Episode Transcript
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Speaker 2 00:00:54 In today's episode, we have the pleasure of speaking with one of my partners and mentor Doug DeVries, who practices in sparks Nevada about novel dry eye treatment pathways. Welcome Doug. Thank you.
Speaker 3 00:01:05 Well,
Speaker 2 00:01:06 I know about your practice, but maybe everybody out here does not know about your practice. So actually, can you tell them about our practice?
Speaker 3 00:01:13 Yes, yes, I will. I'll tell him about our practice. Uh, it is a, a 30 year old, uh, referral practice that was initially started to support the needs of the optometric community. Uh, so we do a lot of surgery. We have done, and we see a lot of medical patients as well. Uh, and, uh, one of the things that has happened specifically to my practice is because of the, over, just this huge demand for dry eye patients and involved in surgery, uh, that now I limit most of my practice to really treating ocular surface conditions, uh, that are surrounding, uh, surgical post-surgical or, uh, just referrals from the general, uh, optometric and, uh, ophthalmology community.
Speaker 4 00:02:01 So why is guys so important to your practice? Would you say just naturally grown out of this coal managements?
Speaker 3 00:02:07 Well, yeah, it is, uh, because I think as we started to learn more and more on what really, I think put it over the, uh, the edge was when with the, uh, the LASIK boom and creating flaps. And we were seeing so many patients that then had this, you know, that four weeks after six weeks after they develop this dryness. And so, uh, you know, my partner came to me, uh, all these years ago and said, you know, this whole thing with dry eye and whether it's post cataract or pre cataract or post LASIK pre LASIK, you know, we have to figure that out. And he said by we, I mean you, because I'm going to stay in the operating room.
Speaker 4 00:02:46 So there's been a lot of changes over the past two decades. And it's been amazing that you were one of these people that's been on the forefront. I mean, you're one of my personal heroes. Um, can you discuss the mechanism action for some of the newer treatment
Speaker 3 00:02:58 Options are out now that differ from what we used to do? Well, yeah, let's go back to 20 years ago and we had punctal plugs and artificial tears, and that was it. I mean, that's what we counted on treatment. We had a baby shampoo, I didn't mean to interrupt, but maybe know we had baby shampoo again, more inflammation. So, you know, as we look at mechanisms of actions and what they happen, I mean, certainly the first one that came out, uh, where we actually had a therapeutic dedicated cause we had, we had some steroids and steroids were widely used at that particular time because it really wasn't known about inflammation. Uh, like we know at this point, so when a cycle Sporn was introduced in, uh, gosh, 2003, it was really to help suppress those T-cells to kind of break that cycle of inflammation. And it just took a little bit longer and we had to really encourage our patients to stick with the treatment because we weren't going to get immediate gratification.
Speaker 3 00:04:00 I think that was one of the problems is both practitioners, as well as patients didn't get that immediate gratification gratification, like you would say with a bacterial infection and then antibiotic. And so you had just a tremendous amount of dropout. And I think from that, it just kind of tainted things. And then as you know, uh, fast-forward to a few more years, we start realizing a lot more, uh, the idea and a lot of us were using steroids in conjunction with cyclists born, but then when lifitegrast came out and we, we really found that, you know, an LFA one antagonist, where we can surround that T-cell and keep that from docking, uh, with the eye cams and the LFA ones, that was really something that brought about faster treatment. So again, I think it renewed the interest at, at that particular time. So yeah, mechanism of action has really advanced and our understanding has advanced with that as well.
Speaker 3 00:04:52 Uh, then as, as you continue on with the new mechanisms of action that we see that we see now, uh, say with, uh, to via with the nasal spray and actually, uh, stimulated in the Obama branch of the trigeminal nerve nasally with a nasal spray, again, a completely different novel mechanism of action. And I think that then, you know, as you see other, uh, refinements with mechanism of action, you also have to include mechanism of delivery. And that's when, you know, as we look at something like sun re-releasing, uh, another cyclist foreign that was in a higher concentration, but a nano my cellular to get better penetration. So now all of a sudden you have over three times greater going to the surface. So, you know, I think mechanism of action has really been something that should encourage, uh, most of us, you know, if you're not treating it jump back in, or if you had less than a stellar results in the past, jump back in and, and try to see some of those, uh, those results that you get with both different mechanism of action and mechanism of delivery.
Speaker 2 00:05:59 Yeah. You mentioned that to your via, and that is definitely a novel treatment and mechanism of action how's that been working for you. And what have you been telling your patients about?
