Dr. Robert Noecker: So, thank you for coming today. I'm Rob Noecker. And I'm in private practice in Ophthalmic Consultants of Connecticut, in Fairfield, Connecticut, where I've been for about the last year and a half

Before that, I was in academics for about 15 years at the University of Pittsburgh and the University of Arizona and then also in Tuft's University in Boston

So, what I'm going to talk about is introducing aesthetics into a practice

So, I'm actually a tertiary glaucoma specialist. I do a lot of anterior segment surgery. But, in our particular practice situation, we felt a need to offer aesthetics to our patients. There was a demand for it

And we'll just kind of go over how we've done that, what we've found that's--works best for us, and how the M22 has kind of fit into that

So, our practice is a--it's a large tertiary referral practice. It's affiliated--has Long Island affiliated with it

It's very refractive surgery based. We do a lot of premium IOLs, have a large optometry network

We're in the same building with TLC for Connecticut. So, we have a tie in with the refractive practice there

And so, we really are a referral center, both for ophthalmologists and optometrists in our region

So, we started offering cosmetic procedures in 2011, started off with doing Botox, dermal fillers like Juvederm, Latisse

For our surgical things, we do refer out for an oculoplastics specialist. So, we're basically an anterior segment practice

In 2012, we began offering the M22-based services. And we also started a pilot study, which I'll go over first, looking at treating rosacea to improve the ocular surface

And we'll go over some of that data first. And then we'll talk about how we've expanded into more general aesthetic applications

Okay. So, first, we'll talk about rosacea. Rosacea, if you look at it, it's about 40 million people in the United States have this. If you look at our daily practice, and actually, it's interesting, all of the physicians in our practice have rosacea as well

But, if you look at our practice, we're seeing rosacea patients every single day when we're treating. A lot of our dry eye patients have this as a comorbidity. A lot of our patients who we're treating, you know, other ways for dry eyes also have this condition

You know, the pathology with ocular surface disease is that you have these, you know, superficial vessels that are dumping out proteins that are proinflammatory

And while it's doing it on the cheeks and the nose, which is the most common areas that we see, and we'll look at some pictures of this, we also have the same phenomenon happening in the eyelid. And then there's inflammation of the ocular surface, inflammation of the meibomian glands

So, the meibomian glands, which is--should be secreting nice olive oil-like lipid to preventive operation are--you basically got to turn into kind of a soapy substance

So, it's irritating. And it also doesn't stop evaporation on the ocular surface

So, rosacea patients can actually have quite a bit of inflammation on their eyes due to this condition. And I'll show you a couple of my typical patients

So, when you look at the eyelids, these are, you know, probably a moderately affected meibomian glands on the eyelid, where the--once again, the oil, when we press gently--and this is something I evaluate on every patient I see--you know, with simple pressure, there should be kind of a clear pooling of the meibomian gland secretions

When they become more turbid and viscous, that's not good quality oil that's going on the ocular surface

Frequently, rosacea, we--if you look closely, there's often vascularization of the eyelid margin, much as what we'll be seeing on the face

So--and when we talk about dry eyes a lot of the patients we're seeing have other pre--risk factors. I don't know why this thing keeps flipping forward

A lot of our patients have had Lasik. And they've had rosacea, meibomian gland changes. You know, pre-Lasik, lot of contact lens wearers, environmental changes, getting older, we're all familiar with this in terms of risk factors for starting this cascade of kind of ocular surface inflammation

And what we're aiming at is improving one component. And that's really the meibomian gland dysfunction, which secondarily will improve the state of the ocular surface

So, I'll briefly touched about an ongoing clinical trial that we have that we're going to present the data at the ASCOS in San Francisco in the spring

And what we wanted to do is to see, by treating--there's some small anecdotal case reports in the literature about patients who've had intense pulsed light therapy for treatment of rosacea and had anecdotal improvement in their ocular surface disease

So, the purpose of this study was to do it prospectively, get a baseline. Kind of we actually selected rather bad ocular surface disease patients, treat them, and then follow them forward six months into the future

So, we took 20 patients with moderate to severe ocular surface disease. So, that means they had to have some corneal changes. They had a sufficient amount of meibomian gland changes on the ocular surface, bad--poor tear breakup times, rapid tear breakup times, quicker than 10 seconds

And also, they had to be sufficiently bothered in terms of the symptoms as we measured with the OSDI, which is the standard tool that's used in dry eye studies in terms of patient symptomatology

They answer 12 questions about what situations they're most bothered by and how severely

Patient underwent monthly IPL treatment for six months. So, they came in, got their treatment, which we'll go over here in a second, and then they came back each month

And so, it was preordained that they were going to go through the whole six-month cycle when they started this

And it really reflects what we do on non-study patients, too

And we looked at each patient before--at the beginning and then also as we went through

OSDI score, once again, they had to be in this range, the moderate to severe range in terms of their OSDI score. So, they couldn't be people like, "Oh, your eyes look bad, or if you have really bad rosacea." They had to be, "Yeah, you have bad rosacea and ocular surface disease, and you're bothered by it.

