Episode 130 – Becoming An Eyecare Icon – Dr. Paul Karpecki 

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Dr. Paul Karpecki may well be the most recognizable name in optometry. Throughout his career, he has established himself as a clinical expert in dry eye and ocular surface disease. Dr. Karpecki runs one of the largest dry eye clinics in North America and is the chief clinical editor for Review of Optometry and co-chair for the TFOS Symposium. In this episode, Dr. Karpecki shares his journey to becoming this iconic figure in the world of optometry. From professional setbacks to personal loss, he reveals the pivotal moments that shaped his path. He shares how going through adversity led to unexpected opportunities, reshaping his perspective on success and fulfillment. Through his story, Dr. Karpecki provides a deeper understanding of resilience, surrender, and the power of faith during challenging times. He also sheds light on advancements in instrumentation, oral medications, and the transformative role of AI in redefining eyecare practices. Tune in now! 

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Becoming An Eyecare Icon – Dr. Paul Karpecki 

Welcome to the year 2024. Happy New Year, everybody. I hope everybody’s had an amazing holiday season and a great start to their new year. I wanted to start the New Year on the show with a bang. I have one amazing guest, the one and only Dr. Paul Karpecki, the legend of our industry. Thank you so much for being here, Dr. Karpecki, appreciate you being here. 

Thank you, Harbir. Happy New Year to you as well. Hope you had a wonderful holiday with your family, your three girls. I’m honored to get to start a new year. It’s such a wonderful time when you start New Year because it’s this way to say, “Let’s refocus. Let’s look at what we can achieve or what we want to accomplish.” It’s almost like a new start. Can’t think of a better way to begin than being on your show. Thank you. 

Thank you very much. I appreciate it. I couldn’t think of a better way than having yourself on the show as well. We can look at this as a clean slate, make the changes that we want to make, and start the year off right on the right foot. I’m going to give a small slice of an intro to Dr. Karpecki. For those in the industry who may not know him. Dr. Karpecki now lives and practices in Lexington, Kentucky. However, he is a Canadian at heart born in Canada, in North Bay, Ontario. We have that Canadian connection, which also makes this more special. He has a residency in fellowship in cornea and runs the largest advanced ocular disease center in the United States, which is incredible. 

Amongst so many other publications and chairing so many other committees and boards, he has co-chaired the last two TFOs symposia and will be co-chair again in the next one, with TFOs being the Bible of dry eye and ocular disease. That means Dr. Karpecki is at the top of the pyramid, as we all know. As I said, that’s a small slice of your bio, Dr. Karpecki. I’d love to dig in a little bit more into who you are and what you do. How would you introduce yourself if you’re coming across another optometrist who maybe lives under a rock and hasn’t heard of you yet? 

That’s why this show is so great that you do because you don’t ask the typical questions. That’s what is refreshing. If someone came up to me I’d just say, I’m a colleague. My goal has always been to strengthen our profession. To advance everyone in optometry in North America. My heritage is in Canada. That’s where I was born. Applied to Waterloo. I almost got into the University of Waterloo. I was down to an interview with two people. I didn’t even know it was two. I called because I was in India and I asked how many people were going to interview for this second opportunity. I guess someone decided to go into another field. 

They had 1 spot, and they’re going to tell me 10. I was going to be like, “I’m not going to drive up.” They said, “We’re only interviewing two.” I thought, “That’s really good odds.” They weren’t good enough. However, the other person got in. I ended up being in the States in a way it worked out well. I still get to do things like this where I’m still involved in my home country, and also obviously in the US.  

I see over 150 patients a week very similar to colleagues. I’m still in the clinic primarily but I’ve been able to do other things outside of that. Like publishing and lecturing but with three children at a busy time, they’re 10, 12, and 12. It’s a big part of who I am. That limits some of the traveling. Fortunately, virtual stuff has helped. I just focus on fewer, but key meetings. That’s really about it. I like to think of myself as one of the colleagues just like you and myself and everybody else. I’m meeting somebody, I put it in that perspective and just happen to be a little more focused on ocular surface disease. 

A little bit more focused. That’s interesting. I’m sure UDub has been kicking themselves for the past few decades since you came out of school and started making your mark on the industry. I’m going to ask you the question that I get asked, people ask me, “Harbir, how do you do what you do? You’re traveling, you do the show, you have practice, you have kids.” My response to them is usually, “Have you seen what Dr. Karpecki’s doing?” Or others in the industry who are doing it at a whole different level. I want to ask you that question. How do you manage that or how over the years have you found a way to balance that? I know it’s not always a perfect balance, but you have your family and that’s a priority for you. How do you set those priorities for yourself? 

You’re right, you’re never going to hit that perfect balance. Since you and I get on planes even when they have a route, they never follow that exact route. They’re usually going up or down, depending on turbulence or adjusting one way, then coming back. I always feel like that’s a little bit of that balance when you’re trying to accomplish career and family, knowing that family’s your priority, family and faith, that thing. I do find I’m constantly navigating. Sometimes I go a little too far this way and I’ve got to pull it back in.  

You’re never going to hit that perfect balance. 

