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Dr. Koetting:
This is CE on ReachMD, and I'm Dr. Cecelia Koetting, and I'm joined with Douglas Devries today. We're going to discuss best practices for following up our patients with Demodex blepharitis after and before therapy, kind of figuring out how are we going to work this within our clinic. What does this really look like?
So let's start with a case. Doug, imagine we have a 38-year-old patient who has signs and symptoms of Demodex blepharitis. We definitely see collarettes here. We see a little bit of MGD, probably 2+, right. We have a little bit of turbid expression. It's a little bit difficult to get out. And we start them on lotilaner therapy. When would you ask them to return for a follow-up? And what do you look for when they're coming in for that follow-up?
Dr. Devries:
First and foremost, you have to bring the patient back. And I think you have to integrate that in, because after all, I mean, you're looking to see improvements, you're looking to see if they feel improvements, but you also want to make sure you have compliance with that patient. So you need to bring that patient back.
Typically, Cecilia, I'll bring that patient back. I'll give them a couple weeks to get the medication just in case there's any lag. So that means going through 6 weeks. I'm going 2 months, 8 to 10 weeks, to bring that patient back.
And when we tell them that we also tell them the importance of doing that. And the importance of it, and I think that when we set that up the best clinical practice is really have your technicians educated so you're not delivering all that they can follow up. And after I leave the room they are going and saying you have to complete this, you need to go through, you need to use that 6 weeks. And then that, when I bring that patient back, yeah, I'm looking for do they have symptomatic improvement. That’s one of the things I'm looking for. But I'm looking at the collarettes again. I'm making a note of how did I actually grade the collarettes on the lid, as well as the irritation. So I'm looking to see if there's a meaningful reduction.
Now, if that patient had corresponding MGD, I am pressing on those meibomian glands, and I'm looking for the quality and the quantity of the meibum.
Dr. Koetting:
I would echo that you don't want to watch them like water boiling, right? You're not going to bring them back in a week. They probably won't even have it. Sometimes we're lucky and they do, but it is realistic when we're having to go through prior auths or trying to make sure that somebody gets the medication covered. It might take a couple of weeks.
And then we want to see them back not immediately after they've started it, because we're not going to really probably see much difference. So I'm that 6- to 8-week mark as well for following up with my patients.
Dr. Devries:
Yeah, and I think when we prescribe lotilaner to those patients and we begin them on the treatment, telling them that you may feel better in a couple of weeks but that doesn't mean they're all gone.
Dr. Koetting:
Right. Got to keep with it.
Dr. Devries:
Because those eggs are still there. And patients really, when you talk about the eggs, they will cringe a little bit when you tell them.
Dr. Koetting:
That means it's also a little bit more buy-in to the treatment.
Dr. Devries:
Totally, 100%. And I think that reality and having that conversation. But bringing that patient back to really see and really from that first follow-up visit and say ‘Hey we're doing a great job. There's a meaningful reduction that I'm seeing here.’ But I just don't let them go all the way out to months and months. I'm going to want to see them back again to just validate that they're doing okay.
Dr. Koetting:
What do you do about retreatment? Do you have a time that you absolutely do it, or is it kind of a watch and see like you're talking about bringing them back to see how they're doing?
Dr. Devries:
Well, first I'm going to make sure that there was compliance. And I'll say how much of the bottle do you have left? ‘Oh yeah, I have almost the whole thing,’ because patients will do intermittent treatment as well. So I want to make sure that they've actually been doing it.
And then again what my hallmark as far as I want to see how many collarettes are there and did we get a meaningful reduction. And then what do the meibomian glands look like. If they had corresponding MGD, which nearly 60% of those patients will have, I want to see what does that meibum look like. Am I starting to get more meibum? Am I starting to get a clearer meibum? Because we reduced that obstruction that we have.
So that all goes in. And it's interesting when you see a patient and you say well we have further to go on this. And then all of a sudden they admit to, ‘Well I wasn't real regular. I really didn't, and I skipped a week here, and I was traveling.’ And it really elicits that when you're bringing them back and you emphasize the importance of the complete treatment. Then, ‘Okay we're going to have to get a little bit more active with this. Want to make sure that you're using it twice a day.’
Dr. Koetting:
Lastly, you add in adjunct treatment from the get-go? Or do you slowly add it in, as far as cleaning and maybe an IPL along with the lotilaner?
Dr. Devries:
Well, I mean, I'll do it right from the beginning. I mean, especially the lid hygiene. I want them cleaning the lids because that’s real good, knock off the signs. Because just because you're using lotilaner doesn't mean that the collarettes are going to disappear. They will with time. But I want to see that are they reforming and are we getting results. So.
Dr. Koetting:
So perfect. Well, I think that covers it. Doug, our time is up. And thank you everyone to listening.
Dr. Devries:
Every time I talk to you, I gain more and more knowledge. Thank you, Cecilia.
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