[00:00:00] Speaker A: Welcome to the Dry Eye Coach podcast series. Click on Dry Eye, your insider path to the most exclusive dry eye topics. 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.
[00:00:21] Speaker B: This episode of Dry Eye Coach is sponsored by Tea Pharma, Inc. The makers of Ivizia and IUSA. For more information on Tea Pharma, Inc's portfolio, please visit teafarmainc.com. That's Thea pharmainc.com.
[00:00:40] Speaker C: Hey, everybody. Today we have Dr. Jake Lang from associate Eye care here on our click on Drive podcast. Welcome, Jake.
[00:00:48] Speaker D: Hey, how's it going, everyone?
Good to see you.
[00:00:52] Speaker C: Hey, Jake. We're so glad to have you here. But before we get started, can you just tell us a little bit about your practice?
[00:00:59] Speaker D: Yeah, for sure. Thanks, Walt. Yeah. I'm Jacob Lang. I'm an optometrist at Associated Eye care on the east side of the Twin Cities metro area, Minnesota and western Wisconsin. There, I head the dry Eye services medical director for Dry Eye services and residency coordinator and help out with all things I can in clinic, as always.
[00:01:24] Speaker C: Well, today we're going to talk about what's hot in 2023 and beyond. But other than some of the things I'm pretty sure you're going to talk about, what are some of the things you're doing in your clinic to optimize your dry eye services within the clinic?
[00:01:37] Speaker D: Yeah, we've expanded our testing a little bit over the last couple of years, kind of trying to integrate more digital computer based analysis of tier breakup time with non invasive tier breakup time, measuring tier meniscus height. Actually trying to put a number with some of these things that we've appreciated clinically for years, but trying to put more of a number on some things and see really what's normal, what's changing. How do we monitor over things over time?
As we all know, the digital age and the age of AI. Hopefully this metadata is going to just help us be better providers in the future.
[00:02:17] Speaker A: It's amazing that you have so many great options for diagnostics. I think that's going to really help to educate our patients and push them more into selecting better treatments. Speaking of better treatments, what are you the most excited for that's new?
[00:02:37] Speaker D: Well, I think there's a lot of excitement around everything coming in the antier segment section. Right? Like, there's just a lot of new buzz. There's a lot of moving parts there's a lot of good things coming. So I think the biggest thing I'm excited about is probably extemvi lodalanner ophthalmic solutions. Probably the thing I'm most excited about.
You want to dive right into it?
[00:03:07] Speaker C: Yeah, just dive right in.
[00:03:09] Speaker A: Tell us more. Tell us what does it treat?
[00:03:12] Speaker D: All right, so loteliner ophthalmic solution as FDA approved for our good friend demidex. Demodex blepharitis. Right. So attacking kind of a different part of the ocular surface in the microbiome that lives on our lashes and having an opportunity to have a new antimicrobial. We haven't had anything that was antimicrobial since, I guess the newest version of a fluoroquinolone. That's been a hot minute since we've talked about killing something that's getting out of control.
And so I think extemvi is allowing us that opportunity to remove a pathogen in our ocular surface that might be getting out of control. And I'm really excited about that because it's a completely new thinking, it's a completely new pathophysiology that we really haven't had an opportunity to attack in the past.
[00:04:12] Speaker A: Yeah, that's what I want to know. Is there a specific patient type for this? How do you know if your patient is a good fit for XMB?
[00:04:21] Speaker C: Yeah.
[00:04:22] Speaker D: So I think if you're thinking about a patient with symptoms, right. A patient that's having problems, a patient that comes to you as their doctor that's having issues with their eyes and their eyelids, we want to find those patients that are having problems with demodex. If we're going to prescribe a medication that's approved for killing demodex. And so to find those patients, to tease those patients out, I think it's number one important that we identify patients that have demodex. Right? So we need to find patients that have demodex. If you're trying to kill demodex in a patient that doesn't have demodex, you're not going to get too far. So having the patient look down and identifying colorttes on the lashes, I think that's just key. Huge take home for all of our providers to identify patients that have cholera and have demodex. Now we're learning, right? So we don't completely know who has too many demodex and who has problems. So trying to pair that finding of, hey, I have cholera, or this patient has Colorado and they have symptoms that might be associated with cholera is the next step. I've found in my clinics that patients that have problems with their itching, especially along their lids, that's a home run. But also anyone that might have increased redness along their lid margin near these colorads, patients that are complaining of crusting along their lids, and honestly, patients that just have disruption of the ocular surface and the meibomian glands, whether that be just meibomian gland disease and signs of that might be things like Chalazian or other signs of disruption in the skin, that is our lids and the lateral functional unit that comes from these lids, that's really who I'm thinking about would be a good candidate for extemb.
