarsusrx.com.

Marc Bloomenstein (18:59): And we're back. All right. While I still have you, Brooke, I know that a lot of your career is interventional kind of contact lens care, and you may or may not have heard when I said patients, when they ask about colored contacts, I said you can't have them because I don't know how to do contacts. I'm still UV4 out the door, Ciba Visitint 8.6, which means nothing to you because you're so young. But for those listeners that remember popping the little vials and dropping it into a patient's eye, having to clean it and stick it back in that vial, we are nasty. Janet Jackson, you're nasty. That's the context we are using, but you use a specific device. What does the ANTERION do?

Brooke Messer (19:44): So, the ANTERION is from Heidelberg and it's an anterior segment OCT, so it's a wide view OCT. And so I like to do it where I get a bunch of cuts all the way around so I can see edge to edge of the lens. And there are a few other anterior segment OCTs that get those nice, like the Solix I think can do it as well, where you can see the scleral lens vaulting over the cornea. You don't have to segment in order to see the edge and limbus, the center. I can just get everything in one cut. And before the break, we were talking about how our staff is so valuable to us, and the ANTERION is a device that our team really enjoys too. It's really fast, it's easy to use, very user friendly, and it's also easy for the patient to perform well during this test.

Brooke Messer (20:32): And so, whenever I call up orders for somebody to grab an ANTERION image of somebody wearing a scleral, we have multiple hands go up because they're trying to avoid the visual field. And the ANTERION is a great device to use in scleral fitting. And we use it for monitoring endothelial keratoplasties, like is the DMEK attached and is the cornea edematous, those types of things. So we use it medically as well, but I've really adopted it in my scleral fitting.

Marc Bloomenstein (21:00): Can you use it for the angle or looking for an EVO lens to see how well that's sitting?

Brooke Messer (21:05): Absolutely. You can do all that. Yep. So we use it for anterior chamber depth and checking out, like you said, where the lens is at and everything. Yep.

Marc Bloomenstein (21:13): Yeah, that's incredible. So, it's interesting because right now I think with Glaukos coming with their Epioxa, right? Epioxa? Epioxa, which is their epi-on. And then there's another company, I believe it's in clinical trials right now. They just finished for epi-on, and the name of the company is Epion. Epion. Yeah. We're seeing a lot more cross-linking for keratoconus. And I think that just draws to light the fact that, again, interventional treatment with this disease, optometry plays such a vital role. So if you could maybe just talk a little bit about some of the surgical treatments, but then some of the, for you, the lens treatments or how do you see this? I mean, to me, when I think of cross-linking, I don't just think of keratoconus. I think of pellucid. I think of irregular RK incisions. I think of just there are lots of other opportunities with cross-linking.

(22:14): Also, myopia control, they've talked about using it in that as well as talking about it for ulcers. And maybe I'm wondering if we can even probably use it in NK patients. I don't know, I'm just going off on tangents here. So talk to me a little bit about interventional care with keratoconic type patients.

Brooke Messer (22:34): Yeah. So, my view has– it's always been trying to do what's best for the patient. And after we finally had cross-linking available to us in the US, it shifted from getting them into the best contact lens, providing the best vision, to cross-linking them early, getting them in a contact lens early so that they can just kind of wipe the KC concerns off their plate. I think the awareness is really growing around how keratoconus quality of life scores really drop. I think they say that they're similar to patients who have grade 3 or even grade 4 macular degeneration. And so by getting these patients treated early, again, it improves their quality of life and then we shift them into a contact lens. Basically, when we confirm that somebody has keratoconus, we're going to cross-link them as soon as we can. So as soon as we can prove that "Hey, insurance, you need to pay for this," whether it's proving progression or getting that prior authorization or whatever it is, we're going to cross-link them as soon as we can rather than moving them into a contact lens first and waiting for them to change.

(23:39): So, we're going to cross-link. We're not going to let them prove to us that they're going to lose vision. We're going to treat them first. Then we shift them into a vision correction option.

