Speaker 1 (00:00): Support for this podcast comes from Bryn Mawr Communications. BMC produces a number of informative podcast series spanning a variety of topics in ophthalmology. Discover a new show at eyetube.net/podcasts.

Marc Bloomenstein (00:23): Hey everybody. Welcome to another edition of Collaborative Corner: The Podcast. In this podcast, I had the opportunity to have a conversation with Rachael Wruble. If you don't know Rachael, she's out of North Carolina. She has a private practice out there called Belmont Eye. She's opening up another one. She had another one. She has five of them. She has three kids. Honestly, I couldn't keep up with her. But I loved talking to her about being in a private practice setting, especially in 2026, what that looks like, how she manages those patients, and more importantly, what kind of sets her aside. So, sit back and enjoy the conversation with Dr. Rachael Wruble.

(1:13): Hi, Rachael. How are you doing?

Rachael Wruble (1:14): Hey, Marc. I'm good. How are you doing?

Marc Bloomenstein (1:15): I'm alright. I'm excited to have you on the last of our podcasts for the 2026 year we're rolling in. Can you believe that the year's almost over?

Rachael Wruble (01:25): No, I don't even like to think about that. It goes too fast.

Marc Bloomenstein (01:30): But the crazy thing is as fast as it goes, it feels shorter and faster. I don't know, time is just, it's a flat circle. It's insane.

Rachael Wruble (01:41): But it's another year older, but wiser for us.

Marc Bloomenstein (01:45): I mean, I'm always excited about... at the end of the year, I used to do a wrap-up of exciting new things that I brought into the practice or things that I'm excited about. So, you have a private practice that you have in, is it in Belmont? Is that why it's called Belmont?

Rachael Wruble (02:03): It is, yes. In downtown Belmont, North Carolina.

Marc Bloomenstein (02:06): So where is that in relation to Charlotte?

Rachael Wruble (02:09): Right outside of Charlotte. We're eight minutes from the airport and 15 minutes to uptown Charlotte.

Marc Bloomenstein (02:16): Okay. And then you had told me that you're opening up another one cold.

Rachael Wruble (02:21): We are, yes. A couple months here, it'll open up the doors and it’s always an exciting process.

Marc Bloomenstein (02:28): So, when you're establishing or opening up a new practice, do you try to do something different in the practice to make it nouveau, to make it kind of bespoke? Or is it just what the Belmont name kind of carries with it? What makes your practice different?

Rachael Wruble (02:47): Our practice is kind of like the mom-and-pop practice, going back old school where you've got hometown optometrists that live near the practice and they're a huge part of the community. And it's not just general optometry, but maybe multiple specialties within it, depending on... We have five optometrists in our current practice and kind of going to build that same model in another town, but be a part of their main street and their community and their chamber of commerce and really immerse the self in the community.

Marc Bloomenstein (03:16): That's interesting because you see so many practices now going to venture capitalists.

Rachael Wruble (03:21): Correct.

Marc Bloomenstein (03:21): They're getting kind of absorbed. In fact, a colleague of mine who I've known for 30 years, he actually, incidentally, he has an identical twin brother who's a judge in Arizona. And one day I remember seeing him and I'm like, “Steve”, and the guy looked at me and just kind of shrugged me off. And then when I saw Steve, I go, "Dude, I saw you at the mall." He goes, "Well, that was my twin brother." I'm like, "Oh, that's my twin brother." Turns out he has an identical twin brother.

Rachael Wruble (03:48): Oh goodness.

Marc Bloomenstein (03:49): Yeah, completely tangential. Look him up. I'm not going to tell you his last name, but it's Cohen. Anyways, so his practice was always this really just kind of unique private practice. People loved him. He would drive to people's houses and bring them to the practice if they couldn't make it. He made house calls. It was nauseating what a sweet person he was, which made me realize I could never have a private practice because I don't really like people enough, especially patients. But he sold to a smaller venture capitalist who just got bought by a bigger venture capitalist, and they're miserable because they can't give that unique kind of service that they were able to give. I admire what you're doing. I mean, is it hard or does it feel easier?

