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.
[00:00:19] Speaker B: As a global specialized company dedicated to ophthalmics, Santen brings a 130 year history of scientific knowledge and organizational capabilities to research, development, and commercialization of pharmaceuticals, pharmaceuticals, surgical and medical devices, and OTC eye care products.
Santon is the market leader for prescription ophthalmic Pharmaceuticals in Japan, and its products now reach patients in more than 60 countries. Santon provides products and services to contribute to the well being of patients, their loved ones, and consequently, to society.
[00:00:54] Speaker C: In todays episode, we have Josh Davidson from Williamson Eye center in Baton Rouge, Louisiana, who has a special interest in ocular surface disease, scleral lenses, and ocular disease. Welcome, Josh.
[00:01:06] Speaker A: Hi.
[00:01:07] Speaker D: Hey, Walt. Hey there, Tracy. It's great to be here.
I'm still kind of shocked that I am here because I listen to your podcast all the time. I listen to podcasts, a lot of different ones, and usually there's all these superstar guests with all the academic credentials and just the the who's who. And I still think I'm a pretty normal optometrist. I just see a ton of ocular surface disease. So might be kind of interesting for your viewers to hear, you know, what kind of your average od that just gets a lot of reps thinks about different types of ocular surface disease. So I'm really glad to be here. What an honor.
[00:01:48] Speaker A: Hey, I think he's being too humble. I think we're going to see that you're a little bit more than just your average Joe, but it's great that you're coming on, and the fact that you see so many OSD patients is one of the main reasons we have you here today. So tell us a little bit more about your practice, like, what's the modality that you're in? Who are you seeing, what's going on?
[00:02:09] Speaker D: Yeah, very cool situation. I am beyond blessed to be where I'm at. I'm at Williamson Eye center in Baton Rouge, Louisiana. It's a family owned ophthalmology clinic. It was started by an optometrist 80, 75, 80 years ago, and now we've got seven soon to be eight clinics, but I think seven clinics, and there's a ton of optometrists, a ton of great ophthalmologists that we work with, and it's really kind of cool because my interest is ocular surface disease, scleral lenses, a lot of dry eye, and so a lot of our optometrists and our ophthalmologists don't have any interest in that. So I just get all these cases funneled to me on a daily basis. And so I've kind of tweaked my schedule. Schedule. So it's very, very high volume, anywhere between 30 to 50 a day.
Mainly allergies, dryness, and specialty lenses. So that's me.
[00:03:07] Speaker C: Yeah. You're at an amazing practice, Williamson eye center. I've known Blake for many, many years and some of the other docs. And, yeah, you all definitely have incredible practice today, as I mentioned earlier to you, is we want to talk to you about ocular allergies and the impact of dry with dry eye, because we know this often does intersect and there are comorbid conditions. So what role does allergies play in ocular surface disease when we're talking about allergies and dry eye?
[00:03:40] Speaker D: Man, I don't think I've got enough time to talk.
[00:03:45] Speaker C: We got 20 minutes.
[00:03:46] Speaker D: Yeah.
Those two are so intertwined. And I am not originally from Louisiana. I'm actually from Michigan, the Midwest. And there's allergies up there for sure. But holy, man, you close your eyes and you imagine Louisiana, you're thinking humidity, you're thinking pollen. You're thinking all the old oaks and the live oaks and the cypress and the allergies down here are unbelievable. And I'll tell my patients that it's these allergies and the dry eyes that play off each other, in my opinion, and I think the opinion of a lot of people, you know, we know that a lot of dry eyes is caused by ocular surface inflammation. Right. We know that. Of course, there's lid issues, too, but, you know, inflammation, that's going to kind of shut that tear production off. And, you know, the tears, what do they do? They wash allergens away. They wash all this stuff that you encounter every day off your eye. Well, if you have nothing to wash it off, it's going to cause less to your production. It's a vicious cycle.
I think the two are especially intertwined, and just my biggest interest was dry eye. And I realized really quickly that as someone interested in dry eye, well, you're going to have to have an interest in allergies, too.
They are one and the same, it seems, for a lot of my patients down here.
[00:05:15] Speaker C: So we ask our patients, does itch or burn? They say both. What's next? What do you do?
[00:05:20] Speaker D: Depends on how miserable they are. Depends on how much inflammation we're seeing. You know, if there's a ton of camosis, if there's injection, if there's just the watery eyes, if they're miserable, you know, case by case basis. But I've been having a lot of luck with throwing a steroid on, you know, just a kind of a. Not one of the strongest corticosteroids. I do a lot of flarex. I love flarex.
I think it's a wonderful medication. Isuvis is really great, too, now that. It'll be interesting to see what happens now that Alcon bought them. But I'll use a steroid very similar to those.
