Walt Whitley: Hi. I’m Dr. Walt Whitley with Dry Eye Coach podcast. Thank you all for joining us. Today our topic will be a conversation with innovators in the dry eye space. Our guests include three key industry executives from small, innovative companies focused on dry eye. Our first guest is Zac Denning, director of Scientific and Professional Affairs at ScienceBased Health; Dr. Tim Trinh, an optometrist and founder and CEO of Box Medical; and Dr. Peter Pham, who is a board-certified ophthalmologist, researcher, innovator and entrepreneur and founder and CEO of Zocular. Guys, thanks for joining us today. So, what we’re going to do, is we’re going to have a conversation and I’m just going to ask you all a whole bunch of questions. We all know each other very well, but we want to hear your story and how did you get to this innovative space and how did you get your products to this space. But that’s what we want to know. Tell us more. And so, Zac, I’m going to start with you. Can you tell us how you got started working in dry eye?
Zac Denning: Absolutely. I’ve had the privilege of having been in dry eye before many people were. ScienceBased Health was started in 1997. It’s the first eye supplement company. I joined the company in 1999 and a year later we launched the first dry eye supplement, specifically formulated for dry eye, on the market. And this was even before there were many options available. Restasis, I think, came out in 2003 or so. And so, in those early days, there were very few dry eye options out there and patients were desperate and it was not being recognized by doctors. There just weren’t a lot of tools. So, we’ve had the privilege of watching the options for treating dry eye grow. In 2013 HydroEye was validated by a clinical trial that you all were involved in, that showed that, a supplement can actually have a measurable effect on dry eye. HydroEye uses a unique omega called GLA that’s not found in the diet or fish or flax. But it’s a precursor to a specific prostaglandin that stimulates tear production and reduces inflammation. So, we’ve had a real scientific approach to this. And it’s been really cool just to see. I think a lot of people just didn’t appreciate how big of a problem dry eye was at the beginning. But we’d have patients coming to us saying “you changed my life”. And just seeing that overwhelming response kind of let us know that we were addressing a need out there. So, its been really a privilege to be in from the beginning and absorb dry eye by osmosis and watch the whole progression of this space. So, that’s really how I came to dry eye. It’s been a great journey.
Walt Whitley: And you have a lot of options at ScienceBased Health. You have a lot of different nutraceuticals. And so, it seems like you love HydroEye. Is there a reason why you love the dry eye space more than others? Or am I just making that up?
Zac Denning: Well, no. I mean, I do have a passion for dry eye. And one reason why it’s an exciting place for nutrition is that, in many ways, nutrition is often something that happens silently in the background, over a long period of time. And you may never notice it even if it’s having benefits such as for AMD or for glaucoma or something like that. You don’t feel your visual field shrinking, but you notice when your eyes are dry. And so, one thing that’s kind of cool about dry eye and nutrition, is you can actually provide something to somebody where they feel better in a certain amount of time. And if people stop taking it, they’ll notice they feel worse. And so, you actually get direct feedback. I think that’s part of it. And the other part of it for me is that I’m a dry eye patient myself now. I use HydroEye and I use Peter’s product, Ocushield. So I know now what a problem it is. And so, I think that’s helped my appreciation of it as well.
Walt Whitley: Yeah. And when it comes to nutraceuticals for me, I have a lot of patients. I use a product, as you mentioned, we are involved with the research, but my patients who are on it, they stop or run out, they’re like, hey, I’ve got to get more refills just because it makes that much of an impact. But nutraceuticals, to me, are just part of the foundation of dry eye treatment. That along with prescribing a tear, prescribing an anti-inflammatory, taking care of the lids. And we’ll talk with Peter here shortly. But also, the meibomian glands and addressing that. So, thanks for sharing that, Zac. Tim? How did you get started working in dry eye? Or Peter? Peter, if you want to go first. How did you get started? Tell us more about Zocular and how you got into that.
