Dr. Richard Mangan talks about how big and small investments in dry eye disease have positively impacted both his patients and practice.

Whitney Hauser : Hi. I’m Dr. Whitney Hauser. And welcome to Dry Eye Coach podcast. Today we’re going to be talking about tips for doctors just starting out in dry eye. So, if you’re looking for some new pearls about how to add dry eye in your practice, this may be the podcast for you. Today I’m joined by assistant professor at the University of Colorado Department of Ophthalmology, Dr. Rich Mangan. Welcome, Rich.

Rich Mangan : Oh, thanks, Whitney. It’s great to be here. I appreciate it.

Whitney : You bet. You bet. We’re kind of excited to get to know, you know, what you think are some of the greatest things that new practitioners, or practitioners that are just trying to bring dry eye into their practice might want to add in as they develop. So, I’m going to jump in with some questions for you…

Rich : Okay.

Whitney : … right off the bat. And, what are the benefits to doctors and their patients for getting started, or treating dry eye disease? You know, there’s benefits on both sides, so give us a little bit…

Rich : Right.

Whitney: … of your thoughts there.

Rich : Right. You know, certainly, the benefit for me as a doctor in getting started was just to have a greater appreciation for the fact that ocular surface disease is in fact a real disease and not just a symptom. To be honest with you, years ago I used to hate dry eye. You know, I would go and see LASIK evals and cat evals and I was really enjoying that. And then I’d pull out a chart and it’d say dry eye and, you know, I’d just shrug in agony thinking about it. But then I went to a speaker training many years ago, in fact, this was around 2002 when Restasis came out, and it really, the panel did an excellent job of just really impressing upon the attendees that, you know, the quality of life scores of dry eye can really mimic, you know, even severe things like angina or disabling hip fracture. So, when I took that to heart, and I decided that it was time to come back to my practice and truly treat it like a disease. And so, I spent some time educating my key technicians, my team leader, and we actually carved out dedicated time just to really focus and concentrate on these patients. And what it did was, after they got to hear, you know, my walking the walk and talking the talk, you know, my dry eye practice really became more efficient because they knew what I was going to say before I was going to say it. And, but they truly developed appreciation for the fact that this is a disease.

Whitney : Yeah. You raise a good point, you know, about the kind of parallels that are between more serious, as they would be noted, diseases and dry eye disease. I think that’s where a lot of the disconnect is. It’s not so much that the doctors don’t believe it exists. I think that most eyecare providers do. But it’s the gravity of it. So, the patient sitting across from them I think is oftentimes what’s missing.

Rich : Yeah.

Whitney : So, I think you probably latched onto that well in advance of a lot of our colleagues, including myself. So…

Rich : Well, I’ve been around longer than you, Whitney. I’ve had a little bit of a head start in that respect. (laughs)

Whitney : Unfortunately, not by as much as one would think. (laughs) You feel like this has a positive impact on new referrals as well? Bringing new patients into your practice?

Rich : You know, it really does. Keep in mind, when I first started my dry eye practice I was in a co-management, a referral center, and one of the concerns we had when I brought this idea up was, how were our referring doctors going to look at this? Would they look at it like I was competing with them? And, in fact, the response was the complete opposite. They loved the fact that they had a resource in the area that really took this seriously. Patients could tell when they came into my clinic, this just wasn’t being treated like a symptom. I was really focused on this disease for them. And it’s funny because, you know, I only started off carving out a half day a week in my clinic, yet it took virtually no time for the word to get around the community that I was a dry eye expert. And I was no more of a dry eye expert than the guy down the road, it’s just that I had a dedicated clinic, and all of a sudden, I was an expert. But the reality is, it was. It was a power tool and next thing you knew I was getting referrals in the community. When I started, when I introduced autologous serum, I was having people drive 3 and 4 hours for it.

Whitney : Right.

Rich : So, I think just the fact that I committed to it, and that’s, if there was one thing I could hammer home to the audience is, you know, you can start with the basics and still make a difference in these patient’s lives. You know, now certainly technology today has become more affordable. I mean, my goodness, if I had all the stuff we have available today, back then, it would be a no-brainer for me because, you know, this stuff pays for itself. Both from a monetary stand-point, but just from a satisfaction stand-point to the doctor.

Whitney : Right. I mean, optometry is pretty notorious for not referring, you know, inter-professionally, not referring to each other. And I think dry eye does present a unique opportunity for that. Because, you know, just like you felt going down the hallway and pulling that chart out and saying, oh, here comes the dry eye patient and saying, oh, no. I don’t really feel a passion for this. You know, as much as maybe you and I’d love to have all our colleagues feel that same level of passion that we do, they’re just not going to.

