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 have the pleasure of speaking with Josh Johnston, OD of Georgia Eye Partners in Atlanta, Georgia, about the future of meibomian gland dysfunction. Welcome, Josh.
[00:01:05] Speaker C: How's it going? Thanks for having me here tonight. Grateful for the opportunity. Good to see you guys.
[00:01:09] Speaker D: Hey, Josh, thanks for being here.
[00:01:11] Speaker C: You bet, Walt. Thank you.
[00:01:14] Speaker A: So why don't you start off by telling us about your practice and your role in regards to ocular surface dryness?
[00:01:22] Speaker C: Sure. Yeah. Sort of my background. I finished optometry school and graduated from ICO in 2004 and basically moved to Atlanta. Grew up in Texas, but came here to Atlanta, was with the group I'm at now called George Eye Partners from 2004 to 2009, and at that time was doing a lot of medical optometry. We're an MDOD practice in kind of a hospital tertiary care setting. And then my wife and I moved to California for three years and got into a practice where I wasn't doing as much medical optometry as I used to. So that's kind of where I started to do more dry eye early on in my career. I ignored it, didn't like it, and then started really following doing more of it in the trenches in California. And that's became my passion. Then moved back to Atlanta about 1011 years ago and really joined the same group I'm with again, George Eye Partners. And we created a dry center of excellence, if you will. And I've been overseeing that for the past ten years, and it's grown and doing well, and it's a passion of mine. So running the dry clinic and then also serving as the clinical director and residency director as well.
[00:02:25] Speaker D: Hey, Josh. Within that clinic, so you have a bunch of doctors there, and you have a large referral network. So how do you manage that and how do you optimize that both within your practice and within the referring ods?
[00:02:37] Speaker C: You know, it's interesting. When we set this up, we thought internal referrals would really drive it, right? And we did the speed questionnaires, and, you know, we have six locations now. And so trying to implement questionnaires for our staff, the front desk, our technicians, the doctors, it just didn't really take off. And so still to this day, I would say 30, 40% of my referrals are from other physicians in the community, mainly optometrists, but some ophthalmologists as well. Google still drives most of our traffic. It's patients looking for other options that are suffering from symptoms of dry eye who have not found relief. We know there's no cure, but we have a lot of new diagnostics and treatment options that a lot of their practices don't. So just a large practice with the ability to have a lot of equipment helps, and then we do get some internal referrals. We have about 20 physicians in our group now, but still to this day, it's patients coming in looking for other treatment options just from word of mouth and other ways of doing that.
[00:03:34] Speaker D: Hey, Josh, I know you started a dry consulting company many years ago, and what are you doing with that now? I know you're working with several different groups.
[00:03:43] Speaker C: Yeah, it started as a passion project and sort of a labor of love and was doing this and ad hoc, and then realized some of this could be automated. So I created a website, really having some digital algorithms there and filling out questionnaires that could automate the whole process. So I didn't have to be. It allowed me to essentially scale anything I was doing, and I don't do as much of that anymore. Now I'm doing more consulting for our group. So our group, Georgia I partners, partnered with a private equity firm out of Chicago, forming ISouth Partners, and that's the name of our MSO. And so with our organization, we're now in 1011 states, I believe. So I'm helping our affiliates that we have partnered with to build dry clinics and some people already doing that. So we're getting diagnostics and existing technologies and treatment options to them and then also some clinics that are naive to this space, helping them build it from scratch, that sort of thing. So that is transitioning more from anywhere, consulting with our colleagues out there to more just within our network at ISAL.
[00:04:45] Speaker A: Wow, that's amazing. You've done quite a bit over the past ten years since diving into what we now know as modern dry eye. How would you say that? The dry eye diagnosis and management has changed, particularly over the past few years.
[00:05:00] Speaker C: There's four FDA approved eye drops. We have three immunomodulators. We have a corticosteroid as well. And then I think a big thing is IMGD treatments.