Peter Pham: Absolutely. So basically, like Zac had mentioned, dry eye is a really common disease. And I think all of us have dry eyes, including myself. And that’s what really motivated me at first to do something about my dry eye. Because I had tried a lot of things that were available for my eyes. And I didn’t find them too helpful in my case. And so, I thought to myself: is there another way to try to address this? Because we know that dry eye, at its root, is an inflammatory disorder. And our arsenal for inflammation control was fairly limited, when I started, with cyclosporine, the NSAIDS and steroids. And, of course, the nutritional supplements like ScienceBased Health’s HydroEye. So I thought to myself, this whole new class of polysaccharides that have shown great promise in the literature, to actually address inflammation. And so what I wanted to do was to use an okra polysaccharide as a model. And when we first tried it, I worked with the lab. And it was a mess. It didn’t work. And so, it started off, I mixed a whole bunch of different formulations, and almost all of them didn’t work. And then one day, I had one formulation I brought to clinic, and I asked my staff, I usually ask my staff to try this. And this one staff said, you know, Dr. Pham, I don’t have dry eye. I go, well, I know but you’ve got something on your forehead. Just try it on, she had a seborrheic dermatitis on her forehead. And then she came back the next day and she said, you know what? This thing is almost gone. The irritation, itchiness, is almost gone. I go, oh, there is that inflammatory effect that we were looking for. And so, that was the formulation that we put into production for Zocular. And ever since then, that’s how we developed there. And so, it’s basically serendipity and need how we got started.
Walt Whitley: That’s awesome. And that’ the part that you have that speaks for itself. And on different chatrooms or different social media platforms, we’re hearing everybody’s experience. And so, you definitely do have something there. Tim? How did you get started in this space?
Tim Trinh: Long, long time ago. Five years is when I was trying to get into the dry eye space. And just really was looking at the root cause of dry eyes. And as you know, MGD has been one of the major components of dry eye. The challenge for us was trying to image and determine which patients were actually going to respond with in-office therapies. At the time, too, the technology that was available was just a little bit financially out of reach and didn’t really meet the form factors we were looking for. And so I sat down with a colleague whose husband is actually an engineer. And he was working for Ring Doorbell at the time and they would pull out some articles about meibography and kind of learn a little bit about it. And I asked him, I was like, do you think you can create this technology? And create it in a way that it’s portable and one that’s a little bit more affordable for doctors. And so the two of us got to tinkering in our spare time and then what started off as a small project ended up being a big endeavor. He quit his job at Ring Doorbell, kind of took it on full time. And when we actually created our final prototype, we posted a few photos on Scott Schachter’s OS. And, man, the response is great! We were able to, docs are like, you know, “where’d you get this from?” And, so, we found that there is really a need and decided to take it to the next level, which was commercialization. But I’ll tell you, there were a lot of challenges along the way, but it’s been a fun journey. And five years later we’ve been able to help out about two hundred docs so far. So, it’s been amazing.
Walt Whitley: So, how do you split your time? I mean, you’re still practicing and seeing patients. But then you have this, your company here. How do you have time?
Tim Trinh: That’s a good question. Sometimes I don’t know! I have two practices and the company, too. But I think a lot of it comes down to building a solid team and trusting your team. And then, on top of that, the creation of our product is designed in such a way that it really requires the least amount of maintenance. Because everything is cloud-based, the IT component really isn’t going to be an issue for a lot of doctors. For my office, I have a team that really runs everything and is able to kind of allow me to have confidence in that need to see patients and then I’ve seen time management company, too. So, it’s really like, it requires like a whole community to kind of get this thing going.
Walt Whitley: Peter? How do you have time? Because, you’re still seeing patients as well, aren’t you?
Peter Pham: Yes, I am. And I think Tim really hit it on the head there. It really does take a team effort to do any of this here. So, building that team is so important. And, for myself, I have had to cut down my clinic quite a bit just to work on Zocular. And I also started another company with a friend of mine in the on-line testing space. And so, it’s been really fun and exciting for me. And I love doing this sort of entrepreneurial kind of work. And so, it’s been good.
Walt Whitley: Well, I’ve got another question for you all. What is your perspective on the current state of the dry eye market in eye care? And how do each of your respective companies fit in? And I’ll let you go first, there, Peter.