For a while we had children. I told a lot of meetings, “I won’t be lecturing for a few years.” They took it literally, six years later I got an invitation. I was too far that way for a while and you just keep balancing it in between. Honestly, the truth about trying to achieve it is, that you do have to have a supportive family and a supportive spouse who is dedicated to being a team on this and making it succeed. At the same time, you can’t abuse that and be always on the road and miss out on life and then later regret that you had a great career, but no real legacy in terms of your family. It’s that balance.  

On the work side, I’ve got an incredible team. They let me see over 50 patients a day because they are so streamlined in what they do. I’ve had the same team ever since I started this last clinic, which is about a decade now. Not lost anyone fortunately because there’s a lot of turnover within the clinic, but not within my team. That combination of being surrounded by very impressive people and a wonderful spouse and family allows you to achieve it, as long as you know your priorities and don’t sway too far off the path to the destination. 

Such amazing advice. Especially coming from somebody who has been doing it for so long and at such a high level. After I commented, “Have you seen what some of these others are doing?” I don’t feel like I’m doing nearly as much or as much as I’d like to even be able to do as goals as I’ve set for myself. The next thing I say is the most important is having that support at home, just like you said, absolutely vital.  

If you’re doing something that your spouse and your family are not on board with, it’s always going to feel so much harder. It’s not going to feel as genuine and as authentic. It’s always going to be a lot more work. My wife’s really on board, to her credit questions me appropriately. Like, “What’s it going to take? How much time is it going to be away from home? Or what does this mean for the kids?” All this thing, and I make sure that helps me keep my priorities in line. As long as I can answer those questions, then she’s right behind me to be like, “Let’s do it.” It gives me so much more energy to do it and do it better. 

That’s exactly right. That partnership and making those decisions go far. It’s not unilateral. You’re not just going after what you want to do. You’re realizing the big picture. You’re partnering with your spouse and the family to say, “This is important, but my family’s priority. How do we make this all work?” I love that because all the success in the world in a career without success at home is not very successful. You have to be able to say, “What are the priorities? What do I want to leave as my legacy long term?” While it is great to serve the profession and try and elevate it as you do so well, many of us focus on that ultimately the biggest impact we’re going to have on life is our children and our family and the legacy that goes through them long-term. Keeping that balance, and partnering with your spouse, they’re great insights. 

That’s wonderful to hear. Let’s talk about the clinic for a moment. You mentioned 50 patients a day. I know that not many of us are seeing that many in a day. The fact with everything that you’re doing, you’re still in the clinic three days a week to see all those patients. It’s incredible. Can you tell me what it looks like in the clinic for you? How do you manage to see that many patients and what types of patients are you seeing? 

I alternate 2 weeks, 1 week, 3 days, 2 days, 1 week, 3 the next week. It’s about 2.5, but you’re right, for example, next week I’ve got a 3-day week, this week was 2. It is over 50. To be fair, the way the clinic has evolved over the years. It’s gone from being an ocular surface disease center where dry eye patients would come in and would be referred in by ophthalmologists, optometrists, especially my colleagues, rheumatologists, etc. We got backed up. We got to where my colleagues were calling saying, “Paul, I’d love to get a patient into you, but it’s four and a half months, and they won’t wait that long.” 

We eliminated direct patients, not fully eliminated them, but if they were put to the back, they’d have to wait 4 to 6 months. Most would want to see another doctor, a colleague of mine first, and then they would be referred in. That allowed us to get to a more reasonable 2 to 3-month timeframe now that we’re at. It’s 100% referral. The great thing about that is that I even have patients sign a form when they come in saying that I’m not going to be doing anything around spectacles, optical refraction, or dilation. You’ve got to continue to see your primary eye care provider, your optometrist every 6 or 12 months as they direct. That helps a lot.  

I didn’t do that selfishly so I could get 50 patients in. I did that because I want to respect my colleagues and ensure that they continue to have their patients and eventually the patients go right back to them and they continue to have their exams. What ended up happening is that I realized that if you don’t have to refract, you don’t dilate, and you don’t do a lot of that pre-testing because it’s being done by their optometrist, you can see 50 quite easily because you’re just doing a standard ocular surface examination. I ask a few questions on a specialized questionnaire I have, I take a look at their eyelids carefully at the slit lamp. I express the oil glands, put some fluorescein in, and that one and a half minutes is my entire testing.  

The pretesting with osmolar other things is already being done. Meibography is done ahead of time. I just have to glance at a few things. It’s not that great of a feat if you’re doing so little or focusing on such a small area as cornea and ocular surface disease. It allows it so it’s not a stretch when you don’t have to do the big stuff. 

I suppose that makes a lot of sense. A lot of the data gathering and all of that is eliminated, but there’s still a lot of mental processing that needs to happen in that very short period. You have all that information in front of you and you have to make these quick and accurate decisions. That already sounds like a lot. I wanted to ask you what your process might be there, but that sounds like it would be maybe a bit complex. If you do have a more straightforward patient in front of you what would be your approach to treating a dry eye patient mild to moderate maybe, or I guess the fact that they’ve been referred to you, they’re not going to be a mild patient, but more run in the mill, maybe type of a patient. What type of process do you have when you see the data in front of you? 

