Episode Transcript
Speaker 0 00:00:00 Welcome to the Dry Eye Coach podcast series. Click on dry Eye. Your insider passed to the most exclusive dry eye topic. The series will raise awareness about the current and future state of ocular surface disease. The podcast will focus on a variety of topics.
Speaker 1 00:00:15 In today's episode, we have the pleasure of speaking with Cecilia, heading from hindsight iCare Center in Denver, Colorado. Now, I've known Cecilia for many years. Um, actually Waltz hired just a sh just a few short years ago, right?
Speaker 2 00:00:34 That's right.
Speaker 1 00:00:35 Is that great? Tell us more about that.
Speaker 3 00:00:37 Almost a decade ago. I can't believe it's been so long.
Speaker 1 00:00:41 Wow. So that's exciting that you're out in Colorado now. When did you make
Speaker 3 00:00:44 That move? Yeah, I, so I made the move about six, seven months ago, and it's been, it's been really nice. Good ski season.
Speaker 1 00:00:53 So tell us about this current practice that you're in.
Speaker 3 00:00:55 Yeah, so the practice that I'm in is myself essentially, and one, uh, full-time ophthalmologist who's a general ophthalmologist. Uh, does a little bit of every kind of surgery, was previously military. So we've got a few part-time docs, um, that are also in there, an MD and an od. But, uh, we see a little bit of everything, a lot of medical, a little bit of primary care, which is new to my world. Um, hadn't done that too much. Contacts made their way back to me and lots of dry eye.
Speaker 2 00:01:28 Everybody has dry eye
Speaker 3 00:01:31 <laugh> Yes. Until Everwise, especially here in Colorado.
Speaker 2 00:01:35 Yeah, I mean, when you and I were at the beach, we saw a lot of dry eye there, but now you're in Denver and I'm in, uh, Reno, Nevada by Tahoe and we still get a lot of dry, so multifactorial. So can you tell us more as we get into this, you know, how would you describe the need to disrupting the vicious cycle of, of dry eye at multiple points?
Speaker 3 00:01:56 Oh, I think it's absolutely needed. Um, so we know that when we talk about dry eye, if you look at the dues report, it breaks it down into aqueous deficient versus evaporative dry eye. Um, and then talks about there being, you know, a mix. I feel like majority of people are probably a mix, and that's because it's multifactorial. There's multiple areas, um, where patients are getting affected, both environmental medications, masks talk about all of these different things. So we really have to disrupt it at multiple points within that cycle to get our patients back on board to where they need to be.
Speaker 1 00:02:33 So how do you prioritize, um, the different entry points of protection, hydration, and lubrication? So is it different for mild patients versus your more severe or moderate patients?
Speaker 3 00:02:45 Yes and no. I mean, there's a lot of, a lot of foundational work that I think needs to be done with our patients. Um, and just the general eye health. Um, we are so used to, everybody knows to brush their teeth, right? But not everybody knows that they should be cleaning their eyelids and they should be doing warm compresses and proactively using artificial tears as opposed to, uh, reactively, right? So I think that, that that's a very good basis that I have and I tried to instill on my patients. Regardless, the level of their dry eye is that we should be doing these things and then make the adjustments based on their particular problem and what I'm seeing, uh, as far as what needs to be addressed for them.
Speaker 1 00:03:31 Really great response. There's something for everybody at different, at different levels and those foundational things are really super duper important. I agree.
Speaker 3 00:03:39 Yeah. Um,
Speaker 1 00:03:40 What role do you think the artificial tiers play and how do you decide, decide kinda which one's best for which patient?
Speaker 3 00:03:47 So I think that artificial tiers are, we know it's, it's not gonna fix the problem, especially in many of these multifactorial patients that have lots of different issues going on as far as like meibomian gland issues and arthritis. But it is still something that should be used. So I, I tend to pull the trigger on artificial tears with everyone. I think that every, especially in Denver, everybody should be on an artificial tear and should be cleaning their lids. Those are two, those are two very good gimmes. Um, and I like to, especially in those patients who may or may not have any signs or symptoms of dry eye, I like to use something that is, um, more versatile and I also kind of tend to stick with those a lot of times with all of my patients anyway, because I think, you know, as we, I've already mentioned, I feel like everybody's a combination of the types of dry eye. So something that's going to have some kind of maybe, uh, lipid layer replacement as well as an aqueous layer replacement. So I like to have something that's got a combination of the two. Mm-hmm.
Speaker 2 00:04:55 <affirmative>. So did you just say that you, every one of your patients in, uh, your practice, you prescribe an artificial tear and lid cleansers? Cause I love it. I agree.
