Informed Consent
Episode 35

Communicating With Patients About Advanced Ocular Surface Disease

Eric Brooker, OD, FAAO, and Lisa Feulner, MD, PhD, join Marguerite McDonald, MD, FACS, to discuss their approaches to the education and treatment of patients with advanced ocular surface disease.

MARGUERITE: Welcome to Informed Consent, Getting to Yes. I'm Marguerite McDonald of the Ophthalmic Consultants of Long Island in Oceanside, New York. The purpose of our podcast is to interview key opinion leaders, leaders in their field, and find out what it is that they say to have patients agree to the proposed regimen, whether it's a new Rx, a new prescription drug, whether it's an in-office procedure or a premium IOL, whatever it is, what do the successful leaders in the field say? Because it really is all about the wordsmithing. And it's out great honor today to have two leaders in the field, Dr. Eric Brooker, who is the founder of Advanced Vision Institute in Las Vegas. Welcome, Eric.

ERIC: Thank you.

MARGUERITE: And also Dr. Lisa Feulner, who is the founder and director of Advanced Eye Care & Aesthetics in Bel Air, Maryland. Welcome, Lisa.

LISA: Thanks, Marguerite.

MARGUERITE: So, starting with Eric, and by the way our topic today is, of course, how to get patients to say yes to in-office procedures for dry eye and ocular surface disease. So, let's have you, Eric, tell the listeners a little about your practice. Then we'll talk to Lisa about that.

ERIC: Sure. Thanks, Marguerite. So, my practice is in Las Vegas, which is a very, very dry and arid environment, so numerous patients come in with complaints of dry eyes, redness, and that sort. And so, we thought it would be great for us to start a practice really focused on dry eyes, and we've kind of created a dry eye center of excellence for people in our community. We feature several things, from BlephEx to meibomian gland treatments, and we've really become very precise on treating dry eyes, and we actually get referrals from a lot of general physicians as well [as] for red eyes just to, to troubleshoot that. So, the majority of the patients are either allergic conjunctivitis or a dry eye condition.

MARGUERITE: Thank you. And Lisa, your practice.

LISA: I have a comprehensive ophthalmology practice. We have an optometrist that does primary care and medical optometry. We do a lot of contact lenses. I do mostly refractive and refractive cataract surgery, and I also have a very large glaucoma practice. I am extremely invested in my premium patients and their outcomes in my refractive patients. We do also have a dry [eye] center of excellence. We employ everything from prescription antiinflammatory eye drops to LipiFlow, and we use a lot of serum tears and amniotic membranes. We'll use whatever it takes in our practice to get patients either ready for surgery or ready to get back into their contact lenses. We treat a lot of limbal stem cell deficiency in our community that gets sent to us because we do a lot of ocular surface care.

MARGUERITE: Do you find when you are introducing the idea of an in-office procedure like BlephEx or iLUX or LipiFlow or TearCare, do you usually mention it when you first meet the patient, that initial visit, or do you try something medical first and then introduce it if they don't have a full response?

LISA: That's a really great question, and I get asked that a lot when I'm speaking or by my colleagues. And it depends who's in my care. You really have to finesse it. If the patient comes to you, you're their third stop on the train, or if they've been referred from the outside, or if they've tried a lot of things, they don't want you to throw another drop at them. They want a definitive thing to be done, or they may come in fully educated and ask you specifically for something. I think the most challenging patients are those that come in who we see signs of ocular surface disease and we know what they need, but now we have to convince them that they actually have a problem that they can't feel. And so, for those patients, I use lots of analogies.

I tell them that, if they went to their primary care doctor and they were told they have high blood pressure or high cholesterol, that they can't feel that, but the doctor tells them, "If you don't treat this, you could have a heart attack. You could have a stroke." I tell them, "If we don't treat your ocular surface, even though you don't feel it or notice it, you could have long-term damage and scarring to your cornea and compromised vision and ocular health." And so, helping patients approach things from a perspective that they understand and that seems real to them is the first barrier.

MARGUERITE: I do something very similar. Eric, how about you? Do you mention these in-office procedures that are not covered by insurance when you first meet them? Do you play it by ear? Do you wait for the second visit? What do you do?

ERIC: I agree with both of you, and a lot of times we have patients come to us for various things. If they come in specifically for dry eyes and they've had several failed treatments, we start with in-office treatments that first visit. We won't do it that day, but we'll recommend it for their next visit to come back, and we'll close the selling of that procedure or offering to the patient on the first visit. And if they're coming in for something else, like it's contact lenses, red eye, anything else where they have no idea that they have dry eyes, which is a large percentage of patients, then we start them on at-home therapies first. And then when they follow up, we do a very specific dry eye workup. And at that time, they get a report card that tells them where they're lacking or where they need improvement, and we make recommendations regarding it at that time.

