CAKE Issue 20: The Cornea Issue by Media MICE

20 THE CORNEA ISSUE

November 2023 cakemagazine.org

Letter to Readers

The Unseen Heroes of the Cornea Dear Readers,

he corneal epithelium has a hard life. Its cells have to do the same job as the skin’s epithelial cells—keep the outside out, and the inside in— but they have to be transparent. The tear film above those cells needs to be in that Goldilocks zone—not too wet, not too dry, and perturbations to any of the cells involved can give the corneal epithelium quite a bad day. Worse, surgeons often remove them either by scraping or laser ablation in procedures like PRK or most cross-linking procedures. Fortunately, as long as the epithelial stem cells in the limbus remain undamaged, they have the ability to grow back. Now, we all know that for surgeons, it’s the stroma underneath that’s the sexiest structure. The corneal layer is the one that gets reshaped by the excimer laser, or where lenticules are removed, ring segments get implanted, or collagen molecules and proteoglycans get cross-linked together. It serves as the backbone of the cornea, providing the vast majority of its structure, and, therefore, its refractive power. But bless these little epithelial cells. They always want to help… although, at times, their assistance resembles that of a three-year-old “helping” with home repairs. You see, these resilient cells love to compensate in cases of pathology—as well as after refractive surgery. Imagine you’re a refractive surgeon from the turnof-the-century olden’ times. Sure, the music was way better than now, as was fashion, cars, and the price of literally everything. However, when it comes to corneal topography, it’s a different story. Klyce and Wilson were pushing the boundaries of corneal topography with their Tomey TMS-2. They played a role in saving numerous patients with thin corneas from post-LASIK ectasias. But it’s worth noting that these Placido ring-based devices weren’t able to perform cross-sectional imaging of the cornea. So in some of these ostensibly “normal” corneas that went on to develop a nasty ectactic surprise afterward, many were due to the epithelium being “helpful.” To be fair to the little guys, outside of the world of refractive surgery, they were. They were compensating for stromal irregularities, altering the corneal front surface topography, and hiding the information the refractive surgeon needed to make an accurate diagnosis. Today, surgeons have access to advanced instruments that can perform high-resolution corneal epithelial mapping, either through very high-frequency ultrasound or anterior-segment OCT imaging. At the ELZA Institute, we use the latter technology. It’s quite exciting what the surgeons can see with it, and how it can better inform their day-to-day work.

cells clearly has the potential to better optimize screening and patient care. Epithelial thickness maps also inform treatment decisions. Irregular astigmatism can be hard to correct with spectacles or traditional contact lenses, often requiring therapeutic laser surgery, scleral contact lenses, or a combination of both to fully rehabilitate their vision. Measuring the epithelial thickness can help to identify the location and extent of the irregularity, which helps the surgeon and their team better determine the best course of action. So let’s salute these cells! They work hard, they do their best to help, and when it comes to ectasia, they act as the “canary in the coal mine” that tells us if danger lies ahead. Think of that next time the excimer laser starts to blast them away—or when you get the ethanol and cotton swabs out, scrape them off with a hockey knife, or switch on the glorified electric toothbrush. You’ll be thankful when they grow back and start performing their old role once again—of keeping the inside in, and the outside decidedly out.

As it turns out, in the earliest stages of corneal ectatic diseases, the epithelium remodels and changes its thickness to maintain the corneal shape. If simple corneal topography is performed, no changes will be seen. But if epithelial mapping is performed, the true situation becomes clear. Nice one, little buddies!

Cheers,

With ectasias, the earlier the intervention, the better the visual outcomes for the patient. So, the ability to map these epithelial

Director of Communications ELZA Institute, Zurich, Switzerland Editor-At-Large | CAKE

CAKE MAGAZINE | November 2023

Mark Hillen, PhD

In This Issue...

Cataract

Anterior Segment

07 10 12

Matt Young CEO & Publisher Hannah Nguyen COO & CFO Gloria D. Gamat Chief Editor Mapet Poso Editor Matt Herman Associate Editor Maricel Salvador Graphic Designer Writers April Ingram Chow Ee-Tan J. Passut Nick Eustice Rich Carriero

Unlocking Clear Vision for Active Seniors with Alcon’s Innovative Lenses XDEMVY vs. Tea Tree Oil A closer look at Demodex blepharitis solutions Quenching Dry Eye with Dr. Tina Khanam A welcome voice demystifies dry eye disease treatment approaches in the modern era

The Latest with Teleon’s FEMTIS and ACUNEX IOLs, Presented at ESCRS 2023

Cover Story

Seeing the Light Resilience, challenges and progress in corneal transplantation and treatment

Roger Lopez Contributor Ruchi Ranga Customer Care International Business Development Brandon Winkeler Robert Anderson Sven Mehlitz

Kudos

Enlightenment

22 24

Caring with CAIRS Armed with an illustrious career in ophthalmology, Dr. Soosan Jacob offers new approaches to reshaping vision

Published by

Rayner’s Bet on Ophthalmology’s Digital Future Key Takeaways from ESCRS 2023 Data, connectivity, patients and sustainability were at the heart of the Congress

Conference Highlights Media MICE Pte. Ltd.

