Between the Blinks #007

In this week’s edition we will discuss a new ocular pain medication in trials, equipment purchase blunders, and Club 33.

Blink Exercise of the Week

Turning Down the Volume

Quick Note From the Author: This piece was planned and written prior to and independently of Bausch + Lomb’s sponsorship of Between the Blinks. B+L did not request this topic, provide input on the content, or review it prior to publication. I had written this piece several weeks ago, and didn’t want to play musical chairs with my releases for the sake of avoiding having this come out soon after the partnership became official.

One of the drugs I’ve been keeping an eye on recently is BL1332, an investigational TRPV1 antagonist being developed by Bausch + Lomb for ocular surface pain. I’ll admit, when I first started reading about it, the mechanism immediately caught my attention because it approaches a problem we deal with all the time from a very different direction.

Anyone who treats a lot of dry eye has had patients where the symptoms and what we see clinically just don’t seem to match. A patient may describe significant burning, pain, or discomfort, yet when you look at the ocular surface, there isn’t enough there to completely explain what they’re feeling. Even more frustrating are the patients where we actually make measurable improvements in staining, tear film stability, inflammation, or meibomian gland function, but they continue to tell us they hurt just as much as they did when we started.

Those cases have made me increasingly interested in the neurosensory side of what we treat. We spend a lot of time trying to improve the ocular surface itself, which obviously remains incredibly important, but sometimes the surface is only part of what is driving the patient’s symptoms. If the pathways responsible for sensing and transmitting pain are involved, improving the tear film alone may not be enough.

TRPV1 is one of the receptors involved in nociception and can be activated by things like heat, acidity, and capsaicin. BL1332 is designed to antagonize that receptor, so rather than simply adding another treatment aimed at tear production, inflammation, or meibomian gland function, it potentially gives us a way to approach ocular surface pain itself.

The early data are what really made me start paying attention. In a Phase 1b study, healthy participants were exposed to capsaicin to induce ocular pain and then treated with either BL1332 0.30% or vehicle. The company reported a significant reduction in pain intensity, with an average duration of pain of 1.6 seconds in treated eyes compared with 37.8 seconds in the vehicle group. An exploratory analysis also found complete pain resolution in 68.2% of treated eyes compared with none of the vehicle-treated eyes.

Of course, there’s a big difference between inducing pain with capsaicin in a healthy participant and treating someone who has been dealing with chronic ocular discomfort for years. These are early results from an investigational medication, and I certainly don’t think we can jump from those numbers to assuming we know how this is going to perform in the dry eye patients we see every day. BL1332 is currently being evaluated in Phase 2 for pain following PRK, so there’s still plenty to learn about where this medication may ultimately fit.

What has me interested is less about one early set of numbers and more about where this type of treatment could eventually take us. Some of my most difficult patients are not necessarily the ones with the worst-looking ocular surfaces. They’re the ones where I can show them that their staining is better, their tear film is improving, their glands are functioning better, and yet they’re sitting across from me telling me they still don’t feel better.

I’ve become much more conscious of that disconnect as I’ve treated more complicated dry eye, and it’s one of the reasons I’ve put more emphasis on things like corneal sensitivity testing in my own practice. The longer I do this, the less I think we can look at dry eye as exclusively a tear problem. For certain patients, understanding what the nerves are doing may be just as important as understanding what the tears are doing.

I have no idea whether BL1332 will eventually become something I prescribe regularly, or even what its eventual role will be if it makes it through clinical trials. There’s a lot of research that needs to happen between where it is today and where it could potentially end up.

I just know that when I hear about a drug attempting to address a part of ocular surface disease that has historically been incredibly difficult for us to treat, I pay attention. This is definitely one I’ll be following.

