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This transcript has been edited for clarity.

I know we're safe for these three plus the device that got FDA approved. But what about the new ones that are very, very close to approval? Let's talk about AZR-MD-001. I don't think it has a trade name yet. So just curious if you're familiar with this new product and if you want to describe it and share your thoughts.

So hopefully, the trade name won't be harder than AZR-MD-001. What's interesting about this one is, up until now, we haven't ever seen something that would change the quality of the meibum that's being secreted. And this is an ointment form, and it prevents buildup within the meibomian glands. In these phase two trials, the actual quality, the amount of oil, the health of the oil being expressed changed in these patients. So that's pretty monumental. That's very exciting to me.Because every day when I'm explaining an MGD, I'm like, all right, there's nothing I can put on there that's going to change what you're producing. It's what goes in your mouth. This could change my old spiel, not to mention help a lot of patients. Now the other really unique thing about it is that it is a twice-a-week dosing. When we think about compliance being the number one hindrance to all of our outcomes in most cases, twice a week, that is pretty profound for us. It's not something that we're used to. I'm excited about that. And results were quick. As early as day 14, they saw a change in the meibomian gland function and in the patient's symptoms.

I know we have a little bit to go into that in terms of availability, but I think it's going to be a pretty important treatment for our patients. And I'll also ask Dr. Nichols about this other product, which I'm very excited about. It's a product that has a PDUFA date I believe in November or December of this year. It may actually be available to us at the end of 2023. It's called Reproxalap. Dr. Nichols, I'd love for you to share your thoughts and understanding of this new product.

 This is an exciting one too.A different vein though than the AZR MD001, but it is intended to be an anti-inflammatory. Before you say, “What do we need a new anti-inflammatory for?” This one impacts the inflammation pathways higher up on the chain, so to speak.

Reproxalap is a reactive aldehyde species (RASP) inhibitor. And it's believed to sort of quelch the inflammation because the RASP molecules themselves are pro-inflammatory. They actually bind to the kinases which initiate the inflammation pathways fairly high up on the chain. It may have an impact on not only things like ocular surface dry eye, but allergy, allergic conjunctivitis, and uveitis, to name a few other ocular conditions that are inflammatory based. You may not need that new test that is IgE versus other if you have Reproxalap. It'll be interesting to see how people fit this in. It does not have the side effects that steroids have. It acts like a steroid without being a steroid. You won't see cataract or, well, you'll see cataract, but you won't see it as a side effect or increased IOP. That's exciting, too. And it also has a silky or smooth feel to it.You almost can't even feel it at all. That's exciting, as well.We will know around the end of November and so in the early part of the new year, we may have it in our practices, which will be super exciting too.

Absolutely.I'm excited about all these new medications for our patients, and I know each of you is feeling the same way. I'm going to jump to this next challenge that we face. We're going to have these new medications, and we have our current medications.And I'm going to start with Dr. Matossian on this one. We're here a mix of, the four of us are a mix of MDs and ODs, but we think alike in many ways in the way we manage the eye.Yet, there might still be some challenges when your patients are from different practices. For example, within my practice, I have a little different way of managing dry eye than I do when I'm outside of the practice. I want you to share your thoughts on some of the challenges when you're managing patients that have dry eye that are not in your practice, but maybe co-managing with another doctor nearby because you're sharing a patient for some reason.

There can be challenges, but I think they're very much [able to be overcome].And the reason is, if we keep the patient in mind and if the patient remains the center focus of what we are all trying to do, we create a network of collaborative care, whether MD, OD, perhaps there will be other physician extenders coming into ophthalmology as there have been in other fields of medicine, such as PAs and physician’s assistants and so forth. Our goal is to provide the best care possible. It's through education, through local forms, virtual forms like this one, that everybody can collectively do the best they can to help patients who are suffering so much.

 I love that. And that's a great way, because I agree we need to be patient-centric. Dr. Brimer, any thoughts? Again, I know you're more of a referral practice, so I assume patients are getting sent to you, and you will send them back at some point. How important is communication? What challenges do you face when working with other practices, doctors outside of practices, MDs, or ODs?

My biggest challenge is in a timely referral, because then, when they get to me, they're frustrated that the person didn't send them sooner. And I have to manage that and smooth that over. But I've tried to assist this communication process: we made a marketing kit, and I made a three-minute video of everything we do- here's the problem, here's what we do. And my staff went around with it and showed them our investment in this space, [saying] “Here's everything we've purchased, we've got all the bells and whistles, we could take care of this patient, here's the report you'll get back.And then I made these prescription pads, and the top page says, tell me what you want me to do. Check the box. Everything you want me to do. Is it a dry eye of eval? Is it just a treatment? And then the bottom says, when do you want them back? And is it just with the report? Is it after the treatment's completed?

Is it for non-ocular surface disease symptoms? Once they're just for routine care. And then that page gets faxed to me. The second page gets handed to the patient, telling them what to expect. But here's what this did. It created a safe place where I am there to serve them. And just like if they sent somebody to you for cataract surgery, they're the gatekeeper. They are in charge of this patient and their ultimate care. And I don't want any part of that. I want to do this. And I want to serve you, the doctor, by helping your patient get better. But you are the one in charge. And when I did that, instead of going and asking for referrals and touting my skill or expertise, I don't say a word about that ever. There's not even anything in there about me. It's all about my investment into this and into my patients and them as referring physicians. And I want to get them better. My packet also talks about, meibomian gland loss and screening for it. It's not about competing for these patients. There are plenty to go around.

And it's about identifying when they need elevated care and what's best for them. Just like you said, Cynthia.

That was a great overview. I think you're helping educate your local community both MDs and ODs, on how to work together and how to send the right patients in early. Dr. Nichols, you're at a teaching institution. Is that a big part of the curriculum? Identify dry eye early? And how are you trying to educate your students to make sure that dry eye is a top priority, even if they don't want to do the treatment?

 I will say that one of the biggest challenges for optometrists is a bit of the misconception of the public. Patients will come in for a vision exam with vision insurance. And that only gives you a very specific exam that doesn't cover the medical part of dry eye. And patients expect to be very well treated. They want everything taken care of within that context. We often sell ourselves short in many instances. And this is where you actually have to be able to tell your patient that they need to come back and have a more thorough dry examination because you think that they have this condition, it needs to be better managed, and you can't do it within the context of that short vision exam. That actually is a barrier or a problem because patients will come into our clinic, they have vision insurance, and they want their exam, and they want everything taken care of.

We fight that as optometrists in terms of the medical versus the vision exam.After that, teaching students to see dry eye early is important. And again, it also gets messed up in the same issues that specialty clinics have in that students are learning how to do their exams, they're looking at retina, they're doing all these things. They may not be thinking about dry eye as much either. It's like prime grounds for teaching them that dry is everywhere you need to manage it. But we also refer to a dry-only practice because sometimes going to a practice like that is intriguing and positive for patients and they want to go somewhere to have that specific need taken care of that's different from a teaching clinic. And we don't have any problem in referring to that clinic. It all boils down to trust. If people who you're getting referrals from and who you're referring to know what each of you can do and know what's your lane and where the lanes overlap and having that communication, I think is an important thing to teach students. Go meet with these doctors or email or Zoom, so that you can let them know your services or have a packet like we heard about so that they can see what your services are. That creates that trust so that you have what's best for the patient in mind.And if you do that, you won't go wrong, as Cynthia mentioned.

