Dry Eye Treatment From Three Angles

P. Dee G. Stephenson, MD, FACS, ABES, FSEE; Mark Kontos, MD; and Ahmad M. Fahmy, OD, FAAO, Dipl ABO, join Marguerite McDonald, MD, FACS, to discuss three different approaches to incorporating dry eye care into a practice.

Speaker 1: Informed Consent, Getting to Yes, is editorially independent content supported with advertising by Johnson & Johnson Vision.

MARGUERITE: Welcome. This is the Informed Consent: Getting to Yes podcast. I’m Marguerite McDonald of Ophthalmic Consultants of Long Island in Lynbrook, New York.

Today’s topic is about treating dry eye disease and MGD.

With Dr. Dee Stephenson, president of the American Board of Eye Surgeons, principal at Stephenson Eye Associates in Venice, Florida, and associate professor of ophthalmology at the University of South Florida’s Morsani College of Medicine, I discuss the value of having a dry eye specialist, or dry eye champion, in your practice.

With Dr. Mark Kontos, senior partner at Empire Eye Physician in Spokane, Washington, I discuss LipiFlow [Johnson & Johnson Vision].

And with Dr. Ahmad Fahmy, who runs the extern program and is the past director of Optometric Services at Minnesota Eye Consultants, with locations in the Minneapolis area, I discuss NuLids.

We’ll begin with Dr. Stephenson.

DEE: Okay, well, I've been in practice for almost 30 years, so I'm, I'm you know, plenty of experience. I have a boutique practice in a very eclectic, 1926 Italian Renaissance building, and about 86% of my patients upgrade to femto and premium lenses. So, I have a premium practice. I spend a lot of time with my patients. I'm the only ophthalmologist. I have no optometrist, no other partners, and I have two technicians. So, we pretty much do everything ourselves.

You know, when you talk about dry eye, you're talking about 30 million people that have dry eye, and about 86% of those have, you know, chronic meibomian gland dysfunction, and this affects the quality of life.

That gives my practice, my small practice, a great opportunity to help patients in a grand way and to cultivate a dry eye chemistry, if you will, or intellect, if you will.

I had to find something that could maybe help us out with dry eye, and LipiFlow kind of fell into my lap.

It’s very small. Because it’s handheld, it can sit on the counter, and it’s really good technology, and it also allows us to be able to do something that we actually, we actually can see. I mean we actually can do a treatment, and we actually can see what we're doing. So, what I put into place is a champion for this. She's the educator. She talks about the symptoms with a person.

This is not the same as my surgical coordinator. This is a person that—her name is Kris—and what she's become is my dry eye queen.

She's the educator. She talks about the symptoms with a person.

And the biggest thing I have to tell you, she has empathy, because she herself has dry eye and, you know, makes a big difference, right?

So, what's she's done for me is, about 2 years ago she, she started this thing called Stephenson Healthy Eye.

So every patient that's ever going to get cataract surgery, she tells them, okay, so you're going to have cataract surgery, and the most important thing I can tell you is that the surface of your cornea is so important because the preop testing determines what your postop outcome is going to be. So with every patient that has surgery and many others, but every patient that has surgery, they're put on Retaine MGD [OcuSoft] b.i.d., they're put on OcuSoft HypoChlor b.i.d., and they're—or Avenova [NovaBay Pharmaceuticals]—and they’re [using] a Bruder Mask, and they're told to do this, and they at least do treatment for 2 to 3 weeks before they come back for their A-scan and preop treatment or preop testing. So, she's already been this person, and oh my gosh. I didn't realize how important this was until patients come back saying, “Oh my God, my eyes have never felt better. Oh, God.” and I've actually canceled patients’ surgeries because they see fine.

MARGUERITE: So she takes a lot of the burden and the time investment, because these discussions can go on, but she takes that off your back and gets it done.

DEE: Absolutely.

MARGUERITE: We do exactly the same thing.

DEE: Exactly, and isn't it wonderful because she can come to me and say, “Dr Stephenson, I really don't think Mr. Smith is ready for a cataract surgery because he's called me twice this week not really knowing how to use his medicine and we went over it again. In fact I've even had him come back, and he came in my room, and I reshowed him to do the HypoChlor treatment or the Avenova treatment. You know? So she is kind of the, the temperature guy or the person that says I don't think that this person is ready because they have not been doing what we've asked to do. So that’s being said, we know a champion is so important, and I can't run my practice without her. I mean she's invaluable to me.

