How can optometry and ophthalmology work better together to improve patient outcomes? Corneal specialist Dr. Alfonso Iovieno shares his thoughts on treating dry eye and how these two fields can join forces to improve patient outcomes. He explains the challenge of dry eye having a very broad range of symptoms, making the diagnosis a bit unclear at certain times. Dr. Alfonso and Dr. Harbir Sian also explore the wide range of available treatments and technologies currently being used and studied right now to address dry eye issues, particularly the "big guns" that yield the most efficient results.
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The Evolution of Treating Dry Eye - Dr. Alfonso Iovieno
Dr. Alfonso Iovieno works as a Clinical Associate Professor at the University of British Columbia. He's based right here in Vancouver. Dr. Iovieno obtained his medical degree and completed his Ophthalmology Residency at the University Campus Biomedical in Rome, Italy, and then subspecialized in Cornea, External Disease, Ocular Surface, and Complex Anterior Segment Surgery during his three-year fellowship training at the University of Toronto and Moorfields Eye Hospital in London.
Dr. Iovieno also completed his PhD in Ocular Microbiology Immunology between the University Campus Biomedical and the Bascom Palmer Eye Institute in Miami. Those are some big-name academic and training institutions that we're all very aware of. The last thing I want to mention before we get into this, Dr. Iovieno, true to his Italian background is an avid soccer fan. Thank you, Dr. Iovieno, for joining me here.
Thank you very much. Thanks for the invitation. I'm glad to be here with you. The only thing I want to tap into my background is that I like to travel a lot as the last part of the background said, hence my experiences in many countries.
We could probably have an entire episode talking about soccer and traveling, but touch on the soccer thing because I'm a pretty big football fan myself. What do you follow? Do you follow Italian soccer or English soccer? Who's your team?
I follow Italian soccer and I'm a Southern Italian, so my hometown is on the outskirts of Naples, so I follow Napoli. That's off to a pretty exciting start to the season. We're having a lot of fun.
Napoli is a historic team and had some good runs and some big players in the past. Maradona, if I'm not mistaken.
There you go.
Thanks again for joining me. The conversation that we want to have is around dry eye and more specifically, the collaboration between optometry and ophthalmology in the treatment of dry eye. This is a topic that gets talked about a lot in meetings and casual conversations but doesn't get spoken about in public like this as much as it should. There's so much opportunity for us to elevate both professions and more importantly, the patient experience and patient outcomes by collaborating and elevating that collaboration. Thanks for taking the time to have this conversation.
It's my pleasure.
Let's start with the various forms of dry eye. Sometimes pigeonholes of the condition, I feel like we say dry eye in a patient's mind and even a doctor's mind will go to one specific set of symptoms, but it's a very broad range of symptoms, diagnoses, and ocular signs that we could be looking at. I wonder if you can, maybe in your opinion, break it down into some of the few categories of the types of dry eye that you're seeing, and then we can go into a bit of the diagnosis aspect of it too.
It's a good chunk of the patients that we see as optometrists and ophthalmologists are affected by its condition that primarily or as a secondary add-on to their primary solid eye pathology. Academically, dry eye patients used to be divided in hyposecretive, evaporative, and neuropathic ocular pain. A lot of this black-and-white distinction has blurred very much.
We'd see these patients with their conditions and focus on their signs and their symptoms. Based on their signs and symptoms, assign them to a specific treatment. It's a whole spectrum of dry eye for which there are many treatments available, but the general umbrella of dry eye now doesn't tend to be divided very much between different categories.
Having said that, there are patients that suffer from dry eyes, a consequence of immune disease. They're very peculiar and will probably be more responsive to certain kinds of treatment versus the dry eye that tends to happen in patients after refractive surgery or the form of dry eye that tends to affect mostly post-menopausal women. They will all have some specific features that are more likely to respond to some treatments in particular.
If we could dive into that a little bit more if somebody who has a particular autoimmune condition, a Sjogren's, or something like that. If we were to make a bit of a distinction between some of these particular forms in postmenopausal women, would there be different signs that you would encourage optometrists to be looking for somebody who maybe doesn't practice dry eye in-depth, but ways that we can maybe see clues that we would know to go down a certain path?
