Episode Transcript
[00:00:00] Speaker A: Welcome to the Dry Eye podcast series. Click on Dry Eye, your insider paths to the most exclusive dry eye topics. 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.
[00:00:21] Speaker B: This episode of Dry Eye Coach is sponsored by Tea Pharma, Inc. The makers of Ivisia and Iuza. For more information on Tea Pharma, Inc's portfolio, please visit teaharmainc.com. that's Thea pharmainc.com.
[00:00:40] Speaker A: All right. Welcome Justin Sweitzer. He's here today to give us the information on the impact on glaucoma patients. Thanks for joining us.
[00:00:49] Speaker C: Excited to be here. Thanks for the invitation to talk a little dry eye and glaucoma. I really appreciate it.
[00:00:55] Speaker A: Tell us more about your practice.
[00:00:57] Speaker C: Yeah, so I'm in a tertiary care practice. It's a practice that focuses on anterior segment disease, cataract, cornea glaucoma, referred into us for either surgical considerations or for treatment of anterior segment disease. I work alongside a glaucoma and cornea trained surgeon and, you know, love what I get to do on a daily basis.
[00:01:21] Speaker D: So, Justin, you know, I love to ask you fun questions. So I know you love glaucoma and you love dry eye. Which one do you like more?
You're on a dry eye podcast, buddy.
[00:01:32] Speaker C: Yeah. If you have a glaucoma practice, and I love glaucoma, you have a dry eye practice. So I love dry eye. So they're about 50 50 because you can't have a glaucoma practice without having dry eye.
[00:01:42] Speaker D: I knew that was your answer.
[00:01:45] Speaker C: I dodged the question.
[00:01:49] Speaker D: All right, so we're talking about the impact of glaucoma on ocular surface disease and vice versa, as you just mentioned. So what's the issue? Tell us more. What do you talk about during your lectures and with your patients?
[00:02:04] Speaker C: I mean, the real issue is that if our patients aren't tolerating medications and medications can lead to ocular surface disease. We know from studies that there can be progression. I mean, that's the big issue when we think about glaucoma. What's our goal as eye care providers? Our goal is to make sure our patients don't go blind. We don't want to lose sight. The problem is, I mentioned a minute ago, a lot of times you have patients that have glaucoma and have dry eye rock or surface disease. And if they are tolerate their medication because it's causing fluctuation in vision or irritation, redness, appearance issues, then they won't take their medication, which is ultimately going to lead to progression, which is ultimately going to lead to us not being able to do the job that we want to do, which is prevent progression and blindness.
[00:02:49] Speaker A: Now, these conditions, sometimes they're chronic, obviously. So how do you juggle the appointment schedules and effectively managing these patients in kind of a practice management way?
[00:03:02] Speaker C: I think it can be challenging. I think the first thing is if it's a glaucoma patient, you're going to run your traditional tests on them. You're going to run the visual field. Oct, uh, you know, you're gonna take a good thorough history with these patients. And, you know, for us, all our patients that come in for any type of evaluation, whether it's a glaucoma evaluation, cornea evaluation, they're filling out a speed questionnaire, and so we're using a dry eye questionnaire to kinda tease out some symptomology from them. All right, I know they have glaucoma, very likely cause they've been referred in to me for that. But how do I understand if they're having symptoms from other things, their drops, or just dry eye in general? And so that really does a great job of starting the conversation around ocular surface disease. And so then you educate on what you see from the glaucoma side, but you're also able to educate very quickly based on symptomology of what's going on with the ocular surface disease side of things.
[00:03:57] Speaker A: Well said.
Go ahead.
[00:04:00] Speaker D: Well, hey, Justin, tell us the numbers. I mean, how prevalent are these comorbid conditions? I mean, we know multiple medications can cause that. We know. I mean, you did a study looking at migs and the ocular surface. Can you speak to either of those?