I'm a big proponent about decreasing inflammation first, and that's the first step for us successfully treating a dry eye. I really target inflammation with the patients and educate them at that time. We've found that, to be really successful in our practice, if you do too much to them all at once, like if they need contacts and this and that and we try to do dry eyes, it's just too much. They're overwhelmed. You’ve got to be kind of focused, plant the seed, and then when they come back, they're more focused and ready to treat their condition.

MARGUERITE: I think the three of us do something very similar, and I agree, when that patient comes in from far away, because they've heard about your practice or they were referred in and they've tried everything, you can talk about in-office procedures that day. Maybe not do it that day, which could be a little chaotic scheduling-wise, but you can talk about it that day. I think the hardest nut to crack is that patient who doesn't know they have dry eye, and you tell them. New Yorkers will look you in the eye and say, "I do not have dry eye, doc." And then I say, "Well, you have tear osmolarity of 380." And I think it helps to have some meibography, some actual solid evidence to present to those people. Do you use diagnostic devices in that way? Eric, we'll start with you.

ERIC: Sure. Thank you. We have a few different meibography devices. We have the HD Analyzer, we have the LipiScan, and recently we have the Firefly Slit Lamp. Out of the three, I'm leaning more towards the Firefly Slit Lamp. That has been remarkable on these patients that don't think they have a problem. I take pictures of their blepharitis. It really images staining unbelievably. The images I get are great. When I show them that, they go, "Oh, okay. I see where you're coming from," and that's made it a lot easier to get them down the line.

MARGUERITE: I agree. A picture is worth 1,000 words, but numbers also help. You know, like tear osmolarity. Do you both use tear osmolarity? One, the other, neither, both?

LISA: I agree with Ericand you, Marguerite, that patients need something physical to look at because unfortunately television has really not helped us. They learn from TV that all you need is Visine to get the red out and you need Visine to treat dry eyes. We have that barrier of trying to get them to understand that this is a true disease of the eye, and we've moved away from calling it dry eye. In our office, we call it ocular surface disease, of which dry eye is a component, so that we've taken it away from something that's treated with Visine, with one drop and you're good, to something that's complex and that we need to treat in an orderly way. I'm very fortunate in my lane because I have two screens. I have one for the MBHR, and I have another screen that I can bring up all of my data on, and I can pull that in front of the patient, and I have my OPD-3, which for me is the best tool.

My whole life is run by the OPD-3 because I can tell very quickly whether someone has ocular surface disease, whether they're symptomatic or not based on their Placido rings, their topography, their higher-order aberrations even, and I can show them that. I can use descriptive things like saying, "Do you see how the surface of your eye looks like the planet Earth with islands and oceans and ... ?" So suddenly, they get that. And I said, "And it really should look like a piece of bow-tie pasta." Things that make sense in their heads, rather than driving science at them. I talk about Placido rings, and I have meibography so in the same screen I can bring up their oil glands.

I tell them that their oil glands should be like piano keys that start at the lid margin and go to the base of their lids, nice, long columns, so that when they have meibomian gland dropout or when they have truncation, they can see, "Oh, this is supposed to look like a piano key, but here's what mine looks like." I think visual things are very, very important. We really have streamlined our process so that we have a dry eye management handout that's like a checklist. It has what drops they're on, whether it's a prescription antiinflammatory, and very quickly I can go through and check, check, check and then you flip it over, and it has more instructions about what we might be asking them.

I think that having visual information and having prepared information to hand the patient are things that can really reinforce that you're taking it seriously and that you have a plan for their success.

MARGUERITE: Eric, do you use a psychometric questionnaire for your dry eye patients on the first visit at least?

ERIC: We do use a questionnaire with the patients. We use the SPEED questionnaire, and it's been really successful in identifying those patients that have a hard time expressing what they're feeling on a daily basis. We try to implement that, and we try to do it as we start their treatment as well to kind of see that it's improving.

MARGUERITE: Yeah, periodically. Do you, Lisa?

LISA: We did before COVID. It's really interesting. We tried to stop the number of things that people are touching in our office, so we have trained our office staff to do it in their HPI for every single patient. So, I can sit down and very quickly, it's right there, and it takes less time than handing the patient the pen and the paper. And then we have all these pens we have to clean, and then somebody has to take that paper and scan it, so we've really minimized the amount of paper and things people are touching. Our staff can do it very quickly now, very, very quickly.

