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Speaker 0 00:00:52 In today's episode, we have the pleasure of speaking with Josh Johnston OD of Georgia. I partners in Atlanta, Georgia about the future of meibomian gland dysfunction. Welcome Josh.
Speaker 2 00:01:04 How's it going? Thanks for having me here tonight. Grateful for the opportunity. Good to see you guys.
Speaker 3 00:01:09 Hey Josh. Thanks for being here.
Speaker 2 00:01:11 You bet. Walt. Thank you.
Speaker 0 00:01:13 So why don't you start off by telling us about your practice and your role in regards to ocular surface dryness?
Speaker 2 00:01:21 Sure. Yeah. Yeah, sort of my background, I finished, uh, optometry school and graduated from ICO in 2004 and basically moved to Atlanta, grew up in Texas, but came here to Atlanta, um, was with the group I'm at now called George eye partners from 2004 to 2009. And at that time was doing a lot of medical optometry. You know, we're at MD OD practice in kind of a hospital tertiary care setting. And then my wife and I moved to California for three years and got to a practice where I wasn't doing as much medical optometry as I used to. So that's kind of where I started to do more dry eye, uh, early on in my career. I ignored it. Didn't like it. And then started really falling, uh, you know, doing more of it and the trenches in California and that's became my passion then moved back to Atlanta about, uh, 10, 11 years ago and really joined the same group I'm with again, George eye partners. And we created a dry center of excellence if you will. And I've been overseeing that for the, uh, past 10 years and, uh, it's grown and, and doing well. And it's, it's a passion mind. So running the dry clinic and then also serving as the clinical director and residency director, um, as well,
Speaker 3 00:02:25 Hey Josh, within that clinic. So you have a bunch of doctors there and you have a large referral network. So how do you manage that and how do you optimize that both within your practice and within the referring ODS?
Speaker 2 00:02:36 You know, it's interesting. We, uh, when we set this up, we thought internal referrals would really drive it right. And we did the speed questionnaires and, um, you know, we have six locations now and so trying to implement questionnaires for our staff, the front desk, our technicians, the doctors, it just kind of just didn't really take off. And so still to this day, uh, I would say 30, 40% of my referrals are from other physicians, the community mainly optometrists, but some ophthalmologists as well. Uh, Google still drives most of our traffic. You know, it's patients looking for other options that are suffering from symptoms of dry eye, uh, who have not found relief. We know there's no cure, but we have a lot of new diagnostics and treatment options that a lot of their practices don't. And so just a, a, you know, a large practice with the ability to have a lot of equipment helps. And then we do get some internal referrals. You know, we have about 20 physicians in our group now, but still to this day, it's patients coming in, uh, looking for other treatment options, just from word of mouth and other, uh, other ways of doing that.
Speaker 3 00:03:33 Hey, Josh, I know you started a dry consulting, uh, company many years ago and it, what, what are you doing with that? Now? I know you're working with several different groups.
Speaker 2 00:03:43 Yeah. It started as a passion project and sort of a labor of love and, um, was doing this and ad hoc and then realized some of this could be automated. So I created a website, really having some digital, um, algorithms there and filling out questionnaires that could automate the whole process. So I didn't have to be, it allowed me to essentially scale, uh, anything I was doing and I don't do as much of that anymore. Now I'm doing more, um, consulting for our group. So our group, Georgia, I partners partnered with, uh, a private equity firm on a Chicago forming I south partners. And that's the name of our MSO. And so with our organization, we're now in 10 and 11 states, I believe so I'm helping our affiliates that we have, uh, partnered with, uh, to build dry clinics. And some people are already doing that. So we're getting, you know, diagnostics and existing technologies and treatment options to them. And then also, um, some clinics that are naive to this space, um, helping them build it from scratch, that sort of thing. So that is transitioning more from anywhere consulting with our, our colleagues out there to more just within our network at ISO.
Speaker 0 00:04:45 Wow. That's, that's amazing. You've done quite a bit over the past 10 years since diving into what we now know is modern, dry eye. How would you say that the dry eye diagnosis and management has changed, particularly over the past few years,
Speaker 2 00:04:59 There's four FDA approved, uh, eye drops, right? We have three sort of immunomodulators. We have a corticosteroid as well. And then I think, you know, a big thing is, is MGD treatments, right? So, um, you know, for many years it was just maybe one drop treating inflammation. We know it's multifactorial. Uh, we need multiple shots on goal. If there's, you know, Leitis and a biofilm, you need to address that there's obstruction. You need to address that treating MGD inflammation, uh, and the tear film. You need to address that with the therapeutic and a prescription, um, many different things, you know, lag, ophthalm come tub SIS. So it's fun to see that more education come with this right with dues too, and everything we've learned. So it's not simple, you know, 15, 20 years ago is one prescription drop and that's it. We know now it's more complicated when we have to do multiple therapies to really help these patients work towards that cure. We, we know there is no cure, but we can put 'em on a journey getting close for most patients.
