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 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.
Speaker 1 00:00:15 In today's episode, we have the pleasure of speaking with Dr. Beta Asari who serves as the associate director of clinical education for Boston site. Thanks for joining us beta.
Speaker 2 00:00:24 Thank you. Thanks for having me.
Speaker 1 00:00:26 Hey, can you tell us a little bit about yourself and you know, what is Boston site? How'd you get there?
Speaker 2 00:00:32 Sure. Uh, so I love this story. It's one of my favorite stories to share. Um, so essentially I was a eager little resident walking around the hallways of GSL S one year. Uh, my residency year, I took it upon myself to talk to anybody and everybody I could, uh, on a personal level, I just, why not meet the people you're gonna be in, in the professor with long term and why not try to make some connections? So I had the pleasure of meeting Tom Arnold for the first time and I was talking to him. And after about a minute or so speaking with him, he's like, you know what? You should really meet the people at Boston site, cuz it sounds like you have a lot in common with him. And he walked me over to their booth as gentlemanly as he always is. And then I met with Karen qui and the team an hour into having a conversation with them. They're like, man, you fit right in. You should, you should come on board. And a month later I was in an interview, five, six months later I was moving to Boston.
Speaker 1 00:01:28 Oh wow. That that's awesome. You know what you just said, going to the meetings and networking that is huge is, and when you're a resident, you know, just starting there or even as a practitioner, an old guy like me, I mean, I love to do that and get, and get to know people as well. So, so at Boston site, you're there now in your role, you're in clinic care, you're doing research. What are you doing mostly over there?
Speaker 2 00:01:50 Yes. So my formal title, as you stated, is associate director of clinical education. Uh, my number one purpose there is of course to serve the patients. I'm there in the clinic. Uh, a hundred percent of the time. Uh, I do work with students from C P HS in Neco, uh, and students and residents. So there's an educational component there. I help facilitate some educational initiatives and programs we have where we invite residents over to learn from us. And now we're expanding that to provide education to practitioners, through webinars in person, uh, educational events, et cetera. Uh, and the research aspect, it just kind of manifested organically. You know, we're in a position where we get lots of amazing rare cases. We have a great collab, collaborative environment, a very unique working place. So it just manifested organically. I think this past, I don't even know three, four months we've had like six publications. We've just been cranking 'em out. So, uh, it's been great to be on that train with all my colleagues to do that with them.
Speaker 1 00:02:49 All right. Those six publications, which one comes top of mind, would you wanna,
Speaker 2 00:02:53 Well, if I'm gonna be biased, <laugh> that I'm on. No, I'm kidding. There's a lot. There. There's some, uh, publications about graft versus host disease. I think that's probably the ones that I, I admire the most from my colleagues, a qu Dan Brock and um, other providers externally talking about how underutilized graph scleral lenses are in the graft versus host disease community, which is probably the patient population. We find finds the most significant relief immediately from scleral lenses. So it was interesting. I recommend you guys, uh, read about it. Uh, lots of other stuff. If you just look at the Boston site bibliography, it's pretty impressive, uh, library.
Speaker 3 00:03:32 So how do patients find you? So how do patients get, um, get to you to get the scleral lenses?
Speaker 2 00:03:38 So we are referral based and you know, we see patients locally, uh, as well as, uh, regional or, uh, distant patients. We call them who are out of state or out of country. Honestly, most of it, we have a very wide network of corneal specialists, mostly MDs who refer to us. We have ODS as well. Uh, but I would say that the book, uh, of the referrals we get are from Corne specialists or other ophthalmologists, um, who just know about us and what we do. Uh, a lot of patients will get referred to us because they either do not have access to scleral lenses locally cannot afford it because we're a nonprofit. So we may provide the care, uh, you know, at no cost to them or because they, you know, they've tried other spiral lenses and they failed and, and they need something more customized or something that requires a bit more attention to detail cetera, cetera. So generally the referral network is doctors who are familiar with what we do and, you know, with the modern day internet, social media, et cetera. Uh, I mean, we have a network of that as well. And then our OD colleagues of course refer to
Speaker 1 00:04:44 All right. I'm gonna be honest with you, uh, beta. Um, I've never even seen a scleral lens. Uh, I refer 'em out. I mean, I worked at a cornea practice and so we referred out to, uh, colleagues that fit 'em, you know, what are the indications or lenses you just mentioned graft versus host disease. Mm-hmm <affirmative> can you tell us more or tell me more?