For example, to take those categories into account, a good chunk of my dry eye patients in my practice come from that autoimmune background. That's because of my collaboration with dermatology or with rheumatology for the care of secret passing conjunctivitis or other complex anterior segment diseases. Those patients have oftentimes a very severe form of dry eye, but it's also a very "rewarding" form of dry eye to treat as a doctor because they're the ones that would respond to medications both from the point of view of signs and symptoms.
Dry Eye: Many dry eye patients come from an autoimmune background.
Those are the patients for whom I can confidently say that I can cure them. Although a cure is not a word for a chronic condition, I can make them feel a lot better. They will present and will be extremely light sensitive, foreign body sensations, and invariably covered in punctate erosions involving the cornea, and the congenital eye and they're the ones that have a standard treatment such as lubricating agents would not touch them very much. They will need to pull out the big guns almost from the get-go with the understanding that the response in their case would be very prompt and satisfactory.
On the opposite end of the spectrum are the neuropathic ocular pains patients, for example, the ones that develop this condition following their refractive surgery. Their signs will be very mild, if not absent at all, but on the other hand, they will have very depleting symptoms. The treatment approach for them is in a way collateral. We don't have any ideological agent that we can give to them and know that they will respond exactly to that. We try to optimize the surface as much as possible and we achieve a certain degree of success in treating them in order, at least in making their symptoms better.
That's wonderful. I want to go back to the big guns, talking about neuropathic pain. Three of the most hated words, when put together, for anybody who treats the ocular surface, is pain without stain. It's like, "How do we fix this?" Do you have any thoughts on why we get this neuropathic pain and how might a primary care optometrist approach that when they have a patient in that setting?
I wish I had a more precise answer for you. If I knew exactly what was going on, I'll be probably richer than I am at this point in time, but the truth of the matter is that there's a lot of science going on to that extent. There are centers of excellence scattered throughout our country and the United States where active research is ongoing.
There's something happening at the level of the peripheral nerves of the cornea, either in the form of the development of neuromas, aberrant regeneration, or maybe there's something at the level of neurotransmitters level on the ocular surface. Once we'll have a better understanding of this, we'll have also better ways for the ophthalmologists that would have to deal with these patients. On its hands the armamentarium for dry eye, which includes anti-inflammatory medications. Moving on in those patients more frequently than others to the use, for example, of autologous serum.
Dry Eye: Centers of Excellence scattered across the country are actively researching dry eye treatments. Something is happening at the peripheral nerves of the cornea other than the development of neuron regeneration.
The presence of neurotrophic growth factors in the autologous serum seems to be one of the reasons why that treatment is justified in patients with neuropathic ocular pain to the use of scleral lenses, which as I tell my patients, “It's like you're sticking your head in a fishbowl and that's a way of seeing the activity of those upper and nerves on the surface of the eye. “
People are venturing into low-dose naltrexone, Amitriptyline, all the way to very diluted topical anesthetics or even cannabinoids for the treatment of those conditions. There's such a tremendous momentum of research in need from our patients for new treatments. I'm sure something new and possibly groundbreaking will come up in the next few years.
All of those things that you mentioned with the low dose anesthetics, the cannabinoids, or Amitriptyline, have those shown some potential positive effects, or is it all anecdotal at this point?
They have. There's no abundance of literature on this, but there is some. I haven't ventured into the more experimental treatments myself, but I do work in conjunction with some neuro-ophthalmologists who are more versed in the use of those types of medications. We have put some of those patients on gabapentin, Amitriptyline, even topiramate, and low-dose naltrexone. These are systemic medications.
The side effects profile from this medication can be quite significant at times, limiting the compliance of the patient, but sometimes the motivation is so strong that if patients do notice some improvement in their symptoms with systemic medications, even if the improvement is not massive, they will still be very tempted to go for that. If I had to pin it down to a percentage, I would say probably in about 50% of the patients, we'd be able to achieve some success.
The side effects of dry eye medications can be quite significant at certain times. Nevertheless, patients' motivation is so strong that they still acquire them in hopes of some improvement.
As I've ventured more into the space of dry eye and treating it and the more of these patients that walk through the door, I realize how much it affects their lifestyle. Quality of life is more important than what I want to get at. You think of it initially as a, "You got a little dryness and irritation," but there are patients who walk in and say, "I can't take it anymore. It affects every aspect of my life."