Rachael Wruble (04:40): I actually know Steve Cohen and his model of practice, and that's exactly the type I love to have. I was in a private practice many years ago that sold to private equity and I learned that's not the route I wanted to be in or the type of practice. This to me is just, it's more taking care of patients. We have the model, you take care of patients, they'll take care of you. The number of patients that text me on weekends because they all have my cell phone number is an abundance, but it's okay because I know they need the help, I'm here and they're going to tell their neighbor, their friends, and we're going to be their hometown family optometrist just like their parents had and grandparents had back in the day. My husband and I are from very small farm towns, and we just want to be a part of a community and take care of it.

Marc Bloomenstein (05:31): Did you guys meet in optometry school?

Rachael Wruble (05:33): The very first day.

Marc Bloomenstein (05:35): My favorite thing about optometrists is that about 20% or 30% of them marry optometrists. It's kind of like, "Come on people, get out of your bubble." Actually, my son is in his fourth year of optometry school and he didn't meet anybody, so now I'm starting to think there's something wrong with him.

Rachael Wruble (05:50): Oh no. We are the only ones in our class that ended up married and that was what, 21 years ago. So, I mean, it's fun. It's cool.

Marc Bloomenstein (06:00): So, what kind of new things are you bringing into the practice? Do you try to bring in new technology? Are you doing digital phoropters? Is the flow of your practice different from the perspective of maybe you have topography or tomography? Walk me through some of the things that make your practice unique besides the fact that it is that kind of, "Hey Jimmy, how are you? Hey, saw you over at the diner."

Rachael Wruble (06:30): I think what's unique about our practice is we have three full-time doctors every single day, maybe sometimes four depending on... The clinic gets a little busy when we've got four doctors, but we have one doctor who's pediatric, so she's got kids going in and out of her rooms all day long. We have myself who's more been around a while. I see ocular disease, dry eye, so my patient population is a little bit older. And we have all these different pretest rooms where I've got radio frequency and IPL going. I've got topography, tomography, meibography and another room going. And then you've got a room, all of our glaucoma, macular degeneration. We've got a doctor that really heavily specializes in that. So, it's just unique because you see in the waiting room, it's an array of patients from zero to 100 and you can kind of walk out going, "I know which doctor you're seeing based on age." But we like to be very high tech.

(07:31): We had someone today new to the practice and was like, "I do not do the air puff tests." And my tech's like, "We've never had that here." She's like, "They like advanced technology here." I'm like, "Air puff? Oh my gosh. I don't even think I've been in your practice."

Marc Bloomenstein (07:45): Wow. Okay. Hold on though. I'm going to push back on that, Rachael. The ORA, the Reichert, has a phenomenal... it measures hysteresis. So, the Ocular Response Analyzer actually does do a modulated form of air puff, but I hear you, sister.

Rachael Wruble (08:04): Yeah, no, I'm talking the old school ones that have been around forever that'll puff your eyebrow and get a reading.

Marc Bloomenstein (08:09): Yeah, that's awesome. That is so cool. I mean, I love the fact that it's like you call up, you get specialized, a little bit different. So, what's your passion, your practice for you personally?

Rachael Wruble (08:20): For me personally, it's dry eye and specialty contact lenses. I've been practicing 17 years in this county, so I do have a lot of glaucoma macular degen, but dry eye is I think more my heavy diagnosis on a daily basis.

Marc Bloomenstein (08:38): Is there one dry eye treatment or one dry eye modality that you go to more than not? And on top of that, do you feel like when you're talking to patients about doing a procedure, and I always kind of feel like ODs have a hard time, I don't want to use the word selling, but just encouraging, insisting that patients move to a level where they're going to have to pay for something to be done. Obviously, you're successful, so is there something that you do that you think helps to get patients comfortable with I'm writing you a prescription or now we need to take, you mentioned IPL and radiofrequency, I feel we have to do that procedure. Is there anything that you feel has made it more successful for you?

