Episode Transcript
Speaker 0 00:00:00 Welcome to the dry eye coach podcast series. Click on dry eye. Your insider passed to the most exclusive dry eye topic. The series will raise awareness about the current and future state of ocular surface disease. The podcast will focus on a variety of topic. In today's episode, we have the pleasure of speaking with our friends and colleagues, Selena McGee, who, who PR practices at be spoke vision in Edmond's Oklahoma about alphabet soup on dry eye. Welcome Selena.
Speaker 1 00:00:27 Thanks Tracy. Thanks Wal. Thank for having me.
Speaker 0 00:00:32 So tell us more about your practice. What kind of modality are you in and where are, what kind of, um, practice you are? You're running.
Speaker 1 00:00:41 Sure. I have been in private practice now for nine years, which is kind of hard to say out lap, but it is, we do a little bit of everything. So primary eyecare is our bread and butter, but I have a dry eye specialty center. And then we also do specialty contact lenses. I do aesthetics. Um, the latest pillar is presbyopia and then we have, have a high end optical as well. So to me it is, and I'm in Oklahoma. So for me, this is practicing optometry at the broadest scope and loving every day of it.
Speaker 2 00:01:16 Are you practice by yourself or do you have several associates with you?
Speaker 1 00:01:19 So I have two associates with me.
Speaker 2 00:01:22 Did you get the one I tried to take for you?
Speaker 1 00:01:26 I Don know I have exactly who I want. So
Speaker 2 00:01:32 I'm just messing with you. Those
Speaker 1 00:01:34 Are fine words, walls <laugh>
Speaker 2 00:01:36 Hey, you know, you know, we've had lots of discussions over the years and you know, about ocular surface disease and aesthetics. So how and why did you get started in both?
Speaker 1 00:01:45 So for ocular surface, I spent my externship as a fourth year in a LASIK practice. And so at a very young age, I was exposed to patients that really experienced bad dryness and were really frustrated with it. And back then, because I graduated in 2002, we had hon plugs, steroid drops and preservative free tears. That was it. That was all we had. And so that just made a, a big impression on me young and I, I just always gravitated towards that because I really wanted to be able to help more patients. And as this space we've learned more and we have more things to help these patients. It just fed that, that initial, um, hunger that I had for helping patients with ocular service disease and the aesthetics piece, actually like when you start to pull the, the thread of dry eye aesthetics comes with it, because so much of what we do in aesthetics can either affect it in a good way or it can it detrimentally. And so it, it just seamlessly kind of came to be. And I found that my patients that suffered with dry eye happened to be in the same demographic that were wanting things that would help them with how they looked as well as how they felt. And so it just, it was a perfect fit.
Speaker 2 00:03:06 Mm-hmm <affirmative> the reason why I asked about the associates and how many you had is how do you get them motivated to, to get involved with it cuz you have the passion for it, but you all have so many specialties. So that, that's where I was good again with that question.
Speaker 1 00:03:20 So, you know, I think it's really important that whoever you work with that they also have a hunger for something that you are maybe not as passionate about because that's when you really start to, to grow things. Right? Cause we can't be the best at all things as much as we would like to be. And so, you know, I wanted people around me that are better than I am at what they do and I can bring that passion of dry eye and they learn that along beside me and whatever they bring to the table than I learn with them. And so then we just, you know, we all grow together. Um, and so I think it's just, it's more important to have the mindset correct, versus what you actually know and what you're passionate about. And so I, both of my associates are, are like that. They, they have a very similar mindset to what I have of, you know, learning new things and always taking it to the next level. And that's much more important than, you know, a very specific skillset I would say.
Speaker 0 00:04:24 So where does your dry specialty service fit into this practice? Like how many days a week are you doing it? What part of your day is broken down into doing that?
