In the previous episode of this three-part series, we talked about entrepreneurship, Claudine’s journey, and beauty products. But today, it will be different. Dr. Claudine Courey is a bona fide dry eye expert. Through working in an OD/MD specialty practice, utilizing the latest technology, and even selling dry eye products on her website, EyeDropShop.com, Claudine has seen the dry eye industry from every angle. In the final episode of our three-part series with Thea Pharma Canada, we dive deep into the world of dry eye to share pearls for every ECP looking to elevate their dry eye game. Whether you’re just beginning or if you’re an expert in your own right, there is something in this interview for you!
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Huge thanks to Thea Pharma Canada for supporting The 20/20 Podcast in this three-part series and for everything they do to support the profession of optometry.
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Dry Eye Deep Dive With Dr. Claudine Courey
Thank you so much for taking the time to join me. I always appreciate all the support and the fact that you take the time out of your busy schedule to join me. I’m very excited. We are at the Théa Pharma Canada Offices in Toronto. I want to say a special thank you to Théa Pharma Canada for sponsoring this episode. This episode is part three of a three-part series of discussions that I’m having with this wonderful person here who you all know is Dr. Claudine Courey.
The last couple of episodes we did are all on different topics. The first episode we recorded was more about entrepreneurship and Claudine’s journey through optometry and sharing her story. The second one was about clean beauty, understanding what’s in beauty products, what’s good for our skin, and what’s good for our eyes.
In this episode, we are going to do a deep dive into the dry eye. I know we’ve talked a lot about dry eye over the years but we are sitting here with an expert. Someone who literally does this every day is going to tell us how to get started if we’re in the beginner stage, how to elevate if we’re in the middle, and give us some more pearls even if you’re an expert and you’re doing a great job. I know there are going to be some more pros that Claudine can share with us. Thank you so much for joining me in this part three, the ultimate third and final episode.
Thank you so much for having me. These have been so much fun and I can’t wait to talk about this one because it’s my absolute favorite topic.
This is what you do. You live and breathe this every day, so thank you. I’m going to ask you to do a little bit more of an intro for yourself in a second. Claudine is an optometrist practicing in Montreal. She runs three dry eye practices and also works in a primary care practice. She is an entrepreneur as well. She has started the EyeDropShop, which is an online store for eye care products. Claudine, tell us a little bit more. What else do we need to know? What qualifies you to be sitting in the hot seat?
It’s been five years that I dove in head first to dry eye and I work in an OD-MD practice. It came about because I love doing scleral. That’s what I did my residency in and my friend had called me. She said, “Will you come do scleral for dry eye?” That was my path into this whole field. After spending the first couple of days fitting scleral, it naturally evolved into me seeing patients and doing work-ups. I love it. It’s such a great way of helping patient’s quality of life. We have so many great opportunities and so many great things to propose now these days that it makes it even that much more fun.
That’s interesting that Scleral was your way into it. Sclerals for anybody who is in dry eye feel like a very advanced age to come into dry eye. That’s interesting that was your point of entry. We’ll talk a bit about scleral lenses for sure because that’s something many of my colleagues have thought about and talked about how to potentially implement that into a dry eye strategy. We want to start in the early stages of a journey. For me, I’ll rewind the clock for five years.
Here’s what I was doing in my practice five years ago. I was not retailing any products. I was handing out samples of eye drops that patients would then go buy or maybe go buy over the counter and I wasn’t recommending any dry eye treatments. I may have been suggesting that patients go home and put a warm cloth on their eyes for a few minutes, but that was pretty much the extent of it. Let’s go talk to Harbir at that stage. What do we need to say to him to give him the information he needs to get started? I wanted to do dry eye. I just didn’t want to invest in all the tools and all the technology and all that stuff at the time.
First of all, I would tell Harbir it’s okay. We all started there. We have to be honest with ourselves.
I’m glad I got that out of my chest.
You’re fine. You’re going to be okay. We all started there. We were all doing that. At the end of my optometry school, it was getting popular to no longer sample. My residency director and everything, that’s when it was getting into, “We don’t want to sample anymore. We want to prescribe. That’s going to make people more compliant.”
There’s all that stuff but truly everybody starts that way and it’s fine. The truth is these patients are already in our chairs. The first step is to open up the conversation and to do things that we already have. To start doing a questionnaire while your patients already waiting for you to see you is such an easy thing. To stain with fluroxene, we do it anyway to look at different things. To express meibomian glands, use a penlight to avert the little bit and try and see the morphology. There are things that we have in our clinic that we can do right away and that will help us with diagnosis, and there’s a slew of treatments that are great to already embark on right off the bat.
We’ll get into treatments in a second, but as far as from a diagnostic perspective, I was thinking I got to go buy my biographer right away or some other type of imaging device, but at that particular stage, offering a questionnaire, is there one that you would suggest? Is there a preference?
Any validated questionnaire.
Is a DEQ-5 too basic or is that good?
As long as you’re using the same one from time to time so that you can compare. You’re not just taking any single one. You want to be consistent. You pick the one that works with your clinic and the one you like interpreting and you run with it. You have to start somewhere.
As far as expressing with your finger, press on a little bit and that’s good enough or do you need a tool to put a bit of pressure?
