Addressing Dry Eye Flares: Early Anecdotes and Experiences with Dr. Adam Ramsey

Eysuvis, a new FDA-approved corticosteroid that is indicated for the short-term treatment, up to two weeks, of the signs and symptoms of dry eye disease. Patients often have periods of exacerbation called dry eye flares, where their dry eye symptoms can be triggered by digital screen time, seasonal allergies, contact lens wear, and AC use. In fact, 75% to 90% of all dry eye patients have dry eye flares, with an average of more than five episodes per year. In this episode, Dr. Whitley chats with Dr. Adam Ramsey of Socialite Vision in Palm Beach Gardens, Florida, about his early experience with Eysuvis in his practice.

Walt Whitley: Hi. Welcome to the Dry Eye Coach Podcast. My name is Dr. Walt Whitley. Today we’re talking about Eysuvis, a new FDA-approved corticosteroid that is indicated for the short-term treatment, up to two weeks, of the signs and symptoms of dry eye disease. Patients often have periods of exacerbation called dry eye flares, where their dry eye symptoms can be triggered by digital screen time, seasonal allergies, contact lens wear, and AC use. In fact, 75% to 90% of all dry eye patients have dry eye flares, with an average of more than five episodes per year. Today we have the great pleasure of chatting with Dr. Adam Ramsey of Socialite Vision in Palm Beach Gardens, Florida, about his early experience with Eysuvis in his practice. Welcome, Adam.

Adam Ramsey: Thanks for having me. I really appreciate it.

Walt Whitley: So, Adam, can you tell us a little bit about your practice before we get into some of these questions here, so our listeners know a little bit about yourself?

Adam Ramsey: Sure. Sure. Sure. And anybody is welcome. You guys are welcome to come on and do a tour for yourself. But I own Socialite Vision in Palm Beach Gardens, Florida. [1:16] Gardens like an hour north of Ft. Lauderdale. That’s where we are. I’m in a boutique practice. It’s a mixed-use complex so we have commercial on the first floor, and then there’s a residential above us. So, it’s our own little ecosystem over there. I look at it as more a boutique practice, more of a high-end medical practice. So, we have some high-end [1:39 frame] and definitely do love treating patients with dry eye, diabetes and contacts and glaucoma. So, we do the medical and we’re trying, we combine the medical with the vision and the cool, funky eyewear. And that’s my practice over in Palm Beach Gardens Socialite Vision.

Walt Whitley: That’s awesome. Thanks for sharing. So, you mentioned dry eye, the medical management, what percentage of your patients, overall, would you say have dry eye disease?

Adam Ramsey: Now, I would say close to maybe 30% of the patients are dry eye patients. Not all of them necessarily want to admit that or want to deal with that part of it. But close to 30% of the patients I would say are currently under treatment for some form of dry eye disease.

Walt Whitley: Is there a way that you find, identify these patients? Do you use surveys? Are you consistently asking questions?

Adam Ramsey: So, in my office we do the SPEED test for everybody, so the SPEED survey is done on every patient for their annual exams. And that definitely does help bring out those questions. Because a lot of times, if the patient doesn’t realize it themselves or they are not voicing those complaints, it’s a little harder to get them to buy in on the treatment side of dry eye disease. So, we use the SPEED questionnaire. We also have the OCULUS Keratograph and we do the testing with that as well. Meibography and everything in addition to trying to show them. Because I think you really have to show dry eye patients their dry eye disease. It has to become real to them. Sometimes we don’t realize that they can’t really see their eyes very well, you know? So, being able to show them what it is and give a numerical value to their dry eye disease is really important. So, I think if we can show them their dry eye disease, they believe, they buy in, and then when you give them a treatment at the end, they’re more apt to actually follow through and go to the pharmacy and do those things that they need to do for their eyes.