Rachael Wruble (09:30): I think building trust with the patients is so important because if they're brand new to me and I'm giving them a list and we have everything really well documented, I go through the check boxes, highlight the things for their dry eye treatment because no one patient's going to have the same treatment. They're all different and really helping them build the trust in me with my knowledge that I'm providing them the best options. And they may go home and think about it. They may come back and go, "I want to do X, Y, and Z. I started X. It's not working as well. It's been four weeks. Let's do Y, let's do Z." I tell my associate doctors the same thing because they don't want to sell a treatment. I said, "You're not selling. You're prescribing a treatment that you recommend that you believe in that will help that patient. And by the patient trusting in you, they'll do it and they'll see that it works and they'll keep coming back and they'll tell others."

Marc Bloomenstein (10:26): Yeah, I love that. I mean, I think the biggest challenge with dry eye is the fact that there's no real clear definition of what the disease is because it's so different for every person. I feel that we as clinicians, I've been practicing for 30 years and it's still, we want to just say, "Here, do this and it'll make it better or try this and all your symptoms will go away” and it's never the case.

Rachael Wruble (10:50): It's never the case. And you can try them on four different drops and none of them work, but that fifth drop, they're going, "Oh my gosh, this is the best." And you're going, "All right, that's great." And you just go, "One thing does not work for everyone."

Marc Bloomenstein (11:05): I also think setting our expectations.

Rachael Wruble (11:08): Oh, bingo. Yeah.

Marc Bloomenstein (11:09): It's literally, we are especially... It's almost kind of funny. It's like if you think about every disease that we manage, we're not curing anything. I mean, we don't cure glaucoma. We're managing their nerve so it doesn't just die out. We don't cure dry eye, we're managing it. We don't cure myopia. We just provide them an opportunity to get past all this, and especially we don't cure keratoconus or pellucid. I feel especially if you can convey that to patients that, look, this is how we're going to manage it and you have the confidence like you just described, Rachel, then I feel that that confidence is reflected back by your patients.

Rachael Wruble (11:52): I think you're spot on, and what you said was very key.

Marc Bloomenstein (11:56): Ok I’m going to stop right there. Thanks everybody. Thanks for coming. We're just going to stop right there because Rachael said, "I am spot on." So no, go ahead, Rachael. I'm sorry.

Rachael Wruble (12:04): Spot on.

Marc Bloomenstein (12:04): I’ve got to take the wins. I got to take the wins, man.

Rachael Wruble (12:06): You are. It is. You're spot on. Patient expectations. If we don't set them up, they're going to go, "That doctor doesn't know what they're talking about. It didn't work for me." I always tell patients, "Whatever treatment it is, it's not a cure. You have a chronic condition. This will be the rest of your life. We're going to find the most simple way to maintain it successfully to give you the best relief." And you've got to tell the patients that. They've got to know there's no cure because that's what they're looking for and that's what they're Googling and doctor hopping for. And I think that expectations, again, building that trust that they go, "Okay, they really do care about me."

Marc Bloomenstein (12:43): So, you're in a private practice setting, how do you manage the PAs? Because I hear from all my colleagues that it's like, "Well, I mean, have you tried to get that new drug approved? How long is it to get a PA?" I work in a cataract refractive surgery center. It sounds like there's just... We have a very small staff. I mean, there's one or two of my technicians that do the PAs for me, but that doesn't hold me back from prescribing what I think is going to be in the patient's best interest. But I hear all the time, "Well, you're in a big practice. In a small practice like ours, it's too much work. How does your practice handle that?"

Rachael Wruble (13:24): You're exactly right. Prior auths, I mean, our inbox can be 10, 15, 20 a day. And we had someone; we had a technician that was doing them. And then as we kept growing, as we have more prescriptions, as we see more PAs for medications we've been prescribing for many years that never needed PAs, we still have a technician that assists, but we actually have all the doctors assist as well. The questions are getting more complex with some of the medications, and we just want to make sure they're answered correctly. So, the doctors do get tasked and they kind of go through in between patients and fill out their own PAs. Anything that's denied, we have technicians that help and work on that. Three of my technician assistants in the office all came from pharmacies. I always like to hire employees that have come from pharmacies.

(14:15): They've got this background of medical knowledge, coding, billing, and medication, and they're really helpful. They're used to fast-paced. They're used to dealing with patients and insurance, and I've got three right now that are just incredible at helping with PAs.

