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 Before we get to our next episode, here's a quick word from our sponsor.
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Speaker 2 00:00:53 In today's episode, we have Josh Davidson from Williamson Eye Center in Baton Rouge, Louisiana was a special interest in ocular surface disease, scleral lenses, and acular disease. Welcome, Josh.
Speaker 3 00:01:05 Hi.
Speaker 4 00:01:06 Hey, Walt. Uh, hey there. Um, Tracy, it's, it's great to be here. Um, I'm still, uh, kind of shocked, uh, that I am here because, you know, I listen to your podcast all the time. I listen to podcasts, uh, a lot of different ones. And usually there's all these superstar guests with all the academic credentials and just, you know, the, the who's who. And I, I still think I'm a pretty normal, um, optometrist. I just see a ton of ocular surface disease. So, um, might be kind of interesting for your viewers to hear, you know, what, uh, kinda your average OD that just gets a lot of reps thinks about, um, different types of ocular surface disease. So I'm really glad to be here. What an honor.
Speaker 2 00:01:47 Hey, well,
Speaker 3 00:01:49 I think he's being too humble. I think we're gonna see that you're a little bit more than just your average Joe, but it's great that you're coming on and the fact that you see so many O S D patients is one of the main reasons we have you here today. So, um, tell us a little bit more about your practice. Like what, what's the modality that you're in? Who are, who are you seeing? What's going on?
Speaker 4 00:02:08 Yeah, yeah. Uh, very cool situation. I am beyond blessed to be, to be where I'm at. I'm at Williamson Eye Center in Baton Rouge, Louisiana. Uh, it's a family owned ophthalmology clinic. Uh, it was started by an optometrist, uh, 80, 75, 80 years ago. And, um, now we've got seven, soon to be eight clinics, but I think seven clinics. And, um, there's a ton of optometrists, a ton of great ophthalmologists that we work with. And it, it's really kind of cool. Cause my interest is ocular surface disease, uh, scleral lenses, a lot of dry eye. And so a lot of our optometrists and our ophthalmologists don't have any interest in that. So I just get all these cases funneled to me on a, on a daily basis. And so I've kind of tweaked my schedule. So it's very, very high volume. Um, anywhere between 30 to 50 a day. Um, mainly allergies, dryness, and, and specialty lenses. So that's, uh, that's me.
Speaker 2 00:03:06 Yeah. You get, you're at an amazing practice. Uh, you know, Williamson Eye Center. I've known Blake for many, many years and some of the other docs. And, uh, yeah, you, you all definitely have a, have a incredible practice. Uh, today, as, as I mentioned earlier to you, is we wanna talk to you about ocular allergies and the impact of dry with dry eye, because we know this often does, uh, intersect their comorbid conditions. So what role does allergies play in ocular surface disease when we're talking about allergies in dry eye?
Speaker 4 00:03:39 Man? Yeah, that's, uh, I don't think I've got enough time to, to kinda talk, you know,
Speaker 2 00:03:44 We got 20 minutes, sir.
Speaker 4 00:03:45 Yeah, that's, that's all I, that's all I got. Um, you know, those two are so intertwined. And I am not originally from Louisiana. I'm actually from Michigan, the Midwest. And, you know, there's allergies up there for sure. But holy man, you close your eyes and you imagine Louisiana, you know, you're thinking humidity, you're thinking pollen, you're thinking all the old oaks and the live oaks and the cypress and, and the allergies down here are unbelievable. And I, I'll tell my patients that, you know, it's these allergies and the dry eyes that, that are very, uh, they kind of play off each other, you know, in my opinion. And I think the opinion of a lot of people, you know, we know that a lot of dry eyes is, is caused by ocular surface inflammation. Right? We, we know that, of course there's lid issues too, but, you know, inflammation that's gonna kind of shut that tear production off. And, you know, the tears, what do they do? They wash allergens away. They wash all this stuff that you encounter every day off your eye. Well, if you have nothing to wash it off, it's gonna cause, uh, less tear production. It's a vicious cycle. And so I think the two are especially intertwined and just, you know, my biggest interest was dry eye. And I realized really quickly that as a, you know, someone interested in dry eye, well, you're gonna be, uh, you're gonna have to have an interest in allergies too. And so it's,
Speaker 4 00:05:08 Yeah. Uh, they are, they are one and the same, it seems like for, for a lot of my patients down here.
