Dr. Mile Brujic practices in Bowling Green, OH. He also owns Optometric Insights, a service providing career coaching to optometrists. He has received honorarium for speaking, writing, participating in an advisory capacity or research from: Akorn, Alcon L
As optometry continues to evolve, it is critical for proactive practitioners to stay abreast of new developments that will help them provide improved clinical outcomes. This article highlights 10 new treatments in eye care that every optometrist should know.
1. Surface treatments
Tangible HydraPEG (THP; Tangible Science) is a relatively new surface treatment for gas permeable (GP) contact lenses. It has been available on SynergEyes Duette lenses, and it is present on the surface of Simplifeyes soft contact lenses. Plus, THP is available on most Optimum (Contamac) and Boston (Bausch + Lomb) materials.
THP is a polymer that encapsulates the lens, improving wettability of the surface through water retention. This increases the lubricity of the surface, providing a more comfortable wearing experience for the patient. Additionally, because the surface is hydrophilic, it repels lipid deposits on the surface of the lens.
With the benefits of this new coating, it is important to understand how these lenses need to be cared for because some of the rules for caring for GP lenses without THP do not apply. As an example, lenses coated with THP shouldn’t be cleaned with abrasive cleaners because such cleaners will strip the coating off of the lens. Five solutions are approved to be utilized for GP lenses with THP:
Some GP wearers have a habit of rinsing their lenses with water. Although this is not recommended with any GP lens, it is contraindicated for lenses with THP on their surface.
Soon, Tangible Science will launch Tangible Boost, a monthly soaking solution formulated to re-build the coating that may have naturally worn away over time with normal cleaning and conditioning of the lens.
2. Glaucoma medications
Prostaglandin analogues have been a first-line therapy for glaucoma patients for two decades. Prostaglandin analogues increase outflow of aqueous from the anterior chamber through the uveoscleral pathway. They provide a significant reduction in intraocular pressure (IOP) while featuring a convenient once-daily dosing regimen. Recently, there have been several additions to the armamentarium to care for glaucoma patients.
Xelpros (latanoprost 0.005%, Sun Pharma) is a recent addition to the family of prostaglandin analogues. What makes this formula different is the presence of a benzalkonium chloride (BAK)-alternative preservative. This medication is preserved with potassium sorbate and is intended to be dosed once in the evening.
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Vyzulta (latanoprostene bunod, Bausch + Lomb) is a new class of medication. The active pharmaceutical is a nitric oxide-donating prostaglandin analogue. In addition to increasing uveoscleral outflow, the nitric oxide that is donated from the latanoprost molecule increases trabecular meshwork outflow, facilitating additional IOP-lowering by working on two outflow pathways. It is dosed in the evening.
Rhopressa (netarsudil 0.02%, Aerie) is a rho kinase inhibitor. Rho kinase is an enzyme that promotes actin-myosin contraction in the trabecular meshwork. When rho kinase enzymatic levels are high, it can act to decrease the aqueous outflow through the trabecular meshwork. By inhibiting this enzyme, it facilitates additional outflow through the trabecular meshwork and thus reducing intraocular pressure.It is dosed once a day.
Another new medication, Rocklatan (netarsudil 0.02%, 0.005% latanoprost, Aerie), is a combination drop containing a rho kinase inhibitor along with a prostaglandin analogue. This drop is intended to be dosed once daily.
3. Multifocal toric contact lenses
ODs are fortunate to have several specialty soft lens designs that allow presbyopic astigmatic patient to successfully wear contact lenses. Benefits to these lenses are that they are custom made and can be modified for patients’ unique needs. Part of the challenge that exists with these designs is that they require the practitioner to order the lenses. If the first lens that comes in isn’t ideal for the patient, another order is then required.
Recently a soft multifocal toric lens has been introduced that is available as a standard design in offices. Fitting a standard design gives the practitioner the ability to fit patients immediately with a proven design.