It's difficult to have that conversation, especially when you have something like this where we don't have any obvious treatment modalities for it, but it's good to know that at least there are some bright spots and some opportunities to help those patients. You touched on it, but often those patients will see, at least to some degree, having these neuropathic symptoms after they've had some refractive surgery, whether it's a cataract or laser surgery. Is that a well-documented thing or is that anecdotal as well?
This is what I tell my patients regardless of the type of surgery, they're going to have on the surface of their eyes, their dry eye will get worse. If they do have dry eye, what I tell them is, "You're looking into at least a few months of worsening of your dry eye condition, which will then, with a little bit of work, return to what it was before. It will not be ameliorated by the surgery and it would not be worsened by that.”
Regardless of the type of surgery people will get done to the surface of their eyes, dry eyes will still get worse.
The only exception to me using this spiel would be patients that are undergoing refractive surgery. For the refractive surgery bit, honestly, the effect of either Lasik or PRK on the corneal nerve plexus as such that there is a subset of patients, not the majority of them, that will experience persistent worsening of dry eye symptoms.
Given the popularity of refractive surgery procedures, a lot of people are trying to work at why this is happening or what can be done to prevent it or treat it more effectively. We don't want to do any procedures on any patient whose ocular surface is not being optimized. That comes from many points of view. Even something as simple as an intraocular lens calculation can be sometimes completely thrown off by an uneven tear film.
Every patient that would approach any cornea procedure should have their dry eye and ocular surface optimized by means of using topical lubricants if they were not using them before. Some surgeons advocate the introduction very early on of cyclosporin or lifitegrast in patients before the advent of a surgical procedure. These are all viable options, but this is not something that should be because the outcomes for those patients and their satisfaction will be very dependent on that.
That's perfect. Thank you for defining the difference there between those two and why PRP potentially may be more valuable. We started to talk about optimizing the ocular surface for refractive surgery. As I was mentioning, I do this and I've spoken to multiple colleagues that are starting to do this when a patient is looking to go get cataract surgery or laser surgery, we talk to them about the importance of optimizing the tear film and the ocular surface and how that, in theory, and hopefully in practice, you'll confirm that it can help to improve the readings that you get before surgery or the outcomes of patients will have after surgery. Is that generally what you have seen?
Yes, very much. In reference, to cataract surgery, when we are using premium IOLs where the level of precision or our calculation has to be held to higher standards compared to mono-focal lenses. Any interference with measurements of astigmatism and all the other preoperative measurements that we do before cataract surgery will translate into suboptimal outcomes from the visual standpoint. It's particularly important for them.
I don't think that patients preoperatively necessarily have a different treatment approach that would apply than any dry eye patients that come from a clinic that's not going to have any eye surgery done. The same thing that I would use for any other dry eye patient, I would use them for these patients, but it's important to consider that those treatments have to be put in place a number of weeks and sometimes even months before the patient can undergo a successful surgical procedure.
It's good to hear it from you, a surgeon and somebody who's an expert in the field to have that confirmation of the importance of doing that. Hopefully, that'll encourage some of my colleagues to have that conversation a bit more preemptively before a patient goes in for consultations and so on. Not necessarily treating them differently than any other dry eye patient, but making sure the patient's awareness of the importance of treating that dry eye.
Let's say we have a patient like that in your exam chair who has dry eye and you mentioned that surgeons and doctors are preemptively getting started in certain treatments. What types of treatments would you be offering this patient? It will depend on the type of dry eye they have but adjusting to them weeks or months before their surgery.
If the patient has any component of meibomian gland involvement, either a meibomian gland dysfunction, posterior blepharitis, or anterior blepharitis, care takes precedence, so the patient will be on warm compresses. Depending on the severity of blepharitis, we can consider the use of oral doxycycline or any of the available devices for the optimization of meibomian gland health. When it comes to the surface itself, if there's a reduced tear meniscus or punctate erosions present, those patients will be on tear substitutes.