So--and we'll talk about kind of patient happiness with this study

So, the results, every single patient improved. The amount of improvement varied tremendously. But, we had patients who were--in the past had tried every possible ocular surface disease therapy from over-the-counter products to, you know, prescription drugs to things for their skin

Everyone improved in terms of OSDI scores as well as overall improvement of their cosmetic appearance

The degree of improvement didn't necessarily correlate to how bad their preexisting disease was. But, everyone improved to some degree

The median time to improvement was four months. So, after usually about three treatment cycles, they showed some improvement

And typically, the strategy we took is that the first treatment we got--because it does hurt--I mean, you feel like a snap when you have this done

So, the first treatment was to basically get through a safety profile, figure how their skin was going to react to the laser treatment, and then we would increase the treatment parameters from there

The earliest patient--actually, since I updated this slide, actually one patient had improvement with dry eye symptomatology at one month. Others took the full six months to establish

And arguably, throughout the course of the study, we became increasingly aggressive as we realized it was a fairly benign procedure to do. We became increasingly aggressive with the treatment patterns

Within two months, every patient to a person noticed improvement in their facial rosacea signs, which sometimes the rosacea was more bothersome on their face. And then other times, it was more the dry eye symptomatology. But, everybody was bothered by both

So, takeaway point from this, and we'll--you know, we'll present more detailed results. But, this is just kind of a little taste. Everybody had improved signs and symptoms of dry eye as well as facial appearance in terms of the inflammation and also the appearance

Okay. So, you know, how does this appear to work? The wavelength of light we used are kind of in the far visible range to the near infrared range. And this is a part of the spectrum that melanin, hemoglobin, chromophores absorb the light

So, part of it is you have to have a differential between your skin and the vessels

So, if you're very, very dark, it won't work as well. If you're on the lighter spectrum with Fitzpatrick skin scores of one or two or three, it--that's the ideal population for this

If you have very dark skin, it will probably not work quite as well

There's filters available with this particular device, which you can adjust for penetration depth. The longer wavelengths will penetrate into the skin to get deeper blood vessels and also cause less superficial changes, which we'll talk about in a minute

Okay. So, the treatment parameters we typically use was the patient--we had them use these little kind of shields. And they're very small because the idea is that we want to get as close to the eyelids as we can, but we don't want to get near the eyeball because, unfortunately, the eye has a lot of chromophores in it that can absorb this wavelength of light. And so, we want to stay away from the eyeballs

So, the treatment zone is up to get as close as we can in the periocular region without risking doing any harm to the eye itself

So, patients had these--wear these shields. And then we use a gel, a coupling gel. And the purpose of that is it actually helps the light from scattering beyond what you want. It also helps keep it moisturized

So, the patient would come in, use like an acne wash typically. And then we put the gel on it, which would help to get rid of the oils on the skin. And then we use the lubricating gel to help couple the light to the skin and treat it

This is a typical treat. This is the M22 head. And we can see it's rather large. So, usually, we'd be much more up on the rim. We actually had the patients look surprised. We tell them to look surprised so we can put the probe as close to the periorbital region as--periocular region as we could

We have this one hand piece. You can see this is one of the filters. So, for the kind of fairer northern European individuals, we use a 560 filter usually

But, you can just slide that filter in and out of the hand piece. So, the hand piece for whether you're doing--using the same thing for other applications, like hair removal, blah, blah, blah, it's the same hand piece. You just need to change out the filter and the exposure times of the energy

So, this is a typical patient

So, this is one of my worst patients. And this is how he looked at baseline. This is kind of the--what we call the low-hanging fruit here

I mean, he--there's no mistake that this guy has really, really bad rosacea. You can see the rims of his eyes are very red. And he's been this way his whole life, construction worker

He says, you know, "It's just my eyes are always irritated." He was referred in from his local optometrist. You know, "Is there anything you can do for this?" And it was like, "Well, let's give it a whirl.

