Joanne Shen, M.D., is an ophthalmologist at Mayo Clinic in Arizona. Dr. Shen, who specializes in the ocular surface and dry eye, shares her strategies for treating the ocular surface and dry eye management for a spectrum of surface diseases.
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Welcome to the Mayo Clinic Ophthalmology podcast brought to you by Mayo Clinic. I'm your host, Doctor Andrea Tooley and I'm Doctor Eric Botham. We're here to bring you the latest and greatest in ophthalmology medicine and more in today's episode, we are joined by cornea and surface disease expert, Dr Joanne Chen. Doctor Shen shares her insights for managing dry eye patients including new and emerging treatments and walks us through the management of severe surface disease in settings like graft versus host disease. Doctor Joanne Shen is a cornea and answer segment specialist at the Mayo Clinic in Scottsdale, Arizona where she also serves as department chair. We're gonna be speaking about surface disease today and she has meaningful leadership roles in that field. She is the director of the dry Eye Clinic at the Mayo Clinic in Arizona. She's active nationally with the American Academy of Ophthalmology, Corny and anti segment ophthalmic technology assessment, subcomittee, the International Ocular Graph versus Host Consensus Group and the tier film and ocular Surface Society. Welcome, Doctor Shen. Thank you. It's such an honor to be here with you today. We are so happy to have you here today. You are a cornea anterior segment guru, um take us through kind of how you've developed a niche in dry eye patients, an interior segment patients, kind of how have you developed this specialty practice? You know, certainly when I came to Arizona, I knew I was going to the land of dry eye, but I didn't realize what was going to happen until I showed up. And so when you're at the mayo clinic and you're in the desert, then that means you're going to get all these seventh opinion dry eyes. So it became my niche even though, but I wasn't really looking for that in particular. And uh my mentor is Bill Bourne and still occasionally talk to him from time to time. But about 10 years ago, I started working with him on trying to figure out what my niche was. And really, he said, you know, we don't know stuff about gvhd. You know, our patients are living longer after transplant. So maybe you should start looking at your population and share what you know, and we were getting lots of dry eye patients that didn't have any solutions. And there was a lot of really interesting things happening about that time in uh 2012. And fortunate to have some technology that we could acquire. So it sort of came to me because of a necessity, either I got good at it or I was gonna have to find some other uh occupation. It's interesting that you say that it came to me out of necessity. I think most ophthalmologists feel that any patient with dry eye comes to them out of necessity and we'd really rather not see them. So it's phenomenal that you've appreciated that need and risen to the occasion and advanced the care and now a thought leader in this field. So it's exciting to share this time with you and just talk through lessons and tips that you have over basic management and then things that are, you know, kind of new and cutting edge to help these complex patients share with us just a little bit because so many people do see patients with run of the mill dryness, mamia gland dysfunction, chronic irritation with age or, and, and we'll talk about sort of some of the more advanced diseases here in a minute that they are associated with dryness, but share some thoughts over when a patient comes in the your exam room with dry eye symptomatology. What are the common questions you make sure you ask and what are the things in the exam? You make sure you do that? You'd encourage the comprehensive ophthalmologist listening to do too. I think it's important to remember that I'm not seeing the typical dry eye patient. Rarely am I getting a, oh, I've had it for three months. Usually they've been battling it for a while. So maybe what I I do is not going to be typical for the comprehensive person seeing. But if you've been seeing somebody for a while and not gotten anywhere, uh, generally I ask them sort of what, what is their, I, I really delve into what their lifestyle is and what their occupation is and when is the dryness the worst? Because, you know, I find out that they have been bicycling without glasses in Arizona or any protective wear and they are having problems. I definitely need to address that or if they are waking up in the morning and their eyes feel the worst in the day. That's a question that maybe not, has not been asked before. But I think is this typical ceiling fan question? You know, if you're, we asked about ceiling fans, but we don't say well, so if they're not, if they're not using a ceiling fan, but yet they're waking up in the morning and their eyes feel terrible or pretty bad then II I am concerned. So I definitely feel like focusing on that aspect