By: Paul M. Karpecki, OD, FAAO Clinical Director – PECAA

This is a question I receive often and seemed like a good feature for the mid-year newsletter.  As I started researching this question I became amazed at what all has happened in dry eye disease in such a short time.

A New Therapeutic for Neurotrophic Keratitis

Oxervate (Cenegermin) is an endogenous human nerve growth factor that was approved by the FDA for the treatment of neurotrophic keratitis (NK).  What you need to know:

  • The dosing is Q2H or 6 times per day for 8 weeks
  • It is essentially a cure rather than a treatment.  Meaning 80% of the patients treated for 2 months that had complete corneal staining resolution maintained it one year later
  • It’s prescribed via Rx and usually requires the patient to submit an additional form to the company (Dompe) to aid in patient assistance programs, help with prior authorizations etc. should patients not be able to afford it
  • The drops are delivered to the patient’s home frozen and the company assists in how to create daily vials etc.
  • Efficacy begins as early as week 4 and 72% of patients had complete resolution or corneal staining and lesions by week 8
  • No systemic risk was noted
  • The only other product that has research to show it can improve nerve function is the cryopreserved amniotic membrane known as ProKera

In Office Procedures Advance

As reimbursements decline and vision plans continue to try to balance patient costs with quality
optometric care (two factors that can be at opposite ends of the spectrum), optometry finds itself in need of new opportunities. One such opportunity is that of in-office patient patient treatments. What you need to know:

  • Insurance does not yet cover these procedures and doctors are able to price them in ways that allow many patients to receive the benefits but also fair to the financial health of a practice.
  • One essential in-office treatment is that of Blephex. Removing the biofilm from the lashes and eyelid margins of patients with MGD/blepharitis has shown a significant improvement in signs and symptoms for patients.
  • I’ve had patients state that their eyes have not felt this good in decades.
  • Another critical in-office procedure is that of thermal pulsation such as LipiFlow (J&J Vision), which was the first advanced technology in this space and is highly effective.
  • One treatment of LipiFlow typically lasts 2-3 years.
  • A recent study showed that a single LipiFlow treatment, in patients with contact lens discomfort, increased wearing time by 4 hours per day.1
  • The cost of a LipiFlow activator has decreased from $350 to $100 this year.
  • Other options for thermal MGD therapy to have recently joined include iLux, TearCare and on June 26th OCuSOFT announced the purchase of Digital Heat’s Eyelid Warming Device.
  • iLux (Alcon) is a hand held device that also heats the back surface of the eyelids and provides the ability to view the expression of meibum.
  • It had impressive improvements in OSDI symptoms scores, TFBUT and meibomian gland expression scores at 2 and 4 weeks after treatment.
  • TearCare (Sight Sciences) provides and on-eye lid, open eye, blink regulated, natural approach to expressing glands.
  • The TearCare hub monitors the temperature over 240 times per second and the treatment lasts 15 minutes.
  • OcuSoft’s Digital Heat Device is likely to be the least expensive option for in-office treatments and involves a device that heats the outside of the eyelid for approximately 10 minutes

Eye-Light IPL

A new IPL was introduced in 2019 from Lombart called the Eye-Light. It has signifiant advantages from any other previous IPL technology.

  • It does not require coupling gel to transmit the effects. Coupling gel was something that patients did not like having on their face.
  • It is a painless patient experience based on a two part IPL treatment.
  • It can treat any skin type or color,  which was not possible prior to this technology.
  • Patients typically require only 2 (sometimes 3) treatments about 3 weeks apart, which is less than in the past.
  • It works! In my first 50 patients I can see a significant improvement in telangiectatic vessels and overall inflammation in the eye. Patients have had noticeable improvements in symptoms.
  • The cost is significantly lower for the equipment and for the cartridges to treat patients.
  • IPL can be combined with the above treatment options like Blephex and thermal pulsation.

Hypochlorous Acid (HOCI)

In about 6 months there have been six new entrants to the HOCl market. What you need to know:

  • Hypochlorous acid, also known as HOCl, has the same active ingredient of household bleach but has a different chemical structure and significantly lower concentrations.
  • Pure HOC1 is produced naturally as an element of the human immune response, specifically released by neutrophils
  • Preservation is an important consideration since the stability of hypochlorous acid solution is generally quite limited. To clarify, although the shelf life of hypochlorous acid may be years in some cases, once a bottle of hypochlorous acid is opened, the product becomes less stable and it begins to degrade  typically lasting only 1-2 months.
  • The newer forms like Zenoptiq (Focus Labs) or SteriLid Antimicrobial (Akorn) have shelf-lives, once opened, that exceed 18 months.
  • HOCl has been shown to be effective against bacteria, viruses such as EKC and fungi (but not demodex)

Lotemax SM (B+L)

SM stands for small molecule and this new formulation of loteprednol from B+L has impressive properties. For one, it defies optometry board questions as a lower concentration of drug (0.38%) results in a higher potency, corneal and aqueous humor concentration. What you need to know:

  • It’s the same ester-based steroid but with a particle size that is 5-10 times smaller allowing for
    greater surface area coverage and more penetration of the drug thus allowing the lower
    concentration (0.38% compared to 0.50%) with the much higher potency.
  • Most pharmacies honor this Lotemax since it has the same name and the Walgreens and
    independent pharmacy forms from B+L allow Lotemax SM to be $25 for all patients under age 65 and $60 for patients with Medicare.

Eveleve (Bruder Healthcare) 

From the makers of Bruder mask comes a hydrating, anti-bacterial compress that showed more than a 3 hour increase in comfortable contact lens wearing time based on a study from  the University of Alabama at Birmingham School of Optometry.  What you need to know:

  • The compress maintains optimal temperature of 104-114 degrees for up to 10 minutes after 20 seconds in the microwave.
  • It has an antibacterial back surface material designed to reduce  bacterial flora to normal levels with each wear.
  • It has clinical proof of a significant improvement in contact lens wearing time in patients who were beginning to notice decreased wearing time.
  • The study showed that use of the mask compared to the bundled method was statistically better  at once a day and only marginally better with twice a day use, so once a day use for 10 minutes is sufficient to achieve these results.
  • It contains silver ions around the Medibeads for further antibacterial moisture release.

Flarex (Eyevance Pharmaceuticals) 

This fluoromethalone acetate steroid was recently launched and has properties no other steroid appears to have. What you need to know:

  • If you see a patient with conjunctival staining, filamentary keratitis or mucous strands in their
    tearfilm etc. consider Flarex as the drug of choice for 4-6 weeks (monitoring IOP).
  • The reason is that Flarex has been shown to positively modulate gene expression of ocular surface mucins.2
  • The ocular surface expresses 3 membrane-bound mucins; MUC1, MUC4, MUC16 and all are affected in patients experiencing the above issues and can be improved with Flarex.
  • The same occurs for secreted mucins (MUC 19).
  • This may be our best  approach to patients with goblet cell or mucin deficient issues.

The world of ocular surface disease continues to expand and advance. These are indeed terrific
opportunities for our practices and our patients.

Summary:
1.  Blackie, CA, et al. A single vectored thermal pulsation treatment for meibomian gland dysfunction increases mean comfortable contact lens wearing time by approximately 4 hours per day. Clin Ophthalmol, 2018; 12:169-183.
2. Taniguchi J., Sharma A.. Fluorometholone modulates gene expression of ocular surface mucins. Acta Ophth 1-7:2019.

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