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. In today's episode, we have the pleasure speaking with Dr. Crystal Bremer from Dry Eye Equation in Wilmington, North Carolina. Welcome.
Speaker 1 00:00:24 Thank you. I'm so happy to be here. Thanks for inviting me, <laugh>.
Speaker 0 00:00:28 So we wanna know a little bit more about this dry Eye focus practice. Tell us more about it.
Speaker 1 00:00:34 Okay. Um, you know, what I would say about my practice is it was built for me. And I know that seems kind of ridiculous because it's a solo private practice. How could it not be? But I, I think that that's really the exception to the rule and, and not the rule itself, because so many times we feel trapped by our practice. I think, or maybe that's just me. You've heard that before, right? <laugh>? Um, but it's a pretty neat story if you, if you wanna hear it. I, um, I, in 2010, I had sold my practice and so I was lecturing a lot. I saw patients an hour away, and I was doing a lot of clinical trials on dry eye. And then in 15, my not compete ended, and I opened up a new practice and this had a dry eye focus. So I had all the tools, um, but I was recruited to do the Vision Source dry eye protocol at that point.
Speaker 1 00:01:28 And the pack, the practice became just this one giant clinical trial basically. And at that time, I approached Oculus to ask if I could help with designing the new, a new software forum, because it was great hardware, but it was kind of difficult to get in and out. And so now the, the, the dry eye protocol was being rolled out to these 20 some cities. And at the Exchange I presented this new clinical software, um, it for the, the five M platform. And it was fantastic. So in the next five hours of the exhibit hall, they sold more than in the history of the company since 1895. So that seemed really good, but then you fast forward a year and, um, practices weren't using it because it's hard to implement dry eye. And I, I looked at this and I said, My gosh, we're all struggling with the same thing.
Speaker 1 00:02:20 Why are we all having to recreate the wheel? And so I spent the next six months or so developing the Manual for Dry Eye Institute and I said, Let me work on this. The billing, the coding, the staff training, the patient education, the, the clinical protocol, all the nuts and bolts. And that was born in February of 18. So this was good. I was enjoying it, but the practice was still draining. And so in 19, I finally took this plunge. I remember writing it in my notebook saying, What's the worst that can happen, <laugh>? But I took the plunge and I took everything outta my practice except dry eye because I had just been trying to do everything for everybody. And it, it wasn't working. And uh, at that point I was like, God, am I gonna sell practice again and just go do ear interior design, <laugh> <laugh>.
Speaker 1 00:03:07 So I, I did this, I took the plunge and it was just one of the most impactful decisions of my life. And I'm so fulfilled now. And, and I think that's why I have such a passion for Dry Eye Institute still is I know what it's like to, to be proud of what I'm doing, but yet not fulfilled. And so my calling is just, it's not to be in front of the masses and do a little bit, it's to make that life changing effect in front of a few, uh, the few that are ready. And a lot of that is based in the fact that, you know, a lot of doctors aren't fulfilled. And I think this dry eye is a beautiful way to add to that, just professional and personable fulfillment because you get such amazing results.
Speaker 2 00:03:48 Oh, that's an awesome story that you have there, Crystal. And I've seen your practice. It is a beautiful practice, but it, I think it was what, 20 15, 20 16 when I was there. So, uh, That's awesome. That's fully de dedicated to Dry Eye. You mentioned a little bit about this 2.0. Can you give us any teasers about it? Or is that still under
Speaker 1 00:04:06 The's, the vision source? Yeah, so the one I was talking about was back in 17. So that was the original. So now we're working on 2.0 and really it's, it's done, um, all the leg work. We've got like a 50 page, um, write up on it, basically the, the didactic part. And then we rolled it out at the exchange, and now we're on that 20 city tour again. So with this one, it's totally different. The original one was more about if this than that, and here's good, better, best treatments. And we had a lot of tools in there for helping them know the difference and differentiation of, of etiology. This one is more about the office itself and where they are. Are they a beginner, are they intermediate or are they advanced? And then really creating a protocol down to the wire of, here's, here's what your screening's gonna be.