Speaker 3 00:05:05 I do, I do. I may have learned from one of the best. So, you know, I have, I have absolutely started doing that with every single patient that makes their way into my room, regardless if they have a complaint or not.
Speaker 2 00:05:16 Yeah. I mean, it just affects everybody and, and so just being proactive, I, I love how you said that, uh, because it's gonna affect them someday or the, or another and, you know, to bring it to light for them is do does your vision ever change or fluctuate throughout the day? And if they say yes, we know it's a tear film issue, so we gonna prescribe the appropriate therapy. And we know that there's a lot of, a lot of different artificial tears and uh, that's available. And you just mentioned the lipids. Uh, what about preservative free? I mean, a lot of things come in bottles. I've gone away from preservatives. I mean, if I'm prescribing this could be preservative free artificial. What about you and what are yours?
Speaker 3 00:05:54 No, absolutely. I, so, you know, say 10 years ago, how many options did we have that were preservative free? Not very many. Um, or, and definitely nowhere near as much as we do now. And we've got a lot more options in the types of, um, preservative free artificial tiers as far as what did they contain when we talk about, um, things with such as, you know, hyaluronic acid, um, talking about povidone, um, making sure that they've got both an emulsion or something that's a lipid layer replacement as well as, uh, aqueous. So we've got so many more options now. So I think it is just so much easier to, to push that button and say it should be preservative free and it, and we really don't wanna add anything onto our patient's ocular surface that may, you know, accidentally worsen. So we know that when we're using even these, what we call safe artificial tears that have preservatives, if they use that at an accelerated rate or using it more than four times in a date, they may actually start to show signs of irritation from the preservatives that are in those artificial tiers. So I think just make it simple, get away from the preservatives and don't add to a potential problem.
Speaker 1 00:07:12 So is there a tipping point then that you recommend if you've got a patient that's coming in and they're an artificial tear or to like six times a day, is that kinda a place where you may wanna, they might need to pull the trigger to do more advanced therapy?
Speaker 3 00:07:25 Yeah, um, exactly. And it, if, if they're already at four to six times a day, they're, they're not doing anything but they're showing me, you know, the artificial tier is probably not fixing it and they're showing me that it's not because they're using it that often and they're telling me that they're bothered enough by it to sit there and take the time to put something in their eye four to six times a day. So we really know that when they get to that point, we are, we're not helping them by just suggesting another artificial tear. Now it doesn't need to say, don't take the opportunity to make sure that what they're using is the most appropriate for them, as well as is there something better that we could suggest, um, and, and make sure that they're not adding to the problem by taking away any preservatives. But then also starting to elevate the, the treatment plan, like you mentioned, uh, to, to really treat the underlying problem versus kind of just continuing to, to bandaid it With an artificial tier,
Speaker 2 00:08:29 I got twice a day if is using it more than twice a dayr, I'm already questions, I'm being more aggressive looking, uh, utilizing the standing to see what's going on. What about you Tracey?
Speaker 1 00:08:41 Uh, definitely I would say because I'm more referral based, sort of the trigger is if you're using it more than four times a day, for sure that you should, our clinic, you should definitely be seeing Dr. Go. So that's one of the points that we pick. But I love what you said about there being so many more options now because I feel much more comfortable in recommending things, not only just the ingredients, it's also kinda like the bottle types too. So there's options out there that we didn't use to have bottles. We all we had was vials over patients with, um, dexterity problems. Now we're moving that direction where you already there, so hopefully sooner.
Speaker 3 00:09:15 And it's not even just the dexterity, um, being, you know, seeing younger patients. Um, a lot of them are more eco-conscious and so they're trying to make sure that they're not adding to the waste in the world. And so using something that takes up less, uh, landfill in or you know, is, is reusable is something that's really important. But you're right, no, now that we've got a lot of different options as far as the modality of the bot or like the bottle itself, dexterity is better, the bottles themselves, I think there's a little few of us who may have gotten burned on some of the earlier iterations of these multi-dose preservative free bottles because it was just not always user friendly. Um, or you may end up just dosing yourself in tears, um, <laugh>. So they have, they have definitely made an improvement and I urge people to go and try them again. It's not, it's not the same bottles we were introduced to five years ago,
Speaker 2 00:10:17 But there's many companies are coming out with, uh, with, with newer products that the bottle's easier. As you mentioned, you started to, to some of the ingredients, which I wanna get back to. We're hearing about, we're hearing about ha we know about HP and combining with the lipids as you mentioned, um, uh, and Prolene, can you speak to some of these ingredients of how they make a difference or do they make a difference?
