health care — The 20/20 Podcast

Dry eye afflicts a third of older people, and one in ten of younger patients. To combat this condition, physicians have used a multitude of treatments, including nutraceuticals such as Omega-3. In this episode, Harbir Sian interviews Dr. Kimberly Friedman as she shares some eye-opening findings about the power of Omega-3 for our ocular systemic health. Dr. Friedman is one of the founders of Moorestown Eye Associates and the VP of Physician Recommended Nutraceuticals (PRN). She shares step by step discussion points for patient interactions and how to know which omega is right for you and your patients. Tune in for more expert insights from Dr. Friedman today.

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Omega-3 Almighty With Dr. Kimberly Friedman, VP of Physician Recommended Nutraceuticals

I'm grateful to be here with an incredible guest, Dr. Kimberly Friedman. You've heard me talk about dry eye. I'm trying to build my dry eye practice and trying to integrate different things. Dr. Friedman truly is an expert in the field. She is one of the founders of Moorestown Eye Associates and the Director of the dry eye clinic at Moorestown. Her resume is incredibly long with many achievements. I'm going to list a few, and then I'm going to let her talk a little bit herself about who she is and what she does.

She's a Diplomate of the American Board of Optometry. She's a fellow of the American Academy of Optometry. She has been on many TV shows to talk about dry eyes and eye health, including the Rachael Ray Show. I'm sure lots of us know what that is. She spends a lot of her time educating, speaking, lecturing around North America. In fact, I was fortunate to attend a lecture here in Vancouver but also in Las Vegas, hearing her speak and having the chance to speak with her personally. I'm excited to introduce Dr. Friedman. Thank you, Dr. Friedman, for being here on the show to share all of your amazing insights.

Thank you so much. That's quite an introduction. I'm very excited to be here with you. I’ve got to say I did not know as much about optometry in Canada as I learned when I was up there in Vancouver with you. I am amazed by all the great things that you've got going on there and your show, business, how you're growing and thriving in this dry ice space as well. It's exciting. Kudos to you as well, thank you.

One thing I want to start with is I'd like you to tell us a little bit more about yourself but specifically, one thing I know you've said in the few times I'd met you is that you're a self-proclaimed nerd. I'd love to know from your perspective what makes you a nerd and how has that benefited you up until now?

I was one of those academic students. I graduated from, at the time, PCO now, part of Salus University in Pennsylvania. A long time ago, I was there in the ‘80s and early ‘90s. That academic background led me through the years to where I am now and where ever I will be tomorrow or the next day. That tendency to always strive to learn led me to what has been the hallmark of my career, which is a constant reinventing of oneself. If you're doing the same thing over and over again, year after year, it does get a little stale. It was exciting for me to do, which is better 1 or 2, maybe for the first 5 years of my practice but after that, I needed to do a little bit more.

The fact that I am a bit of a nerd and I do read a lot, I do look at the studies and I'm always trying to evolve and improve led me to different emphasis during my career. When I first got out, I was doing a lot more pediatrics at that time. As I got older and my patients got older, I developed Sjogren's personally. I started to have dry eye issues and I want to learn more about that. That led to my diving into a specialty clinic on dry eye.

My use of dry eye products and learning more about them in different treatment modalities led to where I am now as a Vice-President of Physician Recommended Nutriceuticals because I was using nutriceuticals as part of my practice. The nerd in me has served me well. It is allowed me to reinvent and reinvigorate myself in this wonderful career because we don't have to take a one size fits all approach in optometry and being a nerd has helped.

I am also a self-proclaimed nerd and I've leaned into that more as I've gotten older. I realized the benefit of being a nerd and, of course, there's this negative connotation around it but being that person who is so driven by learning, absorbing information, and then you have to apply it, which you've done. Let's talk a bit about dry eye practice. I'd love for you to share maybe more from a beginner's perspective. What if somebody was in the early stages and they want to build a dry practice, A) Is there value in it? I know that's a rhetorical question. B) What are the early steps? Not going too deep into too many devices and equipment, but what would you recommend a place to start?

I say to doctors when I'm talking to them about dry eye all the time, “The only thing you need is a slit lamp and your ears, that's it.” I have a lot fancier equipment than that at this point but I didn't start with that. The patients will tell you if you listen, and if you ask the right questions, you can discern what's going on with our patients. What's that rule of thumb like 80% to 90% of the time you already know what the diagnosis is by the time you've done the history, and that's not that different with dry eye disease. Paying attention, asking the right questions, and taking a look at the slit lamp, anterior segment, Meibum, see what's going on. That is 99% of the battle.

You can get a lot of fancy equipment that can help with patient compliance, the bottom line of the practice, treatment modalities, and such but the reality is to get started, you need a slit lamp and your brain, and that's about it. In terms of how I started and how many people started, we do go back to that nerd thing. You do have to go back and learn. You're going to want to read as much as you can read. You're going to want to attend a few beginners dry eye lectures. It's ironic because I grew up in the ‘60s and ‘70s. Before I became President, my job or my role with the NJSOP was that I was in charge of developing their continuing education classes.

Ironically enough, this would have been roughly in the ‘90s or so, the big thing then was, “Not another dry eye class.” At that time, we didn't have the scope of practice that we have now. There wasn't as much with therapeutics, narcotics, advanced lasers, and things that we can go and attend these intense, robust continuing education classes. Back then, it was like, “The only thing they're going to talk about is dry eye and red eyes.”

