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 topic. In today's episode, we have the pleasure of speaking with one of optometry Debu. Lease a a Hornick OD of Stanford ranch, optometry in Rockland, California. Today's topic is on nanotechnology and drug delivery for ocular surface dryness. Welcome.
Speaker 1 00:00:32 Thanks Tracy. Thanks Walt. Thanks so much for having me.
Speaker 0 00:00:35 Why don't you give us a start by talk all about your practice, because I know that you're not the only one that's
Speaker 1 00:00:42 Yes. So I'm in private practice. Um, I work with Dr. Christina Linsky Sipes. So we joined forces in around 2018. Um, and as you said, my practice is Stanford ranch, optometry in Rockland, California, Rockland is a suburb just outside the Sacramento area and we have a predominantly primary care practice, but we do have some, you know, a heavy medical portion as well. And we have a specialty dry eye clinic. We were actually the first practice in the area to have I P and so we're very proud of that. Um, and we offer all different types of dry eye treatment options.
Speaker 2 00:01:19 Well, awesome. But we love talking about dry eye and hearing about everyone's, uh, practice is and how it works for your practice. But before we get into that, can you tell us more about optometry divas in the organization? Cause I hear all about it. I'm sure our other listeners would've would love to hear as well.
Speaker 1 00:01:34 Yeah, absolutely. So optometry divas, it's an organization that was founded to help support women and some of the more complex challenges that we face as women optometry. So we talk a lot about, you know, clinical issues and practice management issues, but we also like to talk about work life balance, um, self care, you know, making meaningful connections, networking, family life. So some things that you don't typically get from when we go to big conferences and, and that type of thing. Um, and it's more just to have women make feel like they're not alone, um, and have a support group. So Dr. Loretta, Justin is our founder and she's amazing if you've ever met her. She's fantastic. So she basically wanted to create a place where women ODS could come together and support each other. She started in Orlando and it's sort of branched out and got more popular. There's now a Tampa, a chapter, there's a Miami chapter. And I think there's even a New York in Chicago, so it's getting bigger and bigger. It is nationwide. And she asked me if I would like to start the first west coast chapter. And I said, absolutely, I would love to do that. So we now have a chapter in Sacramento.
Speaker 2 00:02:42 Well, awesome. Awesome,
Speaker 0 00:02:43 Mom, I really wanted to fly down to your chocolate event. I just couldn't get there
Speaker 1 00:02:48 Next time. Next
Speaker 0 00:02:51 Next.
Speaker 1 00:02:52 Yes, for sure.
Speaker 0 00:02:54 So why don't you tell us how, and when you got started with ocular disease, how did you get the other people in your practice involved?
Speaker 1 00:03:02 Absolutely. Um, so I have dry disease myself. Um, I actually, I think I've had it ever since optometry school and when I actually realized what dry eye was and learned what that was, and I got worse as I got older, as many women do I work contact as well, so that can sort of complicate things. But I feel like when I really became laser focused with dry disease was in around 2014. My husband is in the coast guard or was he's actually retired now, but when we were practicing, we were stationed in Kodiak, Alaska. And that was my first opportunity to practice in, uh, private practice. Prior to that, I was a active duty Navy optometrist. So he got a lip flow machine and he asked me if I would start his dry eye clinic, sort of build up his dry eye practice for him.
Speaker 1 00:03:50 And I thought, wow, this is really interesting. And looking at the lip flow and we had a lipid scan and I looked at my meibom glands for the very first time. So that was the very first time I had seen my biography and my meibomian glands are not in the best shape. And I just thought, I just wanna know everything there is. And I was like a sponge, you know, just needing all this knowledge on dry eye. So, um, it was, it's really great. You know, it's really exciting. We've come a long way since when I started practice and we all only had artificial, she tears and, you know, warm compresses and baby shampoo. So I think that the way that I get the other providers, um, I think my passion is really contagious at at least that's what they've told me. Anyway, I get really excited about all the new advances and dry eye treatments, and I'm always trying to learn more and I love to teach others as well. So, um, and I, it's something that's really important because there are so many dry eye patients out there and they really need our help.
Speaker 2 00:04:47 Hey, Lisa, you know, one of the, you mentioned you were the first that got I P what other treatments do you have? Cause I actually have a question. I just wanna clarify that first.
Speaker 1 00:04:56 Sure. So we do sclera lenses, um, of course pharmaceuticals punctu plugs nutraceuticals.
