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.
Speaker 1 00:00:15 Dr. Parman is gonna share with us her pearls and insights of the role of the trigeminal nerve in ocular surface dryness treatments. Welcome Laura.
Speaker 2 00:00:24 Thank you, you so much. This is awesome to be here.
Speaker 3 00:00:28 Yeah, we're excited to have you there, Laura. Appreciate your time number.
Speaker 1 00:00:31 I thank you so much for your time. We know you're busy ladies, so we appreciate you stopping on by
Speaker 2 00:00:35 Anything for you guys.
Speaker 1 00:00:37 <laugh> now you recently started your own specialty, dry I a practice. Can you tell us more about the practice and how you got it started?
Speaker 2 00:00:46 Sure. So we, um, opened June 5th, 2020 in the pandemic and 200 square feet, <laugh> with a single mission and that is to address dry eye disease our way. And it's a combination of things I've learned across two and a half decades as a molecular immuno biologist, uh, clinical medicine innovations and clinical research. So it's the, the amalgam of all these different chapters of my life. And we have so much fun providing, you know, world class dry eye care to our dry eye patients, giving them to clinical research studies for, uh, you know, early access to innovations. So it's, it's been, um, a lot of work. I won't lie, but a labor of love as well.
Speaker 3 00:01:34 Mm-hmm <affirmative> so tell us about your team. Is it just you, do you have, do you have several team members? Do you have a couple ODS or fellows? I understand.
Speaker 2 00:01:43 Yes. The team is very interesting. So we have, I started off with a virtual office manager, somebody, uh, worked with, uh, she was a technician when I worked at Redmond eye clinic years ago and just loved her just and complete, um, uh, incredible patient advocate, um, heart of gold mouth of a, I love her. She's amazing. <laugh> and then Raquel is my licensed master esthetician and she also helps with the clinical research studies. They both do. They both involved in clinical research studies and it's so much fun because it becomes a career growth path for them as well. And then we have two fellows, optometric fellows, and I love it so much because it's, it's a way to, um, elevate the next generation. Right? And so these are two women who are going after their F AO. And so I'm helping them with research projects, abstracts, presentations, publications, all that kind of stuff. Cause I gotta tell you, like when I go to the a O P T meeting, I love it. When we come out of that first morning session and the carpets are littered with all the brand new FAS, it's just like, it's just, I just float down the hallway. I'm so giddy happy seeing the way these people are having their accomplish accomplishment recognized in such a public and celebratory way. I just love it. So I cannot wait to see their two names on the, the carpet <laugh> on the red carpet.
Speaker 3 00:03:19 Well, we're excited too. I mean, we're both part of the, uh, interior segment section for the academy mm-hmm <affirmative> and uh, yeah, anything they need help with or how we can be of service, please help them reach out with, uh, anytime, uh, for any of that.
Speaker 2 00:03:31 Thank you. That's awesome. I super appreciate it takes, takes a village, right? We're all in this together.
Speaker 3 00:03:36 Definitely. So with, with your prep practice, especially practice. So do you take insurance as a cash base? Cuz sometimes when we hear about these PR some practices, not just in iCare, but in other specialties that it may be a cash based elected type thing. So how was it at your practice?
Speaker 2 00:03:51 Right? So we went completely direct care and there was a very mindful reason for that. I tried over the years to mold myself into the six to 10 minute encounter. And you just can't unravel the gnarled wall of yarn of dry eye disease in six to 10 minutes, these patients deserve more. They, they have questions. They have, you know, anxiety, they have depression, they need to understand, they need to know you support them. They need to know that there's a lot. We still don't know, but we're gonna do our best. And we don't give up easily. That takes time. So we give our patients the gift of time. Now that does create potential access issues. And that's another supporting reason for the clinical research pillar is so that we can help create equity IM parity by access to those early, um, early treatments in the form of clinical research.
Speaker 3 00:04:51 Mm-hmm <affirmative> yeah. You know, be involved with, uh, research studies in the past, you get some patients they love to do research. Like when's the next study? <laugh> You got this one before we can do the next one, but uh, either way. So, so you know, you, you mentioned your background, so how is your, your passion for immunology and dry? How have they complimented each other?
Speaker 2 00:05:12 Well, I think they are born from the same source and that's, I'm definitely a clinician scientist. I'm a nerd at heart. I love understanding how things work. Um, and that, that drive of understanding why things work on a cellular level, on a mechanistic level, on a cytokine level. That's insatiable curiosity that was planted in my brain before medical school has never gone away. Still want to know how things work and how they integrate. And if you think about the awesome things in our toolkit, we have a lot of interfacing with some of that crazy elegant, complex immuno pathophysiology. We call dry eye disease
Speaker 1 00:06:00 When you know why something or how something should work, you can figure out why it doesn't and where to specifically target it. That's what I love so much about your passion for immunology and dry eye. And, um, just love having you hear, I also wanna hear about, um, what you're currently with neurostimulation. Like where do you feel that that's fitting in right now?