90% of the time, you already know what the diagnosis is by the time you've done the history. It's not that different with dry eye disease.

It was considered superficial fluff that they would give to the optometrist because they couldn't give us anything with any meat to it. Now come full circle all these years later, we realized that dry eyes are a heck of a lot more than here's your boatload of artificial tears. Try them all and figure out which one works for you.

Now, there are dry eye classes that are terrific, intense, scientific, and will feed the nerd in you as well as allow you to develop means that would be very successful for your practice. I'll give a shout-out to one in particular but there are plenty. Arthur Epstein does a series that is good, where it's like a four-part series that he does through the year quarterly. It's a webinar. You get continuing education classes, credit for it as well.

It's a nice one because he starts with the basics like, “This is what you might need to do. This is how I set up the protocol in my office.” He goes a little deeper, into equipment, and then those strange outlier cases that are particularly tough but it's a nice building philosophy and I know that there are other ones like that as well. There's a Dry Eye University and a bunch of them like that. I will say I didn't do that. The way I did was a lot of self-learning and reading but there are some great classes out there that can get you started if you don't have the motivation or the wherewithal to do it on your own, those classes are good.

We're fortunate now to have many resources online but quality resource like Dr. Epstein is one of the more well-known names, but the Dry Eye University is great stuff too. I know they spend some time talking about the business of it too, not just the clinical, which is important. When we’re doing this, we want to help our patients.

We want to improve the results clinically but we need to be able to support that side of the business by making some money from it too. You've already touched on it. I apologize. I forgot to mention it in my intro, which is that you're the Vice President of a Physician Recommended Nutriceuticals PRN, which I'm sure many of our colleagues have heard of.

In particular, the talks that I had attended of yours were more related to Omega-3 and its benefits. Before your talks, I knew Omega-3 was important. I was telling my patients, “You’ve got to look for the EPA, the DHA.” After your talk, I've completely changed. My office manager even came up to me. He's like, “We're selling a lot more Omega-3.”

It's a little bit different from the way I talk to my patients. Thank you for that, Dr. Friedman. We're going to see our patients are noticing a lot of benefits in the near future but let's dig into that. If you can, maybe on a broad level, what's the benefit of Omega-3 systemically and then for eye health, and then we'll go a little deeper.

What happened was going off what we were previously talking about when I started the dry eye clinic, one of the things that I started to realize was when I looked at the data. The data relative to Omega-3 fatty acids is even a little more robust than the data that is present on certain drugs that we have available to us. As with anything, we learn as we go, we make our mistakes and adjust. When I started working in the dry eye space, truthfully, what I would do is I would often use Restasis at the time. It was before the Xiidra and Cequa.

Bring them back in three months and if they were not feeling better, I would add the Omegas. What I learned in time was that I was probably doing it backward and I probably should have used Omegas as the foundation, as an inside-out treatment first, in order to address the inflammation that's happening systemically and thereby being reflected in the eye as well, and then I would add on the topical. I flipped my protocol.

When I did that, I started noticing not only whereas I have seen better results behind the slit lamp but I was also getting happier patients back. Overall, what Omega-3 fatty acids do in the body in the right form is reduce inflammation, which we now know is the hallmark of dry eye disease. Omega-3 fatty acids, in a broad sense, come in different forms but the form that works for the eye is the EPA and DHA form, which is the Marine, fish, shellfish or algae-based Omega-3 fatty acids.

Unfortunately, the plant-based Omega-3 doesn't have an effect on the ocular surface and systemically in the anti-inflammatory way that we once thought they did. That would be the ALA like the flaxseed oil stuff. We want to avoid those but in the space of EPA and DHA, and we can get deeper into it if you want to but that will have an anti-inflammatory effect in the body, which is beyond the eye.

When I'm talking to patients about this, I'll say, “We're going to start treating this with a systemic inside out approach to dry eye, which is not going only to benefit the eye but it's also going to have benefits for your overall health, whether it be joint inflammation, the cardiovascular risk for issues there and skin health.” The benefits of Omega-3 throughout the body are incredible and we're not getting enough in our diet but I will say, “For our purposes, I'm doing this for your ocular health. You're going to start taking this product. I'll see you in three months. We'll reevaluate where you are, and then decide if we need to go on.”

When I present it that way, the patients are usually thankful that I'm going with something that has a 90% reduced risk of sudden cardiac death. That's a nice thing. The fact that I'm making them feel better in their eyes are great but the fact that I'm reducing their cardiac risk as well, and other things, is a good thing. Overall, the patients are happier because they know that they're getting a more natural systemic benefit as well as an ocular benefit. Honestly, in terms of tear osmolarity, MMP-9, and all those lovely little numbers that I measure in my office, they get better as well.

The different indicators that we are looking for, Omega-3 improves more of them than some other prescription medications that we often will prescribe to our patients.

The Omega-3 fatty acids in the right form and dose at all are not drugs. The nutriceutical industry, not just PRN where I work but the nutriceutical industry in general, is an industry and a business. When you know that you have Omega-3 fatty acids that can have a reproducible dose indicated a benefit to our patients and a company wants to come out with those, they have two choices, “Am I going to go the drug route or am I going to go the nutraceutical route?” If I go the drug route, the average cost from inception to out in the market for a drug based on a Tufts University study is $2.7 billion.