There is the tool, the MGE that applies the proper constant pressure but at the beginning, don’t get mad at me, everyone. I put on gloves but start with your thumb and see what you see. You’re going to develop that habit of looking all the time. Looking at the lid margin for any teleportation. These are things we’re already there. Our eyes are already in the split lamp, so it is just to take a look down, and look at eyelashes. It’s simple things that we can incorporate in our day-to-day.
You mentioned that when you were graduating, when you were finishing optometry school, there was a shift of like don’t sample because there’s better compliance with retailing. What words of advice you give to somebody who is maybe sampling not retailing now? What’s a good place to start? What are the benefits of doing that?
The thing with sampling is that the patient won’t necessarily take what you’re recommending that seriously. They think you’re reaching back, grabbing whatever, and giving it.
Which is usually the case.
It’s like whatever rep came is what you’re going back and getting, but the truth is there are drops that we’re picking for a purpose. We are picking lipid bass drops if we have MGE. We’re picking different drops for different reasons and that’s the conversation I have with the patient, “I have selected this job specifically for your eye condition. This is why it’s important that we use this one so that when I follow you up in three months, I can make sure that you’re getting the effects that you need to get.” That’s where I would start. Stop sampling would be a good place to start.
When somebody looks to go and start to retail products in their office, there are various options. I have a feeling I might know which products you might suggest to pay for the kids like doctors start to carry in their offices, but I’ll let you make a suggestion and maybe give us a reason why.
First of all, there’s a ton of research out there and every com company has its own research backing. I always recommend that each optometrist looks at that. Use your reps. Meet with them, and get the information. I love meeting with reps. They are the specialists in this field. They know their product on the back of their hand and you could ask all the questions from the research that you previously asked them to email you at that meeting then personal experience. Using the product on the patient and getting that feedback, “When I use this drop for this case, it made a difference.” That patient was helpful and it made it so that I didn’t have to go to steps 2, 3, 4, and 5 of my treatment plan. It halted it, so I do think that those three things are important.
What I was trying to lead you towards was Théa products would be a good place to start.
To be honest, this is for sure. You can look back. When I first started a few years ago in the dry eye practice, I truly did start with Théa products and that’s an actual fact because they had everything that I needed at the moment. There was the mask, Omega, lid wipe, and the drop. Everything came in a whole package, so I did.
I have a lot of experience with the Thealoz Duo and then later on Thealoz Duo Gel. I’m talking about it. We’re sponsored by them, to be fully transparent but it is the truth that is the company that I started with at the beginning and I do have great results. We can go through which products I use when my pleasure but it’s not because we’re sponsored that I’m saying it.
You’re exactly right. That’s not the only reason why. Let’s talk a little bit about the benefit of the specific products, so preservative free, and the actual ingredients that are in there and why those are beneficial.
I love preservative-free. There’s a case for everything but in my opinion, if the service is already inflamed and irritated. I want to minimize the amount of irritants I’m adding to the ocular surface. For Thealoz Duo, I love the gel, to be quite honest.
Let’s finish talking about Thealoz Duo for a second. We do retail quite a bit of the Théa products as well in our office. I love Thealoz Duo because. to your point, the positive response that I got back is this positive feedback. Patients kept telling me, “This drop helps me feel better,” and I kept hearing that so we kept recommending that drop because we knew it worked. The gel, truthfully, I haven’t been recommending all that much. I fear it because it’s too thick but I’ve heard from multiple other colleagues now that it’s gold.
It is. My speech for Thealoz Duo to my patients so that they understand why I’m going with this drop is that I say, “It has a component inside that helps not only hydrate your eye but rebuild the front part of your eye.” That’s how I explain it to the patients so that they know what’s going on. I don’t tell them like, “The Thealoz bla-bla-bla.” I’ll phrase it like, “The Thealoz Duo Gel doesn’t blur at all. I use it on me.” I have some in my purse. I will put it and it doesn’t blur at all. SPK and Thealoz Duo Gel get rid of it. I love it.
I need to start using that more. Good to know. How about refractive surgery patients? Personally, I am usually telling them to stop whatever other drop the surgeons usually told them to get and please start using this because I’m starting to see patients with overall better recovery. Would you agree and have you seen the same thing yourself?
Any corneal disruption works wonderfully. I work in the OD-MD practice, they’re used to Thealoz Duo and they’re comfortable recommending it also. They recommend other drops but it’s a matter of seeing how the eyes react. I’ve seen great reactions.
We’re even finding some of the surgeons in our area are starting to give Thealoz Duo to patients or asking them to buy that right after their surgery. It’s a good starting point. Not everybody’s doing it yet, but a couple of them are. When I’m getting patients coming in, I’m saying, “Here’s the drop of like you to use.” They’re saying, “That surgeon asked me.”
Let’s keep moving all along that journey now. We’ve suggested that Harbir a few years ago should start retailing some drops. Here’s a great place to start. Profitability-wise, there are benefits to that as well. Certainly something I saw myself. Once we start retailing drops, that bottom line starts to increase when you’re selling products in your office. Let’s move on a little further. What about treatments? What is a good entry point? I’ve started to diagnose a little bit more. I’m staining. I’m seeing okay. There’s evaporative dry eye. The tears are drying up too quickly. There may be even some staining on the eye. I want to do something about it. What’s the next step?