Pulse dose them three to four times a day for a couple weeks. And for the really bad cases, I'm also going to hit them with an antihistamine like xerbate. Zerbiate is cetirizine. And I tell patients, you know, this, you've heard of this, it's. It's zyrtec, but for the eyes, and patients are immediately bought into that. So I'll do that twice a day for the really, really bad cases. Um, it, again, case by case basis, that's for the worst. Hit him with a steroid and an antihistamine, or, you know, kind of just the mild to moderate or, you know, moderate to severe cases. I might do just a steroid, get them calmed down, and then put them on something long term, like. Like a zerbiate.
And then for, you know, just the patients with just that kind of minor itch and just. It's kind of seasonal. It's not really too bad. I'm not bothered too much by it. Then maybe just a serviate. I might have them try an over the counter pad a day.
I haven't had a lot of luck with the blue or the red pad a day. I always say, even though I'm a Michigan alumni and I'm not a big fan of Michigan state, I'll tell the patients to go green with the extra strength, and that'll usually work, too. So it's all case by case.
[00:07:18] Speaker A: Are you recommending orals as well?
[00:07:21] Speaker D: You know, I very rarely will ever recommend oral because, you know, especially, you know, those older antihistamines, especially the type ones, like a benadryl. But, you know, even the type two s, the class two s, you know, they're gonna dry out. We know it's gonna cause a little bit more reduction. In the tear film. So I'll hardly ever go with a oral if I think they need something systemic. I've developed a really great relationship with a local chain. I wouldn't say a chain, but a local group of many, many offices with allergists.
So I've got my little form, and I just send them away.
I'll attack the really bad allergens that way, and then I'll handle the topical. And that's been a really great two way referral street. I get countless patients every day from that group right there. So I'll hardly ever use oral, to be honest with you. And I'm sure some people will be listening to this saying, ah, you fool.
That's just not the way that I've had. I've had luck with it.
[00:08:31] Speaker C: You know, what we've been doing? I learned this from John shepherd, our cornea external disease specialist. Is singular.
No, I've read that it's indicated for the seasonal. For seasonal allergic rhinitis. And so I'll take off any of the oral antihistamines and put them on something like that. But, you know, patients are having the nasal issues, the headache, skin issue, throat issues. They need. If they need oral, they need oral. And so that's how we've been treating that.
[00:09:00] Speaker D: And actually, you know, I read that, and I want to say it might have been from you, or it was one of those inserts in modern Optometry magazine, one of the Bryn Mawr publications. I read that with the singular, and I was like, that makes perfect sense. I just read that probably a month ago. So that's something that's. And that. And that's something that, when it comes to dry eyes and allergies, you do kind of have to stay up on this stuff. So, thankfully, we've got great literature like that to kind of help us stay on the up and up.
[00:09:31] Speaker A: I like that you're co managing with an allergy group. I mean, you have such a high volume. I know there's some doctors out there that are doing in office allergy testing, but I think that's a great pearl for our listeners, that if you don't feel like they have the time or the means, that that's, you know, set up a good relationship with a local allergist. Could be just a quick and easy way to get referrals. And I like that two way street that you were talking about.
[00:09:52] Speaker D: And we. I'm sorry to interrupt. We actually.
[00:09:58] Speaker A: Interrupt us all the time. We talk too much.
[00:10:00] Speaker D: I'm all excited.
We're talking ocular surface disease. So you got me excited.
We looked at doing, I think it's aler focus, and then there was another one with bosh. And lam, I think, has an in office allergy testing.
[00:10:14] Speaker C: Yeah. Doctor's allergy.
[00:10:16] Speaker D: Yeah, that's it. And we looked really hard at doing it, and we might still get on board with that, but it's one of those things too, right now where it's hard to maintain a full staff, so we want our staff locked in doing all that. So we actually look pretty hard at doing that.
[00:10:36] Speaker A: And then you diagnose it, but you may not also have the immunotherapy options either. So it's a not a bad idea to make friends with a local if you're not into doing the allergy testing yourself. Good. Love it.
[00:10:47] Speaker D: And it's been very, very beneficial from a practice and a clinical growth standpoint of just seeking someone out and they know you're interested in it, and they know you want the best for the patients. So it's been great.
[00:11:01] Speaker C: So, Josh, I know you have a kid.
Do you like to see kids?
I have a follow up to this, but go ahead.
[00:11:12] Speaker D: I'm a. I'm a single dad of a four year old boy that now does jiu jitsu, so I get. And that's been awesome. But I tell you what, I get enough kids, I'll see a kid, but my son wears me out, so I like seeing the adults, so I don't do. It's not a kids. I will, but, nah, it's not my wheelhouse.
