EyeCon 2024: Laura Periman, MD, shares a surprising clinical experience with Demodex blepharitis

Laura M. Periman, MD, shares her passion for dry eye disease, discussing her discovery of the Alpenglow Sign in Demodex blepharitis and her insights on research and education for clinicians in this interview with Ophthalmology Times. Periman will join the EyeCon 2024 faculty as Honorary Chair. The conference will take place at the Hilton Fort Lauderdale Marina on September 27 and 28, 2024.

To learn more about or to register for EyeCon 2024, click here.

Video Transcript:

Editor's note: The below transcript has been lightly edited for clarity.

Sheryl Stevenson, Group Editorial Director - Eye Care: We are joined today by Dr. Laura Periman, who is one of the cochairs for this year's EyeCon 2024, on September 27th and 28th in Fort Lauderdale, Florida, and we're so excited to have you join us. Thank you for your time today. We'd love to take a few minutes to look at the person behind the role of cochair and have the audience learn more about you.

Your passion is dry eye disease, and you've done a lot of research in this subject across your career. Do you have any favorite studies or even a pet project that you remember fondly?

Laura M. Periman MD: Yes, there is a particular standout study, and that was the Tarsus Phase 3 FDA studies for what we now know as Xdemvy; it's lotilaner 0.25%. First of all, it was one of the easiest studies to recruit for, which was refreshing. And another aspect of it that we really loved is we were masked to active versus placebo. But by Week 2, it was obvious. So it was really neat to see something work that quickly and provide that much improvement in such a short period of time. So that was probably my favorite, if you're going to make me pick one, it was my favorite.

It also literally opened my eyes to really appreciating the role of Demodex, and it led to some personal clinical discoveries. One is the Alpenglow Sign, so this is the Periman Alpenglow Sign. And we're taught in Demodex blepharitis to have the patient look down and look for the presence of collarettes. But some patients are really good with their lid hygiene, and if you take the time to epilate lashes and look under the microscope, which we still do on all suspected cases, you can miss cases of Demodex blepharitis. So the absence of collarettes does not rule it out. What I found one day while I was just like slowly spanning from right eye to left eye with the sidearm just obliquely across the nasal bridge...when I got to the left side, I saw the fine vellus hairs of the face, but then there were these coarser ones, these thick, stubby, coarse ones...like, what's that?

So I took my epilation forceps, took some lashes, like I was going to do anyway, and just grabbed a couple of those dermal collarettes and put them under the microscope. What do you think I saw? Tons of Demodex mites. Oh, my gosh! So I named it after that phenomenon at dawn in the mountains, when the sun is first coming up and it just highlights the tips of the mountaintops. That's the phenomenon that you're seeing under high mag at the slit lamp as the light crosses you see just the tips of the projections in the skin under high mag at the slit lamp. And so I call it the Alpenglow Sign. And that led to some independent work where we were able to demonstrate in an imperfect retrospective chart review, the presence of the Alpenglow Sign predicted the presence of Demodex on epilation 83% of the time. And so we now routinely take note of the presence of the Alpenglow Sign, and we can watch it get better with treatments, IPL, chemical peels, that's treating the load on the face to prevent recontamination of the lids and vice versa. When we had IPL for the longest time, I didn't have anything for treating the lids. And now I do, and I can get this total local, regional clean of the excess Demodex load and all of its accompanying inflammation.

Stevenson: Much of your work has been published as well. How do you feel research has changed over the course of your career?

Periman: How has research changed over the course of my career? Well, the good news is that it's expanding exponentially. That's what's so exciting about dry eye research. Back when I trained, we didn't even have Restasis yet (I just gave away my age) but that's all we had. And just now, we understand on such a much more intimate level, what is all involved when we talk about the immunology and inflammation on ocular surface with dry eye disease, and the story is expanding. One of our papers, I tried very, very hard to break down the complex immunopathophysiology of dry eye. I'm a molecular immunobiologist prior to medical school so I love this stuff, all those little cytokines, they have little personalities in my crazy brain. So I was trying to make it approachable for clinicians to really break down and understand that complex immunopathophysiology, and there's initiation, amplification, recruitment damage, and self-perpetuation, and it's just on this vicious circle that continues unless you intervene with your immunomodulators. So I used it as a construct, and I still use it in my lectures as a way of easily understanding that complex pathophysiology in an approachable, clinically organizable way.

