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Good evening and welcome. Thank you for joining us today for the understanding of and managing of dry eye disease latest advances in treatments webinar. I am Doctor Sherry now, a board certified optometrist at Mayo Clinic, Rochester, Minnesota, and I will be your moderator for today's discussion. We're so very glad to have you with us today. I am pleased to introduce our speakers for today. Doctor Ashley Bernheisel is a board certified ophthalmologist with fellowship training in cornea and refractive surgery and global health. Doctor Barbara Tila is a board certified optometrist with advanced training in ocular disease. We all treat patients in our dry eye disease clinic at Mayo Clinic in Rochester, Minnesota, a clinic that Doctor Tila actually founded. Welcome, Doctor Bernheisel and Tila. Welcome, everyone. Thank you for that wonderful introduction, Doctor Now, and thank you everyone for joining us today on this webinar. My name is Barbara Tila, and along with my good friends, Doctor Now and Doctor Bernheisel, we will share insights on this condition that affects millions of people worldwide. Dry eye is one of the most common reasons why patients come and see us in the clinic. And even though it may seem like a slight inconvenience to some, for many of our patients, it affects their quality of life and overall well-being. It's important to remember that dry eye is an umbrella term, and it incorporates many different ocular surface conditions. Today, we will understand the underlying causes and risk factors of dry eye. We will identify symptoms and go over some diagnostic testing, explore various treatment options, and gain insights into the importance of a multidisciplinary approach when it comes to treating dry eye. So when it comes to dry eye, you can't escape it. So let's embrace it together. We'll go ahead and get started with Doctor Bornheisel. Hello, um, I'm Doctor Bernheisel has been mentioned. I'm gonna go over dry eye disease, as, as, as Doctor Tila said, it's really an umbrella term. It's a multifactorial disease, and it can be from a loss of homeostasis in the tear film. It can be from tear film instability, hyper osmolarity, ocular surface inflammation, or neurosensory abnormalities. And in my opinion, it can even be just from the symptoms of dry eye disease. If someone comes in and says, my eyes feel dry, in my opinion, they have dry eye. This, this dues to definition and classification report was exactly where this definition came from. It was created by 150 experts in the fields, and of which some of them are in industry, but many of them are in academics and did not have um any, any financial disclosures, but I just want to mention that, you know, there's always a possibility there. So, let's talk a little bit about prevalence. So, global prevalence first. This dues to report estimates that between 5 and 50% of populations worldwide. may suffer from dry eye disease. Now, the problem with this is that it's difficult to compare apples to apples with prevalence reports, cause it really depends on who's being studied, what is the population, what are their ages, um, and also, how is dry eye defined. If in one study, it's defined by symptoms and which symptoms, and others, it's defined by exam findings and which exam findings, you can see why you can get this huge variation. In prevalence. Now, some of it's probably real. I did look at the 50%, the study with 50%. It comes from Tibet and it's thought to be from, um, some of it to be from high altitude, although it's not super clear. Um I thought it was interesting. The title of the paper is uh Prevalence of Dry Eye in the Elderly in Tibet, and the inclusion criteria was anyone over 40. Um, I just turned 40 this year, so I guess I am officially elderly, although I already knew that because I've had two geriatric pregnancies in the last 4 years. So, um, there we go. So, um, US, the US prevalence based on the DSI report is about is about 18% on average, um, and that equates to about 16 million US adults who are suffering from dry eye. Um, it is, we know that there's more women than men, and we know that it increases with age. This, um, graph over here shows how it's increasing with age. Um, but you can also, you know, we, we often discount the 18 to 34 year olds. They still have dry eye disease. Yes, they're on the lower end on the spectrum. Um, but I've seen plenty in this age range that have horrible dry eye, um, that is affecting them. So don't, don't discount that, that age group. So, let's talk about quality of life. So, the one, when I think about quality of life, and, and everyone might think about this differently, I think about just the irritation that people have from the dry eye. Um, it, it can affect their functioning due to pain. Um, also, at the time it takes to do therapies and the decreased productivity that comes with that. But also vision-related quality of life. Um, people report that they're more, that when, when their eyes are really dry, they feel like they're more likely to fall, um, having more difficulty with reading, more difficulty with driving. And then, the, the, the big one that I think as providers, we could be doing much better about is thinking about their mental health. Many report anxiety, depression, um, due to their symptoms. And again, due to all the, the time they have to do the, the time they need to put in to treat this. And so sometimes a referral, referral to a, a wellness center or therapy, um, is, can, can be a huge help to these patients. Let's talk about, again, I mentioned this previously, but the time it takes to treat their dry eye. So, this is uh a paper that by our very own doctor now who is moderating. Um, that shows this variation in how much time people are spending treating their dry eye. So yes, there's a huge range here. Um, as, you know, some people are doing nothing, obviously, but there's some that are, you know, there's a lot in this front range from 5 to 30 minutes. That kind of makes up the big chunk of the, the amount of time that people are spending. But also, if you look at the higherness, this is kind of like a, uh, a bimodal distribution. We look at the 60 to 180 minute range, and there's, it's not insignificant there. A lot of people are spending an hour to 180 minutes. Dealing with their dry eye. Um, and you can, can imagine that is, uh, a big deal and a, um, a big negative for their quality of life. All right. So let's talk about individual economic burden. So, from the same paper by our doctor now, they estimated that the mean annual cost of disease management was over $1500 per