Speaker 2 00:06:21 Oh, I love the topic of neuro stimulation. So we had the good fortune of being a phase three FDA study site for I tier bio Olympic ophthalm, they're a suburb here in Seattle and IACA Washington and we got to be a study site for that multi-centered study. And it was awesome, like to have the luxury of time, to really closely observe what's happening with your dry disease patient with respect to an intervention that's powerful. And that has enhanced my understanding of the entire lack of a functional unit, the ocular disease MI in, in such an enriching way. We published on it in, uh, November of 20, 20, 20, 21. I'll get the reference for you. Our data and, uh, neural stimulation is a real thing. Like you can see the tear height going under neural. You can see my bum coming out of the terminal dals during neural stimulation under high magnification video slit lamp.
Speaker 2 00:07:28 It's incredible. And we also know that you get de granulation or musin release from Golet cells under neural stimulation. So this concept that the, the key players in a healthy pre corneal tear film, meibom musin and aqueous are under the neuro biological control of the central nervous system is new, relatively speaking and an understanding of, uh, dry eye disease. But it's also very real and very exciting as well. There's um, there's other neural stimulation modalities as, as we've, uh, good news. We've got tur now, Verlin. That is a really interesting intervention as well. There's um, uh, I love doing test doses in the chair. Like obviously you can't reuse the bottle, you gotta have a fresh one for every fresh patient, but <laugh> cause it goes up your nose. It's a nose spring. <laugh>, it's, it's amazing to me to watch the patients do it and you can see what the little tear is going up. They're like, oh, wow, that really works. So it's very, very fun to have these different neural stimulation modalities. And I use neural stimulation not only is a therapeutic, but I'll even use it as a diagnostic to see if the electrical wiring, if you will, is even intact or is the system completely burned out. So I'll use it diagnostically therapeutically. I think there's a, a short term, medium term and long term benefit of neural stimulation. It's not just shes, there's much more going on with neural stimulation.
Speaker 3 00:09:08 So you just mentioned you use diagnostically. Can you, can you speak to that to make it clear for everybody exactly how you're using that, right? Is it like a, a dose in office? Is it for a week or, or can you tell us more?
Speaker 2 00:09:20 Yeah. So in the lane, if I have a patient that's, you know, got severe dry eye and I need to find out if the system's even intact, then I will use neural stimulation. And if the tumor scores don't budge at all, I know that the system's pretty broken, right. And that's, uh, once you get that complete neural short circuiting or end organ failure, I E the lack of a gland, um, that's, that's prognostically important, uh, for, for the patient to understand you really gotta think big about your modalities. You know, you're definitely looking at scleral lenses, other modalities, such as this, but it's, um, it's also very telling. So if you have a patient that has a pretty normal osmolarity and a high MMP, nine load, and a bunch of staining, you gotta ask the question. When's the last time you used your tears, right?
Speaker 2 00:10:15 Oh, an hour before I got here. Ah, gotcha. Right. So I find that all these things are very, very helpful. And then, um, yeah, so it's, it's another, it's another error on the quiver and I find it, um, I find it to be really helpful in a couple of other clinical situations. Um, if there's a history of migraine headache disorder, if there's a history of depression and these are also neural based problems and dry eye migraine headaches share some, some pathology in the trigeminal nerve. Well with neural stimulation, you're able to bypass the corneal nerves that might be, you know, smoked out from chronic hyper osmolarity and create that, that, uh, that neural flow through the brain stem and, um, the command fibers, if you will, Hey, lack of Aland, pick up the face, getting a little salty in here. Um, my bone's like, come on, there's wind out there.
Speaker 2 00:11:11 I need you to protect all this. And of course the MTIN cells as well. Um, I find that the migraine suffers, they depressed patient really kind of need the neural stimulation. Um, and it becomes a, a particularly beneficial for them. Yours truly suffers from ADHD. I didn't used to, it's a gift of menopause, but <laugh> yay. The gift that keeps on giving. Oh yeah. Yeah. There's lots, lots of that. <laugh> but I, it actually helps me focus just a little bit as well. It improves my focus. I wonder if this is what a smoker feels like after they smoke a cigarette? I don't know. I'm not sure, but I, I feel calmer and I'm definitely more focused and the entire office appreciates that. Cause when I'm around, it's like hurting a cat, like do anything going now <laugh>
Speaker 1 00:12:03 So when you're doing your, this kinda like diagnostic check, are you using more of the mechanical or the pharmacological stimulation or doesn't matter just whatever you can grab first?