That is such a great comment because I like to know who the doctors are that have different areas of expertise and who has different devices for the treatment of dry eye in my community.Because we sometimes need to send patients out for various reasons. You don't want to send a patient that has a certain condition that that doctor doesn't love taking care. I try to find doctors in my area that love taking care of certain types of patients. So, you described having someone like Dr. Brimer who is passionate about identifying and treating and making patients happy with their condition which is just so wonderful. Dr. Matossian, I know in your community, you founded your institute, and you built a huge practice. What were some of the biggest challenges in working with the community of both MDs and ODs in your practice and in your community?

I think communication is so important because when I started to do dry eye, which seems like eons ago when it was not as well known, people didn't talk about it, was something that people were not very familiar with. It took me a while to educate my colleagues about what I was doing and assure them that these patients are coming back to you because nobody wants to lose them. Assuring them that I will treat them, I will send them back when you want me to, or I will chronically take care of them until they develop a disease entity that you treat.

And by showing that we had a huge array of different treatment modalities, in-office, procedures, at-home remedies, and videos that we shared with our patients, it took the burden off of them and helped the patients. This way, they could concentrate on their love, which may be cataract surgery, or LASIK, or glaucoma, and give me the things that they were less passionate about doing. It's creating that trust, that communication, and that community to help the patient.

Thank you. All of you have this great outlook on how to care for patients with dry eye, and how to work with the other doctors in the community. This is so exciting that we have such a breath of expertise here because even though I feel like I'm knowledgeable about dry eye, I learned so much and took away so many pearls from all of you. We have time for maybe one or two last pearls from each of you that you want to share. Our program title is Modern approaches for the optimal management of dry eye disease, and I think we've covered it in a fantastic way. We'll start with Dr. Nichols and then Dr. Brimer and then Dr. Matossia. We go through one or two last pearls for the modern approach of our dry eye patients. Dr. Nichols?

 My first tip would be to just look and then do something, and that's not artificial tears usually. So, slit lamp is your friend and is important and the meibomian glands need to be evaluated, and don't underestimate what patients are willing to pay for their treatment or do for their treatment in order to feel better. I learned that early on in dry eye and I have an example that just stuck with me and so as we get more and more tools, I think it's important to remember that we want to do what's best for our patients and offer these new therapies that are coming out. Since we have a therapy now, we're looking at Demodex too, have the patient look down. That's a critical thing that I think we're not doing, and we need to use dyes. As Cynthia mentioned earlier lissamine green and fluorescein are critical in the evaluation of ocular surface.

I love that. When I'm talking about slit lamp exam and just the uniformity of it, the way I approach it, it always starts with look down. It doesn't matter what they're there for, it is look down and look at those lashes. But that's not my pearl, that's Kelly’s. So, I would say a couple of things. Don't feel like just because you don't have everything you can't treat dry eye. Do something. Get your toes wet because the need is abundant, and these folks, the more you try to put your head in the sand and ignore it, the more you're going to see them recurring on your schedule. It’s going to be a thorn in your side because you don't want to see them because you don't have an answer for them. It's inevitable that you're going to need to dive in. So go ahead and do it. And the easiest way I could recommend to start is to screen everybody. Whatever your method is, just pick something and screen every single person that walks through the door, so that it's rising to the surface, it's coming to your attention, and then you're being accountable to that result and you’re answering the need of the patient. So that's number one: screen everybody. Number two: do not be afraid to invest. I find that this fear of putting capital out there to buy equipment is debilitating for a lot of doctors that they're paralyzed. And my advice to doctors in deciding what to buy is fourfold. Number one: does it work? If it works, you’re going to pay for it and you're going to be building your reputation and your practice meanwhile. If it doesn't work, I don't care how cheap it is, don't buy it because your reputation is going to suffer for it. Number two, what is the experience like for the patient? Is it pleasant? Did it seem like it was worth the money you charged them? Number three, what's the business model over three years? It's not about the check you write, it's about all the things. What's the disposable cost? What's the profit margin, the MSRP? How many times would you repeat it, once a year versus twice a year versus 32 years? And then number four is the people and the support behind the company. For me, if you are thinking about, man, I want to do dry, I want to do something, but I'm afraid, I'm afraid to take that step and write that check. Look at those four factors and stop being afraid because everybody else is going to pass you by. I look in my town and all of a sudden there [are] like six or seven IPLs popping up. Where did this happen? But the last thing I would say is just because you've gone out and you bought a device, and now you're doing something, you cannot assume that it's going to work all by itself. There's nothing out there that fixes all brands of dry eye and ocular surface disease. You still have to take the time to look at the underlying cause and then pair the treatment with what's right for it. But even that needs ancillary treatment. It's going to need the omega 3 or it's going to need something else for bacteria. You've got to take the time to look at it, so that all these IPLs that are popping up, or evacuations, [they don’t] end up giving a bad name to the treatment because it was promised to be something it wasn't.

 That was a great, thank you. So many outstanding pearls. I love them all and I know that Dr. Matossian is probably going to add her own but maybe integrate some of what you just shared because those are really helpful. Dr. Matossian?

Very, very helpful pearls. Thank you, Kelly and Crystal. What I want to say is don't feel overwhelmed. I hear it from so many colleagues. Oh my god, Cynthia, where do I start? I can't keep up. There's so much happening. Help me. Well, there are people who are willing to help you. We are here as mentors. Reach out to us. We will be happy to pair you with other mentors. Start with baby steps. We never end up as marathon runners on day one. We have to crawl, walk, start walking, you know, power walking, and eventually be the dry eye center that we want to be. Start small, buy one or two pieces of equipment, master them, then move on to the next and so forth, and you can't do it by yourself. You need a community. You need your team. Identify people within your practice, staff, people who may be as passionate about dry eye or have the potential to be passionate about dry eye. Educate them, invest in their training, send them to seminars, and take them with you to meetings. Get key people at the front desk who can talk to the patients who are calling so that those patients can be scheduled with you. You create your own mini team within the practice and that's how you start building a dry eye center.

 Dr. Matossian, Dr. Brimer, Dr. Nichols, these are all fantastic pearls. I just love them all. They are really effective in helping our viewers understand various ways that we can help our patients. One pearl I was going to share was that sometimes we could get stuck in that even though we've tried what we think is almost everything, we just can't figure out how to help a particular patient.And the good news I think all three of you shared was that there are experts that love dry eye, and there are other places where patients can be sent. So don't give up. There are always other things that can be done. Maybe some of even the investigational things we didn't even cover today because we couldn't cover everything. So just don't give up on patients. They're looking to us for guidance, but if you can't particularly help them, just recommend someone else who can maybe have a different approach. With that, I just want to thank each of you, and Ophthalmology Times for having us here. It's really fun to share and learn from each of you and I know our viewers really appreciate all of you. Thank you so much.

Bill B. Trattler, MD, Crystal Brimer, OD, Cynthia Matossian, MD, FACS, and Kelly K. Nichols, OD, MPH, PhD, discuss dry eye disease and the various approaches clinicians can take to treat the disease in part 4 of the Viewpoints Podcast.

Podcast: Modern approaches for the optimal treatment of dry eye disease (Part 4)

Let's jump to the scenario that we see a lot.I'm sure all of us see a lot, which is, the patient comes in with some blurry vision, they're not seeing well, they've been told they have a cataract, but they also have significant dry eye. Dr. Nichols, how are you managing those patients? And let's just imagine that this patient that's type A, they really want to get to their surgery ASAP, but they're seeing you for advice on how they can optimize their ocular surface as fast as possible, so they can go back to see their cataract surgeon.