Walt Whitley: Yeah. Definitely. Education is key. What their condition is, what these tests are, what does it show, and what are we going to do about it? And as we get into talking about dry eye flares, I mean, that’s something that many patients, they’ve experienced it, but they don’t know necessarily what to call it. So, my first question for you, actually I kind of cheated. I added a couple of extra questions. But we have both been using Eysuvis for a bit now. So, I wanted to get your thoughts on your experience so far with this new FDA-approved treatment. How has using Eysuvis in your practice been? And what are you hearing from patients?

Adam Ramsey: Okay. Well, great questions. For one, I love the tagline dry eye flares. I think that really sums it up really well for patients to understand what we’re doing with this particular medication. Because there’s so many patients that say, my eyes are dry once in a while. They’re not dry every day. It’s when I use the computer for an extended period it’s dry. But the rest of the day my eyes feel fine. When I go to the mall, and I am in [4:50 an airy] place, my eyes feel dry. But the rest of the time, I feel fine. And to get a patient to buy in on something chronic, something to do every day, when they don’t feel it’s an everyday problem, sometimes it’s hard and we can’t get those treatments to match up with the patient complaints. So, with the dry eye flares, and the second I say that with them, they’re like, yes! That is what I have. Once in a while my eyes feel dry and I need something that’s going to work, and over the counter tears, they are not working for me. I put it in and two minutes later my eyes still feel dry. So, this has been a great resource for my practice. I found a way to really work it into my treatment regimen. I am not replacing anything that I’ve done in the past. I’m more adding it in or using it before or as an adjunct to current treatment. Some treatments take awhile to actually see an effect. And that’s not what patients want to hear when, one, they spend money or they’re doing something. They want, people want, we’re in the world of Amazon and next day shipping. So, they want more of an immediate and quicker response. So, what Eysuvis has done for me is give me a chance to let other treatments work while I use this one in the beginning, to give me an immediate relief and let other things work in the back end. Or, giving them the subsequent relief that they need periodically as a first line treatment. So, I found multiple ways to fit this into my practice.

Walt Whitley: Yeah. And I’ve been using it the same as induction therapy. Steroids, I mean, it’s great that we have, we finally have an FDA-approved treatment for the signs and symptoms of dry eye. But then also the dry eye flares that you mention, because we all have our patients that are on chronic therapy, whether it’s Lifitegrast or their Cyclosporine, yes they may be controlled majority of time throughout the year, but there are going to be those dry eye flares that they do experience. So, is there a patient type or a patient example that comes to mind when you think of success with Eysuvis?

Adam Ramsey: Right now I’m having really good success with the people that are gamers or now they’re doing a lot more zooms. So, you know, their normal thing was not to be on the computer all the time, and now they’re being forced to be on the computer more regularly. Those people that, you know, have to sit at the computer once in a while and it’s for an extended period, they have really been one of the people that have bought in a lot quicker. Especially people that haven’t tried other treatment before so they, this is their, this is me introducing dry eye to them. And it’s their telling me that they’re having flares once in a while, this has been a really good treatment modality that I’ve used for patients that have periodic bouts of dryness that they’re experiencing but at other times of the day they say, no, my eyes feel fine. Its just when I do this, that or the other, which is not every day or is not a chronic thing to them.

Walt Whitley: So, as we know, patients may not always know that they are experiencing a dry eye flare. So, what are some of the specific questions you ask to uncover patients experiencing dry eye flares? I mean, you started to mention a few pearls, but any other specific questions that you ask?