Speaker 3 00:05:53 Yeah. I gave a lecture on left, right. MGD, not too long ago. And I have a slide in there talking about just a decade ago since we're focusing on MGD, uh, as you mentioned, the treatment was, well, do patient education, some heat mask, uh, maybe a Topco antibiotic, maybe add ointment in there as well. And then, you know, for moderate to, to severe was adding doxy cycling, and that's essentially what we did. And so things that definitely, uh, have changed over the years. You know, one of the things that we look at with, in regards to MGD one are the terms we hear is lid wiper. Apathy. Can you talk to us a little bit about that and, you know, is this something you're constantly looking for? How does that play into the whole MGD?
Speaker 2 00:06:33 Yeah. Great question. Yeah. It's also funny with dues one, we really even talk or think about MGD, right. Um, and now we, here we are, and it's maybe the majority, right. 86, 80 7% from limp, uh, with MGD. So, um, and there's a lot going on there, right? Obstruction, um, you know, those two things kind of core pillars of this treating inflammation, treating obstruction. We look at other risk factors that go along with MGD, as you mentioned, lid, wiper, epithelial, apathy. Um, I don't do as good a job as I should. I'll be candid with you all here. Um, but looking for this with listening green, I think I should, and we should a good Pearl is when the signs don't match the symptoms. So if we have a patient that's really struggling, there's no standing on the cornea. Osmolarity looks normal, maybe not a lot of obstruction when you're expressing glands. We need to look for that potential lid, wiper, epi, you know, the proposed function there is that if you have a decreased tear film, that's not, uh, giving enough, um, lubrication and you have some friction there that that epithelial tissue on the lid can certainly cause more friction and cause symptoms there. So if we use a vital dialect li and green on these patients where everything else is just looking normal, maybe we can do a better job at identifying that
Speaker 3 00:07:43 Mm-hmm <affirmative> Hey, Tracy, are you looking for that, uh, within your practice often?
Speaker 0 00:07:47 Yeah. Um, I'm doing, uh, especially the first workup that I do on my patients when they're referred, when I'm working them up, I'm using lisamine green. So I do look for that epi apathy mm-hmm <affirmative>, otherwise it's literally like rubbing a callous on the front surface of the eye. So I think it is important to at least look at it for baseline. And then when I get for my treatments, I'll look at it again, staying it, see if there's an improvement in that area. I used to teach it when I was in education and I still do it with my patients now.
Speaker 3 00:08:13 Hmm. Yeah. Josh, I'm more like you, I should be looking a lot more for it. Um, and also listening green, you know, that's a lot of those patients that you just mentioned, uh, just ocular surface disease. They may not, uh, you know, they're feeling horrible, but you know, if we utilize that dye, we can find earlier signs of damage that's, that's occurring for our patients.
Speaker 2 00:08:34 Yeah. It's a great Pearl. I think it's, you know, I use it maybe once, twice a day, but I think it's a great vital dye to really look when you're kind of scratching your head and things aren't as obvious you'll find other pathologies potentially
Speaker 0 00:08:47 Now in the marketplace, there's so many more options for meibomian gland treatments. Um, but patients often have have this question that they ask me quite a bit, which is, um, what is the role of over the counter artificial tiers? Do those still, are they still players? And if you do recommend, um, artificial tears for meibomian gland, dysfunction, adjunctive therapy, um, do you have a specific recommendation for what kind, what type, what are, what are we educating our patients on for that?
Speaker 2 00:09:12 Yeah, it's a good question. I may be a little bit of an outlier on this. Um, and for me, the reason for that is most of what I'm doing is, is further down the pathway, more advanced, more, uh, severe dry disease. And so, you know, early in my career, I kind of try to balance a lipid tier to replace things, you know, at this point, the folks that are coming to me, see me have a big bag of treatment and I'll check off and, and, you know, give them a customized treatment sheet. And again, probably a hundred percent of my dry patients, you know, will use artificial tears and recommend them, but they've tried X, Y, and Z. They know their favorite flavor. If you will, I'm really a believer that it gives temporary relief, you know, any sort of tier. Um, and I think, you know, they're all good.