Generally speaking, I have a low threshold for introducing anti-inflammatory treatments. That is a point that I want to get through. Because of the cost of such treatments or because of the medicinal, in a way nature of them, sometimes where we hold back on the use of cyclosporin or lifitegrast more than we should. We leave those types of drugs for patients who are more severe in our books. The early introduction of this type of medication goes along with a lot of the patients who are the highest responders to them are not the ones that necessarily present with a ghastly ocular surface, but they're the ones with a mild to moderate dry eye.
We know that the window of intervention of those drugs is going to be better for them. That's based on the literature we have available. Other patients before surgery will need other types of intervention obviously based on their severity. In the vast majority of patients, this will be sufficient then whether we move on to the use of punctum plug or punctum occlusion of sort, autologous serum, or things like that, then that will be dependent on severity.
Dry Eye: Whether autologous serum is superior to PRP is still debatable. But having access to either is still valuable in treating dry eye patients.
That's an important point that you brought up there about the introduction of some of these pharmaceuticals early on. In the past, I have been guilty of that, but I will save the cyclosporine as a 3rd or 4th thing after I've tried a few other things. It's not as effective as I thought it should be, but then also reserve it for the more complicated cases where maybe I should be introducing it a little earlier on. Would you think it's a first-line therapy or a second for that person who seems to need it? Would you be introducing it right off the top, "Here's your lubricants plus your cyclosporine?"
Yes. Honestly, I would give the patient probably no longer than a couple of weeks to see if they receive any benefit from the treatment with artificial tears, preservative-free, depending on what's the frequency of use, and their eyelid hygiene optimization, but if they don't respond, I'll introduce it right away. We've also didn't mention that's often the case of not paying enough attention to that.
Stage zero of dry eye treatment is the environmental modifications. We've all been surprised when we heard from patients, “I sleep with a fan directly onto my face or above the bedroom,” or any other things that if detected and modified will make a very significant impact on this patient's quality of life. We'll facilitate any further medical intervention that we planned for this patient's dry eye. Digging a little bit into their personal history and their habits, it's also something that goes a long way.
It's very important. You're right. The environmental factors get overlooked a little too much. I've had so many patients tell me they'll go on vacation to some tropical destination, Jamaica or something, and come back and say, "For two weeks, my eyes felt amazing." Let's think about you being in a warm, humid climate and not staring at a computer screen all day and all the factors that you eliminated for those few weeks, how valuable that can be trying those address those day-to-day.
I'm a little bit contact lens intolerant myself. I don't wear contact lenses very often, but when I use daily disposables, I don't tolerate them very well. I remember when I was living in Miami. When I was at Bascom Palmer Eye Institute, I thought, "How is it possible to anybody over here has any dry eye?"
It's humid down there. Getting back to then the various treatment modalities, you touched on the fact that there are various technologies. Dry eye has been the target of a lot of new technology and technological advancement and a growing specialty in radio frequency, IPL, low-level light therapy, and all these different technologies out there. Have you had much hands-on experience with these technologies?
Not very much. The only one I have a little bit of hands-on experience with is IPL. That was a few years ago. With the newer technology, I haven't had a chance to test them out myself. This is a reflection of how much interest there is in dry eye research, and how many patients ask us for additional treatments and more effective treatments than what we have available.
On a lot of this newer technology, there isn't enough of a scientific background or pedigree to come up with precise guidelines and conclusions, but I do look at all these efforts favorably. Out of this, something substantial will come up. One of the mistakes is the thing that we are going to find the holy grail. We're going to find the one device or the one drop that we give to everybody and solve everybody's problem. That's not true for many chronic diseases. As doctors, we treat hypertension and diabetes, why would it be the same for dry eye? We will need to approach this in a multimodal way and if technology helps us in that sense, that is very positive.
The best dry eye treatment must not be seen like the Holy Grail. This must be approached in a multimodal way.
That's another good point, not to think that there's any silver bullet. What I forgot to mention in your introduction is that you're an ambassador for TFOSS, Tear Film, & Ocular Surface Society and the DEWS II report is the holy grail or bible of dry eye definitions and whatnot, but in that definition, it says it's a multifactorial disease. We have to always treat it that way and try to address the various factors that may be involved.
I agree with you. There is still a lot to be learned and understood about these various technologies and their application, but again, it's a very positive sign that there's a lot of energy being put into this area where we might be able to come up with new solutions to help our patients. Hopefully, they'll become, at some point, officialized and studied well enough that we can be on here again next time talking about how all of these can be used to help our patients.