Speaker 3 00:06:10 Well, exactly that Walt I've been telling my patients that this is a novel, uh, mechanism of delivery, as well as the mechanism of action of action and explaining how, uh, that, that Obamac branch of the trigeminal nerve, which has the terminal ends and the, uh, and the nasal passageway can be stimulated to create a full compliment here. And what I found more than anything is interest. I mean, patients are interested rather than a drop to that. They're interested in different, uh, different ways to be able to treat that, uh, to early, really to tell. But I mean, I have a lot of prescriptions out there and some of it you're judged by, on their sample. Do they actually fill it? Then you have to differentiate if they didn't fill it, was it due to a cost because they didn't have access or was it that they didn't find it successful? So I think in the next month, as you start to see some of these patients come back, we're going to have a lot better idea on exactly how that's playing out with basic, but I'd say tremendous amount of interest by patient and a willingness to try it.
Speaker 4 00:07:13 So with so many, you know, pharmaceuticals in the water and so many options now, which we have, it's amazing. How do you choose which one's the right fit for your patient?
Speaker 3 00:07:23 Yeah, great question. And I think that causes a lot of confusion. I mean, if I see a patient that has been on chronic artificial tears where they've been trying two or three more tears, I'm going to go to a therapeutic, first of all, I'm going to jump in. And that doesn't mean that I'm also not going to talk about doing something for the lids and, uh, that we're going to have to do something to improve it. But remember all of these that we're, that we're dealing with the lids and we're dealing with inflammation it's as a result of what that inflammation has caused. Say those, my Bohemian glands say the, the PEK on the cornea. So I will take a look and say, okay, depending on the level, I might add a steroid, something like I service, which works very well, which is again, a different formulation.
Speaker 3 00:08:08 I mean, it's the same molecule loader pedinol, but the difference is in the mechanism of delivery. So, you know, you have that mucus penetrating particle that grabs that goes through the mucus. And again, have over three times the penetration to the target tissue. But that's how I, I mean, I know I'm going to use a therapeutic, I want to find out what they're going to, the patient's going to have access to. I mean, I certainly have preferences of where I'd like to start. I want fast acting. I want the patient to recognize, uh, some improvement as soon as possible, because at that way, they're pushing you along instead of you trying to pull them along.
Speaker 4 00:08:45 Yeah. It's a lot easier to give a high five than it is to have to pull out your cheerleading pompoms. That's
Speaker 3 00:08:51 Absolutely, absolutely. And our patients get that. And I think that's, you know, when we look at something like photographs that, you know, in, in half of the clinical style, uh, clinical trials and in two weeks, uh, they showed statistically significant improvement in symptoms. That's great news, as opposed to just keep dragging that out to the patient until they get, they get results. But at the same time, I mean, when you're using something like a cycle of Sporin versus the Lafitte aggressor, remember different mechanisms of action. And so there's no reason that they can't be combined. There's no reason. I mean, if you have a patient with systemic hypertension, it's not unusual at all to see them on two or three systemic hypertension meds. And for some reason, insurance companies does kind of put us in a box and say, oh no, you get one. And only one, well, it's not true. I mean, if they had the different mechanisms of action and getting a synergistic effect, I don't hesitate. And I probably have about 20% of my patients that are on both a cyclist foreign, you know, as an immunosuppressive and an alpha one antagonists and, uh, in lifitegrast. And then would you add a third one with a steroid? Absolutely. It depends on how well you're controlling those symptoms.
Speaker 2 00:10:02 We do have so many options out there and we've all had this question. I know the three of us from, from colleagues say, you know, are you a little photographs guy? You're the cyclist sport guy. You know, one of the things that you just mentioned, Doug was the delivery systems. And so what, so you mentioned Sikh, well, we know about Restasis 0.05%, you know? So how do you make that decision between the two or is it gonna be more of an insurance making that decision for you?
Speaker 3 00:10:27 Yes,
Speaker 3 00:10:32 Not to be sarcastic, but yeah, no, I have preferences. I want fast acting and yet I tell patients, you know, and I, and I think it's, you have to be comfortable with side effects. You have to be comfortable with advising your patients what to expect and creating those expectations. Uh, but you also have to be, uh, you have to be nimble in that. You can't always get exactly what you want, but, uh, you know, I've, uh, in a, in a recent education that I did is that there's, there's not a wrong way to treat unless it's doing nothing and that's wrong, but if you're doing something and if you're going to feel like, if you like lifitegrast and you say, Hey, I want the fastest response. I'm going to deal with the taste. I'm going to deal with the side effect. Then you go for it and you explain the patient.