Speaker 2 00:05:14 So we ask our patients, does it itch or burn? They say both. What's next? What do you do?
Speaker 4 00:05:19 Depends on how miserable they are. Depends on how much inflammation we're seeing. You know, if there's a ton of cosis, if there's injection, if there's, uh, just the watery eyes, uh, if they're miserable, um, you know, case by case basis. But I've been having a lot of luck with throwing a steroid on, uh, you know, just a kind of a, not the, one of the strongest corticosteroids. I do a lot of flarex, I love flarex. Um, I think it's a wonderful medication. Um, IVIS is really great too. Um, now that, uh, it'll be interesting to see what happens now that Alcon bought them, but I'll use a steroid very similar to those. Um, you know, pulse doum you three to four times a day for a, for a couple weeks. And for the really bad cases, I'm also gonna hit them with an antihistamine like, uh, like cerate.
Speaker 4 00:06:07 Uh, zer is cetirizine. Um, and I tell patients, you know, this, you've heard of this. It's, it's Zyrtec, but for the eyes. And patients are immediately bought into that. So I'll do that twice a day for the really, really bad cases. Um, and again, case by case basis, that's for the worst. Hit 'em with a steroid and an a, um, antihistamine. Mm-hmm. <affirmative> or, uh, you know, kind of just the mild to moderate or, you know, moderate to severe cases. I might do just a steroid, get 'em calmed down and then put 'em on something, uh, long-term like, like Aviate mm-hmm. <affirmative>. And then, um, for, you know, just the patients with just that kind of minor itch and just, uh, it's kind of seasonal. It's not really too bad. I'm not bothered too much by it. Then maybe just aviate, I might have 'em try, uh, an over the counter pad a day. Um, I haven't had a lot of luck with the blue or the red pad a day. I always say, um, even though I'm a Michigan alumni and I'm not a big fan of Michigan State, I'll tell the patients to go to go green with the extra strength and, and, um, that'll usually work too. So it, it's all case by, um,
Speaker 3 00:07:18 Are you, um, recommending orals
Speaker 4 00:07:20 As well? You know, I very, very rarely will ever recommend oral because, you know, especially, you know, those older antihistamines, especially the type ones like, uh, like a Benadryl, but you know, even the, the type twos, uh, the class twos, you know, they're gonna dry out. We know it's gonna cause, uh, a little bit more reduction in the tear film. So I'll hardly ever go with a, a oral if I think they need something systemic. Um, I've developed a really great relationship with, um, a local chain. I, I wouldn't say a chain, but a local group of many, many offices, um, with allergists. So I've got my little form and I just send them away. I'll attack the really bad allergens that way, and then I'll handle the topical. And that's been a really great two-way referral street. Uh, I get countless patients every day from, from that group right there. So I'll hardly ever use oral to be honest with you. And, and I'm sure some people be listening to this saying, ah, you fool. Um, that's just not the, that's not the way that I've had, I've had luck with it.
Speaker 2 00:08:30 You know, what weve been doing, I've learned this from, uh, John Shepherd, our cornea external u uh, disease, uh, specialist is, uh, singular. You
Speaker 4 00:08:39 Know, I've read that
Speaker 2 00:08:41 It's indicated for the seasonal, for seasonal allergic rhinitis mm-hmm. <affirmative>. And so I'll take 'em off any of the, the oral antihistamines and put 'em on something like that. But, you know, patients are having the, the, the nasal issues, the headache, skin issues, throat issues they need, if they need oral, they need oral. And so that's essentially how we've been treating that.
Speaker 4 00:08:59 And actually, you know, I read that and I wanna say it might've been from you or it was one of those inserts in Modern Optometry magazine, one of the B brinmar, um, publications. I read that with the singular and I was like, that makes perfect sense. I just read that probably a month ago. So that's something that's, and that, and that's something that when it comes to dry eyes and and allergies, you do kind of have to stay up on this stuff. So thankfully we've got great literature like that, um, to kind of help us stay on the up and up.
