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 00:00:53 In today's episode, we have the pleasure of speaking with Justin Schweitzer from Van Thompson Vision in Sioux Falls, South Dakota, which is a tertiary referral center. He has a special emphasis on ocular surface disease, glaucoma and cataract co-management. Welcome Justin.
Speaker 3 00:01:09 Hey, thanks for having me. Looking forward to the conversation.
Speaker 2 00:01:12 Well, hey, we're gonna talk about something that we've talked about before. It's the impact of glaucoma medications on the ocular surface. But before we get into that, can you tell us a little bit about your practice?
Speaker 3 00:01:23 Yeah, you bet. So, uh, you mentioned, you know, I'm at Advanced Thompson Vision, which is a tertiary care center in Sioux Falls, South Dakota. Uh, you know, we really manage glaucoma, ocular surface disease, cataract co-management, prepare patients for glaucoma surgery. I always say, you know, all the patients that I see really aren't my patients. They're sent in from colleagues in our network that ask us for opinions or are looking at, you know, a patient that needs to undergo surgery. And so my day-to-day activities, whether it's glaucoma, whether it's cataract surgery, whether it's refractive surgery, is managing a lot of ocular surface disease in conjunction with those different conditions.
Speaker 4 00:02:01 So what would you say, what role does the glaucoma medication have on ocular surface then? What? What are you seeing?
Speaker 3 00:02:07 Yeah, you know, I think every lecture that you do on glaucoma now has to include at least a discussion on what's happening to the ocular surface and what you and I have talked about this many, many times and there's plenty of data out there supporting the fact that, you know, glaucoma medications when you're on more than one or multiple medications can be pretty hard on the surface. You think of the fechner studies where they looked at the O S D I, the ocular surface disease index scores and the more medications that a patient's on, the tougher it is on their surface, but also their complaints or symptomology. And then a good friend of ours, Dr. Scott Houseworth, showed me a paper one time published in 2012 looking at neurotoxicity of B A K. And in that study patients took b a k once a day for seven days, 0.01% and 0.1%. And within seven days there was a decrease in corneal nerve innervation. So there's a decrease in the corneal nerves and there was a decrease in tear breakup time and the fennel red test as well. And so there was also corneal staining. So all that stuff kind of play comes into play. Now that's not to bash glaucoma drops. My point being is less is better. How do we reduce the burden? Because the more that patients are on, the harder it can be on the surface of the eye.
Speaker 4 00:03:24 Are there other components to the glaucoma medications that are making them rough on ocular surface?
Speaker 3 00:03:30 I think any type of preservative, you know, different glaucoma medications are preserved with different things. So it's typically the preservatives that are creating the problem. And let's be clear about something. It's not bad to have a preservative all the time. It's not bad to have B a K because that's what allows the medication to get to the target tissue. It's the amount of B a K, meaning a patient that's on three topical glaucoma medications, there may be a ton of preservative that they're dumping on their eye on a daily basis that's gonna be a lot harder on the surface of the eye than if they're just on one topical glaucoma medication. So it goes back to the reduction of medications decreasing that burden.
Speaker 2 00:04:08 So Justin, is there really such thing as a softer preservative?
Speaker 3 00:04:12 Yeah, I think there is. I think there are different types of preservatives. I think there is softer preservatives, but you still run into it if that softer preservative is paired with a bunch of other preservatives. So it really goes back to the amount of medications that the patient's on if they're just on one drop. Even a patient that's just on one drop with B A K will do pretty dang well most of the time. But if they're on those multiple medications, the additive over effect and then the chronicity of it, if they're on these medications for a decade, two decades, that's gonna be a lot rougher on the surface than if they're on it for one to five years. So shorter durations as well matter. Mm-hmm
Speaker 2 00:04:51 <affirmative>. So, so how are you addressing that patient? So you have a brand new glaucoma patient, uh, you're gonna put 'em on drops, but they have uh, a prostaglandin, you're gonna put 'em on most likely, but they have a beat up surface. How are you addressing that?