Speaker 2 00:05:04 So where I was, where I was going that, and this is a question that Tracy and I, uh, and I'm sure you get it as, as well is how did you decide? Cause you just mentioned Thermo pulsation. That's how you got into it. Mm-hmm <affirmative> but then within the practice you went through I P first. So can you tell us about how you guys made that decision, how you all did?
Speaker 1 00:05:22 So it was actually, I, I moved in to a different practice. So I started, I had lip flow, uh, thermal pulsation, and then I moved into a different practice and we decided to bring IPL in at that time.
Speaker 2 00:05:32 Mm-hmm <affirmative> OK. OK.
Speaker 0 00:05:35 Do you think the decision to go with I P over another technology?
Speaker 1 00:05:40 Uh, I think cause I P has so many benefits to it, you know, it's, it's not just the dry eye treatment, but it helps with the lifing, the meibomian glands, it makes the Ibom gland expression easier. It helps with rosacea. So getting rid of those Taang Tasia and redness, the inflammation and the lid margins, it, uh, actually helps to kill DDEX and decrease DDEX it's kind of, you know, all in one that it, we know that dry eye disease is multifactorial. And so I love I P because it actually hits all of those different, um, you know, root causes.
Speaker 0 00:06:15 Totally agree. Mm-hmm <affirmative> well, I do know that a big part of what you do does include, uh, pharmaceuticals. So what are some of your strategies to improve ocular drug delivery?
Speaker 1 00:06:26 Yeah, so traditional methods of drug delivery are obviously an eye drop form. So we know that though sometimes that works, but it's not always the best due to possible cor compliance. You know, we're asking our patients to do drops sometimes more than four times a day, and that can be difficult for them. There's definitely a decrease absorption in the eye with eye drops. So there's research that actually shows that less than 5% of the drug might get to the target tissue where we wanted to go. And then you have to think about the dexterity of some of our older patients might have a hard time getting the drugs into the eye, the drops into the eye. And there are new medications that have special technology called the technology, and that improves the ocular penetration of the drugs. So even though it is still in the drop form, it just does a better job of working and getting to where we want that exact tissue, the, where we want it to go.
Speaker 1 00:07:16 Uh, one of the new drops that we're used, what we really like in our office is se a and se is cyclosporin, which has been out for quite some time, but it's actually a stronger percentage. So it's 0.09% cyclosporin and it uses something called N cell technology, which is their proprietary technology that helps that better penetration into the popular surface. Uh, the problem with cyclosporin is that it has poor aqueous solu ability and that end cell technology solves that problem by encapsulating the cyclosporin into polymers that have a hydrophilic outer layer and a hydrophobic, uh, inner layer to protect it. So when the se enters the eye, it's able to penetrate through the aqueous layer of the tear film, and that gets released and is better able to penetrate the target tissue of the cornea and the conjunctiva. In fact, in clinical trials, it actually showed a three times greater corneal absorption and a 1.6 times greater conjunctival absorption.
Speaker 0 00:08:13 Are you seeing this make a difference with your patients, the nanotechnology with this drop?
Speaker 1 00:08:17 Yeah, I definitely have. So I have a patient who is a long time patient of mine. She's moderate to severe dry eye and she has done absolutely everything she's done. Uh, you know, I P she's done lip flow. She's been on, she even did new lid. She's been on Restasis for a long time. And so I said to her, and we're just not getting the results that we wanted to. Right. So I said to her, let's try some thing different. Let's try qua, uh, it's stronger and has better penetration. So let's see what you think about that. And that has actually been an absolute game changer for her. She told me she it's like night and day. She actually knows when she's ready for her second drop. So she's doing it once in the morning, once in the evening. And she told me around 4:00 PM is absolutely when she's no she's ready and needs that next drop.
Speaker 1 00:09:02 Um, another really interesting patient I had is a Fein's patient. So I started actually he's with seeing a corneal specialist and the corneal specialist was the one that suggested the que. He, he came into me for a, uh, for a refill on his Siqua and he struggled with THS for so long. He actually has exacerbations of the THS every month and a half, which is debilitating for him. He's totally photosensitive. He can't go outside. He has trouble driving. And the se qu, although it is off label, it makes a big difference for him. And he only has his exacerbations maybe every six months. So really, really improved his quality of life.
Speaker 2 00:09:43 I have a similar patient just like that, that I use. It is off label of course, but, uh, very, very effective. And, uh, just the, the technology itself, you know, patients that come to mind for me, it it's that corn staining data. And so we're trying to prove that surface, we, we all talk about this, that dry eyes is a vision disease. And if that cornea's not smooth that patient's not gonna be seeing well. And so, I mean, those are some other patients that, that, uh, comes to mind whenever I utilize, uh, sequin.