I would still stick with at-home treatments as a place to start. With a heating eye mask, Omega-3s, lid hygiene, and the drop. I wouldn’t even only retail the drop-in clinic. I’d retail this whole package and gear depending on what the patient has. Not everyone leaves with all four things, depending if they have Demodex or not. Whatever the case may be, starting with a basis like this is a great start. There are a lot of patients that feel so much better. I had a patient who was like, “Thank you so much.” I’m like, “I didn’t do that much.” I was in my private practice recommending this as the basis because I don’t have any advanced treatments there.
I see both sides. There I was like, “We’re going to start with this therapy then we’ll move on. It’s just good quality products and you did the consistent work.” It demands that they do the consistency. I would also recommend, talking about consistent work, to give the patient written instructions. It’s super key. It helps them do it at home and release the complaint.
One of the things that along my journey now coming to where I am, fast forward to now that I thought was a turning point, especially with the retailing of the products but in general, with compliance with treatments for patients, was I created a little tear-off pad. I designed it in Canva. It’s got like on the top dry eye treatments. It’s got like 6 or 8 lines that have printed with little checkboxes and a bit of space underneath to maybe handwrite.
I might say, “Warm compress,” and I might write the name of the mask that I want them to use, eye drops, and the names of the drops. I’ll check or I’ll circle and I’ll rip it and hand it to the patient. I always found that that works quite well or has worked and has helped with the compliance. You’re right, writing it down. Usually, I’m sitting there and talking to patients, “I need you to do a warm compress for ten minutes. I need you to do this lid-cleansing routine every day. I need you to use these drops four times a day.” They’re like blank stares, “Could you write this down for me, please?”
It’s like an hour of work that you did like on a Saturday, or who knows when just benefits and saves you so much time down the clinic line. It’s that little effort in creating whatever tear-off pad with your logo then afterward, you’re so much smoother in the clinic. I don’t blame them. Who would remember what we’re saying? We’re saying a million things and half of the things like I would have thought that it was so random if my optometrist was talking to me about Omega-3s like, “Where are you coming from?” I left the field.
I tend to audit it. I tend to over-inform which is a problem sometimes. You want to educate your patient, but I feel like sometimes I’m doing a little too much. I try to cut myself back and I write it down, “Here’s your instructions. Take this home.” By the way, I like to share it. If somebody is tuning in and they’re like, “I’d like to create a tear-off pad like this,” message me and I can send you.
It’s like a template. How nice is that? I take them up on it. That’s a lot of work. That’s good.
I have shared it. Other people have reached out to me from previous episodes. If you’re interested, I’m happy to share that. Let’s go back to retailing and treatment. Harbir a few years ago has a question for you. Is Demodex real?
Demodex and cleaning lids in the clinic are your biggest bang for your buck. It’s the easiest way to look at your patient zero with minimal effort because genuinely, after an in-office treatment, it removes all that junk on their eyelids. They’re saying, “I feel so much lighter. I feel so much better.” It’s a great gateway into treatments because it is fairly easy to learn, does not take a lot of time, and is highly beneficial for the patient.
We’re all fed up with using the dental analogy, but it works a lot. It works well on the patient, so I’ll explain like, “You’re here and I’m doing the cleaning so that when you do your lid wipes at home, it’s maintaining. It’s not doing the work.” If you send them home with grade three demodex, it’s going to take a while to get to grade one if they’re doing it by themselves a little wipe morning at night.
You’re saying that demodex is real and it’s a problem for people.
When it’s an infestation, it’s a problem. You’re mole on the face. It’s okay I don’t scare my patients also, because they can get freaked out to hear like, “You have a mite growing in your lashes,” but a little bit’s fine. When it becomes too much and starts to impact the eye, then we would want to kill it.
If you could ballpark it, what percentage of your patients do you feel like Demodex is part of the issue?
For a lot.
Maybe 50?
It depends on the age. Demodex, if we look at the stats, after 60, it’s 60%, 70 is 70%, and 80 is 80% of people have it. That’s the latest that I read. You have your patient look down and people will be like, “I didn’t notice that it was in so many people.” It’s not only in elderly people. It’s also in kids and in all kinds of different ages. It’s important to take a look and treat it.
You would suggest as far as starting to do some in-office treatment lid cleaning procedures, it would be a good place to start.
Evacuating meibomian glands is wonderful.
Tell me about that.
The basic version that anyone can do is you need two rooms though so you don’t monopolize your examination, but you can have your patient sit in the next lane over with the heating eye mask that they will take home eventually. You warm it up, you have them sit there then you go in and you express. You could start by that and give them. Once again, it’s a head start.
The at-home treatments are better. They work better as maintenance treatments or maintenance procedures versus the actual treatment. If you can do something in the office to start that and give that momentum in the right direction, then those at-home treatments are more effective. Versus if that’s what you’re using to go from where you are to try to treat the whole problem. It doesn’t work as well. That’s what I thought.
