Dr. Art Epstein began practice in the NYC area with a focus on specialty contact lenses and ocular surface disease. Collaboration with Drs. Eric Donnenfeld and Hank Perry led involvement with resident education at the local university hospital and an expanding focus on speaking and educating colleagues throughout the world. Relocating to Phoenix Arizona, a decade ago, Dr. Epstein currently devotes about half his time to clinical practice centered on dry eye and ocular surface disease. He is a passionate advocate of patient education and simplifying what is often seen as a dauntingly complex disease.
- DCD: 5. You make some helpful analogies when helping your patients understand how the eye works. Can you elaborate?
Dr. Epstein: I always start by explaining how the tears and ocular surface work before discussing why a patient is encountering problems. The first question I ask is, “Why do we even have tears?” Creating and sustaining a wet environment is not a trivial task. I share that the primary reason for tears is that they create an optically perfect surface and, in primitive times, often made the difference between surviving and perishing. I explain to patients that the eye is unique, as it is the only constantly exposed external surface on the body that is wet.
Creating tears, keeping them on the curved and vertical surface of the eye, preventing evaporation, providing nutrition, preventing infection and myriad other necessities is an amazing feat of engineering (shouldn’t gravity make the tears drop?)! I then share that the tear components that are responsible for their problem can best be thought of as a structure, not unlike a house, with a foundation, the equivalent of walls as well as a roof. The foundation of the tears transforms the ocular surface from water repelling to water loving, allowing the tears coat the surface and defy gravity. The walls are a viscoelastic protective layer and the roof, which keeps moisture in and stabilizes the tears, is made of complex oils produced by special glands in the lids. At this point I show the patient images of their meibomian glands and discuss the potential cause of their problem. Making things easy for patients to understand empowers them and help engage them in successfully managing their dry eye.
- DCD: You mentioned that there is a virtual epidemic of dry eye with an ever broadening demographic – I wonder whether this is limited to Arizona or areas with similar climate?
Dr. Epstein: I believe that the problem isn’t just limited to Arizona – it is happening everywhere. We are seeing a more diverse and increasingly younger population of patients with significant dry eye issues – a virtual epidemic of dry eye with an ever broadening demographic. For example, I have teens and pre-teens, including one five year old, with severe meibomian gland disease and dry eye. There are likely a number of reasons for this demographic shift. In my experience, meibomian gland dysfunction is a major driver of what we typically lump into the dry eye category. Patients do have aqueous deficiency and evaporative contributors, but MGD causing poor tear stability and protection is often the primary culprit in DED and, in my experience, actually easiest to address.
One of the main reasons for the tremendous increase in the prevalence of dry eye is due to how our patients use their eyes: prior to the 1980s there were virtually neither laptops, digital devices nor smartphones, and tablets are a recent introduction. As a result of the nexus of the digital and information ages, blink frequency has dropped dramatically and MGD has exploded as a clinical concern. Adding to this increase device use is a shift in our diets in which imbalances between omega 3 and omega 6 EFA intakes have added fuel to the dry eye “fire”. There are other factors at play that illustrate the complexity of the disease. Japan, for instance, has a high incidence of dry eye but higher intake of Omega 3s, but is also extremely industrialized with high levels of myopia and likely, altered blink patterns. Increased mercury levels have also been reported but there are myriad other possible contributors.
- DCD: Your interest is in new and novel therapeutic approaches with a clinical focus. Can you share some examples, referring not only to treatments but also, even to regulations and macro trends? Do you anticipate more changes and if so, how would they manifest? Is the driver for change only monetary?
Dr. Epstein: Interest in dry eye has expanded dramatically from both a clinical and scientific standpoint. With growing interest and more patients impacted, industry recognizes that there is an opportunity to create new therapies. As a result, novel therapies like Shire’s recently approved Xiidra t-cell targeted medication, Allergan’s soon to be introduced TRUTEAR, and the entry of regenerative medicine solutions like Regner-Eyes amniotic fluid drops are a few examples. The US regulatory environment has been challenging. However, I expect the work of TFOS DEWS II to help open doors for additional novel therapies though redefinition of dry eye disease. I expect TFOS DEWS II to feed the imagination of clinicians.
- DCD: Why do you think that patients suffer silently? How do you draw them out of their silence?
Dr. Epstein: I see many patients who are frustrated and many of them accept their condition silently. Milder dry eye is often tolerated because many patients believe that their symptoms are a normal part of aging, rather than a heralding sign of a chronic and progressive disease. Moderate to severe dry eye patients commonly feel unheard or invalidated, often going from doctor to doctor without effective treatment. Both the science and clinical practice of managing dry eye and ocular surface disease has dramatically changed over the past few years, yet much of the advances and innovation have not yet propagated fully though the eye-care community. By focusing almost exclusively on dry eye, I’ve been fortunate to have had developed a network of referring doctors as well as patients who refer others, so most of my patients arrive hopeful and willing to share their frustrations and hopes.
- DCD: A number of blogs and platforms related to ocular health have recently launched; as a writer yourself with a passion or educating and writing, do you consider this a helpful advance?
Dr. Art Epstein: Anything that promotes improved patient care and support is positive, and I am passionate about the rapid changes that are occurring in the field and the related importance of up to date information. I personally participate in several blogs, serve as the “Dry Eye Doctor” for a large eye-care information site, and contribute articles to trade journals several times a year. I also produce a weekly medical eye-care focused e-journal that deals with a wide range of subjects, but often touches on dry eye and OSD.
I see blogs as helpful for sharing information, but I am sometimes concerned that the online universe doesn’t necessarily reflect clinical reality. “Facebook famous” is a term I recently heard describing how social media can warp the perception of expertise. So while there is great opportunity to learn from others online, the wise clinician and patient won’t believe everything they see on the Internet.