Peter Pham: Yes. So dry eye is a really complex topic. And no company can do it all. And we always have to work as a team like any other company. Any treatment regimen, I think, requires a whole complement of products, procedures and technology, where you need both the diagnostic, you need the in-office procedures, you need the at-home maintenance therapy. And you need all of that in your full complement and arsenal of treatment options. And so, I think what, the nice thing about Zocular is that we’re able to provide both an in-office and an at-home treatment to fill that need there. And the key differentiating characteristic for our product is that it does provide patients with that immediate result that they can actually feel. So, if they were to undergo an in-office treatment with the ZEST procedure, which is an in-office lid debridement, similar to Blephex, in almost all of the cases that have it done, the patients feel a dramatic improvement in the symptomatic score whether you’re talking OSDI or SPEED, within about ten to fifteen minutes of procedure. And we now have studies to show that even with one treatment it lasts for at least a month and more, obviously, if you have an ongoing daily treatment along with it.
Walt Whitley: So, one of the questions, because you definitely did find a place with your okra-based treatment in Zocular, so when someone asks, why should I go with this versus something with, one of these cleansers with tea tree oil? What is your response to that? And what data do you share with them?
Peter Pham: So, the data I like to share with them is that everything works. The tea tree oil works great on dry eyes and has been shown to be highly effective against both as an antimicrobial and against demodex. But it does have an irritation effect there. Whereas with Zocular, there’s a much less irritation effects from it. And so, there’s that compliance issue that I always stress there. It’s always easier to use a product which doesn’t have the issues with pain or discomfort, just to use something that obviously has a little bit more of it there. And the second thing is that we do feel like it does have a lot more of the anti-inflammatory potential than some other products in the marketplace. And I think that’s where our niche is.
Walt Whitley: Yeah. You did mention the in-office treatment as well as the at-home, and that is definitely a key. You also mentioned compliance. And that’s one of the biggest barriers whether it’s dry eye, glaucoma, whatever the condition may be. Hey, Tim? Is that somewhere where your company comes in? Can you help with compliance and education, and diagnosis?
Tim Trinh: Yeah. Absolutely. I mean, you think about how you talk to your glaucoma patients, right? You tell them you have a silent disease that’s causing you tunnel vision and loss of vision every day that’s not treated. But until you actually show them hard evidence, like a visual field or scans of OCTs, or their loss of nerve fiber layer, they’re not really going to get it. And so, if you’re going to recommend nutraceuticals like ScienceBased Health or, recommend in-office therapy, things to remove obstruction that might damage meibomian glands, they aren’t going to understand it until you actually start imaging them. So, as a doctor, I’ve been able to see the impact of it directly in terms of educating the patient because, when you show them the images of their meibomian glands and let them know, like look, long-term wise, this is what can happen. You know, you can have loss of the glands or shortening of the glands because of obstruction. It’s like having cavities inside your teeth, right? Like, sometimes you may be asymptomatic but once you start seeing those x-rays or seeing those images where you have loss, structurally, the dry eye condition is no longer just a symptomatic issue. It has anatomical implications. So, education is a big, big key in what we’re aiming for.
Walt Whitley: Yeah. And you’re telling Mrs. Smith, this concerns me. Look at these little nubbins you have on your eyes and this is why we need to do the various treatments and prescribe the various nutraceuticals. And this is why we do what we do. Can you talk about where your company fits in? Especially in the meibography space and diagnostics, because there are other products out there. And, what is your differentiator within the space?
Tim Trinh: Yeah. I think for us it’s really more like implementation. There’s a lot of great technologies out there. And I think they’re all fantastic. It really comes down to, for us, it’s accessibility. So, accessibility comes in the form of the doctor being able to bring in the technology. So, we are priced fairly low to be able to decrease that barrier of entry. But secondarily, it’s also clinic flow. So, if you have a centralized testing room where your meibographer sits all day, if it’s sharing space with other equipment, it may not be as easily accessible by your technician to run the testing when you want it. So, with our device being portable, you can bring it room to room and just drop it into the slit lamp and image any patient. So, essentially, every single one of your exam lanes becomes a dry eye imaging room. And because of our cloud-based elements, too, we’re aiming to create new technologies that are off on the horizon to really help improve your patient communication goals as well.