Speaker 1 00:10:11 Yeah, definitely.
Speaker 0 00:10:14 And are there any other delivery systems or change that you've made, um, outside of Sequi that seem to be helping?
Speaker 1 00:10:20 So we're using, um, ISS as well, which also uses nanotechnology. And that's a steroid we're frequently use steroids when with ocular surface disease, but ISS is a little bit, um, it's not our typical concentration. It's actually a lower concentration this time. So it's low predone, but it's 0.25%. And, you know, uh, this is something that's been used to treat what we call dry eye flares. So we have our chronic dry eye patients and they can have what's called dry eye flares, which occur around five to six times per year. And that's just when everything is under really good control, but then all of a sudden things just flare up and, and get worse for some reason. So we can use the ISS for around two weeks to really calm things down and get them back to normal. And ISS is the first corticosteroid. That's actually FDA approved specifically for the signs and symptoms of dry disease.
Speaker 1 00:11:12 They have a delivery system called amplify. And what this does is it utilizes, uh, mucus penetrating particles. And so the mucus musin layer of the eye is what typically protects us against things like allergens and particles and carries them away when we blink. But the problem is that medications and eyedrops can't get through that Mein layer. So the is services uses the narrow particles with the special surface coat. So it can better penetrate through the mucus barrier to the cornea and the conjunctiva. In fact, in preclinical studies, it showed a 3.6 times greater penetration to the cornea. So right now there's its really exciting time with dry eye disease. There's actually other ways that we can deliver drugs. So Punto plugs in our practice, uh, especially for our aqueous deficient patients. And right now there's a lot of clinical trials showing this option for all different kinds of drugs for glaucoma medications, possible NSAIDs antibiotics for dry eyes.
Speaker 1 00:12:11 There's a company called ocular therapeutics and they have an intracanicular drug called OTX CSI, which is clinically in phase two clinical trials. And that is also cyclosporine and it's loaded in the hydrogel. So some of the advantages to this are it's preservative free, cuz we know that preservatives can actually affect the ocular surface as well and make things worse. So it's preservative free. It clus the punctu. So we're actually getting more tier to stay in the eye and it also lasts up to 12 weeks with a single insert. So that is something that is really exciting. Um, another thing going on is contact lenses. So there is right now a contact lens is called ACU thera vision. And that is for allergies right now. So it has keto keto. That's a tough word to say. Um, but it releases H one histamine receptor antagonist to reduce itching due to allergies. So think of it as it's very similar to Zertec that we use orally or it's very to Allway that we use in an eye drop form, but this isn't a context sentence form. So this one is actually FDA approved in to use in Japan and Canada. But hopefully with this new technology, it's something that will be in the us fairly soon and something that we can use, not only for our allergy patients, but for our dry eye patients as well.
Speaker 0 00:13:35 If I live in the Pacific Northwest, I can't imagine how popular that would be if you had a contact lens that, um, fought allergies at the same time, that'd be
Speaker 1 00:13:43 Amazing. Yeah. That would be another game changer Sacramento or <laugh> right now, especially everything's in bloom and the allergies are just awful.
Speaker 2 00:13:52 Yeah. Drug delivery's such an exciting topic. I mean, you mentioned the punctual plugs and I presented studies and, and well I presented some safety data as well, looking at it for, uh, allergies. And so utilizing that, you know, ocular surface, uh, issues for sure the, uh, contact lens is 3d printing. There's several companies working on that, uh, right now, whether it's for dry eye, whether it's for glaucoma. And so, you know, the why is it so exciting? Well, it's gonna benefit our patient, but you know, one of the strategies to improving just medicine and patient care is the education part. Because many times, as you mentioned, our patients are just not compliant. They're not doing the medication properly. And that's where our staff comes in. That's where we come in each and every time, what addition is why they did it and what we're going to do next about it, you know, with some of those drugs that you mentioned, this on-label, or off-label matter, um, you mentioned steroids that we have an on-label steroid, you know, what's very impressive about that data to me is a day four for symptomatic relief was highly statistically significant for that, uh, load of pred, uh, 0.2, 5% group.
Speaker 2 00:14:59 So those on-label off-label matter.