Adam Ramsey: I mean, the first thing I’m really doing with the patient is finding out, okay, I ask them what is their current treatment regimen? Even though I know what I prescribed last time. I always start off with, tell me what you’re doing. Because I can repeat it back to them and those are stick in their head and they may not be doing that. So, I first start off with, you know, tell me your treatment regimen. You know, what are you doing with your eyes every day? And they go through their stuff. Then I say, hey, when you’re doing that, are there times in which you feel that your eyes still burn, sting, itch, water excessively, feel like sand is in there, gritty, even though you are doing all these things? And the second they say, well, yeah once in a while, and then when they say once in a while, I dig a little deeper. And I say, is it once a day? Once a week? Once a month? What do you mean by once in a while? Because, you know, I want to make sure that I’m understanding clearly what they’re expressing to me. And when they tell me, well, you know, I do all these things and my eyes feel fine most of the time, but once a week, when I go to my mother-in-law’s house or whatever, my eyes bother me. And it may be some trigger that she’s having when she goes to that place. Maybe allergies. She may have a lot of plants or a pet at that house that’s not normally, you know, your house doesn’t have a lot of plants, doesn’t have a lot of pets, but you go there regularly and that’s when you have those triggers. Is the air conditioning in the building circulating and drying your eyes out where you work? But normally you wouldn’t have that if it’s the AC that’s bothering you. Or, you’re a person that doesn’t have to wear the mask all the time so when you do have to wear the mask, since you’re not at zoom, you’re not doing a zoom presentation, you’re out and about, and when you wear the mask your eyes bother you. But without the mask, you feel like you have no issues with dryness. Or increased screen time and stuff like that. So, I try to find those different triggers that the patient may have so that it’s not something that happens every day and I think that’s where Eysuvis really fits in is for people that are up and down. And they can really have more of a targeted approach to their dryness that we can put a name or attach something to it to figure out what the root cause is, then we can really get to the inflammation on their eye.

Walt Whitley: Yeah. So, going along with the asking the questions, the education, are there any additional resources that you recommend? You know, there’s various patient web sites or, you know, do you have lead behinds or take homes with them to help remind them, if they’re experiencing a dry eye flare, to contact you?

Adam Ramsey: So, I do have pamphlets that I give out. But I also know my patients do well with texts and email. And for the patients, I just send them to myeysuvis.com and that’s going to give them the patient resources that they need to get the information about the product, you know, and having background information on the product they may want to know. Some people want to do their own due diligence about a product. And the myeysuvis.com is where I send them. But for providing other doctors that are listening to this, I will say just eysuvis.com/patientresources, or /resources, excuse me, would be where I would go to get the studies that have been done on the product. And any contraindications and stuff like that that may be out there about the product. The eysuvis.com resources page would be the best place for a provider, though.

Walt Whitley: You know, I had mentioned earlier, finally we have an FDA-approved treatment for steroids, for the dry eye flares for up to two weeks. And we know we’ve been using off-label steroids for many years. So, what is the differentiator with Eysuvis? Why would you choose this over some of the other steroids that are on the market? Is it the on-labeling? Or is it something about the technology? What are your thoughts?

Adam Ramsey: Okay. Alright. I definitely like the on-label. You know what I mean? I have a lot more confidence in prescribing something when it’s on label, it’s been studied, and it’s not something that I’m doing anecdotally. We know it works. But there hasn’t been studies to prove that it works. This, studies had the most, have had the most patients studied for dry eye of any therapy on the market currently. So, that gives me a lot of confidence to prescribe it and know that my patients are going to be safe and I don’t have to worry about IOP increases and cataract formation and other things that you can get with other steroids. I have a lot more confidence with this. And then I would say, we can’t sell it short to amplify proprietary technology that’s actually getting it to penetrate the cornea and the ocular tissues and conjunctiva, and not allowing that steroid to go too many other parts of the eye where you will get those other effects that we got that we’re looking for. So, I think on-label is a big deal and the vehicle in which it’s delivering the steroid is what separates this product from other ones that are on the market.

Walt Whitley: Yeah. I definitely agree. Because if you look at some of the clinical studies and the ability for it to penetrate into the target tissues, I mean, is definitely within the cornea, is definitely a differentiator with the amplified technology. And we know that drug delivery is such a huge topic right now because we need to have these medications that are able to get into those tissues to address both those signs and symptoms. So, how do you feel about empowering patients to give them an opportunity to manage these dry eye flares, to restore balance to the ocular surface, especially when we talk about cosmesis such as conjunctival hyperemia and quality of life benefits?