of the restorative night time. That's the only time my eyes get to rest and regenerate. It's night time. So I think finding a little bit more about what, you know, are they a, a computer programmer on the, on the computer 12 hours a day? Uh Are they in the right refractive uh prescription? Are they in their computer glasses? Those are basic questions that sometimes are missed by, um especially, you know, in our late forties patient comes in late forties and not wearing glasses at the computer. So, they don't, these are not rocket science questions. In addition, every corn external disease specialist would say a thorough exam and it's hard when you're given five minutes to do your whole slit lamp exam. Are you gonna take the time to flip the lids? Are you gonna use a green stain? Which is very messy? Are you, you know, going to look for foreign bodies or just examine the ocular surface instead of just diving right in to look at the cataract? Yeah, I think those are all such good points. And I love that you're kind of coming back to the history as being so important because these patients are really unique. And at least I found in my oculoplastics practice when I'm thinking about the lids and thinking about excess tearing. That's what I see the most and a lot of times it's dryness. Um It's not a one size fits all. They're all super different and there's so many different causes. Doctor Shen. One thing that I always feel like I'm behind the curve on some of the work up and um testing modalities we have for dry eye. Talk to me about, do you do Shermer testing or tear film on molarity or inflammatory markers in the tear film like M MP type thing? I'm always hearing about this, but I haven't incorporated any of that in my practice. Do you recommend that like, what's your basic tearing or dry eye work up? I think it's important to try to figure out, you know, for my practice. They, they're coming from far away. I try to get as much done, but that is virtually impossible in a, in a comprehensive practice. You know, generally I, I feel like the tools that we have like tear osmolarity really just sort of confirms what we already sort of know, you know, if it's evaporative tearing, then they have reflex tearing, uh as a response, then their tear o malaria is gonna be low. I do it to confirm what I've already suspected. Very rarely. Am I surprised? Yeah. M MP nine, I think is helpful. If you're trying to decide about doing oral doxycycline or topical azithromycin, the patient has a lot of maybe tang tasia, more of the ocular rosacea look and you're trying to decide if you're going to add that to the plan because we know that, you know, there are side effects in cost and difficulty getting topical Zithromycin. There was a supply chain issue for a while and, and trying to add that and explain to the patient why you're doing that. It helps to have some, you know, uh some data to show them. And then I like to repeat it three months after I've done the, you know, some treatment to see if we've had some at least qualitative differences cause we can kinda see, you know, something sometimes M MP nine testing is very, very positive. It's like, it's like you're, it's just lights up and sometimes it's very faint and we do sort of write that down because sometimes we can, if we can get it to be a little more faint, uh sometimes that correlates with symptoms for the patient, that that's actually really helpful. Um Does M MP also sorry for these are really basic questions and a lot of this is just because I don't have the, the knowledge base is M MP also indicative of inflammatory disease. And does that help you decide if you want to use an anti-inflammatory, like res stasis or xydra or any of these other newer agents? Or are there different testing that are more specific for those treatments? No, and I don't think there's any data that says that this is what you do and this is what has been proven. So I wanna just preface that whether or not a person decides to use M MP nine. In that way, I do think that yes, the underlying inflammatory etiology for these patients is something you wanna look for for treatment modalities such as um these topical Lafi Grast and cyclosporin. And whether or not you decide to incorporate talk, talk to us a little bit about, I mean, I think most of us are used to managing dry eye to a certain level of lubrication and lid scrubs and warm compresses or whatever people might have from their residency and their previous practice training um share with us what your, you know, beyond the sort of the, the norm. What's your algorithm of? I'm gonna try this next as you go up the ladder for your a dry eye patient that's already failed all that stuff. So they come in with their bag of all their lubricants and they just want the next thing up the chain and I know there's some, you know, these newer treatments that are becoming available. But what's your besides education and look at environmental things as you've talked about and heard their story? But what, what do you pull out of the, of your, of your tool trick? 