For many years, it was just maybe one drop. Treating inflammation. We know it's multifactorial. We need multiple shots on goal. If there's blepharitis in a biofilm, you need to address that. There's obstruction, you need to address that. Treating MGD inflammation and the tear film, you need to address that with the therapeutic and prescription, many different things. Lagophalamus, conjunctival, chalasis. It's fun to see more education come with this, with dudes too, and everything we've learned. It's not simple. 1520 years ago is one prescription drop, and that's it. We know now it's more complicated. We have to do multiple therapies to really help these patients work towards that cure. We know there is no cure, but we can put them on a journey. Getting close for most patients.
[00:05:53] Speaker D: Yeah, I gave a lecture on blepharitis, MGD, not too long ago, and I have a slide in there talking about just a decade ago. Since we're focusing on MGD, as you mentioned, the treatment was, well, do patient education, some heat masks, maybe a topical antibiotic, maybe add ointments in there as well. And then from moderate to severe, was adding doxycycline. And that's essentially what we did. And so things that definitely have changed over the years, you know, one of the things that we look at in regards to MGD, one of the terms we hear is lid wiper epitheliopathy. Can you talk to us a little bit about that? And, you know, is this something you're constantly looking for? How does that play into the whole MGD?
[00:06:34] Speaker C: Yeah, great question. Yeah. It's also funny with do's one we really even talk or think about MGD, right? And now we. Here we are, and it's maybe the majority, right? 86, 87% from limp with MGD. So. And there's a lot going on there, right. Obstruction, you know, those two things, kind of core pillars of this, treating inflammation, treating obstruction. We look at other risk factors that go along with MGD. As you mentioned, lid wiper epitheliopathy. I don't do as good a job as I should. I'll be candid with you all here, but looking for this with Lisman Green I think I should. And we should. A good pearl is when the signs don't match the symptoms. If we have a patient that's really struggling, there's no standing on the cornea. Osmolarity looks normal, maybe not a lot of obstruction when you're expressing glands. We need to look for that potential lid wiper epitheliopathy. The proposed function there is that if you have a decreased tear film that's not giving enough lubrication and you have some friction there, that epithelial tissue on the lid can certainly cause more friction and cause symptoms there. So if we use a vital dye like Lissamine green on these patients, where everything else is just looking normal, maybe we can do a better job at identifying that.
[00:07:44] Speaker D: Hey, Tracy, are you looking for that within your practice often?
[00:07:48] Speaker A: Yeah, I'm doing especially the first workup that I do on my patients when they're referred. When I'm working them up, I'm using lissamine green. So I do look for that epitheliopathy.
Otherwise it's literally like rubbing a callus on the front surface of the eye. So I think it is important to at least look at it for baseline, and then when I get my treatments, I'll look at it again, stain it, see if there's an improvement in that area. I used to teach it when I was in education, and I still do with my patients now.
[00:08:14] Speaker D: Yeah, Josh, I'm more like you. I should be looking a lot more for it. And also listening. Green who? You know, that's a lot of those patients that you just mentioned, just ocular surface disease. They may not, you know, they're feeling horrible, but, you know, if we utilize that diet, we can find earlier signs of damage that's occurring for our patients.
[00:08:35] Speaker C: Yeah, it's a great parole. I think it's, you know, I use it maybe once, twice a day. But I think it's a great vital diet to really look when you're kind of scratching your head and things aren't as obvious. You'll find other pathologies, potentially.
[00:08:47] Speaker A: Now in the marketplace. There's so many more options for meibomian gland treatments, but patients often have this question that they ask me quite a bit, which is, what is the role of over the counter artificial tears? Do those still, are they still players? And if you do recommend artificial tears for meibomian gland dysfunction, adjunctive therapy, do you have a specific recommendation for what kind? What type? What are we educating our patients on for that?
[00:09:13] Speaker C: Yeah, it's a good question. I may be a little bit of an outlier on this. And for me, and the reason for that is most what I'm doing is further down the pathway, more advanced, more severe dry disease. And so early in my career, I kind of tried to balance a lipid tier to replace things. At this point, the folks that are coming to me see me have a big bag of treatment, and I'll check off and give them a customized treatment sheet. And again, probably 100% of my dry patients, we use artificial tears and recommend them, but they've tried x, Y and Z. They know their favorite flavor, if you will. I'm really a believer that it gives temporary relief any sort of tear, and I think they're all good. We want a newer tier that has good technology, and we know there's some that are really, given that layer of oil that we need, that we're maybe missing, we have MGD. But for me, it's really about therapeutics, prescribing therapeutics to decrease inflammation.