Wouldn't that be great if a patient came in saying, “I'd like you to optimize my ocular surface so that I can get my cataract surgery?” But I think, ideally, they get taken care of wherever they come from.So, in the referring optometrist's office or the ophthalmology practice, they're all together, and it's managed ahead of time before they're evaluated for cataract. But oftentimes, we don't have that luxury. Then the question is whether or not you slow down their surgical timeline, or if you can do it within the number of weeks it might take for them to get to the point of having the surgery. So, there's the ideal and the real there. Certainly, you might not have the time to do a long-acting anti-inflammatory if they're going on quickly. But I think the important part is looking at the meibomian glands, because that probably causes as much, if not more, of an impact because it's the outermost lipid layer that is what is the refractive surface of the eye. If you can normalize the meibomian glands to some degree before cataract surgery, or any surgery for that matter, you have a better chance, of having a good outcome. So that's a good approach. And there are shorter versions of that, depending on what kind of practice you're in, I would love to send them all to Dr. Brimer's practice so that she could take care of them before they go on to cataract surgery. But it's important to look and be thinking,and our message should be to tell everybody as often as we can to 

. Because that patient comes in saying that they have blurred vision, they aren't talking at all about dry eye symptoms. They are focused on getting their vision fixed, even if they have dry eyes. Unless you're really looking, you do miss it. They are an asymptomatic dry patient for the most part.

Obviously, those are such great points. And just to share, Dr. Nichols, I'm a big fan of using hypochlorous acid spray for my patients prior to cataract surgery. Now I use it to help with MGD. I don't know if it does, but it may reduce the bacteria around the eyelid. So hopefully, that reduces the risk of infection. There's no clinical trial that's shown that, but theoretically, that's my hope. But thank you so much. It was such a great thought process on how we help our patients with cataracts that aren't seeing well. Let me ask Dr. Brimer, for patients that are coming for refractive surgery, they've gotten at least a consult, and they are a candidate in some ways, but their dry eye is too terrible to consider. How do you manage those patients? And again, imagine they're a little bit anxious to try to have surgery.

So, are they ruled out indefinitely or they've been sent back to rehab?

Right. Their diagnosis says, “You're a minus four, you're going to be the perfect patient, but your dry eye tears aren't working. I want you to see an expert because I'm too busy to manage this. I know this great expert in dry eye and you're going to go right to her practice and she's going to fix you up ASAP.”

So, you're talking to a woman who has a huge portion of her dry eye practice as post-LASIK patients. So, I'm probably not going to steer them in that direction, but I'm not against it. If somebody has dry eye that puts them on the fence about being a candidate for LASIK, it's probably not a good long-term decision and we know that now. So hopefully, we're being discerning about who we allow to pursue that. But if I were trying and really giving them the benefit of the doubt and talking them through both sides, it would probably be procedure-based. Looking at what we've said all along, what's the underlying cause? And the way that I speak to them about this is, okay, we've got a boat, there's four holes in there. We've got to plug every hole, which means we've got to treat them simultaneously, or you're still going down. And if we come back and we're not winning in a category, then we go up to the next level and the next level of aggression. And it's not a trial-and-error thing with me. It's more of a, how far do we have to go? We add on, and we trade up, but I'm not taking away something. I gave them to trade it for something else. It's more of increasing the aggression and adding to it.

I love that. That's a great point. And guess what? Based on your comments, we're going to switch the patient from LASIK to an ICL procedure to avoid any disruption to the accurate surface. Thank you, I appreciate your comment there. Dr. Matossian, so many good thoughts on how to manage these challenging cases. Just as an overview, how do you develop your treatment algorithm? How do you make a plan to manage patients? Because there are different situations, maybe you can give an overview of the treatment algorithm, and how to start.

Bill, that is so important because we want to achieve the best outcome for the patient in the shortest interval. To do that, we have first properly to diagnose,as we talked about at the beginning part of this program. And secondly, target the selected treatment to address the underlying cause. So, let's say, there is tear surface disruption, you may want to look at the eyelid positions and the eyelid margins.They may do better with an in-office procedure to evacuate the inspissated meibomian glands. Maybe they need oral omega supplements to improve the viscosity and the quality of their meibum. If the inflammation is the biggest target, then maybe a short course of aggressive steroid therapy to put that fire out, as Crystal said, but maybe long-term immunosuppression and modulation via some of the products that we talked about. And often, it also depends on what else is going on. Are there telangiectatic vessels? Well, if there are, maybe, there is a hint of rosacea, maybe these people will do better with IPL than with heat-and-evacuate in-office procedures. And lastly, it depends on the patient's personality. If they are not compliant and they're not going to do anything you ask them to do, religiously, day in, day out, morning, midday, evening, however often you're asking them to do it, then take the equation into your hands and do a procedure and minimize the at-home remedies you're asking them to do because otherwise, they're not going to get better.

We have these great technologies and these great procedures for dry and we have excellent medications. And I'm going to ask Dr. Nichols here, when you have patients coming in, and you want to use a procedure, how do you combine the procedures with the pharmacological therapies? Are you using both simultaneously or are you doing a procedure first then adding a pharmacologic or vice versa, just curious about your approach.

It depends on what the whole ocular surface looks like if they, and what they're taking. So, certainly, I'm a lover of meibomian gland dysfunction. Actually, I'm a lover of it being gone, but I do think that almost everybody has some form of MGD, and I believe in preventative treatment, if at all possible. So, I think regardless of what you're doing in the anti-inflammatory categories, you do need to be looking at the meibomian gland and managing that too.Now the challenge is in the financing in some instances and you have to be able to convince your patient, this is the very best thing for them and there are a variety of different things that people have in their offices that they can use.But I do think treating the meibomian gland should continue to be a very important part of managing ocular surface disease. And until we get approval codes that allow us to bill for them, it’s out of pocket.Students will always say, well, I don't want to have to sell something.Well, you're not, you're giving your patient the best treatment for their situation and that's not sales, but I see where some people are afraid to recommend a procedure that costs money when they think that there may be a drop that should fix that. So, I'd love to hear from the two ladies about how they've managed that. Because I think it's an important point to be able to talk to your patient about that and be confident with your decisions related to how you're going to manage the patient.

It comes back to that patient education piece and having the tools just to tell them their story. In the beginning, when I first started, I would stumble over my words, and I would talk it to death, and it felt like I was selling something. And I wondered, who am I trying to sell here? You or me? And then that evolved because I saw the outcomes. I saw what we could do and the changes we could make.And I had the tools to tell them their story. It evolves into me being the messenger and effectively helping them to see it for themselves. One thing I do is in the very beginning when I'm setting up the day, the exam, and the eval, I try to negate the biggest pieces of baggage that I see people coming in with. So, my big points are, I've got a plan, we're going to go through a long list of differentials, whatever’s positive, we're going to pair it with the treatment. It won't be forever, it's just to get you stable and then we can back off.If we need more, we'll climb that ladder of aggression. I'm going to figure out what's going on. I'm going to show you everything, you're going to learn a ton. I'm going to prioritize it, and then I'm going to give you a good, better, best option, and we're going to decide together. And then everything's going to be written down. You don't have to worry about remembering a thing. When you think about the baggage that people come in with, either they've been to a bunch of doctors and it's just going to be somebody else who's going to throw something else at me or I'm not going to understand, you're not going to talk to me, you're going to decide to sell me something instead of me being involved in the decision or how am I going to remember this? These were what I felt were the four biggest points that I needed to deflate the minute I walked in the door. I think what helps with the overall conversion at the end is to put their mind at ease so that they can be in the moment with me and listen. And then I show them their story. I show them what the pictures say. And then I give them that good, better, best so that they feel like they're a part of the decision-making, but I sit back, and I say, if it were me, I would do this, this, this, this. How's that sound? And 90 plus percent of the time, almost 95, they say, okay. Because it makes sense to them. Now, one thing when I'm doing a comparison of, okay, if you don't want to do that, I can write you a prescription for a drop. Here's the difference. If we do these in-office procedures, it’s going to be a quicker trajectory.We're going to get a better outcome quicker and it's not going to be dependent on your perfection. That's the difference. When we rely on the things that you're going to do at home, I’ve got to give you more things to do at home. So, it's going to take more time and it's going to take diligence on your part. And when you go on vacation, or somebody gets sick or you're able and just not able to do it, you’re going to hurt because you didn't do your part. So, it's always going to be dependent on you. And it just helps them put it in perspective that it's not the only route that we can go. We can choose a different route for you but here's what to expect in that route versus this one. And the other thing that I like to mention is that there's no guarantee that at-home procedures are going to be an inexpensive route because we don't know what the costs are for the drugs, and we still need all these collateral palliative treatments that go along with it.