year. And that didn't matter how that was regardless of disease duration. This is about a 65% increase from that what was reported in 2001 when it was thought to be a little under $800 a year. Um, and this this was using very similar methodology. And, and what this tells me is a couple of things. Um, you know, I guess my concern for this is that industry is almost taking advantage of this in some way. They know how desperate people are. Um, and I mean, a lot of the stuff isn't isn't covered by insurance. Um, Other financial burdens, the time away from work, um, to go to a uh to appointments, uh the time away from work to do some of these treatments if they're on the, the higher end of that, uh, graph that I showed you. Um, so this is a paper that looked at the burden, you know, in various areas in the world. Um, of course, the US stood out, um, but in the US alone, we spend $4 billion annually on dry eye disease. Um, again, just showing that this is, this is a real issue. So Let's talk about causes and risk factors. I, I talked, uh, I mentioned them earlier when I talked about the dos too, but let's kind of, uh, you know, we're not gonna go deep into the pathophysiology here, um, but let's talk some basics. So there's Tear production and quality issues. So it can be that the, the patient is just not making enough tears, um, so they're deficient in tears. It could also be that they're evaporative, so they've had a leoplasty, um, and now their eye is dry. Or it can be both. Um, there's also environmental and lifestyle factors. And again, there's kind of crossover between these sections. Um, digital device use, screen time, airflow, AC heating, these are all in the evaporative dry category, um, but just, you know, different ways to think about it. Also, air quality, smoking, air pollution. I'm gonna go over this later in terms of risk factors. Um, it's, there's not, you know, really strong data to suggest that these are, um, really, really strong indicators. But again, they, for some people, they might be a big deal. Also, medical conditions and medication, autoimmune diseases, hormonal changes. So this is that table that I was talking about again from the dues to report and just to be clear, this dues to report was a process that took 2 years and there's multiple parts to it. This is the epidemiology report. Looking at risk factors, and they divided them into non-modifiable and modifiable risk factors. Um, and then they look, look at the strength of the evidence. So basically, really strong evidence um is on the left here with consistent, and then there's moderate with probable and inconclusive. So again, that's where we see for sure non-modified non-modifiable risk factors are aging, being female, being Asian, modifiable ones would be screen time, contact lens wear, um, being on these medications, antihistamines, for example, and antidepressants. Um, and then inconclusive again, like I talked about talked about smoking, alcohol, um, uh, so again, they've, they've, they've broken them out here and you can, can access this, uh, graph if you're, if you're interested. So, diagnosis, again, going back to what I said earlier, if someone comes in and says that their eyes are feeling dry and irritated, I think they have dry eye. Again, that's what Doctor Tila said, this is an umbrella term. And um You know, she'll go over some of the treatments, but it's about knowing when people are coming in with these various, these various symptoms. Um, I, I call it all dry, dry eye. But what's important about these, these exam findings are that this is how we can tell if they're getting better or not. Um, so we often give questionnaires. There are a lot of them out of there. Um, out there, there are various lengths. Um, I personally like the ocular surface Disease index, um, questionnaire that's just 12 questions. There's also a speed questionnaire that's 6, or sorry, 88 questions. But, um, Um, the OSDI is, is, I think, a good one for clinic. Um, all, uh, obviously a slit lab exam, something that we're all doing, tier breakup time, churer testing, osmolarity, um, looking for inflammation with MMP9, Liamine green, fluoresce staining, um, and imaging. Um, imaging might be looking at my bomian glands, um, You know, also looking at placebo disc. So, these are all things that can, can help us really delve into what's causing their dry eye. Um, and then I think one other thing I didn't mention here is that it's important. It can be a really nice test, especially for that neuropathic pain, which, you know, I think we all get a little bit afraid when, when, when that comes along. Um, but one test you can do is a propar can test. What I, you know, what, what, what a lot of um dry eye clinics do is they set up a specific order for all of these tests. Um, so like they'll do the questionnaire, maybe do, um, you know, you know, one other test, then, then ask the patient to rate their pain from 0 to 10 or their just eye discomfort. Then they'll do some more testing before they put in any propparrica. Um, they put in the proparrica and then, and then later ask them, what would you rate it now without telling the patient what they're doing. Um, and if you get a 9 at the beginning and a 9 after proparrica, um, then you can, you can consider that this is potentially a neuropathic. Cause and that you might need some help from neurology. And to go deeper into our treatment modalities, um, I'm gonna give the mic back to Doctor Tila. Thank you. Thanks, Ashley. So, um, let's get started with management and treatment. So when we start and when we first meet our dry eye patients, we want to start with education. We wanna educate our patients that they are dealing with a chronic condition that is multifactorial in nature, like Ashley already alluded to. And we also want to set expectations right from the beginning. So we wanna make sure that our patients understand that dry eye is not something that we can cure, but the good news is that for the most part, we can manage and treat it, and we can usually make things better. So when it comes to education, usually we're discussing lifestyle changes, dietary changes, and also some home remedies. When it comes to lifestyle changes, I like to say what's good for the body is good for the eyes. So, simple things, reminding the patients to stay hydrated, to quit smoking, to take breaks from screen time, use a humidifier, etc. Now, when it comes to dietary changes in the dry eye world, usually we're talking about increasing omega 3 intake. Now we can get our omega 3s from our diets, from fish, from walnuts, from flax seed, but when we currently look at the Western