Ultra Multifocal for Astigmatism (Bausch + Lomb) features the company’s 3-Zone Progressive and OpticAlign designs. The lens is made of silicone hydrogel samfilcon A material and is 46 percent water. Ultra Multifocal for Astigmatism is available in sphere powers from +4.00 D to -6.00 D with cylinder powers of -0.75 D, -1.25 D, and -1.75 D. Axes availability is 10° to 180° in standard 10° increments. The lens is designed with a low and a high add powers. The low add is intended for presbyopes who have add powers up to +1.50 D. The high add is intended for presbyopes who have greater than +1.50 D add.
4. Offset multifocal optics
It has been well established that a patient’s line of sight has a significant influence on the optical alignment of multifocal lenses. Line of sight is often not directly through the center of the pupil but rather is nasally located within the pupil. This creates an interesting challenge for some patients. If the difference between the line of sight and the pupil’s geometric center is low, standard multifocal contact lenses may be an appropriate option of vision correction for these patients.But if large discrepancies exist, there may be better options.
Multifocal lenses that have the optics of the lens decentered nasally in order to better align with the patient’s line of sight are called nasally offset optics. SpecialEyes 54 Multifocal is produced with OptiSync Technology, which offsets the optics nasally and stabilizes the lens on the eye by leveraging a prism ballast.
Multifocal scleral lenses are now also being created with offset optics. Zenlens (Bausch + Lomb) is available as a multifocal scleral lens with offset optics to optimize the optical alignment with the patient’s line of sight. Other manufacturers are currently working on multifocal lens designs with offset optics to help optimize vision for these patients.
5. Other contact lens advances
Other contact lens advancements are noteworthy to discuss.
Recently, Johnson & Johnson Vision incorporated Transitions technology into its Acuvue Oasys contact lenses and refer to the incorporated design as light intelligent technology. Just as ophthalmic lenses are activated with this technology when exposed to ultraviolet radiation darkening the lenses, so are Oasys lenses. It provides patients the opportunity to recognize the benefits that changing ophthalmic lens provides but in the convenience of a contact lens.
Another recent advancement is Eyeris, an advanced doctor locator that provides patients the ability to look online for same-day appointments for doctors who are signed up for the service. Recently Eyeris launched a daily disposable contact lens that is exclusively available through doctors’ offices in an attempt to help control the quality of medical devices prescribed to patients.
In November 2019, CooperVision’s MiSight was the first contact lens approved by the U.S. Food and Drug Administration (FDA) for slowing the progression of myopia. MiSight is a daily disposable lens and will be available in the near future.
Another noteworthy contact lens technology is in the area of scleral lenses. As ODs know, the solution that is utilized to fill the bowl of a scleral lens must be preservative free because the solution will be in close proximity to the cornea for an extended period of time. Nutrifill (Contamac) is a new filling solution that was recently FDA approved.
Nutrifill is a balanced solution containing calcium, potassium, magnesium, sodium, and phosphorous. This fill solution has been engineered to be osmotically balanced to the natural tear film, providing a physiologically balanced environment for cornea.
6. Meibomian gland technologies
Procedures to re-normalize the function of the meibomian glands and ultimately re-establish a normal lipid layer are critical to offer patients for meibomian gland dysfunction. There are several technologies that provide the practitioner an opportunity to provide the benefits of this treatment to their patients.
LipiFlow (Johnson & Johnson Vision) is a 12-minute procedure that warms the meibomian glands from the posterior surface of the lids. While heat is applied to the posterior surface of the lids, intermittent pressure is applied to the front surface of the lids. The simultaneous heat and pressure allows evacuation of obstructed meibomian glands.
iLux (Alcon) is another advanced meibomian gland warming and evacuation procedure. It involves warming the lid through the outer surfaces of the upper and lower lids. Pressure is applied to the lids to evacuate the meibum from the glands. The glands that are being evacuated can be viewed through a magnifying lens that is focused on the lid margin as the procedure is being performed.
TearCare (Tear Science) is a meibomian gland warming and evacuation procedure in which smart lids are placed on the upper and lower lids. There is a simultaneous warming of the lids at 45° C for 15 minutes. After the warming occurs, the meibomian glands are evacuated with forceps designed to optimally work with the lid margins.