Rich : That’s right.

Whitney : And with that in mind, referring to someone locally or regionally who does accept that challenge, and does find that as a passion point, is a great opportunity, in my opinion, for the profession itself.

Rich : Absolutely.

Whitney: You kind of alluded to some investments and things like that that you made a long the way, and opportunities that presented. So, I guess, my next question to you is, what are some of the key things that you recommend with getting started? And maybe what are some of those initial investments that you’ve made or that you would recommend a colleague make?

Rich : Sure. Mine might be a little different from others. But the ones that I think, you know, one of the biggest issues we face, Whitney, is compliance.

Whitney : Absolutely.

Rich : And so, I can tell you that what’s really been a game changer is meibography, as well as slit lamp photography or video. You know, when, you know, we have Lipiflow in our practice and we charge $1,500 per treatment, which I think’s probably a little higher than the national average. But I don’t have patients really balking too much at it when I show them their meibography and the scans of their lids. And I can show them that a third of their glands have atrophied or are in that process. So, you know, a picture goes a long way. And I can say the same thing with slit lamp video or photography. We’ve all had those patients that, right, both sides. We’ve had patients that have been relatively asymptomatic, yet they’ve got florid staining, significant ocular surface disease. And then we’ve had the opposite. We’ve got patients that are very symptomatic with very little signs.

Whitney: Right. Right.

Rich : Well, the video or the photography, especially in that patient that’s just got florid disease, their nerves are no longer functioning, we can show them a picture of that ocular surface, they’re much more likely to buy into the, you know, the extensive treatment regimen I’m going to have to put for, you know, in front of them.

Whitney : Right.

Rich : So, I think that’s been just, you know, I think those are two big ones in my mind that are helpful not only in just getting buy-in, but essentially maintaining and growing your practice.

Whitney: Right. So, buy-in is incredibly important for our dry eye patients. You know, it’s funny. It goes on either side. We have to get the doctor to buy in, initially, and once they’re bought in, then we have to get the patients to buy in. And I couldn’t agree more. I mean, you hate to use diagnostic tools as a crutch, if you will, but gosh! It’s really handicapping for me to think about not using a lot of those things that I’ve grown to rely on so much for patient education.

Rich : Right.

Whitney: So, I couldn’t agree with you more. The picture is definitely worth more than a thousand words when it comes to dry eye, especially as you mentioned in that asymptomatic patient. When you say, look, look at what we see here.

Rich : Exactly

Whitney: And as our good friend Paul Karpecki always says, this concerns me. Well, it really does concern me.

Rich : (laughs) That’s right.

Whitney: When you see then it’s equally, equally concerning that the patient doesn’t have that same level of engagement sometimes. So, what, what has your experience been with patient and physician accessibility? You know, in terms of reimbursement and cost issues. We all say that it’s very daunting, it makes your office, you know, lag sometimes in efficiency. And sometimes, frankly, that’s just enough to get a doctor to turn the other way.

Rich : Yeah.

Whitney: So, what’s your experience been?

Rich : You know, overall, I think the biggest challenge, right, is with some of the pharmaceuticals that are newer that are out. And, you know, sometimes the process of getting those pre-approved can be daunting. I’d love to say I have a magical answer to that. I think it’s just a matter of staying the course. I know our practice has someone actually that’s their role is to kind of help facilitate those things.

Whitney : Right.

Rich : I’d love to see more of the pharmaceutical industry come up with a little bit more of a cash price that’s a little friendlier. I think we’re starting to see that now. You know, as far as things like treatments, though, as far as like meibomian gland dysfunction, you know, again, I’ve just not had too much trouble converting those patients. Because, again, if I show them the scans of their lids, a lot of times they realize, you know, this is my sight. And this is, you know, one of my most precious gifts. And if they can’t swing it immediately, they certainly work toward that.

Whitney: Well, I think you raised a great point there because, in my experience, a lot of times, and this goes with a lot of professions, but in particular my experience has obviously been with optometry, is once a doctor presents a thermal treatment or an intense pulse light treatment, or something that’s an out-of-pocket expense for the patient with dry eye disease, and that patient says no, I think that impacts the likelihood of them continuing to present, you know, over time. I think all those “nos” sort of add up.

Rich : I see.

Whitney : And I think that that, I think that doctors tend to narrow down. They tend to shut down a little bit with their presentations. And that can ultimately impact the number of procedures that they’re doing. But you’ve really got a great perspective that that “no” isn’t a “never”. It’s just a “not now”.

Rich : Right. That’s right.