Marc Bloomenstein (14:31): I love that. Let me ask you another question. In a private practice setting like yours, mom-and-pop, shingle on the side, which we don't see anymore, you're working for the... You’ve got to get those Google reviews. People have got to be like, "I love that place." What do you do before surgery? Do you have any form of, and I mean like cataract surgery, refractive surgery, do you try to optimize the ocular surface? Is there a protocol you have? Walk me through that. Or do you just say, "Well, bye y'all."

Rachael Wruble (15:00): Oh no, because if we don't, the surgeon is going to do that and they're going to think that we weren't doing our job. Why didn't you do that prior to me going for my consult? So, most of my patients I'm referring are already on dry eye treatment plans, but all of us doctors in the office, we do have protocol going, "Hey, they may not have any dryness, but you know what? Let's start them on preservative-free tears or if they have any complaints doing the score study, let's get them started on a drop because if we don't, the surgeon's going to. We might as well start it, be more successful, more efficient through the process of surgery."

Marc Bloomenstein (15:38): Yeah. I just think if enough of us started using, even starting them on immunomodulators like cyclosporine or lifitegrast prior to surgery, talking to them and absolutely looking for collarettes, having them just look down, starting them on treatment for Demodex to kind of reduce that bacterial load, it's almost just kind of saying, "Look, I care about you." And speaking of Steve Cohen, and this is a little PSA that I learned from him, Steve would find out when his patients were having surgery and he would call his personal patients the night of their surgery to see how they're doing. And I would come in and I'd see these patients the day after and they say, "Well, I spoke to Dr. Cohen last night." I go, "Excuse me?" And they're like, "Well, he called to see how I'm doing." I don't know, you can't see it, but I'm getting goosebumps just thinking about that because I think that's so personal and so special and I took that from him.

(16:33): I personally wouldn't call them, but I just love the idea that he does that.

Rachael Wruble (16:36): Oh, it's optometrists like that that go, "Oh my gosh, they exist. They are out there." That's a lot of time outside of his practice. I love that about him and always look into how do you make it a better experience for patients?

Marc Bloomenstein (16:51): Well, it sounds like you’ve got that going. Hey, I want to ask you about how you manage keratoconus in your practice, but before we do that, we’ve got to take a quick break, allow some of our sponsors to come in and talk to the three or four listeners that we have right now. So, hang tight for a sec.

Speaker 1 (17:08): Support for this podcast comes from Bryn Mawr Communications. BMC produces a number of informative podcast series spanning a variety of topics in ophthalmology. Discover a new show at eyetube.net/podcasts.

Marc Bloomenstein (17:25): Rachael, talk to me about keratoconus. I think there's a little bit of a personal reason why you manage those specialty contacts like you do, and I think I'd love to hear it.

Rachael Wruble (17:35): My dad was diagnosed with keratoconus when he was 21 years old at the University of Michigan. They didn't understand why his vision was not good for a couple years, and he was finally diagnosed. Come to find out, two of his three sisters were also diagnosed. One ended up having corneal transplants in each eye. So, with all of that, watching my dad for many years wear these small RGPs, rubbing his eyes, his eyes always being red, but that's all he could wear. I never understood it till I was in optometry school and I'm like, "Keratoconus?" We started learning about it and I wanted to know everything about it. I was like, "Why are his eyes always red? Why does he have to wear these special contacts? What are other options for him?" And then I wanted to be the one to fit him in any option we had.

(18:27): So, in optometry school, we ended up piggybacking just for more comfort. And so, he piggybacked for a long time and fit him in sclerals, but he's a creature of habit, engineer. We went back to the piggyback way until he finally had cataract surgery.

Marc Bloomenstein (18:46): What did that do? Reduce a lot of his spherical load or astigmatism?

Rachael Wruble (18:50): Spherical load for him. He of course is still in RGPs, but his vision, he's just like, it's the best vision he's ever had now, and he has decreased glare and halos.

Marc Bloomenstein (19:05): I mean, I feel 21 is kind of late to be diagnosed with keratoconus. That's a lot of people getting those scissoring Ks, and I had to do manual Ks this weekend.

Rachael Wruble (19:18): It’s been a while. It’s been a while since I've done this. I've done it.

