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 Before we get to our next episode, here's a quick word from our sponsor.
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Speaker 2 00:00:54 In today's episode, we have the pleasure of speaking with Dr. Aad Fa from Minnesota Eye Consultants about lab testing for dry eye. Dr. Fa has been intimately involved within the dry eye space, developing the Twin Cities Dry Eye symposia, and currently eyes on Dry Eye. Welcome, Ahmad.
Speaker 3 00:01:11 Thanks for having me. I really appreciate it.
Speaker 2 00:01:14 Hey, Idaho, all about your practice, but can you tell the rest of our audience about your practice and, you know, how'd you get into the dry eye?
Speaker 3 00:01:21 Sure, sure. I, I, um, I'm in a clinical practice at Minnesota Eye Consultants. Uh, it's an M D O D uh, uh, practice. Um, founders of the group are, uh, Dick Lindstrom, Tom Samuelson, and David Harden. So those are the guys that kind of, um, took me under their wings a long, long time ago and taught me all about, uh, you know, glaucoma and perioperative care. And over the years, I'm a bit of a dinosaur here now. I've been here for a long time, <laugh>. And so, um, so my clinic, as I look back, it's, it's, uh, mostly, uh, perioperative care, urgent care, but mostly now kind of 50 50 glaucoma and, um, ocular surface disease. So I'm, I have a special sort of passion and interest in ocular surface disease.
Speaker 4 00:02:07 So now, why did you develop your Dry Eye symposium and, you know, continuing on with that now, Eyes on Dry Eye, what was the, you said you have a passion for Dry, Is that what led you into, into those, um, developments?
Speaker 3 00:02:21 Yeah, I, I, I, at this stage in my career, I, you know, I've been really, um, one of the things I really love to do is, uh, mentor, um, you know, uh, younger docs and, and students that are still in their training. And at this stage in my career, really what I, what I'm passionate about is, um, you know, putting on really high quality, uh, education. Um, and that's where the whole Twin Cities Ocular Surface Disease Symposium kind of came from. And in fact, it was, it was one of the first meetings in the country that needed to be postponed because of the, uh, Global Pandemic. So, um, and so, yeah, so it was really, it was really unfortunate, but at the same time, it really, uh, laid the groundwork for, um, the current project that I'm really involved with is I'm the co-founder with, uh, Damon Dier of Eyes on, uh, Dry Eye.
Speaker 3 00:03:10 And so we really harnessed that, uh, that challenge and, you know, thought to really try to, you know, replicate really high quality education in the virtual space. And we've been able to really, um, prove that, you know, it's really possible to do that in ways that we just didn't, you know, uh, really anticipate, uh, before. So really virtual education, there's a really neat way to do it. Um, we can really provide high level education. It's not just sort of like a me Too lecture or referencing Me Too studies or something like that, really high level, uh, education that you can take to your clinical practice the day after the symposium or the meeting and really apply it in, in clinical practice. So it's been really awesome to be, uh, a part of that. Um, and the Eyes On Team is just phenomenal. They've done a super job of taking ideas that we present to them, uh, Damon and I, and just take off with it and really do some very creative things. Um, so it's been really neat. It's really neat to work with folks that are like-minded. And so one of the best things about this, I think, is that really our goals are aligned if our, their main goal of, of basically making patients lives better, Uh, that keeping that the main thing, the main thing has been a really good part of it. And everything else just kind of falls into place. So, so, um, I'm really passionate about, um, providing this high level type of education. And, uh, it's been really fun to be a part of.
Speaker 2 00:04:41 We've been involved with the Dr, uh, the Eyes On Dry with You, and, you know, we've done lots of projects in the past that, uh, but yeah, the interaction, you'll have the clinical track, you have the implementation track, and then you have the virtual exhibit hall. I mean, that's been very impressive. Plus the interaction that you have within the polling or that little area where you can interact with the, uh, other attendees. So that, that's been great. And I hear some of your, uh, speakers dress up in costumes too, which makes it even better.
Speaker 3 00:05:10 <laugh>. That's right.