Adam Ramsey: Okay. So, this one is, this one goes to me to one of the best things about this medication. Patients, a lot of times, come to us saying, my eyes are red. Our response to them is, your eyes are dry. They look and say, I didn’t say my eyes are dry. I just said my eyes seem red. I feel like my eyes look tired all the time and I need a solution. And we want to treat the dry eye which is the root cause. But if we don’t treat the purpose that they came to us for, which is the redness, in a timely fashion, sometimes they won’t allow the other treatment modalities to work. And some of them take a while to kick in. And we have to get an answer to the patient’s complaint. And that’s the one thing I really try to do in my office is that, if they came in for this, I want to give them the answer for this. Even though we know dry eye is the root cause, if we don’t treat the inflammation that’s causing their eyes to be dry, they are not going to be happy. And that inflammation is what is causing their eyes to be red. And if we don’t address it appropriately, the patient is still going to do some redness relief therapy because that’s what they do not like. They don’t like when they go to work and their eyes look red, their coworkers ask them if they’re on any drugs or they’re tired or you had a long night last night? And they’re like no. I didn’t have a long night. My eyes are just red. So, if we don’t, they’re going to use some sort of vasoconstrictor or some sort of medication that gets the red out. And I would rather treat the inflammation that’s causing the redness than allow them just to treat the cosmetic reason behind it. And if we can allow the science and the medication to meet the patient with their complaint, then we have a chance for other therapies to work. And we have a chance to have the eye be nice and quiet and happy. And a happy, quiet eye is a more at peace eye. But I really feel like we need to address, we need to address the issue that the patient is coming to us for. And that issue, a lot of times is, my eyes are red. And this medication can do that.

Walt Whitley: And it’s on label as we just talked about.

Adam Ramsey: Right.

Walt Whitley: Because that was one of the primary endpoints. I mean, right now, what, we have four FDA-approved dry eye therapies, but when we’re looking at the endpoints and the signs, it’s either going to be the Schirmer Score or it’s going to be inferior corneal staining with the signs. But this is something that, redness or hyperemia does matter to patients and so I definitely agree with you. The quality of life, whether it’s due to the cosmesis, whether it’s due to just dry eye itself, and the impact the symptoms have. And we’ve all, familiar with the studies. One that comes to mind is from Kelly Nichols looking at decrease in work productivity due to dry eye disease and dry eye syndrome. And not being able to fully function as well. So, my next question for you, in addition to using this as first line prescription therapy for patients on artificial tears only, what are some of the other patient types for whom you’re seeing treatment benefits with Eysuvis? You did mention the chronic therapy. Is there any other patient, maybe a cataract refractive surgery? Maybe you could speak to some of the many contact lens patients that you see.

Adam Ramsey: So, my favorite so far that has given me the best smile for me and for the patient, is that 80 year old patient that we’ve tried everything. And they just have no glands. And their ocular tissue, there’s nothing there. And we’re trying everything. We’re throwing everything at them. And nothing works. And nothing is giving them the relief they actually need, besides this. Besides getting right to the steroid, getting right to the treatment to get them the relief they have. And this patient I’m thinking of right now, she’s one of those that, dryness and dry eye is her problem. But she does not want that to be what I tell her when she comes in. And she’s getting it sporadically. And that’s where she was really having issues in which she would be fine and then it was dry. And she freaks out and she wants to come in right away. And then by the time she comes in, two or three days later, she’s fine. And she’s sitting in the chair saying, both my eyes feel fine today, but when I called two days ago, they were bothering me. So, she’s sitting there like, I want to be able to show you or come in when it’s happening. And she, you know, struggles to do that. And she is categorically the perfect patient for this. So, I put her on, I gave her the sample, I put her on it, and I said, give me a call in a couple of days and tell me what you think. Do you want a script for it? Do you want to keep going with it? And she called back a week later. Over the moon, overjoyed. And saying, yes, this works. This is what I needed. It is not all the time. She’s like, my eyes just bother me once in a while and artificial tears and all the preservative frees and all the lipid based and all the different oil based stuff was not giving her the relief long enough. And this worked for her. So, I was really, really happy to give her that relief that she’s having. Where once in a while we can actually give her the symptomatic relief from the inflammation in her eyes. And she was just really happy. Now of course, you know, other patients with contacts and all the other stuff, which would probably be the bread and butter of it, works really well. But this 80 year old patient just really hit home for me and gave me some confidence in what I’m prescribing a little bit more. And I was like, well, if it can work for her, it can work for a lot more.

