Episode Transcript
[00:00:00] Speaker A: Welcome to the Dry Eye 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 podcasts 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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[00:00:53] Speaker A: In today's episode, we are crossing the border and interviewing our good friend and my classmate Maria Madan, OD from Vancouver Eye Doctor in Vancouver, BC, to share with us her perspectives and experiences with treating and managing dry eye up north. Welcome, friends.
[00:01:13] Speaker C: Yeah, thank you so much for having me on the. On the show today. I love that we're all pacific grads and not a biased opinion at all, but I think, like, really smart people come out of Pacific, you guys think go boxers.
[00:01:29] Speaker A: Before we get started, please tell us a little bit more about your practice and how you come to have this love of dry eye.
[00:01:38] Speaker C: Yeah, absolutely. So I went to school with, you know, at Pacific. I'm originally from Vancouver, Canada.
And then after finishing my optometry degree at Pacific, I moved to Minnesota with my husband and actually practiced there for a couple of years at a really great private practice and then kind of decided, hey, I'm missing something. I really kind of want to learn a little bit more about disease, or I want to focus on something a little bit different in my career. And so I decided to actually go back to school and do a residency.
And, yeah, so I'd already been practicing for a couple of years, and, you know, sometimes it's not an easy choice to make once you've already been out in practice. But that was a decision I really felt like I had to do for myself. And so I went back into the pool and I matched in Houston, Texas, and so kind of left my husband, who was in Minnesota. He was going to school there. And then I packed my car and moved all the way across country to Houston and then did a residency there, which really, really inspired me in the way that I now practice. And, you know, when you talk about treating dry eye and how did I get into the space? And I really feel like, you know, that was a foundational year for me where I just learned so much at the eye care center in Houston, Texas, where I did this residency with ophthalmology and optometry and just really opened up my eyes to the way I want to have a career and shape my career. And then I went back to Minnesota again, practiced there for a few more years, and then moved back to Canada eventually, once we had our first kid who's american, and he always reminds us that he's american and we're all canadian.
[00:03:18] Speaker D: Well, wait a second. I'm thinking out loud now.
You went to eye center of Texas, and you were supposed to come to eye care associates of Nevada. Now that I think right here now.
[00:03:33] Speaker C: Yeah. So that was a really fabulous experience. And then being back in Canada, you know, I feel like I have one of those, and I love this episode that we're doing because I feel like I have one of those unique perspectives where I got to practice in the United States for, you know, almost ten years before moving back to Canada. Now I've been practicing here for ten years here. I'm in an ophthalmology practice as well, working. You know, I focus on dry eye and glaucoma management in my practice. This is also very unique for, at least for British Columbia and this province, for ophthalmology and optometry to be working together in a capacity that I am. Yeah. Because when I came from the states, I mean, that was really, really common, especially in Minnesota with Minnesota eye consultants, and in Texas, like you mentioned, with Jeff Auto and all these other wonderful practices with integrated ophthalmology and optometry practices where they really kind of see that. But that's not something that's very common in British Columbia at all. So I'm loving the way I'm practicing. It is a full scope medical practice.
And then I also have an optometry practice as well, where I do split some of the time and then see some primary care patients, and it's really provided a really great balance for me.
[00:04:46] Speaker D: So you mentioned full scope because the scope here in the states is all over the place and everyone's trying to advance the scope. So what is that scope right now?
[00:04:57] Speaker C: Yeah, that's a really good question. And so when I say full scope, what I mean is practicing to the full scope of what my province allows here. Right. And it is very different here in Canada versus in the United States. And, you know, we're kind of all over the map in Canada as well, with different scopes in different provinces in British Columbia, optometrists are able to manage eye diseases and dry eye glaucoma with eye drops. We actually cannot prescribe orals here in BC and in Vancouver, so that's a bit limiting. Now, across Canada and other provinces, there are. You know, most of the provinces actually can prescribe orals as well.
None of our provinces have lasers and advanced procedures like they do in the United States. Right. So we just heard that Colorado got some scope expansion and then some of the other Virginia.
That's right.
So, no, that's not something that we have in Canada right now. But, you know, I currently, this year, I'm also serving as president for BC doctors of optometry.
[00:06:09] Speaker A: Congratulations.
[00:06:10] Speaker C: Thank you. So I'm super honored to be in that role. And, you know, of course, protecting optometry and then moving the scope. Moving the scope needle in the right direction.