Speaker 2 00:12:11 Well, it does matter it's it's D all the above, what do I have handy? What's ready to rock. And is there going to be barriers to acquisition for the patient IE issues? Right. So that enters into my calculus as well. If I'm, you know, looking at a patient who I'm pretty darn unsure their insurance, isn't gonna cover it yet, then I'll reach for the mechanical. Um, some patients prefer the mechanical, the, the, some patients prefer the nasal and it's just wonderful to have another option. Um, the very keen observer patient will tell you that their vision is better after neuro stimulation. And so this can be something that we can, um, potentially try on our 20, 20 unhappy post cataract patients. There's a, um, a term, gosh, it was just, just recently pav by Tel Raviv and Daryl white. It's like the pro, oh, what do they call it? There's an acronym for it. But basically it's dysphoria, um, at, after cataract surgery, like some kinda like discontent malcontent with your visual performance after cataract surgery. And I think this is a great thing for that, including pup modulation, but that's probably another podcast episode. Yeah. <laugh>
Speaker 3 00:13:28 No worry. Hey, you, you mentioned, you mentioned for the diagnos increased Shems in, uh, you also mentioned the, the other layers of the tiers. And I think one of the things is we only see part of the data. I mean, one of the things I referenced in a lot of my lectures is that paper, uh, that or poster you presented at a S C R S we were able to show the improvement within the myo gland, secretion, and, and other factors as well. So how so? How do we, no, we have your data. We have more studies coming out. Right. Um, but it's, it's a huge topic here,
Speaker 2 00:14:01 Right? So again, I love understanding how things work. If you go to James J's work from about five, six years ago, published in the ocular surface journal, he's brilliant PhD researcher at UC Irvine. He was able to demonstrate that the meibomian glands are wrapped with sympathetic and parasympathetic fibers. Um, it, and on the, the diagrams reminded me of a, of a tree wrap on a Christmas tree of the lights, right. It's just like, it's all over. It's all over the tree. There's lights everywhere in there. And so when you do neuros, you're actually getting some of that as well. And that sympathetic parasympathetic tone helps influence the mem gland stem cell activity. So I think that experience why we saw this really impressive improvement in my secretion scores over the course of the mechanical neuro stimulation study.
Speaker 4 00:15:01 Mm-hmm <affirmative>, mm-hmm
Speaker 2 00:15:02 <affirmative>
Speaker 1 00:15:03 How many times a day are you recommending that your patients do neuro stimulation?
Speaker 2 00:15:09 I'm I'll answer that in just a second for have to tell you one more thing. Oh, when we, when we saw the myo actually coming out during neural stimulation, um, there's a, a, a little tiny muscle called the muscle of Rhon, which, um, surrounds the MYM glands. And that probably gets activated in squeeze just a little bit as well, maybe that, so it's sort of like giving a woman Pitocin during child, but it just like forces that stuff out of there <laugh> anyway. Yeah. How many times a day? Um, so it depends on the severity of the disease and what I'm treating. So if it's a neurotrophic, like a stage one neurotrophic keratitis, I'll do it more like four times a day, trying to stimulate those corneal nerves to send that, you know, substance P epithelium, everything's fine. It's groovy. Don't worry, like putting that happy music out there on that corneal surface.
Speaker 2 00:16:03 Um, so more like four times a day, very severe disease, more like four times a day. Um, and then usually we can taper back at the end of 30 day a to more of a, twice a day maintenance and then duration completely depends on the clinical picture as well. Some patients, their basal tear production improves to the point where they kind of don't need it, so they stopped using it. Um, but when they start, when that starts, Duane, maybe because they're not being diligent with their immunomodulator therapy, cyclosporine, lithographs, you know, postal, steroids, whatever this is, uh, there, omegas, fatty acids, all those things. Um, when that baseline tear meniscus height starts to wane just a little bit, then they go back to the, uh, external neural stimulation device and they get that same robust Shermer's, um, tear, tear production. What was so interesting is, um, during the of study, there's a, from the mechanical extranas stimulation, it Olympic ophthalmics is there was a robust improvement in stimulated tear on day one. And the amount of tear release at two weeks and four weeks was a quite as robust. And the patient misinterpreted that is it's no longer working, but what actually happens is your basal tear secretion increases, which is a claims why the tear breakup time was so much better why the corneal Carpathy improved it's um, that, that sensation is not where the only magic is. There's so much more going on with neural stimulation.
