Ophthalmologists from the USA shared their favorite medications, exciting technologies and promising solutions during the Real World Ophthalmology 2022 conference…
Drugs and Devices that Enhance Cataract Surgery Outcomes
Intraoperative miosis is unpredictable and a challenge in cataract surgery. Surgical trauma from cataract surgery can trigger an inflammatory cascade that often results in miosis, diminishing visualization during intraocular surgery. “When you have miosis, the case becomes impossible. So, if you can prevent it, you don’t have to manage it,” said Dr. Mitchell Jackson from Jacksoneye as he proceeded to share about medication and devices that can help to deliver better outcomes in cataract surgery.
According to him, FDA-approved drug OMIDRIA® (Omeros) can be added to an ocular irrigating solution used during cataract surgery or intraocular lens replacement to maintain pupil dilation, thereby reducing the use of pupil-expanding devices. It also prevents intraoperative floppy iris syndrome (IFIS), and reduces complication rates and cost.
Meanwhile, Dextenza® (Ocular Therapeutix) is a preservative-free intracanalicular insert indicated for the treatment of ocular inflammation and pain following ophthalmic surgery, and the treatment of ocular itching associated with allergic conjunctivitis. “What I like about it is, it really enhances the ocular surface and is a great benefit for my premium IOL patients. It also reduces the need for one additional drop, thereby reducing the toxicity from preservatives,” he said.
In terms of devices, Zepto® is a great addition to those trying to improve their surgical outcomes. It is a handheld instrument consisting of a disposable handpiece and capsulotomy tip that performs consistent and uniform 360-degree capsulotomy. “Zepto is very easy to use and it streamlines your surgical workflow. Reproducibility is very easy with this technology. It seamlessly integrates into a range of cataract surgeries in clinical practice. I find it the best for premium IOLs and complex cases. For routine cases, it makes the procedure more efficient and saves time,” he said
New Technologies for Dry Eye Treatment
Meanwhile, Dr. Laura Periman from the Periman Eye Institute shared the latest innovations in treating dry eye. In terms of medications, they include: TP-03 (Tarsus), BAK-free (TearClear), Zerviate (Santen), and Ketotifen (J&J); neuromodulators like iTear, Tyrvaya and Oxervate; and neuroinflammatory modulators like TRPM8 agonist (Aerie), TRPV 1 antagonist (Novartis) and CGRP antagonist.
As for in-office machines, she covered OptiLight, an intense pulsed light (IPL) device approved by FDA in 2021; iLux and Lipiflow, which use heat and pressure to massage your eyelids and help unclog oils; and TearCare, which adopts localized heat therapy. “Killing demodex with IPL is also important because demodex is a local-regional problem. It’s not just in the lids,” she added
On the other hand, at-home equipment that patients can use to relieve dry eyes are: NuLids-30, an all-natural, one-minute per-day soothing massage and cleaning treatment; iTEAR®100, a device that activate natural tear production; Umay REST with cooling, heating and vibration modes to provide digital rest and recovery; as well as Eyedetec medical devices.
Pharmacological Treatment for Presbyopia
Presbyopia has a significant impact on quality of life and current solutions have their individual drawbacks. For example, glasses are inconvenient and can cause fogging and can negatively affect self-confidence. Contact lenses can cause dry eye compliance issues, and require adjustment to monovision and lack of depth perception. Other solutions like multifocal IOLs, refractive lens exchange (RLE), corneal inlay and monovision laser vision correction come with their own issues and are not suitable for everyone, noted Dr. Jennifer Loh.
Thankfully, the solution can be found in presbyopia eye drops, an exciting new treatment which can help patients regain good near vision and their youthfulness. “Currently, most of the presbyopia drops being studied are pupil-focused (miotics), which uses the concept of the pinhole effect to increase depth of field,” she said.
According to her, good candidates for presbyopia drops are emmetropes, post-LASIK emmetropes, hyperopes and pseudophakes. The treatment is contraindicated in eyes with long axial length and a history of retinal tear.
Presently, there are at least eight companies working on presbyopia eye drops. Allergan’s drug Vuity (1.25% pilocarpine with pHast technology) was recently approved. Meanwhile, companies currently conducting phase 3 trials on their presbyopia drops are Orasis (CSF-1; low dose pilocarpine); Eyenovia (MicroLine; 1 or 2% pilocarpine); and Ocuphire (0.75% Nyxol + 0.4% pilo). Companies in phase 2 are Visus (Brimochol®, brimonidine + carbachol); Lenz (PRX-100, aceclidine) and Novartis (EV-06).
Updates on Geographic Atrophy, Genetic Testing and Gene Therapy
Last but not least, Dr. Christina Weng from the Baylor College of Medicine shared about upcoming game-changers in the treatment of eye diseases. “Complement cascade over activation has been linked to dry age-related macular degeneration (AMD) or geographic atrophy (GA), and complement modulation may be a key mechanism of action in slowing the progression of GA. Two molecules — pegcetacoplan (blocks at C3, Apellis) and avacincaptad pegol (blocks at C5, IVERIC bio) — have shown effective reduction in lesion growth rate with intravitreal injections every month or every other month. This is exciting because very soon we may potentially have the first treatment for over 5 million people suffering from GA,” she said.
She also noted that genetic testing for inherited retinal diseases (IRDs) is of growing importance as various treatments are actively being explored. “This is why it is important to consider genetic testing for your patients. Only when they know exactly what mutation they have can they be aware and eligible for the clinical trials that are going on and potential emerging therapies. There are two companies that are offering no-cost testing: Invitae and Blueprint Genetics, which test for over 300 different mutations that are associated with ophthalmic manifestation.”
Meanwhile, gene therapy may revolutionize the way we treat diseases such as IRDs, macular degeneration and diabetic eye disease. Approved by the FDA in December 2017, Voretigene had been administered in 10 U.S. treatment centers. “It is an adeno-associated virus vector (AAV2)-based subretinal gene therapy indicated for biallelic RPE65 mutation-associated retinal dystrophy. Costing $425,000 per eye, it is currently the most expensive treatment in ophthalmology,” she said.
Besides IRDs, there are also ongoing gene therapy trials for common diseases like wet AMD, GA and diabetic retinopathy. These gene therapies leverage on the “biofactory” concept where a transgene allows the host cell to reproduce its own therapeutic supply of the encoded molecule, serving as a promising treatment for diseases that were once deemed untreatable.
Editor’s Note: The Real World Ophthalmology conference was held virtually on 2nd April 2022. Reporting for this story took place during the event.