Marc Bloomenstein (23:49): So, I'm going to challenge you on that. Why? Because I can. So, now I'm going to put you back to Brooke Messer who had her private practice. I feel like the hoops that we have to go through to get patients who have keratoconus to get coverage by their insurance– Is anything at VTV? Are you guys doing anything special? Because part of my frustration with keratoconus right now is that you have to show that it's like you have to be worse. It's almost kind of like you can't stop from getting worse. You have to show that you are worse, and then you play that game with the insurance companies. Do you find that in your practice too? Do you find that it's like as much as you want to keep doing this, it's harder to get these patients covered?

Brooke Messer (24:39): It can be, yes. So we have to play the games too. We have to try and do what we can to get them covered. We get them back as soon as we can to prove progression. We take, I would say we have multiple devices, three or four topographers. We have two tomographers. We have the anterior segment OCT. So we're throwing these patients in every device to see if we can find a way for those Ks to change based on referring notes. Just like other practices, I'm sure they do the same where they go back as far as they can to get old notes, prove those refractions and refract to the best that you can to see if they'll accept more astigmatism, all the things. I'm sure you do the same tricks. So yes, I don't know that there's a secret sauce. We just work really hard to find every ounce of information we can to get covered.

Marc Bloomenstein (25:25): But you bring up a point, and I think I was trying to make this point, is that if I was seeing kids, if I was seeing anybody who I suspected had keratoconus, then in my practice, I would just absolutely encourage you to start keeping meticulous notes, doing topography, doing refractions, seeing if there's a diopter, seeing if there's any difference, any even minor changes. Because then when they get into a Vance Thompson Vision Center or they get to a place, they now have the ability to say, look, let's pull the trigger right now. It's interesting because back in the day before LAL, this is so funny that we're talking about this, is that we used to tell our LASIK patients, you need to keep a card with your preoperative Ks and your preoperative refraction so that when we do need to get that measurement for your lens, we have all this preexisting information and we don't need that as much as we used to.

(26:22): So what kind of interventional lenses and things are you looking at?

Brooke Messer (26:26): For KC patients?

Marc Bloomenstein (26:28): Yeah, KC, for regular corneas, ectasia.

Brooke Messer (26:32): What I'm really loving is scleral lenses with HOA correction. So, we get the lens to fit really nicely and then we measure them with aberrometer. That aberrometer can then connect with the laboratory that you're using to create, they call it a patch. The patch then goes on the lens and its HOA correction so that we can correct coma, sphere aberrations, those types of things to take vision one step further, consistently one to two lines of visual improvement with the aberrometry correction. So that is probably my favorite thing right now because it goes from 20/20 with smears or glares down to really crisp 20/20 or 20/40 down to 20/20. It's really incredible working with this technology and it's really fun. I do enjoy the challenge of glaucoma, shifting from private practice to a place where we do lots of glaucoma surgery. But when you're working with specialty lenses, (1) you still see a lot of disease and (2), the ability to really elevate the patient experience, there's nothing like it.

Marc Bloomenstein (27:37): Yeah, a hundred percent. So I had a patient today, and I know this is, maybe it's just a reminder to people that actually still see patients. So I keep saying, oh, I had a patient today. But she came in because her dad was frustrated because she's 17 and she couldn't see out of her left eye. She'd been to a couple of the national chains who basically said there's nothing we can do. And he was really lamenting the fact that he's a single dad. He didn't get her in that often. They're telling her there's nothing you can do. And so to your point, we did an iDESIGN, we did an Orbscan, a Pentacam. We looked at it and her refraction on her left eye was a –24.50 with three diopters of cylinder. And in her other eye, she was like a –7.00.

Marc Bloomenstein (28:27): So, she'd been wearing a –7.00, seeing okay. And he just said, look, is there anything you guys can do? And I said, well, hang on one second. So, I got some loose lenses and I put up –24.00 and she was hand motion. I mean, sorry, she was counting fingers. So she's like, I can see something. It's clear. And the dad started to cry. And it was just the fact of knowing that there's something that can maybe make it a little better. So the gratification that patients have when they know, and I think especially parents, parents who feel they've done this to their kids, whether it be myopia control and I don't know, I'm just rambling. I just wanted somebody to say to me, "You're such a good doctor, Marc. You are so amazing to me.”

