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.
Speaker 1 00:00:16 In today's episode, we have the pleasure of speaking with our friends and colleague Daymond, Drucker, who practices the eye surgeons of Indiana in Indianapolis. We're going to be talking to him all about innovations in dry eye. Welcome Damon.
Speaker 2 00:00:31 Hey,
Speaker 3 00:00:35 Thank glad you're here.
Speaker 2 00:00:37 Excited to be here,
Speaker 1 00:00:39 But why don't we get the thing kicked off with you telling us about your practice? What kind of modality you're in and what are the things that you're focusing on?
Speaker 2 00:00:48 Yeah, so I'm a partner at eye services of Indiana. We have five locations in central Indiana, two surgery centers for referral practice, you know, probably a 70 to 80% of our businesses is refractive cataract surgery. We do, we have medical retina and then I've had a dedicated dry eye center for the last six years at our Indianapolis office. And then a new challenge for 2022 is in our second surgery center location, which is in Lafayette about an hour up the road. I'm actually going to develop a second dry eye center. So I'm excited about that.
Speaker 3 00:01:25 So David Howard, why did you get started? I mean, you, and I've had this conversation, but can you share with our listeners how you got started in dry?
Speaker 2 00:01:33 Yeah, so I've been practicing for about 20 years all at eye surgeons. And I actually started out in retina and did a retina fellowship and kind of acted as a liaison between our retina specialist and the optometric community and did that for a few years. And now that was good, but I just saw what was happening, you know, 10, 12 years ago and the dry eye space and the diagnostics and therapeutics and looked around and there really wasn't anybody in central Indiana doing this really well. The cornea specialist didn't really care about dry eye ocular surface disease. And I was just asked so many patients in our practice that needed help. So I took it upon myself to learn as much as they could and, and really work at becoming a better dry eye clinician and, you know, 10 years ago, that was not the easiest thing to do.
Speaker 2 00:02:21 There. Wasn't a lot of resources out there, a lot of conversations with colleagues and reading trade journals and looking up things in my spare time and just learning as much as I could. And I really enjoyed the process, but I also looked at it and said, I can't really expect my eye care colleagues to go through that same process that I did. So one of the things that I've done in addition to building Jaya center and leading our community here in central Indiana is really work with folks like Chayc and Wal to develop education programs. So that it's a little bit easier for our colleagues to embrace dry. I understand the why, and then really have a patient centric approach so that you can be successful really in any sort of eyecare setting. So it's, it's been quite the journey over the past 10 years and has moved into the virtual space now with education, but I've enjoyed every minute of it. And at the same time, I love, you know, tomorrow is a dry day. I have 30 patients in my Indianapolis clinic that need a lot of help, and I enjoy doing those things on a, on a day to day basis, but I also really enjoy engaging with colleagues to help them, uh, take better care of their patients as well.
Speaker 3 00:03:36 I, and a lot of us know that you started dry eye bootcamp. Do you ever wear your fatigues in clinic?
Speaker 2 00:03:41 I, I don't, uh, I have worn the dog tags occasionally just for fun, but sometimes our patients are pretty savvy and I get a fair number of self-referral, uh, you know, people that have found us, uh, on Facebook groups or web search. And occasionally I get asked about drive bootcamp from patients. So that's always fun. And, and I that's something that dry bootcamp is still on the back burner. It's, uh, is on hiatus right now. Uh, live in-person education is still a little bit of a challenge in the way that we want to do that in a, in a bootcamp setting. But I would predict that at some point there'll be a reincarnation of, of bootcamp in some form. No,
Speaker 3 00:04:27 We want to give kudos to and a shout out because I mean, when it comes to education, you definitely helped lead the charge with that drive boot camp then now with eyes on dry eye. And, and so keep up the good work on that, but I'm totally digressing Tracy, so you can get us back on track.