What I would say is it works but it would just take longer to get there as opposed to if you gave them that boost in-office. If you remove the obstruction and you clean the lashes, then the treatment will pick up faster is what I’ve observed, versus sending them home with all of it. It’ll work but it might take like 90 days instead of less.
What’s the next level up here? Keep climbing. We went from total beginner, sampling drops, not doing any treatment to now we got questionnaires and we’re diagnosing with dyes under the slit lamp. Now we’re maybe doing some microblepharoexfoliation and maybe we’re doing gland expression. What would be the next step?
You have two fields of next steps. You have your diagnostics. It’s how deep you want to go into your diagnostics, to osmolarity, and to visualize the meibomian glands, and to all those pre-tests I would say that will complement and help gear your treatment. There are in-office treatments. That’ll be fun. What ends up happening is you start off like this and you help a certain percentage of people.
You get to a point where you’re like, “I need something else.” Let’s say you helped 50%. You’re like, “I need something to help the remainder.” That’s when you feel like, “Maybe it’s time that I start looking into solutions.” I don’t know about you, but if you go to any trade show, there are so many new dry eye technologies and treatments. That’s why it’s so much fun.
Let me ask you a couple of quick things on the diagnostic side if you were to prioritize a couple of pieces of diagnostic equipment. Let’s say I’m I feel like I’m seeing a good number of dry eye patients daily and I’m recommending these things. I got my little tear-off pad going like every other patient now. Which piece of diagnostic equipment do you feel? What would you say maybe is priority or ranking maybe 1 or 2?
Osmolarity. Osmolarity is crucial in my diagnosis and my management and visualization of the meibomian glands. Mobiography of some kind. There are so many different ways and tools, but those two I would say are key.
Mobiography is self-explanatory, taking a scan of the meibomian glands. You can see the structure and if there’s a dropout. Tell me about osmolarity. Where does that factor in and how does that change your treatment plan?
The key is I do it on everyone for a first consult. Every time they come, they get an osmolarity measurement. Over a 3 or 8 or a difference between eighteen between the two eyes. I will be able to gear what I’m going to go through next. The way I explain it to patients, which I don’t know if anyone else uses this language, but it might help if you do have osmolarity in your clinic. I say, “I’m measuring the saltiness of your tears.”
How salty are your tears and that makes people understand. If your tears are very salty, then they’re going to burn and it’s not going to be comfortable. We want to get it to a point where it’s neutral. We want to lower that, so it’ll help with what treatment and what drop I’m using. You use a hypo or a smaller drop or not and gear where I’m going. Asymmetry between different eyes, how fast I’m referring for cataract surgery.
There’s a lot of different things that come into play. That’s an important one and mobiography because it allows me to visualize the potential and how fast we’re going to get to where we need to go. Patients can literally diagnose themselves. When you take out the normal scan and then you show them their scan. They’re like, “We need to do something about this.” Not only for compliance but to see afterward, the improvement or lack thereof or whatever we’re going.
You mentioned cataract surgery. How fast would you refer for cataract surgery? Is that simply because if the osmolarity is too high, you are not going to refer them at that time? Is it that simple or is there something else?
I want to make sure that we get them to a point where it’ll maximize the results, especially all the patients that we’re seeing more are doing these premium IOLs. We need to make sure that the ocular surface is pristine before sending them. It’s good all-around because the patient will be much happier after. The surgeon is much happier operating on a clear surface, or cornea and having the patient be happy. Overall, all around, it’s wonderful.
For any refractive patience that I have, it’s so important to optimize that ocular surface. I haven’t personally thought much about osmolarity. It sounds like that might be something I need to invest in. Let’s move on to now on the treatment side of things if we were going to level up on technology as far as treatment. The big things. I feel like that are getting a lot of attention are radio frequency and intense pulse light.
There are some other thermal pulsation treatment options that have been out there for a while now and still seem to be very beneficial. Do you think that there’s a better entry point into that more advanced treatment technology for somebody? Do you think like RF versus IPL or both together? I feel like we’re jumping a little here quite a bit but there’s not too much in between. I don’t know if there is. Maybe I’m missing something.
At this point, it would depend also on the clinics’ ability to go to the next step because there are options at each price level and they are effective. I still use thermal pulsation and it’s effective but I use IPL and RF for different reasons. It’s normal that if it’s not a referral center, you’re not going to spring for all of them.
It is a significant investment. Let’s go with IPL and RF for now because that’s the one that is gaining in popularity. I can easily say that it is the treatment that revolutionized the clinic. It took patience. Let’s say that we were helping 70% and now we’re close to like 95%. It took it to the next level. The combo, which I know some people do IPL or RF on the same day. It’s still being figured out, but having those two options is key.
Do you combine them at the same time?
I do.
Are you comfortable sharing? Which do you do first?
It depends. If the patient has obvious rosacea, I will start off with IPL. Let’s say the first exam, I won’t do both. The first one I’m going to do is IPL and if that goes well, then I layer our EF on it the next time. If something goes, then I attribute it to the combo. I won’t do it the first time. Again, some people do IPL before our RF.
