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 topics. Before we get to our next episode, here's a quick word from our sponsor.
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Speaker 2 00:00:52 In today's episode, we are crossing the border and interviewing our good friend and my classmate Maria Madon od from Vancouver Eye Doctor in Vancouver, bc British Columbia, to share with us her perspectives and experiences with treating and managing dry eye up north. Welcome friends,
Speaker 3 00:01:12 <laugh>. Yeah. Thank you so much for, uh, having me on the, on the show today. I love that we're all Pacific grads and, uh, not a bias opinion at all, but I think like really smart people come out of Pacific. What do you guys think? Go boxers, <laugh>. Woo
Speaker 2 00:01:28 <laugh>. Geez. Before we get started, um, please tell us a little bit more about your practice and how you come to have this love of dry eye.
Speaker 3 00:01:36 Yeah, absolutely. Um, so I went to school with, um, you know, at Pacific. I'm originally from Vancouver, Canada. Um, and then after, uh, finishing my optometry degree at Pacific, I moved to Minnesota with my husband and actually practiced there for a couple of years at a really great private practice and then kind of decided, hey, I'm missing something. I really, uh, kind of wanna learn a little bit more about disease or I wanna focus on something a little bit different in my, you know, in my career. And so I decided to actually go back to school and do a residency. And yeah, so it was, I'd already been practicing for a couple of years and, you know, sometimes it's not an easy choice to make once you've already been out, uh, out in practice. But that was a decision I really felt like I had to do for myself.
Speaker 3 00:02:21 And so I, you know, went back into the pool and I matched in Houston, Texas, and so kind of left my husband who was in Minnesota. He was go to school there. And then I packed my car and moved all the way across country, uh, to Houston. And then, uh, did a residency there, which really, really inspired, um, me, uh, in the way that I now practice. And, you know, when you talk about treating dry eye and how did I get into this space and I, I really feel like, you know, that was a foundational year for me where I just learned so much, um, at the Eye care Center in, uh, in Houston, Texas where I did this, uh, residency with ophthalmology and optometry and just really opened up my eyes to, you know, the way I want to kind of have a career and shape my career. And then I went back to Minnesota again, practiced there for a few more years and then moved back to Canada eventually once we, uh, once we had our first kid who's American. And he always reminds us that he's American and we're all Canadian. <laugh>,
Speaker 4 00:03:17 Well wait a second. I'm thinking out ne out loud now. Um, you went to IS Center of Texas and you were supposed to come to iCare Associates of Nevada now I think
Speaker 3 00:03:27 <laugh>, right?
Speaker 4 00:03:28 No, I got a phone to pick with you now. Yes.
Speaker 3 00:03:30 Right, <laugh>. Yeah. So that was a really fabulous experience. And then being back in Canada, you know, um, I feel like I have one of those, and I love this episode that we're doing because I feel like I have one of those, uh, unique perspectives where I got to practice in the United States for mm-hmm. <affirmative>, you know, almost 10 years before moving back to Canada. And now I've been practicing here for 10 years. Um, here I'm in an ophthalmology practice as well working, um, you know, focus on dry eye and glaucoma management. In my practice, this is also very unique for, uh, at least for British Columbia and this province for ophthalmology and optometry to be working together in a capacity that I am. Yeah. Cuz when I came from the states, I mean that was really, really common. Uh, especially in Minnesota with Minnesota Eye consultants and in Texas, like you mentioned with Gel Twe and all these other, you know, wonderful practices with, uh, integrated ophthalmology and optometry practices where they really kind of see that. But that's not something, um, that's very common in, in, uh, British Columbia at all. So I'm loving the way I'm practicing, uh, you know, it is a full scope medical practice. Um, and, and then I also have an optometry practice as well where I do split some of the time and then see some primary care patients. And, and it's really provided a really great balance for me. Um,
Speaker 4 00:04:45 So, so you mentioned, you mentioned full, you mentioned full scope. Cause the scope here in the states is, is all over the place and then everyone's trying to, you know, advance the scope. So what is that scope right now?