It is incredibly expensive to get through the trials, the FDA process, the regulatory process, let alone then go and get it on the formularies and get it so the prescription drug plans will pay for it without a high copay or deductible and then do the coupon game. We all know it. We deal with it every day. The prior authorization game, all that. That game's expensive, $2.7 billion for one little drug to get out there in the market.

We know Omega-3 fatty acids play a role in anti-inflammatory in the entire body. If I decide to go a pharmaceutical route, the way the Vascepa, Lovaza those drugs did, I'm looking at a $2 billion price tag to get there. The other way to do it is with a nutriceutical company, certainly a price tag to get there but it's not in the billions.

If you do it with a nutriceutical approach, the countries are different. In Canada, you can make different claims than you can in The United States. In Canada, you have to prove efficacy in order to get it there. In the United States, you have to put a disclaimer that says, “This product has not been indicated for the treatment cure or prevention of the disease.”

It's interesting how the different states and different countries deal with nutriceuticals but a nutriceutical is not necessarily less effective than a drug. It was a different business decision on how to get it to market. You do have to have a nutriceutical company that is using good practices, that is willing to submit their product for lab analysis and show a certificate of analysis and things like that. All nutriceutical companies are not created equal but with a good quality nutriceutical company, PRN is not the only one. They are producing products that could make an impact on our patients, just as a drug does but as a different approach.

Finally, I would like to add, going back to nerd again, look at the studies Restasis, hit the endpoint of Schirmer's. Xiidra hit the endpoint of corneal staining and a dry eye questionnaire that they had developed. Cequa hits the endpoints of Schirmer's, staining, dry eye questionnaire, and their stainings were conjunctival as well as corneal. If we look at an Omega-3 fatty acid in an EPA and DHA form in the right form dose ratio, that hits the endpoints of MMP-9, tear osmolarity, corneal staining was improved by over 50% as well. The OSDI was improved by over seventeen points. The blood index level.

Omega-3 fatty acids in the body in the right form reduce inflammation, which we now know is the hallmark of dry eye disease.

All of the objective and subjective markers that we utilize for dry eye have been shown to be met with roughly 2 grams, 3 to 1 EPA to DHA, re-esterified triglyceride form Omega-3 in a blind randomized multi-center placebo-controlled study. Comparing study to study, there is a heck of a lot more endpoints there in the Omega-3 box than there are in some of these topical boxes that we use.

When I first heard you say that, I was blown away because I knew Omega-3 was valuable and how to place it in my dry eye treatment protocol but I didn't realize that it was hitting all of those endpoints. Maybe more so I didn't realize those other drugs were only getting 1, 2, maybe 3 because they don't tell you. We didn't hit these other endpoints. They zone in on a dial-in on the one that they did. It's important to know that this nutriceutical that can have these other systemic benefits to our health, as well as improving dry eye symptoms and signs, can help this much compared to the medications.

The next thing I wanted to ask you was something you already touched on, the form, the dosage and the ratio. A lot of my patients that I'm talking to, I'll say, “You got to be on good quality and taking Omega-3 daily, which we don't get enough.” Most patients say, “Don't worry. I have already taken one.” I'm going to let you talk, and then I'm going to give you my side of the story but if you can tell me about the difference and not all Omegas are made equal, what are we looking for in a good quality product?

I am the Vice-President of PRN, I'm biased but when I'm doing an interview and things like this, I want to play real with you. I want to not be an infomercial here. I want you to have the information that you can have to make an impact in your practice and in your patient’s bottom line in terms of their health. What it comes down to is regardless of what product you use, form, dose and ratio.

Form, we need it to be in re-esterified triglyceride form. In Canada, I'm pleased to say that most of what is sold in Canada is in the re-esterified triglyceride form. Canada has a big headstart than in the United States on this. In the United States, not so much. Most of what's out there are in ethyl ester form. To cut to the chase of the two forms, if you were to get an Omega-3 fatty acid from fish, it would be in a triglyceride form. That is the form that our body can absorb, identify and get all the benefits of Omega-3s.

When we make a non-Omega-3 supplement, we have to clean the oil that is harvested from fish because, unfortunately, we put PCVs, heavy metals and all the lovely stuff in our oceans. In the process of cleaning the Omega-3 from the fish, it biochemically converts them into an ethyl ester. Most of the companies in the United States and the two pharmaceuticals that I talked about earlier as well take that ethyl ester form, put it in a capsule and put it out there in the market.

The problem is that it's not that absorbable in the GI system. Only about 1/4 to 1/3 of it gets absorbed. The rest of it sits in your stomach, gives you fish burps and indigestion. If you've ever had a patient tell you they were tasting it all day, it was disgusting and they won't take that again, it's because they were on an ethyl ester.

The only way you can get a form like that to work is to megadose it. You got to give them 4,000 to get 1,000 in, 8,000 to get 2,000 in, roughly depending. Any of these Omega things that I talk about if you take it on a full stomach, it does absorb a little better than an empty stomach and that's true if it's ethyl ester or triglyceride.

The ethyl ester is not going to be bioavailable enough to make an impact on the ocular surface. The first thing we remember is the form has to be re-esterified triglyceride. That's the same form that is found in nature, only cleaned, and then reconverted back into a triglyceride form. It's as close as you can get to nature in a clean form. Canada's good with that. In the United States, not so much.