[00:06:21] Speaker D: You mentioned integrated care with ophthalmology and optometry, and so do you see a lot of the surgeons wanting to do dry eye? I know there's surgeons that love dry eye, but what are you seeing in your practice? Are they referring those to you and to the optometrist, or are they managing it themselves?
[00:06:38] Speaker C: Yeah. No, in Vancouver, I do find that the surgeons are more interested in doing surgery, whether it's glaucoma or cataract or retina. And then the dryden is more of a condition where optometrists are much more involved in taking care of it. And I think one of the reasons for that also is that we're in a socialized medicine kind of a system, where ophthalmology billings are a little bit different.
Some of the treatments that have come out with dry eye to be really innovative and to really help these patients, we can offer in office treatments. And that's something, you know, perhaps with the medical system hasn't quite caught up to cover. So where optometrists are in a unique position in Vancouver and in Canada, where we can, you know, go through insurances or go through the private billing versus ophthalmologists are limited to billing through the public health system.
[00:07:36] Speaker A: That's definitely different than what we have here. So what technologies are you using in your practice for dry eye? So I get a lot of questions from a lot of canadian doctors that are interested in doing some of the advanced technologies that Walt and I do.
Which ones can you do and where you're at?
[00:07:56] Speaker C: Yeah, we're super fortunate here. So we have an IPL in our practice, intense pulse life therapy. We have radio frequency in our practice, we've got the whole gamut of micro blepharo exfoliation type devices in our practice, and we can do that in my practice. We're a little bit unique, and we also do autologous, platelet rich plasma eyedrops, and we've got a phlebologist that we work with. So that's something we're able to offer within our practice. Yeah. So in terms of technologies, I would say, yeah, yeah, I think we're pretty stacked up. How about you in the United States?
Are you finding that there's more over there that you're utilizing?
[00:08:36] Speaker A: It sounds like you have the same capabilities that we do, at least where I'm practicing in Oregon, but it does vary from state to state. I would say that. But right now, most states, with a few exceptions, have the ability to do most advanced dry therapies, which is good, but it's at least in BC, that's a possibility for future practicing optometrists.
[00:08:56] Speaker C: We have access to amniotic membranes as well. They are a little bit different here versus in the United States. We don't currently get Prokera here.
We have more of the dehydrated membranes to work with, and there's different companies.
So the logistics of it and cost of it can be a little bit different versus in the United States, but we definitely have access to all that stuff, which is really fantastic.
[00:09:21] Speaker A: Okay, so not crowd preserved, but you can get the dehydrated version.
[00:09:25] Speaker C: Yeah, that's good.
[00:09:26] Speaker A: That is the difference. Thanks for that. Thanks. Letting our listeners know that that's good.
[00:09:30] Speaker D: So, as we're talking about amniotic membranes and the dehydrated ones, what about topical biologics? Do you have more access to different ones than we do? Because we have the regenerize is available. There's regenerized lights. There's another company that was just, someone just told me about the other day. Do you have several companies like that that have those topical biologics?
[00:09:53] Speaker C: No. So that is an area that we are definitely lacking here, at least in BC, that we don't have access to. Regenerize. Patients can order regenerized through, like, going through the company itself, but ods are not able to stock it at their clinics and have access to it through that way.
[00:10:14] Speaker A: But you're one of the innovators and. And the kind of the lead people in your area on working with platelet rich plasma, correct?
[00:10:23] Speaker C: Yes. Yes.
[00:10:24] Speaker A: So that's super exciting, because that is. That is, you know, an autologous biological type eyedrop which I think is great that you're doing a lot of education and talking about that. Right.
[00:10:34] Speaker C: Yeah. And it's been so fascinating working in that area of eye care as well. Right. The regenerative medicine and seeing the capacities of it, but having it so close to you where you can vary things and see the results of how these things are behaving on the eye. And so that's been really fascinating. But I would love to see, I mean, with every technology there are great things about it and then there's limitations about it. Right. There are some patients that don't love having their blood draw every three or four months or, you know, perhaps it's not so convenient. You have to put everything in the fridge or the way, you know, these things are used. So it'd be nice to have some drops that are of that natural origin. Right. Like regenerize or other companies coming into Canada. So that is a little bit limiting for sure for us here.