Brooke Messer (29:16): I just tell myself that when patients, they see through their scleral lens and they're like, "Yeah, my vision's pretty good." And I was like, "I know."

Marc Bloomenstein (29:23): Hey, girl. Have you ever used Christine Sindt’s lens? Have you ever used the–

Brooke Messer (29:30): The EyePrint? Yes.

Marc Bloomenstein (29:31): The EyePrint, yeah.

Brooke Messer (29:32): Yep.

Marc Bloomenstein (29:33): I mean, that to me in itself, that's something I would just want to do. I wouldn't know how to do it. And can you describe that real quickly for those that are listening?

Brooke Messer (29:42): Yep. So, the EyePrint is a molded lens. So, we call it a little martini glass. It's about the size of the front of your eye or the eye socket. So, we fill it with this, we call it the blue goo, it's the mold, and we fill it in the martini glass. We pop it on the eye behind of course, and then we let it sit there similar to how you would do a dental mold if you were going to the dentist. We send the molds to the lab and then they analyze the shape of that mold to create a scleral lens. So, in my practice, I would say across the board, fitters who use the EyePrintPRO, we're prescribing it for patients who have blebs or lots of scleral irregularity. If they have a patch on the sclera, blebs is a very common one or just other very atypical cornea shapes where we need just tons of coverage to create that.

(30:35): So, the lenses you get from EyePrint tend to look really wacky when you spin it on the contact lens tool. They're very asymmetric, and so that's when EyePrint really shines. However, in my practice, because we are in Fargo, we pull patients from all over the state of North Dakota. So, Williston is six or seven hours from me. And sometimes we have patients that come from there. And so, occasionally we'll do an EyePrint just to really save ourselves the time on the fitting process because we'll mold them, we'll send it off, we'll come back, maybe we do a power adjustment and then we're done versus the diagnostic fitting where there's a little bit of the artsy-fartsy part of sclerals where you adjust a vault where the EyePrint, typically that chamber over the cornea is darn near perfect and the landing looks really nice too. And so sometimes a power adjustment, but it does save time for patients who commute to you from quite a ways.

Marc Bloomenstein (31:31): That's awesome. You're incredible. I mean, the beautiful thing that I love about our profession is how it's so diversified and there's so much opportunity for us to just help each other, help our patients because we're all kind of going that way. And even in the recesses of up there ay, North Dakota, it's just wow.

Brooke Messer (31:57): Oh yeah.

Marc Bloomenstein (31:58): Oh yeah. Brooke, is there anything on the top of your mind that you think is exciting that you want my one listener to hear about or is just the fact that it's like I feel that we just have to just keep educating ourselves and just if you don't have something today, and this is what I've learned in my three decades of practicing is that I always tell patients, look, there's so much stuff coming on the horizon. I'm going to see you back in six months or I'm going to bring you back in a year. We may have something different that we can talk about, but I always let patients know that there's always something we can do until we can't do anything.

Brooke Messer (32:38): Yeah. And I think a good way to wrap around that is just to always keep your mind open to new technology also. Just because multifocal implants 20 years ago were not good, they are good now. And it goes the same with other technologies where we had an FDA clinical trial in the practice where we were stripping the endothelium for Fuchs patients and using an eyedrop to try and make their endothelium grow and migrate and all of that. And of course we were like, no way, this patient's going to need a rescue DMEK. But guess what? At three months, we had patients seeing 20/16 using an eye drop in clinical study. And so again, just the people that put the work into the developments that we have access to, it is really incredible. And so again, just keep an open mind as these technologies roll out.

(33:30): Certainly there are some bumps along the road for some, but many of these technologies are really, really fun to work with and certainly improve quality of life for our patients that need it.

Marc Bloomenstein (33:42): Awesome. Brooke, you've been fantastic and thank you so much for taking your time. And more importantly, thank everybody out there in our Collaborative Corner Podcast listening group. I hear you. I see you. I smell you sometimes. Appreciate you. Brooke, thanks so much.

Brooke Messer (34:01): Thank you.