Speaker 1 00:04:43 Okay. We just, we just love how innovative you are and how at the edge of the field you are and how much do you just have a passion for not only your patients, but for all of your contemporaries that are in the field. So thank you for all the work that you put in, but yeah, I'll go ahead and get us back on track since you're an innovative guy, let's talk about what's the newest, innovative treatments that are come to the marketplace, topical steroids to inter nasal sprays for dry disease. What are your thoughts and your experiences on some of the newest things that have come out this year?
Speaker 2 00:05:15 Yeah. So now in the U S we have five pharmaceutical agents that are approved for dry eye or case sicca and three, and they'll just the last two years with a C quad. I assume this into your via. And I think that, you know, looking at that in combination with Xiidra or Restasis, you know, we've got five tools that I'm using regularly, and that's just the pharmaceutical agents. So, you know, having the ability now to have a preservative free nasal spray, to, you know, improve natural tear production, basically tears on demand with a tear via and varenicline. I think that has been a nice addition. You know, we've just had that for the last six weeks or so. I probably have 40 or so patients that are on that, I have a couple of patients where we've had success and we're just starting to see these patients back in the clinic.
Speaker 2 00:06:09 I don't think I have a home run patient, you know, a patient that I can, you know, shout out to the world, say, boy, this was the greatest thing ever for this patient, but I'm starting to get these, you know, doubles and triples, which I like too. And I just had a patient today was actually one of our technicians, but she's got pretty significant dry eye. And the nasal spray has been really the most effective option that she's had. And she has had quite a bit of therapy in the past. So I think having that is, has been a great addition having, you know, I assume it's on label to treat dry eye flares and just understanding how common those flares are. And, you know, one of the things that I'm starting to do now, especially in my followup patients, is, is having more intelligent conversations to help guide what adjunctive therapy they may need.
Speaker 2 00:06:55 You know, a lot of these patients we've done IPL or thermal pulsation, or maybe they're on a immunomodulator, but then these patients that are having flares and we, we specifically asking when's the last time you had a bad day, do you ever have, uh, you know, symptoms that you feel like he can't get under control as those are patients that just do really well with five Subarus and having that on label, um, for the last year or so? I, I use routinely. And then if someone is using teardrops on a regular basis, more than occasional, I introduced the concept of tear via, as you know, if we got the ability to make natural tears, why did we want to settle for an artificial tear? So think about that. It's just a couple of the innovations there. And we haven't even got into the things in the sort of dry eye device space or some of the things that are common.
Speaker 2 00:07:44 So I think that what's been interesting is just every tool we want to understand. We really want to analyze that and understand where the places and where the role is for those patients in our practice. And I enjoy that challenge and, and understanding how to best use the tools that are out there for eye care practitioners. So the innovation is just that I get excited about everything that's that comes out because it's like, all right, I can help some more patients that I couldn't help yesterday. And I think it's exciting time to be a dry eye doctor that's for sure.
Speaker 3 00:08:18 So could you tell us about your conversation with the patient when it comes to, you mentioned tier via, so what are you telling him?
Speaker 2 00:08:25 So I let them know that we now have a new medication that's approved for signs and symptoms of dry eye is actually a nasal spray. And actually, uh, about a third of our natural tear production comes from stimulation within chest inside of our nostrils and patients, you would think that patients would be maybe skeptical about this, but in a trial setting where they know that I'm going to be doing everything I can to help them, they have, uh, just a, a huge amount of trust, what we're doing in our clinics. So when I introduced this concept there, they're ready to go. And I say, it was one of the, you know, the it's a dry eye medication now that we have that works immediately. You know, it works within the first five minutes and we don't have any medication like that in the past. So a nasal spray twice a day, uh, instead of, you know, trying to shoot it up towards your brain, you're actually going to aim more towards your ear. You're just trying to get inside that nasal passage, uh, in the inferior turbinate. But I tell my patients it's more or less two years on demand. We use the nasal spray to stimulate the nerve to make more natural tears. It works immediately, and this is something that, um, should be a nice, welcome addition to their regimen.