Dr. Brimer, that is a great approach. Thank you so much for sharing that. It's helpful. And I just loved how you say you write it out for the patients to take home and think about it. That also seems helpful. One of the things that's exciting for all of us here is that we have three new medications that got FDA approved recently. Dr. Matossian, can you give an overview of the three new medications, because it's very exciting. This is going to add to our armamentarium and work very nicely with our procedures as well.

We're so fortunate that the field of dry eye disease is literally exploding. It's mushrooming with diagnostics and with different treatment modalities. The three newest ones are not in any particular order, but I'm just going to list them. One is called Miebo. It's an anhydrous product, and it has no water whatsoever. Therefore, there's no osmolarity or pH associated with this product. The feel is very velvety and luxurious. There's absolutely no stinging, and it is used QID to help stabilize the tear film and prevent evaporative dry eye. The second one is Vevye. It’s cyclosporine mixed in with that cyclosal solution. So again, the stinging, the burning, the instillation site discomfort is eliminated, but the main ingredient is cyclosporine. The third one is Xdemvy, [which] is lotilaner, and it is the only FDA-approved product for the treatment of blepharitis caused by Demodex mites. The studies were very robust in that the mites were actually killed, and it is used for a six-week period twice a day.If the infestation reoccurs, then the patient may be able to use it again or is encouraged to use it again, maybe semi-annually. Those are the three new products on the market in terms of treatment options. And the newest kid on the block is a new diagnostic device for IgE immunoassay so we can differentiate allergic conjunctivitis from other red eyes. And this is a kit available with a billable code.

Now, these are all really big additions to our armamentarium. Any thoughts, Dr. Brimer, Dr. Nichols, on these three new agents?

 Just super excited to see the clinical trials are continuing at such a rapid pace. And look, we have three new options. Now, that's going to confuse a lot of people, I think, in terms of, well, now what? There's even more, but that's great. We're going to start to see how we all use them in a stepwise approach or in addition to others, without other things or in place of other things. Unfortunately, there's going to be the issues of insurance. And that always is a huge barrier in the first bit of new medications coming on, but I think there'll probably be some pretty robust patient assistance plans, in the beginning, to help people to get using all of these medications. So boy, let the fun begin, is what I say. It's going to be exciting when they all do come to market. They're all approved, but we haven't seen them in practice yet. I've been involved in some of the clinical trials and we're either getting better at clinical trials or these medications are just getting better because we're just seeing some great results that are very convincing for all of these products in terms of their FDA application. So, [these are] really exciting times.

Bill B. Trattler, MD, Crystal Brimer, OD, Cynthia Matossian, MD, FACS, and Kelly K. Nichols, OD, MPH, PhD, discuss dry eye disease and the various approaches clinicians can take to treat the disease in part 3 of the Viewpoints Podcast.

Podcast: Modern approaches for the optimal treatment of dry eye disease (Part 3)

Thank you guys so much. That was just a great overview of all the different variety of ways we can diagnose patients with dry eye. And now we can get to the fun part, which is how we treat patient’s dry eye. Let's start with Dr. Nichols. You know, there's so many different ways you can treat patients. Let's talk about [if] your patient comes in. They only have had artificial tears. What's your kind of first line treatment for patients? If you want to separate evaporative versus aqueous-deficient, that's perfectly fine too.

I'm going to take a tiny little step back before that, though. I think it really depends on how they're coming to you, where they are in the dry eyes road. Because they make it to like a practice where, you know, a specialty practice and they've never seen anybody before. Like they think that they've they have dry, they've heard something on TV, they've gone to the market, you know, found something on their own. But then there's also people who have this long history. And so, they may look like they've not tried anything, but they've tried a lot, maybe not a lot for a long time, like they've never stayed on anything consistently. So, it really does depend on how they're coming to you, where you start. So if they're like a naive to everything [patient], they're usually not, because they've tried something on their own, like artificial tears, and so your next step should be a process so that you can follow a process with your patients depending on what type of dry eye they might have, whether you think it's aqueous-deficient or it's evaporative or some combination of both. And if it's one or the other, you're going to lean towards some different treatments, especially if you think there's a lot of inflammation there or not, or how bad their meibomian glands might look. So, what you don't want to do is like what I call a "kitchen sink it," all at one time where you're just throwing everything in at once. So, you should start with what you think is the most predominant factor of their dry eye, the finding of their dry eye, and go from there. But I don't know that there's a simple answer to that because they all come to you different, you know, from their history and what they've tried before. Finding out what they've failed is really important to success, I think, in a new setting.

Now, those are great points. I totally appreciate exactly what you're saying because this is a difficult question. But for time reasons, we'll just try to make sure everyone gets some thoughts here. Dr. Brimer, when you see a patient, and I really want to set the stage as Dr. Nichols shared, there's not just one type of patient, but let's imagine a patient that is a contact lens wearer, they've used artificial tears and now they're coming to see you because they're having contact lens intolerance. What is your typical first line treatments for these types of patients?

I want to look at the underlying cause of what's creating the dryness. So, if it's a contact lens patient, I'm going to look at the material and I'll look at how they clean them, is it daily disposable, that sort of thing. But I'm just not the person that typically recommends tears much at all. And [it's] fine, if it's an occasional dry eye and its situational dry eye, I want them to use preservative-free tears. But most of the time and again, my perspective is different because they're coming to be more advanced. So, we've got to throw that out there. But most of the time they've gotten where they are because they've been using the tears chronically for years and it's progressed because they've pacified the emergent need by putting tears on it. So, they've made it through another day and another day, but meanwhile, things were getting worse. So, I tell patients, I'm not going to stop you on your tears. You can keep using them for now. But my goal is to figure out what's going on so that you don't need them anymore. And when you come back to me and you say, "Oh, I'm just using tears, you know, once or twice a week." Then we know we're where we need to be. So, I'm not going to change the tears. I am going to look at the material. I'm going to look at what their modality is, how they're cleaning them. But primarily, I'm going to take those contacts off and say, what else is going on here that we need to address more at the root cause?

These are a beautiful way of approaching this type of patient. You're absolutely right. Well, let me ask Dr Matossian about artificial tears in general. What are your thoughts on artificial tears in general? Are there some challenges them or are you happy with them? And how often do you, you know, as Dr. Brimer suggests that she doesn't stop tears, but maybe tears aren't always the answer. I'm just curious of your thoughts on tears.

You know, Bill, there are challenges with artificial tears. The first one is if we as eye care providers don't take the time to look at what's going on and instead just very rapidly or superficially say, "Oh, Mr. Jones or Mrs. Jones, just use some artificial tears." We are not doing the patient the service that they deserve. We need to dig and figure out the cause and appropriately treat. Just throwing tears just to kind of mollify the patient is not ideal. Secondly, if we don't specifically recommend a type of tear, we're also doing that patient a disservice. Have you recently checked the shelves in the grocery store or the drugstore, in the eye section? It's row after row after row of different types of artificial tears. So, somebody who is not an expert in the field, how are they to choose? They don't know. So, they go either A, the cheapest one, B, that's on sale, or thirdly, they buy something completely wrong, like an anti-allergy drop to get the red out because their eyes are red due to DED (dry eye disease), not from allergies, or they get an eye whitener. So, this then further exacerbates a dry eye condition. So, these are the challenges. We need to help our patients by digging deeper to specifically recommend certain types. And lastly, like Crystal said, preservative free artificial tears are the way to go. These are people who are already suffering. They're in your offices for a reason. And the preservatives in tears can make the situation worse.