There are a bunch of discussions which is fun to me because it means that there’s interest in the field and that eventually we’ll all come to a consensus. Everyone’s trying which is the point of being at the forefront of something. I personally do RF before, I warm up the lids then get it all nice and red then I do IPL on top of that. That’s simply because that’s how I was taught by different Canadian people who came before me. You’re being one of them. Do you remember? I called you.
Don’t get me in trouble here. If somebody’s going to call me and say, “That’s the wrong way.”
It’s not the wrong way. There’s no wrong way.
You’re right. That is the way that I do it as well. What about expression?
I do it all the time.
As far as RF IPL, do you do RF IPL express after or RF expressed IPL?
RF, express, IPL, and express.
Double express. That’s got a new title now, the Courey Double Express Method. We’re going to TM that.
It just made sense to me and I see great results with it, but it takes a long time because you have to sit the patient up after RF express and do upper and lower, then put them back, get them set up, IPL. When they sit back up, I feel like I get the remainder.
We have now our tech. We have a trained technician assistant. Do you do the treatments yourself?
I do, which is another thing that I realize I’m like a lone soldier but I do them myself.
I started that way but it takes a long time. The protocol for us is RF and the way our chair is reclined, we have one of those like ring-late mirrors that people use for doing lashes and stuff.
You can express it right there. Not a mirror but a magnifying glass with the patient lying back. We bought it on Amazon. It was like $30. We roll that thing over and put it over their eyes. Through there, you can see magnified and express, then put the shields in and IPL. To express again, it’s not that much more work because the patient’s always in the same position. I express gently. I also think this is very important. We don’t want to crush the glance. It’s very gentle and whatever comes out, comes out in the first round. After IPL, I get the remainder but it’s usually not like very tight.
That’s a mistake that I certainly had made before and others maybe are using a bit too much force, especially when you get in there with the meibomian gland expressor, whichever one you have, the forceps. There are different names for them. They’re named after people but they all look the same. When you get in there, it’s easy to put a lot of force on there inadvertently. RF, IPL, and expression, I’m going to adopt your new double expression technique. Do I have to pay royalties for that?
It will be fun. Let me know if you see as much success as I did. When I started doing this, I felt like the next appointment, people like, “That last time worked.” I was like, “Okay.” The first time I was vocalizing that I do this because I was doing it in my corner. Hopefully, that’s fine to do.
You read it here first on the show.
Only chatting with you.
That’s great. I appreciate your sharing. Those are the types of things that people reading are going to gain from this. It’s like those little pearls. This is what Claudine does in the clinic because you’re seeing these patients day in and day out every day at your clinic. Whereas most of us like myself, I have lots of dry eye patients, but I’m not doing as many of these treatments as you are.
I’m not doing as many of these other procedures as you are. Learning from someone like you is going to help as we implement those things in our own practices, so thank you for sharing that. We talked about RF and IPL. Is there anything more you want to share about those technologies? I know there’s so much out there on that.
It’s so great. It’s been a great addition. I’m so happy and it is a big investment. It’s a matter of calculating how you can monetize it but genuinely it has been quite easy to do when you see the results. I feel like a lot of patients come back to me and say, “I wish I knew this was going to be like this. I would have done it sooner or I wish other people would know who are on the fence.” Once they feel better, they have to spend a little bit more for the initial treatment, but they’re saving a ton afterward on not having to do repeat intense treatments.
Speaking of repeat treatments, do you have patients coming back on a routine, every six months or every year? Is there something like that you see regularly?
I do four treatments, initially, spaced out between 2 to 4 weeks then I’ll do a follow-up in six months and another one six months after that.
Are you doing treatments at those times at the six-month mark or is that just assessing?
Usually, I am and I boost it, but I see the person first. If they’re coasting, then we’ll coast with their at-home treatment. I always tell them, “I’m going to do this for fun. I want this to be beneficial for you and this is going to be something that will benefit you.” Usually, we have a 5 to 10-minute discussion first. I check all their scans because they re-go through that whole loop of everything. Following that, I’m able to decide, “Let’s do an extra one, or maybe we’ll do it in six months.”
I’m finding it similar. It is based on the patient and their outcomes and symptoms. There are some patients that we have coming in every three months because they swear that this is the only thing that’s helped them. They keep coming back every three months and if that helps them feel good, then great. Some come back six months or a year or not even for a couple of years, depending on how good they feel.
One question that’s a tough one that I feel personally to answer is, how do you define success for a moderate to advanced dry eye patient? Is it based on their symptoms? Is it based on the signs that you’re seeing? Is it a combination of both to put more context to it? One of those patients who comes back every three months, he’s a relatively young guy. He’s in his early 40s and before he came to see us he was using drops at minimum every hour while he was awake. He said on average probably 20 to 25 times a day.
That was the only way he was able to function. Otherwise, his vision would go blurry. He wouldn’t be able to read. He is at some corneal stuff. He’s tried a bunch of other treatments, so we did RF-IPL and the series of treatments and now he needs drops 5 to 6 times a day. If you were to compare that to another person and tell them, “You’re going to need to use five drops 5 to 6 times a day.” They would lose their mind like, “That’s so much.” The answer to what’s successful is going to be dependent on the patient, but do you look for certain things? Do you lean more on symptoms? Do you lean more in signs? How would you define that?