Marc Bloomenstein (19:20): I'm spinning the dial. I'm doing it. I think I went and Googled it. I think Mile Brucic had a video or something. I don't know. I'm just like, "Oh, I’ve got this. I’ve got this." But it always reminds me how we always talk about mires are clear and regular. That should have been earlier, right? I mean, shouldn't diagnosis of this disease happen younger than 21?

Rachael Wruble (19:41): Oh, absolutely. And he probably was undiagnosed for many years just because it wasn't heavily known. He was going to a smaller clinic in the Detroit area, and that's when his parents took him to University of Michigan and that's where he was diagnosed. And then just a year or two after, two of his sisters were also diagnosed. So yeah, he probably should have been diagnosed earlier. Would that have changed the treatment plan? At that time, probably not. We're lucky we have more options nowadays.

Marc Bloomenstein (20:14): So, what kind of things are you guys doing in your practice? What are we doing in Belmont? Are you looking for things? I know there's a device that is potentially coming out that basically is like red light, green light, yellow light that basically talks about irregularity in the cornea for keratoconus. I mean, I think we've gone many, many decades without having something of that nature. I think topography or tomography kind of gives us a better Pentacam on these patients, but what kind of things are you doing to diagnose it and then what kind of newer things are you looking for for treatment?

Rachael Wruble (20:54): So, when the patients come into the clinic, especially we've got a lot of new young patients. First thing we're looking, the technician is doing an auto refraction. She's trained if they have two diopters of SIL or more as a new patient, she does an automatic topography on them. We have a Pentacam and she's doing that prior to them even seeing the doctor, just so we have a baseline. You've got two diopters of SIL, you're under 25 years old, let's just get that done. From there, the doctor is talking to them about the SIL, getting previous records if they've been somewhere else, talking about family history, and maybe there're patients out there we find that are like, "Oh, grandpa couldn't see since he was 20, but we never knew why." And really talking to patients, trying to get a meaningful history to determine could this potentially be keratoconus there?

(21:45): I think education with parents and patients is key, not to scare or intimidate teenagers, young 20-year-olds that are diagnosed and really setting up expectations with options they have. And nowadays, of course we talk about specialty contact lenses with sclerals, hybrids, and then really watching the progression, watching them in six months, in a year, two years, is it progressing? Are they a candidate for cross-linking? So, kind of setting the stage early on with education and watching there closely for steepening, irregularity, the astigmatism in patient symptoms.

Marc Bloomenstein (22:28): When do you consider referring a patient for cross-linking?

Rachael Wruble (22:32): When we're seeing a diopter increase in the steepest K, maybe a diopter change of astigmatism, even a myopic shift in patients, we're going to use those as markers to say, "Hey, we see this progression from last year to this year. Let's send you for a consult," and really educate them. We have found over the years, we've seen patients post-corneal cross-linking going, "Why do I still need contacts?" And we found that's a big education… educating them that we're doing this to stabilize the vision, not to correct it. It's not LASIK surgery. I think there's a common misconception of that, that we're going to stabilize that cornea, but you still will need correction for vision rehabilitation of some kind.

Marc Bloomenstein (23:18): Again, it goes back to setting that expectation. It's like this isn't meant to make you see better. It's meant to make it so you don't see worse. I love seeing older patients after they've had procedures done and I'm like, "Look, everything's exactly the same. It's like when we get to be our age, we want things to be the same." And they're like, "Oh, you're not that old." And I'm like, "Yeah, you're right. You're old." But I mean…

Rachael Wruble (23:41): Stable is good. I always say stable is good.

Marc Bloomenstein (23:45): But we mentioned cross-linking and I have a love hate right now. I love the fact that Glaukos went through their phase III clinical trials with the Epioxa, which it's the transepithelial, so EpiOn type procedure. And we were part of a clinical trial about 15 years ago for EpiOn, and it's just such a dramatic patient experience to be able to go through. It's literally the difference between having LASIK, not even, just almost like having a light adjustable lens and having PRK. Patients are miserable. It's a long healing process, but I'm finding that a lot of surgeons across the country are not engaged in it because the fact that Glaukos has now an FDA... What's the term I'm looking for? It's a rare disease. Glaucoma has now been diagnosed as a rare disease, so they can bill at a level that is just not commensurate with a cash pay patient.