We look at a dose, you have to look back again at the studies. There are studies that have shown that Omega-3 doesn't work. There are studies that show that Omega-3s work like the best thing since sliced bread. That's why Omega-3s can be a little confusing in our profession because there are inconsistent results in some of the studies. If you read the studies, you'll see that there are no inconsistent results at all. The studies that show it doesn't work are generally doing 1,000 milligrams of ethyl ester, and then 1,000 milligrams of ethyl ester won't work every day of the week.

The studies that show that it does work are generally doing 2,000 milligrams or more of re-esterified triglyceride. The data that I was pointing to was a study that was published in Cornea in 2016, which to this day is still considered one of the best blind randomized placebo-controlled studies in the dry eye on Omegas and it did hit all those endpoints.

That study was roughly 2,200 milligrams of a re-esterified triglyceride. We know roughly 2,000 is what will work. The last part is the ratio. What that study showed is that the EPA to DHA amount was critical to getting these results. What does that mean? Omega-3 supplements come in ALA, EPA and DHA, largely. ALA does not work. There are studies that indicate that it becomes pro-inflammatory in the body and has a 49% increased risk of macular degeneration.

If you have a patient who's taking a flaxseed oil-based substance or if you're taking it, please stop. We now know that ALA is not a good source of Omega-3 and, in fact, increases the inflammatory burden in the body. EPA and DHA are what we're looking for. If it's anti-inflammatory intent, which is what we're using for dry eye, we want more EPA. It is more anti-inflammatory.

If it is brain health or retinal health intent, we would like a little more DHA. It resides in the cell membranes in the brain and the central nervous system like the retina and EPA in more of the peripheral nervous system and the peripheral body. Upshot all is form, dose and ratio matter. The form needs to be re-esterified triglyceride.

The dose needs to be above 2,000 milligrams, and the ratio needs to be EPA to DHA, and what we use at PRN is a 3 to 1 product. It's the one that's been clinically proven three times as much EPA as DHA for dry eye. Form, dose, ratio, that's pretty much what you can remember. In America, we say FDR because FDR was a President everybody knows.

It's interesting you say that in Canada, we're doing a little better on that as far as the form because if it doesn't say triglyceride on the bottle, are we going to safely assume it's not triglyceride form, it's ethyl ester?

Most likely. When it is a triglyceride form, the manufacturers usually want to tell that. They usually want to sync it from the rafters or whatever because it costs more to produce a triglyceride. It has to go through the normal process that everybody else does but then there's an additional process on top to reconvert it back into a triglyceride.

When you look at two Omega-3 sitting on the store shelf in America, one of them might be $17.99 and the other one might be $39.99, it's like, “What are you going to buy if you're the consumer?” There's a significant price difference between them. Usually, the manufacturers will want to put triglyceride on the label to highlight to the informed consumer that this is not the same thing. That's in the jug official at Costco for $1.99. It'll usually be on the label.

One of the other ways you can tell if it's not on the label is in an ethyl ester form. The poor quality form is usually going to have an enteric coating around it to try to prevent the fish burps or it's going to have a D-Alpha Tocopherol preservative in it to prevent it from going rancid. There are a few other cues that you can take from it but usually, if it's going to be a triglyceride, they're going to tell you.

That Tocopherol, is that vitamin E?

Yes, it gets a little confusing sometimes. Almost all Omega-3s are going to have vitamin E in them in some form. All Omega-3s aren’t equal, and all vitamin Es aren’t equal, either. The full natural form of vitamin E is a sub-components of two tocopherols and tocotrienol combined together. That combination of mixed Tocopherols and mixed Tocotrienol is the nutritionally sound beneficial of vitamin E. Most of your Omega-3 products are going to have some form of vitamin E in it because vitamin E does act a little bit as a preservative. It can help maintain stability.

The reality is that the proof is in the clinical studies and the patients.

What some companies do, going to a cheaper route, is they don't use the full form of vitamin E. They use a synthetic form. One part is called D-Alpha Tocopherol. I've seen it written as Alpha-Tocopherol or DL-Alpha-Tocopherol, it can be written in different ways but it's usually the Alpha-Tocopherol one. That is 1 of 8 sub-parts of a full vitamin E. If you are seeing only that 1 of 8 sub-parts that D-Alpha-Tocopherol, that is a good clue that its ethyl ester.

That is also a good clue that the product may have with it a bleeding risk because you always hear about how they say, “Go off your Omegas before you have surgery. If you're on Plavix, Warfarin, Coumadin or if you're on a blood thinner, you can't be on an Omega-3.” That's not true. Nobody says, don't eat salmon because you're on Plavix. You can eat Omega-3s when you are on a blood thinner or when you have surgery.

What you can't do is take an Omega-3 supplement that is D-Alpha-Tocopherol because it is a blood thinner. It's the preservative. That’s the problem, not the actual Omega-3. It gets a little convoluted but if you turn the bottle over and take a look at what it says on the back, it'll tell you what vitamin E is in there. If it's a full form, vitamin E, you're fine. I pulled a bottle here and it said, “Natural mixed Tocopherols.” That means that it has that full mixture of food-based vitamin E. That's fine, no problem but when you see that D-Alpha-Tocopherol, that’s the synthetic one part thing that has the bleeding risk and you have to be more careful with that.

I know that there are at least a few other people out there who like that stuff because I get people telling me, “I didn't know that tiny little detail.” That's what Dr. Friedman's all about. Since hearing you speak and speaking to you personally, I've been more aware of this. I've been looking at the bottles I have at home.