There's just such great points. I totally agree with you. So now that you've pointed all those issues out and ways of approaching artificial tears, I'm going to go back to Dr. Brimer and ask the next question, which is, okay, so they exhaust artificial tears, they've used them and they're not doing anything. So now you're ready to use an anti-inflammatory agent. I guess the question is, when do you make a decision? When decide, okay, now it's time to add an anti-inflammatory agent into the therapy for dry disease.

Two situations. So if a patient comes to me and it is very obvious they are on fire, their eye's red, their lid margins are thick and hyperemic, there's a lot of telangiectasia, there's just chronic inflammation, and especially if the patient's in a lot of pain, I know that a lot of the other things I'm about to ask them to do are going to involve delayed gratification. And so, if I go ahead and give them a steroid to kind of quench the fire at the moment, it's going to help them stay on course and stay on track to do what I'm asking them to do, because they're going to get some relief early on. Now, when I do that, honestly, I like to use a steroid ointment because I'm asking them to do other things. And that way it's only a once-a-day dosing and it kills two birds with one stone because it gives them that nighttime lubrication. And I'm not doing refills. I'm just trying to get them over this hump so they can feel a little relief while the other stuff is kicking in. And the other times that I'll do it is more when we're along the journey and there's a flare. So, I don't think that was really your question, but I threw it in there. And typically, I'm going to implement more in-office procedures than I am going to [use] a chronic drug. So, I use chronic anti-inflammatories, but I'm more likely to do a quick steroid to put out the fire, do in-office procedures to get to the root cause, and then if I need that ongoing anti-inflammatory, then I'll incorporate that.

Okay, beautiful. And I totally agree. I mean, you made some great points on how we can use steroids so effectively for a dry eye patient in different scenarios. Maybe we just talk about, in general, just all the various anti-inflammatory technologies that we have available to us. I'm going to ask Dr Nichols because, you know, we have a few different options. We have cyclosporine, we have lifitegrast, we have obviously topical steroids, and Tyrvaya or varenicline, I hope I said that right. As everyone knows here, I'm not the best at pronouncing names. So, Dr. Nichols, maybe share kind of how these and anti-inflammatory treatments are similar or different and I guess an overview of those products’ product.

Great. And I will have a question for all the panelists too at the end, because if you don't have the ability or you haven't done in-office procedures, then your approach might be different relative to some of these other therapies that Bill just mentioned. So, you know, it is interesting, depending on where you are, I know if you have, I know what I would do if I had everything in my office versus if you only have yourself and your slit lamp. So having said that, you know, inflammation is one of the body's ways in which it can respond to insult or injury or irritation. And so, you're going to have inflammation with ocular surface conditions regardless. In some cases, it's not going to be obvious, and in others it's going to be much more obvious. And in some instances, there's going to be associated factors where they have inflammatory diseases that go along with what you're seeing on the ocular surface. So, your choices may be different depending on what else is going on. We have cyclosporine, [its] been around for the longest of all of these medications. It had like at least a 15-year head start on lifitegrast. So, we tried it, we used it. It was all that it was available. And originally when cyclosporine came out, I think a lot of doctors saved it for the worst dry patients because they really didn't know how it fit into the algorithm and what they should do. And then there were a number of doctors actually who tried it for a short period of time or patients, and then patients stopped for whatever reason, they didn't get the full effect or maybe they didn't realize they got some effect. And so, they quit. When we are seeing patients for clinical trials now, most of the time they've tried cyclosporine at some point in the past, but when they describe how they tried it, it can be like they just they say, "well, I did try it." Well, how long did you try it? "Well, I don't know." You know, you ask them if they refilled their prescription to find out if they really tried it. And most of the time they don't. And I would say that's even sort of true with lifitegrast, especially if the patient has symptoms of the negative side effects, you know, whether they have blurry vision, or with cyclosporine, if they have a lot of stinging. Now there are ways that you can coach a patient around those if you really do feel like having a chronic anti-inflammatory therapy works, and they do, they just do take some time to kick in based on their mechanism of action. They're all slightly different. Then of course, we talked about steroids just a moment ago, which give you that first initial burst acute help. And then there's, I'll just call it Tyrvaya as well, because Bill I'm with you, I'm the camp of can't pronounce any of the new names. There's a few that were just approved, that we'll talk about later, and I'm like, wait a minute, how do you say that? What do we to do? But yeah, so I don't know that I'd put that in the controlling inflammation category because it is sort of like an internal, self-regulated, artificial tear that your own body makes. So, I guess it can help calm any inflammation on the ocular surface because it's helping to sort of give some lubrication, perhaps, that might have been what was part of the problem, in terms of causing inflammation. But you do have to get to the root of it. And these can all help in their own ways, but they don't solve the problem in most cases.

That is a great overview. That actually was lovely to hear because I think it really helps us kind of set the framework for everything. I think, you know, obviously the two main categories, cyclosporine and lifitegrast, we've had them both now a little while, and you know cyclosporine was first. I'm going to ask Dr. Matossian, maybe you should explain the mechanism of lifitegrast and give an overall view. Because I think even though it's newer and it's been around for a bit, I think it's always helpful to kind of review that.

Well, I will try to make it as simple as I can, but it is complex. In essence, Xiidra or lifitegrast blocks LFA-1. So, what is LFA-1? LFA one is a surface protein found on the surface of T-cells. So, T-cells are just floating about regularly, looking to be invited to an inflammatory site. When the surface is stressed, there's something called ICAM-1s that are overexpressed. ICAM-1s invite or recruit T-cells. The way a T-cell docks onto the ICAM-1 is by its LFA-1. So, it's kind of how they come together. So lifitegrast blocks that ability of the LFA-1 to dock with the ICAM-1, and it's only through the docking that the T-cell is then activated and then it releases all the pro-inflammatory cytokines, and more recruitment of T-cells happens. So, by blocking it, not only inactive T-cells, but active T-cells as well, it kind of reduces that perpetual inflammatory cycle on the surface of the eye.

That's a beautiful explanation. That was fantastic. I definitely could not have explained as concisely as you did, Dr Matossian, that was beautiful.

We all realize, I think all of us, enjoy being able to use lifitegrast or Xiidra. And I'll ask Dr Brimer, you know, how do you decide? So, your patients come in, and you know, there's a cost to using medications, you obviously don't want to over medicate. How do you decide when to use lifitegrast versus cyclosporine, when you're going to add one or the other. What is the key [difference]? How do you decide between the two?

I feel like that's such a biased answer I'm going to give you. You know what I mean? In my clinic I have my favorite, I have my tear. I feel like absorption is important. You see all the newer molecules coming out with smaller size molecules and ways to protect it to get through the aqueous, so that it absorbs in the tissue better. But ultimately, I think a large factor is going to be patient tolerability. And I had a patient today, and I hardly ever do this, but I broke down and did it, I gave them samples of each because everything I've ever given, it was like, "No, no, no, no." And I said, "Listen, take five days with this. Take five days that call me back." Because I just don't expect a difference in how you feel. I just want to know what you can tolerate. So, at this point, I'm grateful to have options because none of these three, and even the ones to come are going to be perfect for every patient. And yes, we care about efficacy, and we want to get the most efficacy as quickly as we possibly can. But if they're not compliant, we're not going to get anything. And so, everybody is going to have a different response on what side effects they have, and what side effects they can tolerate. So, does it burn, does it give blurred vision? Is there a bad taste? And so that's one of the factors. One of the factors is cost. And I no longer can predict anything when it comes to that. But I do know that a couple of the companies have patient assist programs and I appreciate that, when they're able to come to the table and help my patients that can't afford it.