Speaker 3 00:11:19 This is your first choice. If you like the fact that the 0.09% cyclist foreign and the nanomole cellular, uh, formulation on that. And again, you, you set the expectations with the patient, then go for it and explain to them that if the insurance doesn't give them access, they're still going to get a drug that works. They're still going to have some, it's not like that's a failure at that point. It just may take a little bit longer. We may need to add some other treatment along the way. And you know, you just need to be able to pivot a little bit with that. So, you know, I don't think, you know, in terms of absolutely being locked in, I would like to have, you know, initially one of the drugs that is going to get better penetration in is going to, uh, turn around symptoms faster. So in sequence or in the photographs, but it doesn't mean that if all of a sudden they don't have access and now they're using Restasis that I consider, well, that's a failure. That's not going to work because, you know, I have 18 years of experience with Restasis working. Your job just becomes a little different as a provider at that point.
Speaker 2 00:12:22 Yeah. I'd say it may. It mainly comes down to understanding all the different drugs and how they're utilized to set proper expectations for patients. All right. So now we're going to have fun with you. It could be different case scenarios too, to show us and the listeners where the MLA comes in. So the first one, actually, Tracy, you can ask them the first one.
Speaker 4 00:12:43 Okay. So you have a new patient who presents with moderate signs and symptoms. Where do you start moderate? They walk in the door. They've been, they've been everywhere, moderate signs and symptoms. They're coming to you because you're the guy.
Speaker 3 00:13:00 Okay. W where I'm going to start at that point. And we'll talk about different mechanisms of action as well is I am going to, unless there's a contraindication, they're going to be under the mega six. So may get three, uh, something like hydride with gamma linoleic acid, but that's not going to be, I'm just not just going to leave him on that and give him time. That's just, I'm going to tell them you're going to be on that. If they have any live involvement at all, I'm probably going to give them a commercially available, warm compress, like with Metta beads, with ruder, compress, something like that. But they're also going to get a prescription for a therapeutic. At that point, they are going to be prescribed a therapeutic now, and we have a lot of options. If it, if it's strictly where we're getting episodic and this patient isn't, uh, isn't this chronic symptoms all the time, I'd probably go with an eye service at that point. What I hesitate if there was not coverage to go with a Lafitte aggressor sequence, not at all, but they're going to get a therapeutic at that point. And now that we have the nasal spray, I mean, that's another one that can enter in. But I looked at is, you know, is that going to be a primary? I'm going to get things under control as fast as I can, because I just don't have the experience, but I wouldn't hesitate to add it in at some point as well.
Speaker 2 00:14:14 So I'm going to add something to that. So that same new patient was referred for cataract surgery with moderate signs and symptoms. So does that change anything? Let me take it, we'll go with a steroid, but
Speaker 3 00:14:28 Yeah, I mean, it absolutely changed something because now we're trying to be expedient as possible in getting the best readings for that patient so that we can get them to surgery. You know, we don't want to have that delay too long. The patient gets frustrated. So yeah, most likely at that point, I'm probably with that, they're going to get a therapeutic, but I'm probably going to go to a lid procedure. If they have any evidence of MGD to get them quickly to that, I'll start them on something to, to take care of their inflammation. And it might be multiple drugs at that point, but I'm going to recommend a lid procedure pretty fast. And if they're surgical patients, I may not go through that. That for, uh, the four sessions of the IPL, I might go right to the lid procedures. See if we can't get that, my mom really helping get some, uh, some quality readings. Yeah.
Speaker 2 00:15:14 And then the other drug that's predict that they have the data is going to be with sequel at one month, the improvement in courthouse. So that's the other one that I would consider. So you're our next patient. So what about a new symptomatic patient? We'll say their speed scores 20 now they've tried several artificial tears. They had minimal signs.
Speaker 3 00:15:34 So not much staining, not much stating. Yeah. You know what? That's like, that's an ideal patient because that also tells me that they have pretty good neural upregulation, so they don't have that neurosensory abnormality yet. So we're going to get a response on that. And I think that, you know, they would fit into the same category. I don't care if they have stadiums. I actually consider that a victory that I'm getting to it before the damage is done. And I think that's great, especially those patients that really sends that in. And as another tip, I would say, you know, what you want to do is check, check corneal sensitivity on these patients, because it also gives you a reason that you can tell the patient. And I tell the patients all the time, if I've checked corneal sensitivity and I see a decreased amount of corneal sensitivity, I'll tell that patient as we start your treatment.