diet, that omega 6 to omega-3 ratio should be somewhere in the 4 to 1 range and it ends up being 15 to 1. So most of us lack omega 3 intake. So that's where the omega 3 supplement discussion comes into play in many dry eye clinics. In the last few years, there has been a lot of discussion and a lot of debate whether omega 3s are beneficial for dry eye. And at this point, I would say there is enough evidence to support omega-3 use. Uh, we know that omega 3s are anti-inflammatory. But not all omega 3s are created equal. So it's important that our patients understand that the dose, the form, and the ratio matters. We want around 2 g a day of that uh reaserified triglyceride form of omega 3, and we want that ratio of EPA to DHA to be somewhere in the 2:1 to 3 to 1 category. I will also often tell my patients to make sure that they're getting their supplements from a reputable source. Then we go to the home remedies, and these include simple things like warm compresses and hygiene, again taking breaks. Um, so when it comes to warm compresses, we're usually recommending twice a day for 10 minutes at a time. When it comes to eyelid hygiene, usually we're talking about eyelid sprays like hypochloric acid or different uh types of eyelid wipes. Now, um, compliance with these treatments can be difficult, can be low. Um, and again, I feel like if we educate our patients and they understand why they're doing these simple home remedies, they are more likely to stick with the treatment. So oftentimes at my initial dry consultation, um, Ashley uh mentioned imaging, I will show. The my biographies to my patients. So I will show them their own mybomian glands and say that this is what we're working on preserving. And even though these treatments may sound silly and they're not gonna make you feel better tomorrow or next week, they are working on keeping your mybomian glands in good shape because once we lose them at this point, we don't have a way to bring them back. Then as we keep going with management and treatment, um, we can again go to another section of the TASUS2 report that was published in 2017 and look at the management and therapy report. Now, this report includes all the possible treatments for dry eye that were available up to the year 2017, and it is a really nice list, and then there's also the data behind those treatments. This report also kind of gives us a stepwise approach uh when it comes to treatment, and I do think that approaching treatment in a stepwise fashion and using an algorithm is, is a good thing to do, but we have to remember that dry eye varies from patient to patient. So as a provider, we have to modify and customize treatments for our patients depending on what their needs are. So when we continue with our conservative treatments, that includes ocular lubricants, and we will go into a little bit of detail about those. We always want to address the lids as well. Um, uh, so at this time, we do have a single prescription drug for blephritis that we will discuss and again, the simple home remedies like the eyelid um hygiene is good here. Uh, we will use puncta plugs often as well in the dry ice sector, and here I'm usually choosing between silicone or collagen plugs. And again, there is no such thing as a perfect plug. It depends on who the patient is that's sitting in your chair. So if I want short relief, maybe I'll choose a 3 month dissolvable collagen plug. If I want a longer term relief, maybe I'll go for a silicone plug. Knowing that statistically, the plugs do end up um Falling out, you know, the first few months after placing them, more than 50% of our patients can end up losing our plugs. So it's also important that we follow up and make sure that those plugs are still in place later on. Then we can look at things like moisture chamber goggles or wraparounds. And even though these treatments can sound very basic, they can be quite helpful to our patients. For example, the sleeping goggles for our patients that love the ceiling fan that you. Oxygen, the CPAPs. And I also think it's very important to demonstrate this to our patients. So it's not enough just to say these words out loud. I usually like them to see the goggles, touch them, and then I'll send them over to the optical to get fit for the proper sizes. The wraparounds I find very helpful, especially for things like my athletes that feel like the dry eye has interfered with their sports, so they can't bike anymore, they can't run anymore because it hurts too much. Um, those little wraparounds, especially the ones with those little silicone inserts, can be helpful in protecting the ocular surface. Then we often will also use ointments, especially at bedtime to create a barrier, same idea as the sleeping goggles, and then we will go into a little bit of detail about the prescription medications. So when it comes to ocular lubricants, we know that ocular lubricants simply supplement the natural tear film, but they don't, uh, they don't target the underlying pathophysiology of dry eye disease. And when we go over the counter, there is just a ton of options. So when we flip those little bottles around, um, they will contain Active and inactive ingredients, and we know that the goal of the active ingredients is to actually give us the lubricating or moisturizing effect of the drop. The inactive ingredients sometimes exist to make the active ingredients work better, sometimes that's the preservatives use the pH adjusters, or the viscosity enhancers. So this is a list of the numerous different active and inactive ingredients we can find in our over the counter products, and the list isn't even complete. There's many more out there. But for the most part, most brands uh of lubricating drops share similarities in their major components, but they can vary in the similarity in the viscosity, or in the pH. So sometimes patients will ask which is the best one, and unfortunately, the answer is that there is no. Single best drop, and there definitely isn't data comparing the drops, so we can never um you know, recommend a superior or a better product. I will tell my patients, try to stick to brand name and whenever possible preservative-free products, and again, um, get your uh drops from a reputable source. So clinically speaking, usually, Uh, we are thinking about, OK, what are we supplementing. So we know that more than 80% of dry eye is evaporative in nature, so many of us end up um recommending the lipid-based tears. Uh, once in a while, some patients will say, oh, for one reason or another, I don't like them because they're a little too oily for me. So then we can always recommend the aqueous-based