Speaker 1 00:04:57 Here's what your workup's gonna look like, here's the staff support you need. Here's the patient education piece. Just tear it off the sheet and hand it to 'em. Um, so really the, the, the details in the nuts and bolts, and then making it an easy transition to go from beginner to intermediate. And that was the key is before it was so detailed, which was great, but it was hard for them to go from zero to a hundred. And this is meant for everybody to get involved and just do something and then take baby steps to get up to the next level and the next level. So we're proud of that. We've got a, a beautiful interactive tool that lets, um, create customized patient education, but that's more at the advanced level. Um, in the first two levels, we just wrote it all out for 'em and, and want them to, to take it, to steal it, to adopt it
Speaker 2 00:05:45 <laugh>. So is there a, is there a section I, I like how you have it broken down by, you know, beginner mo intermediate, because I, we've all done these lectures and, uh, we have to talk to everybody at once and these lectures or workshops, but that's awesome that you're focusing it. Is there a, is there something focused on the staff because they're critical into making a dry eye practice successful?
Speaker 1 00:06:06 So true. Um, we do, we focus on the staff support that's needed, but in this one, we don't have a lot of dedicated training yet to say, Okay, here's a staff session that we're gonna do. Now we're continually expanding the resources though, so that's gonna be more of the online portions where we can work and have more workshop type, um, learning sessions that they can access online.
Speaker 0 00:06:32 Well, I like what you said about just do something mm-hmm. <affirmative>, because the best way to start getting into managing ocular service dryness is to just do something, pick something, do any, Right.
Speaker 1 00:06:46 Exactly.
Speaker 0 00:06:47 I have a question for you now. Are you the crystal of the crystal report?
Speaker 1 00:06:54 So it's funny how you say that. Um, I am, so that's what I was talking about before. That was part of the, my story, you know, of, of taking that little hiatus to go to them. But it was because I wanted a, a tool that was quicker for doctors to be able to implement. And what came out of it was just beautiful as far as an avenue to tell the story to the patient. And I think everything comes back to that. Um, when I look back at that first year, you know, we were really successful. We had 29 referring doctors for no good reason, <laugh>. But I look back and I was like, Oh, I know the reason it was because we got outcomes, but the outcomes were because the patient was compliant. And that came from the patient education piece, and that's everything. And so many times doctors are intimidated by the chair time that it takes to do dry eye. Um, but this is the key to it. You spend that little bit of time on patient education that very first visit, and it creates this partnership where they're bought in and they're, they're willing to do the treatments, therefore they get the results.
Speaker 0 00:08:00 Well, I have to say that my patients are huge fans of the Crystal Report because of everything out for them. They can, they know exactly what they're supposed to do, really helps with compliance when they have it written down in one place and love the graphs. Everything is fantastic. So I'm huge fit and it's great. It's been, um, amazingly helpful for my patients. Mike, thank
Speaker 1 00:08:20 You. Well, it helps with Dr Referral too, right? Yes.
Speaker 0 00:08:24 The report to send back to me, like, Hey, this is what we're doing. You don't have to reinvent the wheel and write an entirely new, you know, letter
Speaker 1 00:08:31 Something. Well, so Tracy, what happened to me when I first started using it, the first couple years I was doing dry eye, I would get referrals and every patient said, Oh, my doctor referred me to you because you have the equipment for it. And it was like, verbatim, and it, it just blew my mind. And they don't say that anymore. So I think I've earned my place now, <laugh>, but that's what it did. It gave them permission to refer from optometrist, optometrist or ophthalmologist, optometrist, because I was invested in that. Mm-hmm. <affirmative>.
Speaker 2 00:09:02 Hey Crystal, you know, there's a lot of great data that comes from the, uh, from the five M and the and the Crystal report. Do you have any pearls on how to simplify the data? Because there's so many different tests that you can do some brief quick, you can let our listeners know.
Speaker 1 00:09:17 Yes. Uh, first of all, my, my big preaching moment is screen everyone. And if I wanna have a snapshot of water, oil, and inflammation. So you can do that with the tear meniscus height, the tear breakup time, noninvasive tear breakup time or, or sorry, and the redness score. But that takes two minutes to do. So if you're in a super busy practice and you're getting push back from staff flow, then get rid of the noninvasive breakup time and replace it with interferometry. So you still have water, oil and out and, um, redness, inflammation. Now the other thing I would say is I have two go-to dry eye valves. One is a 12 minute acquisition and one is a six minute acquisition. And basically that six minute acquisition is gonna fill in eight of the nine pictures on the collage. So it's tier meniscus height, lower lid photo, upper lid photo, um, interferometry tier, um, sorry, fluorescein video biography, and then tear film dynamic. And what's the last one? Redness. That's, but it gives, yeah, it's great. It gives you a tremendous amount of information in six minutes. Um, the 12 minute one adds in the limine green dies.