Speaker 2 00:09:53 We want a, a newer tier that has good technology. Um, and we know there's some that are really given that layer of, of oil that we need that we maybe missing. We have MGD, but for me, it's really about therapeutics prescribing therapeutics to decrease inflammation. Um, it's really about addressing obstruction the, my booming glands with an in-office procedure. So we'll recommend it here. Uh, but most of my folks are already on tier. They know which one they like, and to me it's palliative, it just gives them temporary relief. It's not really addressing, uh, the disease state itself. So I don't really dive into it as much as I should. Maybe.
Speaker 3 00:10:25 What about you, Tracy? Is there one you go to,
Speaker 0 00:10:28 Um, I am a complete agreement. I think if artificial tears had worked to treat my bone gland dysfunction or, or the severity of dry am seeing that the patients wouldn't be sitting in my chair. So most of the time I'm recommending something that's preservative free just to not have any extra irritation going on to the ocular surface. If you try to target it more towards, if they're having, you know, need more oil based versus more water based, or if it's a combination of both, but they're not really taking care of the underlying issue. So I agree.
Speaker 3 00:10:57 Yeah. I mean, it's for treatment of symptoms and, you know, the one I've been using a lot is, uh, sustain complete. Uh, they're actually coming out with a preservative free one that comes in a as well for patients. And as you both mentioned, preservative free is always important, but we have that, you know, we already have the active ingredient, which is the lubricant for this. It'll be purple Lyco. But if you combine the, the nano lipid technology, it's in additional HP GU I mean, we have something that's gonna address all forms of dry eyes, so we don't have to make it too complicated. We can say, Hey, this covers everything. And so that's something, uh, that I'm looking forward to. And I know retain MGD has been a great one as well. And I, and there are others on the market, but I simp simplify things. I pick one for my patient that way decreases the risk of them going to the, uh, pharmacy and getting that retail confusion that often does occur, uh, with that. So
Speaker 0 00:11:48 Refresh omega3 is a really big popular one at my clinic. I think it just feels expensive, I guess, is the right way to say it. It has a little bit more of that. It's a little bit thicker, but dissipates quickly. So that one's pretty popular in addition to the ones that you mentioned.
Speaker 3 00:12:01 Hey, so Josh, tell us about the role of Deb Brit in MGD. Are you doing this, uh, consistently? Are you doing this only when you're doing some of the procedures or what are your thoughts?
Speaker 2 00:12:10 Yeah, I think it's sort of a secret weapon, right? I was trained, we bought lip flow about 10 years ago in the crew, uh, that came in, um, you know, from Don CORs clinic back then would train us. Right. And that was a tool I learned, lived Britt using a golf club, bud, and now I use the car PEI. Uh, debrider from Bruter, but I, you know, the keratin is a big piece of this, right? So if we have these, uh, keratinization over the MYI glance, you're gonna get obstruction just over the orifices itself versus the duct itself being obstructed there. So it's a two-prong approach. If we debride and move away that keratin upfield tissue, you're gonna have paper, or there's a literature paper on this that shows it really doesn't improve symptoms anyway. And then also you'll have, I think better expression when you're doing these, in-office my booming gland, uh, treatments there.
Speaker 2 00:12:55 So we see patients with that biofilm and you sort of scalped and heaped up EPHI Ridge, if you will. And we can use listening green to look at that, you know, muan, mucocutaneous junction and the line of marks. Um, it's a very valuable tool to do as far as treatment to do it in the office. I don't charge for it. We certainly do it before every procedure and we do it on the follow up afterwards. And I also do it in the clinic, you know, a couple times a day if I just see a really, uh, more advanced, uh, you know, pleuritis patient with that, that biofilm and lid debris there. I think it's a very useful therapeutic treatment if you will.
Speaker 0 00:13:29 Yeah, I agree. I think you can get a couple months extra, especially if you have patients who are trying to, you know, watch their pocketbook and need a little more of extension between maintenance therapies. This will get you a couple months in between those too.
Speaker 2 00:13:40 Yeah. I agree. Agree with that. And there's that chronic patient that does so well that men shows up every four months, right? For the, the free debridement, if you will. And obviously we're, we're building the exam and seeing 'em and checking up on other things, but some people love that treatment there and come back for it specifically.