tears, which are a little more watery. And then we also have, again, room for our gels or ointments, especially when we're creating a barrier, for example, at bedtime. And then we'll go into the prescription dry eye drops available. So, the point of this timeline is to show you, um, as I'm sure you already know, that the dry eye world is booming, and I suspect that this is only the beginning. So if we go back to the year 2000 to 2003, that's where we have the introduction of cyclosporin 0.05%. And that's actually the time that I was a young high school student and got my first job at an optometrist's office. So I very clearly remember the rep coming in and telling us about this new amazing job on the market, the first of its kind. And then look at that gap. We had more than a decade with nothing else. And then in 2016, we got our lifidographs, and in 2018, cyclos 1.09%, 21, we had our Veranic clean nasal spray, and then last year was just a really busy year for the dry eye world. We got um. 0.1% for fluorohexyl octane. I did include Lorainer on this graph, knowing that it's not a prescription dry eye per se, but oftentimes, again, we will treat Demodex plephritis along with treating dry eye. Um, so just making the point that we had a lot of new products come out last year. And also last year Thos did publish another report. It was a lifestyle report that we'll see later on. So when it comes to um treating dry eye, we know that ocular inflammation is a major contributor to dry eye disease, and the source of inflammation has been linked to T cell activation and the release of pro-inflammatory cytokines. So all of these options on here are anti. Inflammatory options. So I do think that there's a good uh place in the dry eye world for corticosteroids. When it comes to dry eye, we know that it is a chronic condition and we can't leave our patients on chronic steroids because of the side effects such as an increase in eye pressure, cataract formation. Um, so I do like using soft steroids or ester-based steroids for flare-ups or when my patients are just feeling really miserable. So, uh 0.25% loopretinol is approved for dry eye, up to 2 weeks for signs and symptoms of dry eye. Clinically speaking, I will often reach for fluorometholone just because it's easily accessible to my patients, and it's pretty inexpensive. And I will sometimes send my patients home with an emergency soft steroid, because dry eye can cause quite a bit of anxiety for our patients, and maybe if there's a wedding coming up or an important job interview, I want to make sure that the patients feel safe and they will always reach out to me and let me know if they're starting this little emergency drop, but I don't want them to feel like they're stuck and, and have nothing that they can do. And then we go into our cyclosporins at this point we have 3. So again, the 0.05%, that's our oil-based emulsion, uh, the 0.09% is our aqueous-based um nanomy cellar formulation, and our 0.1%, our newest one is our water free formulation. When it comes to cyclosporin drops, um, I think the biggest challenge we deal with as providers is compliance with these drops, especially the early cyclosporins, because our patients will often report that the drops are uncomfortable. So again, here, the education and setting expectations is very important. I usually will tell my patients, when you're using these drops, they can be slightly uncomfortable, but you're not using them to feel better in that moment. You're using them so that we can decrease inflammation over time and hopefully increase tear production. Now this uh increase in concentration of these cyclosporins over time, I think the goal has been how do we make a drop that works a little faster, that doesn't take 2 to 3 months to work, how do we make it more bioavailable, and how do we make it more comfortable for patients. And then we have lieddores, um, which also helps inflammation. Um, and sometimes with the photographs, patients will report that they have a, uh, an, a bad taste in their mouth. Then when we go into this other other category, we have the Vareniclelu nasal spray. And this spray is a nicotinic acetylcholine receptor agonist. So this medication activates the trigeminal parasympathetic pathway, so it's almost like a pharmacologic neuroactivator, and it stimulates the lachrymal functional units. So that's how we're producing more tears. Again, setting expectations and educating our patients, this is probably the only um nasal spray spray they will use where they're not. Trying to inhale it in to the sinuses. They're trying to point it towards their ears so that they activate a nerve in the side of the nose. It's also pretty common for patients to sneeze, and I want to reassure them that it's OK to sneeze. It's OK if you have a little bit of a drip coming out of the nose right after installation. The medication is still working. So again, this is more like more likely going to increase our patient's compliance. And then we have perfluorohexy octane, ophthalmic solution, that's a mouthful. And um that drop targets tear evaporation, and the way that it does that is it creates a monolayer at the air liquid interface, so it almost like tries to mimic the natural mum, and this is also a one of a kind we haven't had anything like this on the market before. And then again, not a prescription dry eye drop per se, but a drop forgainex plephritis, which blephritis often goes hand in hand and dry eye. Um, this medication inhibits the gabagated chloride channels that are specific to mites. So they will paralyze and kill the mites, but we are safe, um, as humans. Then we go into this category of advanced treatments. The 1st 3 on this list, the thermal expression, the IPL and the eyelid cleaning exfoliation. I like to put that in the category of my booming gland dysfunction and eyelid margin disease. The bottom three, the blood derived drops, the amniotic membrane, and therapeutic contact lenses. I like to say I put that in the Nerve category and, and Doctor Byrne has already discussed neuropathic pain a little bit, so we will get into the details of that there. So these in-office treatments that we have available for our patients are essentially targeting my boing gland dysfunction, and we know that my boing gland dysfunction leads to evaporative dry eye, and evaporative dry eye is the most common form of dry eye. When we have gland dysfunction, we see chronic gland inflammation, we see thick my bum, and then over time gland destruction and gland atrophy. So essentially these in office treatments try to help us with this dysfunction. So there are a few systems