Podcast: Modern approaches for the optimal treatment of dry eye disease (Part 1)

Editor’s note: This transcript has been edited for clarity.

Bill B. Trattler, MD: Hi, and welcome to this Ophthalmology Times Viewpoints titled, Modern Approaches for Optimal Management of Dry Eye Disease. I'm Bill Trattler. I'm a refractive, corneal, and cataract surgeon at the Center for Excellence in Eye Care in Miami, Florida. I'm very lucky to be joined with three outstanding experts in dry eye. These are just rock stars in dry eye. I'm excited I get to learn so much from each of them. And let's start off with that. Dr Brimer, if you could introduce yourself and share your love for dry eye.

Crystal Brimer, OD: I do have a love for dry eye, Bill. I'm Crystal Brimer, I'm in Wilmington, North Carolina. I have a solo, private practice. It's a referral center and we only treat ocular surface disease every day, 100% of the time. I also have [the] Dry Eye Institute where we focus on the training other doctors and just equipping them to get better outcomes and trying to inspire them along the way.

Bill B. Trattler, MD: I love it. That's wonderful. Thank you so much. Thank you for being with us. Next, I have Dr Matossian. If you could introduce yourself and share your love, because I know you love dry eye; I've spent a lot of time with you. Thank you.

Cynthia Matossian, MD, FACS: I am passionate about dry eye as well. Thank you very much for inviting me to this program. I'm Cynthia Matossian. I'm the founder and past medical director of the Matossian Eye Associates. Matossian Eye is an integrated ophthalmology/optometry practice with all the different subspecialties. My area of sub specialization was refractive cataract surgery and of course, dry eye. I'm delighted to be here with all of you.

Bill B. Trattler, MD: Wonderful. Then last but certainly not least, Dr Nichols. You're passionate about dry eye. I've had a chance to work together many, many times. So, thank you for introducing yourself.

Kelly K. Nichols, OD, MPH, PhD: Thank you for allowing me to be with everyone here this evening. This is such a treat and especially to have a wonderful audience, as well. I am passionate about dry eye, always have been since before it was probably cool to like dry eye. I'm currently the dean of the University of Alabama at Birmingham School of Optometry and I've been involved in dry clinical research and translational research, as well as seeing patients for too many years that I care to say. So, it's nice to be where we are today, having this in-depth discussion about what's going on in dry eye.

Bill B. Trattler, MD: Thank you so much, Dr Nichols. I guess just to give you a quick overview; I'm super excited to be here. We're going to talk about a variety different topics on dry disease. We're going to talk about how we all diagnose dry eye, because there are all different strategies you can have, and some of the current emerging treatment options, because there are so many new things that just become approved and are about to become approved. We will also discuss other strategies, [like] how to handle the more challenging patients. I'm really excited to get started with each of you. I guess we'll start with the basics, which is, Dr. Brimer, how common do you see dry eye? Well, this is a bad question because I know you're 100% dry eye, but I guess how common is dry in general, then? And who's at increased risk for dry eye?

Crystal Brimer, OD: Well, I think if we go back 30 years, people would label it as a woman's disease because we tied it so closely with hormonal change. And yeah, that's still happening. But it seems like such a fraction now of what I see because there's nobody that's not at risk for it. I think it's almost appropriate to reverse that question, because you think about [it], our diets are completely different than they were 30 years ago. We've got more systemic disease; we have more side effects from medications. Then the biggest one, we've got way more device use than was even dreamed about 30 years ago. And you couple that with the changing of times where you've got these young kids who are growing up and basically being babysat by an iPad, which I understand. I don't have kids, but I think I can understand. But what's that going to look like in the future? It's going to be the opposite. It's going to be who is not at risk for dry.

Bill B. Trattler, MD: That's a great thought. I just love how you frame that. I don't know if maybe Dr Matossian wanted to share similar thoughts, and then we'll ask Dr Nichols as well, but Dr Matossian?

Cynthia Matossian, MD, FACS: That was a great description, Crystal, and that's how I used to approach my presurgical patients. Anybody who came in for a cataract consult, for example, I had to rule out dry eye disease before or concomitantly with evaluating their cataracts, because from your study, Bill, it showed what a high percentage of people who had never been diagnosed with dry eye were scheduled for their cataract surgery. So, like you, Crystal, I mean, we really have to almost rule out who doesn't have dry eye if such a thing exists.

Bill B. Trattler, MD: I love that. Dr. Nichols?