It's really about addressing obstruction of the meibomian glands with an in office procedure. So we'll recommend a tear. But most of my folks are already on tiers. They know which one they like. And to me, it's palliative. It just gives them temporary relief. It's not really addressing the disease state itself. So I don't really dive into it as much as I should, maybe.
[00:10:26] Speaker D: What about you, Tracy? Is there one you go to?
[00:10:29] Speaker A: I am in complete agreement. I think if artificial tears had worked to, to treat meibomian gland dysfunction or the severity of dry, I'm seeing that the patients wouldn't be sitting in my chair. So most of the time I'm recommending something that's preservative free, just to not have any extra irritation going on to the ocular surface. You try to target it more towards if they're having need more oil based versus more water based, or if it's a combination of both, but they're not really taking care of the underlying issue. So I agree.
[00:10:58] Speaker D: Yeah. It's for treatment of symptoms. And the one I've been using a lot is sustain complete. They're actually coming out with a preservative free one that comes in a bottle as well for patients. And as you both mentioned, preservative free is always important. But we have that. We already have the active ingredient, which is the lubricant. For this, it'll be propylene glycol. But if you combine the nanolipid technology, it's in addition to HP guar. I mean, we have something that's going to address all forms of dry eyes so we don't have to make it too complicated. We can say, hey, this covers everything. And so that's something that I'm looking forward to. I know retain MGD has been a great one as well, and there are others on the market. But I simple simplify things. I pick one for my patient. That way it decreases the risk of them going to the pharmacy and getting that retail confusion that often does occur with that.
[00:11:48] Speaker A: So refresh. Omega three is a really big popular one at my clinic. I think it just feels expensive, I guess is the right way to say it. It has a little bit more of that. It's a little bit thicker, but dissipates quickly. So that one's pretty popular in addition to the ones that you mentioned.
[00:12:02] Speaker D: So, Josh, tell us about the role of debridement in MGD. Are you doing this consistently? Are you doing this only when you're doing some of the procedures or what are your thoughts?
[00:12:10] Speaker C: Yeah, I think it's sort of a secret weapon. Right. I was trained. We bought lip flow about ten years ago and the crew that came in, you know, from Don Corps clinic back then would train us. Right. And that was a tool. I learned lid to bribe using a golf club spud. And now I use the carpecki Debrider from brooder. But, you know, the keratin is a big piece of this, right? So if we have these keratinization over the meibomian glands, you're going to get obstruction just over the orifices itself versus the duct itself being obstructed there. So it's a two prong approach. If we debride and move away that keratin in the epithelial tissue, you're going to have paper, or there's a literature paper on this that shows it really does improve symptoms anyway. And then also you'll have, I think, better expression when you're doing these in office meibomian gland treatments. There we see patients with that biofilm and this sort of scalloped and heaped up epithelial ridge, if you will. And we can use lissamine green to look at that mucocutaneous junction and line of marks. It's a very valuable tool to do as far as treatment, to do it in the office. I don't charge for it. We certainly do it before every procedure and we do it on the follow up afterwards. And I also do it in the clinic a couple times a day. If I just see a really more advanced blepharitis patient with that biofilm and lid debris there. I think it's a very useful therapeutic treatment, if you will.
[00:13:30] Speaker A: I agree. I think you can get a couple months extra, especially if you have patients who are trying to, you know, watch their pocketbook and need a little more of extension between maintenance therapies. This will get you a couple months in between those two.
[00:13:41] Speaker C: Yeah, I agree with that. And there's that chronic patient that does so well that then shows up every four months, right. For the free debridement, if you will. And obviously we're building the exam and seeing them and checking up on other things, but some people love that treatment there and come back for it specifically.
[00:13:58] Speaker D: Hey, Josh, I gotta ask this question because you were part of this, this panel. So at the academy, we're talking about compresses, hot versus cold.