Speaker 3 00:13:57 Hey, Josh, I gotta ask this question because you were part of this, uh, this panel. So at the academy, we're talking about compresses hot versus cold, uh, you know, that I said, Hey, we need hot compresses, but one of our good friends said, cold's the way to go. What are your thoughts on this?
Speaker 2 00:14:12 Yeah, this is the new great debate in optometry, right before it was, do we build a vision plan or do we do medical insurance? Right. And after a full house at academy with a fun lecture, um, you know, how do I handle that for me? I ask, you know, if it's an ocular rosacea patient rosacea patient, and we see MGD, um, I'm gonna ask them, do your eyes get red and irritated in the shower? If they take a hot shower, if the answer's yes, I'll just recommend a cool compress. And I think that just feels good. I don't have any literature to prove that helps. Um, obviously, you know, most of my patients, probably 60% of those reservation patients are doing okay, and we'll recommend a warm, moist compress, and then your dry MGD patient that doesn't have rosacea, I'll just recommend a warm, compress, warm, uh, moist compress there. And the goal of heating it up, uh, you know, getting some, some of that Miba moving and, and working on, uh, hopefully some self expression with blinks and that sort of thing. So I like heat on most of my folks. Again, if they have, uh, get irritated and red in the shower with rosacea, I'll tell 'em just to use a cool compress for relief there,
Speaker 3 00:15:15 Tracy.
Speaker 0 00:15:17 Um, I actually take most of my patients off hot compresses. Um, I'm kind of the other, uh, side of the spectrum to start with in particular, because I don't like to put heat on inflammatory disease states. So until I get them stabilized, um, then if they wanna go back on warm compresses, that's fine, but absolutely no for rosacea patient, because that does tend to make it worse in my experience. But, um, I don't like to put heat on inflammation, so I don't put heat on, um, other areas of my body. If you go to a chiropractor or you go to a muscle specialist, they'll tell you to put, hold on things that Aren inflamed. So I heat away until it's time for maintenance therapy. That's where I'm at. Yeah. You
Speaker 3 00:15:57 Know, the hard part with that because we know heat is a trigger, especially for realization, but the hard part is, is you mentioned Josh, you try to look up the literature, you can't find anything. And so, I mean, we're just using it in our clinical experience. And I, I do the same as, as you Josh, if it's a trigger, then I won't, I'd recommend cold, but, um, either way, I just wanna make sure we brought that up there.
Speaker 2 00:16:18 Yeah. Uh, Tracy, great. He raises two great points there. As one, after I do one of my in-office MGD treatments, those rosacea patients that I have heated up and squeezed their whole face and lids are gonna be pretty red. And it's more apparent, you know, what heat can do to some folks there with that inflammation. And then again, the chiropractor analogy, Tracy, I love that, you know, when you spray your, your, or you spraying your ankle right in high schools, playing sports, the glory days, we put ice on it, we didn't put heat. And you know, when you throw out your back and go to a chiropractor, they're not heating you up. It's what we all think to do with a, a warm, uh, sort of, you know, treatment, but it's gonna be ice right. To reduce that inflammation.
Speaker 0 00:17:00 Good talk guys. I love it. So with MGD procedures that you're talking about in the office, there's a lot of them that are available. Um, which ones do you have experiences with and kind of, what's your go-to one?
Speaker 2 00:17:14 Yeah, so we were an early adopter of Lipa flow many, many years ago, and that worked Wellforce for many years, that was sort of the first to market and where we've moved on. Uh, most recently in the past three years is with tear care. And, um, for me, Lipa flow is good. Um, but it's sort of your more gentle, uh, treatment option if you will, at this time, it heats up the lids from the inside out. And then of course there's a warm, uh, and then a gentle pulsation, which can squeeze the lids there. Um, tear care for me a little bit warm or a little bit longer treatment there. I can customize where the heat is put on the lids. And then of course I can come in after the procedure and, and really, uh, express these patients being a little bit more invasive, a little bit more aggressive as far as customizing the treatment there, getting a little bit more potential, uh, you know, treating the blockages a little bit better there. So that's what we've been doing in the past three years, having good clinical outcomes with that.
Speaker 3 00:18:06 So do you do that or do you delegate that?