1st, 2nd, 3rd and, and what are your thoughts and why that way? Yeah, tell us all your secrets. I don't have any tricks and honestly, if they, if they pull in the whole bag, I'm like, ok, well, maybe we should just do a medication holiday. Let me just see what natural looks like. Obviously, at my stage, if I'm seeing them after months of what things have been going on for years, uh Sometimes the treatments that they have piled on have actually started to cause some toxicity to the ocular surface. And I can't figure out are they just washing away tears? We used to in training say, ok, if they're not good, pre preservative free tears every hour and then if they're really not good, then preserve tears every 30 minutes. And then if you just can escalate and over the years, you know, I've been at Mayo in Arizona now for about 15 years. I really have just backed off on that because I, I feel like they're almost washing away their own natural tears and, and we all know what's in those bottles is nothing biologic that we would naturally have occurring. So, unfortunately, I don't have, if, if I did, I probably could have a robot do the dry eye clinic because then they could just give out the instructions if a patient comes to me and um he's in a wheelchair and he's with his wife and I can tell he's not gonna be getting up to the shower very often. Someone like that, you have to make it easy. So, you know, I may just say, you know, some cu soft lids wipes or something of that variety where it's commercially easy. You don't have to get a patient in the shower. It's kind of messy trying to baby shampoo in a wheelchair. Uh So realistic based on the patient. Um most patients come to me, their eyelids are already very clean, sometimes super clean. And some of these Hypo Chloric Acid uh wipes are nice to and sprays are nice to sort of cut down on the dander if patients can, you know, implement. Yeah. So that's a nice uh added tool to our toolbox. Now, I love the Hypo Chloric acid sprays. I tell everybody to use Ava Nova as my favorite thing ever. Um, I, I think it's so great. I just have to add a little tidbit. It's like my new favorite thing. Yeah. And I really like it that I rarely see people react to it. I, you know, I've looked at a lot of, uh, very allergenic patients and, uh, you know, the, the eyelid skin is very thin so you have to be really careful not to overdo it. And people sometimes take scrubbing to the nth degree. Well, if a little is good, let me just go crazy. And then they start irritating the protective cuticle of the skin, right? Or whatever that doctor t you know, better. But, you know, honestly, it cannot take that much cleaning. So you gotta be careful not scrubbing away vital epithelium. I'm talking about agents that you might, um, choose, uh, the for my BOM and gland dysfunction that's meaningful that you're gonna use, um, an oral agent and doxycycline or in my, I have a pediatric practice that I'll use clery from one of the things that I've found or you've seen variation out of how long people will treat, um, to supplement or kind of reboot the surface health. Um, how long to treat with some of those. I, some people give a course for two weeks and other people do it for two months and taper thoughts on that and, and when you, you choose a longer agent or shorter agent from a topical or from an oral antibiotic perspective. When you're talking about shorter agent, what were you referring to? Well, shorter duration? So I just, when prescribing antibiotics for two months is something that a lot of ophthalmologists may hesitate to prescribe longer acting. And yet, at least in my population when a child comes in with blepharitis of meaningful degree and surface disease and corneal changes. I'm sort of under understanding that I'll be tapering an oral medicine over many, many weeks and oftentimes it goes beyond two months. But how common is that or uncommon in prescribing longer courses? And what would, how would you encourage a comprehensive ophthalmologist that's gonna prescribe doxy or cloth fromm Mycin. What, what's a typical regimen to try, you know, if a patient comes in and they're about average build I I my standard dose is like 100 mg of doxycycline and depending on which um high plate I like. But monohydrate formula sometimes while that's available to a patient, I think I try either. It really is a tolerability most of the time I have some patients who could probably take it forever. They're the minority. Um, many patients are intolerant, they get a UT I or yeast infection. Um They don't feel well, they have palms digesting, they love dairy, they can't have it with this, you know, antibiotic. They're scared of side effects, they're scared of long term antibiotics. So, the myriad of excuses comes, I just say, let's try it for a month and if we have any sort of indicator that things just feel calmer and less, uh, irritated, gritty, dry and I, my exam sort of, uh, is consistent with that, then I will have them finish a three month and then depending on how they did, if there was any tolerability