You know that I said, hey, we need hot compresses, but one of our good friends said cold's the way to go. What are your thoughts on this?
[00:14:13] Speaker C: Yeah, this is the new great debate in optometry. Right before it was do we build a vision plan or do we do medical insurance? And after a full house at academy with a fun lecture, how do I handle that? For me, I ask if it's an ocular rosacea patient, rosacea patient. And we see MGD. I'm going to ask them, do your eyes get red and irritated in the shower if they take a hot shower? If the answer is yes, I'll just recommend a cool compress. And I think that just feels good. I don't have any literature to prove that helps. Obviously, most of my patients, probably 60% of those rosacea patients are doing okay. And we'll recommend a warm, moist compress. And then your average dry MGD patient that doesn't have rosacea, I'll just recommend a warm compress. Warm, moist compress there. And the goal, heating it up, you know, getting some, some of that, my bum moving and working on, hopefully some self expression with blinks and that sort of thing. So I like heat on most of my folks. Again, if they have get irritated and red in the shower with rosacea, I'll tell them just to use a cool compress for relief there.
[00:15:16] Speaker D: Tracy.
[00:15:18] Speaker A: I actually take most of my patients off hot compresses. I'm kind of the other side of the spectrum to start with, in particular because I don't like to put heat on inflammatory disease states. So until I get them stabilized, then if they want to go back on warm compresses, that's fine. But absolutely no for a rosacea patient, because that does tend to make it worse, in my experience. But, um, I don't like to put heat on inflammation, so I don't put heat on, um, other areas of my body. If you go to a chiropractor or you go to a muscle specialist, they'll tell you to put cold on things that are inflamed. So I heat away until it's time for maintenance therapy. That's where I'm at.
[00:15:57] Speaker D: Yeah. You know, the. The hard part with that, because we know heat is a trigger, especially for Rosacea, but the hard part is, as you mentioned, Josh, you try to look up the literature. You can't find anything. And so, I mean, we're just using it in our clinical experience, and I do the same as you, Josh. If it's a trigger, then I won't. I'd recommend cold, but either way, I just want to make sure we brought that up there.
[00:16:19] Speaker C: Yeah. Tracy, he raises two great points. There is one, after I do one of my in office MGD treatments, those rosacea patients that I have heated up and squeezed their whole face and lids are going to be pretty red. And it's more apparent, you know, what he can do to some folks there with that inflammation. And then again, the chiropractor analogy. Tracy, I love that, you know, when you sprain your. Your sprain your ankle, right? In high school playing sports, the glory days, we put ice on it. We didn't put heat. And, you know, when you throw out your back and go to a chiropractor, they're not heating you up. It's what we all think to do with a warm sort of, you know, treatment. But it's going to be ice, right, to reduce that inflammation.
[00:17:00] Speaker A: Good talk, guys. I love it.
So with MGD procedures that you're talking about in the office, there's a lot of them that are available. Which ones do you have experiences with and kind of, what's your go to one?
[00:17:14] Speaker D: Yeah.
[00:17:14] Speaker C: So we were an early adopter of lipiflo many, many years ago, and that worked well for us for many years. That was sort of the first to market. And where we've moved on, most recently in the past three years, is with tear care. And for me, lipid flow is good, but it's sort of your more gentle treatment option, if you will. At this time, it heats up the lids from the inside out, and then, of course, there's a warm and then a gentle pulsation, which can squeeze the lids there. Tear care for me, a little bit warmer, a little bit longer treatment there. I can customize where the heat is put on the lids. And then, of course, I can come in after the procedure and really express these patients being a little bit more invasive, a little bit more aggressive as far as customizing the treatment there, getting a little bit potential, you know, treating the blockages a little bit better there. So that's what we've been doing the past three years, having good clinical outcomes with that.
[00:18:07] Speaker D: So do you do that or do you delegate that?
[00:18:10] Speaker C: I do it? Yeah. I'm just a big believer of optimizing patient care, customizing it. My technician will put the smart lids on the patient and talk about it, you know, but I will actually come in at the end and do the expression there. So there's an argument that's not necessarily needed and maybe a decrease of my time and not a great use of my time and inefficient. But I think the sort of personalization with the patient, with the doctor doing that has a little bit of a better overall feel, if you will.