Walt Whitley: And we’re finding that it definitely does work. You know, for me the patient that comes to mind are those patients that have cataracts that are visually significant. That, you know, they need to get the procedure done and we want a therapy that, short term, that we can get in, get out, prepare that surface before I refer to the cataract surgeon. And so, that’s the type of patient that comes to mind. In addition to our chronic therapy patients that, you know, for me, you know, for our chronic patients that we’ve been seeing for a while, and I’m sure you do this as well, we know that anytime we prescribe a steroid we always check the pressure, we always look at the nerves, and the nerve function. But, you know, we know what their pressures are normally. We know if they have a healthy nerve. But because of that FDA safety profile, with Eysuvis, what, .2% of patients had greater than 10 mm of mercury increase over 21. I mean, that’s such a small amount. It just shows how safe this is. And so, I confidently prescribe it for the patient and say, if you have this flare, just use it for a week or two, you know, twice a day and then, you know, if it’s not getting better within a couple of days, call me and I’ll get you right in. And so, that’s typically where I’ve been using this. And you’ve shared so many great insights in regards to dry eye flares, and how you use Eysuvis within your practice, do you have any final thoughts for our audience or any pearls that you want to give about prescribing Eysuvis or where you see this fits in?

Adam Ramsey: Definitely, Walt. What I would say is, for all the practitioners that are listening, give Eysuvis a chance. A lot of times when patients come in, and they hear chronic, and they hear I have to be on this forever, they are not willing to do anything. Because they don’t want to start anything. I don’t like taking medications. I don’t like doing this. I don’t like doing that. And what happens is their eyes get worse. And if we can give them something that’s giving them some symptomatic relief today, that is actually treating one of the root causes which is inflammation, then we may be able to win them over to do other treatments in the future. But when you tell them that this patient, er, this medication, you need to take it twice a day forever, a lot of times they shut down. Mentally, physically, everything. And they are not listening to a word that you say after that. And you go and prescribe that medication, and you check back at the pharmacy, you see them the next year, and they never picked that up from the pharmacy. So, for the patients that are out there, there are so many patients like we went over today, in which it can be chronic, it can be acute, it can be adjunct to something else, it can be a first line medication, there’s a lot of ways in which this medication can fit into our treatment modality for our patients. Now every practice should have to find their comfort level and what, and how they fit it into their treatment modality, because it can be used a lot of different ways. It’s one of those great things you want to keep in your back pocket. And it can be, it can fit in and it can be used different ways for different types of patients. But I would say, give it a chance. And giving it a chance, I think is giving patients the opportunity to get better quality of life. And I think quality of life and getting right to the symptoms that the patients are experiencing is, at the end of the day, the most important thing is patient’s smiles. And I think this medication does that. And I’m excited to have it as one of my treatment regimens. And it has done wonders in my practice and I hope other people give it a chance as well.

Walt Whitley: Hey, well thank you so much there, Dr. Ramsey. I agree with you 110%. Appreciate you joining us for this episode. And I also want to thank you all for listening to this episode of Dry Eye Coach Podcast.

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