Speaker 3 00:04:56 Yeah, that's a really good question. And so when I say full scope, what I mean is practicing to the full scope of what my province allows here. Right? And it is, it is very different, um, here in Canada versus in the United States. And, you know, we're kind of all over the map, uh, in Canada as well, with different scopes in different provinces. In British Columbia, uh, optometrists are able to manage eye diseases and dry eye glaucoma with eyedrops. We actually cannot prescribe orals, um, here in, in BC and in Vancouver. So that's, that's a bit limiting now across Canada. In other provinces, there are, uh, you know, most of the provinces actually can prescribe, uh, um, orals as well. Um, none of our provinces have, uh, lasers and advanced procedures like they do in the United States. Right. So we just heard that Colorado got some scope expansion, um, and then some of the other Virginia. That's right. So no, that's not something that we have in Canada, um, right now. But, um, you know, I, uh, currently this year I'm also serving as president for BC Doctors of Optometry.
Speaker 2 00:06:08 Congratulations.
Speaker 3 00:06:09 Thank you. So I'm super honored to be in that role and, you know, of course protecting optometry and, and then moving the scope, moving the scope needle in the right direction.
Speaker 4 00:06:20 You mentioned integrated care with ophthalmology and optometry and, you know, so do you see a lot of the surgeons wanting to do dry eye? I know there's surgeons that love dry eye, but what are you seeing in your practice? Are they referring those to you and to, to the optometrist? Or are they managing it themselves?
Speaker 3 00:06:38 Yeah. Um, no, in, uh, you know, in uh, Vancouver, I do find that the surgeons are more interested in doing surgery, right? Whether it's glaucoma or cataract or retina. And then the dry eye is more of a, uh, a condition where optometrists are much more involved in, in, um, in taking care of it. And I think one of the reasons for that also is that we're, we're in a socialized medicine kind of a system where ophthalmology billings are a little bit different. Um, you know, uh, some of the treatments that have come out with, uh, dry eye to be really innovative and to really help these patients, you know, we can offer in-office treatments. Um, and that something, you know, perhaps with the medical system hasn't quite caught up, uh, to cover. Uh, so where optometrists are in a unique position in Vancouver and in Canada where we can, you know, go through insurances or go through, um, the private billing, uh, versus ophthalmologists are limited to billing through the public health system.
Speaker 2 00:07:35 That's definitely different than what we have here. So what technologies are, are you using, uh, in, in your practice for dry eye? So I get a lot of questions from a lot of Canadian doctors that are interested in doing some of the advanced technologies that, um, mal and I do. Um, which ones can you do in, uh, where you're at?
Speaker 3 00:07:55 Yeah, we're super fortunate here. So, you know, we have, um, an I P L in our practice, intense pulse light therapy. We have radiofrequency in our practice. We've got the whole gamut of, uh, you know, micro bleph, exfoliation type devices in our practice, and we can do that. Um, in my practice we're a little bit unique and we also do autologous platelet-rich plasma eyedrops, uh, and we've got a ologist that we work with. Uh, so that's something we're able to offer within our practice. Yeah, so in terms of technologies, I would say, yeah. Yeah, I think we're pretty stacked up. Um, how about you in the United States? Are you, um, are you finding that there's more over there that you're utilizing?
Speaker 2 00:08:35 Um, it sounds like you have the same capabilities that we do, at least, um, where I'm practicing in Oregon, but it does, it does vary from state to state. I would say that right now most states, um, with a few exceptions are have the ability to do most advanced dry therapies, which is good, but mm-hmm. <affirmative>, it's gonna do that. At least in, in bc that's a possibility for future practicing
Speaker 3 00:08:54 Optometrists. Absolutely. You know, and we have access to amniotic membranes as well. Uh, they are a little bit different here, uh, versus in the United States. Um, we don't currently get ProKera here, uh, so we're, we have more of the dehydrated membranes to work with and, you know, and there's different companies. Uh, so the logistics of it and cost of it can be a little bit different, um, versus in the United States. But we definitely have access to all that stuff, which is really fantastic.