Speaker 2 00:05:11 Hey, so what's next for Eyes On Dry Eye?
Speaker 3 00:05:14 So we really wanna just, you know, Max, you know, continue to, That's one thing I really love about my, uh, my friends and respected colleagues at Covalent, is that they're never really satisfied with doing the same thing, you know, year in, year out or, you know, so, so really just kind of looking back every year, doing a really careful review of the things that we felt like were successful and trying to, you know, take that to the next level. So you can expect to have a lot more, um, interaction and a lot more, um, you know, involvement and communication between attendees and, and speakers. Um, and so that's what we're, you know, kind of gonna be, um, you know, adding to what we've already accomplished year in and year out. And then, you know, just kind of listening to our colleagues, you know, the thing that we wanna make sure we, you know, we have a great tool at our disposal.
Speaker 3 00:06:07 We know how to do this, and we wanna listen to our colleagues and what they think is valuable to be talking about and bring, bring together these courses in a very relevant way, again, so we can, um, you know, implement these things in clinical practice and just keep innovating in how we do that. Um, and so this, this team at Vale, and I can't say enough about them, and just, uh, partnering up with, with, um, Damon, you can expect a lot of innovation and, um, just understanding the disease state in a much higher level, in a really fun way.
Speaker 4 00:06:41 So, real quickly before we move on to our topic, where can our listeners find more information on Eyes on Dry Eye?
Speaker 3 00:06:49 Uh, so Eyes on Dry eye.com. Uh, and, uh, you can, you can see that this amazing Covalent team has expanded that. Uh, so the Eyes on Brand is now focusing, you know, there's multiple, uh, meetings, um, eyes on eyecare and eyes on glaucoma and, um, eyes on dry eyes, so they've always got something cooking.
Speaker 4 00:07:13 Awesome. Thank you so much. All right, let's get, let's get to our topic at hand because, um, everyone is interested in hearing a little bit more about, um, Sjogren's syndrome and how we as eyecare providers can identify these patients with, um, Sjogren's syndrome. Can you tell us a little bit more about what Sjogren's syndrome is and how to identify these patients?
Speaker 3 00:07:35 So I, you know, all these, uh, our colleagues listening in and, uh, know, very smart, uh, group. We all know that it's a, uh, immunological, uh, disease, it's a inflammatory condition. And in, in clinical practice, really, I think the, you know, we're, we're very, very well positioned to, um, you know, detect this, this problem early on. Um, in, in my experience, it's usually, there's kind of some common common themes on the, the patients in my, in my, uh, ocular surface disease clinic that have been diagnosed with Sjogren's syndrome. The, the main thing that comes out is that they're usually a little bit, you know, they're ocular surface disease, epithelial, uh, you know, uh, conjunctival epithelial and cornea epithelial compromise is usually a little bit worse than the average dry eye patient. And they just have, usually these, you know, the conjunctiva is just chronically a little bit more inflamed than, than the usual patient.
Speaker 3 00:08:33 So they're usually in the little bit, um, tougher end of the spectrum as far as the disease severity state. So that, that's usually kind of a red flag for me when I see patients that are referred to me that have a little bit worse, you know, worse sort of, uh, clinical and, and symptoms, clinical signs and, and symptoms. I usually think about those patients. I have to, to check off that, that, that sort of, uh, you know, check off Sjogren's syndrome in my, So it's one of the things that I always ask of patients that are referred to me in clinic. Uh, anybody in your family have autoimmune, uh, disease? Anybody in your family, uh, have actually been diagnosed with Sjogren's syndrome? And then the obvious one, of course is you have dry mouth, and sometimes you can really, um, you know, kind of anticipate that the answer to these things is gonna be, um, yes. Because if you're, sometimes if you're just talking to these patients, they may make a very distinctive kind of, uh, sound with their mouth, um, and, uh, you know, so <laugh>, so they, yeah. So there's like this smacking of their mouth sometimes that they make. Um, and, uh, so that's been my experience in kinda the red flag things in my mind as I think about, uh, Sjogren's syndrome.