MARGUERITE: And you know I'm so glad to have you say this, because there's this widespread misconception that if you care about dry eye it will cannibalize your cataract practice, and nothing could be further from the truth.

DEE: Absolutely, and I have had, you know, numerous patients come from other practices who are, not that they're bad practices, they just you know high volume. They see the optometrist. They don't ever have a go-to person. There's no Kris for them to call, you know, type of thing, and they come to me, and they say, “I just want somebody to take their time with me.” And I say, “You know what, Mr. Smith? You’ve got cataract, but you’ve got other stuff going on. Until we fix the other stuff, I'm not taking your cataract out.” And they're blown away, and yes, not only do they stay with me, but they bring their husbands, they bring their best girlfriends, and they bring two or three people that live in their community. So like you said, absolutely, it is a practice builder, not a practice deterrent.

MARGUERITE: Now if you get them all tuned up, you and Kris, they're all tuned up, now their ocular surface disease is under good control, and you think they're pretty good candidate now, say, for an EDOF lens. Do you say, “By the way, you're going to hate these lenses unless you keep all this up?” I mean, do you explain to them that this is a long-term problem, and it requires long-term care?

DEE: I tell them from the get-go there is no cure, [and] it will change the quality of your life if you stop, stop doing what you're doing. It is forever, and it has to be as important as taking your heart medicine, as seeing your grandchildren, as whatever makes you happy.

MARGUERITE: Absolutely. Dee, this [has] been tremendous. Thank you and I hope that you will come back and talk to us again as you have before. We love having you.

DEE: You bet. Thank you, Marguerite. Wonderful to be with you.

MARGUERITE: Next up, for a conversation about LipiFlow and the overall value of treating dry eye, is Dr. Mark Kontos.

MARK: Hi, Marguerite. It's a pleasure to be here with you today. Thanks for having me.

MARGUERITE: It's our pleasure. Tell everybody a little about your practice in Spokane, Washington, and in that area. I know you have more than one office.

MARK: Yeah. We're up in the other part of Washington and northern Idaho. Everybody thinks of Seattle when they think of Washington, but on the east side is the second largest city in Washington, Spokane, and that's where our main office is. And then, just across the border in northern Idaho, we also have an office in Coeur d'Alene, Idaho. It's kind of a small resort town that's growing rapidly, a lot of new patients or a lot of people moving in there. So, it's kind of a growth area for our practice. And we've been in practice, this practice has been in existence since 1947 continuously, and I've been in practice here for 27 years.

We're primarily a cataract and refractive surgery practice. We have a very large dry eye portion to our practice, and then we also do some cornea work as well. But we work closely with a lot of optometrists. We have about 120 optometrists in our area here that we work with and see patients. Sometimes people are in rural areas, and they have better access to optometry than they do our office. So, we work closely with those folks.

MARGUERITE: Great. I know you've been a big fan of thermal pulsation therapy for some time now, as am I. How long ago did you get into it, and how did you work it into your practice?

MARK: Well, we got started, actually I think you had a lot to do with us getting started. I remember years ago when you gave a lecture kind of relating to PRK and dry eye and how kind of ubiquitous that was in the post-LASIK and PRK patient and what a significant issue that was. And we were doing a lot of refractive surgery at that time. That kind of stuck with me, so when we had the optometrist in our office, Dr. Claypool, he has a very strong interest in dry eye, and when he joined us, that gave us the opportunity about it's been maybe 6 or 7 years now that we've just been building on that and adding more and more things to dry eye.

So, really as soon as thermal pulsation became available, way before LipiFlow was part of Johnson & Johnson, we brought it into our office and really embraced it and made it a big part of our dry eye therapy. And Dr. Claypool really should take the credit for all of that, and he's grown that part of our practice dramatically. So, we've had thermal pulsation really from the very beginning when it was available and have been using it consistently since, just adding on to other aspects of it. So, it's been a big part of our practice for a long time.

MARGUERITE: You know there are a lot of misconceptions about it, one of which is if you suggest it to a preop cataract patient or a preop LASIK patient, they won't then proceed with, say, premium IOL surgery or femto surgery, or they won't go for wavefront-based ablations because they've already spent so much of their disposable income. I've found that not to be true. How about you?

MARK: I would agree with you 100%. In fact, that's probably, right now, I would say that's probably the largest section of patient population that we're seeing the most interest in.