[00:11:36] Speaker C: Well, the reason why I ask is because we know that there's a drug for vernal keratoconjunctivitis that is used with kids, young boys, oftentimes. And so it's a 0.1% cyclosporine. So I was trying to see if you had any experience with that at all. But since you don't, kids, just remember that's an option.
[00:11:58] Speaker D: Well, I tell you what, they did drop it off at the office, and I looked at it, put it in my own eyes, because I, if it's safe, I'm going to put anything in my own eyes just to check it out.
[00:12:08] Speaker A: I'm going to do the same thing.
[00:12:09] Speaker D: Except. Except. Yeah, but anyway, yeah, it worked out. I thought it was very comfortable. I thought it was a great drop. So it's one of those things that I don't see a lot of the indication for that, and there's a lot of other options that are unlabeled for the patients. I do see. But I was very impressed with how comfortable that drop was. So I think it's Santen. Good job. It was very comfortable.
[00:12:33] Speaker A: Well, comfortable in kids. That's always a good match. Right.
[00:12:36] Speaker C: So, Josh, I want to go back to this allergy once again in dry eye. So many times patients have both. How do you simplify treatment? Because you mentioned steroids, you mentioned anti histamine. We know the data shows the more drops patients do, the less they're going to do it. So what have you found? The most successful. I mean, I agree. The post dose steroids and putting them on, putting them on antihistamine. There's preservative free, over the counter allergy drops as well. Any pearls on that?
[00:13:04] Speaker D: You know, you kind of got to read the room because if someone is miserable enough, I'll tell you what, they're going to use the drops. And so if it's a really, really bad case, you know, my suggestion would really be to hit them with a steroid and don't be afraid to, you know, pound them hard and pound them fast and kind of see where they go. Because even the best antihistamines, to be completely honest with you, a lot of times I'm just not getting the relief that the patient really needs to kind of break that cycle of inflammation. If I do suspect that I can get by with just an antihistamine, not every office is blessed like I am. I'm so spoiled. I've got, in my clinic, there's 26 exam rooms. I mean, just mind blown, right? So I can leave. I can leave a patient in an exam room if I think it's just going to be an antihistamine that they need and just dose some reserve and walk away. Come back in, you know, ten minutes and I'll know pretty quickly if that's going to just be enough.
But the allergies down here usually are bad enough that I'm going to need a steroid and then I can mate, I can maintenance treat them with, with an antihistamine. Which actually brings me to one of the big things that I have found. I feel like I'm talking a lot about xerviata. Sorry, but there are some really strange dry eye patients where their eyes look perfect. The keratograph five m. Everything is just looking great. Our inflamma dry is great or mild. The tear lab is good. And for these patients, I'll actually just test them with an antihistamine in office, even if I don't think they have allergies, or even if. I just think it's just a straight, dry eye patient, and I have probably had 100, 150 over the last year where that has been the missing link. You wouldn't think at all that it was allergies. But you know what? They're still not happy after getting on all the different treatments. I pulse dose them. They're not pulse dose. Just sample, drop, zerviate or pad a day or whatever is laying around in clinic, and I'll come back, check back in ten minutes. And they say, what was that? Liquid gold? So that's one thing that I have found. And even if it's a true dry eye patient, you're just not getting the relief you're looking for. And you're kind of running out of ideas. You're kind of running out of Runway. I don't know what you can try.
There's actually been cases where, you know, it's not looking like allergies yet. When you put that antihistamine on, boom.
[00:15:48] Speaker A: So that is so. I mean, I think you're proving yourself wrong on being the expert sort of a deal here. If you're literally. I think you've just solved the problem for a lot of doctors out there who are spinning their wheels and wondering why their dry patient isn't getting better. So I don't know. I think you're selling yourself short, friend. That's an amazing tip. Thanks for sharing that with us listeners.
[00:16:09] Speaker D: One thing that I have found with those patients, and this is not always true, but if, you know, you're looking at their tear breakup time, you're looking at the front of the eye, the tear lab, everything that you've got is really, really good, but they're still not comfortable. Might not be an itch, but if that inflammatory is getting a little bit positive, that MMP nine, there must be some correlation there with. With allergies. I think there is, because if everything's perfect but that little bit of that inflammation is still present, you'd be amazed at exactly what an antihistamine is going to do, even if it doesn't scream allergies.
[00:16:50] Speaker C: Hey, can you talk about the role of patient education, making sure look at the pollen counts? I mean, what is that discussion with the patient?
I want you to be brief, because I want to talk about something else. So I want your short answer here.
[00:17:03] Speaker D: I have never talked about the pollen.
[00:17:05] Speaker C: Count, because it's ubiquitous.
[00:17:08] Speaker A: You can see it.
[00:17:10] Speaker D: Yeah, it's, you know, every day you wake up in your car, your vehicle is green or yellow in Louisiana, so there's no point. Because guess what? Did you wake up this morning? You did. All right. The pound's high.
