At the beginning of a new year, we have an incredible opportunity to take stock of the previous year’s successes and failures. We also have a chance to reposition our practices and try to anticipate where things are going. The following new technologies may be instrumental in shaping the future of clinical care in 2019 and beyond.
Optometry plays a key role in glaucoma management, and we now have new drugs to improve our efforts. Vyzulta (Bausch + Lomb) can lower IOP by as much as 9.1mm Hg with Qhs dosing. Another new option is Rhopressa (Aerie Pharmaceuticals), a rho-kinase inhibitor designed to expand the trabecular meshwork. In 2019 we might see Roclatan (Aerie Pharmaceuticals), a combination of Rhopressa with latanoprost.
We also have new surgical options to recommend, such as additions to the slate of minimally invasive glaucoma surgery (MIGS) devices The recently approved Hydrus microstent (Ivantis) has shown one of the greatest IOP lowering of any MIGS device in FDA clinical studies to date in patients undergoing phacoemulsification with Hydrus vs. those undergoing phaco alone. Most notably, the delta increased from one to two years post-procedure.
As far as diagnostics, hysteresis data (Ocular Response Analyzer, Reichert) has been validated to predict field loss progression.
Many diseases we diagnose arise from gene mutations. Conditions such as Leber’s and Stargardt’s disease may see treatment options in the near future (Ophthotech), and even common conditions such as age-related macular degeneration (AMD) and glaucoma have genetic origins. Genetic testing is expanding, and some are now fully covered by insurance, including testing for corneal dystrophies. In 2019, a test that can help diagnose keratoconus at an early stage may hit the market (Avellino Labs). Other companies continue to work on vast retinal genetic testing akin to 23andMe but for ocular conditions (EyeCheck).
This year, we can expect a long-awaited roll-out of a toric presbyopic soft contact lens from Bausch + Lomb. In time, we may also see drug-eluting contact lenses (Johnson & Johnson Vision and OcuMedic) and lenses to measure IOP (Sensimed) that could help us predict fast-progressing glaucoma patients.
With greater awareness, it seems inevitable that myopia control will be a major opportunity for optometry. Clinicians who still need to invest in ultrasound for A-scan measurements might consider DGH’s new option that is cheaper than a traditional ultrasound unit and uses tablet technology. Better access to specialty contact lenses and atropine drops will help clinicians better care for this patient population.
Ocular Surface Disease
This is on the list of opportunities each year, and in-office treatments with technologies such as LipiFlow (TearScience), Blephex and iLux (Alcon) are leading the way. Another device to expect in 2019 is Sight Sciences’ TearCare.
Intense pulsed light is becoming a useful technology, as new entrants such as Lombard Medical have found ways to make the treatment more efficient and convenient. Blephex hopes to further expand its in-office treatments for biofilm with a product called Aurora.
Companies such as VitalTears now make autologous serum available nationwide, which is essential for patients with severe keratoconjunctivitis sicca. Punctal plugs that dissolve in 180 days (Oasis Medical, Beaver-Visitec International, OcuSoft, Paragon Biotech) are gaining traction as the optimal balance between duration and side effects.
Amniotic membrane and amnion-based eye drops (BioTissue, Ocular Sciences), expected in 2019, can help treat superficial punctate keratitis, persistent epithelial defects, neurotrophic keratitis and even neuropathic corneal pain. We may also see an ocular bandage lens made from cross-linked hyaluronic acid for the treatment of abrasions and epithelial defects (Eyegate).
In diagnosis, 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). From a drug perspective, a new version of cyclosporine in a 0.09% concentration (Cequa, Sun Pharmaceuticals) was approved at the end of 2018.
Both Bausch + Lomb and Kala have or will advance the efficacy of loteprednol. Kala recently received FDA-approval for Inveltys, a 1% loteprednol that uses mucus-penetrating particles (MPPs) to reach the target tissue. Kala may also receive approval for a version of loteprednol for dry eye flare-ups.
Bausch + Lomb will soon launch a 0.38% loteprednol that appears to match or increase the efficacy of the current 0.5% by using sub-micron particles sizes, additional moisturizers and a better pH. It does not require shaking, adding one more improvement to the drug profile.
Today, clinicians could add an AMD management focus involving dark adaptometry (Maculogix), wet AMD monitoring (Notal Vision), blue light-blocking technology (e.g., BlueTech, Prevencia) and nutritional supplements. Low vision technologies are also crucial, and inter-professional referrals, such as to an OD colleague who specializes in low vision, should be on your mind for patients with advanced AMD.
Cataract Patient Management
The future of cataract surgery lies in technologies that give patients more options such as light-adjustable lenses (RxSight), femtosecond lasers applied to the IOL to correct post-cataract refractive error (PerfectVision) and products that allow for future IOL upgrades or the addition of augmented reality or monitoring technologies. Diagnostic technologies now combine Scheimpflug imaging with back corneal surface elevation for optimal calculations (Visonix, Oculus), and ocular scatter off the lens can help determine the exact level of cataract your dealing with or if the issue is on the ocular surface (Visiometrics).
All of these advances keep our profession moving forward, but we must not get caught up in the excitement. Remember to carefully evaluate how they can best serve our patients and enhance our practices.
Note: Dr. Karpecki consults for a number of manufacturers with products relevant to this topic.