Speaker 2 00:09:20 Okay. So not crowd preserved, but you do, you can get the dehydrated version. Yeah. That's good to know. That is the difference. Thanks for that. Thanks for letting our listeners know that. That's good.
Speaker 4 00:09:30 As we're talking about amniotic membranes and the dehydrated ones, what about topical biologics? Do you have more access to different ones than we do? Mm-hmm. <affirmative>, because we have, uh, the, the, the, the generalized is available. There's generalized lights. There's another company that was just, someone just told me about the other day. Do you have several companies like that that have those topical biologics?
Speaker 3 00:09:52 Uh, no. So that is an area that we are definitely lacking here in, uh, at least in bc, uh, that we don't have access to Regener. Patients can order regener through like going through the company itself, but ods are not able to stock it at their clinics and have access to it through that way.
Speaker 2 00:10:13 But you're, you're one of the innovators and, and the kind of the lead people in your area on, on working with platelet-rich plasma, correct?
Speaker 3 00:10:22 Yes. Yes. And that,
Speaker 2 00:10:23 So that's, so that's super exciting because that is, that is, you know, an auto autologous biological type eyedrop, which I think is great that you're doing a lot of education and talking about that, right?
Speaker 3 00:10:33 Yeah. And it's been so fascinating working in that area of, uh, eye care as well, right? The regenerative medicine and, and seeing the capacities of it, but having it so close to you where you can vary things and see the results of, uh, you know, how these things are behaving on the eye. And so that's been really fascinating. Uh, but I would love to see, you know, uh, I mean with every technology, there are great things about it and then there's limitations about it, right? Mm-hmm. <affirmative>, there are some patients that don't love having their blood draw every three or four months or, you know, perhaps it's not so convenient. You have to put everything in the fridge or the way you know, these things are used. Um, so it'd be nice to have some drops, um, that are of that natural origin, right? Like generalize or other, uh, companies coming into Canada. So that is a little bit limiting, um, for sure for us here,
Speaker 2 00:11:19 Right? So most biologics do have to be refrigerated, so thanks for bringing that up. So if it's a true biological um, eye drop that's a high quality, it should definitely be refrigerated cuz that is a biological material. So thanks for bringing that up. Cuz some of my patients who aren't get interested aren't aware that that's one of the capabilities that you have to have is refrigeration, <laugh>. Mm-hmm. <affirmative>.
Speaker 3 00:11:38 Yeah. Yeah.
Speaker 2 00:11:40 So did you say that you didn't have that orals sometimes can be a little bit tricky, is that right? So if you wanted to prescribe like an oral, um, antibiotic or doxycycline, are you co-managing for that currently?
Speaker 3 00:11:52 Yeah, absolutely. So I, you know, if, if I had a wishlist, I, I really wish that we could prescribe orals here in, uh, in bc right? Uh, to be able to manage our patients with dry eye, with, you know, oral medications like doxycycline or even for herpetic patients, uh, you know, to be able to treat them and, you know, I mean, and there's urgency for those patients. We wanna get them on these antivirals as quickly as possible. So right now we do have to work with our, uh, GP colleagues, uh, to be able to get these medications. So it just sounds like extra work, do you know what I mean? And, uh, and our, you know, GP colleagues are working really hard too to kind of meet the demands of post covid d I feel like things are really busy everywhere and, um, and it's so, it's a burden that I wish we could offload from, from them and say, Hey, you know, we're here to help. Uh, and be kind of those primary care for the eye and kind of take care of all of those things.
Speaker 4 00:12:45 Hey, let's talk about some of the dry eye products and medications that are available there in Canada that aren't here. Uh, Trey Hellos, you know, that's something that we're seeing in some products here, uh, right now mm-hmm. <affirmative>, um, uh, as well as ha hyaluronic acid mm-hmm. <affirmative>. And so here, that's always gonna be an inactive ingredient. Uh, what, what, what are some of your go-tos up, up, up north there?