Practice Notes

The Hidden Price of a Good Deal

I don't want Between the Blinks to become a highlight reel of my experiences or career. Obviously, it's fun to write about the things that have gone well, but I've had plenty of shortcomings along the way too. I think there's probably more value in sharing some of those than pretending every decision I've made since graduating has worked out exactly as planned. If someone reading this is thinking about opening a practice someday, hopefully they can learn from a few of my decisions without having to repeat all of them themselves.

When you're building a practice, there are so many things to take into account, and unfortunately a lot of them cost a significant amount of money. You're constantly trying to balance the things you really want with the things you can actually afford. There are the shiny new toys that are exciting to buy, but there are also the things that aren't particularly exciting and are going to be used on nearly every patient who walks through your door. For most practices, the exam lane is arguably the most important money-making room in the building. Your chair, slit lamp, acuity system, and everything else in there are the bread and butter of our profession.

Before optometry school, I spent about ten years working as a technician in my father's ophthalmology practice. I became very familiar with the equipment he had in his office, which, looking back, meant I was pretty spoiled. I learned on Haag-Streit slit lamps and spent years using them without ever having much reason to think about what they cost. It wasn't until I took the leap into opening my own practice that I learned just how expensive the equipment I had taken for granted all those years actually was.

When it came time to build my own exam lanes, I started looking for a balance between quality and cost. That's when I found Equipment Company Whose Name I Will Not Disclose. The pricing was significantly better than some of the bigger names, the equipment felt great, and I had actually gotten my hands on their slit lamps at different conferences throughout the year. I wasn't buying something completely blind, nor would I proceed without doing some due diligence. I had tried the equipment, liked it, and felt pretty comfortable with what I was getting for the money. It seemed like a great way to get the quality I wanted without spending quite as much outfitting the practice. My dad warned me about it.

His concern wasn't necessarily the equipment itself. It was that I was buying through a much smaller, lesser-known company instead of going with one of the established names like Haag-Streit. There is some security that comes with buying from a company with a long track record, particularly when you're purchasing equipment that you expect to use for years. I understood what he was saying, but the difference in cost was significant and I really liked the slit lamps, so I went ahead with them.

Fast forward to about ten months into owning my practice, and I started hearing information from people familiar with the industry that raised questions for me about the future of the company I purchased the equipment through. I want to be very clear here: I do not have firsthand knowledge of the company's financial condition or future plans, and I'm intentionally not naming it for that reason. I'm also not presenting anything I've heard as confirmed fact. What I can talk about is my reaction as a relatively new practice owner when I was suddenly faced with the possibility that a company I had relied on for a significant equipment purchase might not always exist in its current form.

My mind immediately went to everything that could potentially affect me. What would happen to my warranty? Who would I call if something broke? Where would replacement parts come from? Would another company service or distribute the equipment? I'm only about ten months into owning the practice, so even having to consider those questions after spending tens of thousands of dollars on equipment was enough to make me nervous.

I typed a very strongly worded email to the owner and staff of the company. Thankfully, I deleted it before pressing send. As a side note, I highly recommend doing this whenever you're angry. You still get the satisfaction of writing everything you wanted to say without having to deal with the consequences the next morning.

Once I calmed down a little, I called someone I knew who was more familiar with the equipment and distribution side of the industry. Based on that conversation, my understanding is that the warranty on my equipment may ultimately be supported through the manufacturer rather than being dependent solely on the distributor I purchased it from. I was also told that, depending on what happens, it's possible the equipment could eventually be represented or supported through another distributor. I'm hopeful that's how things would work if there are changes, but at this point I'm treating those possibilities as exactly that—possibilities. Despite all of this, I genuinely love my slit lamps and hope I'm using them for many years to come.

Looking back at the decision now, though, there were things I probably should have weighed a little differently. The price was extremely attractive, and while customer service and support were certainly part of the conversation when I purchased the equipment, I was still trusting a significant portion of my practice to a smaller and less established distributor. I was focused primarily on whether I liked the equipment and whether the price made sense. I spent much less time thinking about what the support structure would look like if that distributor ever changed ownership, stopped carrying the product, ceased operations, or simply wasn't the company I was calling five or ten years later…which brings me back to my dad.