I’ll tell you exactly what I do and this might be another thing that you’ll let me know if this is what you do in clinic. The first time I see someone, in my chart it says goal, and I ask them, “What can you not do because of your dry eye that you would like to start doing in the future once we get better?” I was finding the same thing. I’m like, “How do I measure that they’re happy essentially?”
I measure it based on how they’re feeling. I will continue treating if I see pathology, but, for me, for the patient to be satisfied, for example, your five drop-a-day patient. That’s a success because he must be so happy that he went from 20 to 5. Maybe interlacing some other different treatments in there and he’s golden. He’s three times a day.
I say, “What’s the goal?” Let me give you a more recent one. She said, “I love reading and now, I could only read five pages. I have to put it down. I have to blink. I have to look away and it frustrates me. I’m not happy and not in a good mood because I cannot read more than five pages.” In my chart, I write, “Reads five patients pages currently. Would like to read more, done.”
I look at the patient and I’m like, “This is going to be a starting point. Every time I see you, you’ll let me know, are you able to read one more page?” I like to niche it down to that person and specifically target them and their goals, then they’re happy in the end. We get my side happy, which is all the objective things that I’m looking at. Ultimately, if everything I’m looking at looks fantastic and the patient is not happy. I don’t consider that a success.
If everything looks fantastic and the patient is unhappy, it’s not a success.
Even though you need the pathology to improve and the signs to improve, you do weigh the symptoms pretty heavily in that success, but that’s awesome how you do that. That’s such a great suggestion for writing a goal in the beginning. With dry eye treatment, a lot of times it’s quite gradual. After six months of doing things, patients are going to be like, “I’m not sure if I noticed that much difference,” but I’ll go back to the chart, our first chart and I’ll say, “You complained about this. Do you still feel that? Not really. You also complained about that. How’s that? That’s gotten a little better.”
When you do it like that, then they’re like, “It has improved.” It happens so gradually that they don’t have that comparison. Writing down a goal in the beginning is a great idea because then you can say, “You said you wanted to read this many pages and you can.”
You’ve exceeded it. It goes goal and let’s say, we have OSDI and that we could show, “These were your numbers at the beginning and these are your numbers now.” Different ways of benchmarking it but I added the goal in because I feel like everyone comes in with frustration and a pain point. I’m like, “What is your pain point and how could we help improve your quality of life with this treatment?” That’s what matters. These are people. They’re sitting in front of you and they want to do something that they cannot do.
That’s excellent. A great advice. We talked about some of these advanced treatment options. List of few that are maybe more advanced but there are things that I’m not doing. Others may have heard of all of them, but maybe we’re not doing them that much. Scleros we’re going to talk about, but amniotic membranes, punctal plugs, and autologous serums. Some of these more maybe things that require a bit more expertise. Where do you fall on some of those?
It’s different because Provence by Provence is also regulated differently. Let’s say when you’re talking about autologous serum. I do think they have a place. I don’t do plugs that much to be quite honest simply because there’s usually a ton of inflammation on the ocular surface. I feel like if I’m plugging it, I’m keeping that inflammation on the surface.
Again, everything has its little place. Scleral is the one that’s in this category that we’re talking about that I wish would be pulled into an earlier phase. Fitting a scleral on a dry eye means otherwise, a normal cornea. No pathology, no cone, no pellucid, and nothing is a great way to start fitting scleral because you’re fitting it on a spherical cornea. It’s a nice simple way to get into it.
I’ve seen it like I’ve seen some things that colleagues have done where the cornea is beat up like a lot of SBK. It’s a rough shape and they put scleral on top. It creates this barrier. It bathes the cornea in some solution and within a couple of days, whatever period of time but it seemed relatively quick. The corneal is looking a lot healthier. It seems amazing. A couple of questions for you, does it work?
Yes.
Isn’t it hard? Isn’t that a big process to go through? I’ve called you as I started to fit scleral. I know you’re a huge advocate and a big fan of scleral. You’ve helped me get more encouraged to do it but, to me, so far, being so early in the journey, it seems like such a process to fit a scleral because it’s not so quick and easy for me. Doesn’t seem like too much of an effort to treat dry eye? Are there alternatives that would do it better?
If we also think about it in the other way in the sense that you’re also providing them a solution if they wear glasses to wear something else. It’s not just a treatment in the sense that now they can go glass is free and they’re getting their dry eyes treated all in one and their vision is clearer because they have a more regular surface. It does look daunting and I completely agree. Can I try and simplify it to the bare bones of it? Truly, you could take your child set and pick any. Let’s say seven nine. You take it. You fill it with flu and liquid. Put it onto the eye. Based on what you see, do you have an OCT?
No.
You could evaluate with the thickness of the beam and the thickness of the actual flu you’re seeing if you do like a little slit. Based on that, you’re able to gauge if you want to remove one or put one on. A lot of the maybe apprehension and you’ll tell me what it is. It’s how do I pick the first lens? This looks like such a process, but you could take any lens and then insert it. Evaluate it at the slit lamp and if you’re close, you could refract over that and do all your calculations after the person leaves.