issues, I don't give them a three month break. I feel like it stays in our system for a while and then just reassess do I need to pulse them later? And uh otherwise, if they fail to taper off completely, they may be a candidate for a short a smaller dose, a smaller dose or the same dose every other day. So we just play around with it depending on how the patient is doing. I like that a lot. That's great advice and very customizable. I don't, I don't see this as much with patients that I put on doxycycline. But I don't know if you guys have ever taken doxycycline. I took it as a malaria prophylaxis um a couple of years ago and had the most intense sun sensitivity. It was unbelievable. And I don't see this as much with our patients. I think it's because it's slightly lower dose. But I was on a beach and I had to wrap my body, my hands, especially my hands were so sensitive in cold washcloths to go outside because I felt like my skin was on fire. It was crazy. And so I really commiserate with patients. I don't know if I would want to be on it long term, but I think it's, that's less of a side effect, but I just always think of that from when I had to take it. It's everything changes when you're in the patient seat. You know. Um One thing Dr Shan I want to ask you about is um IP L laser options, lipa flow. Kind of these new tech options for dry eye that are super popular. I think some people were, were skeptical of things like lile flow. Um I've actually seen great data from IP L and you were one of the first to publish on this. And so, um tell us about using IP L and other kind of high tech options for ocular rosacea, dry eye lid disease, those kinds of things. It's been exciting just the developments and the tension towards dry eye and intense pulse. I, I was skeptical and it really was out of a neces, uh out of born out of necessity, you know, patients had exhausted everything else and had we given up on my bowing glands or were we gonna try this? And I have loyal patients who, who want it like it come back for it and it's not the most comfortable procedure. So I, I, you know, I've done some limited pilot studies where I just did expression only versus IP L with expression and patients still like their IP L I and of course, it's very hard to mask because it is a very unique experience. You can't really fake it because they can actually feel the intense light hitting their skin. So I think unfortunately many of the studies in the literature are industry funded because not a lot of people are spending the time doing IP L research and the people who are doing it are sometimes in private practice and they don't have time to publish their results on, on what their patients are experiencing. I generally like to use IP L if patients are good responders to doxycycline but just become very intolerant, you know, they're too sun sensitive, they can't handle the G I side effects some other issue. And it has been nice if they respond well to doxycycline and just can't tolerate it. They generally, in my experience, of course, it is is I have expo responded, but we have not done a prospective study where we've sort of uh did a head to head doxycycline versus IP L lipo flow and Ilex and those other sort of just massaging only treatments aren't covered by insurance. I think they're very safe and can only help. There's very low risk, unlike IP L where if you don't do it properly and you uh accidentally in and uh subject IP L to the iris and internal eye, you can actually cause severe U Vitis and damage and vision loss. So we wanna avoid that. But uh these other mym gland automated expression or sort of semi auto manual expressions, I think are very helpful in just sort of decompressing these glands that get backed up to keep them moving. So in a normal practice, a patient comes in and goes through the, the treatment algorithms or care and you find you're ready for that is, are those procedures being formed same day or are they rescheduled? Then at what frequency is a typical patient having those repeated for someone that my my dry eye patients or my adult strey patients that really come in thinking their double visions because of strass and I send them back to say we need more dry eye care. But so just not being someone that manages those things, share with us how your practice manages that those procedures. And in what frequency many of my patients are waiting three months to get in. So I try to uh have time to treat them at that first visit. If they're a candidate for lipi flow or, and that's what I have for um thermal pulsation or intense pulse light, then I actually will do it at that visit. And then for intense pulse light, it's actually a series of monthly treatments. Um and it's a series of four spread every 4 to 6 weeks. And generally, if they improve, then we'll finish the full if they improve 100% then we're, we're done after the first treatment, but that's rare. Most of the time patients will need 3 to 4 treatments to sort of get to a plateau effect. If they don't respond by the third treatment, we sort of move