Speaker 1 00:04:32 Sure. So procedures wise, when I do that, that is pretty much specifically on Wednesdays, but we treat dry eye all day, every day. So every patient that walks across the threshold of our clinic is screened for dry eye. And I think that's the most important piece that people need to hear if they're exploring dry eye and how they want to grow their practice. Because, you know, if you walk into your clinic with the mindset that this patient has dry eye, until they prove that they don't that's, that's when things really start to grow. So I treat dry eye all day, every day procedures I typically do on Wednesdays. But if a patient needs a specific appointment at the end of the day or the end of the morning, we're gonna tuck those into our general clinic. If you're just starting this, I think it is really smart to do it on a half a day when it everybody's like got the, the right mindset until you get your flow and you get your muscle memory, you can start to, to dot and roll that out to more days.
Speaker 0 00:05:34 And, uh, can you share with us what the different procedures are that you're doing, um, on your special Wednesdays? Yeah.
Speaker 2 00:05:39 Let's do your alphabet soup is what we're asking.
Speaker 1 00:05:42 Love it. Yes. Okay. So myography on everyone questionnaires on everyone. That's the, that's the everyday run butter, but procedure wise, I'm doing, I P we're doing tear care. Um, you know, we might do an membrane. Um, you know, those are the procedures that we're typically doing on those days. And then I have my aesthetics tucked into that because a lot of patients that are doing, I P also want radiofrequency or they want neurotoxin. And so those are all typically on the same day,
Speaker 0 00:06:19 How do you figure out which procedure to recommend over another
Speaker 1 00:06:22 One? So look at the disease state. So for I P that that particular technology treats what I say are reds and Browns. So you're going after a, a specific CHMA four CHMA fours are water, blood pigment, and even an exogenous pigment like tattoo pigment. So you have to really think about what you're trying to achieve with each technology and each modality and what it's capable of doing. So for, I P if patients have tele injected vessels on their lids, which is ocular rosacea, then that's what we talk about with them. If they have Mebo gland dysfunction, which often happens hand in hand with ocular rosacea, or even with just dry eye disease, because it's multifactorial, right? That's when we bring in tear care. So a lot of patients are having multiple things because we're treating them, in my opinion, we're treating the whole disease state, not just pieces of it.
Speaker 1 00:07:21 Um, and then radio frequency comes into effect when we're treating more around aesthetics. There are, there is one clinical case report. It's a white paper on a physician that, that did, um, RF and one eye and treated lids, which I don't actually do. I treat just aesthetics because I have tear care. Um, but he did one eye with lip Aflo and one eye with radio frequency, treating the lids with corneal, um, shields in place that were plastic. And he had really good results with that equal to lip Aflo. So, you know, there's, there's ways that you can utilize what technology you have as well. But for me, we are treating with I P L typically followed by some kind of thermal pulsation. We use tear care, there's lots of thermal puls stations out on the market. So ultimately you just have to take a step back and go, okay, what am I really wanting to treat with this patient? And now I have technology wise to help them in the best way.
Speaker 2 00:08:27 Uh, so Leah, do you have any, um, experience with low level light therapy,
Speaker 1 00:08:32 So low level light therapy? I don't have any personal experience with, um, I've read the, the white papers and looked at the technology, but because I already had, I P I did not invest in it, so I don't have any personal, like, experience with it still too new for me to have an opinion,
Speaker 2 00:08:48 Tracy,
Speaker 0 00:08:49 Um, I'd actually have to echo Selena exactly because I have, um, the technologies that are working to treat the conditions that I'm seeing, but, um, I'm still kind of waiting for more of the research to come out. The main paper that everyone's quoting right now is mixing, I P I P terms pulse light with low level light therapy. And I really wanna see those two things separated and see what each can do, you know, strong land zone.
Speaker 2 00:09:12 Got it. So, yeah, I have the end of 15, we, with that low level life therapy and mostly for M G D and you know, so it works, but I only have end of 15, but just like you mentioned earlier, Lina having several different options already. It's like, where is this gonna fit in? How's this gonna add value to, to the practice. And so, um, next question for you ele with so many procedures available, what is the role of the pharmaceuticals? Cause there's so many different drugs that are available to us and is everyone that's getting a procedure getting a, a drop or how's that working.