Every time I pop into a drug store or wherever I'm flipping. There's a store here called London Drugs, which is like Walgreens. I turned over every bottle of Omega-3 and none of them said triglyceride. I was like, “Is there something else I'm missing or all of them are ethyl ester?” They were all at different prices and concentrates. Some were bad as far as the concentration, the ratios and whatnot.

I tell my patients, I'm like, “I get it. You've been taking Omega-3. I've been taking Omega-3 for years but now I realize that the one that I was taking was not the best.” A little while back, I switched anyways but now I'm more conscious of it. I'll tell patients like, “We sell this one here, whether you buy this one or not, next time you buy an Omega, look for this word. If you don't see that word, don't buy it.” It’s because they see me being as transparent as I can about it, they're more likely to buy it from me because they don't want to go through the effort of sifting through all the bottles. They end up buying from us and knowing that we have that better quality product.

I hate to use the cliché that you get what you pay for, I'll say in this particular instance, you do. There is a difference in quality. They're not all the same. If you have an asymptomatic patient, one of the things you can say is, “If you were taking the right Omega-3, you would not be as symptomatic as you are now or if it was working for you, I would not be seeing Meibum, Meibography or the dry eye look like this.”

Sometimes, depending on the study, it takes somewhere between 2 and 3 months to get a clinical effect from an Omega-3 fatty acid approach. Sometimes I'll even like, “Humor me, give me three months, take the good stuff for three months. Let's see what happens if you don't see a difference, I'm not going to argue with you anymore.” They always see a difference.

If I can get them to switch for three months, I know that they will experience the difference and be okay. We are skeptical by nature. There is a bigger price tag associated with the better Omega-3s. If the doctor is selling it in their office, people will naturally get a little bit more skeptical. The reality is that the proof is in the clinical studies and in the patients when they come back to your office. Doctors don't have any trouble talking to the patients about why a daily contact lens is better than a monthly, a yearly contact lens or why an anti-glare coating from company X is better than the cheapy $15 one that they get it online.

We don't have a problem saying that. Why do we have a problem explaining that nutriceutical A from Costco is not going to make a difference but nutriceutical B in a good quality form, dose and ratio will make a difference? We have to stop getting in our way. We don't have a problem prescribing TobraDex. Why do we have a problem prescribing an Omega-3 when it works as well and it's got as much clinical data?

Omega-3: Not all nutraceutical companies are created equal.

We do tend to get in our way when it comes to that. I was guilty of this for so long, too. A patient doesn't want to pay that much and you're afraid of bringing it up with them. Give them the information, knowledge, and then let them make the decision after that. On the note of prescribing, something that we started doing is I have these little prescription pad things that say on them, hot compress, artificial tears and Omega-3. I'll fill in the blanks with what brand or product specifically. I'll tear it off the little pad and hand it to the patient. I feel like that has a little bit of an effect on them psychologically of like, “This is something I need to do as a prescription,” and that’s been helpful to us.

In my office, I have this GI folder and it has a checkoff sheet at the beginning where it's like, “We're going to do this.” I also like it because they can see that there are other things. I may have given them, in your case, the checkoff pad. Maybe you gave them 2 or 3 checkoffs on that pad but there are 3 or 4 other things listed there that you did not check off for them.

Psychologically what that does is that they know that, “If I'm not feeling better in 3 months or 6 months, I don't need to go doctor shop and find another doctor. I sold this thing that he gave me and he wasn't giving me the full paraphernalia yet. There are more things we could do if I'm still having a problem. I'm going to go back and talk to him a little bit more.” It shows them that there's plenty we can do. We're going to start simple and then we'll build up if we have to but I'm not going to throw the kitchen sink at you if you don't need it yet.

I didn't think about that but that makes sense because we have a bunch of other stuff listed on there and I'm rarely ever checking all of this stuff off.

Reinforcing to them that, “This is our starting point. This is going to work on you.” There was a study that was done with a particular doctor out of Wills Eye. In his case, 70% of dry eye patients with the Omega-3 approach were asymptomatic after, in his case, it was an eight-week study. I have hard patients, though a lot of them have rheumatology conditions, co-morbidities and stuff.

I would say half of them are okay on the Omega-3 and an occasional artificial tear approach or the Omega-3 with maybe a breakthrough Lotemax here in there on a bad flare-up in a week or something. A lot of my patients are controlled well with the nutraceutical approach with some little bit of stuff with it but the other half are not.

I certainly am writing my share of Restasis, Xiidra and Cequa. I'm on Restasis personally, so I'm not anti these drugs at all. They work great. When the patient sees like, “This is where we're going to start,” I even say to them, “There are tons of things we can do with this to make you feel better and it took you many years to get to this point. It's going to take me a few months to figure out what the right cocktail is for you.”

“We're going to start simply because if I throw everything at you off the top. It's going to cost you a lot of money, rigmarole and maintenance. Maybe you only needed one thing. We're going to start with this. I'm going to see you back in three months. We'll see how you are.” If you're like the study, 70% of patients, were done but if you're like the 30 percenters, we're going to need to do more. Let's see where you are and then we'll go from there.

That's remarkable, even if it's 50%. That Omega-3 fixes that half of the people that are walking in the door is crazy. My staff was noticing that we were going through the Omega-3 a lot faster than we were. I'm hoping to see those people back and hoping to hear a lot of positive things. You alluded earlier that you spend less time clinically.