Kelly K. Nichols, OD, MPH, PhD: Right. I completely agree. There are so many associated factors with dry eye these days that almost everybody has one of them. It's just a matter of if they are compounding with one another and it's starting to impact the patient, and if we're asking the right questions to be able to detect it. So, I agree. It's almost like you consider everyone has dry eye until you rule it out these days.

Bill B. Trattler, MD: Dr. Nichols, that's perfect. Thank you so much. That leads us into the next very important question, which I'm actually going to turn right back to you, Dr. Nichols. Why is it important for us to recognize and treat dry eye for all of our patients?

Kelly K. Nichols, OD, MPH, PhD: I think I'll step back into the discussion a bit about how everybody [is] glued to some sort of screen or device or maybe more than one at the same time. And certainly, if you have any irritation, if you feel your eyes, you have dry eye, then that can impact your ability to be able to do your work or your activities, especially on that screen or towards the end of the day. So, I think that we're learning a lot more about the impact of dry eye on the ability to be able to work, the ability to be present at work and with dry eye and even time off from work due to dry eye and all those things. There's been research in those areas over the last several years and it's not surprising, you know, that patients are very impacted in their activities, it even can be reading, driving and other things. So, when we stop to think about who is impacted and how, you know, we might be able to help that, whether they're going on to surgery or they're having trouble functioning in their day-to-day activities, I think it's really important to be able to recognize dry eye. So, we should be asking questions all of our patients, regardless of what kind of exam it is, to try and determine if we can help them have a better outcome.

Bill B. Trattler, MD: I love that. Dr. Brimer, any additional thoughts? That was really comprehensive.

Crystal Brimer, OD: What I would say is, in being that referral center, I see the difference that it makes in their final outcome, whether we were able to implement treatment at year one versus two, two versus three, and three versus four; it's a significant difference. I mean, just today, seeing a patient with almost no glands and all she can think about is, "this could have been prevented." And so, everything that inside of me just points to the overall outcome and quality of life of this person ten, 15 years down the road, depends on when we intervene.

Bill B. Trattler, MD: I love that. Dr Matossian, you always [have] so many good thoughts. As you all know, Dr Matossian and I go to a lot of conferences together. How do you kind of approach these patients and why do you feel it's so important to address these patients with dry eye?

Cynthia Matossian, MD, FACS: You know, dry eye disease is chronic and progressive, and think of it as chronic pain. Obviously, not all dry eye patients have severe pain or moderate pain, but some do. And when somebody is in constant pain, they are grumpy and their mood swings all over the place. They snap back at their colleagues or spouses or family members, and there is depression associated with it. This is real. Studies have proven this. Therefore, just like Crystal said and like Kelly emphasized, identifying patients with dry eye disease, intervening early, and treating them as comprehensively as possible, we truly change the quality of the life of these patients, and that is a gift that many doctors have.

Bill B. Trattler, MD: Let's just talk just a little bit more in-depth about how dry eye affects coexisting ocular conditions, or focusing on accurate conditions, like how does it make you approach the patients with other ocular conditions, and how does dry eye impact that?

Cynthia Matossian, MD, FACS: I'm so glad you asked that question, Bill, because so many of us are siloed into our own subspecialties. Let's take right now, for example. You know, these doctors see day in, day out, people who are losing vision, going blind, let's say, from AMD. Geographic AMD or, you know, neovascular AMD. They're getting injections, you know, every so many weeks apart. And their fear is, can I maintain the patient's vision? But these patients are also suffering, many of them, from dry eye disease. All the prep, all the anesthetic, the gels, et cetera, are really wreaking havoc on their surfaces. So that's just an example where coexisting diseases does not mean that we as ophthalmologists and optometrists can only focus on our little niche area. We truly have to look at the surface. Same with those who wear contact lenses. You know, their surface may be getting pummeled by over wear of contact lenses, sleeping in contact lenses, maybe extending the wear when they shouldn't be to save money, or with people who, for example, have glaucoma. We are requesting our patients to be compliant with their [medications]. Most of the glaucoma drops have what in them? Preservatives. So, we're not just glaucoma specialists. We also have to be surface specialists.

Bill B. Trattler, MD: You nailed a couple of great areas. I agree. I'm going to take a multi-specialty practice with each of those specialists. And I realize we need to continue to train everybody to manage dry eye, not just those that love dry eye. So, everyone needs to be able to handle those patients generally. Maybe Dr. Nichols next, any additional thoughts? I guess you see so many patients with dry eye in your practice. So, I'm just curious your thoughts on how dry impacts coexisting ocular condition.