Whitney : And we have to kind of consider that these conversions of patients to out-of-pocket procedures is really not always an immediate conversion. You know, and we have to look at those conversion rates from an immediate, a short-term and a long-term perspective. And measure in that way. And I think that would really open up a lot of minds to continue to present. I think the failure of a lot of these advanced treatments is that doctors just shut down. They feel like it’s not working for me.

Rich : Yeah.

Whitney : I tried for a month or two and it’s not taking off the way I wanted it to.

Rich : Yeah. I agree. And I think the other thing I’ve found is that doctors have felt pressured to try and get all the answers on one visit. Sometimes even with their VSP exam, and you know, I try to impress upon them that, you know, this is a medical condition. This is something that should be billed through their medical insurance. And I tell patients up front, you know, I tell them dry eye management’s a marathon it’s not a sprint. And, I’m willing to take this run with you, and it’s always my goal to keep your cost as low as possible and to keep you in my office as little as possible. But ultimately the goal is to improve your quality of life and protect your vision. And I think when patients hear that, you know, they’re willing to take their time and work on this together. And at some point, you know, if we get to a stagnant level, or even backslide a little bit, that’s when maybe the husband says, honey, you’ve tried everything else. Let’s go ahead and pull the trigger and let’s do this advanced treatment for your eyes.

Whitney : Well, that’s a great perspective because it is oftentimes more of a family disease, if you will. You know.

Rich : That’s right.

Whitney: And we see this with other things, too, but, you know, I feel like you get, almost need to have that third level of buy-in from family members because, gosh, if you’re sitting in the chair across form your spouse and you’re hearing the words “dry eye”, that sure doesn’t sound very serious. You know.

Rich : That’s right.

Whitney: And it’s hard for sometimes those family members to really have that same level of buy-in about their spouses or their, you know, mother’s ailment. And you raise a great point. So, as we go forward, you know, kind of thinking about, what would you recommend for doctors as some of the top treatments? Just getting started. You know, there’s practitioners out there that, you know, are practicing primary care optometry, doing a fantastic job, they want to start to pull things into their practice to really focus on dry eye disease. Where do you begin?

Rich : Sure. Right. Well, I think the first thing I would kind of impress upon our colleagues is that, while artificial tears certainly have a role in dry eye management, and in helping short-term symptoms. If all we do is go to the cabinet and hand a sample to our patient, you know, we’re not going to get very far. You know, studies have shown that the average patient tries 3 ½ different types of artificial tears before they even come in for their chief complaint of dry eye. So, we have to be mindful that we need to be a little bit more advanced in our management. The second thing is, you know, if you’re seeing any kind of staining on the ocular surface, you know, that is definitely telling us that we have not just mild ocular surface disease. We need to start thinking about some kind of anti-inflammatory to use. So, that would be one thing. And then I think nutrition is also very important. You know, I live in Boulder, Colorado and this is like the health and wellness mecca of the United States. And so, everybody is very tuned into that here. And rightfully so. And, I think one product that we’ve embraced here is called HydroEye. Which is not just an Omega-3, but really the component to that supplement, which is really, I think, a difference maker, is the GLA in it. That, combined with Omega-3, has been really studied extensively. I think over at least 7 good clinical trials that have looked at the positive effects that it has, not just on general body inflammation, but specifically for the eye. And, one of the things that they studied in the HydroEye trial which was one reason we’ve decided to make it our main Omega here is the fact that it really also stabilizes the ocular surface. So, we’re in a practice where we do a fair amount of LASIK and cataract surgery, and one of my roles in my dry eye practice is surface optimization prior to surgery. And so, it’s one of the key things we really look to incorporate as well. So, I’d say those are the first few that comes to mind. Is there something I’m missing, Whitney?

Whitney : No. I think that, I think that sounds like a great spot. Artificial tears, really refining your recommendations for artificial tears. Not just, like you said, here’s one out of the cabinet. In terms of nutritional recommendations, I make that same recommendation. And I find that, beginning with making a presentation, to a patient, about an out-of-pocket expense, nutritional supplementation is a great place to start. Because, perhaps you’re not at a point where you’re recommending Lipiflow, iLux, TearCare, you know, Intense Pulsed Light, whatever the, you know, option may be, but you need to present something. You need to present it with, you know, like you said, some significant information behind it, why I’m making this specific recommendation for you, not just any nutritional supplement. But in your case, you’re using HydroEye. Why that’s of value to you as a doctor and why it should be of value to the patient. And that really refines the presentation still.

Rich : Yeah.

Whitney : And I think it’s a steppingstone to doing more and more in dry eye disease.

Rich : Absolutely.

Whitney : So, I couldn’t agree with you more. The other thing perhaps maybe is, I would add in, and you might have touched on this just a little bit more about lid hygiene.