on to other modalities because I don't know if we're gonna achieve anything and obviously they have to have viable my bomia glands. So we do before I do any of these treatments, I'm doing a my biography which is just flipping the lids and using infrared photography, which is now pretty widely available in multiple platforms to look at the my bom glands and make sure there is something to save before we go on these expensive treatment and time consuming for uh for lipi flow. I think it depends on their patients. Um It can be anywhere from probably 6 to 12 months before we would do a repeat, assuming that they've got an effect after eight weeks. Usually they'll be better after eight weeks of treatment, uh uh eight weeks after their lipo flow treatment, that's really helpful to know. I think the other thing that comprehensive us who are seeing these patients might be deciding is when to invest in these platforms. You know, li a flow, getting an intense pulse light laser. These are really expensive investments in a practice. You're chair of the Department of Ophthalmology. So you understand the overhead and and these investments, do you think with technology and where this is going and how we're treating these patients, that these are wise investments for practices and how, how might a comprehensive is make that decision of when to incorporate some of these platforms into their practice? That's a really good question. Um Some practices have made it so that the provider comes in and puts the actuators in for the lipa flow and has a technician monitor and then remove them and then have the patient sit for cornea check just to make sure the cornea is not abraded, but it is, I think it's, you wanna offer these services because you feel like it's going to make a difference in helping you're, you're addressing what your patients are asking for, right? You're not just doing them to make money. Um I'm sure there's other ways to, you could sell glasses and make money. You don't necessarily have to embrace this. But if you do decide to do it, then you sort of own all of it. You know, what are you gonna do with the ones that don't respond? The ones that are angry that they spent, you know, hundreds to thousands of dollars on lipo flow. You really have to have an idea of where are you going? Who are you gonna partner with for these ones that don't respond and aren't getting better, you know, looking for other ocular surface disease that may also impacting the patients. On that note, I'd like to transition a little bit because you've part of your expertise has grown and and matured in, in, in light of other ocular disease affecting your treatments. Um Share with us a little bit about graft versus host disease or other surface conditions that um are rich in your practice that we could learn from. You know, I mayo's uh certainly has AAA mean a unique um tertiary quater referral location with transplants being done at high levels. And so you see patients with complex graft versus host situations. And I just know that's an expertise of yours. So share with us how that practice is the same or different in managing their surface disease. Back in training, I alluded to before, back in probably 2000. Um many patients who got stem cell transplants for leukemia and lymphoma basically died if they got ocular gvhd, the mortality was quite high. We didn't have antifungals that were effective that we do now. And so by the time I came out of fellowship and was in practice at Mayo, you know, we started seeing people fortunately survive, you know, they survived their transplant, they survived their cancer and now their transfers were working really well and their eyes were uh feeling terrible and their quality of life was just miserable. And I don't think in training, we really had good experience because these patients were so sick. So we didn't, you know, they won't live very many months. And so you never had to get good at this. And I think the, what I've come to understand is and what we didn't back then is that I sort of treat these patients like once they're through their initial gvhd attack is they're like Steven Johnson's patients, not as severe but quite scarred, uh, quite aqueous deficient. And, you know, our group showed that there are also my booming glands were atrophied and really much of the ocular surface was affected. And you know, I would get patients, you know, I was told you just do steroids on them, you immune suppress them. If they're symptomatic, it's an immune attack. But really what I've come to realize is that they're just super dry. And so now just like I would with a Shogren S patient or Steven Johnson's patients who's through the initial phase and that was three months out is really working on rebuilding the ocular surface with uh the tear film was just missing. And y you know, I got desperate to a point. I even tried running IP L on the series of patients and uh ran a prospective trial where I actually was doing IP L on patients. Uh as uh and the one thing that I pill does not work for GVHD, I just wanna make