That’s the key. To be fair, I started my first dedicated dry eye clinic many years ago. Hard to believe. It wasn’t like I knew this would be the future. I’m like, “I’m going to go into the dry eye because I know one day we’re going to have this be an important area of practice.” I was in Kansas City, I’d finished my fellowship. I was practicing in cornea refractive. They’re like, “We’ve got this big dry-eye population.” We were doing refractive surgery in the clinical trials back then in the mid-90s. We didn’t want to disturb or upset our referral optometry colleagues because, at that time in the 1990s, people were scared that LASIK was going to like, take over and we didn’t have contact lenses. We didn’t know.  

This all ties into your answer in a moment, but we won’t take patients from you except for those who are contact lens intolerant and don’t want to be in spectacles, which was enough for us to research a few hundred patients. Guess what? Those patients who are contact lens intolerant have dry eyes. We were doing refractive surgery on almost 100% dry eye patients, and we created this huge dry clinic and nobody wanted it. It was either this is your role or you don’t have a job. I’m like, “I’ll take it.” At the time I wasn’t ready to go back to Kentucky, which is where I expected I’d be, I did my residency in Kentucky and I was doing all kinds of things and busy at that point so I stayed. 

It was frustrating at the beginning, but over 26 now we’re in 2024. I’ve learned that you have to take the patient and determine the type of dry eye. A lot of things have evolved over those 25 years, but this one has, so I had to run the mill patient, let’s say the most common. The person who’s on a digital device extensively may have rosacea. They’ve got an evaporative form of dry eye. When I expressed their lower eyelid, and again, it’s a five-second test, you don’t need anesthetic. You just need to see what oils come out of the lower central to the nasal eyelid. If it comes out like toothpaste, you know that’s abnormal. If it comes out turbid, that’s not normal. It should be this thin olive oil consistency.  

That’s my indicator. Even though I did check for dry eye based on their symptoms, and I took a good look at their eyelids, had them looked down, looking for collarettes and blepharitis looking for telangiectatic vessels, focus on that eyelid, because most dry eye, 86% according to the lymph study of all dry eye involves the meibomian glands. That does involve a little expression. It’s a simple thing to do. Paddle your fingers a Q-tip, but you have to milk that lower eyelid up and see what comes out. I have a lot of residents and colleagues who say, “I would love to do dry eye, but do I have to do the expression?” I’m like, “One, it takes about 3 to 5 seconds and you don’t need anesthetic. It’s really easy to do. Number two, that’s like saying, I want to manage macular degeneration, but do I have to look at the macula?”  

That’s where 86% of dry eye is you have no choice. You got to see what those glands are doing. Let’s take the fact that it’ll come out paste-like or won’t express. That’s going to be to your question, the average moderate patient, they’re going to be in evaporative form. Years ago, when I first started we had nothing but artificial tears. I don’t even use artificial tears anymore. I took a term from [00:17:57] right now, call them artificial lubricants so that they know they’re not a tear supplement that we still have to treat the disease, even though I still do recommend artificial tears throughout the day, or artificial lubricant. 

That’s all I was doing. We started using steroids because that’s all we had. We couldn’t use them long-term, usually Prednisolone, and stuff like that. We were getting some success, but not a lot. I had days where half the patients would come in and say, “Is there another doctor I could see?” I’m not doing great but that was many years ago. We were limited but I stuck with it. Now and then you’d get a few patients. Over the years I discovered that if you control the OBIT, the OBIT, the obstructed glands, the blepharitis that’s usually present. Hank Perry did a study many years ago that looked at patients with evaporative dry eye and found that somewhere between 94% and 98% of them had some biofilm, whether it be Demodex or staphylococcal or some bacterial form. 

The B is for blepharitis or biofilm, the eyes for inflammation the T is the tear film. When I started going from steroids, which is inflammation back then, and tears, which is the tear film, and taking care of the O and the B, we started getting this huge success. For a milder patient, with contact lens intolerance, starting to notice their eyes aren’t as comfortable at the end of the day. That would maybe be for the [00:19:19] maybe a hydrating compress that works well, got [00:19:23] or whatever those good forms. Number two would be a lid scrub for blepharitis. Inflammation might be an omega fatty acid and tear film might be a lipid tear. It doesn’t have to be more complex than that but you have to cover the OB in the IT. 

Now, if this is a serious case, you’re down to the last ten glands. When you’re looking at meibography, you’re getting zero expression. You’ve got these scalloped eyelid margins that are also an evaporative form of dry eye because they’re likely not getting any expression. Your O might be like an IPL or something that’s going to try and get those obstructed glands to where they need to be have to do a little debridement of the eyelid. You’re going to be focusing on things to get the obstruction in control much more aggressively. For blepharitis, you might have to clean up the eyelids with the new DMV drug that will be coming to Canada.  

Right now it just got approved in the US, any demodex would be handy there. The eye would probably start with steroids in addition to your omega fatty acids. The IPL will help that to some extent too. If your low-level light therapy works there well. For the tear film, I might be a little more aggressive in the type of tear, maybe HA-based tear, your high lows, those things. You’re still treating each level, but you’re being much more aggressive because they have so few glands and you don’t want to lose more. That’s a good way to look at the most common form because you’ll notice I didn’t mention plugs unless 3, 6 months later they had a thin [00:20:53] would come in, but an aqueous deficient dry eye where the lacrimal glands aren’t working I’m probably going to plug 95% of those patients early on. 