[00:04:17] Speaker C: Yeah, you bet. So we know from various studies that, number one, meibomian gland dysfunction is extremely prevalent in patients that have glaucoma. There's some studies that say 90% form of MGD if they're on a prostaglandin analog. Does that mean advanced MGD? No, but some sort of it. We also know that blepharitis, demodex blepharitis, is a high percentage in our glaucoma patient population study on that, around 60% or so. Our glaucoma patients have demodex blepharitis. That leads to a lot of the issues we talk about with ocular surface disease. And then the study you alluded to walt that, you know, we looked at about 50 patients. These patients were going to undergo a MiGS procedure plus cataract surgery, drawn about one and a half glaucoma medications. We had them fill out an OSDi. Preoperatively, they fell at a score of about 40, which is severe on the OSDI post surgery after undergoing MIgs plus a cataract procedure, we dropped that down to around 17, which is in the mild phase. And really, that's because we minimize some of their drop burden. We didn't eliminate it, but we minimized it. And so 40 is a big number. 40 is a big number on the OSDi guys. Only 50 patients, you know, these patients were in that severe symptomology state. So it's very prevalent.
[00:05:34] Speaker D: Going back to that practice management that Tracy asked you about earlier. So you have a patient come in, you're in a referral practice. You know, they have glaucoma, and, you know, you're gonna see them three to four months or whatever it may be. You know, how does that flow happen? Because if your technicians are checking your pressure, you can't check the oculus surface. So what are some of the pearls you can. You can provide our listeners and viewers?
[00:05:56] Speaker C: Yeah, it's a great question. I try to minimize the visits where my patients come into our practice. Glaucoma patients will have to come back often for pressure checks, things like that. We utilize a technology in our practice called ocular response analyzers to check intraocular pressure. That's helped a lot with the workflow, because then I'm able to use fluorescein dye, the things that I would use to check for deer breakup time staining and things like that. So that's helped. That's one thing I will say that I've utilized, and that's a technology that I think is very accurate in measuring and get some other things with it as well. I think the other thing is, a lot of these patients we are bringing back for a pressure check because we're making changes. And so at that pressure check, typically that's where I can assess and work with them on their ovular surface disease. It's a much quicker visit, typically not going to dilate them. At that pressure check, we're really just checking their pressure, and then we can dive into the dryness and that type of thing. And so maybe not doing it all on the front end when you're running a visual field, OcT dilated funds exam, you know, pack chemetry, all those things doing gonioscopy that could be a lot, but formulate where, hey, you're gonna bring them back in four weeks, check their pressure. That's a good time to maybe focus on the ocular surface component.
[00:07:06] Speaker A: Out of curiosity, do you see a difference in the compliance with glaucoma drops once a patient's dry eye starts to become more under control?
[00:07:16] Speaker C: You know, clinically, I would probably say I can't tell a difference, because the fact is, our patients compliance is an issue. The studies definitely shown a difference in our patients with compliance and progression rates. When you look at ocular surface disease, patients in glaucoma and ones that are having symptoms versus patients that have ocular surface disease and medications that are not causing symptoms, we've seen studies where, over time, the rate of visual field progression increases in those patients that are symptomatic, suffering from surfaces, from their glaucoma medications versus those patients that are not suffering from symptomology or ocular surface disease. So the studies show it. Clinically, it's challenging, because I think all of you would, you know, both of you would agree that, you know, our patients on glaucoma medications, the more they're on, they're typically not compliant anyways. It's better if we can keep them on one, if at all possible. But once you start adding medications, dryness goes up and compliance starts to drop pretty drastically.
[00:08:24] Speaker D: All right, Justin. I have glaucoma. You just gave it to me. I have dry eye. What are my options? How do you present it to patients?
[00:08:31] Speaker C: Yeah. So if you have dry eye and I initially diagnose you with glaucoma, I talk about a few different things, typically with my patient. Talk to them about selective laser trabeculoplasty.
Not a forever treatment, but a nice treatment to maybe minimize the use of drops for a three to four year period. We're able to repeat it, give them maybe another three to four years. Great data out there on this from the light study. It's a great option for our patients, something to consider, at least in an option for them. Number two, I talked to them about some preservative free medications. Now we have a brand new one on the market. I use a, which is a preservative free latanoprost, a great consideration for a patient that walks in the door. You diagnose with glaucoma, they already have ocular surface disease. Let's not dump a bunch of preservative on the surface of the eye. So I talked to them about some preservative free options as well. And then I finally, I'll talk to them about drug delivery. Again, drug delivery, not drug delivery. Pellet that's on the market. Mamatoprost Sr. Or Durista finally came to me, Walt, that we utilize and that is something that can last six months, a year, or two years. So again, just trying to minimize that drop burden initially, and then at times migs plays a role. You mentioned it earlier. We did a study on this, looking at that hard to use it as a first line therapy. But if you have a patient that's maybe on a medication, has to be considered as well to try to minimize that drop burden. So that's kind of the conversation that I have with them.