Speaker 3 00:05:05 So I attack it in a few different ways. You know, I think first line therapy is different now than ever before. I think the discussion with patients has to be different. I think we really have three options to consider first line therapy. I think medications definitely serve that purpose. I think prostaglandin analogs are, are that first line therapy, but I also think S L T has to come into play. So selective laser trabeculoplasty, when we look at the light study that came out recently, you look at that at three years, 78% of patients were drop free. And when we think of glaucoma, it's a marathon. And when we think of ocular surface disease, it's a marathon and we're just trying to buy our patients time. And if I can give a patient three years of not being on a topical medication that's three years where their ocular surface is gonna be probably better than it would be if they were on one, I may have to go to that drop at some point in time and I may have to utilize one. But the point is I'm able to kind of stretch it out over an extended period of time. And then I think the other thing we have to consider is glaucoma drug delivery. Now we have something on the market that we could consider that is implanted inside the eye that releases a prostaglandin that can help to lower interocular pressure and by our patients some time again off of topical medications. And so I think those three things should at least be discussed or educated for our patients.
Speaker 2 00:06:25 All right. So you discuss it. So what are you gonna go to first? I'm gonna put you on the spot cuz I can
Speaker 3 00:06:30 Yeah, no I love it. I think it's a great question. I would say for me it would be S SL T. I'd go for S slt. But what's interesting Walt is when I talk to patients and I look at my practice, there's still about 65% or so of patients that would prefer or choose to go on topical glaucoma medications. And the other 30 to 35% choose to do S slt. So even though I recommend S SLT to patients, that's a lot of 'em prefer to be on drops. That's what they've heard about. That's what friends have been on. So for me on the spot I pick S L t.
Speaker 2 00:07:00 Okay. So then what do you do at the same time you did S slt. So what are you doing to fix the ocular surface or address that?
Speaker 3 00:07:07 Yeah, so that's a really good question because you know, if they have a surface that is kind of beat up and they need a holiday from their drops or, or they're a new patient that we've put on a medication and then their ocular surface becomes beat up, there's a variety of ways that we can address that. You know, I talked about glaucoma drug delivery a little bit ago. I've been thrilled having glaucoma drug delivery on the market and it's not a long-term therapy. We really can only implant one of these little pellets, which is called bimatoprost sr. We can just put one inside the eye right now and it dilutes medication for four months. There's evidence in some phase one and two clinical trials that it actually can lower pressure for six months, maybe even 12 months, even out to two years. And so I really have liked that because I'm able to give my patients a drop holiday, get 'em off their drops and then treat the ocular surface.
Speaker 3 00:07:53 And how do I do that? Depends on the type of ocular surface disease they have. I'll get 'em that drop holiday, I may put 'em on immunomodulators, I may use even some soft topical corticosteroid to calm down any inflammation they may have. The point being is I try to get 'em to a good spot before I have to go back to maybe utilizing some type of medication. And then I try to focus on a medication that maybe is not necessarily preservative free, but maybe be a K free or even go into some of those preservative free options to try to just be gentler on the ocular surface.
Speaker 4 00:08:27 So for our audience that may not be familiar with the new drug delivery system, are you saying that this is something you can only do one time?
Speaker 3 00:08:35 Yeah, that's a great question. So right now, F D a approval for that is, is only implantation of it one time. And so once you put it in the eye, once it's not lowering intraocular pressure anymore, then other therapy needs to be done. And so when we look at the phase one and two clinical trial data on it, you know, we know it alludes medication for four months and it's bimatoprost that's being released. So it's a, it alluded, it's a prostaglandin we're all familiar with and there is evidence in their phase one and two that we could get six months in about 68% of patients, we could get 12 months in about 40% of patients and we could even get two years of ILP Lauren in about 25% of patients. But once it wears off, once we don't have I L P Lauren, then we have to go to something different.