Speaker 2 00:05:03 Well, uh, it's any sort of irregular corneal shape or ocular surface disorder. Um, the indications would be, is there room to improve vision? Is there room to improve the patient's comfort or support the ocular surface? So, um, anything from your garden, variety, dry eye MGD related or to something more severe? Like I was fitting a patient today with ocular cicatricial pemphigoid or SJS graft versus O disease. Any form of Dictas post Lasic P Dax, you name it. If there's any regular cornea that the spiral lens can mask the corneal irregularity of to provide a smooth refractive surface, that's an indication corneal opacities included. Um, and then yeah, anything that just needs support of the surface to, to support the corneal epithelium.
Speaker 1 00:05:52 So what about RGPs? What, what is that role now? Because I know a lot of people they've fit RGPs before now they've go into sclerals. Is there still a role?
Speaker 2 00:05:59 Oh, a hundred percent. If I have a patient who comes in for a consultation and I think they would qualify for a corneal GP, uh, we have corneal GPS in our clinic. I'll throw a corneal GP on, I'll do an over fraction. I'll see how they're tolerating it. I mean, I tell patients if I had it my way, no patient would ever wear a contact lens in the world. Your eye does not want a lens in its eye, unless it needs to have a lens in its eye. So if they're coming in for a scleral lens, I'm gonna be very transparent with them. If I think they would do better with a corneal GP, which long term fit properly may have less complications, maybe more cost effective. I'm gonna have that conversation with them. I think scleral lenses may feel like they may be easier to fit for patient adaptation, but it comes with its own wide array of complications, long term, which I think more, more, uh, intention in, in practitioners who are fitting them. So if you can lean on a corneal GP, don't forget how valuable they are.
Speaker 3 00:06:50 So where do scleral lenses fit into ocular surface disease? Is there a particular algorithm you have? Is there a way to know if that helps somebody with dry eye disease states? I know you talked a little bit about graphs versus host disease.
Speaker 2 00:07:03 Mm-hmm <affirmative> so, um, it depends. I think, you know, there's so many, I mean, Walt's never fit his spiral lens. Never seen one, but yet he's managing all these patients, right? Like you don't necessarily have to have a spiral lens in there. Um, but I think I tell patients just like any other dry eye treatment, um, you know, you go in like a step by step fashion, right? You start lubrication, you do immunomodulation, you do serum tears, you do punctual plugs, cetera, etc. And you just go up that chain star lenses can, uh, be anywhere on that chain. If you are a habitual. For example, I had a patient today, habitual soft contact lens where Sjogren's syndrome. Um, she has, she's been wearing a soft lens, 16, 18 hours a day has some early limbal stem cell deficiency from it. I mean, are we going to take her out of the soft lenses, which she, so are we gonna add, take her outta contact lenses entirely?
Speaker 2 00:07:57 I mean, that just seems like an organic transition to just take her to scleral lenses, improve her comfort, support the corneal health and also add immunomodulating therapy, et cetera. So there's no perfect recipe of when to intervene. I think it's a matter of, um, every patient can be different, but there are certain conditions. Like if you have somebody with just recalcitrant neurotrophic keratitis and they've not responded to ate, or they can't get approval for Oxy, they don't have access to it. I mean, that's kind of a slam dunk. Exposure is another slam dunk because you know, these patients punctual plugs ver don't work that well, immunomodulation is not a, it can maybe help, but their problem is exposure. So when you put a lens on you're bypassing everything, you're providing constant lubrication, and now you've taken, uh, the description of the cornea from the exposure out of the equation entirely.
Speaker 1 00:08:49 So when you have your sclerals, you're, I'm hearing, you're still using all the different drugs. You're still doing the very various, uh, my land, uh, treatments, because you know, one of the things you have a dry eye patient, you have to treat the inflammation, you have to treat the glands, but here this helps protect the surface as well, uh, with the constant lubrication that those SCLE lenses, uh, do provide. So my next silly question says I'm allowed to do it <laugh> but actually I do have one slide of a scleral lens. It was, uh, uh, uh, Melissa Barnett's cover her book saying, Hey, if you got dry eyes, you wear contacts, consider, consider scleral lenses. So yes, I do have have that in my lecture, but do you have to take the sclerals out when they're putting the medications in cuz every indication for every pharmaceutical says always take contact lenses out. Yes. Is it
Speaker 2 00:09:36 Different?