Speaker 2 00:10:43 Okay. Well, no, we appreciate that. People wanna know, hey, what's, what's gonna give the quickest information? So I do like two different options. What, and you did mention myography, so the imaging, and I do wanna talk about that. Uh, what is the role of key therapy and why isn't a washcloth for your patients? Oh yeah. I used a washcloth. Why isn't that enough?
Speaker 1 00:11:05 Well, the washcloth is gonna maintain the moisture, but the heat doesn't stay long enough. I mean, what I've found is literally just 30 seconds in, it's already cooled off to too much to be effective. And what the research shows is that it needs to be at least 15 minutes, 104 to 110 degrees and moist heat. And, and I tell patients that literally in my dry eye valve, I'm like, Here, here are the three things I need to accomplish. And I have one that does that. And I primarily recommend the I Eco Tranquilize Excel. I like the bigger one because it stays hot longer and patients love it. They, it feels good. The one thing I'll say that I always make a point to, um, to tell them is to buy a little $10 tea kettle where it boils the water for, because that's the only thing that makes it seem more of a chore to 'em when they get that. Like I, I show this, I demo it all the time in the office, and then we just keep throwing them in the kettle, grow 'em in the kettle, and at a few days in we'll put the water in there and push, push, go and walk away from it. But that makes it just so simple and definitely more effective than a beaded mask or certainly more than a, a hot wash rag.
Speaker 0 00:12:21 Now, do you prescribe this heat therapy for all of your dry patients? Are there some patients who are not candidates for it, like rosacea patients, maybe? Where you prescribing the hot compresses too?
Speaker 1 00:12:32 I still prescribe it for my rosacea patients, because most of them, yes, they've got inflamed lids, but because of that, they've also got, um, meibomian gland disease and, and the lid inflammation is keeping that oil from coming just as much as the inflammation is thickening their mi bum and, and making it stagnant. So I'll prescribe it for them. But what I like about that same mass, the tranquilize Excel is it comes with the one I the one I sell comes with three pairs of the hot ones, the blue clicks, and one pair of the green beads. And so I tell 'em to put that in the freezer. So with my rosacea patients, if they get irritated or a little bit flared, pull that green one out and just put that in the same mask and use it for three or four minutes and it helps calm it down.
Speaker 0 00:13:17 That's a very, that's a very good pearl. Thank you.
Speaker 1 00:13:20 Mm-hmm. <affirmative>.
Speaker 2 00:13:21 So that's the one that you prefer. But there's other masks that are available there. Uh, I mean I heels, I use that quite, quite.
Speaker 1 00:13:29 Oh, I love I heels
Speaker 2 00:13:30 The, So how do you choose, because there's a lot of different options on there. Or just pick those,
Speaker 1 00:13:36 Just those two. Um, those are probably the, the two biggest things I saw in my entire office. We go through a lot of 'em, and I look back to the way that I used to practice where I wasn't asking about quality of sleep and I wasn't asking 'em, right. If you get up in the middle of the night to go to the bathroom, how do your eyes feel? Would you be thinking about 'em? And that is my gold question. Um, because if they're waking up in the middle of the night and they're feeling their eyes, we've got a poor lid seal, it's just a, a given. Unless they're completely, you know, have a a, a horrible case of blepharitis, then it's gotta be that. And of course, I look with the core Blackie light test, but sometimes that can be deceiving. And so if I don't see a lid seal issue, but yet they have that complaint, I'm giving them an eye seals, and if they're not good sleepers, then I'm gonna make sure that it's the opaque one where it doesn't allow light through so that maybe it helps 'em sleep better. And then we're killing two birds with one stone.
Speaker 0 00:14:32 Mm-hmm. <affirmative>.