One of the core topics, as I mentioned off the top, is to talk about dry eye, but more importantly and specifically about the collaboration between ophthalmology and optometry, and the opportunity that we have here to improve our patient outcomes with this collaboration. I wanted to dig into that, in general. What are your thoughts on that? We'll dig in a little bit more about how we can improve that collaboration.
I don't know if the situation that we have here in British Columbia is representative of the rest of Canada, but I have to say that dry eye is one of the areas in ophthalmology, and in your segment where I do see the fruits and the benefits of a respectful and effective collaboration between optometry and ophthalmology.
The thing is the incidence of this disease is such that the mass of patients that need treatment for dry eye will be overwhelming for almost every health system. Having more than one health professional dealing with these patients is a winning move. A lot of these patients will need many treatments. We need a model approach. Oftentimes, our time is restricted. Our clinics are busy and there are patients that need much attention from many points of view. Dry eye patients do require a certain amount of time and a certain level of expertise.
The optometry community has been at the forefront of dry eye science, at least in British Columbia. Every optometrist I have interacted with has been very up-to-date, versed, and predisposed toward the treatment of these patients. Collaborating on this and in the care of surgical patients or refractive standpoints is one of the very many elements where the collaboration between optometrists and ophthalmologists can flourish.
This might be a tough one, but how do you see that coming to fruition? As you said we understand that with ophthalmology, your time with patients is quite brief, you're very busy, and lots of patients are coming through. There is a lot of handholding required with dry eye patients. We're all very familiar with that as it can be quite a challenging condition to treat, but where do you see that overlap happening? If you could give me an example of a patient whom you think both ophthalmology and optometry could work on and collaborate with.
For example, one of the situations that you mentioned before, so preparing patients for surgery, cataract or refractive surgery is one of them. The optometrist oftentimes will be the port of entry of a patient with a cataract or a patient that's interested in refractive surgery. Putting in place at an optometry clinic, the preoperative treatment that will then influence good measurements on our end, and good outcomes of our surgery is one possibility.
Among optometrists and ophthalmologists, there's obviously personal interest or research interest. The fact that some optometrists in our community have put together dry eye clinics where they have acquired the latest devices and are able to offer a comprehensive approach to these patients from any point of view, from ecological with the technology, either at the diagnosis or at the treatment point. It's something that has to be recognized by whoever has the willingness and desire to explore this type of field and provide a standard of care to patients.
Telling patients, "We have artificial tears here. If it's bad enough, you can go and get some cyclosporin there. If that hasn't worked, that's about it. You got to live with it and that's the end of the road." I don't think it's standard of practice in this day and age. We have to be able to offer more than one modality of treatment. Ophthalmologists or optometrists would want to dwell on that and offer the whole range of treatments to patients that need to be recognized.
Dry Eye: In this day and age, medical practitioners must offer more than one modality of treatment. Ophthalmologists or optometrists who want to offer a whole range of treatments to patients needs to be recognized.
In my mind, for a long time, the relationship between optometry and ophthalmology has seemed somewhat one-way. I'm not trying to put on a negative spin on it, but in general, we're referring to ophthalmologists for treatment and then the patient will come back to us. To have it a little more open and two-way where perhaps an ophthalmologist sees the opportunity for certain treatment modalities and has the patient coming to see the optometrist who's developed that dry eye clinic and the patient has open access to both, that seems an ideal scenario. To be able to create that would be very nice. Any suggestions in your mind as to how we can maybe better the opportunity for this collaboration or if there are any last thoughts you want to share on that?
Honestly, there's probably enough expertise on either hand to build on that and keep the lines of communication open. That's what matters the most. That's for the interest of our patients, knowing that in a specific area, there's somebody with an interest in dry eye and somebody willing to collaborate on the care of patients before cataract surgery or refractive surgery. At the same time, among ophthalmologists, there's somebody who may have more of an interest in dry eye than in other areas of ophthalmology. If we keep the lines of communication open and build on the interest and expertise of one another, that's a win-win game.