Speaker 3 00:09:21 And that could be S SL t, there's nothing wrong with bridging it with that. It could be going to one of those medications. But the reason I bring it up and why we talk about it is I don't think it should be ignored. I think given a patient even a six month break from a medication and being able to attack the ocular surface with the variety of different options we have available, getting the surface healthy again can make a big difference for these patients. Because arguably in a patient that has mild glaucoma or even moderate glaucoma with a small visual field defect, that's probably not necessarily affecting their vision noticeably. They can't even tell the ocular surface disease is the bigger issue. That's the issue that's affecting their quality of life, not that visual field defect. As doctors, yeah, we care about that visual field defect cuz that's what we're trying to prevent from getting worse. We don't want our patients to obviously go blind, but the quality of life issues that that patient's suffering are more of a problem for them than what that small visual field defect cause they just don't notice it.
Speaker 4 00:10:24 So how many of your patients percentage would you say are currently on a drop for glaucoma and also a drop for dry at the same time?
Speaker 3 00:10:33 Yeah, great question. I can't say all of 'em, but I could say a majority of 'em are at least undergoing some type of therapy for dry. And that could be as simple as they're on a topical glaucoma medication and they're taking an artificial tear, simple regimen, something to just help the surface of the eye. And then there's others, for example, that are on medication that every six month we're having to do some type of in-office procedure, whether that be treating the glands or they're coming in for something like i p l. There's also patients that I don't have to do anything for for a couple years, but they come in and there's something going on and we need to give them that drop quality or we need to put 'em on a topical corticosteroid to kind of decrease inflammation. So the majority of 'em are having some type of therapy in addition to their glaucoma therapy to control their ocular surface.
Speaker 2 00:11:20 You know, I think one thing I'd add to that there Justin, is yes, you know, they're on the glaucoma therapy, whether it's a prostaglandin, uh, but then putting 'em on an artificial tear, one of the things I've been making sure is I make sure that's a preservative free artificial tear because they're already on the, on a preservative, we don't wanna add extra preservatives on onto that, onto that ocular surface. You know, my threshold, and actually we've talked about this before, is, you know, if you have a glaucoma practice, you have a dry eye practice. So you have to identify those patients. So how do you identify that? So someone who, you know that they've been in practice for a while, they've been treating a lot of glaucoma, where does the dry testing come in and how are you doing that? Because you don't wanna add on those, all those tests on at that visit because they've already done O C T, they've already been dilated, so they're certain they've been marinating in the, in those drops, and so their surface looks horrible by the time you see it. So how is that, how, how's that management protocol for you?
Speaker 3 00:12:12 Yeah, no, that's a great question. I, you know, a majority of my patients, again, are, are new patients that are coming in. They're sent in, they're referred in. And so even our glaucoma patients, we use, you know, a speed questionnaire, we use, you know, some type of, of questionnaire to kind of find out if they're struggling with anything, if they have symptoms or symptomology. That then triggers my technicians to go ahead and do some, you know, point of care testing. They do a bunch of different things in my practice. We test osmolarity, we test inflammation we'll at times also do my biography. And then from there it really comes down to me talking to the patient and I'm trying to find out a few things. Number one, I wanna know if they're compliant. Okay, that doesn't have to do necessarily with the ocular surface disease, but there is some connection there because if it's a patient that is not taking their drops all the time, I wanna know why.
Speaker 3 00:12:59 And a lot of times the reason they're not taking their drops is because it's irritating their eye or creating problems for them. It's not necessarily forgetfulness. And so I dig a little bit in regards to that compliance and then I'll ask 'em, are you taking your drops? And if they are, then I ask, do you like your drops? And if they're on multiple drops, I ask, which one do you like the least to kind of dig deeper to find out are there problems with the compliance or with the comfort of them. Once I have that kind of pinpointed, then what I do is just ask them, would you like to consider some options where we could maybe reduce the burden of the medications that you're on? And then that leads me down the path of talking about things like s l t talking to things like drug delivery, talking about minimally invasive glaucoma procedures.
Speaker 2 00:13:47 Yeah, you're right. I mean if they're, if it feels horrible when they put it on the surface, they're not gonna do it. And then when we're monitoring for the, for the glaucoma, that's only gonna get, uh, worse over time. So going back to the, the dry eye, yes, we know the drops are easy. Uh, they're on the back to prostaglandin once a day. We put 'em on immunomodulator twice, state preservative free, uh, to, to adjust the surface. We know arita did a study where 96% of patients on prostaglandin have M mg d. So are you, so where are you incorporating the meibomian glam imaging? Are you waiting for the, the, the, the symptom surveys for the patient to fill out? Or is that part of your, hey, when you come back, I'm gonna do imaging of your lids and a visual field or how are you doing that?