[00:18:39] Speaker D: And then they did have that paper that was presented from doctor Zlo, the Olympia trial that looked at. It was a non inferiority study comparing that versus normal pulsation. And it was very effective in addressing the signs and symptoms. Well, what are some of the innovations in MGD that you are excited about in the pipeline?
[00:19:03] Speaker C: Probably the biggest thing coming, I think, will be the keratalytics. Azura is a company out of Israel and Australia looking at this. So potentially in office treatment, you can put a gel on the lid or potentially a lower dose, therapeutic. We prescribe on top of that, really breaking down those disulfide bonds, those keratolytics there.
This will hopefully cause some increased expression of the meibomian glands once you break these bonds and the keratinization there, and there's maybe some potential to have regeneration there with these meibomian glands increasing lipid production as well as expression there. So, you know, it's not one single thing I think we'll look at dry with, you know, one drop, just treating inflammation. I think MGD will be expression. It'll be in office treats, in office treatments, if you will. Sorry. And then also most excited again about the keratalytics there, hopefully opening up these glands, maybe some potential for rejuvenation. These are exciting things we'll see.
[00:20:00] Speaker D: Yeah. Adjunct to the current treatments that we have. And the one thing about that, it's twice a week, so it's not twice a day. It's just you do it twice a week, and that's what, that's what's been improving. And the early data for that AZR medication is very, very exciting. Tracy, what are you excited about for MGD?
[00:20:19] Speaker A: Actually, that's exactly. I was actually having a conversation with a patient of mine who does tend to get that keratinization buildup, and she's expressing, just have to express her really, really regularly. So she was asking what the pipeline was, and I was talking just about this with her today. So I'm excited to see what happens when we get rid of that lid wipe repitheliopathy, that keratinization, that buildup over the top.
Excited to see what is going to happen with that, too.
[00:20:44] Speaker D: That's only one. I mean, there's a couple more on the pipeline, too. Novo three comes to mind. Treatment for signs and symptoms of dry eye associated with mgdheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheheh it's essentially a single disease or a single entity drop entity, where it's preservative free, water free, and essentially it helps dissolve those obstructions in the meibomian glands. And the Gobi trial, the Mojobi trial as well, the phase three studies, they've been very promising in improving both the corneal staining, total corneal staining, as well as the symptoms for patients. Those are just a couple. There's been many more, so it's been super exciting.
So, hey, Josh, lastly, what is your clinical pearl for mgD? I mean, we could talk about this all day long, but we only have a 20 minutes podcast, so give it to us.
[00:21:28] Speaker C: Yeah, I mean, a few things to kind of sum it up. A great question there, right? It's not that easy. So, for me, it's really to do something, and that's going to look at this. I want to look at the quantity and the quality of myvom on every single patient we see. If there's MGD there, and it's mild, we may start with something like a warm, moist compress. Right. And then if we're not getting a breakthrough in symptoms, we need to potentially look at an in office procedure, whether that be thermal pulsation with lipo flow or ilux or tear care.
Pick your diagnostic treatment option there, or treatment option, if you will. But to me, it's not one thing. Right. So we need to treat inflammation with the immunomodulator. If there's a lot of staining on the cornea, we may potentially use an amniotic membrane, address biofilm, blepharitis, all these different things. Looking at this and you'll have better outcomes, better clinical success while you're treating MGD.
[00:22:22] Speaker A: Thanks, Josh, for your insights on MGD and where we are and where we're going. It was really wonderful to have you on the podcast this evening.
[00:22:30] Speaker C: Tracy, Walt, it's been a pleasure and look forward to seeing you all soon. I appreciate it.
[00:22:35] Speaker D: Thanks, Josh.
[00:22:36] Speaker A: Thanks for listening. Join us for our next episode soon.
[00:22:39] Speaker E: For over 18 years, IECO has been an industry leader of natural effective, at Home dry eye management. You and your patients with scientifically proven products for mild, moderate.