that quite clear. But it was interesting because I saw these patients intensively for the six month uh study and I soon realized their GVHD was, is there was one eye that was worse than the other. And I really, after hearing them complain about how bad their eyes were, despite this miracle IP L that had shown up and we're, we were so hoping that it would help. I realized that they really just needed punctual clu. So it's not, it's not very glamorous, but I am very aggressive about punctual clu for these patients. And I, I have, I have seen a lot of patients do much better just with punctual clu. So if they come to me and they've been treated with a lot of topical steroids, generally, I'll try to say let's just work on your tear foam and tone back the steroids, which probably aren't helping with wound healing. Those are all really good tips and, and super challenging patients to treat. Is there a point where you have to flip to surgical options? Um or anything different? I'm, I'm always thinking of this from an ocular plastics standpoint or, or when do you need a torso or when do you just need to cl these patients completely to let the surface heal? Um versus just doing medical management. I definitely am very aggressive with medical management. But I do, I, if you call punctal artery surgical, I implement that pretty quickly. I'll try plugs first. I use a three month dissolvable because I don't want any silicone flange on the ocular surface, uh rubbing on the already irritated surface. Uh We do autologous serum t uh moisture chambers are very important to protect the ocular surface. Unfortunately, they're not covered by insurance and then without SCLE lenses, I'm not sure how good of a cornea specialist. I would be. I do a lot of combined SCLE lenses and moisture chambers just to protect the ocular surface from the Arizona desert. And my goal is to be aggressive. So they don't show up with a neurotrophic ulcer cause then that sort of leads to a transplant. And once they've had a transplant, you know, they, they don't have great feeling, they don't make good tears. And uh then that's a disaster ready to happen. And I, you know, knock on would like to avoid doing tars on them. So if I can get them into a sclera lens, get their serum tears installed so they can have some tears uh to substitute what they don't have. Um I find that, you know, they, these patients are able to go back to work and have productive lives. Yeah, we're so lucky at mayo that we have the ability to get sclero lenses for our patients. I use them a lot too and I really love scleral lenses. They're such a good option for patients. I actually don't know what the landscape of sclero lens therapy looks like in private practice. What, how easy is it for comprehensive to get the, get those, get them made, get them fitted for their patients. I think 10 years ago, it was tough now. We have, I think the optometry community is definitely learned in the last 10 years. And now, you know, the technology between PAC cam uh imaging and working with these um these centers that make the scleral lenses, they're just have gotten so good at troubleshooting uh fits for. And generally these patients are fairly normal in their fit. They're, you're not dealing with a very abnormal shaped cornea. The conjunctiva may be a little bit scar, but most of what you're using on the sclera lens is that's sitting on the sclera is normal. So the community now has a lot more support that I think that most people know who's the regional specialist in their area. Yeah, that, that's so great. That's such a wonderful option. What do you think about um Procera or those, those other types of options? I don't use those in my practice. I had difficulty having patients tolerate Procera bec. Um So sometimes I'll do, I probably don't utilize amniotic membrane a whole lot because I just haven't had to II I think that some people like to use it just as, you know, e early first line. But for me, it's like, OK, which eye is worse? I'm gonna do one eye at a time. I can't do both. So generally like some of these other modalities first, if they look like they're about to do an ulcer on me, then uh then I will employ that, but I generally will use some of these bandage soft contact lens um and you know, enabled uh uh disks that they have available that are easier to use, easier to store and tolerate for the patients. Well, this has been wonderfully enlightening and sharing it. I think I always like these podcasts that are very tangible. Like whether it's a simple punk to plug discussion versus um some of these new, you know, lip of flow and what's new on the market and how to incorporate in practices. Thank you for sharing virtually your expertise with us um on a common condition that gets really tough and we celebrate the expertise you have here at Mayo and the ability to share your voice on our podcast. Agree. Thank you so much. It is great. You can find all episodes of the Mayo Clinic ophthalmology podcast on our website. Thank you for listening and we definitely look forward to sharing more.
