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 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 Dr. Leslie Odel. Who's the medical director of medical optometry of America. Welcome Leslie.
Speaker 1 00:00:26 Well, thank you. Um, Dr. Dell, thanks for having me. And, um, well, it's been, um, a long time coming. I've been hoping to get back to dry eye coach. So thank you for the invite.
Speaker 2 00:00:36 Yes. Glad to have you back.
Speaker 0 00:00:39 So can you tell us about, uh, your medical optometry of America and what's your role in that?
Speaker 1 00:00:48 Absolutely. So about a year and a half, or actually maybe the spring of 2020, I joined with this, um, group called medical optometry America. They're based at a Bluebell Philadelphia area. Um, and they were really in this exploratory concept of opening an optometric practice that was not your traditional optometric practice. And so it really has evolved, um, into this first national brand. That's exclusively focusing on medical eyecare. And my practice in Shrewsbury, Pennsylvania was the first of the locations in the United States. And so really I was like the beta test. So I make the joke, no pressure there. We had to really prove out the concept. Um, so that's what I've been up to for the past year. And four months is just seeing, would, you know, the community at large understand what a medical optometric practice instead of a general ophthalmology practice had to offer. And would there be any resistance to them seeking care in a facility of that sort where glasses and contacts weren't the primary focus, but I'm pleased to say that it has been a success thus far. And our second location just opened in Newtown square with, um, Dr. Chris cook as its medical director.
Speaker 0 00:02:06 And that just happened, right?
Speaker 1 00:02:08 Yeah. Yep. That just happened April 20, 22. So about two years after I joined. Um, so it's really exciting to see it, it kind of in the fast lane right now.
Speaker 2 00:02:18 Yeah. It is definitely exciting. The team that you all have put together over there, but just the concept itself and, you know, working, you've told me stories about working with other ODS and they refer you patients, you refer them out several years ago. I wrote an article on, uh, intra optometric referrals and that's not happening enough. And that's essentially where you're coming in is to be a resource for the ODS and MDs and everyone else in the community.
Speaker 1 00:02:42 And it was kind of the perfect storm as well because with COVID and just, um, the delay and barriers to care, I feel like even providers that maybe were a little bit more resistant to do that referral, um, you know, have really been welcoming this, um, you know, in the community. So we, we are getting a lot of referrals. Um, I was doing an exclusive focus on dry eye, um, at the dry eye center of Pennsylvania, about, for about five years prior to this. And I did build a very strong relationship with the ODS in my community around dry eye management. Um, but what I'm excited to see is that that's also now spilling into other disease aspects like glaucoma management, for example,
Speaker 2 00:03:24 Mm-hmm <affirmative> mm-hmm <affirmative>. So you mentioned dry eye, and I know you shared with me about your clinic before. Uh, why are you so passionate about dry eye how'd you get into it?
Speaker 1 00:03:34 Well, I feel like maybe serendipity, that seems to be what guides most of my decision making. Um, <laugh> just kidding. But I was working for a surgeon, like many of us who was a refractive, um, LASIK cataract surgeon. And this was 2004 was when I had my first job. And so if you think about the landscape of dry eye, then we really had one therapeutic to treat dry eye, and there wasn't a lot of knowledge, you know, going on around the disease at that time. This was even before the first, uh, TFOs Dews report came out. And I really just remember feeling so bad for these postsurgical patients who had horrific caratitis and would have the 20, 20 vision, but be really miserable with their outcomes, just because of comfort that I was motivated to just help them feel better. And once you, you know, once you improve the quality of life for one dry eye patient, I think it just motivates you to keep moving and learning more, to try to continue to make that difference for these patients.
Speaker 2 00:04:37 You know, you do a lot of clinical research as well. How'd you get started in that, cuz you've been involved with TFOs, uh, dues dues too, as well, but you present a lot of different papers and posters at the academy and other meetings how'd you get into all that?
Speaker 1 00:04:51 So I really just said to myself, I was, I was working for this surgeon for several years and I was just feeling, you know, I just felt like I had more to learn and also more to share. So actually the first thing that I did was, um, I went to a TFAs networking dinner. And so that usually was happening around the time of ARVO when ARVO was consistently in Fort Lauderdale. Um, and I remember I scheduled two meetings that I feel like have changed my career forever and they both have been just in a hotel lobby. Um, one was with David Sullivan, the founder of, um, tear, film, monocular surface society. And I just told him, you know, my passion for dry eye and if there was ever a need for me, um, that here I was and I was, you know, willing to do the work.