You could compensate and you could do all kinds of stuff afterward. The reason it’s great is because you’re giving them a contact lens option which probably they couldn’t wear because of the state of their cornea. You’re healing their cornea as you do it. Also, your religion doing it in a way that at first, will mess with the flow of your clinic because it’s new. Anything you do that’s new is like, “What a process.” The more you’re you and your staff, this is a team work effort thing. I don’t think you should do the whole thing yourself. The more you guys get into the groove, you’ll see the benefits of it.
The more you guys get into the groove, the more you will see the benefits.
I’m excited to try it. That’s a big part of it. I need to set up a bit more of a system and a protocol around who’s going to do which step just to streamline it a bit. When you put that lens on, I know there’s normally some solution that you put into the lens. Is there a benefit or can you use something like a Thealoz Duo in that lens to have that solution now covering the surface of the eye?
It’ll go and start healing and working on the cornea even better. I use theoloz duo to fill it. I can use other drops as well to fill it. This is like a personal preference. You ask any fitter and they like their little drop but you could use Thealoz Duo.
Is that fine in general for scleral lens or is that something you’d mainly do if you had somebody with dry eyes?
You got to keep in mind that all these things, also patients, there’s like a cost factor. They’re filling up their lens. Are they okay with it or they’re dropping half of it on the floor when they’re trying to insert and they’re using half the bottle? You want to go for something more viscous if they have bubbles in the lens and insertion. I’ll go for a gel drop so that it’s easier to manipulate. Again, it’s like picking your drop for your patient. This one is case-dependent but if you’re saying like, “Can you?” You can.
In theory, you can but you wouldn’t in practice.
I would for some patience.
For the dry eye patients. Not for the average scleral lens and contact lenses.
They could do it too.
Cost-wise, it would be?
It depends. That’s another thing. I give all options, then it’s up to the patient to determine what they could buy and what they can’t buy. I don’t assume for example like, “I’m going to give them the less expensive one.” I’ll say, “This is the one I recommend.” If not, then my tech will play around with, “This is another good one.” Maybe it’s a little less at that point.
Speaking of cost, scleral is not inexpensive. Does that get in the way of making this suggestion for patients taking your prescription?
No, but I see how it could in the sense that I’m very comfortable with it. I recommend it with confidence. As well, it’s one pair. You’re spending a lot of money, but they last like 1 to 2 years if you’re taking good care of them. Imagine what they’re spending on the rest of the stuff on all their at-home treatments, IPLs, and RFs. It goes in the mix. If this is a good treatment for them and they can do it, then they usually go for it.
That’s a good point. If this lens is able to solve a lot of their issues, it will maybe take the place of having some of those other treatments and potentially cost less. You still have to get to the underlying cause though. This is like fixing the cornea but then we still get a treat for the MGD if that’s there. Maybe more of an additional cost but it’s still something that will heal that cornea like some other treatments probably cannot.
It’s another thing in our toolbox. I consider it. I have all these options in my toolbox and which one am I going to pluck out for what patient? That’s what’s fun. At the beginning, you’re like a detective. You’re figuring out what’s going on then you’re using what you have. Even if I don’t do something very often, I’m like, “This would be a good case for that. Let’s try it. Let’s go.” I’ll tell the patient, you’re a good candidate for this but for X and Y reasons. They always know what’s going on. My patients genuinely always know what’s happening at all times.
That’s good. That’s important especially when you’re going to be making some pretty significant recommendations and some more invasive recommendations as well as the first treatment. The other question about scleral which I’ve heard come up is the concern about trapping inflammatory cells and things under the lens. Is that an issue? Is that something you see as being a real problem?
I haven’t seen it as being a real problem because these patients, we treat them a little bit before but it tends to heal with the scleral lens on it. I haven’t noticed anything and if we did, we’d tweak as we went.
On the note of inflammation, where do steroids come in for you? How easily do you prescribe? How often do you prescribe steroids?
I will prescribe them if needed but it’s not like my first go-to. I do this a lot and I see a lot of people. I say this because I know that at the beginning, everyone’s like, “Go with steroids.” That is totally fine and there’s nothing wrong with that but I genuinely find that with solutions we’ve had that we have at our disposal.
I’ve had to use them less and now I don’t use them as much. For example, Thealoz Duo gel for real. Whereas before, I might have put a steroid on that. I’ll start them on the Thealoz Duo gel and I see a significant improvement that I’m not going to start them on the steroid for fun. It does help in those mild cases to moderate events. If they need it, they’re getting it. I’m prescribing it, but I wouldn’t say I’m very forward with it.
My threshold for prescribing steroids is very low.
That’s cool, too.
Now that I know that Thealoz Duo gel works so well on SBK. That’s certainly going to become my first line.
We could try and that’s it. See how it works with your patients and you’ll develop that comfort. It just happened this way that I was starting to do that and I thought, “Funny. That patient, I would have normally put them on a steroid but now I don’t have to,” then went that way.
How about like immuno-modulating types of drops? Are you recommending those quite a lot? Is that something that’s commonly used in your toolbox?
When needed, we get there right. Here’s my philosophy and I tell this to my patient. What I say to my patients is, “My first job is to figure out why this is happening. My second job is to try and get your own body to function the way it should.” That’s my philosophy. It might be a little bit granola or organic in that way in the sense that I truly want to give patients the ability for their eyelids to function as they did or as best they could.