This is him after he's basically gone through four months of study. And you can see, while it's not--you know, the vessels aren't completely gone. His eyes are happy. He doesn't put any ocular drops in his eyes. And his facial improvement is like the best it's ever been since he was a teenager

And he's like, "I didn't know that I had--that there was anything to do. I just always accepted that I had this red face and that I live with it.

So, he has done very well. And he's once again the kind of low-hanging fruit. But, he's an example where, even the worst cases, we can actually make a lot of improvement

It's another one of my patients, another--this is a younger guy. He has kind of--the exposure's a little bit different in the two pictures, but he has a lot of redness

His primary complaint on the flip side was dry eye symptomatology. He was just always irritated, couldn't stand the blower in the car. On windy days, he was really red

This is him after a few treatments. You can see his eyelid margins are greatly improved. And it's just--you don't have--he doesn't have the little kind of bumps of the kind of acting like picture that sometimes comes with rosacea

Even further on the end of the spectrum, a post-Lasik patient, and here, what she complained is like--and she had photographs which I didn't get the permission to show you

But, she has them from like last year and, like, said, "Every time I go out drinking at night, my nose would turn bright red. It was kind of embarrassing. My nickname was Rudolph. And my--people would make fun of me. And also, my eyes are really dry and scratchy, and I don't know what to do about them.

So, we treated her--she completed six months of therapy. And her skin is clear. And she has a little bit of residual area there around the edge of her nose. But, she is very happy and basically, once again, has gone on with life, so kind of impressive changes

So, what we've found--so, our study is basically documented. We can--if you--you can see we've improved the kind of superficial appearance of these patients but also the functional quality of the ocular surface of their dry eye

This is another one of our patients who came in. You can once again see the rosacea changes, also with the dry eye changes

And she--you know, she's been--gone on through it. But, this is where the using the M22 has actually opened the gateway for other procedures because it's like you're there. You're kind of talking

And she's like, "Well, you know, the redness is getting better. You know, what do you think about this?" And it's like, "Oh, well, we can take care of that a different way, you know, while we're there.

It's like, "I don't like my crow's feet." It's like, "We can take care of that while you're here.

It's like, "What about these creases?

"We can take care of that.

You know, so, what we've found is that, by using the M22 to basically--for this therapeutic function from a kind of an ophthalmic perspective is we've--are saying patients are basically utilizing our other cosmetic interventions, like Botox, fillers, etc

This is another lady who came in the study for her ocular surface disease and her dry eyes. But, you know, she has this pigment lesion here. And it's like--and she noticed during the course of treatment that it was starting to fade, you know, which makes sense because this wavelength of light will target pigment lesions

And so, we basically finished the treatment for her dry eyes and relatively mild rosacea in her particular case

And she's like, "Well, I noticed it coming down. So, can you take care of the rest of it?

It's like, "Yes, we can set the parameters to target that more specifically." And you know, she underwent, you know, additional treatment for that as well

On the flip side, what we've found is that, with our preexisting aesthetic population, this is a--this is one of my patients I do--I don't want to say she's a Botox addict, but I've--we do a lot of Botox on her. She likes having Botox

But, she has this one little like mark that is like--she comes in for like every month to get

But, once again, it's like, you know, we're doing this Botox stuff, but your cheeks are really pretty red. And you know, how--and how are your--you know, let's look at your eyes under the slit lamp

And you know, you do actually--and you start talking. It's like, "Yeah, when I get up in the morning, you know, now that it's winter time in the colder weather, you know, my eye--I have a harder time. My eye's kind of burning." She's a school teacher. They're burning in the classroom

And it's like, "Okay. We can take care of that.

It's like always--"I've always just had these ruddy cheeks." And it's--but, you know, that's--this was contributing to your dry eye and your ocular surface disease. And so, we're actually starting to begin therapy on her

So, it's actually--we've brought them in from the other end of the spectrum to be more complete in our treatment. And the same--and we've had the same thing with patients who've had Botox or fillers. And they still have the fine lines or age spots

We're in the coastal Connecticut, where a lot of people are sailors and been on the water for most of their lives

So, there's a lot of kind of sun spots and things. And this is the--these are the perfect applications for the M22

So, the nice thing about using the M22 is, with our own captive population, it's served twofold. It's brought people in for therapeutic reasons, i.e. being able to treat their ocular surface disease and the rosacea when other things have not worked

And what we've found was that there are patients who have rosacea and dry eyes. A lot of them are actually seeing dermatologists already or have seen in the past

And a lot of times, the story is, "They put me on this $500 cream. It kind of worked, not really. And I kind of just gave up on it. And you know, now, I'm here about my eyes.

But, it's like, "Well, you still have the rosacea that they were treating you for, albeit not successfully.