Kelly K. Nichols, OD, MPH, PhD: I'll just say, just to piggyback on Cynthia, when people are so siloed into their particular areas, and of course they're usually really good at those particular areas, it's really hard to then like take a step back and maybe think about the ocular surface. And that's where a really good partnership comes in, whether it be somebody in the practice whose sole job is to be doing ocular surface or the referral down the street. I think it's recognizing and having that good network to be able to, then take care of that patient. If you want to focus on that specialty and don't want to, we'll just say, be bothered by the ocular surface part which somebody else probably really loves. So, I think it's a matter of finding the people who are going to be part of your network so that the patients can get that care and it really will result in a better outcome all the way around for all the subspecialties, if that's done.

Bill B. Trattler, MD: Oh beautiful, great. So many great points. Completely agree. Dr Brimer, your thoughts?

Crystal Brimer, OD: Well, not only do I agree, but I would reinforce that by saying, my number one referral source is the two glaucoma specialists in town, the three retinal specialists, the neuropathologist and the corneal specialist, because they're getting the referrals for dry eye. But it's not really what they want to do either. But definitely the retina and the glaucoma, because it's either coexisting or they're creating it with the side effects from the medications. So, it's evident every day.

Bill B. Trattler, MD: Perfect, I totally agree. I guess I'm somewhat like you, actually all three of us, because in my practice I have multiple specialists. So, I'm getting the referrals from everybody in the group. Thankfully, [and] we'll talk about these new medications coming up, I think all these new medications continue to help us take even better care of our patients. So, this is an interesting question. And I would say controversial, but I say that just that different people have different feelings on this. Dr. Brimer, what are your thoughts about requiring a dry eye questionnaire for all your patients that we're concerned about dry eye? Do you think it's required, what do you do in your practice, [and] can we get by and maybe skip that?

Crystal Brimer, OD: No, you can't skip a screening. Maybe it's not a questionnaire. So, it's interesting that you ask me this question, because when you say it's controversial, I'm probably going to give the opposite answer of what everybody else in a lineup would give. When I'm talking to other doctors, I want them to visualize two different scenarios. One is, okay, we gave them a questionnaire. That was great. We had a screener, and I applaud you for doing a questionnaire versus nothing. Right? It's something. So that's step one if you're doing nothing. Yeah, pull the questionnaire out. Let's do it. Because it at least it presents itself. But imagine this patient does the questionnaire and then you get them in the exam room and you say, "Oh, yeah, I see this, this is bad, and I'm going to need you to do A, B, C, and D, and it's going to take an hour or two at night, but it'll be fine and it's going to cost you about $2,000 out-of-pocket. But listen, this is what we need to do." You know, they're either going to look at you and say, "yeah, it's not that bad," or maybe they do something, but then as soon as they feel better, they stop because they believe that everything you requested them to do was based on subjective inputs. And that's what I don't want. So, while I appreciate using a questionnaire and I think it's better than nothing and it's good in a really busy practice that's just trying to bring the complaints to the surface, when you're really digging for it, I don't think it's enough because I want it to be based on objective findings. So, what we used, and we started this way back in probably 2015/2016 when we first got the oculus keratograph, but especially when the software got redesigned. We use that screener, and it's your tear meniscus height, interferometry or break up time, and redness score. So, for me, it gives me a snapshot of water, oil and inflammation. The patient gets a report, is completely objective and it just brings it to light and says, you know what, you may have symptoms, you may not, but this is progressive. And to me, that also plants a seed so that if they don't have symptoms and they don't come back for eval, they're wearing their contacts, at some point in the year they get uncomfortable, it's in the back of their mind that, "all right, let me go back and take another look." So that's my take.

Bill B. Trattler, MD: I love it. Now, that's such a great way of framing it. And also, you know, having objective technology like a keratography device that can actually give you lots of objective measurements and can really help us understand where a patient's level of dry eye is. That's fantastic that you have to have your practice. Let me ask Dr. Matossian your thoughts on questionnaires, how you view them, and maybe thoughts on Dr. Brimer's thoughts as well.

Cynthia Matossian, MD, FACS: I really liked how you framed that answer, Crystal. A lot of practitioner’s view questionnaires or surveys as a nuisance. It takes too long. It jams up the pass through or the throughput of the patients. It leads to confusion and so forth. What we were trying to do, at Matossian Eye, is do it virtually, send a survey to the patient prior to the office appointment. This way the patient, in the comfort of their home, leisurely can answer the question, and the responses were getting integrated into the EMR. This way the patient at least started to think about their environment, [ fans or, you know, whatever it might be. Fatty acids, you know, omega threes, their diet, things that they may not be able to connect the dots [on] because they don't have that background like we do. So at least it helped the patient understand that perhaps something is going on. So therefore, when the objective testing was done in the office, then all of it kind of merged together and the patient was able to better understand their diagnosis.