6001 Beach Road, #09-09 Golden Mile Tower, Singapore 199589 Tel: +65 8186 7677 Email: enquiry@mediamice.com www.mediaMICE.com

Zooming in on Presbyopia Will we ever be free of reading glasses?

We are looking for eye docs who can contribute articles to CAKE magazine. Interested? Let's talk! Send us an email at editor@mediamice.com. To place an advertisement, advertorial, symposium highlight, video, email blast, or other promotion in CAKE magazine, contact sales@mediamice.com.

Advisory Board Members

Dr. Harvey S. Uy

University of the Philippines; Peregrine Eye and Laser Institute, Manila, Philippines harveyuy@gmail.com

Dr. Boris Malyugin

S. Fyodorov Eye Microsurgery Institution Moscow, Russia boris.malyugin@gmail.com

Dr. Chelvin Sng

Chelvin Sng Eye Centre, Mount Elizabeth Novena Hospital, Singapore chelvin@gmail.com

Prof. Jodhbir S. Mehta

Singapore Eye Research Institute (SERI); Singapore National Eye Centre (SNEC) Singapore jodmehta@gmail.com

Society Friends

Arunodaya Charitable Trust (ACT)

CAKE MAGAZINE | November 2023

Dr. George H.H. Beiko

University of Toronto; McMaster University, Ontario, Canada george.beiko@sympatico.ca

Dr. William B. Trattler

Center For Excellence In Eye Care Miami, Florida, USA wtrattler@gmail.com

IOLs

ataract

Nailing the target with FEMTIS Dr. Florian Kretz kicked off the day at the Teleon booth with his presentation entitled, Precision and Accuracy Counts: Auto-CCC and the FEMTIS IOL Family. In his talk, Dr. Kretz demonstrated the many advantages surgeons and patients can expect when opting for automated continuous curvilinear capsulorhexis (CCC) and FEMTIS IOLs. For Dr. Kretz, choosing FEMTIS IOLs is all about nailing the target. “If you use a FEMTIS IOL, then you actually fix it into the capsulotomy, meaning that the optics align perfectly because the capsulotomy was aligned to the visual axis. That gives you a very precise target with very good centration,” he commented on using the FEMTIS IOL in conjunction with the Lensar ALLY™ Adaptive Cataract Treatment System and other options to perform automated capsulotomies.

Dr. Florian Kretz presented during the Teleon booth talks at ESCRS 2023 in Vienna.

The Latest with Teleon’s FEMTIS and ACUNEX IOLs, Presented at ESCRS 2023 by Matt Herman

Top names in cataract released the latest on Teleon’s FEMTIS and ACUNEX IOLs in a symposium and series of booth talks on Day 2 of ESCRS 2023.

bewildering variety of optical designs, materials and defocus curves awaits the modern cataract surgeon navigating the crowded intraocular lens (IOL) market in 2023. And nowhere else is this more apparent than in the proverbial World Cup of cataract and refractive surgery—the annual congress of the European Society of Cataract and Refractive Surgeons (ESCRS). This year’s 41st version of the Congress (ESCRS 2023) was no

exception. For its part, Teleon Surgical BV (Spankeren, The Netherlands) was content to let the data and patient outcomes with their latest ACUNEX and FEMTIS IOLs speak for themselves. A round of presentations and booth talks showcasing the latest research from renowned names like Dr. Florian Kretz, Prof. Thomas Kohnen, Prof. Rudy Nuijts, Prof. Oliver Findl and more showed just what Teleon optics offer cataract surgeons and their patients.