Speaker 3 00:13:08 You know, that's really interesting because we have had tray lows and hyaluronic for a, i I feel like a little longer time than probably in the United States, right? I feel like I've been using those drops for at least the last like four or five years, you know, very easily. And things that we've been seeing in our clinics, uh, that the doctors are able to stock. Um, yeah. And so some of my, uh, trios type products are to do with Lian, right? Lian, there is a big company here in Canada. Um, and then also candor vision. Um, and so they've got some really fantastic drops over the counter drops that we're able to utilize with those key ingredients here in Canada. Now, we don't have some of the prescription medications that I wish that you guys have in the United States and patients are always asking about it. I mean, this is not a dry eye product, but, um, you know, beauty to see up close. I mean, I can't tell you how many patients ask me about it <laugh>, and I'm like, Nope, not in Canada. Nope. Sorry guys. We don't have it.
Speaker 2 00:14:08 Are you able to get the other, um, topical, uh, chronic anti-inflammatory versions of eyedrops, things like cyclosporine and Lifitegrast? Do you have those there?
Speaker 3 00:14:17 Yes, we do have Cyclosporine. We do have Xiidra. And this year, uh, earlier this year we got c a from Sun Pharma. Mm-hmm. <affirmative>. So that's huge. We do have, um, generic Restasis, which we actually got earlier than United States did. So we've had it for the last three, four years here in Canada. Um, we don't have the nasal spray, uh, for dry eye yet. I think it's called, uh, trivia. Right?
Speaker 2 00:14:42 Trivia. Mm-hmm.
Speaker 3 00:14:43 <affirmative>. Yeah. And I, you know, that's, uh, that would be really interesting to have that in our toolbox here in Canada, but we don't have that and Interesting. Do you
Speaker 2 00:14:51 Have any neurostimulation devices approved or not just yet. Okay. That's, that's up and coming. Needs to be up and coming. Gotcha.
Speaker 3 00:14:59 Yeah. Yeah. And interestingly enough, we also don't have AZA site. Uh, and I know that's been in around in the US for a long time cuz when I used to practice there, you know, that was, that was a, you know, medication that we used even back then. So no, we don't have it.
Speaker 2 00:15:15 But you do have some things that we don't get, which is the, the awesome active ingredients in your artificial tears. Are there any other pharmaceuticals that you have for dry that we don't get in the United States? Or is that pretty much run the gamut?
Speaker 3 00:15:26 I think, yeah, I think, no, I can't think of anything else that, uh, in terms of pharmaceuticals that, uh, you guys don't have in the, in the US and we have here. The other challenge I do find is compounding things can be a little bit challenging here as well versus when I practice in the United States, uh, that was something, uh, a little bit more accessible.
Speaker 4 00:15:47 Yeah, that's what I was gonna ask. I mean, we use a lot of preservative-free dexamethasone and we work with, uh, compounding pharmacies, so it's a little bit tougher up there to get those, huh?
Speaker 3 00:15:56 Yeah, yeah, we do have, uh, preservative free pred Forte mm-hmm. <affirmative>, uh, here in Canada. But, uh, yeah, you're right. So compounding can definitely be a bit of a challenge here.
Speaker 4 00:16:07 So is generic Restasis a dollar cheaper than brand? Restasis up there? <laugh>?
Speaker 3 00:16:14 Um, I wanna say it's, it's considerably cheaper, but I don't know for sure. I know
Speaker 4 00:16:19 <laugh> you don't, you don't have to say the cost. I was just kidding. I, you know, we've had some patients and I haven't seen many patients back with a generic, uh, cyclosporine right now. I know some have gotten it for like 10 bucks and others said it was like a dollar cheaper than the brand. So it was, I was more joking, but we're still trying to figure out where it's gonna fit into our, our momentum because, you know, especially down here, we have in the, uh, the various insurance carriers and they're gonna, it's gonna be step therapy. You gotta go through this first before you can prescribe this brand or this brand or whatever brand it is.
Speaker 3 00:16:50 Yeah, you're absolutely right. It's trying to figure out where this all fits in, right? Mm-hmm. <affirmative>, um, and, and what do we see in our patients for sure. Yeah.