You do have to look at the type of dry eye to then determine what’s the most effective method. There are four types. There’s obstructive, the evaporative, which we just covered. There’s aqueous deficient, which you have to get the tear volume up and get the inflammation controlled. There’s mucin deficient, that’s where your vitamin A, your [00:21:23] help place anti-inflammatories. There’s exposure, which is your inadequate lid seal cases. Amongst those four, you’ve got all your forms of dry eye disease.  

TTTP 130 | Eyecare Icon
Eyecare Icon: You really do have to look at the type of dry eye to then determine what’s the most effective method.


Unfortunately, there are another fifteen mimicking diseases from EBMD to [00:21:41] conjunctivitis to eye misalignment that make it difficult for patients to respond because they don’t have dry eye but it sounds like it. If you have that, I know it’s a pretty complex, for a simple question, what do you do with the run-of-the-mill patient? It is straightforward. It’s just identifying what the type of dry eye is, and then it’s easy to manage it effectively. 

That’s a great answer. I felt bad asking that question because I didn’t want to oversimplify such a complex process that you’re going through with each person. You could have five run-in-the-mill, an evaporative dry eye patient, but your treatment might be different for each of them because there’s some other small data point that’s not the same. I apologize for oversimplifying, but thank you for giving that very comprehensive answer I’m thinking about colleagues who might be listening and who are into dry eye, but feel like they might be missing a little piece of the puzzle here and there. You may have filled in some of the gaps for some people there. Thank you very much.  

Wanted to go back to the travel aspect and you’re attending all of these conferences. I joke with some colleagues, that a year disclosure slide looks like a page out of a phone book and it’s great. It’s amazing. It’s incredible. From all of that, you gain so much insight into what’s happening in the industry. I wonder from that, if you could distill it down to a couple of things that you’re excited about that are happening right now, where maybe coming down the pike that you’re able to share that we could be looking forward to in the industry. 

I’d love to and I’ll just have one quick comment because you’re very insightful on simplifying in actuality, and it’s a great time to talk about that real quickly. I’ll go right into your question because starting a new year, 2024, I would say one of the things we have to achieve for this year is to simplify dry eye. We’ve made it more complex than it needs to be. I love the quote from Mark Twain who said if I had more time, I’d have written a shorter letter. When I started working with dry eye, I wrote a long letter. I tested everything. We were doing Schirmer’s testing back then, and you name it, to try and figure out what was going on.  

These days, we’ve simplified it. While that sounded fairly complex, OBIT is straightforward. You have to control the obstruction, biofilm, inflammation, and tear film for aqueous deficient, its tear volume, and inflammation. You get it to where it’s so simplified, even though there are multiple options in there. The more you do it, the easier it gets. That’s what’s going to make it successful. I like that. I’m embarrassed. I have so many names up there, that people are going to think I’m looking to work with everybody. There are a lot of it’s research. The great thing about research is you get to work with therapeutics and devices before approval, and you have a pretty good idea when they come out. You’ve already treated 100 or 50 patients. 

TTTP 130 | Eyecare Icon
Eyecare Icon: The great thing about research is you get to work with therapeutics and devices prior to approval.


While many trials are masked, you’re able to get a good insight that this thing works. I had patients coming back saying, it’s the best their eyes have ever felt. I got to assume they were on the drug, not the placebo. That helps so much. It’s the starting point. It’s exciting. You have to have a good team to do it. It gives me an avenue for these severe patients and just general patients where they’ve run out of options where I can say, “I’ve got some research that allows you to do it.” Or a procedure they can’t afford that we could do under research.  

I would say about half of the list is research and that’s exciting to me because I could peek into the future of where things might go based on what we’re studying now, provided they get approval. In the last month and a half, we’ve had 3 drugs, 2 on the market, another 1 coming, and 5 approvals. It does point to where we need to go. The others are typically companies that are trying to understand the field of dry eye. They’ll come in and spend a day and they’ll like, “This is what it’s like and this is what we’re looking for.” I’ve been doing research with them, but they’ve got a drug candidate on the market or they’re trying to figure out how to position things where they’re at. 

The last might be some of these startup companies that I’ve always had a heart for if they’ve got a great product, many of them never make it simply because they don’t position right or they don’t understand where it might fit in. If you can’t find the ideal candidate for a product, you have very little chance of succeeding. If you don’t know the patients where this won’t work, you’re also going to fail. Doctors might try their worst patients, their trained wrecks, and because that’s what I do, the new drug. They think, “This drug didn’t work,” and they don’t utilize it. You’ve got to identify that ahead of time.  

I spent a lot of time trying to do that in terms of its positioning and where it’s at. Some like Jobson, I’m their chief medical editor. That would be a disclosure that goes up there. That’s the list as a whole but I do find it as a positive. It’s a really good way to help position the profession to anticipate what’s coming down the pike. How to be legislatively in the right spot for what we’re going to see. How to build your practice around what we should anticipate in the next 1 to 3 years. I see that being the sentinel role for me when I’m working with the companies.  