[00:17:24] Speaker C: I bring that up just because, you know, avoidance is the number one thing, right?
[00:17:28] Speaker D: That's true.
[00:17:29] Speaker C: Trigger is. But okay, I want to ask you, what is this dry eyed juice box that I hear about you can't even.
[00:17:36] Speaker D: Get the name right.
[00:17:37] Speaker C: It's called the dry eye drink. It just sounded better when I said juice box, but go ahead.
[00:17:42] Speaker D: Listen, I'm not a marketing guy, but I might be taking that you know what's crazy? And thank you for bringing that up. It's very nice.
Dry a drink was actually just kind of born out of necessity, to be honest with you.
Gosh, how many times have I told patients, you know, you just got to drink more water, drink more fluids, you know, it's a thousand degrees outside with 98% humidity. Drink more water. Or, you know, they came back from Colorado and they're all dehydrated because they were hiking and it's a mile up in the air. And I would just tell patients, just drink more water. Drink more water. And they all say, yeah, when I'm properly hydrated, my eyes feel better. So after a year, two years of telling people to drink more water than not doing it, I said, all right, go drink some liquid iv. Go drink some drip. Drop all that, the powdered substance that you shake and you drink. And patients were getting benefits there, and we were seeing a difference. Clinically, it was great. But then one of my best friends, who's one of our ophthalmologists, came to me and said, hey, dummy, you know, all these things are loaded with sugar. I said, oh, yeah, they are. He said, and, you know, sugar is very pro inflammatory. I said, oh, yeah, it is. He's like, so you're telling dry eye patients who have inflammation that they should drink a product with a ton of sugar? I said, okay, well, I'm just going to find one that doesn't have sugar. And it didn't exist. So we went through, like 40 formulations. We made the product. It's been really great.
Patients seem to like it. We've been selling it for about six, seven, eight months, something like that. We already have patients on a to reorder, so it's going really good. And we're kind of branching off into other products. We've got disposable steam activated masks. But I love the brooder masks.
[00:19:29] Speaker C: It's great.
[00:19:29] Speaker D: They're a great company.
But a lot of patients don't like the microwave, or they don't have a microwave.
So this is one you just open where it heats up for about a half hour, then you throw it away and it's totally recyclable. That was huge.
[00:19:45] Speaker A: So what's in this drink, other than water, I should specify?
[00:19:50] Speaker D: Yeah, we got, of course, all the electrolytes, which is going to help the kind of hyper hydration, but it's got vitamins a, b 3612, c, taurine, turmeric, and a bunch of anti inflammatories like taurine, turmeric, green tea extract, and omega three s from sea kelp in the South China Sea.
So it works really well. We've had a lot with it. Patients swear by it, and we're just kind of getting out there with it.
[00:20:22] Speaker A: Is it like a bottled drink, or is it like a powder that you mix in?
[00:20:26] Speaker D: It is a powdered substance that you.
[00:20:28] Speaker A: Pour into your bottle.
[00:20:30] Speaker D: Shake, shake, shake, and drink. Which, if anyone, is going to the Academy of Ophthalmology. I'm sorry. Academy of Optometry meeting in San Diego. They're having their inaugural bright ideas pitch competition, and it was one of the ones chosen to.
[00:20:46] Speaker A: Oh, congratulations.
[00:20:48] Speaker C: Thanks.
[00:20:49] Speaker D: I get to get up there and talk, which I like doing.
[00:20:54] Speaker A: That's great. Well, amazing. This is so good.
A lot of those vitamins that you did talk about are definitely supportive of the occupancy surface. So thanks for including other things other than just, you know, basic electrolytes. That's great. I know.
[00:21:09] Speaker D: Vitamin D three in it, but it's proven to be a lot more difficult to get it to mix well.
[00:21:16] Speaker A: Yeah, that's okay. There's always room for improvement. Right?
[00:21:19] Speaker D: Version 2.0 of the dry eye juice box as well.
[00:21:24] Speaker C: It's called the dry eye drink. I was just having fun with it.
[00:21:27] Speaker D: I know.
[00:21:28] Speaker C: That's awesome, though. We were excited to hear more about it.
[00:21:32] Speaker D: Absolutely.
[00:21:35] Speaker A: Okay, well, thank you so much for coming on the podcast today and teaching us all about your great allergy tips. I think the most important thing you've given our listeners today is great ideas that they can take into the clinic tomorrow. So that's what an expert does, is they help to educate and give our listeners ideas that they can implement. So you've done a fantastic job, Stan. We just loved having you on the show.
[00:21:57] Speaker D: Well, thank you. It's such an honor. Anytime.
I really appreciate it. This is great. Great to see you guys.
[00:22:04] Speaker C: Thanks, Josh.