Speaker 1 00:14:33 So, uh, totally different, Well not different patients, but different uses, different reasons. So one is gonna be because they're likely to have a poor lial and they're waking up dry. And then the other one is because the mim is stagnant, not flowing. And so I want the heat to, to let it go. Um, now what's cool about the, the, um, eye seals one and how I explain it to patients, I'll say, Listen, it's not that that this two minutes or 30 seconds or whatever it is of discomfort in the morning is what I care about. I I really don't care about that. What I care about is the fact that you had eight hours of, of sleep and you missed out on the recovery time that you should've had during that period. And so all this is cumulative and we're waking up dry. And then of course it's gonna go down as the day goes on, but if we can wake up better, then we're gonna be raising the bar. So I, and I tell 'em, what's great about this is there's no evaporation. And so the, the heat from your body creates the steam, then it, there's condensation within that mass, so it becomes this little moisture chamber for you where all night long you get your recovery. And if they say, Oh, but I take it off every night, that's okay. Just keep putting it back on, put it back on, put it back on. Cause even if I got four hours of recovery instead of eight, I'll take it. It's better than nothing.
Speaker 2 00:15:54 I'll definitely agree. And I do wanna reiterate that we're, we're, we've been consistent in saying, you know, the warm washcloth is just not effective enough. You need to prescribe a, uh, uh, mask, ask for your patients. So, um, so going to that, you mentioned a couple, and we know there's other products, speed once again, prescribed something. So are you giving this to all your dry eye patients as well? And in addition, how long are you having them keep the heat?
Speaker 1 00:16:21 Well, I have 'em keep it on until it cools off. But I, I tell 'em my goal is at least 15 minutes. And if it's staying hot, 20 minutes, keep it on. Um, and yeah, I, I prescribe it to all of 'em mainly because it is a rare occasion that I have a patient who doesn't have mgd, especially by the time they get to me because they're moderate to severe patients. Mm-hmm. <affirmative>.
Speaker 0 00:16:45 And how many times a day is that, that you're recommending it?
Speaker 1 00:16:48 Once a day? Now I, I'd tell patients from the beginning though, it's a commitment and are you, you know, are you willing to do this? Are you gonna do it? And if it's not something they'll do, um, or won't do that long, then I might add something else to it. You know, I may say, Okay, let's do the warm compress. If you can't give me 20 minutes, give me seven minutes. I at least want it to be hot the whole time. And then I might ask them to do new lids, massage, you know, a bleo exfoliation, but mainly the massaging part of it to help move that oil out. But my primary go-to is gonna be the Tranquilize xl. And something really cool that we did, we got the tranquil vibes Excel, so the one that vibrates and in our little relaxation room out front, I'll have patients just come in whenever they want to, no charge, um, no appointment needed, and they can lay in the relaxation room and have that tranquil vibes on.
Speaker 1 00:17:46 And then if I have a patient, let's say I've already done thermal evacuation, we've done I P L and they're starting to thicken up again, I'll tell 'em next time, come 20 minutes early, sit out there and then I'll pull you right back and do some expression. And again, it's not really a treatment I'm offering or something I'm charging for, it's just a little add-on. But what's cool is when the patient comes, you know, a lot of times their husband or their wife will be sitting there when I come out and we've got their glasses in the ultrasonic cleanser, we might have poured them something to drink and <laugh>. And it's just the experience. And the reason I really initiated it was because I realize what an influence stress has on systemic inflammation and then how much influence that system systemic inflammation has on the eyes. And so I wanted to make them aware of it and just make a small offering of, uh, something we could do to help.
Speaker 2 00:18:39 Yeah. I wanna follow up on something you met, you mentioned your green bees, I think I heard you say for rosacea patients. So typically with rosacea and mgd, we are prescribing sheet. Are you still doing heat or do you wait to, if they, you know, heat's a trigger for rosacea? Is that when you're using the green ones instead? Or can you, uh, comment on that?