available out there. The idea with all of them is to apply heat and pressure to the eyelids for a few minutes to melt the mybu, and then we're expressing the old Mbu, so then the body can produce newer, finer, better quality MOM. So hopefully we can improve the function of. My boing glands. Now, these thermal expressions can be combined with other treatments. For example, in our dry eye clinic, I will often combine a thermal expression with a micro bluff for exfoliation. So usually I wanna clean up the eyelids first, um, and then I will heat and express. Now, there is no perfect science um here. Uh, for the most part, clinically our patients, I think, feel better from this and they respond well, but again, we have to educate and set expectations. These treatments are not a cure. They are a treatment and They usually need to be repeated periodically. How often? Usually I will say about once a year. There is some data out there that says that maybe the effect can last up to 3 years, but oftentimes they can be dependent on how compliant the patient is with the home therapies that they're doing. And these are out of pocket along with the next view that we will go over. So this can be an economic burden to our patients, and they can be beneficial. This treatment can be beneficial for patients with compliance issues. Then we go into intens post light therapy or IPL. So this is essentially a non-laser light source where we apply pulses of light to the skin. So we will do tragus to tragus twice, and then we'll use a smaller device to get closer to the eyelids twice as well. And again, there's proposed mechanisms for how this works, and uh the way that this works is it improves my bone quality by increasing the perioiocular skin temperature, so again, we're heating things up. Um, it can help by causing destruction of the periocular injectasia. So patients that have ocular rosacea, this can be a really good treatment option for them, and also it can have some antimicrobial properties and possibly help with uh lephritis. So, the IPL um has some, you know, uh, myboin gland dysfunction, uh, properties. Like it helps with my bone land dysfunction, but it also has a little bit more some anti-inflammatory properties as well. Now, this treatment also is not one and done, because again, we're not carrying dry eye. So we're starting usually with 4 to 5 sessions, 2 to 4 weeks apart, and then there's always maintenance, and maintenance can be one maintenance session every 6 to 12 months depending on the patient. Now, we know that my boing gland expression has a synergistic effect here. So after each light therapy, we do an in-office expression. And this again can be a benefit for our patients with compliance issues, and it is also a um an out of pocket procedure. And then we go into cleaning up the eyelids. So we have the eyelid cleaning and exfoliation. The idea here is simple. We're just cleaning the lids, getting rid of the biofilm. Now, most of the time patients that have moderate to severe blephritis will feel better right after a treatment. And depending on how good they are with the home therapies, they can repeat this every every couple of months. I would say I usually try to aim for not more than twice a year, but there are patients that um want to come in every 3 months or so and, and get their lids cleaned, and this also is out of pocket. So now here, and this is where I'll get a little bit of advice in a minute from Doctor Bernheisel, we are entering what I would call the nerd world. So when we are looking at blood derived eye drops, we are usually talking about the autologous serum tears and the platelet rich plasma. So, we don't fully understand the science on how these work, but most experts agree that it's good for you and that it works. Um, in the future, we do need to standardize the use and the manufacture of these products, um, because currently there are no head to head studies, for example, comparing the various dilutions, so whether it's serum, uh, tier 20% or 50% is better. Uh, you know, we don't really have that answer. But the claim to fame of these drops is that they resemble human tears. So they have some vitamins, some growth factors, and some nutrients, and that these uh blood derived drops are also mentioned in the Thaus to report, and then there they are step 3. So again, they're usually not the first thing you're reaching for. You've tried other things and maybe they haven't worked, or maybe they worked, but they're not good enough and you need more. So then you go to this category. This can help heal ocular surface, um, and reduce inflammation, and again, we're reserving it for the moderate to severe cases. Uh, and this is a commitment from our patients because they do need a blood draw every few weeks and uh you need a compounding pharmacy to be able to make this. This can be expensive, it's not covered by insurance, and then because these drops are um compounded, um, you know, we wonder, is everyone that's making these following the same guidelines. Um, Doctor Bernheisel, do you use serum tears or platelet rich plasma in clinic a lot? Um, I'm using serum tears. I really like serum tears, like you said though, I mean, I'm not reaching for it first, mostly for, again, the financial barriers which you discussed. Um, but I do have patients where I try everything else and I put them on that, and they wondered why I didn't start with it. Um, so they, they tend to be, you know, again, I never guarantee them anything, and that's why I say, and, you know, that's why I explained why I didn't put it on right away. Um, but I do, I do have a conversation that, you know, this can, can make a big difference, but it's a financial cost to them and that there is no guarantee. But again, I do end up with, um, you know, I probably say a little, you know, around 60% of patients who nothing else helped and and this was a thing. Yeah, and I agree. And also another thing I would mention is, you know, the question of, well, how long do we leave them on something like this, and we're talking about a blood draw, right, every few weeks. What I usually think about is if I have a really young patient in my chair, for example, in their twenties with neurotrophic teratitis, I am hopeful that maybe a few months serum tier regimen will get us to a place that's good enough to where then possibly I can manage with what's available without the blood draw. Um, but again, I don't think there's perfect science behind that. But yeah, I don't want a 20 year old to be tied to blood draws for the rest of their life because um they need to stay comfortable. Um, and then as we continue this