[00:10:00] Speaker D: So do you think this is going to change? I mean, we've had preserver free options in the past. We know glaucoma is a chronic condition. Do you think, do you see preservative free being a first line? I mean, we live in a insurance world, so generic does play a role. They have preservatives. What are your thoughts on that? Because we know dryness is going to happen.
[00:10:20] Speaker C: Yeah, I think, number one, doing something like this, what you two are doing right here, having a conversation about it raises awareness. Number one, I think when you go to any of our major meetings, theres discussions around this. Now, were talking dry eye, were talking glaucoma and were talking about how they go kind of hand in hand. So again, I think that raises awareness. To answer your question about managed care plans and dealing with preservative free drops, I think initially, yeah, itll be a little bit of a challenge. Uh, but our job as, as eye care providers is, uh, to diagnose the condition glaucoma, to diagnose ocular surface disease options out there. And we may have to jump through some hoops. We may have to put a patient on a preserved glaucoma medication to start with, knowing in the back of our mind that very shortly, a month, two months, maybe even three months, we're going to make that switch to preservative free in order to jump to that hoops, because we know that that patient is suffering from dryness and we know thats the best option for them. I think over time it might be where we can utilize these things first line. And I do think theres opportunity to do that. I think we always have to keep in mind whats best for our patients. If its not an ocular surface disease patient with glaucoma, I probably wouldnt do preservative free right away. Im comfortable. We have great prostaglandins as first line agents that work beautifully. But I said earlier, a lot of our patients present to us with ocular surfaces along with early glaucoma or more moderate glaucoma, sometimes on drops, sometimes not on drops.
[00:11:45] Speaker A: Now, I'm from the Pacific Northwest. I have to ask you this question because I get asked all the time. Everybody's into natural. So if you get asked is there any supportive nutrition or the nutraceuticals that can play a role in helping the patient balance their ocular surface with their glaucoma therapy, what would you say?
[00:12:05] Speaker C: Yeah, I'm a big believer still in nutraceuticals. You know, I'm a fan of a product that has gla in it. You know, there's, I think, seven peer reviewed studies that have looked at this particular, you know, nutraceutical. I'm a fan of ocular sparing treatments for my glaucoma patients, and nutraceuticals falls in there if we're not having to add more drops to our patient's regimente, typically a disease glaucoma that's treated with drops, at least for us optometrists. Right. I would love to spare the ocular surface, and nutraceuticals fall in there. Leads me down the path of other ocular sparing treatments. You know, we have in office therapies, you know, meibomian gland treatments, thermal pulsations, heating and IPL available. These are ocular sparing treatments that can really make a difference for our glaucoma patients. You know, there's a, there's a nasal spray now that stimulates the trigeminal nerve. So we have a lot of different options that are ocular sparing that I think about for glaucoma patients to kind of reduce them having to be on more medication from a drop standpoint.
[00:13:09] Speaker D: Justin, one of the hot topics right now is evaporative dry eye. Actually, it's been a hot topic for a long time with, we know 86% of all dry eye has MGD or evaporative component. So for a glaucoma patient, they're on drops. Where does something like per fluorohexyloctane come in?
[00:13:28] Speaker C: Yeah, no, that's a great question. Well, I've had this question before and thought long and hard about it. I think, you know, it's an option. I think that the challenge is you are, you're not being ocular sparing in glaucoma patient. But I think the advantage is when we think of what I mentioned earlier, that there's a high prevalence of meibomian gland dysfunction in our patients with, serve a purpose for those particular patients. And so I wouldn't shy away from it. Again, with glaucoma patients, I lean a little bit more ocular sparing whenever I can. But again, if we're addressing the actual cause of the dryness, which a lot of times in glaucoma patients, it's evaporative dry eye, we want to use the best types of products available, and that particular agent falls right into that category.