One final question on that for you. We're in BC so we're going to be a little bit biased as to how things work here, but would you encourage optometrists to write or somehow call the ophthalmology office and express that interest in that area? What would be the best way for us to connect?
I've heard of optometrists reaching out to our office and saying, "I have done fellowship training. I have done a specific training in this area. I have acquired this technology. I now fit scleral lenses. I do that," making your community around you aware of that is something that goes even beyond ophthalmologists and possibly reaching out to rheumatology or patients that treat with autoimmune diseases to the refractive surgery clinic, which may not be the same as an ophthalmology office in a hospital like mine. Informing everybody around you that this treatment or this option is there, is paramount.
Thank you. That's maybe a question that optometrists would like to be answered. "Do we call you? Do we email you? What's the right thing?" It's because sometimes we're a bit tentative about that. We know you're busy, especially someone like yourself who has a lot on your plate. I appreciate you being open to that communication. That's important and much needed so we can improve that collaboration.
Thank you very much, Dr. Iovieno. Thank you so much for coming to the show. I appreciate it and you have great insights and things that we can all learn from. It's not just simply in the clinical sense of treating dry eye, but in this important conversation about collaborating and learning how we can all work together. I appreciate your time. Thank you.
Thank you. It was a great pleasure to be here and to hear and know about your successful show. Thanks for the nice conversation.
Thank you. Next time we'll talk more about soccer.
We should do one on soccer only.
You got it. Thank you to everybody who's tuned in. Thanks for taking the time. I'm sure you found Dr. Iovieno's thoughts and insights very valuable. If you did, please share it. Take a screenshot and put it up on Instagram or share it on LinkedIn. Don't forget to leave a review. Leave a comment. Hit like and do all the good things that helped our show grow. I will see you in the next episode. Take care guys.
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About Alfonso Iovieno
Alfonso Iovieno is a Clinical Associate Professor at the University of British Columbia in Vancouver, Canada. Dr. Iovieno obtained his medical degree and completed his Ophthalmology residency at University Campus Bio-medico in Rome, Italy. He then sub-specialized in cornea, external diseases, ocular surface and complex anterior segment surgery during his 3 years of fellowship training at the University of Toronto, Canada and Moorfields Eye Hospital in London, UK. Dr. Iovieno also completed a Ph.D. in ocular microbiology and immunology between University Campus Bio-medico and the Bascom Palmer Eye Institute in Miami, Florida.
His research focus has spanned from ocular surface immunology to corneal infections, corneal transplantation and keratoprosthesis. He has won numerous awards and recognitions and holds several patents for biomedical devices. Dr. Iovieno regularly presents and moderates at national and international meetings and has been extensively involved in training courses on the latest techniques for corneal transplantation. He is a member of the bord of directors of the Italian Society of Corneal Transplantation, member with thesis of the Cornea Society and the Tearfilm and Ocular Surface Society Ambassador for Western Canada. He has authored over 90 papers in peer-reviewed journals and 15 book chapters.
Alfonso Iovieno lavora come Professore Associato presso la University of British Columbia a Vancouver, Canada. Il Dott. Iovieno si è laureato e specializzato in Oculistica presso la Università Campus Bio-medico di Roma. Ha successivamente completato un percorso triennale di fellowship cliniche in cornea, superficie oculare e chirurgia del segmento anteriore presso la University of Toronto ed il Moorfields Eye Hospital di Londra. Ha inoltre conseguito un dottorato di ricerca svolto in collaborazione tra il Campus Bio-medico di Roma ed il Bascom Palmer Eye Institute di Miami.
La attività di ricerca del Dott. Iovieno spazia dalla immunologia della superficie oculare alle infezioni corneali, trapianto di cornea e cheratoprotesi. Il Dott. Iovieno ha ottenuto numerosi premi e riconoscimenti in Italia e all’estero e svolge attività di relatore, moderatore ed invited speaker ai più importanti congressi nazionali ed internazionali. Il Dott. Iovieno è membro del consiglio direttivo della Società Italiana del Trapianto di Cornea (SITRAC), della Cornea Society ed è ambasciatore della Tear Film ed Ocular Surface Society per il Canada. È autore/co-autore di oltre 90 articoli in giornali peer-reviewed, 15 capitoli in libri e detiene 2 brevetti internazionali per device biomedicali.