Speaker 3 00:09:29 Yep. I like that you're co-managing with an allergy group. I mean, you have such high volume. I know there's some doctors out there that are doing in-office allergy testing, but I think that's a great pearl for our listeners that if they don't feel like they have the time or the means that that's, you know, set up a good relationship with a local allergist could be just a quick and easy way to get referrals. And I like that two a street that you were talking about.
Speaker 4 00:09:50 And, and we, we, um, I'm sorry to interrupt. We actually <laugh>,
Speaker 2 00:09:55 I guess you can interrupt us. I'm
Speaker 4 00:09:57 All, I'm all
Speaker 3 00:09:57 Interrupt us all the time. We talk too much
Speaker 4 00:09:59 <laugh>. I'm all excited. Um, we're talking ocular surface disease, so you got me excited. Um, we looked at doing, um, I think it's Aller focus and then there was another one with, um, BOLO I think has an in-office allergy testing.
Speaker 2 00:10:13 Yeah. Doctor's allergy.
Speaker 4 00:10:15 Yeah, that's it. And, and we, we looked really hard at doing it and we might still get on board with that, but it's one of those things too right now where, um, you know, it's hard to, to maintain a full staff. So, you know, we want our staff locked in doing all that. So we actually look pretty hard to do that.
Speaker 3 00:10:35 And then you diagnose it, but you may not also have the, like, the immunotherapy options either. So it's not a bad idea to, to make friends with the local if you're, you're not into doing the allergy testing yourself. Good. Love it,
Speaker 4 00:10:46 <laugh>. And it's been very, very beneficial from a practice and a clinical growth standpoint of just seeking someone out and, and they know you're interested in it and they know you want the best for the patients. So it's been, it's been great.
Speaker 2 00:11:00 So Josh, I know you have have a kid. I do. Do you like, do you like to see kids
Speaker 4 00:11:06 <laugh>? I'm a I
Speaker 2 00:11:09 Have a follow up, but go ahead.
Speaker 4 00:11:11 I'm a, I'm a single dad, uh, of a four year old boy that now does jujitsu. So I get, and, and that's been awesome. But, um, I'll tell you what, I get enough kids, I all see kids occasionally, but, but my son wears me out. So I like seeing adults. So I don't do, it's not a kids i'll, but nah, it's not, not my wheelhouse.
Speaker 2 00:11:35 Well the reason why I ask is cause we know that there is a, there's a drug for vernal, carto conjunctivitis, uh, that is used in with kids, young boys, uh, of oftentimes. And so it's a1 percent cyclosporine. So I was trying to see if you had any experience with that at all, but since you don't, the kids just remember that's an option.
Speaker 4 00:11:57 Well, I tell you what they did drop it off at the office and you know, I, I looked at it, put it in my own eyes cuz I, if it's safe, I'm gonna put anything in my own eyes just to check it out. They do the same thing. Except, except, um, yeah. But anyway, yeah, it worked out. I thought it was very comfortable. I thought it was a great drop. So it's one of those things that I don't see a lot of the indication for that. And, and there's a lot of other options that are unlabeled for the patients. I do see, but I was very impressed with how comfortable that drop was. So I think it's uh, uh, good job. It was very comfortable.
Speaker 3 00:12:32 Mm-hmm. <affirmative> well comfortable in kids. That's always a good match. Right?
Speaker 2 00:12:35 So, so, so Josh, I wanna go back to this allergy once again in dry eye. So many times patients have both. How do you simplify treatment? Cause you mentioned steroids, you men and the histamine, we know the data shows the more drops patients do, the less they're gonna do it. So what have you found the most successful? I mean, I agree the pulse dose, uh, steroids and putting 'em on, uh, uh, putting 'em on antihistamine. There's preservative-free over the counter allergy drops as well. Any pearls on that?
Speaker 4 00:13:04 You know, you kind of gotta read the room because if someone is miserable enough, I'll tell you what, they're gonna use the drops. And, um, so if it's a really, really bad case, you know, my suggestion would really be to, to hit 'em with a steroid and, and don't be afraid to, you know, pound 'em hard, pound 'em fast and, and, and kind of see where they go. Because even the best antihistamines, to be completely honest with you, a lot of times I'm just not getting the, uh, the relief that, um, the patient really needs to kind of break that cycle of inflammation. If I do suspect that I can get by with just an antihistamine. Not every office is blessed. Like, like, like I am, I, I'm so spoiled. I've got in my clinic, there's 26 exam rooms. I mean, just mind blown, right?