Bill B. Trattler, MD: I like that. Thank you. That really makes a lot of sense, [and] obviously sounds like a very good strategy. Dr. Nichols, what are your thoughts on this topic?

Kelly K. Nichols, OD, MPH, PhD: So, we do, in our setting, a little bit more survey driven work just because we're screening for a lot of dry clinical trials and there's usually a symptom cut point to get in. We want an idea whether or not they might qualify. So, we do some surveys for that purpose, but signs and symptoms don't correlate very well with one another. We all know that, and that's persisted over time. And so, a set survey doesn't really give that tailored information that you need to find out by just asking questions along with your objective tests. So, I'm imagining, Crystal, that while you're doing some of those tests, you're asking additional questions and getting additional information that's very tailored to the individual who's with you at the time. So, you know, it does provide some information as a way in the door or for a clinical trial to find out if somebody might qualify. But it's not the only thing, certainly, that you should do by any stretch.

Bill B. Trattler, MD: No, this is great. We each have some different approaches. I'll share [my approach] in my practice. I'm [not aware] in our ractice of using a questionnaire, but we do ask specific questions to patients. You know, certainly for me what I think is important is to ask different questions. And of course, I involve objective tests, as well. So, with that in mind, I'd love to hear how everyone would diagnose dry eye, what objective tests everyone's using. So, let's go with Dr Matossian first. What tests do you feel are the most helpful for you to objectively diagnose dry eye?

Cynthia Matossian, MD, FACS: I think if you were to ask a room full of dry eye specialists what diagnostic tests they would do, each one would come up with a different kind of list. What they would do first and what they would do to follow up to see whether the treatment is effective. At Matossian Eye, what we used to do were three things. One was meibography. Everybody got meibography because to me it's like the X-ray of the lungs. When somebody shows up with a cough, I needed to see the images of the meibomian glands. You know, their health, their structure, their architecture, where they dropped out and so forth. The second one was tear osmolarity (TO), because that helped me understand kind of the surface evaporative state, how disrupted or dysregulated the tear film was. And lastly, everybody got an MMP-9 test so that I could see whether there was inflammation. According to the results, my treatment algorithm varied, and I could titrate my treatment to whether the MMP-9 was positive or negative, whether the TO was significantly abnormal or not, et cetera

Bill B. Trattler, MD: I assume you did other tests; did you do Schirmer's test, break up time, staining? I just want to get a just a good sense of what you do besides those three diagnostic tests.

Cynthia Matossian, MD, FACS: We didn't do Schirmer's [test]. They took a long time. There was reflex tearing involved. I just, you know, I thought it was a bit too subjective. I didn't do that. But of course, [with] staining, I always do is lissamine green 100% of the time to look at the conjunctival staining, which told me a very different story than fluorescein staining on the cornea. I did both. I looked at tear meniscus height and commented on that. Of course, I looked at the lid margins and the orifices of the meibomian glands, whether they were powded or inspissated. And [I] kind of pressed on the eyelid with just a Q-Tip to see the quality and the consistency viscosity of the meibo, and of course a good slit lamp exam period.

Bill B. Trattler, MD: That's really helpful. Let's hear from Dr. Nichols and then we'll actually go through all of them, and we'll talk a little bit more. But, Dr. Nichols, tell me your approach.

Kelly K. Nichols, OD, MPH, PhD: So, I think it depends on if we're targeting somebody who hasn't done any dry eye before in terms of the recommendations, I think that what we're going to hear is what I would say is like the nirvana of a dry eye practice from our panelists here today. And so, if the goal is to try and get somebody who hasn't done any of it before, you know, the most simple approach would be some sort of assessment of symptoms, verbally usually, and then an evaluation of either staining or osmolarity or tearful breakup time. And if any one of those three is abnormal with some sort of symptomatology, which I think you can get from most anybody, then that would be a positive screening for dry eye. That was recommended by the DEWS 2 work group as the most simple, basic entry into dry eye as a screener. And then if you have the ability to do additional testing, like you have meibography, you can use that to evaluate the meibomian glands, but the simple slit lamp exam and pressing on the eyelids, of course, that is something that anybody could do in the context of their office. As well as look at the tear meniscus height as a surrogate for Schirmer because who's really going to go do a Schirmer's test in practice? So, you can kind of hit all the different areas in a simple way if you don't have that fancy equipment, which we all love, and then either refer to somebody who does, like Crystal or Cynthia or you, Bill, and so that they can have a more detailed workup. So, I think that's really two approaches for those who are just starting out. You have a great instrument in the slit lamp, and you can do a lot with it. And a thorough lit exam is really critical