MARGUERITE: I often say that the difference between dry eye specialists and people who aren't is that we will actually treat people who have no symptoms. If you're not a dry eye specialist, you only treat people with symptoms and with a tiny handful of bullets in your gun. People who are not dry eye specialists don't usually use amniotic membranes, etc.. They might use the three prescription meds and maybe some punctal plugs, and that's kind of about it. But, I'm a huge fan of nighttime ointments. Do you both use them? Eric, do you?

ERIC: I do, in fact. We do a similar situation where we have handouts for each specific condition, and it has everything listed out. So, if I put them on, like, Oasis Tears, it would have everything about their dry eyes. It talks about Oasis. Then it would also have a nighttime ointment they would use. I usually start them on that for the first week or so till they come back for their full treatment.

MARGUERITE: I'm going to pretend to be Mrs. Smith, and I have serious ocular surface disease. Lisa, you have decided that you want to do an in-office procedure on me, so you can pick your go-to. I would love to hear you talk to me as Mrs. Smith and tell me what you propose.

LISA: Mrs. Smith, you've already asked me, "How did I get this? You know, how come all of a sudden I feel dry?" So, I'm going to go through with you how you became a dry eye patient and why we need to address this. I'm going to identify you by your gender and your age. I'm going to look at your medicines that you're on, what maybe ocular surgeries you've had in the past, and what your other past ocular history is. So, we're going to set the stage for why I need to take care of you. We can't change your risk factors, but we can help you feel better and look better and see better. I'm going to have a conversation with you about what is the tear film and how does it work? I'm going to tell you that it's like a sandwich. There's an oily layer on top made by oil glands that line your eyelids, and, when you blink, that oil is released into your tear film. It keeps the next layer down from evaporating.

Your bottom layer is a mucin layer, and it protects the cornea, and it helps the tear film move over the eye. We're going to focus on the top two layers to get started. We're going to work on getting those meibomian glands functioning again so that, no matter what we do to that watery layer, we have it protected and sealed onto the eye. I think, if we correct your watery layer of your tear film but we don't take care of that top layer, it doesn't matter. It's just going to evaporate. So, I recommend that we do a procedure to optimize your oily layer, and it's called LipiFlow. It heats up your oil glands to 108º and melts that oil, and then it massages your eyelids for about 12 minutes to help that oil get out into your tear film. And then we can work on that quality of that watery part, improve it, and make it balanced, and get it back to its normal homeostasis.

Get some of the antiinflammatories to get rid proteins and antibodies that are destabilizing your tear film, give you more comfort and heal your cornea. We're going to start by scheduling you to get your LipiFlow done to clean up those oil glands. In the meantime, we're going to start you on a prescription antiinflammatory eye drop so that we can get rid of that inflammatory process that's at the root of that damage to your ocular surface and interrupt that process that's causing damage to your cornea. Usually at that point, they ask me, "Why do I need an antiinflammatory?"

I'm going to give you an analogy ofwhy anti-inflammatory prescription eye drops are so important. If you're a runner and you sprain your ankle, the first thing you do is you give it rest, you give it ice, and you give it an antiinflammatory because you know, if you keep running on that ankle, you're going to create more inflammation. That's going to cause more tissue damage to your ankle and therefore result in more inflammation. Your cornea is just like that sprained ankle. We need to cut that inflammation so that we can get the healing process going. We’re going to work on the top two layers, and we're going to get to feeling better. It may take us up to 3 months or longer, but we'll get you there.

MARGUERITE: Very good. I'm in. I'm convinced. Eric, what would you tell Mrs. Smith? What's your go-to procedure for me? Pick one and tell me what the regimen is and what you'd like me to do.

ERIC: Well, Mrs. Smith, you presented to our office today with some red irritated eyes that get worse you noted in the morning. Your eyes have been watering quite frequently. What I'm going to talk to you about today is something you may not have heard of. It's called blepharitis. This occurs when you get an infiltration and an overwhelming amount of bacteria that have colonized your lid margin. I know that sounds bad, but this is what it looks like here. What happens is it lays down what's called a biofilm. This biofilm is very similar to plaque on your teeth. It doesn't mean you're not clean, you don't have good hygiene. It just means, just like when you brush your teeth every day, sometimes you’ve still got to get your teeth cleaned and get the plaque off, right? Okay.