Speaker 1 00:15:02 So I think it matters somewhat, but it's, it's not an end all be all, you know, I we've been in practice for so long and with dry is disease, we really have to use our own clinical judgment. Right. So for example, the Fein's patient with the qua, although it's not particularly, you know, it's not on label, it is an off-label use, but it makes sense clinically. So we're decreasing inflammation, same thing we're getting rid of that superficial Punte titis with dry disease. Especially we really need to use our clinical knowledge because as we mentioned, it is multifactorial. And so that's why I love dry disease actually so much because it's like a mystery that we have to solve, right? It's a puzzle. So we're putting all the puzzle pieces together and seeing what's gonna fit the best. And so sometimes it's on label, sometimes it's off label, but as long as it makes clinical sense, it's okay.
Speaker 0 00:15:51 It is worthy to know that there, uh, there's the potential for, um, preservative allergies with the FDA approved version. So I have a couple of patients who can't take that FDA approved topical steroid mm-hmm
Speaker 1 00:16:03 <affirmative> cause
Speaker 0 00:16:04 It's preserved with, um, fluorides. So always have use our best clinical judgment as to what we can use and what we should use for, for patient.
Speaker 1 00:16:12 Absolutely. And that's why I really like that idea of the Punto plugs as a drug delivery because they are preservative free. So that's really huge. Yeah.
Speaker 0 00:16:22 So you know, so much about dry eye, but how do you keep up to date on advances in ocular surface dryness? Where are the places that you're looking to make these, you know, clinical purchase decision, these, these decisions for your patients other than
Speaker 2 00:16:36 Listening to other than listening click on, on dry eyes.
Speaker 0 00:16:40 <laugh>
Speaker 1 00:16:40 Well, that is my favorite podcasts are my new favorite. They're a lot of fun. Um, they're so convenient, right? Because you can listen to them when you're driving, when you're working out. Um, yeah. Podcasts are really great, especially this one, of course, but I, I do like to read, I love journals. I love moderate optometry review of optometry. Um, my favorite thing to do of course, is to go to conferences. In fact, I was awesome to see both you at Tracy and Walt at, uh, the academy meeting in Boston. That was really fun. Vision expose a great one. Um, I also really love of the fact that we're sort of in this hybrid model right now, where we can meet in person. There's just something that is special about meeting in person. You just, there's something that you just can't take away from that, but it's not always the most convenient and it can be a little pricey sometimes. So it's also great that we have, you know, our online, we have that model as well. So eyes on I is a great conference. I like that one that's coming up soon. So the fact that we can do things virtually is really great as well. Yeah. And I just, I like to look at PubMed. I like to look at just whatever the new research clinical studies are. They're really interesting and exciting.
Speaker 2 00:17:51 You, you mentioned podcasts. If you ever get a chance, I'd listen to Scott shocker, him and Chris star. They did Acular surface academy, the TFOs dues too. I mean, if you want some pearls and you know, they, they interviewed all the experts there and, um, that were part of that, the, that report, I mean, so that that's a really good resource. So, so to finish things off, do you have any final pearls for procedures? You mentioned? I P so how do you get patients to get I P done? What, what is, uh, the best kept secret tool to increase in convergence for I P
Speaker 1 00:18:21 Increasing conversions from I P so when I explain to them, so we take interior SEG photography on all of our patients. And so when I look, when I show them, this is what your lid margin looks like. And then I show them a picture of what it's supposed to look like. That's really an eye opener for them. So I think patient education is key, right? But then when I let them know, Hey, we're gonna treat your dry eyes. We're gonna treat your symptoms. We're gonna treat your Myan bland dysfunction, but you're gonna look better too. That's really huge for them. There are those aesthetic sort of side effects that we talk about. So we're gonna get rid of that redness on your cheeks and your nose. We're gonna get rid of that inflammation on your eyelids. So women especially get really self-conscious when they don't look good with dry eyes, because it's frustrating for them. You know, they can't wear their makeup. Um, it's just, it really affects their quality of life. So when you explain to them, not only are you gonna feel better, are you gonna look better too? Patients are really, really excited and very happy about that.
Speaker 2 00:19:22 Mm-hmm <affirmative> awesome. Hey, well, thank you so much, Lisa, for your time and expertise in helping us understand your pearls for I P but also talk about drug delivery as well as strategies to improve, uh, the drug delivery, uh, process itself. So, so thank you so much.
Speaker 1 00:19:39 Thanks guys. I appreciate it. You so nice to
Speaker 0 00:19:41 Spend time with you.
Speaker 1 00:19:42 You'll be you too. Hopefully we'll see you soon in person.
Speaker 0 00:19:46 Thanks for listening. Join us for our next episode. Soon. Here's a quick word from sponsor
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