Speaker 2 00:16:59 So as far as coverage goes, do you get to pick for everybody what you want them to have? Or is there a stepwise approach like we just described here in the United States?
Speaker 3 00:17:09 I think from what I kind of understand the system to be a little bit, I feel like we are a bit fortunate we don't have as many insurance kind of barriers to work with. Um, and in terms of even the way we practice, we don't have to go through insurances a whole lot to bill things. I remember a lot of resources being spent when I was in the United States, uh, you know, trying to figure out what insurances cover, what they don't cover, uh, and that being a major challenge, no, that's not something that we, uh, you know, that we kind of face with in our practice. I do generally prescribe what I think is best for the patient and sometimes they might come back and say, Hey, my insurance doesn't cover this, would you consider an alternative? But I would say on the, you know, on the majority end, I, I feel, um, you know, fortunate that patients are like, yep, no, I'm, I'm happy with this and I can go along with this.
Speaker 2 00:17:58 Mm-hmm. <affirmative>. Well, I mean, what's great is it does sound like you are doing full scope dry eye the way that you are able to do it in, in your province, which is great. So you have all this amazing equipment. Um, if you could give us some, like one great pearl for dry eye, what would it be?
Speaker 3 00:18:18 Um, one great pearl. Oh man, this is hard <laugh> when I'm talking to like the dry eye gus here, um, one great pearl, you're one
Speaker 2 00:18:26 Too.
Speaker 3 00:18:27 Yeah. One great pearl would be to really, you know, work with the patient in, in what is gonna work for them in their daily life. I mean, dry eye is so overwhelming. Uh, number one would be to just be very empathetic with, with the patients and say, Hey, this really sucks, you know, and I, I'm kind of your partner. How do we, when you come back for a follow up, you're gonna tell me how this schedule worked for you? Cuz as you know, there's so much stuff that they have to do at home as well, and then you can provide them feedback and, hey, look, this is what I feel like is working when I look at you, you tell me what's working for you and let's come up with a plan that you and I can be both happy with that we're gonna see results with.
Speaker 4 00:19:07 You know, I I, I agree with everything you just said, uh, and a patient today that said, you know, I'm glad we, I I came, saw you because you listen and you're empathetic and you're, you understand my frustrations, my vision fluctuates. I can't see, I can't work, I can't do whatever or their symptoms, you know, I'm in pain all day. You know, what can, what, what can you do to, to help me? But setting realistic expectations is, is gonna be key. And so we, we do appreciate all the insights that you have. You know, one last question I have for you is, you know, you are quickly building your, your name within the dry eye space. So any pearls that you have for some younger ods or p people who want to get more involved in establishing yourself as the dry eye, uh, expert.
Speaker 3 00:19:51 Absolutely. You know, so I think you really nailed it too. I think empathy in, you know, when we understand the disease more, we can really understand, um, how this affects our patient's quality of life, right? So it comes with education, educating ourselves. Then we really understand, wow, now I get it, how this affects you. And then from that empathy comes that treatment plan, right? Like where I really care about this patient. So my, um, advice to new students and new grads really looking to go into this is, is just continue to read. Really educate yourself, you know? Uh, and don't just leave it out there, uh, for somebody to teach you. But if you're passionate about it, if you feel like this might be something that's, that is drawn, you know, is drawing you in, then read about it, really read about it, um, you know, and that's really important to just be, continue to keep on top of it, um, and educating ourselves
Speaker 2 00:20:43 Or in this case, listen about it. Right, <laugh>.
Speaker 3 00:20:45 That's right.
Speaker 2 00:20:48 Well, thank you so much for joining us today and sharing your insights in ocular surface, you know, above the border. Uh, I know you've been a great resource for our listeners, so, uh, again, thank you so much for your time. Always nice to see you friend <laugh>.
Speaker 3 00:21:01 Yes, absolutely. Yay Pacific.
Speaker 2 00:21:04 Yay <laugh>. Go boxers.
Speaker 3 00:21:07 That's right. Well, thanks for having me here, you guys.
Speaker 0 00:21:10 Thanks for listening. Join us for our next episode soon. Here's a quick word from our sponsor.
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