Speaker 4 00:13:54 So I can leave, I can leave a patient in an exam room if I think it's just gonna be an antihistamine, uh, that they need and just dose some aviate and, um, walk away, come back in, you know, 10 minutes and I'll know pretty quickly if that's gonna just be enough. But the allergies down here usually are bad enough that I'm gonna need a steroid and then I can ma I can maintenance treat 'em with, with an antihistamine. Which actually brings me to, uh, one of the big things that I have found. I feel like I'm talking a lot about cervi, sorry, but, uh, but um, you know, there are some really strange dry eye patients where their eyes look perfect. You know, the photograph five m um, everything is just looking great. Our InflammaDry is great. Um, or you know, mild, the tear lab is good mm-hmm <affirmative>.
Speaker 4 00:14:46 And for these patients, um, I'll actually just test them with an antihistamine in office even if I don't think they have allergies or you know, even if I just think it's just a straight dry eye patient. And I have probably had a hundred, 150 over the last year where that has been the missing link. You wouldn't think at all out of those allergies. But you know what, they're still not happy after getting on all the different dry eye treatments. I pulse dose them with, they're not pulse dose, just sample drop, um, Zvi or Pataday or whatever's laying around in clinic. And I'll come back, check back in 10 minutes and they say, what was that liquid gold? So that's one thing that, uh, I have found. And um, you know, even if it's a a true dry eye patient, you're just not getting the relief you're looking for and you're like kinda running out of ideas, you're kinda running outta runway on what you can try. Uh, there's actually been cases where, you know, it's not looking like allergies when you put that antihistamine on. Boom. So
Speaker 3 00:15:47 That is, so, I mean, I, I think you're proving yourself wrong on being the expert sort of a deal here. <laugh>, you're literally, I think you've just solved the problem for a lot of doctors out there who are spinning their wheels and wondering why their dry patient isn't getting better. So, I don't know, I think you're selling yourself short friend. That's a amazing tip. Thanks for sharing that with our listeners.
Speaker 4 00:16:07 So one thing, one thing that I have found with those patients, and this is not always true, but if you know, you're looking at their tear breakup time, you're looking at the front of the eye, the tear lab, everything that you got is really, really good, but they're still not comfortable. Might not be an itch, but if that InflammaDry is getting a little bit positive that MMP nine, um, uh, there must be some correlation there with, with allergies. Uh, I think there is. Um, because if everything's perfect, but that little bit of that inflammation's still present, you'd be amazed at, at exactly what an antihistamines gonna do, even if it doesn't scream allergies. Mm-hmm. <affirmative>.
Speaker 2 00:16:49 Hey, can you talk about the role of patient education? Making sure to look at the pollen counts? I mean, what is that discussion with the patient? I want you to be brief cause I wanna talk about something else. So I want, I want your short answer here.
Speaker 4 00:17:02 I have never talked about the pollen count.
Speaker 2 00:17:06 Cause it's ubiquitous. Yeah.
Speaker 4 00:17:07 If you can see it. Yeah. It's, you know, every day you wake up in your car, your vehicle is is is green or yellow in Louisiana. So there's, there's, there's no point <laugh> because guess what, did you wake up this morning? You did. Alright. The pollen's high.
Speaker 2 00:17:23 I bring that up just cause you know, avoidance is the number one thing, right? That's true. Your trigger is, but okay, I wanna ask you, what is this dry eye juice box that I hear about?
Speaker 4 00:17:34 You can't even get the name right.