Speaker 3 00:10:40 Yeah. Um, and I, I think they do. It's, it's kinda interesting cuz the more you start to see these things coming up and, and looking at them, we, we start to see that the trend is following a lot of what's going on in Europe or there's companies that are coming over from Europe and introducing their products here. So the poone, um, is, uh, a hydrating polymer that actually helps to decrease the dry eye discomfort. And it all, it forms kind of like this protective matrix over the eye. Um, so it, it's helping with essentially the, um, the adherence of the drop as well as it can help to, there's, there's this thought I was reading about it, it was kinda interesting and you guys tell me if you've heard about this, but it's an insoluble crystals that conform due to reaction with calcium. So there's calcium that's released from the damaged cells of the eye surface, and so it's helping to protect from these calcium crystals. So I hadn't heard a lot about that and I know we were getting ready to talk about it, so I started to delve a little bit more into it and was interested to hear how it actually works. Um, now I don't go thinking about that necessarily. I think about the, the more hydration portion of it, but it was kind of interesting to hear the science behind it. Um, and then trays, we've been hearing a little bit more about this as well. I don't know, are you familiar with where it comes from, Tracy?
Speaker 1 00:12:12 Um, not the original source. I do have some patients that are, that are really, you know, the clinic loving it since it, since it just came over across years, uh, a few months ago. So yeah, but I'm kinda the exactly source that I had, I'll have to look that one for you. So, so
Speaker 3 00:12:28 Idea. Oh no, I, its kinda of, it comes from the roses of Jericho. Um, cool. So the idea is it's this plant, right? And it's in the middle of the desert and it's a plant that it, when there's no water, it looks like it's dead, but then water gets reintroduced and it blooms back up. So the idea, it's, it's doing the same thing to the epithelial cells, it's protecting the epithelial cells so that when they're in a state of hyperosmolarity and there's a decreased amount of, uh, fluid, um, or hydration, they don't die. It's not atrophying. They're, they're desiccating and they're shrinking, but they're still protected so that when they get back into an environment where water is reintroduced or reintroduced, they actually come back, which I thought was really cool. So it's not just an artificial tier, you know, ingredient, it's actually helping to protect those epithelial cells. So that, that is one that I was actually really excited to see come over and be in, in some of our tier, um, over the last couple of months. We've had more of them pop up with that.
Speaker 1 00:13:36 I'm definitely gonna be looking up that rose of Jericho. That sounds fascinating. Yeah,
Speaker 3 00:13:41 I know. I'm, it's, I thought it was kinda cool, so I had to share it.
Speaker 1 00:13:45 I know you're making, you're making artificial tears super exciting right now. I really wanna go in and do, dig a little bit deeper on this because I did not realize, thank you so much.
Speaker 3 00:13:55 Of course, of course. That's what we're here for, right? Is to share with each other,
Speaker 1 00:13:59 Right?
Speaker 2 00:14:01 Definitely. So no, thank thanks for sharing that because there's so many different ingredients that are out there. But when it comes to lots of ingredients, lots of products from both of you, I'd love to hear how do you all address or minimize retail confusion and what can, what are steps that you can recommend from the staff to the providers to the patient in regards to making sure they're getting the product that you recommend?
Speaker 3 00:14:27 Yeah, so that's really important because it is just, it is too confusing and not even just for the patient. It is starting to get a little confusing I think for us as well because there have been so many different things popping up, like you mentioned, as far as ingredients. So I think that having, um, samples in the office or something, either samples or to sell an office, something where you're handing it to the patient and they see it and they know what they're going for and what they're looking for is really helpful. Um, it, you know, they're, they're able to not only try it or see it, they can recognize it when they go to the store to get it. Um, and then I also think as, as a doctor, don't over inundate them. If you hand them two things, say why one might be better than the other, uh, so that they, the patient understands the difference between the two if you're gonna give them. But I wouldn't go beyond that. I think that once you try giving them more than two ideas of anything, um, let alone an artificial tier, they start to get a little bit lost in the mix and forget which is which. So giving a point i, you know, what you want, why you want them to use this one. Um, I like to give them a sample, like I said, and tell them exactly how they're gonna use it and when to use it.
Speaker 2 00:15:49 You sell it outta your office
Speaker 3 00:15:51 Office? A few. A few. There are a couple that we, we have in office but, um,
Speaker 2 00:15:58 So which ones, I'm gonna put you on the spot cause people, <laugh> <laugh> ones ting and I'm happy to share, uh, Tracy play as well.