[00:11:20] Speaker A: Right. So most biologics do have to be refrigerated. So thanks for bringing that up. So if it's a true biological eyedrop, that's a high quality, should definitely de refrigerated because that is a biological material. So thanks for bringing that up because some of my patients who are getting, aren't aware that that's one of the capabilities that you have to have is refrigeration.
[00:11:39] Speaker C: Yeah.
[00:11:41] Speaker A: So did you say that you didn't have that oral sometimes can be a little bit tricky. Is that right? So if you wanted to prescribe like an oral antibiotic or doxycycline, are you co managing for that currently?
[00:11:53] Speaker C: Yeah, absolutely. So if I had a wish list, I really wish that we could prescribe orals here in BC, right. To be able to manage our patients with rai eye, with oral medications like doxycycline or even for herpetic patients to be able to treat them.
And there's urgency for those patients. We want to get them on these antivirals as quickly as possible. Right now, we do have to work with our GP colleagues to be able to get these medications. It just sounds like extra work, do you know what I mean? And our GP colleagues are working really hard too, to meet the demands of post Covid. I feel like things are really busy everywhere and so it's a burden that I wish we could offload from them and say, hey, we're here to help and be kind of those primary care for the eye and kind of take care of all of those things.
[00:12:46] Speaker D: Hey, let's talk about some of the dry eye products and medications that are available there in Canada that aren't here. Trehalose, that's something that we're seeing in some products here right now, as well as ha, hyaluronic acid. And so here, that's always got to be an inactive ingredient.
What are some of your go tos up north there?
[00:13:09] Speaker C: You know, that's really interesting because we have had trellos and hyaluronic for, I feel like, a little longer time than probably in the United States. Right. I feel like I've been using those drops for at least the last, like, four or five years, you know, very easily. And things that we've been seeing in our clinics that the doctors are able to stock. Yeah. And so some of my tree lose type products are to do with laptitian. Right. Laptitian, Thea, is a big company here in Canada.
And then also candor vision. And so they've got some really fantastic drops, over the counter drops that we're able to utilize with those key ingredients here in Canada. Now, we don't have some of the prescription medications that I wish that you guys have in the United States, and patients are always asking about it. I mean, if this is not a dry eye product, but beauty to see up close, I mean, I can't tell you how many patients ask me about it, and I'm like, no, not in Canada.
[00:14:06] Speaker D: No.
[00:14:07] Speaker C: Sorry, guys, we don't have it.
[00:14:09] Speaker A: Are you able to get the other topical, chronic anti inflammatory versions of eye drops, things like cyclosporine and lefidographs? Do you have those there?
[00:14:18] Speaker C: Yes, we do have cyclosporine. We do have zidra. And this year, earlier this year, we got cequa from Sun Pharmaceutical. That's huge. We do have generic restasis, which we actually got earlier than the United States did. So we've had it for the last three, four years here in Canada.
We don't have the nasal spray for dry eye. I think it's called trivia. Right?
Yeah. And that would be really interesting to have that in our toolbox here in Canada, but we don't have that. And interesting.
[00:14:51] Speaker A: Do you have any neuro stimulation devices approved or nothing just yet? Okay, that's up and needs to be up and coming. Yeah.
[00:15:00] Speaker C: Yeah. And interestingly enough, we also don't have azocyte.
And I know that's been around in the US for a long time because when I used to practice there, you know, that was a medication that we used even back then. So, no, we don't have it, but.
[00:15:16] Speaker A: You do have some things that we don't get, which is the awesome active ingredients in your artificial tears. Are there any other pharmaceuticals that you have for dry that we don't get in the United States, or is that pretty much run the gamut?
[00:15:27] Speaker C: I think, yeah, I think no. I can't think of anything else that in terms of pharmaceuticals that you guys don't have in the US and we have here, the other challenge I do find is compounding things can be a little bit challenging here as well, versus when I practiced in the United States, that was something a little bit more accessible.
[00:15:48] Speaker D: Yeah, that's what I was going to ask. I mean, we use a lot of preservative free dexamethasone and we work with compounding pharmacies. So a little bit tougher up there to get those, huh?
[00:15:57] Speaker C: Yeah. Yeah, we do have a preservative free pred forte here in Canada, but yeah, you're right. So compounding can definitely be a bit of a challenge here.
[00:16:08] Speaker D: So is generic restasis a dollar cheaper than brand restasis up there?