Speaker 3 00:09:40 So w so you said you've seen a couple patients back, how's the sneezing being, cause we know that's the most common side effects,
Speaker 2 00:09:47 Right? Awesome. Yeah. So Stacy and it's going to be in 85% of patients at some points in the clinical study has had some sneezing and I've used it for a couple of weeks. I'm not a dry patient. I have MGD, but I've proactively managed that I'd really don't want to get dry eye, but, uh, stays in when I first used that I S I had four or five real hard sneezes, and I would probably say that it took me two or three, uh, applications before maybe I got good at how to do it properly. So now when I have used it here recently, it's maybe an occasional sneeze. So I tell my patients expect us nays as not a problem. It's not something that's gonna make you not want to be on it. Uh, but it is, uh, unique in the fact that that's just an expectation.
Speaker 2 00:10:34 At some point, you're going to sneeze, but it's, as long as you can tell patients ahead of time, what's going to happen. Whether it's burning with eyedrops that you use for dry eye or the sneezing with tear via, I think that patients welcome that information up front. I think we get into trouble. If we don't have that conversation, then they call back and say, Hey, Dr. Jurich I have a sneeze and what the heck is going on. I think it's really on us to be able to set appropriate expectations. But, uh, the station has, I've not had a patient that has discontinued because of Stacey and in the, in the 30 to 40 patients that we've had on it so far.
Speaker 3 00:11:12 What about you?
Speaker 1 00:11:13 I am, I'm actually a non sneezer funny enough. So as about my personal experience that, but, um, I'm a non Caesar. I have any patients discontinue it yet because of the sneezing. Um, most of them are just looking. They want to actually use it more often than just that day indication for twice a day, because you do feel the tears. So they actually want to use it more than just the twice a day is what's interesting that I'm finding, but it is only indication.
Speaker 2 00:11:38 What do you tell them?
Speaker 1 00:11:42 I tell them that it's really only indicated right now for twice a day. We haven't looked at more frequently. So I'd be interested in knowing what you say. Um, you say about it, um, only twice a day right now. I don't know, um, much past that, but they like the sensation cause you really can actively feel it putting tears on your eyes.
Speaker 2 00:12:02 Yeah. I haven't had a patient asked me about using it more often, yet. That is definitely common. And I think my advice would be that at this point we just don't have enough information to be able. We really don't have any information to guide us on more than twice a day use. But I think what, what we will find is our patients are going to do what they're going to do. Right. And we're going to have patients that don't care that we say it's twice a day, they're going to use it three, four or five times a day. And hopefully some of those patients will tell us that and we'll make sure that they're doing okay. And then I can maybe share down the road, if there is positive, you know, anecdotal reports of people having success using it more than twice a day, or maybe someone will do a it or something in that area. I think that I, at this point I'm using it primarily as adjunctive therapy. You know, probably these patients are on some sort of anti-inflammatory or even a combination of whether it's a nutraceutical and an IPL, or maybe my modulator as their core therapy using this as supplemental I think is a nice sweet spot there. But I think as we understand who the best patients are with our experience is probably going to be a primary treatment for a lot of patients as well. And the study is, it was, it says primary therapy,
Speaker 3 00:13:24 Sorry, we'll get you back and ask you more of those questions. As we both want me to, I'm trying to get everywhere. And I had a patient the other day that says she sneezed at first, but it got less and less over time. But, you know, as I mentioned earlier, I like to take us off track. And so, uh, when we're looking at innovation, uh, beauty, uh, how's it been working for you? Because I tried it.
Speaker 2 00:13:49 Yeah. I want to say that it is a very interesting, you know, beauty has samples now for maybe two weeks. I was not involved in the studies. So this is the first time I've had my hands on it. And I, I I'm, I'm 45, but I'm not quiet presbyopic yet, if you can believe that, uh, slightly under corrected in one eye after LASIK 15 years ago. And I didn't really, I used it a few times. I definitely could see a little bit of difference, but it wasn't enough for me that it would make sense. I think probably three or four years from now, I'm going to be reaching for view witty or similar, uh, as, uh, my presbyopia becomes a little bit more lightened, but I I've had, you know, at this point with just the timing of things, the holidays is, most of my experience initially has been with, uh, with CA with, um, technicians and staff, as well as a couple of family members.