Speaker 1 00:18:58 Well, most of the time I'm doing, I p for that rosacea. So first and foremost, I wanna get the rosacea, calm down. If the heat bothers them in the beginning, then I will tell 'em to take it easy. You know, not to, to let it stay on as long or not to do it every day. But the reality is once we get the rosacea calm down, it's not a problem. Um, I don't find that it makes the rosacea worse in these patients as long as I'm doing something to treat the rosacea. And it's not like a cycle where, all right, I've treated the rosacea, now it's flared back up from the heat and I keep doing it. That's not the case. But I, I love telling 'em about the green ones so that they can have a cooling effect and relief if they do have a negative response. But most of the time it's not really from the heat, it's just from the rosacea flare in general. Like their face will be flared up as well. But do you find that a lot of when you prescribe the heat mass that you've got a lot of rosacea flas?
Speaker 2 00:19:52 Well, I, I was just saying that because we know heat is a, it can be a trigger for hand flare and so that's when we modify it and just like you mentioned, we just tell to cut back on the heat if it's flaring it up. I just wasn't aware the, uh, the cooling masks to look into that.
Speaker 1 00:20:08 Yeah. So I, you know, she has different versions that you can buy. I get the one with the three pairs of blues and the one pair of green. And as far as cost and benefit, I think it's the perfect combination because there's plenty of other reasons why they might wake up swollen, whether it's, you know, crying or allergies or just an inflammatory flare. And it's one more thing I can tell 'em to, to use on a rainy day. <laugh>,
Speaker 0 00:20:34 The green beets are great cause for allergies cause they're eye shaped. Right. So you're not, instead of just taking a cold washcloth for allergies, green bets are
Speaker 1 00:20:43 Great. Well, and with that foam um, ring, it's gonna trap it in there just like it does with the heat. So it's gonna penetrate a little better.
Speaker 0 00:20:54 That's a great idea. It's allergi season out here in the Pacific Northwest is where you guys are.
Speaker 1 00:21:00 Oh yeah.
Speaker 0 00:21:05 Going. Okay. Any other additional pearls that you'd like to give us about, um, ways to use heat masks or how to do lid seals? Oh, I've got a good question. Ums. What are you using for your patients who have, um, C PPAs?
Speaker 1 00:21:25 I will still, I will use the I seals 4.0. Um, and again, I like the dark one because then these folks may not sleep well anyway and it might help them, but I have a problem with some of their C P A Ps not sealing with the 4.0. And so in that event, I'll, I'll cut back to the courts or the ons, the smaller, um, not journal mask in general, I don't like those as well just because there's a, a hard bridge and if somebody or a hard yeah, a hard nose piece. And so if somebody has a really prominent bridge when they roll over, they might feel it a little more. Whereas the eye seals is just flawless as far as rolling around and being so comfortable. But that's the situation when I have either a really tiny face or somebody has the full mass C P A and the eye seals 4.0 keeps it from ceiling, but it's, it's really pretty rare.
Speaker 0 00:22:21 You ever recommend like the sleep time, the sleep stickers that night, like the sleep tight sleep right. Stickers? Have you heard of those yet? They're new.
Speaker 1 00:22:28 Yeah, I don't, um, because I just feel like, all right, we're not necessarily trying to push 'em close or push 'em down. I want the moisture effect and so I need to to see and look into it and see how much moisture effect they get from that. Um, but if somebody can't use the eye seals then I'll tell 'em to get some press and seal so in the wrap aisle and that will sweat kind of like, uh, like the eye seals does. And so that'll give 'em a little bit of coverage and moisture, but it just may not stay on all night.
Speaker 0 00:23:03 Great.
Speaker 1 00:23:04 And you, you'd be surprised. You can also put that on your mouth <laugh>. So have a lot of dry mouth patients that have dry eyes. Right. And they're most dry during the night because they're sleeping with their mouth open a little bit and they love it. <laugh> need to make an eye seal for the mouth. <laugh>,
Speaker 2 00:23:20 You suffocating your patience or just the
Speaker 1 00:23:24 Yeah, exactly.
Speaker 2 00:23:26 I just, Hey, well Krista, we appreciate your time and your expertise in sharing all your pearls of wisdoms when it comes to the heat therapy and heat mask. Cause there's so many choices out there. But we appreciate you, uh, sharing your pearls.
Speaker 1 00:23:39 Absolutely. It's my pleasure. Thank you guys for what you do.
Speaker 0 00:23:42 Thank you so much. Thanks for listening. Join
Speaker 3 00:23:45 Us for our next episode
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