Walt Whitley: No, that’s great. Zac? What about you? What is your perspective on the current state of the dry eye market? And where does ScienceBased Health fit in?
Zac Denning: Well, the way I see it, I think we’re starting to get some depth in terms of the number of dry eye treatments and diagnostics available. There’s sort of a renaissance of new technologies. But we don’t really have the breadth. It’s not reaching most practitioners, right? I mean, I don’t know what the statistic is, but my just sort of off the top of my head guess would be that maybe 80% or more of practitioners are doing very little for dry eye. And some of them are doing almost nothing. Maybe recommending an artificial tear and maybe writing a Xiidra script or Restasis script, or something like that. But most people aren’t really addressing it in a serious way, most practitioners. And so, I think there’s a lot of room for bringing technologies that are accessible, to get more eyecare practitioners seriously addressing dry eye and really getting into it without a lot of financial barrier, without insurance hassles, without, all these things that become a barrier to entry. And so, one thing that I think is kind of cool, I think Peter sort of alluded to the fact there’s not a silver bullet in dry eye. There’s not one thing you can do either as a diagnostic or as a treatment. But I like that all these technologies we have, we’re talking about today, they’re all very accessible, and they’re very simple. And you can bring them into your office pretty easily. Patients can understand them or see the results of them really quickly and readily. And so, I think that we all have in common being able to hopefully start to make inroads on trying to get more eyecare practitioners on board and trying to address more patients without a lot of barriers.
Walt Whitley: Yeah. And we’ve all talked about this before is, how do we address our patients? And what a huge opportunity we have. I mean, 30 million Americans, only half are diagnosed, only, less than 10% or only about 10% are getting a prescription treatment option. But we know that it takes multiple approaches to fully address our patients. And then, is it more the passive dry eye? Here’s an artificial tear or try these twelve artificial tears. Or hey, Mrs. Smith, this is your dry eye disease. This is your meibomian gland dysfunction, this is your blepharitis, and this is what we need to treat. So, being more proactive versus reactive. And so, definitely lots of opportunities for us to grow. But then also looking at, the changing dynamics within healthcare and looking at insurance-based services versus cash-based services. First, all about the patient. Making sure patient care comes first. But, this is something where dry eye can definitely fit it.
Zac Denning: Right. Right. Absolutely.
Walt Whitley: So, next question I have for you all. What gaps do you see? And you kind of started off with this just recently, there Zac, with your last response. But what gaps do you see in the dry eye diagnosis and treatment? And how’s your company working to address these through innovation?
Zac Denning: Well, I think that our understanding of dry eye has really changed, right? Because it used to be all about, it’s sort of this binary choice of aqueous deficient or evaporative dry eye. And it’s just this either or equation. And now, like with DEWS 2, we started to have a more nuanced understanding that it’s this vicious cycle. There are many on ramps to get into that cycle. But it involves other things that we hadn’t been addressing before. Like effects of hyperosmolarity, nerve dysfunction. Anything that can disrupt the homeostasis of the lacrimal function unit. And so one thing that’s been really exciting for us is that we’re continuing to push research forward. We have new research going on right now and all the time. And continuing to look at new nutrients that actually may address some of those areas as well. So, that’s definitely something we’re actively looking at. We always update our formulas as new research comes out. And that’s something we’re going to continue to do.
Walt Whitley: That’s awesome. That’s awesome. Peter? Tim? What gaps do you all see in the diagnosis and treatment of dry eye? And what are your thoughts there?
Peter Pham: Yeah. Zac really kind of hit the nail on the head there. As we all know, dry eye is a huge problem in the community. A lot of people have it. And they just suffer through it because they’ve tried, like you said there Walt, a dozen artificial tears and it hasn’t helped and they’re reluctant to go to a dry eye doctor because they’ve been to five and none of them have helped them so far. And four out of five want to try more artificial tears. So, it’s more like a funnel where you have this large pool of patients who aren’t doing very much for their dry eye. And so, we all know it’s a progressive disease. And if we start to do something just to slow down that progression, to ward off the symptoms, and clinical progression there. I think it makes an immense difference. And it’s that education and recognition there I think that’s the key missing ingredient. Because it doesn’t take the most advanced and most complex, costly treatments in order to get patients, most patients better. And so, I think we should probably start with that first baby step there.