Speaker 1 00:09:44 So I still rely heavily on pharmaceuticals. And then we just continue to add things as we need them. Now, does that mean that a patient gets a therapy as well as I P at the same time, maybe if they have really bad ocular rosacea. So I still utilize pharmaceuticals and rely on all different kinds of things between cyclosporin LIF photographs, and I've always relied heavily on neurostimulation. So now that we have a chemical version of neurostimulation, that's my newest, um, addition to what we're doing, because it targets the whole entire lacrimal functional unit. I have found that neurostimulation works great to maintain what we have initially done with investment of either I P L or tier care or all of those things. This neuro stimulation just really adds another level to it, to protect that investment maybe is a good way to say it. So I still use a lot of pharmaceuticals. They don't disappear when we do procedures.
Speaker 2 00:10:53 Mm-hmm <affirmative> well, I agree with you with the, uh, tier via, because you're, you're increasing a whole tier
Speaker 1 00:10:58 And exactly
Speaker 2 00:10:59 Patients are definitely gonna gonna benefit from that. And so right now, I mean, I've been trying all patients, you know, drug naive patients, patients been on chronic therapy or procedures. So that's a, that's a great point, uh, uh, on, on that as well.
Speaker 1 00:11:12 Well, and it, I think it helps with compliance too, because you don't have another drop, right? So it's just a different modality. And like you said, it's, it's all three tier layers. I mean, the Golet cells de granulate, the meibomian glands evacuate, and you get this nice flush of aqueous. And there's just nothing else that we do that, that does all of that in one fell SWO. So,
Speaker 2 00:11:36 Uh, Tracy asked you earlier about the days you do procedures and you mentioned you do it on Wednesdays. We know many times patients, if they've been suffering, they want it now, do you ever do treatments that day? Because just like anything, if you delay it, they may not end up doing it. So how do you, how does that fit into your schedule?
Speaker 1 00:11:53 Absolutely. So I have taken my practice to the level where people refer to me now. And so I have MDs dos ODS that will refer dry eye patients. So when they come in for a dry eye consult, we have it slotted in the schedule so that if we're gonna need to do procedure, we've got time to do that.
Speaker 2 00:12:14 Tracy, what about you
Speaker 0 00:12:17 A little bit different? Um, sometimes I find that if an eyelid is too angry or if there's, you know, too much concurrent bluff, we've gotta kind of clean that service and kind of calm it down to be more receptive to the therapies. So E sometimes what I'll do is I'll give the patient, um, a calm down therapy, so something they can start immediately for the next two weeks. And I tell 'em, this is part of it. This is part of the therapy. I want you to do this, that you have better results at the end of your therapy. Cause you really, obviously you can't go in and like squeeze out an angry eyelid. It will not express my bone the same way. So which I'm sure Dr. I mean, Selena, you do the same thing too. If somebody is not a candidate at that day, they're not a candidate that day, but
Speaker 1 00:12:56 Like, right.
Speaker 0 00:12:57 I send them home with what I call a calm down kit, which generally is, um, omega threes, uh, lid, scrubs. And then if they need it, if it's really anger, we need to get topical steroid involved. I'll do that for a couple weeks before I do any sort of procedure on the, on the lids. But
Speaker 1 00:13:15 Yeah, I'm a, I am a huge fan of cleaning up the lids first to Tracy's point. So a lot of times I will do zest and I'll clean up their lids like in office, because what we can do typically in office to clean all that up is more than patients can sometimes do at home. And so that is always like the first thing that we do. And then we do the I P series. I don't ever do thermal pulsation until we've done a whole series of I P, which is typically four treatments. It's sometimes five.
Speaker 2 00:13:48 So since this topic is alphabet soup, I guess the word TOIC Tasia fits in because as the most letters of any word we use in iCare, um, um, you know, we, I was having the discussion. This is at the academy, it was in regards to heat. So if the patient has TOIC Tasia, do you, either of you put heat compress because one of our colleagues says, no, that's the worst thing you can do. And I said, well, you are wrong. I want to go on the record that you're wrong, but what are your thoughts on that?