Speaker 4 00:09:47 Well, do you ever have any things that are big red flags for you when someone comes in for Sjogren's?
Speaker 2 00:09:52 Yeah, they're holding two bottles of water at each hand and doing the smacking as Asad just mentioned. Um, but you know, a lot, a lot of the patients, uh, they have the, they have more of the advanced disease, as he mentioned, you know, for all three of our clinics. I mean, whenever the patient comes in, oftentimes we're leaning toward this, which is, goes our next question there for you is when do you order lab testing since we're interviewing you?
Speaker 3 00:10:21 Yeah, <laugh>. Yeah. I mean, I, I have a very low threshold for testing and retesting uhhuh, you know, and so I've been, you know, multiple times in my experience, I've had patients that, um, you know, are seen by their rheumatologist or their primary care physicians been kind of owning the, you know, that that part of, of the, of the care and, you know, they'll, we'll retest and, you know, even six months after having a negative result, all of a sudden they get a positive, uh, you know, uh, Sjogren's panel. So, um, and so, I mean, I, I have a very low threshold for testing. And even patients that have been, you know, we know that it's, um, the diagnosis can be really tough to pin down. Um, you know, the, the serology is not, uh, you know, always, uh, easy to, to pin down. And so a lot of, a lot of my, uh, colleagues, again, I've been practicing here for, for quite some time.
Speaker 3 00:11:12 So, um, I know a lot of rheumatologists here in the area. And that's one, you know, sort of piece of advice that I'd really encourage everyone who is a, who is passionate about ocular surface disease and dry eye disease, is to get out there and have conversations with your rheumatologist or your primary care folks that are co-managing your patients with you. Um, and, and, uh, you know, help them, um, you know, kind of work on the same page with them to help them understand what the, what the clinical picture of the eyeball looks like and the disease that they're helping to co-manage. And, and my experience has been that, um, once they have a little bit of a better understanding of what we're seeing at the slit lamp, um, you know, the majority of folks that have been co-managing Sjogren's, uh, syndrome with are, are, uh, very happy to retest their patients again.
Speaker 4 00:12:03 So how do you address that issue? Because I have a couple of these where I, everything is pointing towards Sjogren's, but then they go and they do some of these serology testing and they all come back negative, and the rheumatologist is like, Nope, you don't have it. So is it really just emphasizing that these eye signs are pretty much half the pneumonic court? Like they just, this is probably what the patient has?
Speaker 3 00:12:27 Yes, that's, it's, it really is that simple. And that's kind of how I present it to the patient Sjogren syndrome for all intensive purposes, is dry eye and dry mouth. If you have those two things, it's a very high chance that you have this condition called Sjogren's syndrome, which also has a bunch of other systemic, uh, you know, problems that come along with it. But if you have those two things, it's really, really highly, you know, likely that you have Sjogren's syndrome. So, um, and I know Tracy, it's a tough position to be in as you're, um, you know, the, the primary eye eyeball, uh, you know, sort of doctor for your patients, and then you, you know, um, send them off to a primary eye care doctor, uh, the, the primary, uh, care physician or the rheumatologist. And they don't really have that same level of intensity of treating it.
Speaker 3 00:13:16 But it's really been, for me, just fostering relationships with, uh, rheumatologists and primary care physicians. I've, uh, gone to, you know, uh, practices here in the Twin Cities and given, um, talks and ocular surface disease, and it's those patients that were really kind of throwing the kitchen sink at. They're, they're doing a lot of, uh, you know, treatments and they're just not getting better, that they can, in my experience, really benefit from systemic, uh, you know, medications to treat their, their Sjogren's, uh, syndrome. And that makes their, uh, of course, their dry eye much better. So that's, that's the piece that you really, um, you know, work towards convincing your, your rheumatologists on that, that, you know, these patients can really get a whole lot better and their quality of life can really be dramatically improved if we're both on the, on the same page. So it's really about building relationships with those co-managing docs. Well, go ahead, Tracy.