I’m selective too. I only work with companies that have a few key insights. 1) The technology has to be something I believe in, I’ve worked with, I’ve studied, or I’m using that works. 2) It has to have to be good people who recognize that you don’t want to work in a day and age with people who aren’t. I’ve worked with good products, but not great people. It doesn’t always work. You have to have both. 3) It’s got to elevate optometry as well as ophthalmology. It has to elevate my profession.  

4) I have to maintain my credibility. I can’t be up there saying this and the same thing somehow. 5) I want to be able to contribute at this stage. I prioritize wise, I’d rather have an impact that helps our profession and the company than just being out there working. Those are the criteria. You end up with a smaller list, even though it is a page for the book, but it has come down a little. I’ve focused on fewer, and more startups and trying to get that to the next level. Ultimately, it’s to position them and our practices where we should be. 

It was half a joke, but I meant it as a compliment. It’s impressive. Aspirational from the perspective of those of us who are trying to grow within the industry while I know I’m likely never going to have a phone book page as a disclosure slide, I would be excited to have a few more names up on that slide to have known. I’ve been contributing in some way and having some impact 

That’s inevitable. We need that in Canada too. We do need to have those key people who are making a difference and understand the big picture like you do. Everybody benefits from the profession, you will, and the companies do. Quite frankly, there are probably even greater opportunities sometimes in Canada in the way that the structure is set up versus vision plans in the US limits some of my colleagues here. Do continue to do that. Always glad to help myself in any way I can. 

TTTP 130 | Eyecare Icon
Eyecare Icon: We need those key people who are making a difference and understand the big picture.


I appreciate that. Thank you. That’s very kind. You’ve already made such a big impact, but the fact that you continue to in these various ways is great. Out of all of those I want to take one thing you said about the startup side of things and come back to that in just a second, put a pin in that for a moment. Out of all of the stuff that you’ve been involved in, is there anything that you’d say is super exciting? Is it the pharmaceutical side, or the medical device side? What are you most excited about right now that’s happening? 

I am excited about three areas that to me seem most intriguing. Since we’re on the theme of dry eye earlier, and then I’ll move off of it a little bit, every form of dry eye has inflammation. It’s inherent. When you lose your homeostasis, the immune system knows how to react. If you’ve had it long enough, those T cells become primed. There’s no question. Dry eye is an immune-mediated disease. Take a person who’s been out of contact lenses for a decade with dry eye you could treat them, get them to a perfect spot, and they put their contact lens back in and everything comes right back because it’s immune-mediated. The T cells know how to respond to the effects that have been there in the past. 

Inflammation’s important and so was the tear film, but we’ve never really addressed the causes. We’ve always gone after the result that, because you’ve got dry eye evaporative, aqueous deficient, mucin deficient, exposure keratitis, or exposure forms, we’re going to treat the inflammation that results. Why don’t we treat the reason for the inflammation? Now we’re finally moving in that direction. Blepharitis is a big cause.  

We have [00:30:39] approved now in the US with plans to get approval in Canada. We going to have a drug there and here that we’re just starting to use. It’s been out two months, I guess it is what we’ve been using. We’ve had success 2024 will be big for that. At the same time, we’ve got the Miebo drop that came out from Bausch and Lomb, which is a very effective drop, that lasts 4 to 6 hours. It addresses the lipid layer. It’s a monolayer. It does not intertwine with the lipid layer. It treats its monolayer that prevents evaporation better than healthy human Miebo. Very few things are better than our own Meibom. That is addressing the obstruction of the meibomian gland component.  

Over the next few years, we’re going to see a lot more targeted agents like that saying, “I’m going to focus on either a specific collagen repair that comes in, or I’m going to focus on IL-17,” which is one of the key inflammatory components that are related to dry eye or the obstruction, the inflammation, the lacrimal gland to restructure it. These new drugs that we’re looking at look like they’re doing that. We’re getting reversal and we’re getting effects that are much more upstream. It doesn’t say we’re never going to use anti-inflammatories, just go again and control the inflammation. It’s inherent in the disease. Now we’re finally saying, “How do we target that?” 

We’ve been doing the targeting with light treatments, PLs, LLTs, and things for a while. Now we’re going to start seeing access to everybody because it could be on the drug side. Speaking of which, there’s much more movement into orals and topicals, including retinal disease. Seven different companies are working on oral anti-VEGF, anti-DR type medications that optometry would be prescribing so that’s going to be a real key. Some of them are moved all the way intopical. I’ve always seen injection being pretty invasive internal, injection, orals, and then topicals. Everything’s moving in that direction. Now that is more of a 3 to 5-year trend, but it’s on track.  

There’s no way that one of these 7 or 8 companies isn’t going to achieve that, or 3 or 4 that are looking at topical agents. We’re going to see a real movement in there. A third area I’m excited about, and I’m more excited about this one because it is moving optometry forward is the utilization of instrumentation. Debriding an eyelid, expressing averting eyelids, utilizing different procedures from clamps, and other straightforward things that we need to do to get there. That whole path of surgical instrumentation, new punctual plugs, new longer duration, those are all in that category of making it easier, utilizing new things in there, and making that work from an optometric standpoint in terms of how we look professional and medical. We’re serving a real need and helping patients in a way that maybe we hadn’t done many years ago. That’s very straightforward. Has a big impact.  