Those are great comments and I agree. Any challenges? And I'll just briefly ask Dr. Nichols and then Dr. Matossian for this particular question, how do you decide between the two, because there are two good options. They both have really nice effects. But just curious, let’s go with Dr. Nichols, like how you kind of figure out which to use first

We're in a teaching institution, so we keep that in mind as well. I mean, you know, we allow for our students to select which [treatment] they're going to try on a patient so that they can experience that while they're in school. And so, I used to have a preference and now I just sort of like to see where it goes with overseeing patients. Because [in reference to] the cost issue, we have a clientele at the school which isn't necessarily well off. And so, the patient assistance programs are good. Medicaid reimbursement for some of them are really helpful for patients. And certainly, now there's generic, which can be helpful, with cyclosporine. So, I do think that there are some options to be thinking about that, that I would hate to say, you know, yeah, I think about cost, because you never know what a patient is willing to pay for and what they're not. But yet giving them good options is critical and allowing them to try and see what side effect profile they have is also important because they have to stay on it in order to see an effect.

Right. Great. Great points. Dr. Matossian, your thoughts on the two options?

You know, I wish I could say we were in control of what drug our patients received. Just because we are prescribing it does not mean that that is the medication the patient is ending up with. Unfortunately, many switch outs happen at the level of the pharmacy because of the insurance program that the patient has. Maybe because of the amount of co-pay difference. So, there are so many different factors that go into how a patient ends up with a particular drug that I can no longer predict, if I write for A, do they get B, do they actually get A, or is it switched out? So, I'm happy if they end up with an immunomodulator, when warranted.

That's a great answer, and it’s so true. I find the same thing. I'll write one and then I hear from my tech, "oh, sorry. That one wasn't the first time on there are lists of drugs and you have to go to this one now, unless they had failed this one." You know, it’s kind of can be challenging times. But I guess the point is that we have these great options. Our patients do have options. If one doesn't work, they can switch to another, and vice versa.

Bill B. Trattler, MD, Crystal Brimer, OD, Cynthia Matossian, MD, FACS, and Kelly K. Nichols, OD, MPH, PhD, discuss dry eye disease and the various approaches clinicians can take to treat the disease in the second part of the Viewpoints Podcast.

Podcast: Modern approaches for the optimal treatment of dry eye disease (Part 2)

Bill B. Trattler, MD: Hi, and welcome to this Ophthalmology Times Viewpoints titled, Modern Approaches for Optimal Management of Dry Eye Disease. I'm Bill Trattler. I'm a refractive, corneal, and cataract surgeon at the Center for Excellence in Eye Care in Miami, Florida. I'm very lucky to be joined with three outstanding experts in dry eye. These are just rock stars in dry eye. I'm excited I get to learn so much from each of them. And let's start off with that. Dr Brimer, if you could introduce yourself and share your love for dry eye.

Crystal Brimer, OD: I do have a love for dry eye, Bill. I'm Crystal Brimer, I'm in Wilmington, North Carolina. I have a solo, private practice. It's a referral center and we only treat ocular surface disease every day, 100% of the time. I also have [the] Dry Eye Institute where we focus on the training other doctors and just equipping them to get better outcomes and trying to inspire them along the way.

Bill B. Trattler, MD: I love it. That's wonderful. Thank you so much. Thank you for being with us. Next, I have Dr Matossian. If you could introduce yourself and share your love, because I know you love dry eye; I've spent a lot of time with you. Thank you.

Cynthia Matossian, MD, FACS: I am passionate about dry eye as well. Thank you very much for inviting me to this program. I'm Cynthia Matossian. I'm the founder and past medical director of the Matossian Eye Associates. Matossian Eye is an integrated ophthalmology/optometry practice with all the different subspecialties. My area of sub specialization was refractive cataract surgery and of course, dry eye. I'm delighted to be here with all of you.

Bill B. Trattler, MD: Wonderful. Then last but certainly not least, Dr Nichols. You're passionate about dry eye. I've had a chance to work together many, many times. So, thank you for introducing yourself.

Kelly K. Nichols, OD, MPH, PhD: Thank you for allowing me to be with everyone here this evening. This is such a treat and especially to have a wonderful audience, as well. I am passionate about dry eye, always have been since before it was probably cool to like dry eye. I'm currently the dean of the University of Alabama at Birmingham School of Optometry and I've been involved in dry clinical research and translational research, as well as seeing patients for too many years that I care to say. So, it's nice to be where we are today, having this in-depth discussion about what's going on in dry eye.

Bill B. Trattler, MD: Thank you so much, Dr Nichols. I guess just to give you a quick overview; I'm super excited to be here. We're going to talk about a variety different topics on dry disease. We're going to talk about how we all diagnose dry eye, because there are all different strategies you can have, and some of the current emerging treatment options, because there are so many new things that just become approved and are about to become approved. We will also discuss other strategies, [like] how to handle the more challenging patients. I'm really excited to get started with each of you. I guess we'll start with the basics, which is, Dr. Brimer, how common do you see dry eye? Well, this is a bad question because I know you're 100% dry eye, but I guess how common is dry in general, then? And who's at increased risk for dry eye?

Crystal Brimer, OD: Well, I think if we go back 30 years, people would label it as a woman's disease because we tied it so closely with hormonal change. And yeah, that's still happening. But it seems like such a fraction now of what I see because there's nobody that's not at risk for it. I think it's almost appropriate to reverse that question, because you think about [it], our diets are completely different than they were 30 years ago. We've got more systemic disease; we have more side effects from medications. Then the biggest one, we've got way more device use than was even dreamed about 30 years ago. And you couple that with the changing of times where you've got these young kids who are growing up and basically being babysat by an iPad, which I understand. I don't have kids, but I think I can understand. But what's that going to look like in the future? It's going to be the opposite. It's going to be who is not at risk for dry.

Bill B. Trattler, MD: That's a great thought. I just love how you frame that. I don't know if maybe Dr Matossian wanted to share similar thoughts, and then we'll ask Dr Nichols as well, but Dr Matossian?

Cynthia Matossian, MD, FACS: That was a great description, Crystal, and that's how I used to approach my presurgical patients. Anybody who came in for a cataract consult, for example, I had to rule out dry eye disease before or concomitantly with evaluating their cataracts, because from your study, Bill, it showed what a high percentage of people who had never been diagnosed with dry eye were scheduled for their cataract surgery. So, like you, Crystal, I mean, we really have to almost rule out who doesn't have dry eye if such a thing exists.

Bill B. Trattler, MD: I love that. Dr. Nichols?

Kelly K. Nichols, OD, MPH, PhD: Right. I completely agree. There are so many associated factors with dry eye these days that almost everybody has one of them. It's just a matter of if they are compounding with one another and it's starting to impact the patient, and if we're asking the right questions to be able to detect it. So, I agree. It's almost like you consider everyone has dry eye until you rule it out these days.

Bill B. Trattler, MD: Dr. Nichols, that's perfect. Thank you so much. That leads us into the next very important question, which I'm actually going to turn right back to you, Dr. Nichols. Why is it important for us to recognize and treat dry eye for all of our patients?