I just finished clinic a little bit ago, and I had that discussion, I think, four times today about patients who are looking at premium IOLs who are kind of in the area where they're having some dry eye issues and that we need to address that before we do surgery. And they readily accept that as a part of the process. We actually are packaging that within the premium IOL pricing.

So, when we have patients that need to have dry eye addressed prior to surgery, we just say, "Look, this is built into the pricing of our premium IOL patients for dry eye issues. We're going to take care of all this beforehand, and if we need to do some things afterwards, we'll do that as well."

I find it to be very helpful because it gets them on board with their dry eye issues early on in the process. And then you're not backtracking after surgery trying to explain to them, "Well, I think your dry eye is keeping you from seeing well." They're already on board with everything, and it just makes the whole process much smoother.

MARGUERITE: Even if you bundle it preop, Mark, do you make them understand that, in order to continue to enjoy that EDOF IOL, they're going to have to periodically do more treatments?

MARK: Yeah, no, and we do. And we say that “This gets you started. We'll do this treatment before surgery, and then let's see how you do afterwards. And afterwards, if we need to do more, then that's going to be a separate issue, and its pricing is set separate.”

They know that dry eye is a chronic disease. We're not curing it. We're treating it, and there's going to need to be treatments that are ongoing throughout their life, essentially.

MARGUERITE: So, how about the patients who are not coming for LASIK or cataract surgery? They just have significant ocular surface disease, so this isn't going to be bundled with a procedure. Do you find it fairly easy to explain the benefits and to convert them as well?

MARK: It kind of depends. In that patient population, it is a little bit different in that it kind of has to do with the severity of their symptoms a lot of the time how readily [accepting] they are to have a procedure done like that. The other thing that's awfully helpful for us, too, is meibography. Being able to show the patient gland loss is a powerful tool, and it really is another thing that in that population is very helpful in helping to convert patients to see the benefits of this therapy. And so, we kind of use a combined approach where it's the severity of their symptoms combined with what their photography looks like and what their gland loss is at this point.

But it's a little different in that group because we're not looking at an urgent issue like surgery or a really major thing like that. So, for them it's not uncommon for a patient to say, "Well, I'll think about that" or "Let me kind of give that some thought" or this or that before they make a decision.

Other people if they're really ... it's like, "I haven't had relief, and nobody's paid any attention to my symptoms, and nobody seems to want to do anything for me. And I've come to you guys, and you guys really have a lot to say and a lot to offer, and finally somebody's listening to me."

MARGUERITE: And a lot of people, even if they're dying to do it, even if they're thrilled that finally someone is listening to them, it's a big-ticket item, and it's not covered by insurance.

We use CareCredit, and I think we also use Alphaeon, but when patients [pay] a little bit each month with no interest for 2 years, that makes a huge difference.

MARK: And we do the same. It's very important.

Right now, we're actually doing a lot of combinations of thermal pulsation and IPL treatment.

We're combining that in a price that allows people to have a LipiFlow and four IPLs done at what we think is a pretty reasonable price point, and that's been very popular. So, we're excited to see kind of where that goes.

The one issue with IPL is, right after you have it, you don't feel anything different, and it takes a while for the effects to be present, whereas if you combine that with a LipiFlow treatment, patients feel better right away. So, it gives them a positive experience from the get-go.

I can tell you that, for us, from a financial standpoint, we've done really well with it. That's never been the issue. We've never had a problem with thermal pulsation not being able to cover its cost. We're way beyond that, in fact.

MARGUERITE: Well, I cannot thank you enough, Mark, for sharing your thoughts with us. We hope you'll come back for another Informed Consent podcast.

MARK: Well, thank you Marguerite. It was a pleasure. I would love to be back anytime you'll have me.

MARGUERITE: And now, to conclude our discussion of dry eye treatment with NuLids, I’m pleased to welcome Dr. Ahmad Fahmy.

AHMAD: Thank you. Thank you very much for having me.

MARGUERITE: So, tell us a little more about your practice, how it runs, how many offices you go to, and then we'll get into how you discovered NuLids.

AHMAD: So, we have five different locations in our practice. We have mostly an anterior segment-focused practice. It's a high-surgical-volume surgery center. The doctors of ophthalmology and optometry work together in an integrated setting, and we offer very specialized services to our patients and our communities, a lot of different types of corneal procedures, of course cataract and refractive surgery and glaucoma. I've been here for over 13 years now.