Speaker 1 00:05:36 And then the other one was actually with, um, Don Corb. And I remember him like drawing me the landscape of meibomian glands and the eyelid and teaching me a lot about blink dynamics, um, in, in that lobby then as well. So I feel like I just took the initiative there to become involved, um, with my meibomian gland dysfunction, I started to find light minded doctors across the country. Dr. Doll is one of them and we just thought, you know, there's a lot lacking in the research that's going on with these meibomian glands. And so we just kind of all would bounce ideas off of each other, utilize our clinic days to do case reports, um, and just gather data that we were able to publish several abstracts throughout a lot of the major, um, I meetings.
Speaker 0 00:06:23 And one of these, um, focuses that you've done and you've done a lot with evaporative stress, but we, we kinda wanna talk to you a little bit more about the nighttime evaporative stress. Have you done any research particularly involving that, or is most of your work with that, your clinical observations?
Speaker 1 00:06:39 Well, I think that, you know, again, getting back to Dan Corb what really struck me at a presentation. And I honestly can't remember if it was an ARVO poster. Um, and I believe it might have been, but when I first read this research that he presented, um, with Dr. Blackey about just the prevalence of nocturnal, um, lid seal or inadequate lid seal, I was overwhelmed. And I thought here is part of the missing link to a lot of my patients. So this was looking at patients who had kind of the hard to treat dry eye, the patients that were on therapies, but they weren't getting relief. Um, and the study found that about 79% of those patients had lid seal compromise. And of that there was about 61% that had moderate to severe lid compromise. When you look at the opposite side of that, the asymptomatic patients that were, um, evaluated in this study, um, only 20% had lid compromise with nocturnal lid scale.
Speaker 1 00:07:36 So there were several patients that came to mind, right, when I first saw that research and that research is, um, you know, not that old, that goes back to just 2017. I remember thinking, you know, this is gonna help fill in the blank for a lot of my patients. And sure enough, once you start screening your patients, um, especially your dry eye patients, um, because this is a problem that's probably four times greater in our dry eye population, you'll see that nocturnal lag ophthalm is a big, big factor for your patients. And then that evaporative stress is partly to blame for maybe why the meibomian glands are shutting down and causing obstructive meibomian gland dysfunction, as well as, um, atrophy that we see on myography and not to mention my own son has not turned a leg up almost. And I noticed that from probably, you know, age five when I, or even earlier, when I would check on him, you know, at, at nighttime, when he went to sleep,
Speaker 0 00:08:36 Just see a gap there, how, how do you diagnose that the patient's not sleeping with a complete lid sale?
Speaker 1 00:08:43 So in this case of my son, it it's pretty apparent and I do worry about him. He's had myography and, um, it's tough to, you know, tough to consistently treat a kid. I think gel, gel tears are probably one of the easier ways to go about doing that in children. Um, but in the clinic I utilize the core black E light test. So I have the light dim in my, um, exam lane. And then I just place the transluminator on the superior lid crease when the patient's eyes are closed gently, because if you put too much pressure with the trans illuminator on the lid, you actually can sort of induce, um, nocturnal lid seal issue or compromise lid seal. And then I do look at that, um, temporally and centrally and also nasally, and just see if I can see light spilling out at the lash margin.
Speaker 1 00:09:35 So if you have a normal lid seal, you're not gonna notice any of this orange glow from your transluminator coming out through the lash margin. But if you have a compromised lid seal, you will notice this kind of orange hue of light that spills out onto the cheek. And then I ask the patient if anyone's ever mentioned it to them, because, you know, if I've noticed it on my son and it's very apparent to your patient, they might have noticed it, whether their own family members have told them a spouse, you know, if they were a child sleeping over at a friend's house, maybe someone, you know, said, oh, you sleep with your eye open. So I kind of ask them that and what if they say no, but I'm still seeing it. I'm usually using like a refrigerator door analogy and you know, I'd love to hear how you do it. But, um, so I say, it's, it's not that your eyes wide open. It just doesn't have a good seal, like your refrigerator door. And that seal can sometimes even get warped with time, which sometimes is the physical changes you see to the gland with, or to the eyelid with, um, with gland changes, citric changes, or maybe even rosacea changes. Um, and then that, that seal is inadequate. And patients seem to usually understand what I'm saying when I, when I explain it that way.
Speaker 2 00:10:53 So, you know, sometimes I, I suspect the PA uh, patients do have nocturnal leg ophthalm and this evaporative stress, but I do that test. It looks like it's closed. So what are your thoughts there? What, what are the next steps? Do you, do you still treat it the same or,
Speaker 1 00:11:06 I mean, I think if you have that suspicion and you have a negative test, then I would kind of lean on symptoms. So, you know, my question to patients with dry eye is always, what's your biggest symptom, all the things that you feel today or this week, what's the thing that's bothering you the most. And then the next thing I ask is what time of day are your symptoms flaring? So if they say that they are waking up with symptoms, you know, then definitely it's something that's high on my list. But sometimes if you are not seeing that at, you know, the inadequate lid seal, there might be other things that could be causing overnight dryness. We sometimes see it with thyroid eye disease or, um, you know, even patients with high myopia, if they have inadequate lid seal that way. And, and I do think that the in-office tests might not elicit everybody because they're not completely relaxed when you're doing your test. So I think if you have that suspicion because of symptoms, then I would still treat the same way. Absolutely.
