Eyes On 2026 - In the Hot Seat Part 1: A Live Q&A with Cecelia Koetting

Here are some of their questions—and her responses:

Honestly, the best way to do it is to just do it. Because observing either reduced or absent corneal sensitivity in neurotrophic keratitis or suspected neurotrophic keratitis patients is essential to making the correct diagnosis. A little more specifically, there are two types of corneal sensitivity testing: qualitative and quantitative.

Qualitative testing can be done using a cotton-tip applicator, tissue paper, or dental floss. Something to note is that the wisp created from a cotton-tip applicator will be different every time. Conversely, with floss, you can better ensure that the same length with, in theory, the same rigidity of testing material is used each time, potentially offering some amount of quantitative information alongside the qualitative data. Regardless of what you use, you should test all four corneal quadrants (superior, inferior, temporal, and nasal) alongside the central portion, because corneal sensitivity may vary in different areas. Ideally you should check both eyes to assess interocular symmetry and determine whether both eyes are affected—even if other signs and symptoms are only apparent in one eye. But if, for whatever reason, you can only test one eye, have the patient look up and check the inferior segment, alongside areas of corneal staining or epithelial defects.

For quantitative testing, we have the Cochet-Bonnet, Belmonte Non-contact Gas, and Brill esthesiometers. Having an ocular surface disease-focused practice with many patients that end up in clinical studies, my current favored option is the Cochet-Bonnet. It incorporates an optical fiber alongside a scale from zero to six—with the latter signifying the longest extension of the fiber. The underlying idea is that a longer fiber exerts less force, meaning that the eye is more sensitive; the scale then translates this into quantitative data.

It’s a fair question because they all look pretty similar—even if you enjoy regularly examining ocular coherence tomography (OCT) images. In my experience, the key to making the distinction is a patient’s situation and health. For example, I saw an Irvine-Gas syndrome patient whose OCT images showed a bit of an ERM alongside possible vitreomacular traction (VMT). Identifying VMT with CME from something else requires us to take in the wider context, in this case the fact that the slight ERM that we could observe just wasn’t enough to cause any of the fluid or distortion that was also visible. Another patient that also highlights the wider scope that you need to take when making these distinctions had one quadrant of ‘blood and thunder’ fundus appearance and loss of blood supply in the superior quadrant—together indicative of non-perfusion ischemic retinal vein occlusion (RVO). However, if we’d only looked at the patient’s OCT imaging, we might have missed some of the wider signs that helped us to come to this conclusion.

But I’d also question how much, in the grand scheme of things, making the distinction matters. I’m not sure. Because ultimately, regardless of the specifics, anytime I see any kind of edema, my next step will be the same: refer the patient to the retina specialist. Even if we’re considering ERM patients who haven’t yet developed CME—but in whom we observe irregularities and changes in the retinal folds—a specialist referral is still warranted. Technically speaking, in cases like the one I referenced earlier with Irvine Gas syndrome, you could add steroids and see if there’s improvement—and, personally, for DME, I’d definitely start the patient on steroid injections while I refer them. However, you might not necessarily feel comfortable with this, or you may not be in a setting where this is feasible, based on the nuances of medical insurance.

Yes, absolutely. We brush our teeth, we wash our faces; and we change our underwear—all to help control bacteria and balance pH. Unfortunately, eye hygiene is something many of us aren't talking about, but should be. A lack of lid hygiene can result in the progression of several things, including demodex blepharitis, saponification, the appearance of the volcano sign and biofilm, or even worsening of meibomian gland function or the development of staphylococcus marginal infiltrates.

Lid hygiene has definitely come a long way from our starting point of baby shampoo—but why did we even need alternate options? Some baby shampoo formulations still contain formaldehyde or formaldehyde derivatives (Quaternium-15 or DMDM hydantoin), or polyethylene glycols (PEGs), parabens, or sulfates—which may actually exacerbate dry eye. We try to avoid such preservatives in eyedrops, making it logical to also avoid them in other products used on the eyes. I know some doctors, especially retina specialists, do still prescribe baby shampoo. When I encounter a patient for whom this is the case, I’ll first tell them that I’m glad that their ophthalmologist has opened the conversation. However, I’ll also explain, as carefully as possible, that as eyecare professionals, we all have our areas of expertise, and eyelid hygiene may fall more under my remit—and that there are better products available that I can suggest.

When thinking about the range of eyelid hygiene products that are out there, there are two main things to keep in mind. First, although products that are safe for the eyes are likely to be safe for the rest of the face, the opposite isn’t necessarily automatically true. Second, if a product comes in a multipack—an example being a package of baby wipes—it inherently isn’t preservative-free. Two preservatives to specifically look out for in over-the-counter hygiene products are benzalkonium chloride (BAK), which can aggravate problems; and polyhexamethylene biguanide (PHMB), which is actually also used as an alternative swimming pool sanitizer and works by disrupting the cell walls of bacteria, potentially also leading to issues for patients using products with PHMB day-in day-out.