Speaker 1 00:14:17 That's a, that's a good question. And I understand where they're coming from, but clinically, what I have seen with my patient base is if we clean up the lids, we have to have heat to be able to get those glands back under control. At least now, you know, maybe, maybe it's different with Teva. Maybe it's different with NeuroStem. I think there's more that we need to learn there, but that's one of the reasons that I don't squeeze on glands after I P because by the time that you take the patient from laying down to the slit lamp, they've cooled way off. And so you're squeezing on cold glands. So I still, I still use heat. Um, I think there's more information, you know, those, those, my Boian glands are, have all those beautiful petaloid, you know, little tie, tiny, very delicate structures in there. I do not wanna do anything invasively. That's gonna disrupt that. And to me, heat makes, makes sense. But I do understand the argument. I just haven't seen that play out clinically
Speaker 2 00:15:26 Macy, what are your thoughts?
Speaker 0 00:15:28 I like controlled heat. So obviously heat that's done in the office. Uh, that's a control type of heat, which is why high quality expression techniques I think work better. So to, you know, whatever, if it's lip flow, whether it's Lux, um, I tend to hold, I tend to take patients off of hot compresses until we get the inflammation under control. Um, that's kinda my own personal philosophy, just because I don't wanna put heat on inflammatory disease process until it's a little bit calmed down if it's super angry, so controlled heat at the right time, I think makes a difference.
Speaker 2 00:16:05 Well, I'll just say you're both right, because I, I do agree. I, but, uh, you know, for me, I still use the heat. We still need more data on that traditionally. I mean, just like you said, Selena, you know, we, you, we need this amount of heat to, to, to, to soften those obstructions, to address the glands. And so, uh, I'm, I'm on the same page page as you.
Speaker 0 00:16:24 So if you had to pick only one, because I get asked this question constantly, if you had to pick only one advanced piece of equipment to bring into your practice, because it end of the year, and you're trying to make that big purchase. <laugh> one thing you would choose
Speaker 1 00:16:41 Myography in a heartbeat. If you don't have myography anything that you try to add behind it is gonna be that much harder.
Speaker 2 00:16:49 Mm-hmm <affirmative>, what's yours, Tracy.
Speaker 0 00:16:53 Um, so as a diagnostic, I absolutely would hundred 10% agree with my biography. Um, if I had to pick one thing because of the patient base that I have, um, I would probably pick intense pulse light because it does do a great job of at knocking down the inflammatory response. There's papers out that show that it kills demodex. Um, and we get great aesthetic benefits from using it. I would choose IPL if I had one out of anything. And that's hard cause
Speaker 1 00:17:19 No, I, I
Speaker 0 00:17:20 Still wanna squeeze the glands out. <laugh>
Speaker 1 00:17:23 I, I agree with you. Um, if I had to pick one procedure, it would be, I P
Speaker 2 00:17:30 And since you boas said, I P I'll just pick something else. I'll just say thermal pulsation, because it encompasses many different thermal, uh, out on the market. But I think the biggest thing is do something and choose the technology, talk to your friends, see what's working within their practice. I mean, can you share how have these procedures impacted your practice? I mean, your success that you've been growing, I'm pretty sure. And your patients benefit.
Speaker 1 00:17:55 Yes. I mean, we have grown exponentially and this is a big piece of it, a huge piece of it. Um, this probably makes up close to 30% of my revenue and that part just continues to grow. And, you know, that's one thing that they can't buy down the street. Um, so we've become a destination for dry eye.
Speaker 2 00:18:18 That's awesome. So any final pearls for procedures in the dry eye space and for your practice.
Speaker 1 00:18:25 So keep it simple and change your mindset. Walk in every single room with your patient. This patient has dry eye until they prove that they don't. If you commit to that mindset and you keep it simple with a, a questionnaire, look at structure, look at function of Mabo glands and use vital dye. That's it? That is your dry eye clinic, and you are going to blow it out of the,
Speaker 2 00:18:51 Thank you so much, Selena for your time and expertise to help us understand the alphabet soup for dry eyes.
Speaker 1 00:18:57 Perfect. Thanks Wal. Thanks Tracy.