Now you do a lot of stuff outside of the clinic, whether it's speaking or PRN. For any young ODs or any ODs out there who may be looking for opportunities outside of the clinic and I feel like I hear that conversation is a lot more. There's a bit more of this entrepreneurial spirit floating around. I'd love if you could share any pointers, tips or whatever for somebody looking to do those types of things.

You have to learn to say yes to some of the opportunities that present themselves because you don't know where they will end up.

I don't remember those conversations taking place like in the early ‘90s when I got out of school. You were going to practice as an optometrist with patients and that other aspect I didn't hear as much about. Now certainly, that is a big part of what a lot of us as optometrists do as well. Patient care is critically important and we all love that. That's why we got into this but it doesn't mean that we can't have an entrepreneurial spirit and look into other aspects.

It comes down to a lot of the same old stuff that is true at any stage of life. It's a lot of networking. It's a lot of getting out there and getting to know people, attending the conferences, stopping by the boosts, introducing yourself, making sure that the products that you personally use regularly in your office, you're the best person to speak about those products. That's how I got involved with PRN.

I honestly did not set out to be doing what I'm doing now. I was fairly content to write out my life as the Co-Owner of a four-doctor optometric practice. I run the dry eye clinic. The office does well financially. I was happy and what happened is, in my case, the corporate world came calling to me. They came to me and they said, “You're going through a lot of Omega-3 fatty acids, more so than your colleagues are at a greater rate. What are you doing? What are you saying? Why is it successful in your office?” I honestly started with them being a consultant and teaching doctors is what I was doing.

Teaching doctors like, “This is what I say, and this is what I say if the patient comes back with this. This is why I think it works.” That led to me doing more speaking engagements for them and teaching their salesforce what I was doing and saying so that they could go out and say it to the doctors. That ultimately, led to me being a Director with the company and then a Vice President of the company. It was about a four-year process from somebody who is a lowly Account Manager in my office saying, “You use this. Do you mind if I give your name to my superior? We could go somewhere with this,” and then going up the ladder that way. I am on the speaker bureau for 3 or 4 different corporate entities now.

A lot of times, it starts at the local level. It starts with the local rep coming into your office and saying to them, “I'm impressed with your product. I've been happy with this product. If there's ever an opportunity where you want somebody to give a testimonial or to speak about this product, I'd be all in. I'm comfortable with this. I like it.” I've seen some of the colleagues in my office get speaking engagements and things like that from that.

Honestly, a lot of times, it's networking, being able and willing to put yourself out there and say, “I'm interested in doing this.” I was on the board for the advisory board for Women In Optometry Magazine for a while and it was the same thing. I met somebody at a conference, we got to talking and they were like, “Would you be interested in doing this?”

It builds slowly and organically over time. It's like anything else, don't be afraid of a little self-promotion. Don't be afraid of going out there needing but if you're sitting in your room taking virtual CE classes and I know COVID was different, as things get back into in-person meetings and such, that's where the connections are going to be made.

I do think that we lost a little bit of that colleague connection and that interpersonal relationship and networking when we did have to sit behind a screen and talk all the time. As things slowly open up and as your comfort level improves, getting out there and getting to know the reps and the Regional Directors is how you can move into other areas in optometry. How do you do it? I've seen you do it. You work in a room like nobody else.

That's taken practice. I don't know if I do it better than others but getting comfortable to go around and talk to people is something that takes practice but 100% agree with everything that you said and, in fact, similar to the answer that I give a lot of people, as well as the networking side of things and getting involved with the association.

I give a lot of the credit for opportunities that come my way. I started with me being involved in our provincial association, being part of committees, attending meetings the conferences and it is a little bit of schmoozing for lack of a better term. Something that I talk a lot about or I did up until a while ago was branding as being a personal brand.

Omega-3: You can eat Omega-3 when you are on a blood thinner or when you have surgery. What you can't do is take an Omega-3 supplement.

Everybody has their own brand, whether you think about it that way or not, whether you're a doctor who sits in the office, sees your patients, goes straight home and doesn't do anything else. Whatever your patients think of you, that's your brand. If you want to be the person who's out there speaking, you have to expand your brand to be something that the industry will recognize as something that they want to present to their customers.

When you're out there talking, think about who you are and why that company or whoever might want you to speak on their behalf, one of them is you sell a lot of their product. That's one thing that's going to get their attention but perhaps you have other qualities and you have to let them be known and like you said, “Never be afraid of a little self-promotion.”

You have to let people know that you're interested. Otherwise, they'll say, “That's a nice person who sells a lot of our product but they don't seem interested in speaking. I'm going to go to the next.” I did plant a lot of those little seeds as well. I continue to when I can and say, “If there's an opportunity, let me know.” I do a lot of the same things that you mentioned.

I underestimate the value of those getting involved with the state or the provincial association. The truth is, even long before I started utilizing PRN products in my office, became a big user of them and started working with account managers, that probably is what put me on the path towards alternate careers right out of school.

One of the problems that our profession has now is that, for whatever reason, a lot of optometric organizations have trouble getting new blood in. It can sometimes be perceived as a woman. It can sometimes be perceived as the good old boys’ club and it's hard to breakthrough or if it's not even a male-female thing, just an almost an age thing where as a younger doctor, feel like you're the only one in the room that doesn't quite fit in.