Speaker 2 00:12:06 You do you feel, this is one of the reasons why, uh, medications may not be working cause we're missing this.
Speaker 1 00:12:12 Absolutely. And that's kind of what that core, um, Blackie study was showing. These were patients that were treated and had this 80% incidence of inadequate lymph seal. So I do think if it, you know, I explain it sometimes to patients, like if you were standing in front of a fan all day, that's kind of what it's happening overnight. And then if they combine it with any other evaporative stressor, whether it's low humidity, just in their homes in the winter, if they have a fan that they sleep with, if they change the location, like they're traveling and they're sleeping in a hotel room versus their home base, you know, all of those things can really cause, um, symptoms to flare.
Speaker 0 00:12:50 What's your, what is your go to treatment if you do see that, you know, improper seal where it's not that the eye is frankly open, but that there's just a little gap. What are you recommending for your
Speaker 1 00:13:00 Patients? Um, you know, hands down, if I can get you comfortable sleeping in a protective nocturnal mask, um, I'm gonna go that route because, um, in the long term, it's, it's more effective in my opinion, and cheaper to my patient, if I can get them comfortable in a mask. And really the one that I use the most is the ICO, um, ICO 4.0, um, for whatever reason, my patients gravitate toward the clear, so this can be opaque or it can be clear. Um, and the ones I, I carry in my office are, are clear. Um, and that's just because historically when I was, you know, trying to figure out what to bring in patients always were kind of leaning toward that option. Some, some of my patients that maybe have, um, little bit different work schedules and they might be sleeping during the daytime, they really do appreciate the, the opaque masks that they, that they carry. But that, that ICO 4.0, makes a really good fit around the orbit. Um, it, it fits most faces. Um, sometimes if I have a very petite face, I might go to the Onyx or the quartz, which is just a smaller version of the ICO. Um, but what I like about it is patients will quickly notice improvement of symptoms and tell me that they're waking up to humidity. Um, so basically it's like sleeping with a comfortable swim Goggle mm-hmm <affirmative>
Speaker 0 00:14:26 Okay. Have you tried any, have you tried the sleep tight sleep right shields yet? The little ice stickers yet?
Speaker 1 00:14:32 Yeah. So I've just actually got my first pair, um, this weekend and I'm excited to give them a try, but I was looking at them, um, and it looks like another great option for patients. So I'm excited to, to give them a try on a few patients. And then of course, gels and ointments. Um, I really have been liking the high, low night from scope. Um, it seems to be a little less tacky on the lashes for patients when they wake up than some of the other over the counter ointments. Um, and then, you know, with patients preference, I, I have them explore the gamut when it comes to gel tears, because I've found that some patients just prefer one to the other. And one of the downsides of gel tiers and ointments is just the clumping on your eyelashes and make you almost feel like you have your lid sealed shut in the morning. Mm-hmm
Speaker 2 00:15:23 <affirmative> so what about C PS? Do you recommend that eye seal for that?
Speaker 1 00:15:27 So there is a mask that's been developed. I think that's actually how they even started in this space. Um, ICO is there's a mask that, um, is just called IE that with traditional C P a P machines that maybe rest on the forehead, it even gives like a barrier because some patients that was breaking down their skin, but this is a great place, you know, nocturnal, protective eyewear, um, masks are great options for your patients with sleep apnea because not only, not only the way that their masks are fitting, could be creating a little bit of exposure, but then you have the exhaust from them as well. That's kind of a, a double whammy on your patients with dry eye mm-hmm <affirmative>. And then I would also say with lid, you know, with inadequate lid seal, the other test that I like to do is the lid snap.
Speaker 1 00:16:17 So I like to, you know, pull down on that lower lid and see how quickly does it come back to, um, position because sometimes your patients might be really losing tonicity of the skin, and that also will lead to that nocturnal lid exposure. Mm-hmm <affirmative> I had a patient once that I'm pretty sure, you know, had a five second delay on his return to baseline. Um, it really only returned with the blank and, you know, we did some gland expression. We had him on therapeutics, but until he had a surgical procedure to tighten that lower lid, we really struggled on, you know, his symptom and also surface health control.
Speaker 0 00:16:55 So the litter traction test is amazing. Um, do you use that to test for floppy eyelid syndrome or using another diagnostic to see if the upper lids are, are involved?