Speaker 1 00:09:37 So
Speaker 2 00:09:38 That is true. And, and if you, the way I explain it to patients is that that is, you know, if you're putting Xiidra in that's one expensive medication to not really absorb, like I don't, I don't know if anyone's ever done testing to see how it absorbs to the contact lens itself, cuz that's what we're concerned about with soft lenses, right? If you're putting drops that in patients wearing soft, lens's gonna absorb the medication. Um, that's one variable also, how is it gonna be absorbed if you're putting medication over the star lens, number one, it's not gonna get absorbed properly. Um, if there's enough tear exchange perhaps, but not anywhere near, like it would be if you put it on the naked eye. So what I tell patients, another example, I had a patient today, uh, it's a good day of patients for this, for this podcast.
Speaker 2 00:10:20 <laugh> um, actually that same patient, uh, she was taking Restasis Q I D and I had the conversation with her as part of the consultation. I said, listen, if you're gonna be taking Restasis four times a day, that that you're gonna have to take the lens out every time. So either we need to adjust your dose or let's change you TOSA, try it twice a day and see how you do from there. Um, so these conversations are had pretty regularly in our clinic. You know, someone coming in with CRM tiers six to eight times a day is not uncommon. Those are generally, you know, the more severe dry eye patients. And I tell them, that's just the sacrifice they have to make, uh, whatever medication they're on. We kind of adjust it. Um, and a lot of times once you have the, in a spiral lens where the ocular surface inflammation is calming down and is getting better controlled, you can reassess your medications. You can reassess to reduce perhaps the cyclosporine to reduce perhaps the steroid, et cetera. Uh, so it kind of works itself itself out in that regard, but it is a little bit of a balancing act as you're fitting a patient.
Speaker 3 00:11:20 So where do meibomian gland dysfunction and like blepharitis treatments fallen? Do you recommend that patients, those issues cleaned up first before going into sclerals at the same time after?
Speaker 2 00:11:30 That's a very good question. Every it's a, I kind of take it as a case by case basis. If a patient comes in and they have evaporative dry eye and not a lot of corneal staining or minimal, and they say they feel relief from the bandage lines. I tell them from, excuse me, the spiral lines. I say, look, you are masking your symptom, but you're not treating the problem. So you have to continue to manage the li disease. You have to continue because what happens in these patients and what I, what I really, uh, stress heavily with them is a big component of, of lid disease. Meibomian gland, dysfunction, blepharitis is the blink mechanism. And what happens when you put the scleral lens on is you are now dampening the eyes reflex, the corneal reflex to blink because it's doing so much better. So now you have a reduced blink rate and you are wearing contact lens, inevitably.
Speaker 2 00:12:20 I mean, we know that if somebody's wearing a contact lens, it there, it can exacerbate the meibomian gland, dysfunction, BLE. So I have a very honest conversation say, look, if they're already on a regimen, I say, wonderful. Keep going. This is a tool in addition to what you're already doing. If they are not, I tell them, look, we don't necessarily have to do anything more aggressive at this time, but I'm gonna monitor you. And if it becomes problematic, I could be the best fitter on the planet, but you're gonna be symptomatic and you're not gonna like these lenses. So again, it's a balancing act.
Speaker 1 00:12:54 Okay. I got another great question. Cause I don't know the answer. That's why you're here. What's the difference? I know you all do the pros at Boston site. What's interesting pros and scleral lens.
Speaker 2 00:13:05 Love this question. Love this question. Cause when I was joining Boston site, I had the same question. Um, so essentially pros has been around for decades far before I joined the organization. It, the acronym itself stands for prosthetic replacement or the ocular surface ecosystem. What does that mean essentially? Uh, what pros treatment is? It's a model of care between optometrists, corneal specialists or other ophthalmologists or low or, um, all as part of a team to take care of a patient. So if you are somebody who is a pros provider, that means you have gone through the pros fellowship to not only learn how to provide this type of care in a co-management setting and be familiar with these specific, uh, conditions, but you are also learning how to fit what we call the pros device, which is essentially a highly customizable scleral lens. So it is beyond your, uh, you know, limbal curve base curve, et cetera.
Speaker 2 00:14:06 There is an entire limitless, uh, customization process of this, where you can fit any diameter, any sag value, any base, essentially almost any base curve. Um, and you could add rations, you could do custom base curve on the back surface, eight Meridian. You could do so many things. So it's an elevated level of fitting, um, in the hands of a type of care team, all with the same training. And I think it's great that scar lenses are more widely available everywhere. I mean, not everyone needs a highly customizable, sterile lens and not everyone needs a, you know, the pros treatment. Um, but again, it's, we are here for the patients who may have more severe disease, but we also do get patients who, uh, you know, we are nonprofit. So we may just provide the care at no charge to them if they qualify.
