Episode Transcript
Speaker 0 00:00:00 Welcome to the dry eye coach podcast series. Click on dry eye, your insider pass to the most exclusive dry 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 of speaking with our friends and colleague, Dr. Bila YUSA of FOBA, um, who practices in Portland, Oregon. And we're going to talk to her about modern treatment for drooping lids. Welcome Mila.
Speaker 1 00:00:28 Thank you so much for having me
Speaker 0 00:00:31 Now. Uh, I know that you and I have Portland pretty well covered cause I've got the west side and you're in south Portland, right?
Speaker 1 00:00:39 Yes.
Speaker 0 00:00:40 Why don't you tell us about your stunningly beautiful practice? What, what kind of modality are you in?
Speaker 1 00:00:46 Oh, thank you so much. You're too kind. Um, I love having you in Portland with me. Um, so I've been practicing optometry for the F for almost 15 years and I opened my practice in Portland, Oregon, and south waterfront. So it's called south Waterford eyecare, uh, in 2013 and put it early in my practice. I decided that I wanted to do more for my patients struggling with dry eye disease. As you Tracy and waltz, you can relate. I'm sure it's frustrating to treat patients for dry eye and not get the results. And so, um, over the years I've invested in all the new tools and technologies to really and myself to, to really understand and treat dry eye disease, which is what I love to do. I love treating dry eye and with that, um, really over the time, uh, over the years I've developed, that's, that's kind of dry eyes led me to other interests, specifically like nutrition to study nutrition and also dabble a little bit in aesthetics.
Speaker 0 00:01:57 So that's been an amazing part of your practice. I love it so much
Speaker 2 00:02:01 And we love that practice. It sounds like both of our practices and, and like I said earlier, it's, it's great to meet you and finally connect with you. And we're so excited to have you on this podcast. And so even though our focus is more on dry eye, you know, we look at these saggy baggy lids all the time. And so can you talk to us about how addressing ptosis and these baggy lids has impacted your practice? Because you just mentioned you start to getting aesthetics.
Speaker 1 00:02:27 Yeah. So for me, it's, it's been kind of a natural, like organic transition or sort of, uh, you know, we're already in the, um, w we're looking at eyes and patients coming in specifically for if it is for dry eye. Um, it's allowed me to kind of step outside of just, you know, looking, you know, prescribing contacts or glasses and go more with obviously with medical, um, practice, but it's, it's also allows me to discuss these options that patients may not be aware, right? So when a patient comes in, they may not necessarily think that there are some options that are nonsurgical. They may not bring it up to you. And when I do talk to them about like radio frequency or prescription eye drops, um, they're happy, they're thrilled and they want to hear more,
Speaker 0 00:03:19 But you find that patients, you know, it's kind of a tricky thing when you bring up, you know, physical, um, you know, age related change, do patients, are they really receptive about, um, talking about their droopy lids?
Speaker 1 00:03:30 Absolutely. I mean, you know, an example of this happened a couple of weeks ago at a patient came in, she was 48, you know, she's not, um, she's not older patient, but she's saying she's on zoom all day long. And she's, I'm tired of seeing she, she specifically said in the beginning of the day, my eyes look nice and white and open. I mean, now she's also dry eye patient, but, um, towards the end of the day at the, you know, maybe her fifth or sixth, a zoom call a meeting of the day, she's noticing that her eyelids are droopier and she looks more tired. And, um, so again, it's, it's good to be that provider for those patients where I can say, Hey, um, you know, you may not be ready for surgery, and this is not a, this is a mild case of droopy eyelids. So we're not ready to do surgical consult to get, but they are some options that we can talk about. And she was thrilled. She was, you know, she did it for her. We started off on, uh, with, with her, with <inaudible>, but there are other treatments that we'll get into in a little bit, um, that worked for other patients as well.
Speaker 2 00:04:41 You know, one of the things that we do within our practice, we, we have that, that picture that has the different droopy levels, if we'll do their intake forms. So the bedtime time they come to us for like, you know, they were like, okay, well, they need to have this discussion because it's already been brought up just right when they, they, they came into the practice. So, uh, you know, so, you know, you identified the patients with the droopy lids and, you know, we can talk about their drops and we can talk about surgery. And the reason why we're bringing this up is because lit issues do affect the ocular surface in dry eye. And especially patients who've had, you know, Botox, or if they've had a blepharoplasty that can happen as well. So when you're making that referral, do you differentiate between lid versus brown ptosis? Or do you just talk about the droopiness and then defer that to the surgeon?