Speaker 2 00:18:10 I do it, yeah. I'm just a big believer of optimizing patient care customizing it. Um, my technician will put the smart lids on the patient and talk about it, you know, but I will actually come in at the end and do the expression there. So there's an argument that's not necessarily needed and maybe, uh, decrease of my time and not a great use of my time and inefficient, but I think the sort of personalization with the patient, with the doctor doing that has a little bit of, uh, uh, a better overall feel if you will.
Speaker 3 00:18:37 Mm-hmm <affirmative> and then they, they did have that, uh, paper that was presented, uh, from, um, doctor low, uh, the Olympia trial that looked at it was non-inferior already studied comparing that versus normal pulsation, and it was very effective, uh, in addressing the signs and symptoms. So, well, what are some of the innovations and MGD that you are excited about in the pipeline?
Speaker 2 00:19:01 Uh, you know, part of the biggest thing coming, I think will be the car Alytics right. So a zero is a company out of Israel and Australia looking at this. So potentially in, in office treatment, you could put like a gel on the lid or potentially a lower dose therapeutic. We prescribe on top of that. Um, really breaking down those, those di sulfide, uh, bonds of those carlytics there. So, um, this will hopefully, you know, cause some, uh, increased expression of the BIC glands. Once you break these bonds and the characterization there, and there's maybe some potential to have Reju, you know, regeneration there with these Bian glands, increasing lipid production, as well as expression there. So, you know, it's not one single thing. I think we'll look at, um, dry with, you know, one drop, just treating inflammation. I think MGD will be expression. It'll be in office treats in, in office treatments, if you will. Sorry. And then also most excited again about the car Alytics there, hopefully opening up these glands, maybe some potential for re rejuvenation. These are exciting things. We'll see.
Speaker 3 00:20:00 Yeah. Adjunct two, the current treatments that we have. And the one thing about that it's twice a week, so it's not twice a day, it's just you do it twice a week. And that's what, uh, that's, what's been improving and the early data for that, uh, a Z uh, medications. Very, very exciting. Tracy, what are you excited about for MGD?
Speaker 0 00:20:18 Um, actually that's exactly. I was actually having a conversation with a patient of mine who does tend to get that ization build up and she's an expressing just have to express her really, really regularly. So she was asking what the pipeline was and I was talking just about this with her today. So I'm really excited to see what happens when we, you know, get rid of that lid, wipe epithelial, that ization, that buildup over the top. Umm, excited to see what is gonna happen with that too. So
Speaker 3 00:20:44 That's only one, I mean there's a couple more on the pipeline too. Novo three comes to mind, you know, treatment for signs and symptom of dry eye associated with MGD. Uh, it's essentially a single disease or single entity drop entity where it's preservative free water free and essentially it helps dissolve those obstructions in the meibomian glands and the Gobi trial, the Maho, uh, trial as well, the phase three studies they've, they've been very promising in improving both the, the corneal staining, total corneal staining as well as the symptoms for patients. And so those are just a couple, there's gonna be many more. So it's been super exciting. Um, so Hey Josh, lastly, what is your clinical Pearl for MGD? I mean, we can talk about this all day long, but we only have a 20 minute podcast. So, so give it to us.
Speaker 2 00:21:28 Yeah. I mean a few things gonna sum it up a great question there, right? It's not that easy. So for me it's, it's really to do something and that's gonna look at this. I wanna look at the quantity and the quality of the, my on every single patient. We see if there's MGD there and it's mild, we may start with something like a warm, moist compress, right? And then if we're not getting a breakthrough in symptoms, we need to potentially look at an in-office procedure. Uh, whether that be Thermo pulsation with Lipa flow or eye looks or tear care, pick your, pick your diagnostic or treatment option there or treatment option if you will. But to me, it's not one thing, right? So we need to treat inflammation, um, with the immunomodulator, if there's a lot of standing on the cornea, we may potentially use an amniotic membrane address, biofilm, uh, you know, all these different things, um, looking at this and then you'll have better outcomes, better clinical success while you're treating MGD.
Speaker 0 00:22:21 Thanks Josh, for your insights on MGD, Anna, where we are and where we're going was really wonderful to have you on the PA podcast. This
Speaker 2 00:22:29 Tracy, Walt, it's been a pleasure and uh, look forward to seeing you all soon. I appreciate it.
Speaker 3 00:22:35 Hi Josh. Thanks
Speaker 0 00:22:36 For listening. Join us for our next episode. Soon
Speaker 4 00:22:39 For over 18 years, I ego has been an industry leader of natural effective at home dry eye management. We support you and your patients with scientifically proven products for mild, moderate, and severe dry eye. Join us
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