Additionally, we have some things on the horizon, hopefully in 2025. We are expecting the approval of several new medications, one of which absorbs aldehyde species. It's called 'rasp' or 'rasp inhibitor' [reactive aldehyde species (RASP)] and that has the potential to be very adjunctive and synergistic with all of our other things that we're offering our dry disease patients. So we're really excited about that. Really excited about understanding the neural component, the neurosensory component of dry eye disease—it's part of the definition—in more intimate ways. We have neural stimulation, but now we're going to be able to tap into neural stimulation using a new class of molecules called TRP: transient receptor potential molecules. There's a huge, huge class of super receptors across all mammalian species. Even nematodes have it; they're nonmammalian, but it's like super well conserved. There's one called M8, which detects cold and the new medication, a cultured one doesn't have a trade name yet, stimulates that receptor directly to directly stimulate tear production using chemo receptors. So cool. So interesting. So the story about immunopathophysiology is expanding in three dimensions. As we gain more understanding about what these things are, it helps us understand our patients even better and know where to plug and play all of these different interventions,

Stevenson: Is there anything that you'd like to see evolve further in research?

Periman: Yes, I think there's some huge unmet need when it comes to neuropathic pain. Neuropathic pain can occur with severe, chronic dry eye disease after ophthalmic surgeries, excess contact lens wear, too much screen time. So I'd love to see more developments in that category, because those patients are really suffering, and I would love to be able to offer them more.

Stevenson: How does education inspire you?

Periman: I love education! Perhaps there's a bit of a selfish component, because I get to learn too, like none of us are masters of all of these things. It's the constant discussion with other colleagues and their clinical experience and what they're trying, what they're using. That constant learning is what keeps it fresh and fun for me. Even being in clinic on any given day, I'm constantly learning from my patients. I love being able to share that with my colleagues. I love learning from my colleagues, so it becomes a I call it circle of good, where good begets good when it comes to education. So it's a necessary thing.

And in addition to that, I think being an eye doctor, whether you're an optometrist or an ophthalmologist or a resident or a fellow, can be a bit lonely, and to know that there's other doctors that sometimes have the same questions as you, and having an opportunity to ask them, I think, is very empowering and confidence-building for our colleagues.

Stevenson: Can you highlight some specific opportunities or benefits at EyeCon that it offers to residents that they might not find at any other conference?

Periman: Oh, that's a great question! So EyeCon is going to give you a very high-quality education with references, and these are things that you're going to implement in your career as a resident/fellow, but as well as an early clinician as you get out of training. So I think that to the level of education and the practicality in which it is presented will help connect the dots in our colleagues' brains and become part of your knowledge base. It'll be something that you can absorb and learn and make it yours.

Stevenson: Is there anything particularly at EyeCon for you that you're really excited about?

Periman: Well, I always like connecting with new people. It doesn't hurt that we're in Fort Lauderdale. I can't wait to get my toes into the water and feel the sand beneath my toes, so I'm looking forward to that as well. The environment, the setting, the thoughtfulness with which this meeting has been set up, the agenda—these are all things that I'm excited about, and I can't wait to share it with everyone that's going to be there.

Stevenson: When you're not busy at EyeCon, you mention Fort Lauderdale, what local spots are you interested in discovering or rediscovering or visiting while you're there?

Periman: Anything where it's warm! One of my pet peeves is an overaggressive air conditioner, like I'm going there to be warm. We get shortchanged here in Seattle with our summers. It's so short and so fleeting; it's already gone. So I'm looking for a last blast of summer, warm my bones, because winter's coming. I'll see you there!