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


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.

Editor’s note: This transcript has been edited for clarity.

Bill B. Trattler, MD: 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.

Kelly K. Nichols, OD, MPH, PhD: 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 look. 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.

Bill B. Trattler, MD: 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.

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

Bill B. Trattler, MD: 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.”

Crystal Brimer, OD: 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.

Bill B. Trattler, MD: 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.

Cynthia Matossian, MD, FACS: 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.

Bill B. Trattler, MD: 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.

Kelly K. Nichols, OD, MPH, PhD: 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.

Bill B. Trattler, MD: That's a great question, Dr. Brimer?

Crystal Brimer, OD: 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.

Bill B. Trattler, MD: 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.

Cynthia Matossian, MD, FACS: 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.

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

Kelly K. Nichols, OD, MPH, PhD: 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.

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