From the instruments we’re using, which again, it’s very medical. That doesn’t take away from primary eye care. You’re still going to want to do both, but now you’re fully comprehensive. Those are the three big things I’m most excited about. There are other areas I do think we’re going to see if you look at the world of virtual reality everywhere. AI is everywhere. We’re not going to be immune to that in eye care. You’re seeing virtual reality headsets now for visual fields, for neural lens testing, for dark adaptation, you name it. It’s all these VR headsets and everything’s moving in that direction because it works. 

AI is everywhere. We’re not going to be immune to that in eye care. 

Some of the newer ones, like [00:34:20] M&S are showing data that are equivalent to the big stand on alone visual field tests and these are much easier, faster, and efficient. Virtual is more of what we’re doing, but even augmented comes in. Finally, AI plays a real role. It’s whenever redefines these algorithms I just described. Even when I applied a little bit of AI to some of the stuff I thought, I learned that I was wrong on some of the things I’ve been teaching. These are longer-term trends, but they’re pretty exciting. 

AI is one of those very intriguing, exciting, and a little bit scary areas. Hopefully, we’ll be able to, as a profession, and as an industry, get a grasp on it and be able to control it versus the other way around but time will tell. Going back to one of the things, the third thing you were sharing is that you’re excited about the equipment and the instrumentation that we have. Bringing back the other point of startups. 

One of the companies I did want to talk about was a small company out of Canada called Meivertor which was started by MaryAnn Klassen. It’s like forceps that make it so easy to single-handedly flip the eyelid. We’ve had it for a month or two, and we’ve used it a bunch of times, and I was surprised at how easy it was. You’ve used it in your practice many times. I would love it if you could share how it’s being utilized and your thoughts on that product. 

That’s a perfect example. It sounds like minor things with instrumentation because you could do it in other ways in Q-tips and things. They’re much more efficient, much more professional-looking, and much easier to accomplish than you need to accomplish. They free up a hand. Sometimes you need three hands like getting meibography and the upper eyelid is a good example where a technician’s got to pull in another person to hold the eyelid with the Q-tip so that they can get everything lined up. Versus this, you just hold and you can move everything you need to. It holds its position. That’s a perfect example, Harbir, of that whole instrumentation side that we underutilized, but is becoming a strong trend.  

For me, that has been a very valuable tool. MaryAnn’s a wonderful person. She’s been in eyecare a long time [00:36:49] when I first met her and played a key role in that company and the whole dry eye field. I’m not surprised she would use her innovative skills and come up with something that could help a lot of patients and our practices. It’s a very straightforward little tool, but it’s well-designed. It’s got a forceps design. It has these little grippers that are put on that you can just use to turn it for one eye. You grab a couple of silicone tips, you just place it in them and they come right out with it. The softer one has a little flap that allows it to bend over and you just hold it.  

For me, where it’s been really helpful is both for staff and sometimes we’re fighting over it. We had to get a second one. I started by first only looking at lower eyelids on meibography. I realized that some of these patients have only 6 or 7 glands. We need to avert the upper eyelid. We were amazed sometimes how it didn’t always correlate that the upper eyelid might have had many more, but they were very squiggly or had the same in some cases or even less. It became a requirement. Now it’s become a requirement that my staff has gotten so good at it, that they can flip the upper eyelid and both are imaged then that way they don’t have to have the patient go back for my meibography, the upper eyelid. They just know to do them both, and they do it in seconds.  

That has helped streamline it. Until we got our second one, I was taking it from them and saying, “I’ve got concretion under the upper eyelid I’ve got to remove and I need the instrument to help me see.” Or a person who I got some dust in the eye and it had been there for a while, we irrigated and still felt like it was there. This helped me to look much further up to be able to see what was there. Again, I didn’t quite see anything, but it gave me a chance to irrigate that out effectively. Which hopefully, solves it, but wouldn’t have been able to do that as well with Q-tips or other avenues that we may have. 

It’s not just that it’s more efficient it’s better, but it’s also more impressive to the patient that you’re utilizing some of these high-scale technologies that instrumentation, they’re used to going to other doctors where instruments are part of what you do. We use instruments, we have random scopes and ophthalmoscopes, it’s not a transilluminator, and it’s not a far stretch, these are more the handheld instruments, the debridement, the expression, the upper eyelid, and the lower eyelid. It also my inverter does lower eyelid diversion. Those tools are valuable.  

TTTP 130 | Eyecare Icon
Eyecare Icon: It’s also more impressive to patients that you’re utilizing some of these high-scale technologies and instrumentation.


I had a patient who had about 30 concretions in the upper eyelid. I’m thinking, “I’m going to get rid of all of these.” No way could I ever remove them without having my inverter. Even removing just one helps so much to have something that keeps it stable. They don’t have to worry about it falling over the eyelid that is in place. The big utilization is staff imaging the upper and lower eyelids. 