Speaker 3 00:16:05 Absolutely. We have preservative-free Oasis that we sell in office and we also have, uh, retain MGD in office. Um, those are the two that we currently sell in our practice.
Speaker 2 00:16:18 Mm-hmm. <affirmative>? Mm-hmm <affirmative> Tracy.
Speaker 1 00:16:21 I'm currently not selling yet cause I'm on the fence, but I'm trying out the new ones that I've just kind crossed over, but I am really liking. Um, and um, some of the hur acid ones are okay, but I do make a point to tell people what I want them to get and I, it's like a prescription, so I'm telling them I am prescribing you this artificial tier. Even
Speaker 3 00:16:43 Though we carry those in our office with some of the newer ones coming out, it's like, oh, do we need to, do we want to switch? Do we sell through what we have? Um, with TE's iia coming onto the market, I really like it and I was, uh, able to get some early samples of it. It's, you know, speaking of all of these things, it's got, it's, you know, not only a preservative free multidose bottle, it's got codone, hyaluronic acid as well as tray in there. So it's kind of ticking all those boxes. And I, you know, I've, my gave it to my staff to use. I've been using it and I've given it to patients to trial and everybody's been coming back with it. So that's one of those ones. I, I think I may pull the trigger in either add in and rotate out, uh, one of the others just to keep it easy in our office.
Speaker 2 00:17:32 Yeah, Tracy and I, we both had those, uh, the, the early samples of it, the early experience and so far as you mentioned, patients been very excited about that. And so that's what we're looking into. I'll commit as well, I carry the same thing, same products that Cecillia does, um, within the practice. Uh, for me it typically it's gonna be preservative free, but it has to address the lipid component or the EVA dry eye. Uh, one of the, one of the ones that I've been seeing a lot more is, is with the, um, p prolene glyco and, and the lipid layer that with the sustained complete pf because it's preservative free because it's for VA dry eye. And so I haven't found a way to bring it in the office, but you know, those are some of the things that I'm looking at whenever, whenever we're, we're making that decision what to, what to give the patients because if you can give it to em out the practice, that's gonna help alleviate the retail confusion. Yep. So now to switch what you just said earlier and either of you can answer. So what if you don't have any samples? Cause not all of us have all the samples. How do you go about it? Tracy, you mentioned that you'd write it on the script. Uh, uh, what I you Cecilia?
Speaker 3 00:18:43 Um, I have done before back, um, where we were previously, there were some people and someone I, um, had talked with actually sending in a prescription to the pharmacy for the patient of what you want them to get. Um, that could be an option, but I think no matter what, it's something tangible written or a sample. Um, so I think that writing down exactly what you wanna get, don't write down artificial tier. Don't write down preservative free artificial tear. Give them something written, uh, that has what you want them to get.
Speaker 2 00:19:14 Yeah.
Speaker 1 00:19:15 Yeah. It can be as simple as pulling up a picture, you know, on your, on top of your laptop and having them take a screenshot of it. Younger patients will do that too.
Speaker 3 00:19:23 I've done that with other things that we don't carry in office. Bring it up so that they can see it. Yeah,
Speaker 1 00:19:29 Like I don't carry blue eyeshadow, so for today I had to find a clue, you know, for somebody. Cause I don't do blues, so screenshot it. There you go. Easy to do. So you artificial too.
Speaker 2 00:19:40 Well there's so many different great products on the market and we, we just highlighted a few of those and just wanted and appreciate you discussing with us. So some, uh, the things that make, help make your decision on what to prescribe the preservative issue of preservative free, the ingredients itself. But the main thing is coming from you, we don't recommend a grab bag approach. Uh, that's the other thing I was getting at with the staff. I, a staff member, uh, you know, patient would call up with symptoms of dry eye and the staff goes, oh, we'll just try this brand, this brand, this brand and just it, just use it a few times and if it doesn't help it call back. I'm like, wait a second. I don't, brands didn't recommend of those <laugh> on board as well. So hey, final uhs of wisdom that you have for, uh, Cecillia.
Speaker 1 00:20:27 I get it.
Speaker 3 00:20:29 Yeah, don't hesitate to be proactive and definitely be poignant in your suggestions to your patients as to what you want them to use and exactly how to do it.
Speaker 2 00:20:41 Perfect. Well thank you so much Cecilia, for all your great insights in regards to the over the counter artificial tears and where it fits into all of our patients, whether being deliberate or for patients that have already been suffering as adjunct too. So thank you so much.
Speaker 3 00:20:56 Absolutely. Thank you guys for having me.
Speaker 1 00:20:59 <laugh>. Take care.