You do have to be confident, strong enough to work through that, get a seat at the table and show up. The truth is your local organization, state organization, provincial organization, national organization are all volunteers. They're no different than you and the only difference is that they agreed to show up at a meeting. They agreed when somebody said to them, “Would you be willing to come and attend this committee meeting?” They said, “Yes.” Granted, you're volunteering. It takes a lot.

I can tell you that the two years that I was President of the state organization, which would be equivalent to the provincial in Canada. I took an income hit. You're traveling all over the place. You are lecturing all the time and volunteering. You're flying, in our case, to the national organization in St. Louis. It is a dedication but, in the end, you end up being able to have incredible connections, incredible network of people that you know, and you can then move into some of these entrepreneurial and they don't even have to be corporate but all kinds of different areas. It's a short-term investment in your career and the future of your career that ultimately leads to a long-term personal investment in yourself, too. To me, it's the best of both worlds.

On a similar note that you alluded to it there again in your answer but when I have a successful woman on the show, I've had lots and amazing from different industries, athletes, Olympians. I liked to have them share their path and if there have been obstacles as a woman to get to where you are. If you're able to share some of your insights, perhaps for younger ODs or other professions who are trying to build their way up.

I'm hoping that it would be different for a younger female OD graduating now than it was back in 1991 when I graduated. Honestly, in ‘91, it wasn't that bad compared to maybe the women that graduated twenty years before me. I do think that we are seeing improvement in this area, which is positive. That being said, there were plenty of times I walked in the room where it was like, “When's the doctor coming in? or, are you the nurse? Could you send the doctor?” I have had patients refuse to see me because I was female but that was a long time ago. Now, there are more patients that will refuse to see my male colleagues because they want the female. I do think at this point, it can go both ways but there were times where it would come up.

We all need to learn to tune in to that inner voice, that gut instinct, because it generally won't lead you wrong.

I was the first female President of the New Jersey Society. At the time, that was like a big deal. Now, there's been 5, 6 or 7 since me. It's not that big of a deal anymore. We've seen change there. That being said, it will still happen at times. We need to understand that when a certain demographic has dominated a profession for a long time, change comes but it takes a little time. You will still bump up against that occasional person who hasn't kept up with the time, so to speak.

I've been fortunate that I've surrounded myself with both strong men and women that have been inclusive, that have invited me to the table. On those few times, you have to think of it as feeling more sorry for that person that thinks that way because they're shutting themselves out of 50% of the great people in the profession.

That takes strength, courage, and confidence to think that way versus the other way of potentially shutting down and thinking that person has taken this opportunity away from me. That's a lot of credit to you and other women who do continue to work through that. Huge kudos to you for being the first woman President of the New Jersey Society. That's incredible. You paved the path for all the women that came after you.

I really enjoyed it. Going back to networking and things like that, the way that happened was when I was in college. I was working for the NJSOP as an intern. I’ve got to know them, and then when I got out of optometry school, I started volunteering for committees. A lot of this stuff starts a long time ago and they start in these little subtle ways that you don't realize are going to balloon into something else down the road. You have to learn to say yes to some of the opportunities that present themselves because you don't know where they're going to end up. Being willing to walk through those doors that open, that's a lot of it.

If anybody is following me on social media and show, I love philosophy, quotes and things like that. One of my absolute favorite quotes is a long one but the core of it is, “Being bold and moving forward is the key to everything because once you do that, you don't realize what all these other opportunities may present themselves and they may be acting on this one thing that's right in front of your face but once you take that step, all of a sudden, there's a bunch of stuff behind that door that you didn't even know existed.” I've had that personal experience many times. I always encourage people to do that.

The flip of it is as a woman and as a man, you also have to know when to say no because now my problem is I'm over-scheduled. You have to take the opportunities as they present themselves. I'm a yoga teacher. In my yoga world, I do believe that our gut instinct, that internal awareness that we all have, that we tend to shut off and go, “That's a crazy thought. That's a coincidence.” We all need to learn to tune in to that inner voice and inner gut instinct because it generally won't lead you wrong.

If your gut instinct is, “I would love to do this, but…” If you would love to do it, go do it. If your gut instinct is, “Something feels wrong about this,” then don't do it. Don't allow yourself to be put in a position that you're not comfortable with and allow yourself the honor that grants yourself the potential for joy and opportunities by taking them when they come and tell that inner voice to shut up if it's telling you, “You can't do it.” Listen to your gut instinct. You probably can.

The fact that you are also a yoga instructor on top of everything else you do, that's pretty cool. Dr. Friedman, we're getting closer to wrapping up here and I always ask two questions of all my guests at the end of the show. I want to close to you now. The first one is if we could hop in a time machine and head back in time to a point where it was a difficult time for you, feel free to share that moment if you'd like but more importantly, what advice would you give yourself at that time?

The first thing that popped in my head, that's the one I got to go with. I'm not going to censor it. In 2014, I had Legionnaires' disease. I was sick. I was out of work for about six months and I got to this point where I was too sick to work but I was not so sick that I was lying in bed, half unconscious and not knowing what was going on. I was bored out of my freaking mind and I was depressed. It was bad because I was sick, I couldn't do anything and I felt useless.

That's when I created my dry eye clinic because I was sitting in bed, I could not work, my brain was awake but the rest of my body was not awake. I started conceiving of everything. You would do with what you do. I created the logo and look. I figured out the scheduling protocol. What equipment I was going to buy right away. That six months break from life allowed me to decide what my next reinvention was going to be.

