By: Paul M. Karpecki, OD, FAAO Clinical Director – PECAA
At the beginning of a new year, we have this incredible opportunity to take stock of the previous year’s successes (as well as failures we might learn and grow from). We also have a chance to reposition our practice for future growth and try to anticipate the most rewarding opportunities. As an example and a scary one at that, refraction is listed as one of the prime areas likely to be commoditized over the next decade as technology advances. Imagine if Amazon decided that optical was their next targeted opportunity. Could happen. But like anything, we just need to stay diversified to succeed. We have one huge advantage: optometry sees 88% of all comprehensive eye exams putting us in a power position. That doesn’t mean we rest on our laurels or assume the past will be the future. If we take a proactive approach to diversifying our practice, differentiating our practices and staying on top of technology advancements, our patients will most likely stay with us. Let’s look at some of the opportunities in 2019 in each category of practice.
Optometry plays a key role in glaucoma management and for the first time in over 20 years we have new drugs that lower IOP more than any previously studied, and exciting new surgical options such as microincisional glaucoma surgery (MIGS), where we can work with glaucoma surgeons that value our contribution and knowledge. The most recently approved drugs include Vyzulta (B+L), which has IOP lowering of as much as 9.1 mmHg in one of it’s FDA pivotal trials. Whenever we can increase the likelihood of hitting our target pressure with a single agent dosed nightly, we need to consider it. The nitric oxide in Vyzulta targets the trabecular meshwork (TM) and also causes vasodilation allowing for greater outflow. Another is Rhopressa, which received FDA approval in 2018 that also targets the TM, allowing for IOP lowering at the site of glaucoma by working as a RhoKinase inhibitor to expand the TM. A third very recent approval is Sun Pharmaceuticals Xelpro a PA that avoids BAK and may be ideal for glaucoma patients with ocular surface disease issues. In April or May of 2019 we might see Rocklatan, a combination of Rhopressa and latanoprost, dosed QHS also, which has shown even greater IOP lowering in recent FDA clinical trials. The newest MIGS device called the Hydrus (from Ivantis) has shown the greatest IOP lowering of any MIGS device in US FDA clinical studies to date. It is inserted in glaucoma patients at the time of cataract surgery. What stood out was the increased delta of IOP lowering compared to patients that didn’t receive the Hydrus over the 1 to 2 years post procedure. It was thought that shunt procedures like this might lose effect over time but this particular one has not shown that. As far as diagnostics, hysteresis measurements (Reichert) have achieved validation as being the top predictor of visual field loss progression and hand held tonometers such as the newest iCare TAO1i, are accurate and even easier and quicker to use than previous versions, making them essential for busy practices.
This is a field we need to watch closely as so many of the diseases we diagnose are based on one or few gene mutations. Conditions such as Leber’s and Startgart’s disease may see treatment options in the near future (Ophthotech). But even common conditions such as AMD and glaucoma have genetic origins. There is expansion of genetic testing that is now fully covered by insurance including testing for corneal dystrophies (Avellino Labs) and perhaps in 2019, the test can help diagnose keratoconus (Avellino Labs). There are companies working on vast ocular genetic testing akin to “23 and Me” but only for genetic eye diseases (EyeCheck).
In 2019 we can expect a long awaited roll-out of a toric presbyopic soft contact lens (B+L Ultra). This is often listed as the top request by most contact lens practices. We may also see drug eluding contact lenses continuing to advance (JJV and OcuMedic), which would be a great optometric therapeutic application. Contact lenses to measure IOP as wearables (SensiMed) should also come available in 2019 and may help us predict fast progressing glaucoma patients when patients wear these for one day.
With greater awareness it seems inevitable that myopia control will be a major opportunity for optometry because there are few parents with high myopia that wouldn’t find ways to prevent their children from facing the same fate. Also the risks of glaucoma, myopic retinal degeneration and CNV, detachment etc. that go with it may be avoided. But you need key equipment such as ultrasound for A-scan measurements (DGH has recently launched one that is 1/10th of the price of a traditional ultrasound unit that uses tablet technology for high resolution imaging), certain contact lenses and new drops such as atropine approved for this treatment to manage the condition well.