7. Controlling ocular surface inflammation
It has been well established that ocular surface inflammation is at the root of dry eye disease. Clinicians have leveraged this understanding of the ocular surface physiology to help their patients with dry eye disease.
Cyclosporine has been the traditional pharmacological therapy for patients with dry eye. It has been available for over 15 years (Restasis, cyclosporine 0.05%; Allergan) in unit dose vials that is dosed twice a day. Recently, cyclosporine has become available in a multidose bottle that is preservative free, providing patients the benefits of 0.05% cyclosporine in a bottle (Restasis Multidose, Allergan).
Lifitegrast 5% (Xiidra, Novartis) has been FDA approved for both signs and symptoms of dry eye disease. It is dosed twice a day. It is available in preservative-free unit dose vials. Lifitegrast’s mechanism of action features a lymphocyte functioning antigen-1 (LFA-1) antagonist. LFA-1 are molecules found on T-cells that bind to intercellular adhesion molecule-1 on the surface of inflamed ocular surface tissues. This interaction propogates ocular surface inflammation promoting the signs and symptoms of dry eye. Lifitegrast is a LFA-1 antagonist preventing this interaction.
More recently, a newer formulation of cyclosporine has been approved-Cequa (cyclosporine 0.09%, Sun Pharmaceuticals). The vehicle that the molecule is packaged in is referred to as nanomicelle technology; it optimizes absorption of the medication into the ocular tissues. It is intended to be used twice a day.
8. Hypochlorous acid
Hypochlorous acid is released from neutrophils as an essential part of the immune system. Hypochlorous acid kills microorganisms by neutralizing inflammatory toxins released by pathogens. It is beneficial for the management of lid margin disease by helping prevent excessive biofilm formation on the lid margin.
Over the last several years, a number of hypochlorous acid formulations have been developed and available to eyecare providers and patients. Currently available hypochlorous acid formulations are:
9. OCT angiography
Optical coherence tomography (OCT) has revolutionized the way that ODs view ocular tissues. It allows for viewing cross-sections of the retina and optic nerve, providing critical diagnostic information to manage a plethora of ocular conditions.
Recently, angiography capabilities have become available within the OCT software platform. OCTA allows the clinician the ability to see blood vessels within the retina. This offers clinicians new perspectives of the vasculature bed within the retina. This is useful for macular degeneration patients to help rule out neovascularization and in glaucoma to help understand early reduction in vascularization around the optic nerve with early glaucomatous damage.
Additionally, new insights into the diabetic patients are now giving us a better understanding of the foveal avascular zone (FAZ). Early increases in the FAZ in diabetics may represent the earliest forms of diabetic retinopathy and capillary dropout.
10. New drug delivery
The vast array of pharmaceuticals available to treat ocular conditions provides the practitioner with a large armamentarium of choice. With that said, manufacturers are constantly exploring ways to better deliver these medications to their target tissue. Cyclosporine 0.09% was previously discussed as one of these options which has been formulated in a nanomicellular technology.
Loteprednol is now being formulated to be more targeted for tissue penetration. Two new formulations are noteworthy to discuss here.
Inveltys (loteprednol etabonate 1%, Kala) is FDA approved as a bid dosing regimen for postoperative inflammation and pain following ocular surgery. Amplify is the drug delivery technology. Nanoparticles 200 nm to 400 nm enhance penetration through the mucous barrier on the ocular surface.
Lotemax SM (loteprednol etabonate 0.38%, Bausch+Lomb) is FDA approved for postoperative inflammation and pain following ocular surgery. The delivery mechanism features sub-micron particles (0.4 µm to 0.6 µm) leading to greater tissue and aqueous humor penetration.
Often, newer medicines are accompanied with a higher concentration of active medication. In this case of Lotemax SM, the concentration of loteprednol has been reduced from its predecessor, Lotemax Gel (Bausch + Lomb), which contains 0.5% active medication.
With the advancements in optometry, it is critical for practitionersto stay abreast of changes in eye care. In doing so, optometrists will have a larger armamentarium of diagnostic and treatment options to help care for patients.