journey, we have amniotic membrane grafts. Um, now there is a study here that you can see to your right, and this was a retrospective chart review at 10 different clinical sites, and essentially they looked at about 100 eyes, and um this study did show that there's promise to enhance recovery and ocular surface health with the use of amniotic membranes. Here specifically, they were looking at the Cryopreserved amniotic membranes. Now, the way that these work is when you put them on the eye, essentially they do act like a bandage, um, and they also have some anti-inflammatory properties as well as, as some regenerative properties. So again, usually we'll, we are reserving these for the more moderate to severe cases. I usually keep the acquire preserved membranes on for about 3 to 4 days. The patient comes in and I, I remove the ring. Um, and, and I have seen this help, um, the ocular surface quite a bit. Do you use these in clinic at all, Doctor Bernheisel? You know, I use the dried membranes for graft versus hos or neurotrophic keratiti. I'm not typically using them for dry eyes. I mean, by the time I've tried, tried everything including serum tears, um, I'm usually sending them your way for some of these more advanced therapies. Um, but, I you know, I, I, I think it, I think it's not a bad idea. Um, and I wouldn't, I wouldn't certainly wouldn't be opposed to it, cause like you said, some of the, some of these patients are in such chronic inflammation that then leads to more dryness, and then the dryness leads to more inflammation that some of, some of, sometimes I could, you know, I could see how this would get them out of that cycle. Yeah, I totally agree. And, and again, the science here isn't perfect and hopefully we'll get more good data in the future, but at this point, um we have to do everything we can to help these patients. Do now, how about sharing some contact lens knowledge? You're a contact lens pro. Absolutely. So I, I know on here are listed so um bandage soft contact lenses, and that can be an easy thing to grab, but I don't grab it very often and I'm very cautious with it. I'm, especially in a dry eye patient, I'm really worried about having a complication or infection, so it's rare that I would grab a a soft bandage lens for someone. But I go to scleral lenses quite a lot. I'm, I'm comfortable with it. I fit them and I've seen them be very helpful. I know earlier, especially sports was mentioned. So if someone's in sports and a lot of high air flow is bothering their dry eye, this is a great solution as well. This does help protect that surface. They're not perfect either. So if someone has a really Um, poor mybomian gland function, they can get a lot of haze on the front surface of the lens. Some patients get a lot of fogging between the surface of the eye and the and the lens, so they find they have to handle the lens often, take it out, clean it, replace it. It can be very good, but you again goes back to education, patient education and expectations, but I've had patience with this too. Why didn't you tell me about this earlier? I've had the patients that I have said about this earlier and they're like, oh no, I don't want to do a contact lens, and then they finally try everything else and they, they will try it and and it works for them. So it's a good thing to keep handy and available for use. Fitting well is is key because you can certainly with the contact lens create other problems, so making sure the fit is good, that The lens itself isn't causing a complication, and sometimes I do use it with other things. There are a few patients that I have a sclero lens and autologous serum drops. So there are a few that that have to go that route, but if we can keep them comfortable and functional, it's, it's a great option. Absolutely. And oftentimes I will send patients your way to fit them. Sometimes you will send patients my way, so I can make them my bone better so they don't have the deposits on the lens. And I think that's the idea, the way that this dry eye world works is, is sometimes it takes a couple people and a little bit of work to get to where we need to be. Right, and like everything in the dry eye world, sometimes, you know, the sclero lens works for a while and then all of a sudden they're getting The, the fogging with the lens and so then I can send them your way. So it's not a, a static condition. It, it changes and we need to be flexible with the patient as they change. Totally agree. So now let's um go to some neurosensory abnormalities, and Doctor Bernhauser at the beginning already alluded to this a little bit. And again, if we go back to the original uh dry eye disease definition that was published by by TADS2 in 2017, this specifically is listed in that definition, and we do end up seeing a good chunk of these neurosensory abnormalities that we should remember when it comes to our dry population. So the first type of case you can see is neuropathic pain. So, this is a patient that essentially, I, the way I explained it to the patient is you have some rewiring of your nervous system. You can look at the eye, you can look at all the dry testing you did and everything actually looks pretty good, yet the patient will say that they're 9 or 10 out of 10 pain. Um, and Doctor Bernheiser already explained this. You can do a proparin challenge test in the office. If the proparicine helps them, doesn't help them at all, then you know you've got some sort of a neuropathic pain issue. Um, from a dry eye, uh, perspective, if there is peripheral sensitization, I feel like there is still some room for me in the picture, but when central sensitization happens, that's where I need my neurology colleagues or I'm sending my patients to the pain rehab clinic. Now, by that I mean that peripheral sensitization can come from issues with the corneal nerves. So maybe there I am likely to start the patient on autologous serum tears, um, but again, once the central nervous system is involved, usually those patients will need oral medications. And then we have the other side of the spectrum. You look at the eye and you say, oh my goodness, that looks terrible. Yet the patient's like, I feel fine. Maybe my vision's a little blurry. So this is where we have decreased corneal sensation, and this can happen after viral infections, after neurologic cases. So I've seen them after brain surgeries. This can happen just from chronic dry eye. Um, I will also see this in, in our glaucoma patients that maybe are on numerous glaucoma medications with preservatives. So again, here, educating. Our patients is very important, possibly showing them the picture like