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


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.

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

Bill B. Trattler, MD: 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.

Crystal Brimer, OD: 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.

Bill B. Trattler, MD: 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.

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

Bill B. Trattler, MD: 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.

Cynthia Matossian, MD, FACS: 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.

Bill B. Trattler, MD: 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?

Crystal Brimer, OD: 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.

Bill B. Trattler, MD: 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?

Kelly K. Nichols, OD, MPH, PhD: 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.

Bill B. Trattler, MD: 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?

Cynthia Matossian, MD, FACS: 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.

Bill B. Trattler, MD: 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?

Kelly K. Nichols, OD, MPH, PhD: 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.

Crystal Brimer, OD: 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.

Bill B. Trattler, MD: 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?

Cynthia Matossian, MD, FACS: 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.

Bill B. Trattler, MD: 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.

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