Speaker 1 00:05:27 You know, what is severe cases? I tend to defer them, you know, if it's, if it's going to be a surgical case, um, uh, again, example of case of patient had a patient who's 86 year old came in and she said she was holding her eyelids up while she was reading the news the morning paper, you know, so in those cases, it's, it's, it's a surgical and I, you know, discuss the, uh, the surgery and, and coordinate the referral and follow up with the patient. So, um, as dry eye doctors, we're obviously we're also yes, aware of bad surgery, so really having it, um, a good surgeon that you have a good relationship where that, that you can see this patient's back, making sure that they don't have any lag almost, or, you know, corneal exposure after surgery. Um, so COVID management is very important and, um, a lot of times it's the ones that are, uh, coming in for more severe. I go straight to consultation surgical with oculoplastic, and I don't really do any of the in office treatments,
Speaker 0 00:06:38 If there's too much skin, there's not a whole lot that we can do in our offices for that. So we're milder cases. I know that's, I know that's what I'm doing for in-office things, but if the skin is redundant, if, you know, if you basically got a second pocket for DMX to breed in it's time for surgery, right. So why don't you tell us a little bit more about these topical treatments, because I think you mentioned, um, up unique, which is, um, oxymetazoline, what is it, um, and how are your patients, um, accepting this, uh, novel medication?
Speaker 1 00:07:14 Yeah, it's, you know, as you know, it got FDA approval last year, and it's been a great, you know, we didn't really have a solution like this or an option for patients. It's an alpha adrenergic agonist, so it works on the Mueller muscle. So it causes contraction, um, which lifts the eyelid temporarily. And it's actually, the half-life is pretty good. It's, uh, I think it's from six to 13 hours, so average of eight hours. So it gives a pretty good duration. Um, so patients that use it in the morning, or maybe, you know, right before their meeting start and, and it covers them pretty much all day, and I love that it's presented preservative frame, right. So that's a huge thing for us as dry ducks. Um, so that's, that, that was, um, an important thing for me to look for. I always look for that BAK, you know, um, if medications have the, ACAM very cautious about them,
Speaker 2 00:08:15 So we have the drops and then, you know, we wanted to get into radio frequency. We know you do a lot of that, and that's one of your interests. Can you talk about radio frequency applications? And I care whether it's for the droopy lids, you know, its impact on, uh, dry eye. Uh, and how's it working for you and your practice?
Speaker 1 00:08:32 Oh, I love this treatment. So we do frequency has been around in aesthetics and dermatology for a long time. And, um, just like, you know, intense pulse, light IPL is that kind of stepped into the dry eye world, uh, radio frequency, radio frequency, RF is a new, um, treatment that now we've been implementing. So we've had it for about a year and a, I believe in my practice, we've had IPL for longer for about four years and, um, they're completely different and we can talk about the differences, but specifically for radio-frequency. So what it is, it's, uh, uh, it's radio waves that are generating, um, energy heat in the tissue, in the skin, uh, and, um, it goes into the deeper, so there are two different kinds there's monopolar and bipolar, the monopolar, which is what we use goes into deeper layers of the dermis, where they work on the fibroblasts cell.
Speaker 1 00:09:29 So fiberglass and that regenerates new collagen and elastin. So, um, this is, uh, when I learned this statistic, I was shocked apparently after the age of like in our mid twenties, you know, the it's anywhere from 20 to 25, we started losing about one to 2% of our body college in our skin per year. And with that account wrinkles and saggy skin, and yes, so w so would this, does this treatment actually boosts our own college production? So for us again, on the skin or on our eyes where we using, you know, wrinkles and tightening the skin, so that helps with lid laxity and, and also, um, can prevent like dermatochalasis or places, however you say it. Um, so again, that can prevent droopy down the road, but the way we implement it for dry eyes is that, um, it produces, generates that magic temperature that melts my bum 42, uh, about 42, but it can go higher, but we'll use 42 degrees Celsius, um, on around the eyes.
Speaker 1 00:10:38 So that is enough to melt my bum. So that way we can express glance easier, which is very different from IPL, right? So I feel as a light therapy, so it's not radio waves, it's light that, um, targets basketry. So for rosacea patients for eyelid talented Asia, that's the most more appropriate treatment, but they kind of compliment each other really well. So, you know, once we treat the inflammation islands with IPL intense pulse light, then we can add weight or frequency to melt the Maya them to, um, heat those glands enough for us to be able to express the Glens. So again, when the patient comes in, if I'm, if they're joy patients, they have MGD, um, you know, we have LipiFlow in our office, we have my book flow. So we, we talk about different options. But when I say, Hey, I can treat your dry eye, but I can also smooth out the wrinkles around your eyes and, uh, potentially prevent, you know, droopy lids down the road with radio-frequency of course, you know, that's a win-win patients really are excited about that option.