If you're reading this, Dad, you were right. You'd think after 32 years of life I would have gotten a little better at taking your advice.

I still don't think the answer is that every new practice owner should automatically buy the most expensive piece of equipment available. When you're opening a practice, that's not realistic. You have a finite amount of money and an almost infinite number of places to spend it, so you're going to have to make compromises somewhere. I also don't necessarily regret buying these slit lamps. I saved a considerable amount of money, I still really like using them, and there's a very real possibility that the concerns that sent me into a panic will ultimately have little effect on my ability to use and maintain the equipment.

What I will do differently is ask a few more questions the next time I'm making a purchase like this. Who is actually responsible for the warranty? Who services the equipment if the company I purchased it from is no longer involved? How easy are parts to get? Is the manufacturer different from the distributor? What happens if the distribution relationship changes? I thought a lot about the product sitting in my exam lane and probably not enough about everything required to keep that product sitting there for the next ten years.

There is no way to eliminate risk when you decide to open a practice. Every decision you make comes with some amount of it, and sometimes you're going to make a choice that works out beautifully while other times you're going to find yourself wondering why you did it in the first place. I'm trying to get better about cutting myself some slack when I end up in the second category. I made the decision I thought made sense with the information I had at the time, and now I have some additional information that will probably change the way I make the next one.

I can't go back and choose different equipment, nor do I know yet whether I would even want to. I can use the experience to ask better questions the next time…and maybe listen to my dad a little more often.

Life Between the Blinks

33 Reasons to Say Yes

While Ada and I were in Anaheim for Academy, we had the opportunity to do something that I honestly never expected I’d get to do. We had lunch at Club 33.

For anyone who isn’t familiar with it, Club 33 is a private club tucked away inside Disneyland in New Orleans Square. It originally opened in 1967 and has become one of those almost mythical parts of Disney because most people can walk right past it without ever knowing what’s behind the door. Membership is extremely limited, there’s reportedly a long wait to join, and it’s not somewhere you can simply decide to make a reservation for dinner.

Fortunately, I knew someone who was generous enough to make a reservation for Ada and me while we were going to be in town for Academy. Considering this was also my first time visiting Disneyland, I’d say I found a pretty ridiculous way to set the bar for future trips.

What struck me almost immediately was how understated the whole thing felt from the outside. Disneyland has no shortage of things fighting for your attention, yet here was this relatively unassuming entrance hiding something that people wait years for the opportunity to experience. Once you walk through the door, though, it feels like you’ve stepped away from the park for a little while. The crowds and rides are still right outside, but the experience feels completely separate from everything happening around you.

There was obviously the novelty of being somewhere so few people get to experience, and I’d be lying if I said that wasn’t part of what made it exciting. Ada and I spent plenty of time looking around, taking pictures, and probably acting exactly like two people who very clearly were not regulars at Club 33. What I appreciated most, though, was simply having the opportunity to do something memorable while we were already in California for work.

I wrote recently about trying to get better at making time for experiences outside of work. Conferences have traditionally been pretty easy for me to turn into nothing but work trips. I fly in, spend a few days in lectures and meetings, have dinners that are usually still somehow related to optometry, and fly home. There’s always value in that, but there’s also something to be said for looking around once in a while and realizing you’re somewhere you may not get back to anytime soon.

This trip happened to include my first visit to Disneyland, and somehow, lunch at Club 33. Neither had anything to do with dry eye, practice ownership, consulting, or anything else that normally occupies my brain. It was just a really cool experience with a friend that I’m going to remember for a long time.

I’m also becoming increasingly aware that some of the best opportunities in life aren’t necessarily things you can plan for. Sometimes someone opens a door for you, quite literally in this case, and you’re fortunate enough to be in a position to walk through it. I’m really glad we did.

Please enjoy some of the photos I was able to capture from our experience.