the one on the right, saying, you know, I know you're feeling pretty good, but this is risky, risk for infection, risk for scarring, so this is something we need to address. And again, when it comes to these nervey issues, we are usually reaching for amniotic membranes, autologous serum tears, sending them to doctor now for a sclero lens fit, um, and, and then surgically, there are some options as well, but again, usually we try to do the um. Most conservative or low risk approach first. When it comes to innovation and dry eye management, um, there is some technology available now to help us in treating these patients, and in general, the metrics help us with diagnosis, they help us track the disease, and they also help with patient education. Um, so, imaging technologies, we've already mentioned this before, like my biography is very important. To show the patients how their glands look. And sometimes we do a my biography and there are zero glands left. So we know that right from the beginning of this is gonna be a tough one, so maybe right away we're bracing the patient for serum tears or for scleral lenses. Um, terrasmolarity at this point has become almost like a gold standard for treating dry eye. Um, and this is a great biomarker with a very high positive predictive value. So, If you have a true dry eye patient, um, not that any test is perfect, um, but a true dry eye patient should have increased asthmolarity. Here we're talking about numbers over 300, sometimes seeing them 320, 340, 360. And then again, it's nice to see whether there's an inflammatory component to the dry eye, which we can easily uh test for with the matrix metal checking for the presence of MMP 9s and this is a tiny little stick, um that's single use. I Google and say it looks like a pregnancy stick. Um second line means it's positive, um, and then we know we need to go after inflammation. Um, and then all of these I utilize in clinic. I don't, uh, use, or at least not yet, use the lactofein and IGE testing, but many times that can be quite helpful because the dry eye and allergy symptoms can be difficult to tell apart. And so if you have testing, um, telling you that there's also an allergy problem, then you can go after the allergies as well. Now the future of dry eye is exciting. Um, like I mentioned last year in 2023, we had TFAS published the lifestyle report, and that just really makes me happy that we're starting to look at the whole picture when it comes to dry eye. So for example, whether we like it or not. Not, sometimes we have to talk about makeup and cosmetics in the dry clinic. So, you know, asking our patients, what are you using near the eyes and what are you using on the face? You know, it could be something as simple as maybe the product you're using that's uh contributing to the irritation. And then there also are going to be um some exciting treatment options coming. So with regenerative medicine, we think about stem cells and possibly regenerating the lacrimal gland. Um, with biologics, we're kind of sort of in this category already with serum tears and PRP, but hopefully these will only grow and and get better and we will have better data on them. Um, I'm pretty excited about sustained release technologies, because again, the quality of life of these patients is affected if they have to use drops after 30 minutes. So there's a way that we can keep them from having to constantly put something in their eyes that would be helpful. Um, I think we're gonna see more of the neuromodulation. Um, telemedicine is hopefully going to, um, increase access and more patients can reach us. Um, when it comes to AI and machine learning, I kind of sort of use it in the dry eye clinic already. I have an AI ambient listening app, um, that has saved me quite a bit of time. When I'm discussing my dry eye treatments with my patients, I can focus on the patient and this ambient. Listening app is taking pretty nice notes, um, and, and these notes actually make sense. Usually, I am, um, still adjusting them a little bit, but the gist of what I'm saying and what the plan is, is, is in the notes. So maybe if I had a super busy day and wasn't able to keep up with testing, I can always go back and see what AI said. Um, I do think we're gonna also look into the microbiome a little more, um, and, and see how that's related to dry eye. And I hope that we all stay informed and we advocate for research, uh, because there's a lot of need here. Do now, how about the team approach to this? Yeah, I will say this is one of the benefits of being at Mayo Clinic is we do have a great access to creating a team approach. We've already talked about how we have your dry eye clinic with some of the testing and some of the technology to do some in-office treatments. We work together when I fit the floral lenses, and then we have patients that are seen in other departments that are very predominant for for dry eye complications. So I have a graft versus host disease clinic that I've been working in for 1010 years now, that one of the hematologists develops. So he knows these patients have issues and he, he reached out to different subspecialties to create access for his patients. The Shogren patients have now done the same, so we'll be starting a clinic for them. For our patients that we've talked about that have The chronic pain, we've done some, some work with our pain rehabilitation clinic and get to see how they work and help these patients that don't have great treatment options. If there's not a treatment, they can work with these patients to help them find ways to live with their condition a little bit better. So it's, it's amazing to have the resources to, to pull everyone's skills and interests together to help our patients. Have a better coping mechanism, have better treatments for their for their condition. So it's, it's really fun to be able to do that. It's very important for those that have dry eye clinics to reach out to other providers that have the dry eye patients to bring them in and providers that have dry eye patients to reach out to someone who's a dry eye specialist to to refer. We need that networking, so it's great to have that here. Absolutely. And then when it comes to the Mayo Clinic's dry eye, we're pretty new. Uh, we just recently celebrated our one year anniversary. Um, now, naturally, we've been treating dry eye at Mayo Clinic for decades, just like all of you, but we have an official space now with the testing, um, that allows us to, to take better care of these patients. And, and I would say that if possible, establishing a, a specific dry clinic can be quite helpful because that