That’s huge. In the slit lamp rather than using a Q-tip and having to flip the eyelid or some people are, “I can’t do the single-handed thing yet.” As many times as I’ve flipped eyelids, I still use a Q-tip. It’s like double-handed in there. Now to have a single hand in the slit lamp is amazing, but the staff is where I thought it was going to be the most valuable. The staff doesn’t have the hands-on experience that we have, learning how to flip eyelids. Some of these biographers are a little bulky, and trying to get around them is a little tricky and stuff. That’s where I was seeing it as being the most valuable. It’s cool to see that you’ve experienced that on both sides. 

That’s a great point. It is because you’re right, that the staff frustrates them. They’re not going to do well with a Q-tip. They’re not going to be able to get that. That’s why a lot of times we’re not getting that valuable up-eyelid information unless you have an instrument like this. That’s well said. 

Dr.Karpecki, there are always two questions I’d like to ask at the end of each episode. Before we get to that I’d like to ask, is there any information you’d like to share about yourself? How people could get in touch with you or learn more about your dry eye center, anything else you’d like to share? 

They could always reach out by email. It’s [email protected]. It’s not like Smith. No one was clamoring for a domain name of Karpecki. It was sitting out there easy to get, but at least that makes it easy. They can reach out to me that way. My clinic, Kentucky Eye Institute in Lexington, couldn’t get a hold of me for some reason, or my email was bouncing or something strange. They could reach out to that clinic and they’ll get ahold of me. I’m always honored to receive correspondence emails from colleagues.  

Especially, my Canadian colleagues since I have a link or heritage there. It is an honor and any way I can help them, always willing to. That’s probably the easiest way. Just encouraging people to move in this direction. It’s one of the most rewarding areas ever. Even over the holidays, the number of gifts from patients. I leave that to my staff. That’s one of the benefits to them is, “You’re going to have anything except the bourbon.”  

You’re in Kentucky, you going to have the bourbon. 

I know, get three bottles. People are so grateful. There’s nothing that I do that any one of us couldn’t do. It’s just I’ve had to do it for decades you figure out how but the goal is not for everyone to reinvent the wheel. It’s to say what works and how we take it from here and advance it even further. That’s my only main point. Feel free to reach out to me if you want to try and advance that area of your practice, but I would also encourage it because it’s extremely rewarding for patients, for yourself, and ultimately to make a difference in their lives. 

That’s wonderful. Thank you. I appreciate that you’re so open to communicating and you’re pretty quick to respond given how busy you are. That’s great. Thank you. The two questions that I like to ask every guest at the end of the episode. Number one, if we could step in a time machine and go back to a point in your life where you were struggling if you’re open to it, you’re welcome to share what it was you were struggling with. Most importantly, what advice would you give to young Paul Karpecki at that time? 

There’s no one who I think achieved anything can say they didn’t have a time when they struggled. That difficult time helps position you to learn from it. Hopefully, learn from it in advance. I bet if you interviewed and you do this all the time, every one of them has a story here. That’s why I love that question, because it’s so much of life is built on mistakes not everything’s wow. Whoever you’re interviewing, because you’re going to interview people who’ve achieved things just had this easy road to get there.  

So much of life is built on the mistakes. 

I can think back to a time when I’d put in a lot of work. Within about a six-month timeframe, most things crashed. I lost the place I was working at way back when the private equity group had come in, not like the ones now, but back then. Purchased a practice and looked at what the other ODs were making and what I was, didn’t realize the history of building is a $30 million practice, I had a lot of time as a single guy for most of my life to be able to dedicate to that. They called and said, “We’re going to let you go.” I lost a relationship I was in at the time, which wasn’t healthy anyway quite frankly.  

Unfortunately, a house was near the financial crisis time when everything had fallen. I had a negative network. This is after fifteen years of working. I cannot believe this. Everything I could think of. I lost my dad, who was my best friend that same year. We’ve all got those. A couple of wonderful things. It brought me to my faith and having to pray and figure this out. It allowed me to realize there were great things that were still there, like my profession, and my career, I had that and prayed that the other stuff would fall into place as it was meant. 

I remember talking to Ben Gati, he’s like, “If I were you, I’d declare bankruptcy and start all over.” I can’t do that. It’s going to affect me for the rest of my life. That’s probably because the house was underwater that I’d had gotten. It was a tough time but it was the greatest time because had I not had that, I don’t think I’d be on this interview here. I had a path already in that direction, but it wasn’t going to allow me to refocus, figure things out, and stop relying specifically just on myself. Meaning there are bigger things out there. There is a path that we’re all meant and intended for, and God may have intended us for us. Sometimes you have to just surrender and figure it out. That’s what I had to do because everything I thought would work didn’t work.  

It was a time when I thought more stuff I had and bought like this house and cars was going to bring happiness, and it sure didn’t. That was my restarting point, and now I look back on it and that was the greatest thing. Soon after I met my wife moved back to Kentucky, which where I’d planned to be is the only place I kept state licensure as I knew I was going to end up there. I had three children. Soon after that career took off, still couldn’t find a good job, so I had to go to Cincinnati. For a while, I had to go to Louisville I was driving to find a job, and then things finally settled in. 

Most of my friends, and their children are in college. They’re in careers and having weddings. I’ve got a 10-year-old and two 12-year-olds. It is such a blessing and it’s the perfect time. Everything happens when it’s meant to. Being single for all that time essentially also helped me to achieve the career stuff when the time was right. Now I can have a better balance and focus on family while still maintaining elevating the profession of optometry. I hit a hard. I was about a 9 to 12-month patch. All in a row is crazy, but it’s increasing in hindsight. 