Speaker 3 00:16:22 And it doesn't matter what it's lip treatment. It doesn't matter. It's a therapeutic, I'll tell him, you may not feel what I'm going to see. You're going to have to rely on me for the improvement because they have that downregulation. And they may not really have that in it also, it's a lot easier to tell the patient that before they come back and don't feel results than it is when you're trying to explain away why they don't feel results. So corneal sensitivity is a real big one for me, and really looking at those and saying, Hey, if you're not going to feel what I'm going to see, you're going to have to rely on me. It may take a little bit longer.
Speaker 2 00:16:55 Yeah. So back with the symptomatic patient, uh, does on-label matter. Cause we do have a couple of drugs that are odd label for the treatment of the symptoms. Does that matter to you? Or does it go back to the coverage?
Speaker 3 00:17:08 Uh, it really goes back to access the, I mean, cause I've been using things for off-label so many times that it's, it's kind of nice when something's on label, but I think to a lot of doctors, it does make a difference. And I think it, if it gets, you know, 5% more treating because it's on label, then I think it's a giant success because, and not just for that on label, I service it as on label for steroids, not just that, but they're going to be involved in other therapeutic agents and treat more. I mean, when we see this huge disconnect between the number of patients and the number of people on some type of therapeutic treatment, I mean, it's just phenomenally low, some 35 million in 1.5, uh, being treated. So I think that if that generates more for people being on label, I think that's great. Uh, you know, I've been kind of doing this for a lot of years, but I still think it's good that we have a label on it.
Speaker 4 00:18:03 So I got one for you. So the patient that comes in and says, doctor, I feel good on the therapy that you put me on most of the day. But boy, I tell you when I wake up in the morning, that is when I feel the driest. Is there anything that we can do about that morning during?
Speaker 3 00:18:22 Absolutely. And I think that is a key question that I ask all my patients have been asking for a long time. And if we can actually, cause I mentioned earlier, everything we do right now is in response to inflammation and trying to quiet inflammation, if we can actually get to the root cause of inflammation and stop it as it's happening. And that patient you described probably is an exposure patient due to nocturnal. I got Fama's amid ULID misalignment, uh, you know, just a floppy eyelid. They're just not completely sealing in those eyes because the best time of day should be for that patient. First thing in the morning. So, you know, utilizing something like the, uh, the sleep tight sleep, right cover to keep that eye. And it's a very simple device and it's not like tape it's hypoallergenic, it's latex free. It'll actually keep that eyelid close all night long. And then you've attacked inflammation at the root cause, which is how it's happening. And then it just inflammation begets more inflammation. So yeah, it really has shown some, some great success, but it's a key question to ask when of your symptoms and if you're waking up that way, then they don't have a raging bluff riotous or they don't have this incredible demographics going on. Then you have to look at the potential for exposure.
Speaker 4 00:19:41 What was the name of that? Again? It had a really cute name. Could you tell us what that name of that, um, devices that
Speaker 3 00:19:47 Sleep tight? T I T E sleep, right? Alrighty. E and it can be found on, I like eye sleep, tight.com.
Speaker 4 00:19:58 So do you have any final pearls on the novel treatments of dry disease? We've talked about a lot of great medications. We've talked about some high-end pieces of equipment. You talked about taking care at night. Is there any, and, uh, um, nasal stimuli, neurostimulation, is there anything that we've forgotten about or anything else that you feel like yeah. In that we can't end our discussion without speaking?
Speaker 3 00:20:19 Well, I think the, the biggest thing Tracy is use it. I mean, start and make that move, or you're using something again, the only way you do something wrong is by not taking a, an action, uh, an actionable step. And I think that's the biggest because with the neurostimulation to via with ice service, being for episodic dry with, you know, uh, I mean really all these great drugs that we've used for a long time with Restasis and , I mean, we know we're to get results. You just have to set the expectations and I'd say set expectations for your baby, but use them
Speaker 4 00:20:53 Well, thank you so much, Doug, for your time and your expertise. Um, the helping our colleagues better understand the mechanism of action of various dry treatment pathways.
Speaker 3 00:21:02 Well, thank you at happy new year to everybody. And, uh, thanks for inviting me.