Speaker 2 00:14:47 And I've had some where, you know, a 50 year old, who's a plus one wears a contact lens in one eye for near and kind of fights through the other eyes. She put it in both eyes. We said, wow, this is just amazing work, you know, send the prescription. And so I think it's going to be something that, again, like with all of these innovations, it's really up to us to judiciously prescribe these things right out of the gate. So we can understand who is going to be the best candidate and who's going to be the early adopter. So I've been, I've been pretty, um, impressed so far with what I've seen. And it's something that I think is just going to be individual individual, cause I've had others that have tried to Sydney. Yeah. You know, I've maybe had a little bit of a headache or a little bit of dim vision, which, you know, those things can occur.
Speaker 2 00:15:37 So I think it's going to be something that we'll be much better at prescribing maybe three to six months from now, but right now I am offering it to patients where it makes sense, but in my practice, I've not really managing presbyopia all day every day. You know, we don't do any sort of primary eyecare. I've never fit the contact lens in clinical practice, beyond the bandage lands. I don't write glasses, prescriptions. So most of what I'll be doing is helping to engage and educate our community and our primary care optometrists about the role of, of pharmacol therapy for, for presbyopia. And then using it selectively in some patients maybe in ocular surface disease clinic, or maybe later they don't have a primary care optometrist and they don't really want to wear glasses or contacts. And we'll talk about that option. So I think, I think it's definitely going to be the start of something big and, uh, 20, 22, or we're going to hear a lot about presbyopia, but I've been impressed so far with beauty.
Speaker 3 00:16:38 So now you'll get this new Tracey where I bring it back in. So David says, this is for dry eye coach and click on dry eye for a chronic medication. Patients are going to be Presby opics. So, you know, upper forties, fifties, and more mature. What are the, what are your thoughts on the ocular surface and using dut?
Speaker 2 00:17:00 Yeah, so we, we do know it has big K as a preservative and, you know, that's, uh, three nasty letters in the OSD community is BAK, right? But there's so many things that we have even, you know, medications in the dry eye space, you know, I assume as BAK and you know, Lumify has BAK. So I think that there's things that our patients are using, maybe not chronically, you know, that we are going to be okay with having a preservative like that. I think it's too early to tell. We didn't really see dry eye issues in the, in the studies to get beauty approved, but it's definitely on my radar as something to pay attention to, especially if they're on any sort of other BAK, a containing agents, I think we have to be aware of it, but it's not something that at this point I've seen any issues with, obviously in, in limited experience in just a couple of weeks. But I think that we have to weigh the pros and cons just like anything else that we do for our patients.
Speaker 1 00:18:07 So maybe for our severe dry patients, if they wanted to try this would be a once in a while thing, but not a daily drop.
Speaker 2 00:18:14 I think that's reasonable. I think again, reiterating that as long as we set appropriate expectations for patients, you know, I don't think we're going to have any drop that's going to make it totally eliminate other things that we may need to do to manage their presbyopia. So I think if we position it correctly and that are know severe dry eye patients know that this may be an option, but may not be an everyday option. I think that that's the appropriate expectation.
Speaker 1 00:18:41 So speaking of new technologies, are there any new diagnostic technologies that you're aware of that we should be out on the lookout now?
Speaker 2 00:18:51 Not so much on the diagnostics side right now. I think we've got really pretty good diagnostics and you know, I'm a big advocate of point of care diagnostics with tear osmolarity and MMP nine. And the use of my biography. I definitely encourage colleagues to get videography into their practice as well. That's just been so huge with patient education and be able to track those things I think on the therapeutic side. And I'd be interested to hear what you guys think as well is I think there's more of an emphasis of shooting, uh, ocular surface disease and dry eye as, as a dermatologic disease, right? Photo biomodulation low-level light therapy, IPL, but some of the things that are coming with, you know, managing patients with index blood, for itis, with Tarsus, their, their product that maybe we'll have in a year, year and a half. And then, you know, Azura having a keratolytics that basically is cells in blue, a active ingredient that is going to melt away. Those keratinized plugs is, is treating dry eye more like a dermatologist and maybe a little bit less like an optometrist is, do you guys see us going in that direction?