Speaker 1 00:15:00 So someone that fits the pros, this is typically done with the educational institution, is that correct? So certain cities
Speaker 2 00:15:08 Correct. So U C S F USC, uh, while Cornell, et cetera, Baskin Palmer. These are some of the places that have it and more and more there are about, I believe 30, uh, trained pros providers in the world. If I'm not mistaken at this point in time, mm-hmm,
Speaker 1 00:15:25 <affirmative>, mm-hmm <affirmative> see, I did my homework. That's why I knew to ask that question.
Speaker 2 00:15:28 You did and, and not to, oh, one big part is the fact that we actually have a laboratory on site that has, that is probably, I mean, without that I couldn't do what I do. I mean, I can have a lens turned around within two hours time. So I'm, I'm fitting a patient right now with bilateral fenestrated lenses. I'm cutting a lens. You know, I cut a lens, I see what it looks like two hours later. I have another lens. We get a lot more done in a much more short amount of time for patients who don't have the luxury of time or can't wait between appointments. So that's another variable there.
Speaker 3 00:16:02 So you've been talking about how you do a lot of nonprofits, a lot of work, but for the average practitioner out there, they, they good question that I get asked a lot of times is, um, are sclerals covered by insurance.
Speaker 2 00:16:14 So you have to have certain partnerships with, uh, in certain insurance companies. And I, I would just say, reach out to the patient's and medical insurance plan and see if you get the coverage. But I know that is a challenge definitely, uh, with this patient population.
Speaker 1 00:16:29 So what is a,
Speaker 3 00:16:30 There are certain that are more likely to get covered by insurance than others
Speaker 2 00:16:35 Say that again was, is there, uh, insurance,
Speaker 3 00:16:37 Are there certain diagnoses that are more likely to be covered by insurance versus others? Like insurance generally,
Speaker 2 00:16:44 Generally dry eye syndrome is the one that's kind of a broad blanket, um, diagnosis. It's not because patients with graft versus host disease or, uh, you know, exposure don't need it any, uh, any less. It's just, I think it's just the coding and, and the system itself. So I would just, whatever patient I have, if I have a GVH G I'm also putting dry eye syndrome as a diagnosis, just for the ease of, of billing.
Speaker 1 00:17:13 So let's say I wanted to start, which I'm not, cuz I like to refer to you all. But if I wanted to start into scleral lenses, what is a good resource? What are some of the go to resources you can give to our listeners?
Speaker 2 00:17:27 Sure. I think the scleral lens society and the gas permeable lens Institute are wonderful resources. I still refer to them from time to time when, whenever I need to look something up, I, I looked into them a lot as a resident. I think there's tremendous resources there, billing education included. Um, so I would definitely start there. There's a whole world of thorough lens education out there now. And, and, and it's getting more and more every year. Uh, so outside of those resources, going into lectures at your conferences, uh, I think, and watching any webinar you can, would be, would always be a good idea.
Speaker 1 00:18:05 Well, there is a meeting coming up, the ICSC it's in, uh, Fort Lauder a believe. And, uh, I actually used to chair that. So I do know a little bit about sclerals and the only reason why I'm not doing it is cause I referred out to the experts such, such as you all. Uh, but that is a great meeting as well. Uh, do you have any final pearls when it comes to scleral lenses, pros and ocular surface disease you'd like to share?
Speaker 2 00:18:27 Yes. Um, the biggest thing I say, remove the lens at follow up, remove the lens because I, the lens could look good on the eye. The fit might look good on the eye, but you don't know how it's actually fitting on the eye until you remove it. You look for limbal edema, rebound, hyperemia impression rings, et cetera, because how it looks on the eye is gonna dictate how the patient's gonna tolerate wearing it in the short term. But how the eye looks when you remove the lens is gonna dictate how the patient looks long term in terms of corneal health. So always remember to remove and stain.
Speaker 3 00:19:05 That is an incredible insight. Oh my goodness. Vita, thank you so much for coming in and talking about the role of scleral lenses for ocular service disease.
Speaker 2 00:19:14 No problem.
Speaker 3 00:19:15 Have you on we're like we need someone to talk about contact lenses cause we do a whole lot of it. And so you're the expert that jumped right to my mind. So thanks so much for coming.
Speaker 2 00:19:24 Oh, thanks. Yeah, no, it's always fun. I geek out over this stuff. So anytime
Speaker 1 00:19:30 We appreciate you, thank you.