Speaker 3 00:14:32 Yeah, no, not necessarily. I mean, every patient that I evaluate, no matter what it is, I'm, I'm evaluating the lids with, with really my thumb, I'm checking the glance substance. I'm looking at that we get my biography on these patients as well. So every glaucoma patient, and you stated it earlier, Walt really has ocular surface disease until I prove otherwise. And that's really how I'm doing it. So yes, not every patient is necessarily getting the point of care testing or doing, you know, inflammatory tests, osmolarity tests, they're all taking, you know, a questionnaire. But every patient is getting a slit lamp exam where I'm evaluating the glands, I'm evaluating the MyUM, and then we kind of take it from that point forward. So that's really how I'm identifying them if we need to additional therapy. And then it's education and talking to patients about the disease process.
Speaker 2 00:15:18 Tracy, what about you? How are you, I, I know you do have a dry eye clinic, but how, how does glaucoma fit into your patients?
Speaker 4 00:15:25 I mostly referred the patients that are non-compliance. The ones not like the same way thing we talked about. They're not using their drops because of complaints about irritation. Um, so I'm kind of the, um, I'm the compliance girl, so I get, I get the patients in, I do get them treated. We talk about why I like that question that you asked, which is, do you like your drops? That's a fantastic way to to to phrase it. Um, I also ask questions to really get to the, to the, the bottom line of, um, compliance, which is I basically ask them, how many times a week are you? Do you forget your drops? And that makes it sound like it's normal. I try to normalize it so that they don't feel judged if they're not taking it. And they'll say, oh, I miss it a couple times. And I'll say, is there any reason in particular why you miss it? Do you like, yeah, do you like your drop? Is your drop comfortable? Um, I find that when you do clean up the ocular surface and make patients comfortable, they will start taking their, um, glaucoma drops again. So my role is as kind of like the, um, compliance enforcer, I guess that's,
Speaker 2 00:16:23 Yeah, well I'm doing on compliance, but patients aren't even doing their glaucoma drops and you're gonna add in dry eye medications,
Speaker 4 00:16:30 Not always medications. It doesn't actually always take medications because we do have adjunctive therapy that doesn't necessarily require a patient to always have to take another topical
Speaker 3 00:16:40 Drop. We didn't even touch on, you know, that too that, you know, there's, there's makes procedures as well that you can get medications reduced with that. We know from all the FDA clinical trials on a lot of the minimally invasive glaucoma procedures that there is a reduction in the medication usage. And you know, I, along with a good colleague, a friend of mine published a paper in 2020 in, uh, ophthalmology therapy looking at patients that underwent a MIGS procedure. They took an O S D I before they underwent procedure. Their average O S D I score was 40.1, which is in the severe level. Did the MIGS procedure three months later, had 'em take the O S D I again and their level went down to 17.3. So still not normal, but more in the mild area. We decreased corneal and conjunctival staining, we increased tear breakup time and really all it came down to was just reducing the medication burden. So I can't claim that was a brilliant study, it just had never been done before. And we were curious on, you know, what would happen with the MIGS procedure and if you reduce that medication burden. So MIGS can serve a purpose as well in the treatment of ocular surface disease in our glaucoma patients. Mm-hmm.
Speaker 2 00:17:49 <affirmative>. Well I thought it was a brilliant study. So great job that you
Speaker 4 00:17:52 I I did too. I <laugh> what you're talking <laugh>. It's an amazing
Speaker 3 00:17:55 Idea. Thank you. Thank you.
Speaker 4 00:17:56 Sometimes just sometimes doing a study that really just summers home, like, hey, guess what? This is actually effective. Like we think it is. That's always a great study to do cuz it just makes everybody feel more comfortable that this is the direction that we should be going in. Right?