The results the lens produces are eye-opening across the board. Results from multiple studies showed FEMTIS IOLs producing postoperative best corrected visual acuity (BCVA) of 6/12 or better in 84-100% of patients, an improvement from preoperative BCVA of 6/12 or better in 27-54% of patients, respectively. More research from an international trial at the prestigious University of Heidelberg demonstrated more advantages. Preoperative spherical equivalent was reduced from 0.5 to around 0.25 D, monocular corrected distance visual acuity (CDVA) from 0.19 to -0.12 (logMAR), and monocular uncorrected distance visual acuity (UDVA) from 0.51 to 0.02 (logMAR) at 12 months postoperatively. One of the main reasons for this performance for Dr. Kretz was the exceptional centration performance of the FEMTIS IOLs. The 12-month postoperative rotation was an exceptional 0.22°, and decentration of 0.02 mm, compared to a competitor measured at 0.30°.* “These are significantly better results than any other IOL on the market,” said Dr. Kretz. The data from Dr. Kretz kept coming,

CAKE MAGAZINE | November 2023

ataract

IOLs

but in the end, his conclusions were straightforward. For Dr. Kretz, the FEMTIS family of IOLs shows highly predictable results with excellent rotational stability, minimal tilt and decentration and all with the ease of implantation he has come to expect with Teleon’s FEMTIS lenses. “With FEMTIS IOLs, we have never been closer to nailing our target,” he concluded.

The ACUNEX advantage Up next at the Teleon booth was a talk presented by Dutch optometrist Astrid van Os entitled, ACUNEX Vario – Case reports in practice. In this talk, Ms. van Os presented cases featuring patients implanted with the ACUNEX® family of IOLs, Teleon’s hydrophobic line of refractive premium lenses made from a cuttingedge non-glistening material. Ms. van Os presented two very different patients, but the unifying theme was clear. IOL selection is multifactorial, and for Ms. van Os, Teleon’s ACUNEX family offers the flexibility needed to suit a wide variety of patients. In the first case, a 67-year-old male cataract patient, Ms. van Os went with a mix-and-match approach. She implanted the ACUNEX Vario extended-depth-of-focus (EDoF) lens in the dominant eye, and an ACUNEX VarioMax Toric varifocal IOL in the non-dominant eye. The results were a binocular UCDVA of 1.0 and an uncorrected near visual acuity (UNVA) of 0.63. But more than this, the patient was very satisfied with his spectacle-independent intermediate

vision, which aligned with his preoperative expectations. The second case of a 71-yearold female involved a passionate musician with a desire to play the saxophone and read music sheets without glasses. Ms. van Os opted for binocular ACUNEX Vario implantation. The outcome matched the patient’s expectations very well and she could play the saxophone and read notes without glasses even in dim light. End UDVA in the dominant eye was 0.8 and UDVA in the non-dominant eye was 1.0, hitting Ms. van Os’ preoperative targets. Even more noteworthy for Ms. van Os were the near vision results -0.5 in the right eye and 0.32 in the left. And Ms. van Os’ conclusions? “With the ACUNEX lens options, patients get an optimal cataract or clear lens treatment, with excellent depth of focus at all ranges,” she said. The flexibility this offers means even patients with high requirements, like the ability to read music or use a smartphone with natural image and color perception and improved contrast and depth of focus will be satisfied. “This high patient satisfaction rate after surgery ensures a high degree of word-ofmouth recommendations,” she concluded.

A sneak peek of what’s to come To wrap up Teleon’s ESCRS 2023 Day 2 offerings, Teleon brought

out some of the brightest stars in ophthalmology to showcase the ACUNEX family’s merits. A live recording and report of the complete findings presented will be available soon, but in the meantime—some highlights. Presenting for Prof. Rudy Nuijts, Dr. Noël Bauer compared the AcrySof IQ Vivity with the ACUNEX Vario. In this study, the ACUNEX Vario demonstrated better binocular uncorrected intermediate visual acuity (UIVA), a larger continuous range of vision, fewer visual disturbances—and most importantly for Drs. Bauer and Nuijts, higher spectacle independence for ACUNEX Vario. In a study led by ESCRS President Prof. Oliver Findl, presenter Dr. Stefan Palkovits talked through a randomized trial comparing binocular ACUNEX Vario lenses vs. monofocals. Spectacle independence was the focal point here, with ACUNEX Vario showing significant increases in visual acuity over monofocal lenses. “ACUNEX Vario is a safe option for increasing spectacle independence,” Dr. Palkovits reported in his concluding remarks. And finally, the venerable Prof. Thomas Kohnen presented preliminary three-month follow-up results on the ACUNEX VarioMax varifocal IOL. Praising the lens’ refractive design, Prof. Kohnen was encouraged by visual acuities at all ranges, high patient satisfaction, and over 80% reported spectacle independence—all with excellent contrast sensitivity.

Reference * Choi SK, Kim JH, Lee D, et al. IOL tilt and decentration. Ophthalmology. 2010;117(9):1862-1862.e18624.