Rich : Right.

Whitney: It’s often overlooked. And it’s an easy product to have in your office that is not going to go, it’s not going to expire on the shelf. You’re going to be moving that product because it’s so ubiquitous. And I think gives a great opportunity, again, to refine that for those presentation skills. Because I think what doctors will find is, as they’re presenting things like nutritional supplements, and lid hygiene, you’re going to step on yourself a million times before you figure out exactly how to say it. And once you got it, you got it.

Rich : Right.

Whitney: We’ve all done that with everything else we do in practice.

Rich : Right.

Whitney : So, I think that’s a great steppingstone.

Rich : Yeah. And Science Based Health just makes it so easy to, for both the doctor’s office and the patient. And it’s a dollar a day, you know, a money back guarantee. And I just love the fact that I can hand the patient a copy of the study that specifically was for dry eye.

Whitney : Right.

Rich : And I think they really, really appreciate that.

Whitney: Yeah. Yeah. And, you know, oftentimes nutritional supplements don’t have the research behind it the way this one does. Which I think is definitely supportive. But, funny about that money back guarantee. I’ve told many patients about it over the years. Because I’ve probably been prescribing HydroEye for 5 years or so.

Rich : Okay.

Whitney: I think, out of that 5 years, I’ve had maybe, maybe, 2 to 3 people ever, you know, tried to get that money back guarantee. It’s so infrequently used. But somehow it’s validating to the patients.

Rich : Right.

Whitney : That clearly the company’s standing behind it.

Rich : And, don’t you find it’s just so well-tolerated, you know, compared to just doing Omega-3 only? I find that patients just stick with it because it’s, you know, there aren’t really any side-effects with it.

Whitney : Well, and a lot of my patients just like wellness. You know, I think as doctors we are trained to treat sickness, particularly in eyecare. We don’t necessarily have a lot of wellness objectives with our patients, always. And I think that this is something that the patients are pretty keenly interested in in terms of wellness. So, the objection that they have is not usually to something nutritional. A lot of times I have to do a little bit more coaxing when it comes to pharmaceutical agents than it does giving nutritional supplements.

Rich : Right. That’s right. Yeah. Good point.

Whitney : So, my last question for you is, how is having a dry eye practice benefitted your practice and patients? What are the benefits you’re seeing coming back to you?

Rich : Yeah. Well, certainly it’s kind of amazing at how quickly the practice grew. So, certainly any doctor that is, you know, especially maybe a new physician to a group practice that’s looking to build their patient base, trust me. It would take no time, you know, for that clinic to grow. And then, you know, as you start off, you’re going to find that it’s maybe a little inefficient at first. But, again, you’ll learn quickly how to make it efficient. So, it makes sense, from a financial perspective, too. I think the big thing for me is just the personal satisfaction of really helping people. When you get that first hug from a Sjogrens Syndrome patient that couldn’t leave the house.

Whitney : (laughed) Right.

Rich : I mean, the wind and everything. They were just so miserable.

Whitney : Right.

Rich : Now, that alone is validating. And so, you know, I think it’s a win/win for everybody. And let’s not forget that, you know, it is, while men certainly are in my dry eye clinic, it’s still predominantly female. And when you think about it, you know, who are the primary caregivers of the household? It’s usually the mom, right?

Whitney : Right.

Rich : So, if you make a mom happy or you make grandma happy, the next thing you know you may be bringing an entire family into your practice.

Whitney : Right.

Rich : Anyway, yeah.

Whitney: Well, and the reason I laughed when you said that about the hug is, it was the first thing that jumped to my mind is, you know, my dry eye patients are huggers. You know, they, it’s such a, if somebody that wants to have that emotional connection with you, it really means you are making a big impact in their lives. It’s above and beyond a lot of the things that we have the privilege of doing that, it’s kind of like that first pair of contacts in a high myope or whatever. But this really benefits to you emotionally as a physician.

Rich : Absolutely.

Whitney : That a lot of other disease processes don’t. So, I couldn’t agree with you more. Well, Rich, I really appreciate your time today. It’s been really valuable. I think we both agree, we encourage our colleagues to jump in with both feet in terms of dry eye disease.

Whitney: You’ve really given us some food for thought and some real actionable things that can be taken into practice right away. So, I certainly appreciate your time today.

Rich : Oh, it was my pleasure, Whitney. Thank you so much.

Whitney : You bet. And thank you for joining us for Dry Eye Coach podcast. We’ll have more. We’ll be adding to iTunes soon. So, keep listening.

Dry Eye Coach
Dr. Richard Mangan talks about how big and small investments in dry eye disease have positively impacted both his patients and practice.