Dry Eye Disease (DED)/Meibomian Gland Dysfunction (MGD)
Because of the 30 million or more patients with dry eye disease and likely 2 or 3 times that many with MGD, this has to be on the list of opportunities each year. One significant opportunity appears to be in the area of in-office procedures with technologies like LipiFlow and Blephex leading the way. Then we have iLux approved in 2018 and purchased by Alcon showing great clinical data and exciting new entrants including Sight Sciences’ TearCare technology possibly in May 2019. IPL is becoming a sought after technology as new entrants (Lombard Medical) seem to have found ways to make the treatment more efficient, convenient and less expensive for patients— but equally effective. Blephex hopes to further expand it’s monopoly on in-office treatments for biofilm or “meibofilm” with a product called Aurora that certainly warrants monitoring. National outfits such as VitalTears make autologous serum, which is essential in the management of patients with KCS, available through doctors across the US. 180-day dissolving punctal plugs are my preferred choice of punctual plugs as they sit in the optimal position of long duration with no irritation to the ocular surface or retention issues (Oasis Medical, BVI, OcuSoft, Paragon Biotech, Lacrivera all make 180 day dissolving plugs). Amniotic membrane – ProKera (BioTissue) and amnion based eye drops (BioTissue, Ocular Sciences) help treat SPK, persistent epi defects, neurotrophic keratitis and even neuropathic corneal pain and the drops are expected to be available in 2019. We may also see an ocular bandage lens made from cross-linked hyaluronic acid for the treatment of abrasions and epithelial defects (Eyegate). From a diagnostic standpoint I believe that meibography (Oculus, Topcon, Johnson & Johnson, Meibox, TelScreen) will become essential as will point-of-care testing— especially with devices that can measure osmolarity and MMP-9 in one unit (TearLab Discovery), just as POC testing is essential in pediatric offices. From a drug perspective a new version of cyclosporine in a 0.09% concentration using micelle technology known as CEQUA (Sun Pharmaceuticals) is likely to be available by mid-year and one in a 0.10% concentration made with chondroitin sulfate is already available (Imprimis Pharmaceuticals).
Both B+L and Kala have or will advance the efficacy of a drug commonly prescribed by optometry. Kala recently received FDA approval for IVELTYs, a 1% loteprednol that uses mucus-penetrating particles (MPPs) to get the active drug into the target tissues of the eye. The result was the first BID approved steroid for post surgery. B+L will launch a 0.38% concentration of loteprednol that is a lower dose then their current 0.5% but appears to match or increase efficacy by using sub-micron particles sizes, additional moisturizers, a better pH and does not require shaking as improvements in an already excellent profile drug. And we may see a version of loteprednol approved for dry eye flare-ups in 2019 (Kala).
If dry eye isn’t your passion then perhaps it’s AMD. Your practice should actually have 3 times more AMD patients than glaucoma patients based on prevalence data in the US. And now we can do something to slow the progression of the disease or prevent rapid advancement with wet AMD. With today’s technologies one could easily add an AMD management focus involving dark adaptometry (Maculogix), wet AMD monitoring (Notal Vision), blue blocking lens technology (BlueTech, Prevencia etc.), supplements ranging from carotenoid supplements including lutein, zeaxanthine and meso-zeaxanthine to AREDS2, and of course OCT technology to effectively monitor potential wet-AMD development. Studies have shown that the patients entering VA at the time of diagnosis of wet-AMD indicated their outcome. The sooner the better. So start looking early. Dark adaptometry picks up AMD 3 years before signs are evident on average. And if you had a patient with what looks like possible drusen, the only way to confirm is dark adaptometry testing which takes 6 minutes. Even low vision technologies, because of the advent of augmented reality, can be made available to the profession (Eyedaptic). But having said that, inter-professional referrals, such as to a low vision specializing optometrist, for patients with geographic atrophy or advanced disease should be on your action list.
Cataract Patient Management
Extended depth of focus lenses and tonic IOL’s have had a significant benefit for our patients and will continue in 2019, but the future is clearly technologies that give patients more future options such as light adjustable lenses (RxSight) which can be adjusted with a UV laser for up to a month after surgery, femtosecond lasers applied to the IOL to correct post-cataract refractive error (PerfectVision) and especially technologies that can house space for future IOL advances to be swapped out or augmented reality or monitoring technologies (e,g, IOP) to be added. (Omega Ophthalmics). Diagnostic technologies now combine Scheimpflug imaging with back corneal surface elevation for optimal calculations (Visonix, Oculus), but also for corneal disease diagnosis and ocular scatter from the crystallin lens can help determine the exact level of cataract your dealing with or if the issue is on the ocular surface such as dry eye disease (Visiometrics).
It’s exciting to be in eye care today but we must also plan for how to best serve our patients and enhance our practices to be best positioned for the future. Optical may not provide us our primary revenue at some point and being diversified in medical eye care today, may be the key to decades of successful practice.