Speaker 3 00:17:40 Yeah. It's such an exciting topic right now. And, you know, and, and to be clear, it's been around for a while. I mean, we had true tier and
Speaker 2 00:17:49 <laugh> yeah.
Speaker 3 00:17:51 I mean,
Speaker 2 00:17:51 We have, I hoard, I hoard the activators <laugh>
Speaker 3 00:17:54 Yeah. I mean, we have patients that say, Hey, this is, this thing has truly changed my life. Yeah. And we wanna be clear that it does work. It was the business model is essentially why true tier isn't available. Do you have any comments on that?
Speaker 2 00:18:06 Uh, I think I, it made me sad that it wasn't sustainable because it is a great technology and the more tools we have the better cuz you know, let's be real, not every patient is going to accept every type of intervention. Um, so it's nice to have options, access, all those sorts of things. I think we're learning as we go along what the market will bear, what patients will bear. And I think lot of it has to do with our colleagues understanding and how they present and explain it to the patient, how they show the value of what they are recommending and prescribing.
Speaker 3 00:18:42 So tell me about sneezy. What are you tell the patients?
Speaker 2 00:18:45 I tell 'em I tell 'em it's normal. It gets better in a few days.
Speaker 3 00:18:50 I do as well.
Speaker 1 00:18:51 Yep. That's the biggest hurdle I find with the patients that I'm trying to prescribe to is that they just they're like sneezing the first couple of days and they wanna quit. I'm like, Nope. Keep going through it. Keep,
Speaker 2 00:19:00 Keep going, keep going, give, give the full seven day. Try. Let's go.
Speaker 1 00:19:04 I'm a non sneezer. So I don't have that. Oh, you
Speaker 2 00:19:06 Don't sneeze. You're lucky. Yeah. I high sneeze like crazy the first couple days. Woo. That was an
Speaker 1 00:19:11 I'm. I'm one of the weird ones that doesn't
Speaker 2 00:19:13 <laugh> nice. I, I kinda like the sensation, honestly. I like that black pepper tingle, like, cause I like to cook soup and like you put too much pepper in there and you go over too soon and I go like, Ooh, goes, they're like, woo. Yeah. That's pepper,
Speaker 1 00:19:26 Maca
Speaker 2 00:19:26 Cooking.
Speaker 1 00:19:27 I like wasabi for the same reason. I love
Speaker 2 00:19:29 Wasabi for that same reason. I'm like, oh, all those tears that feel so good. <laugh>,
Speaker 3 00:19:35 You know, one of the questions we often get is, you know, where do you use something like Teva, if we're gonna go back to the, for the, the drug itself, you know, are you using in drug naive patients? Is this chronic or maybe what's the, what's the one thing that you're noticing the most whenever you're using the, uh, tear VI,
Speaker 2 00:19:52 I think the thing I'm noticing the most is the improvement in the basal tier secretion, um, over continued use. That's the thing I'm noticing the most. There seems to be. I also see improvements in staining over the course of time. Um there's uh, yeah, so I, I think we're all learning together in the post market, but I had a little bit of an early start because of our involvement with the mechanical extranas and I think they work pretty similarly. Actually it's the same pathway we're tapping into.
Speaker 3 00:20:20 Yeah. Tracy, what, what are you noticing for me? I'm noticing them using less tears, their eyes using artificial tears as often
Speaker 1 00:20:29 The contact lens patients are really big fans because there's nothing that they can, especially with the sclerals. And you're trying to get the sclerals to keep wedding effectively. They're they're probably the biggest fans.
Speaker 2 00:20:40 I love that. That's that's a really smart use of it in a contact lens patient. You betcha.
Speaker 1 00:20:46 Okay. Do you have any one take home Pearl for our listeners when it comes to ocular service disease? I know it's hard to get you to boil down one fact, cuz you're just a found of knowledge. One take home Pearl for our listeners.
Speaker 2 00:21:00 One take home. Pearl is stay curious, keep learning because this rapidly expanding field it's thrilling. Exciting. Don't let it overwhelm you on mute. Just stay curious with it. Stay with it. Keep studying, keep learning. Keep coming to the meetings. Keep listening to us podcasts like this, but just lean in. Don't be afraid of it. The future looks bright.
Speaker 1 00:21:23 Thank you. Any other questions from you while
Speaker 3 00:21:27 Now? Hey, we just appreciate you at being here there, Laura. Thank you so much for your time and expertise in sharing with our listeners, the role of the trigeminal nerve and ocular surface disease, treatment and diagnosis as well.
Speaker 2 00:21:40 You are welcome. It's always a pleasure. Can't wait to see you both in person.