Bill B. Trattler, MD: Great comments, that's fantastic. Dr Brimer

Crystal Brimer, OD: I completely agree. Kelly brought up a good point of sometimes we get so involved and here's the 100 things that we do because we love it, right? It is our passion. And I want to know. I can't stop myself most of the time, to be quite frank. But you make a good point. And one thing I would add to that, for somebody who doesn't have a meibographer, transilluminate, pull the lid down and look. It doesn't excuse you to not know what's going on with the glands, because in some people you can see it with just white light. If you can't, then turn this slit lamp off, put the transilluminator under that lower lid and fold it over, and you can get a decent idea of, is there truncation, is there drop out? What I would add to the list of tests that were initially listed by Dr. Matossian is, I do a cotton whisk test on every dry eye eval, and I do debridement because I want to see where any tear film debris is coming from. Is it biofilm on the lid margin? Is it poor quality meibomian that's coming out? Is it allergic mucus? What is it? And then, I use meibomian expression paddles. And I feel like that gives me the most production without a lot of discomfort at all. I go through the whole gamut of test. One that's valuable as a patient education tool is the tear film dynamic, which is basically just a video showing how much debris is in the film. That tends to get quite a response from them, and it makes them a little bit more motivated to do something. And it helps them understand why the eyes read when we have all these contaminants in there.

Bill B. Trattler, MD: Perfect. Everyone has [shared] so many great tests that can be done. I guess we put a list together. There's so many different choices that anyone doctor can do and as Dr Nichols shared, a lot of times it's something more focused. You don't need to do everything on every patient, unless you're in a totally dry center as a patient that has failed therapy elsewhere. One thing I didn't hear from anybody is pulling eyelashes for mites. Does anyone tell you eyelashes for mites? Is that important, if you see scurf and blepharitis, are you treating as if they have mites. Just curious as that's a hot topic.

Cynthia Matossian, MD, FACS: I don't pull lashes. I have the patients look down. And when you see the collarettes at the base of their lash follicle, that's almost pathognomonic for demodex blepharitis. So, I don't have to pull. I don't have a big microscope to look under to see the live mites. But looking for collarettes is really important.

Bill B. Trattler, MD: I agree. Dr. Nichols, Dr. Brimer, are you guys pulling lashes or just kind of following Dr. Matossian's plan.

Crystal Brimer, OD: I just look for the collarettes and then call it like I see it.

Kelly K. Nichols, OD, MPH, PhD Agreed.

Bill B. Trattler, MD: Perfect. That's me too. I just want to make sure I'm on the right track there. Again, just going back because I think is one of the most challenging parts, because you know, we have our listeners, our viewers, watching us and we were listing all these tests, it can be overwhelming. I'll just share that, in my typical practice, a lot of patients are coming in with specific problems [and] they're not even mentioning dry eye; your cataract evaluation patients coming in for their annual exam, their diabetic retinopathy, and they need a screening. You know, for those patients, it's much more simple. I just typically would put some fluorescein looking [at] tear breakup time and if there's corneal staining. The tear film volume, for me, is also important. Those were the two tests, beside symptoms; it's kind of what I'm doing a typical non-dry eye patient just to make sure I'm not missing dry eye that should be evaluated or should be treated. But this is really helpful because I know making the diagnosis is just part of it. Then we have to figure out how to treat these patients. Any other comments? Dr. Brimer, I know you're always excited about dry eye, did you want to make another comment? If you want to make it, go ahead.

Crystal Brimer, OD: So just like what Kelly said. All right, we've got a slit lamp, and a good slit lamp exam goes a long, long way. But if the patient can't see what you see, does it? So, you don't necessarily need the fanciest equipment out there. But I do feel like, to convert that patient to get them, to come back for an eval, or to get to ask them to do a treatment, it's a lot easier to show them a video, to show them that magnified lid margin where the collarette is there, and get a response, then it is just to talk about it. So, if you're out there and you're struggling with compliance and you're struggling with patient buy-in, I believe it's because your diagnostic tool, your way of showing them, may be lacking.