Speaker 2 00:18:11 Well then going back, they're not just the quality of life, the efficacy, because we already know that doing the stents or doing these MIGS procedures are very, very effective in lowering the pressure and controlling it. So patients aren't given that diurnal variation that they would do if, oh, I took the drop tonight, I missed the next three days, I took it again. And so whenever you have those high fluctuations, we know that the, the relative risk of progression's gonna be very, very high, uh, for those patients. And so, um, so what are a, any tips on being a referral center, having a glaucoma patient, you know, is there anything that if you're getting a referral for glaucoma that a referring doctor should be doing, uh, prior to, do you guys ask them to do anything?
Speaker 3 00:18:51 We don't necessarily ask 'em to do anything. I think it's more along the lines of just assessing, you know, the, the, the, the level of the glaucoma that they have letting us know what they're thinking on a different, what procedure they'd like. Are they sending them to us for s slt? Are they sending them to us for a MIGS procedure? And then the reason why, you know, assessing the lids, assessing the ocular surface disease, mentioning that in the note as well. Saying, Hey, you know, this is a patient that has been compliant with their medications. This is a patient that isn't progressing. But what I'd really like to do is have a procedure done to try to reduce the burden, number of medication. Or this is a patient that has been non-compliant, they're also suffering from ocular surface disease and they're progressing. Boy, I'd love it if you'd consider a MIGS procedure. Cause I love it when the patient has already been educated on all of that and maybe not a specific MIGS procedure, or maybe not specifically s l t, but the doctor took the time to educate on the fact that I'm gonna send you to this referral center to not only help the dryness and the ocular surface disease that you're having, but help your compliance and also manage your glaucoma as well.
Speaker 2 00:19:54 Awesome. You know, we mentioned, you mentioned drug delivery. I, I just thought of this, the punctal plugs. I mean, what a great area for glaucoma and ocular surface to intersect. Can you comment on any of the early pipeline, uh, things that are, that are out there?
Speaker 3 00:20:08 Yeah, so there's some Inca canalicular inserts that are being looked at and utilized. You know, unfortunately in the phase three clinical trial of one of these types of, of inserts, it didn't meet its end point. And so there's still work being done there. You know, there's some work being with some contact lenses to deliver medication as well with some companies. So that could be an exciting area optometry could be involved in. And then there's also some other inserts inside the eye that are showing good efficacy, you know, around 30% reduction in I L P for extended periods of times even out to a year, past a year out to two years and, and even possibly out to three years. And so drug delivery, if you asked me right now what I'm most excited about in the treatment of glaucoma, I'd say glaucoma drug delivery is very high on my list.
Speaker 4 00:20:51 Mm-hmm. <affirmative>. Mm-hmm. <affirmative>. Okay. Cause I was gonna actually ask you that. So thanks for answering that <laugh>, what you're most excited about coming down the pipeline. So where do you see, um, the future of this, um, marriage between ocular surface and um, glaucoma going? Do you think we're gonna be moving more towards surgical interventions in the future and away from just topical drops?
Speaker 3 00:21:16 Yeah, I don't, I don't think topical drops ever go away completely, but I've had long discussions with Walt about this. I think the terminology that a lot of us have heard this interventional glaucoma, uh, terminology or physician driven therapy, meaning we're taking the bottles out of patient's hands when you think of medications that's more patient driven because if they're not taking it, then we're not slowing progression. So more physician driven and that's S L t migs drug delivery. I think these can pair well with some of our very good topical glaucoma medications. W it's not gonna eliminate 'em completely, but I think what can be gone are the days where our patients need to be on three medications to control their glaucoma. Now if I'm having to put patient on a third medication, I'm thinking of something else. I'm good with one and I'm pretty good with two as well. But boy, the less the better and I think that's where that marriage is gonna kind of happen.
Speaker 4 00:22:08 Awesome there. Justin, thank for your insights. I'm, that's, that's incredible. Um, we are so happy that you came on to talk to us about your insights on where Oculus and are lighting. So thank you so much for your time, Justin.
Speaker 3 00:22:20 Oh, it was an honor. Thanks for having me, both of you. I appreciate it.