And you know, my opinion, using IPL for rosacea is actually probably the best way to treat rosacea. It really handles the problem very well

And once again, as we've had patients come in for this procedure specifically, we've found that our other aesthetic procedures go up by 25 percent

I mean, they're there. You know, they have to sit there and scrub with their tech. And my tech is very good about talking to them about that. And they feel very comfortable talking to him

And it's like, "Well, do you--is there anything--you know, can the IPL take care of me on my crow's feet?" And Josh is like, "No, but, you know, Dr. Noecker will--can help that with you, you know, if you want to come back at another time.

So, it's really been a nice entry point into facilitating other procedures

And it's very complementary to, once again, fillers and Botox, you know, because it's important. You know, you can use chemical peels. But, this works I think very well in terms of being able to get rid of the superficial lesions, like the sunspots and the fine wrinkles that some patients may have

And you know, we--and for better or worse, we have the only machine in our area. And it's--we've gotten referrals from dermatologists, which is somewhat unusual in this area, oculoplastic specialists, you know, who might not have this technology and other people who are doing Botox and fillers. But, they actually will send us to them for the IPL therapy because--if they don't have the device

And one--and in our practice, once again, we have a large kind of premium IOL Lasik population. So, we already have identified individuals who value, you know, their eyesight and are willing to pay, you know, a premium for that

And in terms of outcome, we've really kind of harvested a lot of post-Lasik patients who are still struggling with ocular surface disease and dry eyes

And this may not be the only component. And a lot of times, it takes a kind of a multi-tier approach in terms of, you know, treating--tear film deficiency

But, a lot of times, these patients do have meibomian gland disease. And we get referrals for some of the patients who are still having dry eye symptomatology or somewhat unhappy with unstable vision after their Lasik

And it's kind of changed. So, we used to get the problem patients. But, now, we're getting more--they're identifying a TLC, more and more of the problematic--the potentially problematic patient. And we're actually pretreating them before they have the refractive surgery done. And it appears to be increasing their satisfaction

So, the nice thing about the M22 hand piece because there are a number of other IPL systems out there which have smaller hand pieces and provide more focal, I like the M22 because the way we do it with the shields, there's no way we're going to hurt the eye

I mean, the light with the IPL is extremely, extremely bright. And we have our patients, you know, all, you know, close their eyes after--you know, during the treatment, say, "Just close your eyes because, even with the shields, the light is still very, very bright.

But, there's no way we can damage the eye because this--with this intense light, we have to be careful of the eye. So, we get the effect and get close to the eyelids

But, with that large probe, we get the secondary effect of the cosmetic. And once again, what we've found--so, some people, the cosmetic improvement is more important. Other people, it's the dry eye symptomatology

Even though both--everyone improves on both fronts, it's kind of a way to hedge your bets. And it's a win-win situation

And once again, it--once they see that they look better and they feel better, it's driven patients into the practice for other therapies

I think we said that, and the cosmetic effect

So, you know, once again, when we do the treatment, you know, the hand--the light source is relatively large and covering a large surface area. So, it's easy to go--our study protocol is just to use the cheeks. But, a lot of times, you know, it's--it doesn't take that much to go above the forehead for additional effect sometimes, just getting all the superficial vessels in that region

So, in terms of the economics, at this point, you know, treatment of rosacea for ocular--and ocular surface disease, it's a patient-pay item. It's not covered by insurance. So, it's a cash base, which, you know, is a double-edged sword

In some ways, it's a source of cash-based income for the patient. It's--or for the practice. But, the patient does have to foot the bill

It's not totally unreasonable. We usually tell them to expect treatment for at least four months is usually what we feel safest with

Six months, I feel very, very safe. And then we'll--our--the expectation is that some people may need to come back in a year to get like a kind of a touch up, one more round of therapy to kind of keep the blood vessels away

But, in the patients that--we have our longest-term patient who's a few months beyond his six-month therapy. And he's been totally fine, you know, doesn't ever think that after 30 years of using, you know, eye drops

So, you know, once again, in our practice, the patient issue comes in with these other--when we identify patients who've paid for premium IOLs, they still have, you know, rosacea and dry eyes, refractive surgery, cross linking, Botox, fillers, Latisse

We do a lot of recommending of omega 3 fatty acid supplements. And we find that actually works very well in conjunction with the IPL therapy for ocular surface disease

So, once again, there's a fairly high ratio in our practice of patients who value and will pay or self-pay for these services

But, usually, to be honest with you, I do a lot of procedures, I think save vision and, you know, do cataract surgery. I have great outcomes. These patients are the happiest patients and most grateful patients in my practice by far

So, in terms of marketing, some of the things that we've learned is it's very important to engage the staff. Like I said, my technicians know. I've done treatments, you know, all these aesthetic areas for the staff

And that's--you know, because that's who the patients, be honest with you, spend the most talking about these things. And they're like, "Is this going to be okay?