Walt Whitley: Yep. Tim? Anything to add?
Tim Trinh: Yeah. I think Peter and Zac kind of hit it on the head. I think our main philosophy has always been, keep it simple stupid, right? Because, it’s like, especially for doctors, sometimes we get all hung up on all the extremely difficult cases of dry eyes that people are going to require a lot of expertise and everything else to manage. But, and the fact of the matter is like 85% of the dry eyes can be managed with simple solutions from how we counsel patients about their diet to how they maintain their eye hygiene to just addressing their meibomian gland dysfunction. And, I think a lot of it comes down to educating patients and educating doctors, that it doesn’t need to have a super complex solution to be able to do that. And removing that barrier of entry for a lot of docs that, they’re fearful to kind of take plunge in this. Because they think it’s going to require significant investment. And with new developments these days, you have so many tools available at hand you can address about 85% of them with a simple slit lamp and some of the tools that are available from both Peter and Zac.
Walt Whitley: You know, one thing that comes to mind, you just mentioned educating the patients, educating the providers as well, but what about the role of technician there? Are you all targeting the, because, you know, without my dry eye counselor, I’d have a tough time here at the practice and keeping our clinics running in this space. I mean, are you all working closely with the technicians and educating them as well?
Tim Trinh: For sure. I mean, for us part of our next stage of our company is really removing a lot of that educational burden off of the doctor and off of the office. Because as you know, with COVID, time becomes such a necessity. And you don’t have a lot of it to spend in the clinic anymore. So, we’re actually in the process of creating a patient portal that will allow a patient to be able to access these interactive elements to be able to understand their condition better. But also, on top of that, be able to download the resources that are provided by the doctor and to learn more about the technology. Because sometimes within the thirty-minute exam, there’s no way that a patient can fully grasp the complexity of the condition. And oftentimes that becomes a hurdle for the patient to actually want to move forward with a new therapy.
Walt Whitley: Yeah. You know, you mentioned the keep it simple stupid part, and then I’m just thinking about that dry eye patient I saw earlier today that I was with them for like twenty-five minutes, talking about the dry eye. And I was trying to keep it simple but, there’s always going to be patients like that. But that’s going to be more, that’s not going to be a typical patient that we see. Did you, Peter, Zac, did you have anything to add on that? On the education piece or technicians?
Peter Pham: Well, I think, technicians are really key here because you empower them. I think patients a lot of times have even more of a social connection with your staff than with the doctors. And so, if the technicians and your staff are highly knowledgeable and motivated, I think there’s a much better response from the patients and better clinical results as well. And so, what we’ve been trying to do is that we’ve been trying to get the staff trained on how to perform the ZEST procedure in the office. It takes that step out of doctor’s hand and have, and let them do other critical elements of their clinic.
Zac Denning: I’d agree with that. I think that part of keeping it simple is making it accessible. Simple enough that it can be accessible and doable by anyone in the practice. And not just, I mean, there’s a place for procedures that only doctors can do, obviously, but it’s helpful to have approaches that the tech can do. And the tech can learn how to do. And I think one sort of disservice, in a way, that maybe the industry and maybe the medical community has done sort of inadvertently is I think that we’ve maybe made dry eye sound more intimidating than it has to be. Like, it can be really, it is a complex disease, but by emphasizing so much how complex it is, and also sometimes emphasizing the most premium or high end procedures which all really have their place and are great, but sometimes, doctors who are in the audience doing CE or CME, are just thinking to themselves, wow, this sounds complicated and expensive and I could never do this. And so, that’s one thing that I think we need to change and make it so a tech can do it. Make it so that you can bring it into the practice and make it accessible to patients. And, I think that all of us here, Tim, you know that the Meibox, the MX2, has been great because now, we know that if we go into an office and, someone is just using HydroEye they’re not going to be successful. They need some other tools. And one of those things that I always recommend is meibography and having a really simple, modest cost meibographer that’s all cloud-based, will really help the patient’s compliance when we’re recommending HydroEye. So, all these things, I think, fit together. And having these really simple solutions are definitely key.