Thank you for sharing that. I can only imagine how challenging that must have been, the lesson there was surrendering, coming back to your faith, understanding your path, and then creating what you have now from that. It’s incredible. I didn’t know that. I imagine most people tuning in have not heard that story before. Thank you for sharing that. The last question. Given everything that you’ve accomplished, how much of it would you say is due to luck, and how much is due to hard work? 

You’ve heard the adage “The harder I work, the luckier I get.” I can’t remember who said that quote. They do go together. You’ve got to put in the effort, but I will tell you it was Woody Allen who said that 90% of success is just showing up. There’s a lot to be said for that. Sometimes people don’t try the stuff that they know they should. They’re like, “That sounds frightening. I don’t think I could speak in front of people. I don’t know if I wrote, what if they rejected the paper or the publication?” They don’t show up. They have something that inhibits them from putting their neck out a little bit to see what could be achieved. You’re not going to have the fullest life unless you take those chances, those risks. You have to be courageous.  

You’re not going to have the fullest life unless you take those chances and those risks. You have to be courageous. 

You look at anybody who’s had a full life and you’d never see someone who’s uncourageous. They’re trying things. They’re going to go after things. They’re going to fail and they’re going to fail forward. That’s the hard work part of it. You do have to show up. You have to put the effort in. As you do, and especially if you can imagine the vision, you know where you want to be and you can feel it. You know what I’d like to have in life, and I had to learn this during my hard time, not before what I thought was the right path failed miserably. The more things I accumulated, the worse I felt because they were all hollow. There wasn’t anything of substance.  

When I had lost it all then I started focusing on the really important stuff. When you can visualize it and almost feel like it’s there, it’s amazing what you can achieve. You still have to do the work, but when you have a direction, somehow your heart and your brain help you get there, doors open, and things that can’t imagine all of a sudden happen. That could not have been a coincidence. The word coincidence means to coincide things are lined up. It’s a combination of vision and humility. Realizing that sometimes your direction isn’t always the one that’s going to be most successful. You have to surrender or relinquish and rely on your faith and then put in the effort while enjoying the journey. It’s not the endpoint that matters. It’s the process of the way, the friends you develop, the relationships, what you learn, and how you advance. That in itself is the successful part, regardless of where you end up. 

That’s true. That’s great. Wonderful answer. Thank you so much, Dr. Karpecki. I appreciate that. Any final words you want to share before we wrap up? 

Thank you, Harbir. Thank you for getting to start the New Year with you. My colleagues and my home country, and getting to be able to share stuff I don’t normally share. Just don’t get those questions. That’s what makes your show so special. I’m used to being on a fair number of these, but they’re always focused on certain areas, disease, career, and there’s so much more. Thank you for more to life and thank you for the questions, the direction, your insight, and congratulations on such a successful show. I could see why it is, I’ve tuned into some of them. I was impressed with them, but you take a different aspect. You do in corporate, the profession, the career, you look at a bigger picture and that’s refreshing. I’m honored to be part of it. 

Thank you so much. That’s very kind of you to say. I appreciate that and that is the direction I try to take the show. I appreciate that you noticed that as well. Thank you very much, Dr. Karpecki, for taking this much time out of your insanely busy schedule. I appreciate it. Thank you to everybody who’s been tuning in to the show, Canada’s number one optometry show. I know that this episode had so much insight. I hope you can share it with your friends, whether it’s posted on LinkedIn, or send a link to your friend via text message, Instagram, whatever it is. Please let everybody know that Dr. Karpecki was here sharing this amazing insight. I will see you guys in the next episode. 


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About Dr. Paul Karpecki

TTTP 130 | Eyecare IconIn 2002, Dr. Karpecki was named to the National Eye Institute’s Dry Eye Committee to provide insights into the condition and its effects on women, in particular. In 2003, he was appointed to the Delphi International Society at Wilmer-Johns Hopkins, which put him in the company of the top 25 Dry Eye experts in the world.
He currently serves as the Chief Clinical Editor for Review of Optometry, the most read journal in the profession. He is the Director of Clinical Content, as well as Chairman, of the New Technology and Treatment Conferences, and serves on the board for the charitable organization Optometry Giving Sight. Dr. Karpecki has also served as Co-Chair for the optometry profession’s Dry Eye Summit, Director for the CJO Optometric Dry Eye Guidelines for EyeCare, and Committee Member for the DEWS II Diagnostic sub-committee. Most recently, he was appointed Co-Chair of the Tear Film and Ocular Surface Society Symposium in 2016 in Montpellier, France. Dr. Karpecki is dedicated to making a substantial impact in the quality and consistency of dry eye patient care in the Louisville community.
Dr. Karpecki received his doctor of optometry degree from Indiana University before completing a fellowship in medical cornea and refractive surgery at Pennsylvania College of Optometry. In addition to his responsibilities with Gaddie, he also currently serves as Clinical Director of Advanced Ocular Surface Disease at Kentucky Eye Institute. He lives in Lexington with his wife, Chandria, and their three children.

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