And they're like, "I just had that last week myself." And after that barrier of anxiety goes down, it's very, very easy. And they can explain what the--what happened. Yeah, it hurts a little bit during it, but you feel fine afterwards and go about your business

And it really takes away a lot of the anxiety that patients have undergoing these procedures

We do incentivize our staff economically so that they benefit when patients do come in for these cash-paying procedures. And we find that motivates them and makes them engage in the success of the practice that we're doing higher-value patient encounters as well as procedures

We have some takeaway marketing materials that are practice specific with our logo on it, you know, because, once again, there's--are other practices that provide some of the materials. But, it's important that they have our contact information if they do decide to do it

And we've found that going around and talking to our optometry as well as our primary care and ophthalmic networks actually helps quite a bit once they understand because, once again, their primary care doctors were sending people out for rosacea treatment. And they get put on metronidazole gel or whatever at the dermatologist

And it's like, "Well, you could go this pathway or this pathway." And once we've increased awareness with some of the OB/GYNs, primary care doctors, who are sending us, you know, diabetics or whatever, we've actually--they've actually become a good source once they've seen the value and all the happy patients coming back

So, these are a couple of the--you know, the marketing materials that we've done, talking about the treatment capabilities

Once again, we--our entry point is rosacea because I--it's really a health issue in terms of treating ocular surface disease but also getting into the issue of pigmented lesions, sunspots, other vascular lesions, kind of tightening up the skin

You're using the same technology, just changing the treatment parameters in the areas that are treated. And this is one of the brochures that Lumenis has helped develop

We actually require our staff at check-in as people are sitting in the waiting room to basically fill out a brief cosmetic interests questionnaire

We also do the same thing for premium IOLs and other things like that. But, it covers--number one, it's a driver to make them think about other things that are going on

They may be coming for glaucoma. But, we also can treat, you know, your cataracts. We can treat your dry eye

But, it also makes them aware because, to be honest with you, people don't think that ophthalmic practices typically do a lot of, you know, Botox. Most people don't think that their ophthalmologist is doing that, or IPL, most people don't think that their ophthalmologist is doing that

So, by giving these questionnaires, it increases--everyone in the waiting room by the time they leave knows that we offer these services

And these are just some trivia cards that were made up just to be--once again, to engage the patients and give them kind of more concrete examples of what to expect

And we've tied it into, you know, doing glaucoma and SLT and some of our other studies as well as treating, you know, with the IPL the rosaceas we have talked about

So, I think takeaway points is what we've learned in the last--or what I've learned in the last year or so is that aesthetic treatments, they're actually fairly easy to integrate into an ophthalmic practice. You don't have to change your workflow all that much

I think a lot of it happens on the front end with the staff, you know, at check-in by doing the surveys, having the--you know, the staff being rewarded economically when patients engage in these

And also, at the technical level, having our technician, who actually helps do the procedure or has had it done themselves, it's very, very easy to engage them because the truth is, if you look at any ophthalmology practice, we already have these patients in there. It's not like you have to go out and seek a whole entire different practice

These comorbidities are there if we're treating dry eye, if we're treating refractive patients. You know, certain demographics, I mean, a lot of our patients are going elsewhere maybe to get Botox and--or you know, be seeing the dermatologist for other reasons

And these patients are already in our practice. And if once we can make them aware, they're happy to stay with us. They're comfortable with us. We're doing other things. They're letting us take care of their eyesight. And it's fairly easy to do

Staff awareness and education, we give patient--we have lunchtime meetings, and we talk about these issues. We either talk about--we also talk about cataract surgeries and what the premium IOLs do and don't do

But, one of our--you know, every couple months, we have a staff awareness thing. And it's like, "This is the new thing we're offering to patients. This is why we do it. And this is what they can expect to get out of it.

And lastly, the patients who have already, you know, undergone self-pay procedures, whether it's cross linking or premium IOLs, other aesthetic things, they are usually the ones who are readily--they've already demonstrated that they value their eye care and their health and are willing to pay for it

And it's--the financial conversation is actually usually very easy to have with them

And relative to what they spend on their Lasik, usually, this stuff is less

Oops. So, that's all I have prepared. If anybody would have any questions