[00:16:15] Speaker C: I want to say it's considerably cheaper, but I don't know for sure.
[00:16:21] Speaker D: You don't have to say the cost. I was just kidding. You know, we've had some patients and I haven't seen many patients back with the generic cyclosporine right now. I know some have gotten in for like $10 and others said it was like a dollar cheaper than the brand. So it was, I was more joking. But we're still trying to figure out where it's going to fit into our momentum because, you know, especially down here we have the various insurance carriers and they're going to, it's going to be step therapy. You got to go through this first before you can prescribe this brand or this brand or whatever brand it is.
[00:16:51] Speaker C: Yeah, you're absolutely right. It's trying to figure out where this all fits in. Right.
And what do we see in our patients, for sure? Yeah.
[00:17:00] Speaker A: So as far as coverage goes, do you get to pick for everybody what you want them to have, or is there a stepwise approach like we just described here in the United States?
[00:17:09] Speaker C: I think from what I kind of understand the system to be a little bit, I feel like we are a bit fortunate we don't have as many insurance kind of barriers to work with. And in terms of even the way we practice, we don't have to go through insurances a whole lot to build things. I remember a lot of resources being spent when I was in the United States, you know, trying to figure out what insurances cover, what they don't cover, and that being a major challenge. No, that's not something that we, you know, that we kind of face with in our practice. I do generally prescribe what I think is best for the patient. And sometimes they might come back and say, hey, my insurance doesn't cover this. Would you consider an alternative? But I would say on the, you know, on the majority, and I feel, you know, fortunate that patients are like, yep, no, I'm. I'm happy with this. I can go along with this.
[00:18:01] Speaker A: Well, I mean, what's great is it does sound like you are doing full scope dry eye the way that you are able to do it in, in your province, which is great. So you have all this amazing equipment. Um, if you could give us some, like, one great pearl for dry eye, what would it be?
[00:18:19] Speaker C: One great pearl. Oh, man, this is hard.
And I'm talking to, like, the dry eye gurus here.
One great one, too. Yeah.
One great pearl would be to really, you know, work with the patient in what is going to work for them in their daily life. I mean, dry eye is so overwhelming. Number one would be to just be very empathetic with the patients and say, hey, this really sucks. You know, and I'm kind of your partner. How do we, when you come back for a follow up, you're going to tell me how this schedule worked for you, because, as you know, there's so much stuff that they have to do at home as well, and then you can provide them feedback and, hey, look, this is what I feel like is working. When I look at you, you tell me what's working for you, and let's come up with a plan that you and I can be both happy with, that we're going to see results with.
[00:19:08] Speaker D: You know, I agree with everything you just said. I had a patient today that said, I'm glad I came, saw you because you listen and you're empathetic and you understand my frustrations. My vision fluctuates. I can't see, I can't work. I can't do whatever or there's symptoms. I'm in pain all day.
What can you do to help me? But setting realistic expectations is going to be key.
We do appreciate all the insights that you have. One last question I have for you is you are quickly building your name within the dry eye space. So any pearls that you have for some younger ods or people who want to get more involved in establishing yourself as the dry eye expert.
[00:19:52] Speaker C: Absolutely. I think you really nailed it, too. I think empathy, when we understand the disease more, we can really understand how this affects our patient's quality of life. It comes with education, educating ourselves, then we really understand. Wow. Now I get it, how this affects you. Then from that empathy comes that treatment plan. I really care about this patient. My advice to new students and new grads really looking to go into this is just continue to read, really educate yourself, and don't just leave it out there for somebody to teach you. But if you're passionate about it, if you feel like this might be something that is drawing you in, then read about it. Really read about it. And that's really important to just continue to keep on top of it and.
[00:20:42] Speaker A: Educating ourselves, or in this case, listen about it, right?
[00:20:46] Speaker C: That's right.
[00:20:49] Speaker A: Well, thank you so much for joining us today and sharing your insights in ocular surface, you know, above the border. I know you've been a great resource for our listeners. So again, thank you so much for your time. Always nice to see you, friend.
[00:21:02] Speaker C: Yes, absolutely. Yay, Pacific.
[00:21:05] Speaker A: Yay.
Go, boxers.
[00:21:07] Speaker C: That's right.
Well, thanks for having me here, you guys.
[00:21:12] Speaker A: Thanks for listening. Join us for our next episode soon. Here's a quick word from our sponsor.
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