[00:06:20] Speaker C: Hey, Jake, so you mentioned the patient that's symptomatic. They're actually asking for help. What about that patient has three plus demodex asking, how you doing? I'm fine. So how are you going to get buy in for that? For that patient?
[00:06:32] Speaker D: I'm just, you know, I think a picture is worth a thousand words there, Walt. When you show a patient like, this is your lids and this is the buildup I'm seeing, I think that really motivates patients to want to do something. If I showed a patient how much plaque they had built up on their teeth or between their teeth, I think that makes an easy sell for a deeper cleaning in a dental office. And I don't think this is much different. So pictures are huge, but teasing out what does fine mean to you and things like that. A lot of these patients are quote unquote asymptomatic, when really they just are used to their symptoms. They've dealt with them for so long that they've kind of just put up with things.
[00:07:18] Speaker C: So, Jake, thank you for giving me that. Go ahead, Tracy.
[00:07:22] Speaker A: I was going to say even the word might. The word might is definitely something that motivates patients to do something different. So no one likes to hear that. Right. Okay, continue.
[00:07:31] Speaker C: Jake, you just gave me mites. You just gave me demodex. All right, so what is that discussion? I'm the patient. Can you talk to that?
[00:07:40] Speaker D: Yeah. So I rein it in a pretty good amount. I say there are these things that live on our lids and lashes, just like bacteria, but there's other things besides bacteria that live on our lids and lashes, like something called Daminex. I'll say something like, there are different organisms that live along our lids and lashes, and sometimes they get out of control. I try not to dive too much in the mites personally, but depending conversation and the patient, we can delve a little deeper. But I usually try and stick with microorganisms and say that they're just normal things that live on all of us so that they feel included. But letting them know that this is something that people have, but it's just getting a little out of control. Something's out of balance.
What about you guys? What do you do?
[00:08:36] Speaker A: I just tell the patients that they're just too delicious. That the dry condition that they have, the underlying MGD, whatever it happens to be, just makes them a great food dish. So, like feeding stray cats. You put a food dish out for stray cats, you get too many. One or two is fine, but 200, probably not great. So I just try to think of them so that they don't feel like there's something like unhygienic about themselves. I just tell them they're delicious. That's all.
[00:09:03] Speaker C: Yeah. I just tell them it's normal. They have it. I have it. We all have it. My scribe hates it when I say they have it. But either way, we just say this is a treatment for and tell them what to do. So that's definitely exciting. What else are you excited about? I mean, there's another drop called mybo. Tell us more. Yeah, unless you're not.
You can change it. Change the topic.
[00:09:24] Speaker D: I am excited about mybo or perfluorohexal octane. Really? Because I get to have more syllables in my vocabulary.
But no, mybo is exciting. It's again, something different, something we haven't had in the past in that it's really a tear film stabilizer. And we've been working on our meibomian glands to help stabilize the tear film over the last 510 years. And I think that's probably been the biggest area of growth in ocular surface disease is acknowledging the meibomian glands, what they do, how they help stabilize the tear film, and how important they are to that lacromal functional unit again. And to have something that can supplement what we've been doing with meibomine gland health is really exciting. And that we know that this is meibomian gland disease is a chronic progressive condition. And we've all seen those patients that we're really hesitant to promise too much when we know their meibomian glands are pretty far gone. And be able to say, I have something that might supplement everything I can do to help restore and rejuvenate your meibomian glands as much as possible. But I also have this drop that's going to help stabilize your tear film in a different way. But a similar way to what your normal mybum would do is really exciting. So I'm really excited about that part in that we have something to prevent evaporation, to help stabilize the tear film, but also the frictional things. I think that's really interesting from an anterior sag nerd perspective, that these frictional forces we've talked about in other ocular pathologies, like lid wiper epitheliopathy, filamentary keratitis, maybe in things like superior limbic keratoconjunctivitis, and how frictional forces play such a role in a lot of these patients. I'm excited to use this in different avenues that have frictional forces at their root to see how that'll help other conditions, like comorbid ocular pathologies.