Speaker 4 00:14:13 Maybe you were just gonna ask it. Cause I wanna know exactly what tests that you are that you're order,
Speaker 3 00:14:19 We used to do a lot of this in house, but, um, we're just not able to kind of manage all these things now. So we use, um, uh, a lab, uh, we use Quest, which has a bunch of different locations, uh, here in the Twin Cities. And as you guys know, there's the, there's the traditional, uh, markers. There's the, you know, role and law, uh, rheumatoid factor, ana, those, those are really kinda the, you know, really have to be in any SHO's workup. And there's also the, the more sort of novel, uh, antibodies, the parotid and the, uh, you know, the, uh, parotid gland and the uh, um, uh, uh, salivary gland, uh, anti, uh, you know, proteins and carbonic hydrate. So, so those three markers have been shown in clinical studies, as you know, very well, uh, to really improve, uh, you know, our ability to detect it probably about five years earlier than the more traditional markers.
Speaker 3 00:15:14 And the question is, getting back to your point, Tracy is like, you know, some rheumatologists, and I've actually had this happen multiple times, some rheumatologists are of the mindset, Okay, I can figure out that the patient has Sjogren's syndrome five years than I would've otherwise. What's the big difference? I'm not gonna do anything differently. It's the same, it's the same approach. Well, if we know that it's a, it's a, there's low grade chronic inflammation that is likely to only get worse, I'd like to know that way ahead of time so that we can really prevent some of this stuff getting, getting worse. And so, again, um, for our rheumatologist, sometimes it's just hard for them to really connect with what it's like to have chronic ocular surface disease, inflammation, immediate tear breakup on their quality of life. And so when you kind of help them understand that, well, your patient that we are taking care of together is really actually struggling to, uh, watch their, their son play baseball or do some of these, you know, activities and yeah, they don't have horrible, you know, they don't have scars, they don't need a transplant, but this is actually something that we can help them with and improve their quality of life.
Speaker 3 00:16:20 So once you make those, those connections, you know, um, I I I really recommend, you know, testing with the novel antibodies so we can know early, as early as possible so that we can be appropriately aggressive once we have that information.
Speaker 2 00:16:34 Those are great points. So those are your retest, right? Is that what I'm assuming they've already had the test done, it was negative. Well, here we're still treating you aggressively, but here we're gonna retest this so we can, uh, identify earlier.
Speaker 3 00:16:46 That's exactly it. Yeah, that's exactly it. And, and if, if these patients, you know, they do, you have a family, you know, history of rheumatoid arthritis or lupus, uh, you know, scleroderma, you know, uh, you know, different skin conditions, all of these things are kind of red flags that make me, again, kind of have a very low threshold for, for testing these patients. And, and you know, when they see that you've actually taken those steps, they actually really appreciate it. I have not had, uh, you know, patients really push back on that and say, Yeah, I'm really struggling with my ocular surface disease, but I don't really wanna have any blood work done. That's, I've never really actually encountered that.
Speaker 2 00:17:26 Yeah, exactly. So, um, but it still goes back to, you know, the why, right? We think SHO's dry mouth, dry eye, dry skin, dry dry eyes, but it's the rest of the body, cardiovascular, depression, kidney function, I mean, it affects everything in the body. And that's why I agree with you. It's so important to identify these patients sooner. So going to treatment, I know this focus is lab testing, these, we're seeing a lot of the, the more difficult patients. Where does NK fit in neurotrophic keratitis? And then, actually I'll start there. I have like 12 other questions for you in two minutes.
Speaker 3 00:18:01 Well, one of my smartest colleagues taught me that most of these cases that we sit here and kind of think about with dry eye disease are, are mostly just NK <laugh>. And, and that's actually you all, so <laugh>, So, so, you know, we were having this conversation at Modern Optometry and he's like, you know, you know, a lot of this stuff that's what's nk. And we just kept kind of watching the, the presentation and then the final slide was this was nk. And so, so, you know, we're, we're really, you know, we're, we're really learning a lot more about this condition. Um, it's a lot more prevalent than we probably have, uh, proof of so far in the clinical data. But if you think about the underlying reason, you know, the, you know, uh, the skin cells and neuronal cells just start not to function very well because of low grade chronic inflammatory change, ocular surface compromise.