Speaker 1 00:17:05 Well, absolutely. Great. Great question. And Flo floppy eyelids is a big concern because, you know, with your sleep apnea patients, um, about 25% of them are gonna have floppy eyelids. Sometimes you might be the reason why you're even sending a patient for a sleep study. So the bottom lid is sort of my tip off to see, you know, how lax is the lid, but then I do do the traditional, um, pull up the upper lids up and away from the globe and just see, you know, do I get the lid averting without me averting it? And, and, um, how easy is that to pull away from that upper, the upper eyelid to pull away from the globe, and that can really help you. Those patients sometimes will have the morning symptoms and they oftentimes will complain about like a muy, a muco discharge, like a white string that they pull out of their eyes in the morning as well.
Speaker 2 00:18:02 You know, when it comes to the various treatments, I I've learned once you start identifying these patients earlier and addressing the condition, which is the evaporative stress, ophthalm almost incomplete closure. I mean, I've been able to take some patients off of medications as well, because it wasn't a medication it's a chronic exposure. And so just educating the patient on the why they need the goggles or the, or the, the sleep type ments I'm using less and less. That's more on my last, last, uh, um, resort, because it's so messy for most patients,
Speaker 1 00:18:32 But it's hard to use one. I mean, some, some of them, as soon as you open the cap, it's already coming out, you know, and it, it's a tricky thing to put in your own eye. I, I do agree with that. Yeah.
Speaker 2 00:18:42 So I, the sake of time, I know this topic, you both can talk on forever and so we're gonna condense it and the role of makeup and cosmetics and ocular surface when it comes to nighttime, I'm gonna focus it there. So what are some pearls that you both have? I'll go with you Leslie first, and then Tracy, I would love to hear yours too.
Speaker 1 00:19:02 Well, I think nighttime and makeup, the first thing that comes to my mind is are you removing your makeup at nighttime? So that's oftentimes my first conversation with patient is with patients is, do you routinely wash your face and remove your eye cosmetics every night before they go to bed? And then my next question is always, what are you removing that with? Because it's really been eye opening to see some of these, uh, BK laid in eye makeup, removers that are marketed to, to patients as for sensitive eyes,
Speaker 2 00:19:34 Tracy.
Speaker 0 00:19:36 I absolutely agree. Um, what are, what are you using to take off your makeup? Because it happens over and over again that I will see makeup on a patient's eyelid margins, and they'll say they took their makeup off. So is it effective? Is it actually taking the makeup off? And if you're leaving, it's not just the makeups themselves. If you're also leaving these harsher chemical filled makeups on your eyelids overnight, you know, combine that with a poor lid seal, this is just a recipe for, you know, chemical soup causing further irritation on the ocular surface while the patient is sleeping.
Speaker 1 00:20:09 I like that chemical soup. You always come up with the best little, um, analogies or, or I love your, your words. Um, the last thing I would just say that I, I wanted to add, um, is just when you can modify your patient's environment with these patients with nocturnal inadequate lid seal, it really helps. So if you can educate them to not be indirect airflow, whether that's a ceiling fan or an air conditioning window unit, um, and if you can even advise them of these, um, small, um, room humidification systems, it can really help in those dry winter months.
Speaker 2 00:20:47 Well, perfect. Any final pearls of wisdom you have in regards to treating or identifying nocturnal? Like ophthalm,
Speaker 1 00:20:55 You know, I just say it, like I say it with meibomian gland dysfunction in general is, you know, ask the right questions and look, it doesn't take a lot to do. It's an easy test, actually use my trans illuminator to look for inadequate lid seal. And then I use it at the slit lamp to look for meibomian gland, atrophy, all in one. Um, and it probably takes me less than 30 seconds to do both of those tests. So I think it's just, um, up to us to be proactive and continue to just look for the problems before the patients really are having a lot, is exposure care apathy, or, you know, tremendously symptomatic.
Speaker 0 00:21:32 The only other Pearl I have is to, um, make sure that you're not just using staining as a guide for an nocturnal leg up almost because if you do have younger, healthier patients, you see that patient around three or four o'clock, the corneal may have relia by that point. So you're really looking at when are they symptomatic and then doing the wonderful tests that Leser has brought to our attention. Um, my favorite stories I pair of 15 year I, uh, 15 year old triplets that kept being bounced around different clinics in the university system that I was at. And, uh, it turned out that they were all three of them sleeping with a, with a gap and no one had caught it because they were always coming in for their eye examinations after school. So forget to catch the,
Speaker 1 00:22:16 Yeah, I really love that idea of just the later day. You know, a lot of times you think about the later day would be worse, but in that case, the later day would be better. So that's a really great call out.
Speaker 0 00:22:26 All right, Leslie, it's been incredible as always thank you so much for coming on and giving us your amazing insights to how to help our patients at night, which is the time that we often don't think about. Um, so we would, again, thank you for your time and, um, we hope to have you back again sometime.
Speaker 1 00:22:42 Well, I appreciate it. Thank, yeah. Thank you guys. Both so much.