My first job is to figure out why this is happening. My second job is to get your body to function how it should.
I will sit there and layer on adjunct therapies. Maybe before it was like steroid and immuno modulator. That was what we did right out the gate and we’re like, “Go.” Now, I’m more of the mindset of, “I talk a lot about nutrition. Dr. Mila put out an amazing guide and she works with another Dr. Footsch.” I refer them to that.
I will refer them to use other different kinds of things that will heal them from the inside out which I believe that’s what IPL and RF are doing as well. All of these things I use, but I try and get the patient to have their own body healing as much as they can so that when I do put something in later on top, it’s not going against it. We talk about the cosmetics.
That’s what we should aim for. It is for the body to function the weight and it’s best at it’s best if we can. Shout out to Dr. Mila Loussifova and go check out Eye Thrive Wellness. It’s great. I’ve been doing the doctor’s side of that protocol where you get the training. It’s been nice to get that and it has inspired me to have more of those conversations with patients about how nutrition can affect your eye health. Your gut health can affect your health or if there’s inflammation in your body. It’s more likely to lead to inflammation in other places. Good to try to control that everywhere. Have we missed anything? We’ve gone through a pretty long journey.
We did a lot.
We started with Harbir a few years ago, who was sampling drops. We stopped him from doing that. We got him to start retailing some good products. We got him to start using questionnaires and checking for dry eye then recommending home therapies, and warm compress. Maybe even doing some simple therapies in the office like blepharoexfoliation, then we stepped it up. An IPL and RF started doing that and seeing good results with that. I may even start doing scleral for dry eye and I’m going to let you know how that goes. What else do you want to say to the people out there about dry eyes?
The thing again, to be real for a second like every year, there’s something that’s the hot thing. For a couple of years, there’s something that’s a hot thing. Now dry eye was the hot thing for a couple of years and it’s still popular. For example, we’re in Toronto. The Dry Eye Summit is happening. That conference is growing and it’s always sold out.
Clearly, there’s still a hunger for this information. I’ve personally felt a lot of talk about myopia management. I’ve had a lot of that on my show as well. I feel like sometimes the audience may get a little numb to like, “Dry eye again,” but I wanted to create a conversation here that was a full spectrum of things.
Not like talking about one dry eye topic. On that note, do you think there’s anything else you want to share? There are still people and lots of our colleagues out there who are not doing a lot of dry because they feel like it’s tough to get into or it’s too much hand-holding with the patient. Is there anything else you want to share that might help encourage those colleagues to get into it a bit more?
There are two things. The first thing is doing something is already a huge step. Anything you do. You don’t have to go out and get the IPL and RF on day one. Those little modifications that we talked about at the beginning are awesome. If this isn’t your thing, it’s okay. It doesn’t have to be your thing. There are things that aren’t my thing but let’s get in the habit of inter-referring and that’s what I love.
I work with a ton of optometrists in my region and they’ll refer to me. I’ll do the treatment. I am sending a report. I refer back to them and this collaborative model is where it’s going. It doesn’t mean it has to be your thing. If you don’t want to dive into it, it’s okay but it still has to be your thing to identify and address the person’s problem. That’s all.
If someone’s like coming in and they are voicing that this is something and you’re like, “I do not want to go down this path.” Find a friend who does and who loves it. Build that rapport and whatever you’re good at because 100% you’re good at something too. That friend will refer right back. That’s something that I wish we did more of. I would continue to advocate for that because it’s just such a beautiful profession of Optometry. I adore it and I feel privileged to be part of it. We all have sometimes something that we love a little more, so why not maximize and make it the most efficient profession by inter-referring to each other?
We all have something we love a little more, so why not maximize and make it the most efficient profession by interfering with each other?
Great message. Thank you for sharing that. That collaborative approach is so important for our personal success and satisfaction in our own work. You get to do more of the things that you love and you can refer out the things that you don’t love. Refer to someone like yourself who loves doing it. Everybody’s happy. The patients are happy. The patients see that we have a cohesive profession and we’re supporting each other.
It’s going to protect our profession from potential intrusions but other entities coming in and potentially invading the profession. I was listening to something someone said about what happened in that case. Let’s say somebody doesn’t refer or doesn’t treat. We have those types of gaps in the profession or in our treatment. If that gap remains too long, something is going to come and fill that gap. That something might not always be something that we want there. If we stay, we stay cohesive and we work together. We’re filling all those gaps together. That’s going to be best for the long-term success of the profession as well, so thank you for sharing that. That’s it. That’s the end of the third episode.
That’s it. Thank you so much.
We recorded three episodes and we’re all done. Thank you, everybody. Thank you, Claudine.
Thank you.
I love you. You’re amazing. Thank you so much for sharing so much of your insight on these three episodes. It’s just gold. Anybody who reads this, I know they’re going to get so much out of it. I want to say thank you again to Théa Pharma, Canada. You are the best for supporting this episode and this whole series. Optometry in general, thank you so much for all the support and to everybody out there for reading the episodes, Canada’s number one optometry show. I’ll see you guys in the next episode.