[00:14:14] Speaker A: So when do you pull the trigger to go from drops to surgical intervention?
[00:14:22] Speaker C: That's a great question. I mean, if it's someone that is, number one, visually significant cataract, visual complaints on multiple medications or even one medication that has glaucoma, that's the low hanging fruit. That's an easy one for me because, boy, we're going to make that patient happy. Number one, they're going to see better. Number two, they're going to be a lot happier because they're probably going to be on less medications. The challenging one are those patients that present to you, they're on one or two medications.
They're suffering from ocular surface disease.
They're not progressing. Their oct looks stable. Their visual field looks stable.
Do we recommend a surgical MiGs procedure, for example, for those types of patients? And I would argue, yeah, I would consider it because a lot of these MiGs procedures are safe. They are effective. We look at the data around them, seeing the medication burden. We're taking them from two medications to one, sometimes one to zero. And so if we can reduce that burden, not eliminate medications, I don't think we're ever going to get away from complete medication removal from a glaucoma standpoint. But if we can minimize it, we're doing these patients a favor.
[00:15:32] Speaker A: It's so great that that one drop right now, it could be an option that may be preservative free. I like that. We might be going in that direction.
[00:15:39] Speaker C: Yeah. And we've had, you know, we've had some preservative free options out there in the past. Preservative free agent, that's out there. There's some compounding agents as well that are available from compounding pharmacies that are preservative free as well. It's great to have now I use on the market a preservative felitanoprost, something that we're all really comfortable with. We're all really comfortable with a PGA. We're very comfortable with once a day dosing, and to have a preservative free option to utilize in these patients that do have some already present ocular surface disease, I think is a win.
Doctor Justin.
[00:16:09] Speaker D: Hey, Justin. For the last couple of minutes, we have. Let's talk about pipeline. And, you know, I've just had this discussion.
Eye dose, we know that that's coming close to market. We know about punk and plug delivery. Can you comment on both of those and where those are soon to be available?
[00:16:26] Speaker C: Yeah, I dose is a, you know, traveprost intraocular implant. And so it's something that likely will need to be done in the OR. And this is implanted in. It's. It puts. It's through a clear corneal incision. It goes into the trabecular meshwork, and it releases. We'll probably see that very soon. We'll probably see it next year, first quarter or so, to be available. You know, the data around it looks impressive. It looks good. It looks fairly long lasting. I think to have another arsenal in the drug delivery world is important, mainly because we're going to be able to reduce medication burden for some of these patients that are definitely not compliant.
And so that's an exciting option. Again, data looks good. Safety looks good around that. In regards to intracnicular, that's a little bit unknown at this point in time. There were some studies done around that, uh, didn't quite meet its endpoint in their phase three clinical trials. You know, I really want this to work, because as an optometrist, it's something that'll fall right into arsenal immediately. We'll be able to implant these, we'll be able to loot a medication that's preservative free onto the ocular surface, lower intraocular pressure. And so I'm very hopeful that at some point, we're going to have that in our arsenal as well.
[00:17:37] Speaker D: Well, awesome. Any last, uh, final pearls you want to give our listeners and viewers?
[00:17:43] Speaker C: No. I, number one, appreciate you guys having me again. I think that it's very easy to overlook the quality of life things with a glaucoma patient. It's very easy to overlook redness and irritation because you say, boy, I got their pressure down and their visual field's not progressing. Their Oct is not changing. The problem with that is, I would argue that that patient that has just a little, tiny inferior nasal step could care less about that. They don't notice that. They don't know that's in their vision. But what they do care about is when their friends say, man, your eyes are really red, or their eyes burn every time they put a drop in. Or the end of the day, they're unable to spend time with family on a computer. And so don't forget about the quality of life pieces with your glaucoma patients. Yes, takes a little bit more chair time, but boy, it probably makes just as big of an impact as you control in their progression.
[00:18:33] Speaker D: Hey well, Justin, thank you so much for being here. Great pearls that you shared with us. And thank you all for tuning in to click on Dry Eye podcast.
[00:18:42] Speaker A: Thanks for listening. Join us for our next episode soon. Find us online at www.dryeyecoach.com and all major podcast platforms.