My little kind of niche is to take care of ocular surface disease, glaucoma, and any other corneal problems, and we work very closely with our surgeons.

So, NuLids is a device that really, I think, has been very effective for my patients for debriding kind of the keratinized lid margin and those patients that have a significant amount of blepharitis, where there is a significant [amount] of biofilm and debris along the lids that is causing some external obstruction to meibum delivery and compounding kind of long-term inflammation to the lids.

And so I found it to be very helpful for those patients, and that ends up being a significant amount of my dry eye patients.

MARGUERITE: Ahmad, do you, you have patients try it in the office, and then they buy the unit and take it home? Or how does it work?

AHMAD: I would like to get to that point frankly. Right now, what I do is I explain what it is and how it's helped my other patients. I think really a smart way to run a dry eye clinic is to have a counselor or someone that can actually help you do, you know, kind of a little demonstration like this. But I basically share my experience with it and let them know that, when I do eyelid debridement in the office, this is the device that I choose for my patients. I point them to our online store where it's available for them to purchase it, and then we stay very closely connected to those patients, and if they have any questions, we certainly go over it and then have them come back in if they have further questions.

But I think if we really want to do a super job of organization [of] an ocular surface disease clinic, I think having a counselor to help with some of these things would be really ideal.

MARGUERITE: So, if you would describe for the listeners, there are little disposable tips. Could you just sort of step through how the patient uses it?

AHMAD: Yeah, so it's kind of like, the biggest analogy that you've probably heard is it's kind of an electric toothbrush for your eyelid. So, it's got a little sort of a magnetic tip on it. It's very soft.

It's basically two little clicks you turn it on by depressing this button, but before that, you put this magnetic little round tip on it, which is very soft, and that's the part that's in contact with the lid margin.

What I like about it is it has these little, little sort of protrusions. It's not a perfect kind of soft surface, and that allows it to be more effective in getting an appropriate amount of that biofilm off of the lid margin.

MARGUERITE: Do you find, is there any risk? Have you ever had a patient sort of treat their cornea with this instead of their lid margin?

AHMAD: I have not. It's soft enough so that it will at some time get in contact with the conjunctival epithelium, and I have not had any patients having corneal conjunctival abrasions.

MARGUERITE: And do you tell them to do it once a day or twice a day?

AHMAD: If they're tolerating it well, I recommend that they use it once before bed so once a day. But if they start to get a little bit of lid irritation or sensitivity, I usually will have them use it, skip a day or skip 2 days. It's perfectly fine to do that, but then the key is to just make sure that the lid margin looks like it's a healthy lid margin, free of those obstructions that can get in the way of the meibum delivery to the ocular surface and without any significant inflammation, so. But most patients do really well with it, if they're using it either once a day or once every other day.

MARGUERITE: And do you ask them to put in a fresh tip every time they use it?

AHMAD: I do. Mm-hmm. And so, I'm sure that some patients won't do that, though. But I recommend that they use a new tip every time.

MARGUERITE: Do you ever find there are patients where you would recommend an in-office treatment by you or your team and then NuLids at home in between the office?

AHMAD: Yeah. Absolutely. So, once I see that the lid margin has biofilm and debris on it, I'll ask the patient to start doing their routine at home. And then I'll have them come back, and if it looks like really like they've gone from 3+ to you know 2.5+ lid debris, then I'll really recommend that I do it in the office. And then most patients that have a significant amount of it, I just know that probably the best thing to do is to do a really thorough in-office treatment and then have them use it at home and try and maintain the results of that in-office.

MARGUERITE: Do you ask them to bring in your NuLids device, and I'll do it for you in the office?

AHMAD: Right, yup. And then we have one in our location, in the office as well, if the patient didn't bring theirs. We have it available in our clinics.

MARGUERITE: I think there'll be many listeners who realize that this is a great way to get into lid debridement and removal of biofilm, both as an in-office procedure and as an at-home procedure for patients. I can't thank you enough, Ahmad.

AHMAD: Of course, happy to do it. Thank you so much for having me.

MARGUERITE: Well, that concludes our discussion on approaches for treating dry eye. I’d like to once again thank my three esteemed guests for their insights: Dr. Dee Stephenson, Dr. Mark Kontos, and Dr. Ahmad Fahmy. Please keep an eye out for the next episode of Informed Consent: Getting to Yes.

Speaker 1: Informed Consent, Getting to Yes, is editorially independent content supported with advertising by Johnson & Johnson Vision.