Speaker 0 00:11:48 It's um, it's FDA approved actually. So radio frequency does have an FDA approval to treat rhytids or wrinkles around the eyes. So it is an FDA approved therapy for wrinkles. Um, a lot of us again are using off-label because it does reach that magic temperature. Like you mentioned Mila. So in a perfect world, I would love for every patient to have both of these because they IPL and radio frequency because they hit two different things and they worked so well hand in hands.
Speaker 2 00:12:14 Well, since you to know all the answers and all this, because I have no experience with radio-frequency. So how many treatments are they doing for radio-frequency is a one-time or is it a four time like IPL? Can you speak to that?
Speaker 1 00:12:28 So in our clinic, we have, um, you know, I used to do all these things myself in the beginning, but we have a, our office has kind of a boutique style. There's only one exam lane. So I found that it was taking a lot of chair time. So now I have two, uh, advanced estheticians doing my treatments. Um, so for, uh, for skin results, we want multiple treatments. So we want, we recommend, and again, my assistant might recommend more than I do it, depending on the page, a patient's skin and you know, how much laxity there is. And so that's kind of, I really liked that team approach where I recommend it for dry eye, but then my aesthetician will say, you know, what to get rid of, or to lift your eyebrow or eye eyes a little bit more when need, um, you know, maybe a two extra treatments, so typically about four treatments, but it may be more than that, depending on patient's age, um, for Glenn expressions, again, even one time treatment, essentially theory could one to glands and you can express them well enough after June series of IPL treatments. So it's case by case, but I would typically recommend series of treatments to get the aesthetic results along with the dry eye treatments.
Speaker 2 00:13:43 So, so you did mention you have several different treatment options. And did I hear you that how you decide between IPR and radio-frequency Tracy, please feel free to jump in as well? Is that when they have the rosacea, the Tila ectasia, is that how you're making that, uh, that decision?
Speaker 1 00:14:00 Yes. Yes. So, um, radio-frequency generates heat. So if patient has rosacea and a lot of tillage, Acacia and inflamed and puffy lids, we don't want to add more heat to that. So we don't want it. Those are not good candidates for radio frequency. We do IPL first calm down the LEDs and reduce inflammation. Then we might do a radio-frequency if there's too much inflammation, I don't recommend radio frequency. We might just do a little flow on them one time treatment. So it's case by case. And, you know, I love having all these tools and technologies, but knowing the right patient or the treatment, the right treatment for the appropriate patient makes it more effective treatments. Um, just like, you know, not everybody's an IPL candidate, not everybody's a radio frequency Kennedy. So we really, um, select the treatments. Perfect. You know, according I used for the patient's condition,
Speaker 2 00:14:57 You know, we're all fortunate to have multiple technologies and procedures to offer our patients. Um, Tracy, I, I, I'm just gonna ask you as well on this one. So do you already have that decision made up? Are you not discussing every one of these options with patients because you're gonna be there forever?
Speaker 0 00:15:14 No. Um, after I do my, after I do my phone, I have a pretty good idea of what's causing underlying. Uh, but what's probably the underlying dryness. Is that coming from a skin condition to that? Something like rosacea or is it something coming from the inside of them, like rheumatoid arthritis, Sjogren's condition, I'm really tailoring the specific indication for the machine to the particular patient. So I tell the patient what I recommend, what I think is the absolute best for them. And then if that somehow is outside of their financial wheelhouse or window, then we scale back, but I'm always tailoring the type of dry eye to the treatment and how their indications go together. So rosacea. Absolutely. I feel like we see a lot of realization. Portland probably you see a lot to Dr. Roussel, right? And it's just, it's rampant everywhere. So I'm pulling out my, you know, my lights, my intense pulse light for that one.
Speaker 0 00:16:05 Um, if it's somebody that's, that's more concerned about aesthetics and a little bit of my Bohemian gland dysfunction from occupational issues, then that might be where I'm pushing the patient towards a radio frequency. You have to go for why the patient is dry and kind of match it with that. But no, I don't have time and neither does my dry eye concierge or my helper, um, to go through every single treatment. It's the treatment that fits the patient best. And I tell them what they need, that's what they want. They don't, they don't wanna, they don't want a spa menu. They want you to tell them what they need because the expert, and they've been other places generally before they've come to see, um, to see us as leaders in the dry space. They want us to tell them what they need,
Speaker 2 00:16:47 Really, anything to add on that?