(24:48): Yeah, that was more editorial. I mean, there was a question in there, Rachael. I don't know what it was, but if you want…

Rachael Wruble (24:53): Well, what we find with cross-linking interesting, you were saying with cross-linking, it's become harder. We have two major surgeons at two major clinics in Charlotte that have stopped doing cross-linking, and they didn't directly say this, but we have heard due to insurance reimbursements and the process that right now it's on hold. And so, we had to go on a hunt of who's doing cross-linking now for us since these are two main surgeons. So, we know that there are changes being made and it's interesting what will happen in the future with it. Is it going to continue? Got to love insurance.

Marc Bloomenstein (25:31): There's another company that actually has gone through the process of the FDA and it's called “Epion”, E-P-I-O-N.

Rachael Wruble (25:38): Yeah, I read about that.

Marc Bloomenstein (25:39): Yeah, so we'll see. I mean, because I think it's a viable option for patients. I really truly believe that it has a benefit to patients, and I've seen it through the decades, and I think it's important for us to have that in your arsenal, especially after doing all the work you do with your specialty contacts. Did you design your own frame line? Did I read that?

Rachael Wruble (26:01): I did.

Marc Bloomenstein (26:02): Okay.

Rachael Wruble (26:02): I did. Yeah, it was fun. It was a couple years ago. I met a guy when I was at SILMO over in Paris, and he had a company, fun, cool trip to go look for different unique frames to bring back that no one has in the US. And he was designing frames and asked if I wanted to be a part of it. So, it's been a very cool experience. Patients, being in a small community and kind of with a unique last name, no one in the state has the last name Wruble. We call them Wruble Eyewear, and we have patients in the community who come up to us and be like, "I'm wearing Wrubles."

Marc Bloomenstein (26:41): That is awesome.

Rachael Wruble (26:41): That's awesome. Yeah.

Marc Bloomenstein (26:42): Is it “Ruble” with an “R” or “Wruble” with a “W-R”?

Rachael Wruble (26:45): W-R.

Marc Bloomenstein (26:46): How many people go Rrr-uble? I mean...

Rachael Wruble (26:49): We hear Rubble, like Barney Rubble all the time, Rublé. It's like Russian money though, a ruble.

Marc Bloomenstein (26:57): That is true. That is so true. Why do they call you Dr. “I got this”? Where's that from?

Rachael Wruble (27:02): Gosh, this goes back so many years. I've always had friends tell me anything that was thrown at me, I could handle. I'd always be like, "I got this." And I never turned anything down. I'd never say no, whether it was optometry related or something community service-based, volunteer nonprofits. I'd be like, "Yeah, I got this." They're like, "Are you sure you're flying off to lecture here, and then you said you have this trip?" I'm like, "Yeah, I got this." And so, friends tell me I said that a lot, so that's kind of where it came from.

Marc Bloomenstein (27:31): That is amazeballs. And I'm going to tell you that as you get a little bit older, you’ve got the three kids, you’ve got the husband, you’ve got the new baby, otherwise known as your practice that you're growing. I'm going to tell you, you should probably say… Dr. “Maybe somebody else should get this” should be your new motto.

Rachael Wruble (27:48): Oh, I've learned to say no, and no is a great word. You can say no, and it's okay.

Marc Bloomenstein (27:55): I have a hard time saying no.

Rachael Wruble (27:56): Because that third kid came along and I was like, "Oh, we've got to say no."

Marc Bloomenstein (28:01): I wish I could, but Rachael, you are an inspiration to our profession, to all that down there in North Carolina. North Carolina has so much to offer, especially as it comes to optometry and ophthalmology, and your state is amazing, but I'm going to keep an eye on the Wruble Eyewear. I might be throwing my Chrome Hearts out for some Wrubles.

Rachael Wruble (28:21): I like the Chrome Hearts though. Can't get rid of those.

Marc Bloomenstein (28:24): Anyways. Well, thank you so much for coming on the pod, and good luck to you with all your endeavors, and thanks for being you.

Rachael Wruble (28:32): Awesome. Thanks so much, Marc. I always appreciate talking with you.