Kelly K. Nichols, OD, MPH, PhD: I think I'll step back into the discussion a bit about how everybody [is] glued to some sort of screen or device or maybe more than one at the same time. And certainly, if you have any irritation, if you feel your eyes, you have dry eye, then that can impact your ability to be able to do your work or your activities, especially on that screen or towards the end of the day. So, I think that we're learning a lot more about the impact of dry eye on the ability to be able to work, the ability to be present at work and with dry eye and even time off from work due to dry eye and all those things. There's been research in those areas over the last several years and it's not surprising, you know, that patients are very impacted in their activities, it even can be reading, driving and other things. So, when we stop to think about who is impacted and how, you know, we might be able to help that, whether they're going on to surgery or they're having trouble functioning in their day-to-day activities, I think it's really important to be able to recognize dry eye. So, we should be asking questions all of our patients, regardless of what kind of exam it is, to try and determine if we can help them have a better outcome.

Bill B. Trattler, MD: I love that. Dr. Brimer, any additional thoughts? That was really comprehensive.

Crystal Brimer, OD: What I would say is, in being that referral center, I see the difference that it makes in their final outcome, whether we were able to implement treatment at year one versus two, two versus three, and three versus four; it's a significant difference. I mean, just today, seeing a patient with almost no glands and all she can think about is, "this could have been prevented." And so, everything that inside of me just points to the overall outcome and quality of life of this person ten, 15 years down the road, depends on when we intervene.

Bill B. Trattler, MD: I love that. Dr Matossian, you always [have] so many good thoughts. As you all know, Dr Matossian and I go to a lot of conferences together. How do you kind of approach these patients and why do you feel it's so important to address these patients with dry eye?

Cynthia Matossian, MD, FACS: You know, dry eye disease is chronic and progressive, and think of it as chronic pain. Obviously, not all dry eye patients have severe pain or moderate pain, but some do. And when somebody is in constant pain, they are grumpy and their mood swings all over the place. They snap back at their colleagues or spouses or family members, and there is depression associated with it. This is real. Studies have proven this. Therefore, just like Crystal said and like Kelly emphasized, identifying patients with dry eye disease, intervening early, and treating them as comprehensively as possible, we truly change the quality of the life of these patients, and that is a gift that many doctors have.

Bill B. Trattler, MD: Let's just talk just a little bit more in-depth about how dry eye affects coexisting ocular conditions, or focusing on accurate conditions, like how does it make you approach the patients with other ocular conditions, and how does dry eye impact that?

Cynthia Matossian, MD, FACS: I'm so glad you asked that question, Bill, because so many of us are siloed into our own subspecialties. Let's take right now, for example. You know, these doctors see day in, day out, people who are losing vision, going blind, let's say, from AMD. Geographic AMD or, you know, neovascular AMD. They're getting injections, you know, every so many weeks apart. And their fear is, can I maintain the patient's vision? But these patients are also suffering, many of them, from dry eye disease. All the prep, all the anesthetic, the gels, et cetera, are really wreaking havoc on their surfaces. So that's just an example where coexisting diseases does not mean that we as ophthalmologists and optometrists can only focus on our little niche area. We truly have to look at the surface. Same with those who wear contact lenses. You know, their surface may be getting pummeled by over wear of contact lenses, sleeping in contact lenses, maybe extending the wear when they shouldn't be to save money, or with people who, for example, have glaucoma. We are requesting our patients to be compliant with their [medications]. Most of the glaucoma drops have what in them? Preservatives. So, we're not just glaucoma specialists. We also have to be surface specialists.

Bill B. Trattler, MD: You nailed a couple of great areas. I agree. I'm going to take a multi-specialty practice with each of those specialists. And I realize we need to continue to train everybody to manage dry eye, not just those that love dry eye. So, everyone needs to be able to handle those patients generally. Maybe Dr. Nichols next, any additional thoughts? I guess you see so many patients with dry eye in your practice. So, I'm just curious your thoughts on how dry impacts coexisting ocular condition.

Kelly K. Nichols, OD, MPH, PhD: I'll just say, just to piggyback on Cynthia, when people are so siloed into their particular areas, and of course they're usually really good at those particular areas, it's really hard to then like take a step back and maybe think about the ocular surface. And that's where a really good partnership comes in, whether it be somebody in the practice whose sole job is to be doing ocular surface or the referral down the street. I think it's recognizing and having that good network to be able to, then take care of that patient. If you want to focus on that specialty and don't want to, we'll just say, be bothered by the ocular surface part which somebody else probably really loves. So, I think it's a matter of finding the people who are going to be part of your network so that the patients can get that care and it really will result in a better outcome all the way around for all the subspecialties, if that's done.

Bill B. Trattler, MD: Oh beautiful, great. So many great points. Completely agree. Dr Brimer, your thoughts?

Crystal Brimer, OD: Well, not only do I agree, but I would reinforce that by saying, my number one referral source is the two glaucoma specialists in town, the three retinal specialists, the neuropathologist and the corneal specialist, because they're getting the referrals for dry eye. But it's not really what they want to do either. But definitely the retina and the glaucoma, because it's either coexisting or they're creating it with the side effects from the medications. So, it's evident every day.

Bill B. Trattler, MD: Perfect, I totally agree. I guess I'm somewhat like you, actually all three of us, because in my practice I have multiple specialists. So, I'm getting the referrals from everybody in the group. Thankfully, [and] we'll talk about these new medications coming up, I think all these new medications continue to help us take even better care of our patients. So, this is an interesting question. And I would say controversial, but I say that just that different people have different feelings on this. Dr. Brimer, what are your thoughts about requiring a dry eye questionnaire for all your patients that we're concerned about dry eye? Do you think it's required, what do you do in your practice, [and] can we get by and maybe skip that?

Crystal Brimer, OD: No, you can't skip a screening. Maybe it's not a questionnaire. So, it's interesting that you ask me this question, because when you say it's controversial, I'm probably going to give the opposite answer of what everybody else in a lineup would give. When I'm talking to other doctors, I want them to visualize two different scenarios. One is, okay, we gave them a questionnaire. That was great. We had a screener, and I applaud you for doing a questionnaire versus nothing. Right? It's something. So that's step one if you're doing nothing. Yeah, pull the questionnaire out. Let's do it. Because it at least it presents itself. But imagine this patient does the questionnaire and then you get them in the exam room and you say, "Oh, yeah, I see this, this is bad, and I'm going to need you to do A, B, C, and D, and it's going to take an hour or two at night, but it'll be fine and it's going to cost you about $2,000 out-of-pocket. But listen, this is what we need to do." You know, they're either going to look at you and say, "yeah, it's not that bad," or maybe they do something, but then as soon as they feel better, they stop because they believe that everything you requested them to do was based on subjective inputs. And that's what I don't want. So, while I appreciate using a questionnaire and I think it's better than nothing and it's good in a really busy practice that's just trying to bring the complaints to the surface, when you're really digging for it, I don't think it's enough because I want it to be based on objective findings. So, what we used, and we started this way back in probably 2015/2016 when we first got the oculus keratograph, but especially when the software got redesigned. We use that screener, and it's your tear meniscus height, interferometry or break up time, and redness score. So, for me, it gives me a snapshot of water, oil and inflammation. The patient gets a report, is completely objective and it just brings it to light and says, you know what, you may have symptoms, you may not, but this is progressive. And to me, that also plants a seed so that if they don't have symptoms and they don't come back for eval, they're wearing their contacts, at some point in the year they get uncomfortable, it's in the back of their mind that, "all right, let me go back and take another look." So that's my take.