Speaker 1 00:16:49 Yeah, I agree. And you know, this is why I love dry eye because you know, it's challenging. So it challenges me to constantly learn and, um, you know, it's, it's multifactorial disease. So we know that there's a lot of factors. So really it's kind of like putting the pieces of the puzzle together to figure out what's causing their dry eye because everybody's dry eye is different and, um, formulating a treatment plan for that specific patient. And that's what's works well, you know, we're not, we're all different. Um, and, and that's kinda why I've pursued also nutrition because I've found that if we don't address that, if we don't address that, you know, whether it's systemic inflammation and, um, their lifestyle, you know, sleep and their stress levels, there's so many factors in it. And, and I love that again, when we started, you know, uh, seems like even 10 years ago, we didn't have as much information on dry eyes we do now. So it's just ever evolving field. Um, so that's really exciting and I love it.
Speaker 2 00:17:53 I said, it's got a million more questions, but my next one is, uh, what are you using to talk to your patients about efficacy?
Speaker 1 00:18:02 Yeah. You know, so I feel like it's radio frequency right now is where maybe IPL was, um, you know, 15 years ago when, um, I think Dr. Toya's started like early two thousands and started doing small studies, you know? And, um, and it was probably also anecdotal treatment back then. And now we have like, it's FDA approved treatment for dry eye. So reading frequency, you know, we don't have a whole lot of studies. Um, one of the small studies Dr. Tacoma did where he compared he did an, um, lip, a flow in one eye and then radio frequency treatment and the other in the fellow eye. And, you know, it was a small study. I think it was only 10 subjects, but the results were, um, that there were equivalent. So that the outcome on, on, on all metrics were the same between the two treatments. And we do have new two new studies that are coming out. I think we're going to have more, there's definitely more studies in dermatology for the, you know, skin tightening and all that. So we do have good evidence for, um, for the skin treatment and for eyes. I think we'll have more, um, you know, down the road in the future.
Speaker 0 00:19:16 I totally agree that the dermatological journals are where we have to start, especially when we're looking at problems stemming from the skin. So I actually started learning a lot more about intense pulse, light and radio frequency from reading dermatological journals. And I'm searching for those first, rather than eye journals. We absolutely do know, um, the temperature at which my bone melts, and there's been a different, there's a number of different technologies that are out there for expression. So if you can, um, document and know that you're getting the eyelids to a very specific temperature, we know that my mum's going to melt at that temperature. So while we don't have specific studies outside of some of the work that EduCom has done, we definitely have a body of research that's been done that shows a particular heat combined with expression absolutely does work. So
Speaker 1 00:20:04 Maybe we should do a study.
Speaker 0 00:20:06 We should have units.
Speaker 1 00:20:11 Yeah. I we'll have more. I think there's going to be more and again, it's, it's just, it doesn't replace what we have, but it definitely compliments, um, IPL treatment. And there are Def, you know, we see good clinical results with it.
Speaker 0 00:20:28 And then answer your question while it's,
Speaker 1 00:20:32 And then this FedEx is just a bonus. You know, that's the thing is patients, um, love that when, when I tell them I can treat your dry eye, but also your wrinkles. They're like, yes, sign me up
Speaker 0 00:20:46 With like intense, full slate. You know, I'm going to take care of your dry, but by the way, where, where I'm treating you for your dry is also going to take that severe redness out of your cheeks. It's a lot of people are concerned about the out-of-pocket cost of these things, but what they don't realize is that a lot of patients that are coming to see us have already done cosmetic procedures to try to help their skin. They're just not disclosing it unless we are very particular and ask about it. I know I want to ask specifically about things like Botox. Nobody tells me unless I specifically pointed out, because I know, I know your forehead supposed to move right there.
Speaker 2 00:21:23 Uh, this has been a great discussion there. Mila, do you have any final pearls when it comes to the modern treatment of droopy lids or dry eye?
Speaker 1 00:21:32 Yeah. You know, I think this is such an exciting time to be practicing optometry. We have so many cool tools and resources. Um, and we already kind of in the business of aesthetics, a little of, we sell beautiful, um, frames and we provide contact lenses and content and colored contact lenses for patients. So it is, we are the right providers to talk about that, to talk about, um, aesthetics and non-surgical options for droopy lids when it's mild to moderate, when patients may not know that there are some options. So we should just, you know, I encourage my colleagues to just start a discussion and ask patients and, um, and talk about the options that we have right now.
Speaker 2 00:22:17 So what you're saying is we all should get into cosmetology. Is that correct?
Speaker 1 00:22:23 Well, you can just dabble, just like, you know, I'm dabbling a little bit. Why not?
Speaker 2 00:22:28 Oh, well, Hey, we love your enthusiasm and your expertise. So thank you so much, Mila for your time and expertise in helping us address patients with, uh, drooping lids and dry eye.
Speaker 1 00:22:39 Thank you for having.