So I'm excited about that with mybo. I think it's interesting that it's completely different molecule. I'm still kind of trying to wrap my head around how it's a solution when it's really just plurflorahexal octane preservative.
[00:11:51] Speaker C: Free, which preservative free, steroid free.
[00:11:57] Speaker D: Right. So it's something we kind of have to. Have to wrap our minds around. I mean, it's been around for a long time. It's even been used in vitrectomies and things like this for a long time. But applying to the ocular surface as a stabilizer is really interesting and something we all need to wrap our minds around and get after it.
[00:12:18] Speaker A: So when are you implementing mybo? Are you starting right at the beginning of therapy? Are you waiting for patients to get through some of the anti inflammatory treatments that you do? Where are you implementing this?
[00:12:30] Speaker D: Well, I think anti inflammatories are a huge part of dry eye. Right. It is really where this is based that we know inflammation is our enemy in the ocular surface and the anterior segment for many other conditions. So inflammation is still a core belief, if you will, a core mantra in my clinics. But I think this is nice in that it supplements what we do. So I do use it early. I think it's really great for early mild disease, but I also think it has a really great adjunct therapy in that we want to target inflammation, but we know inflammation has been coming for a long time, and it's going to take a long time for it to go away. A lot of times that I can't cure inflammation overnight, but I can stabilize the tear film overnight, and I might be able to give the patient some instant gratification. Overnight. And I think that's really what Americans like most, is instant gratification. So any opportunity to try and kill two birds with 1 st and that I'm giving patients some gratification and helping them get better quicker, but also targeting their inflammation and some of the deeper pathophysiologies that are occurring, I think that's a win win for both me and the patient.
[00:13:46] Speaker C: So what do you say when someone says it sounds like an artificial tear?
[00:13:51] Speaker D: Yeah, it's artificial, I'll give you that. But I don't think it really has anything to do with our tear film.
[00:13:59] Speaker C: Right.
[00:13:59] Speaker D: It's not found in our tear film. It has nothing consistent with our tear film. The biggest thing it does have as a similarity is it prevents evaporation and that is similar to our oil layer and that structure. But other than that, its similarities, there just aren't any.
[00:14:19] Speaker C: Just look at the data. I mean, the data speaks for itself. When have you seen hitting the primary endpoint? At day 57, as early as day 15 for both symptoms as well as total corneal fluorocene. Stating, and so that's very impressive. So you mentioned several different patient types.
So is there an ideal candidate or are you, like me, just trying on everybody right now?
[00:14:42] Speaker D: Right? Yeah, I think there's a lot of opportunity too.
[00:14:47] Speaker A: Go ahead, everybody. I'm trying this in all kinds of different ways on everybody. I mean, it is supposed to be dosed QID four times a day. That was shown to be the best over any other dosage amounts of it. But we're having patients putting in that last drop in at night. We're having patients seeing how they feel in the morning after using their last drop of the day at night. So there's a lot of different opportunities to see what this can do.
[00:15:12] Speaker C: Well, awesome. I mean, that's very exciting as well. Well, what else is exciting, Jake?
[00:15:18] Speaker D: Everything's exciting.
So there's a lot of things coming in the pipeline, too. We'll find out more about our possibility of RASP inhibitors within the next month. I think there's some things coming with trip receptors and things that were targeting nerves in the cornea. I mean, we've learned a lot from senegamin and how important corneal nerves are and expanding that horizon of understanding how to stimulate and activate nerves, whether it's vereniclene like tirvaya as a nasal spray to stimulate nerves or topical things to stimulate the other receptors in corneal nerves. So I'm really excited about that nerve function component in ocular surface disease and just expanding our knowledge and getting more specific about that. So I think there's a lot of opportunity for improvement there, a lot of opportunity for expansion, and a lot of opportunity for us to grow as a profession and as a specialty as we unwind many of these multifaceted nuances to our ocular surface.
[00:16:30] Speaker A: Thank you.
That was so great.
We are just the best time for ocular surface right now. There's just so many new things that are coming out, and we completely appreciate your time coming in and giving us your information and knowledge and giving us a key at what's next.
[00:16:48] Speaker D: Yeah. No, it's always fun to hang out with my friends and colleagues, and you two are doing such great things. I always appreciate the opportunity to spend time having a conversation with my friends.
[00:17:01] Speaker C: Thanks, Jake.
[00:17:02] Speaker A: Thanks for listening. Join us for our next episode soon. Find us on
[email protected] and at all major podcast platforms.