Walt Whitley: Yeah.
Peter Pham: I think it’s only going to get better, right Zac and Tim? Because, as you get more data, especially with the Meibox, and then you are able to then hook up some AI too. I think can actually kind of remodel and reposition how you analyze the data that you have and the data you collect.
Tim Trinh : Yeah. And that’s really exciting because that’s really our long-term goal is data acquisition for analyses, right? So, if we can get hundreds of thousands of data points then, once we do analysis and the technology is available, we’ll be able to better understand the condition, so.
Walt Whitley: So, you all are reading my mind, because that was going to be, hey guys, this is my last question! And so, we just keep on that. What does the future hold? What’s the next innovation? Tim? Keep chatting because you were already chatting. I just interrupted.
Tim Trinh: No, no. Well, I mean, we look at where medicine’s going right now, right? And we look at the role that artificial intelligence is playing in it. And, the problem with meibography right now is we don’t fully understand its role in the immediate symptomatology for dry eye. For example, you can have like a pretty decent meibomian gland structure meibographically, but, you can still have symptomatic pathology, right? And so, for us, we want to start closing that gap and bridging it. And a lot of it comes down to like, you know, just from, anecdotal and personal like treatment for patients, we find that comes down from like, you know, expression quality, other external factors as well. But the meibography element, we’ve also seen changes in patients like, that are taking like Accutane where, you know, meibomian gland dysfunction just happens almost immediately. So, what are the elements that we want to look at meibography? And long-term wise, how are we going to use it most effectively in clinical diagnosis? Right now, I think it’s just, the early stages so it’s a lot of data acquisition.
Walt Whitley: Oh, yeah. Definitely. Peter? Where do you think we’re going? What’s the future hold?
Peter Pham: So, I think dry eye and just the eye itself, right, it basically can be a paradigm for a lot of other disease processes, too, right? Because we know that it’s inflammation that underlies almost every disease process where you’re talking about heart attacks, strokes, ulcers in the mouth, etc. there. And so, what we like to do with Zocular is to use what we’ve learned in the dry eye space then to take that knowledge and experience then to try to help other industries and specialties such as the oral side of things there. So, what we noticed is that if you were to apply Zocular, especially the gel, on an oral ulcer, the pain and swelling basically disappears. The pain definitely disappears and the swelling is diminished quite a bit within two or three minutes. And so, that’s really kind of cool findings that we’re seeing there that we would like to then move towards that area.
Walt Whitley: Uh huh. Hey, Zac? What about you? You know, any other points you want to make about, in the dry eye space, what the future holds? It’s all you.
Zac Denning: Well, I think, dry eye space is constantly evolving and so is nutrition. And a lot of people don’t realize how integral nutrition is to dry eye, and to the functioning of the eye. Oxidative stress, for instance, the thing that antioxidants counter-act, is integral, an integral part of inflammation – to cell death, to hyperosmolarity – all these things involve oxidative stress, and omega metabolism. Every NSAID in existence, targets the metabolism of a specific omega, a ‘bad’ omega, called arachidonic acid. So, we think that as our understanding of dry eye continues to evolve, that, as we’ve already seen, nutrition is going to be more and more a part of that because it’s sort of baked into the cake. And so, we’re going to continue to pursue new nutrients and new approaches to approach dry eye more comprehensively.
Walt Whitley: Uh huh. Uh huh. This is…go ahead.
Tim Trinh : I was going to say, it’s like, for the nutritional element, prior to starting dry eye, in our practice, we really didn’t think it was such a big role. But, you can see how a patient’s diet can really impact it. And, it’s exciting what Zac’s doing, too, because we’re using that quite a bit in our clinic as well.
Walt Whitley: Well, I want to thank you all for being on this call and sharing your insights to how you got into this space, where you all are going within the space. So, thank you Zac, Tim and Peter for sharing your thoughts and expertise with us today. And I want to thank you all for attending our podcast as well. A conversation with innovators in the dry eye space with Box Medical, with Zocular and ScienceBased Health. So, thank you all and we’ll talk to you soon.