Speaker 3 00:18:51 And so it's just, it's really important for us to keep that awareness up there and really build corneal sensitivity into all of our ocular surface disease workups kind of, it's a little bit of a challenge with clinic flow, but, um, really that's another, another thing that we really need to identify early on, uh, so that we can treat it appropriately. So, um, but definitely these, these folks with, um, autoimmune disease, chronic inflammation, you know, those, those patients that just come in and they're never really nice and quiet. You know, a lot of the patients we see, they can kind of, um, have flare ups and sometimes they look like they're well, well controlled. Other times they come in and you're like, Oh, okay, I need to be more aggressive. It's clear. There's other patients that just most of the time, look, their conjunctiva is never really quiet despite you using the typical, uh, treatments and, and, uh, you know, soft steroids for their flareups. Those patients, they, once there's that much kind of, uh, compromise to the ocular surface and, and NK is one of those things we really have to check off our list.
Speaker 4 00:19:55 That's something I know I need to do a lot better with is the corneal sensitivity testing. So thanks for bringing that up.
Speaker 3 00:20:01 That's great. And, and again, with, uh, immunological, you know, these folks that have a history of diabetes, um, you know, so I, I make it very try to make it very clear in my return to clinic, the testing, just check their vision and then I'm gonna test corneal sensitivity, don't touch the ocular surface or do all these other tests that I typically ask for in my dry eye patients or ocular surface disease patients. And then we'll do the test. So it's kind of a challenge flow-wise. Uh, but once you have that documented, it's, it's, um, it's, it's such an, a critical piece of your diagnos diagnos diagnostic, uh, testing and then, and then trying to under, it's not an all or none. That's the other thing about NK and corneal sensitivity. You know, some patients have no, uh, you know, feeling of complete hypoesthesia and some patients have it kind of more sectorial.
Speaker 3 00:20:48 So one eye is a lot better than the other, but there's some sensation. So again, just because that patient has, you know, sensation in one of four quadrants that you tested, um, doesn't necessarily mean that you should approach it a little, you know, any differently. I think with nk it's nk it's likely to have a, you knows, a big continuum of, you know, mild to severe, just like there is any, any other disease state. So understanding that this is same process, we gotta identify it earlier and treat, you know, treat it appropriately as early as possible. That mindset, in my experience has been really helpful so that we don't end up with a patient that has a central corneal scar, which is what we, you know, before we had, you know, these, uh, you know, novel treatments that we prescribe right now for neurotrophic keratopathy, uh, that was success, right? You got the epithelium to close down. I bet your patient didn't think it was success. Cause they can see very well, they got a big scar central, you know, scar. So if we can, um, again, kind of work on those things and build more awareness around that and, and really utilize these things that we're really well positioned to help our patients with. That's, that's really neat.
Speaker 2 00:21:58 Well, hey, awesome, uh, awesome insights when it comes to Sjogren's syndrome lab testing and every, everything else. I mean, uh, for those of you listening, there is a Sjogren Syndrome Foundation where, uh, you know, your, your patients can go, you all can go as well to be a part of, I know, in various communities, uh, uh, in, in Norfolk, I was involved with the SROs, Sjogren Syndrome community group as well. And so opportunity to get to know patients, educate them. Uh, but wanted to thank you once again. They're a amod for providing the insights and sharing your clinical pearls on lab testing for Sjogren's. Do you have any last final pearls before we say our official goodbye?
Speaker 3 00:22:37 No, I just, I really appreciate both of you guys. I really appreciate you guys putting this on, and I, I, I appreciate all the hard work that you do to put, put out there some, uh, great discussion and education for our colleagues. Super job.
Speaker 4 00:22:50 Well, thank you. We appreciate you too, <laugh>. Perfect.
Speaker 3 00:22:54 You bet.
Speaker 0 00:22:56 Thanks for listening. Join us for our next episode soon.
Speaker 5 00:22:59 For over 18 years, I Eco 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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