Omega-3: Some studies have shown that Omega-3 doesn't work, while some show that Omega-3 works like the best thing since sliced bread. They can be a little confusing because there are inconsistent results.

It allowed me to create the dry eye clinic at Moorestown Eye, which then allowed me to start to utilize products that I had not done before, then introduced me to PRN, to consulting, to my full-time job now and I love it. That was a low point in life. I was sick and scared. It ended up giving me a break from my previous normal day-to-day to create what is now a better life.

The final question that I'd like to ask you then is everything that you've accomplished to this point in your life, how much of it would you say is due to luck and how much is due to hard work?

We create our own luck. We're all given opportunities and we choose whether to take them or not take them. Sometimes, luck and happiness are not things that are necessarily granted to you by the universe. Those are things that we create internally. We can draw luck and happiness to us. Those are decisions that we make and we tend to unempower ourselves to think that these things are either granted to us or not granted to us. There's some grand wisdom out there that, “I'm going to give you luck now and I'm not going to give you luck now. I'm going to grant you happiness now or I'm not.”

Luck and happiness are something that comes from the inside out. It's something that we create for each other and ourselves. How much was luck and how much was work? I think that it was life. I don't know that it necessarily worked. It's attitude and what you believe. It's how you understand how life works. I'm getting very yoga now, forgive me. It has more to do with what you create for yourself. I don't consider that work. The answer is it's not luck. It's work but It's not really work.

I asked the question in that polar way. There's one or the other but I love when guests go off the board and give that feedback. I love the yogic philosophical angle. That resonates with me, too. Thank you for that thoughtful answer. I appreciate it. That's everything for this episode. I do have a bunch of other questions for you but we're going to have to save them for another time. Thank you for taking the time because I know you're busy. There's a couple of more questions. One is where can people find you?

If you have any questions about anything, the easiest thing to do would probably be to shoot me an email. It's KFriedman@PRNOmegaHealth.com or you can even go to PRN Omega Health and click on the Contact. It'll eventually get to me after it goes to them. That's the easiest way probably or you can even do it on my website for my office. Feel free to steal stuff from my website. Not that it's the best thing in the world but feel free to look at the dry eye clinic stuff on my website. That's MoorestownEye.com. You can click on that and that will get to me too, whatever works best.

Any final words of wisdom that you'd like to impart before we wrap up?

Thank you for your time. For those who are reading that work in optometry, you are in one of the best professions in the world. Do not let the naysayers get to you. Don't let them in. People create their happiness. Some people are happy when they're complaining. Don't worry about that. I have had such an incredible life as a result of the profession that I chose for myself.

Omega-3: As things slowly open up and as your comfort level improves, getting out there and getting to know the reps and the regional directors is how you can move into other areas in optometry.

I would choose it again any moment of the day, anytime. There are many opportunities within this profession for how you would like to practice. Enjoy and explore them all. You don't have to define yourself as one way. Get rid of a little box of the definition of who you are and take the opportunity to explore all the possibilities in optometry. It's a great place.

That means a lot coming from the Founder and the Creator of the dry eye clinic, who speaks, lectures, and is also a yoga instructor. That's your living proof, that can be done and we don't need to put ourselves in a little box. Thank you so much, Dr. Friedman. Thank you, everybody, who's reading. I'm sure there was much great value that you could take away from what Dr. Friedman shared now.

If you did find some value, please do share it, take a screenshot, throw it up on Instagram, wherever you like. Hit like, review, comment and all the good stuff. I always forget what you're supposed to do to fit anything that seems a positive thing to help the show grow. I appreciate it. Thank you all so much. I'll be back with another episode.

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About Dr. Kimberly Friedman

Dr. Kimberly Kester Friedman is one of the founders of Moorestown Eye Associates (est 1992) and the Director of our Dry Eye Clinic. Highlights of her resume include:

Diplomate of the American Board of Optometry
Salutatorian of her doctoral class
Fellow of the American Academy of Optometry
Multiple television appearances discussing eye care topics. Her television appearances can be seen on our YouTube channel - Moorestown Eye YouTube Channel
- Rachael Ray Show
- NBC 10!
- Fox's Good Day!
- Cn8's Your Morning
- Comcast Newsmakers
Multiple print articles
- Philadelphia Inquirer, Courier Post, Newark Star Ledger, Asbury Park Press, Burlington County Times
- Multiple Eye Care Related Journals
Educates doctors, staff and patients throughout the nation and recently presented lectures at the National American Optometric Association Annual Congress.
New Jersey Society of Optometric Physicians' President's Award for serving as the first female president
"Top Docs for Kids" by NJ Family Magazine
"Top 40 under 40" professionals in the eye care field
"People's First Award" for the northeastern region of the United States awarded to a doctor who demonstrates excellence in both eye care and community service
The National Special Olympics Leadership Award
New Jersey OD of the Year Award, the Young OD of the Year Award, the Special Purpose Award, the Chairperson of the Year Award and the Communication Award

Outside of the office, Dr. Friedman is currently a clinical director for the Special Olympics Lions Club International Opening Eyes Program. Dr. Friedman also works as a part-time instructor for anatomy and physiology and is a certified yoga teacher.

Dr. Friedman currently splits her time between patient care at Moorestown Eye and teaching other eye doctors throughout the country about new products and pharmaceuticals in eye care. She sees patients in-office Mondays and Fridays, and also offers telehealth appointments on select days.