Why this is bothering you is these bacteria like to secrete exotoxins into the eye, and it disrupts your tear film, but it also causes an allergic reaction, which is causing some of your itching and some of your irritation. The first thing we're going to do is we're going to give you some eye drops to kind of stabilize those, and we're going to give you an at-home treatment to start addressing these bacteria along the eyelids. I know what you're thinking right now. You're thinking, "Where did I get this?" You could've gotten it anywhere. If you work in an environment that has a lot of aerosols in the air or dusty environment, you fly on planes, things like that, you may have picked it up. But looking at it today, I can see that you're a level 4. I scale it from 0 to 4, so we've got some work to do.

I can tell you, just by doing the at-home treatments, it's not going to take care of it fully. It may contain it a little and prevent it from getting worse, but it's not going to address it all the way. What I'm going to be recommending is that you come back next week, and we're going to do a procedure called the BlephEx. With this particular procedure, I'm going to use a high-speed instrument that's going exfoliate the lid margins safely and comfortably to allow me to get rid of all the biofilm on your eyes, all the bacteria, and get your eyes feeling better. This is our first step. Now, this might not be a full cure, but it's going to get rid of the bacteria. It's going to get rid of the inflammation to some degree so I can get you to the next step in treating your dry eyes. How does that sound?

MARGUERITE: Great, I'm in. Let me ask, does anybody do combo treatment, in other words, where you're doing BlephEx and LipiFlow or BlephEx and iLUX, BlephEx and TearCare, or something like that?

ERIC: We do that in our office. In fact, some of the patients, like I say, "How aggressive do you want to be with this?" And the patients that are in a hurry because of their travel schedule or things like this, we have an advanced eye treatment program. It's a little more expensive, but we do that all at once, and it works really well. Also, sometimes when we do amniotic membranes, I'm a big proponent of making sure there's no bacteria on the eyelids if I'm going to be putting something on the eye for a couple days, so we kind of do those in combination.

LISA: Right before COVID, we were moving into sort of the [inaudible 00:21:29] combination with LipiFlow. We got a little derailed on that, but I think it's a really great like BlephEx, but it's something that we can treat them with in the office and then send them home with it to do some at-home treatments. It also sets us up for continuation of care. We teach them how to use it. We clean up their lids. We treat them with LipiFlow, send them home, and say, "You know what? In 6 months, we’ve got to bring you back in and kind of tune up those lid margins again, even though I'm sure you're going to be doing a great job at home." So, we got a little derailed on that, but that is our plan and the model that I think works best.

MARGUERITE: We're all sort of doing something extremely similar because, in our practice, I think, as you said, Eric, cleaning the biofilm off the lid margin is critical. I don't even offer them separately. I say, "You're either getting BlephEx-LipiFlow, BlephEx-iLUX, BlephEx-TearCare." Whatever thermal procedure I'm doing, it's paired with BlephEx because microblepharoexfoliation is so important. As far as the Rx's, Restasis, Cequa, Xiidra, do either of you—and we'll start with you, Lisa—ever have patients who are on two of them, like Xiidra-Cequa or Xiidra-Restasis? Do you have patients who are on two?

LISA: We do. It's a rare event, not because I think that more people don't need it. I think a lot more people could use both of them than I actually prescribe, and usually that comes down to finances. Just last week, we had a severe Sjogren's patient that was on serum tears, was on each of them separately, so Cequa and Xiidra trials separately, has had everything known to man, and we just last week, as an example, started her on both. I think that, if money weren't an issue, there would be a lot more. It's very hard to get people to spend money on both of those. It's hard enough with one, but when they're so desperate I think that it's appropriate if they can come up with the money for it. It's not easy to get it paid for.

MARGUERITE: How about you, Eric? Do you have any patients on two agents?

ERIC: At this time, I do not. Generally, I have them on usually one or the other. Everyone has been successful, and we haven't needed that, but I do start everybody on a steroid pulse,to start anywhere between like 2 and 4 weeks. Most of the time we use Flarex, which has shown good comfort for our patients, and they generally come back feeling good right away with that, and then I just kind of taper them off that and keep going. We've had such good success that we haven't needed that yet.

MARGUERITE: I have I would say quite a few people on two agents, and the issue is, of course, money, especially if they're Medicare patients, because Xiidra and Cequa are not covered well on Medicare. Those people have to be on Restasis only. But if they have commercial insurance, both Xiidra and Cequa have plans that vastly decrease the copay for a commercial patient. So, most of my Sjogren's patients end up on both of them and thank goodness most of them have commercial insurance. But they do act synergistically. They attack dry eye from different directions, so one plus one equals three for those very poor people. Well, great. I have learned a lot from both of you. Thank you, Eric and Lisa, and we hope you will both come back again.

LISA: Marguerite, thank you for having us.

ERIC: Yeah, Marguerite. That was great. I learned a lot, too. Thanks both of you very much.

10/21/2020 | 24:44

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