Speaker 1 00:20:03 I do so many of my patients, their dry eye is stemming from dermatological conditions because it's not just the eyeballs sitting there, plainly they're covered by lids that are covered with skin. And a lot of inflammation comes from different skin diseases. So I have to say I concur.
Speaker 3 00:20:23 Yeah, definitely. The other thing that were done there was several, um, studies and press releases is Nova three, which is essentially a single, uh, chemical entity that is going to be for the signs and symptoms for dry eye disease in patients with MGD. And essentially it's theoretically, it's going to help remove some of those obstructions within the, my Bowman glands. And so in one of the studies of the CK studied that improved both the symptoms, but also total corneal staining, uh, for those patients. So I'm pretty excited about that, that one diagnostic technology. I know you've been, uh, you've been working with this as well. Damon is the, uh, the Ilex squared. Uh, can you tell us a little bit about that?
Speaker 2 00:21:09 Yeah. So as far as, um, diagnostic, you know, my biography is not new to thermal pulsation. It's not new, but having that in one product with Ilex squared, you know, having a thermal pulsation device with built-in my biography, you can, I actually had a little bit of a chance to work with that. And you know, that should be available here in early 20, 22 is, you know, having a capability that have that diagnostic and therapeutic in one handheld device, that's mobile within the clinic, be able to have a little bit better visualization as you were, you know, removing those mobile main glands obstructions, being able to capture my biography, capture videos, to educate your patients, the videos it's just spectacular. What's coming out of that. I love square. So I do look at that as not necessarily a new technology because we've had those tools, but having those put together in a device, that's going to be, you know, easier for people that want to get in this game as eye care providers, to be able to invest in a single product, that's going to be both a diagnostic and therapeutic. I do think that that's pretty innovative.
Speaker 3 00:22:19 Well, definitely. And you know, whether it's diagnostic or therapeutic, I mean, we didn't even go into the whole RAF inhibitors and we know that there's current studies on that as well. And so looking at, you know, the, the, uh, inflammatory levels within the body, but if there's a way we can inhibit that it's only going to help our patients. And so that's still in the early studies, but I'm excited to hear more about that. Anything else you're super excited about there, Damon?
Speaker 2 00:22:43 Yeah. So I think what's going to be the challenge. And I think you'll both agree is now that there's so many tools and we're starting to have a better grasp of what's causing dry eye. There was so many different factors, but we're, we have a much better handle on things than we did 10 years ago. As if our colleagues aren't embracing this now, what is it going to be like in three to five years when the number of different tools in our tool belt, maybe double or triple, what they are now is like, how do you even start that at that point? So I would definitely, you know, put the shout out that as it's, if you're not getting in the dry-eye game now, it's just going to be a lot harder a couple of years now because of the rapid growth of technology in the sector.
Speaker 2 00:23:31 So that's why we have, you know, eyes on dry eye drive, who can't from the past, you've got the podcast, you know, with Walton Chasey here, these are great opportunities to be able to engage and innovate and just collaborate, but it gets started now because the future is bright. And, you know, the things that we've talked about as far as innovation, it's also just in the next couple of years, we hopefully will have access to those things. And, and it's an exciting time again. I said it before, but, uh, it's really a pleasure to be able to have access to new, uh, diagnostic and therapeutic tools to help her patients
Speaker 3 00:24:08 Well. That's awesome. Well, Hey, thank you so much, Damon, for your time and expertise in sharing innovations in ocular surface disease with our listeners. So thank you.
Speaker 2 00:24:17 Thanks for the opportunity. Be safe, everybody. And I hope to talk again soon.