Bill B. Trattler, MD: I love it. Now, that's such a great way of framing it. And also, you know, having objective technology like a keratography device that can actually give you lots of objective measurements and can really help us understand where a patient's level of dry eye is. That's fantastic that you have to have your practice. Let me ask Dr. Matossian your thoughts on questionnaires, how you view them, and maybe thoughts on Dr. Brimer's thoughts as well.

Cynthia Matossian, MD, FACS: I really liked how you framed that answer, Crystal. A lot of practitioner’s view questionnaires or surveys as a nuisance. It takes too long. It jams up the pass through or the throughput of the patients. It leads to confusion and so forth. What we were trying to do, at Matossian Eye, is do it virtually, send a survey to the patient prior to the office appointment. This way the patient, in the comfort of their home, leisurely can answer the question, and the responses were getting integrated into the EMR. This way the patient at least started to think about their environment, [ fans or, you know, whatever it might be. Fatty acids, you know, omega threes, their diet, things that they may not be able to connect the dots [on] because they don't have that background like we do. So at least it helped the patient understand that perhaps something is going on. So therefore, when the objective testing was done in the office, then all of it kind of merged together and the patient was able to better understand their diagnosis.

Bill B. Trattler, MD: I like that. Thank you. That really makes a lot of sense, [and] obviously sounds like a very good strategy. Dr. Nichols, what are your thoughts on this topic?

Kelly K. Nichols, OD, MPH, PhD: So, we do, in our setting, a little bit more survey driven work just because we're screening for a lot of dry clinical trials and there's usually a symptom cut point to get in. We want an idea whether or not they might qualify. So, we do some surveys for that purpose, but signs and symptoms don't correlate very well with one another. We all know that, and that's persisted over time. And so, a set survey doesn't really give that tailored information that you need to find out by just asking questions along with your objective tests. So, I'm imagining, Crystal, that while you're doing some of those tests, you're asking additional questions and getting additional information that's very tailored to the individual who's with you at the time. So, you know, it does provide some information as a way in the door or for a clinical trial to find out if somebody might qualify. But it's not the only thing, certainly, that you should do by any stretch.

Bill B. Trattler, MD: No, this is great. We each have some different approaches. I'll share [my approach] in my practice. I'm [not aware] in our ractice of using a questionnaire, but we do ask specific questions to patients. You know, certainly for me what I think is important is to ask different questions. And of course, I involve objective tests, as well. So, with that in mind, I'd love to hear how everyone would diagnose dry eye, what objective tests everyone's using. So, let's go with Dr Matossian first. What tests do you feel are the most helpful for you to objectively diagnose dry eye?

Cynthia Matossian, MD, FACS: I think if you were to ask a room full of dry eye specialists what diagnostic tests they would do, each one would come up with a different kind of list. What they would do first and what they would do to follow up to see whether the treatment is effective. At Matossian Eye, what we used to do were three things. One was meibography. Everybody got meibography because to me it's like the X-ray of the lungs. When somebody shows up with a cough, I needed to see the images of the meibomian glands. You know, their health, their structure, their architecture, where they dropped out and so forth. The second one was tear osmolarity (TO), because that helped me understand kind of the surface evaporative state, how disrupted or dysregulated the tear film was. And lastly, everybody got an MMP-9 test so that I could see whether there was inflammation. According to the results, my treatment algorithm varied, and I could titrate my treatment to whether the MMP-9 was positive or negative, whether the TO was significantly abnormal or not, et cetera

Bill B. Trattler, MD: I assume you did other tests; did you do Schirmer's test, break up time, staining? I just want to get a just a good sense of what you do besides those three diagnostic tests.

Cynthia Matossian, MD, FACS: We didn't do Schirmer's [test]. They took a long time. There was reflex tearing involved. I just, you know, I thought it was a bit too subjective. I didn't do that. But of course, [with] staining, I always do is lissamine green 100% of the time to look at the conjunctival staining, which told me a very different story than fluorescein staining on the cornea. I did both. I looked at tear meniscus height and commented on that. Of course, I looked at the lid margins and the orifices of the meibomian glands, whether they were powded or inspissated. And [I] kind of pressed on the eyelid with just a Q-Tip to see the quality and the consistency viscosity of the meibo, and of course a good slit lamp exam period.

Bill B. Trattler, MD: That's really helpful. Let's hear from Dr. Nichols and then we'll actually go through all of them, and we'll talk a little bit more. But, Dr. Nichols, tell me your approach.

Kelly K. Nichols, OD, MPH, PhD: So, I think it depends on if we're targeting somebody who hasn't done any dry eye before in terms of the recommendations, I think that what we're going to hear is what I would say is like the nirvana of a dry eye practice from our panelists here today. And so, if the goal is to try and get somebody who hasn't done any of it before, you know, the most simple approach would be some sort of assessment of symptoms, verbally usually, and then an evaluation of either staining or osmolarity or tearful breakup time. And if any one of those three is abnormal with some sort of symptomatology, which I think you can get from most anybody, then that would be a positive screening for dry eye. That was recommended by the DEWS 2 work group as the most simple, basic entry into dry eye as a screener. And then if you have the ability to do additional testing, like you have meibography, you can use that to evaluate the meibomian glands, but the simple slit lamp exam and pressing on the eyelids, of course, that is something that anybody could do in the context of their office. As well as look at the tear meniscus height as a surrogate for Schirmer because who's really going to go do a Schirmer's test in practice? So, you can kind of hit all the different areas in a simple way if you don't have that fancy equipment, which we all love, and then either refer to somebody who does, like Crystal or Cynthia or you, Bill, and so that they can have a more detailed workup. So, I think that's really two approaches for those who are just starting out. You have a great instrument in the slit lamp, and you can do a lot with it. And a thorough lit exam is really critical

Bill B. Trattler, MD: Great comments, that's fantastic. Dr Brimer

Crystal Brimer, OD: I completely agree. Kelly brought up a good point of sometimes we get so involved and here's the 100 things that we do because we love it, right? It is our passion. And I want to know. I can't stop myself most of the time, to be quite frank. But you make a good point. And one thing I would add to that, for somebody who doesn't have a meibographer, transilluminate, pull the lid down and look. It doesn't excuse you to not know what's going on with the glands, because in some people you can see it with just white light. If you can't, then turn this slit lamp off, put the transilluminator under that lower lid and fold it over, and you can get a decent idea of, is there truncation, is there drop out? What I would add to the list of tests that were initially listed by Dr. Matossian is, I do a cotton whisk test on every dry eye eval, and I do debridement because I want to see where any tear film debris is coming from. Is it biofilm on the lid margin? Is it poor quality meibomian that's coming out? Is it allergic mucus? What is it? And then, I use meibomian expression paddles. And I feel like that gives me the most production without a lot of discomfort at all. I go through the whole gamut of test. One that's valuable as a patient education tool is the tear film dynamic, which is basically just a video showing how much debris is in the film. That tends to get quite a response from them, and it makes them a little bit more motivated to do something. And it helps them understand why the eyes read when we have all these contaminants in there.

Bill B. Trattler, MD: Perfect. Everyone has [shared] so many great tests that can be done. I guess we put a list together. There's so many different choices that anyone doctor can do and as Dr Nichols shared, a lot of times it's something more focused. You don't need to do everything on every patient, unless you're in a totally dry center as a patient that has failed therapy elsewhere. One thing I didn't hear from anybody is pulling eyelashes for mites. Does anyone tell you eyelashes for mites? Is that important, if you see scurf and blepharitis, are you treating as if they have mites. Just curious as that's a hot topic.

In this podcast, Bill B. Trattler, MD, Crystal Brimer, OD, Cynthia Matossian, MD, FACS, and Kelly K. Nichols, OD, MPH, PhD, discuss dry eye disease and the various approaches clinicians can take to treat the disease. 

Dry Eye

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