um calendar flow can be a little different. These patient appointments can Can be a little longer. And also I find um the staff to be uh very important in making a clinic like this successful. So I have the same team that works with me during these dry clinic days where they are educating the patients and they are doing some of those in office therapies and, and they essentially um make this happen. So, um, so yeah, we're here if you have any questions and um and looking forward to a good discussion. Yeah, wonderful. Thank you both so much for all of your comments. So we will uh dive into some questions now. If anyone has additional questions, you can still write them into the little chat here. But I'll start with this one for the two of you. What have you found to be the best new products? Or if there if there's a a favorite or best product that you have, or when you're excited about. Sure. Um, you know, I, I think it's been a nice breath of fresh air because Lodolaer has just been working so well. But I feel like what I've seen with Loolaer and addressing Demadex plephritis. It really works. So, uh, it's just nice to have um treatment that really uh goes after the root cause of the problem. I'd say my favorite is that I have Doctor Tila to, to send patients to and are just that we have a dry eye clinic. I, I, you know, we Again, we've been treating dry eye at Mayo for, for many, many years. But to have that clinic flow, again, I, I know we just talked about this, but I, I think that's just my favorite new thing. It's just new to me, I know. Um, but for, for those of you who are, you know, live, you know, working at a bigger practice, I mean, definitely, definitely consider setting up a separate dry eye clinic just for the flow and the support. I, I will second that comment that that having that dedicated clinic is amazing, and the thing I find with these patients is that they, they take so much time for discussion. Both what, what is their disease, why is it and all the treatments that they have to go through. So this isn't just to sit down and hand you a prescription and go. So it's very nice to have that time set aside by someone who's very knowledgeable to go through this. So thank you, Doctor Tila. Oh, thanks guys. And I mean, I think uh one thing I want to mention though about that is that, you know, I think Using your support staff for that too is so important. We, we know that um we're being everywhere, we're being pushed to see more patients and fewer time. Um, so, uh, a lot of this education can be done by our technicians and support staff, um, so don't be afraid to, to take the a little bit of time to train them, um, to save you time later. Yes, empower your staff because they are phenomenal, and, and if you believe in them, they, um, I mean, they are amazing. I, I, I love my staff. Find someone who's had dry eye and who's been helped, and then they'll they'll be especially passionate. Yes, right. And empathetic as well, which is also important. Along those lines, what do you feel the best advice is that you can give to patients suffering from dry eye? I'll, I'll take this one. I'm sure Doctor Tila has, um, has a spiel too, but I, when I sit down with someone who is there for dry eye. I, I have, I, I, I sit down and say. Look, dry eye is a chronic disease. We don't have uh uh one magic wand to fix everything. Our goal is to get you from being, you know, miserable or wherever your pain level is, your discomfort level, if it's a, you know, a 78 or 9, it's to get it down to a level like a 2 or a 3 or a 4, or at least to just get you more functional. And that Again, when we're trying some of these things, it's trial and error. It is a success if we get one thing to get you 5% better. Our goal is to get you As, uh, you know, as much, uh, you know, lower your pain as much as possible with as few, few things as possible, but most likely, it's not gonna be just one thing. Just to set from the very beginning that, you know, this, this, this isn't just one thing we can do to make it better. Now, I, I, uh, you know, I, I think what I've, you know, learning from this whole process is that, um, I also like to be very Scientific about what I'm having my patients do. I'm not throwing the kitchen sink at them. I don't want them to be doing the 180 minutes. Um, I tell them to start with one thing, note what percent they feel like it helps, and then start the next thing. Um, again, cause I want them doing as few things as possible for the biggest impacts. And I, I agree with all of that, Ashley, and, and sometimes, honestly, the best thing we can do for these patients is tell them to hang in there, give them hope, say that, you know, um, sometimes I'll say that I'm not gonna give up on you. If you come back and you're still not doing great, I'm here, um, and, you know, if we don't find something that works, we will see what else is coming out there in the future. But again, the, the giving up hope and really helping the patients hang in there. It is very important for those neuropathic pain patients cause many times those patients have done everything, yet they're still in so much pain and and they can, that can take a really big toll on them and on their mental health. So, um, so just being available and, and supporting your patients. I, I agree with you both completely, and I think it's so important to, to set the expectations and to let your patients know that you're And with them on this, that you're, you're, you're part of the process of their healing and that it's a process. I appreciate all the comments and all your time. Do either of you, and we've got one minute left, do either of you have any final comments you want to make before we end the evening? I would just say thanks for joining us and the fact that you're here says that you care about these patients, so, so we appreciate you. I agree. Thanks for being here. Yes, so I will just add that on behalf of Dr. Spernheisel, Tolka, and myself, we thank you for participating today. We treat over 250,000 outpatient visits each year for dry for eye care across all of our sites, Minnesota, Arizona, and Florida. We welcome patients referrals for rare, serious or complex conditions. To discuss a patient or to learn more about referring a patient to Mayo Clinic, or contact contact our referring physician services at one of the numbers on your screen or by visiting MayoClinic.org/medical-professionals. Thank you again for joining us today, and again, thanks to my My speakers here and all of their skill and patience in in helping us treat these special patients that we have. Thank you both, and goodnight to everybody.