Speaker 2 00:17:36 It's called the dry eye drink. It just sounded better when I said juice box. But go ahead. Maybe
Speaker 4 00:17:41 Listen, I'm not a marketing guy, but I might be taking that <laugh>, you know, what's, what's, what's crazy? And, and thank you for bringing that up. It's very nice. Um, Dr. Dry, a drink was actually just kind of born out in necessity, to be honest with you. Um, gosh, how many times have I told patients, you know, you just gotta drink more water, drink more fluids, you know, it's a thousand degrees outside with 98% humidity, drink more water or, you know, they came back from Colorado and they're all dehydrated because they were hiking and it's a mile up in the air. And I would just tell patients, just drink more water, drink more water. And they all say, yeah, when I'm properly hydrated, my eyes feel better. So after a year or two years of telling people to drink more water than not doing it, I said, all right, go drink some liquid iv, go drink some drip, drop all that, the powdered substance that you shake and, and you drink.
Speaker 4 00:18:34 And patients were getting, you know, benefits there. And we were seeing a difference clinically, it was great. But then one of my, uh, best friends who's one of our ophthalmologists came to me and said, Hey dummy, you know, all these things are loaded with sugar. I said, ah, yeah, they are. He said, and you know, sugar's very pro-inflammatory. I said, ah, yeah it is. He's like, so you're telling dry eye patients who have inflammation that they should drink a product with a ton of sugar. I said, okay, well I'm just gonna find one that doesn't have sugar. And it didn't exist. So we went through like 40 formulations. We, we made the product. It's been really great. Um, patients seem to like it. We've been selling it for about 6, 7, 8 months, something like that. And we already have patients on a reorder, so it's going really good. And we're kinda branching off into other products. We've got disposable steam activated masks, but I love the BR masks. Great. They're great company. Um, but a lot of patients don't like the microwave or they don't have a microwave. So this is one you just open where it heats up for about a half hour, then you throw it away and it's totally recyclable. That was huge. So
Speaker 3 00:19:45 What's other than water? I, I, oh
Speaker 4 00:19:47 I should specify. Yeah, we got off course all the electrolytes, which is gonna help the kind of hyperhydration, but it's got, um, vitamins a, B 3 6, 12 C uh, Toine, turmeric, and a bunch of anti-inflammatories like Toine, turmeric, green T extract, uh, and omega three s from um, C kelp in the South Tennessee. So it works really well. We've had a lot of luck with it. Patients swear by it and we're just kinda getting out there with it.
Speaker 3 00:20:21 Is it like a bottled drink or is it like a powder that you mix then?
Speaker 4 00:20:25 It is a powdered substance that you pour into.
Speaker 3 00:20:28 Got it. Ok. Bottle
Speaker 4 00:20:29 Shake, shake, shake and drink. Which um, if anyone is going to the Academy of Ophthalmology, no, I'm sorry, academy of Optometry, uh, meeting in San Diego, they're having their inaugural bright ideas pitch competition and it was one of the ones chosen to
Speaker 3 00:20:46 Oh, congratulations.
Speaker 4 00:20:47 Thanks. Good to get up there and talk, which I like doing.
Speaker 3 00:20:53 That's great. Well, amazing. This is so good. Of those vitamins that you did talk about are definitely supportive of the O surface. So thanks for including other things other than just, you know, basic electrolytes. That's great. I know
Speaker 4 00:21:08 We're trying to get vitamin D3 in it, but it's proven to be a lot more difficult to get it to mix well.
Speaker 3 00:21:14 Mm-hmm. <affirmative>. Yeah, that's ok. There's always room for improvement, right?
Speaker 4 00:21:18 <laugh> version 2.00, the dry eye juice, juice box, <laugh>. It's called the dry eye
Speaker 2 00:21:24 Drink. I was just having
Speaker 4 00:21:25 Fun with. I know, I know.
Speaker 2 00:21:27 That's awesome though. We're excited to hear more about it.
Speaker 4 00:21:31 Absolutely.
Speaker 3 00:21:34 Okay, well thank you so much for coming, um, on the podcast today and teaching us all about your great allergy tips. I think the most important thing that you've given our listeners today is great ideas that they can take into the clinic tomorrow. So that's what, that's what an expert does, is they help to educate and give our listeners ideas that they can implement. So you've done a fantastic job, Stan. We just loved having you on the show.
Speaker 4 00:21:56 Well, thank you. It's such an honor. Anytime. I really appreciate it. This is great. Great to see you guys.
Speaker 2 00:22:03 Thanks Josh.
Speaker 4 00:22:04 Thank you.