Editor’s Note The 41st ESCRS Congress was held in Vienna, Austria, on September 8 to 12. Reporting for this story took place during the event. A version of this article was first published on cakemagazine.org.

CAKE MAGAZINE | November 2023

PRESBYOPIA

nterior Segment

Alcon’s Eye on Cataract Survey, recently surveyed over 7,000 people, found that 83% of respondents consider vision to be a critical factor of aging, only behind memory. In addition, 3 in 4 people surveyed said everyday activities are what they look forward to enjoying post-cataract surgery. Of the survey participants, 83% wanted to read as before, 80% sought to use digital devices, and 74% deemed driving important.1 These findings underscored the significance of near vision in the lives of active seniors. “I think it’s even beyond what we call near vision,” Dr. Ike Ahmed said. “You know we can divide near vision into reading and intermediate, and I see more and more folks keen on enhancing their intermediate vision for iPad use, maybe cellphone use. Unfortunately, myself included, people are reading fewer books and less small print. You know our lifestyle evolution has clearly changed over the last decade.”

Unlocking Clear Vision for Active Seniors with Alcon’s Innovative Lenses by J. Passut

In a world where seniors are living longer and more active lives, one thing remains crystal clear—they want to see well.

lcon’s Eye to Eye–Elevating Presbyopia Correction session at the 41st Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2023) shed light on the changing landscape of vision care for the elderly, focusing on the advancements in cataract surgery and presbyopia-correcting IOLs. Experts Dr. Ike Ahmed, Dr. Chandra Bala, Dr. Giacomo Savini, and moderator Mr. Arthur Cummings gathered to discuss the latest developments.

Healthy aging for an active population Mr. Arthur Cummings kicked things off by addressing the evolving expectations of seniors in today’s society. He noted that older adults are more active than ever and increasingly prioritize their vision as they age. “Today’s 70-year-old is very different from a 70-year-old 40 years ago, so vision is among the most important aspects of aging, alongside mobility and memory,” Mr. Cummings said.

Meeting evolving expectations The surgeons discussed the role of modern cataract surgery and IOLs in meeting the evolving expectations of senior patients. Dr. Chandra Bala emphasized the importance of personalized solutions for complex cases. “There is a particular lens for a particular person,” he noted. Factors such as refractive history, ocular conditions and patient expectations play a pivotal role in the selection of IOLs. Dr. Bala highlighted two remarkable Alcon lenses that are revolutionizing the landscape of vision correction: AcrySof IQ Vivity® (Vivity) and PanOptix® Trifocal. These lenses offer more benefits to patients, considering their diverse needs. In two cases presented, he opted for the Vivity for one because it is more forgiving and flexible defocus curve delivers confidence in hitting a refractive target. Vivity IOL allows surgeons to regularly offer the benefits of presbyopia correction to patients, especially those who are not suitable for trifocal IOLs. He opted for PanOptix trifocal for the other patient, a semi-professional snooker player, who wanted a full range of vision from near to far to play snooker.

CAKE MAGAZINE | November 2023

nterior Segment

PRESBYOPIA

Case 1: Far, far away2 The first patient was a senior refractive surgeon who had known about her cataracts for some time. She previously had LASIK surgery for myopia but felt forced into monovision, which she didn’t like. She has -2.75 of astigmatism, which is unexpected after LASIK. Corneal topography showed irregularities and higher-order aberrations suggested instability, possibly due to dry eye. “This suggests that this eye is not stable. It’s not perfect. The dry eye component is something that’s affecting the metrics,” Dr. Bala explained. The dilemma was whether to proceed with surgery and decide which IOL to use, its power, and its axis. “So, I do an IOL Master. It says put a 21-diopter lens, T2, at 168 degrees, and you will get -0.1. I know she doesn’t like -0.1. She wants distance as much as possible,” Dr. Bala continued. “But the decision has to be made. Do I put a T2 and at what axis? Do I believe the IOL Master? Do I believe the Pentacam? Do I believe the Orbscan? I am now in paralysis by analysis.” The decision is made to prioritize distance vision and use intraoperative aberrometry to guide IOL selection, resulting in a successful outcome with the Vivity lens. The audience agreed with Dr. Bala’s choice. “I went with Vivity largely because I need a landing zone,” Dr. Bala said. The Vivity has a broad landing zone, hence if the patient is a little bit on the plus side or a little bit on the minus side, the surgeon is still going to land on an excellent quality distance visual acuity. “I understand there is higher order aberration. I understand there is asphericity. I understand there are toric issues. But fundamentally, if I need to have a good outcome, I need my sphere right.”

who realized he couldn’t see in his right eye when he closed his left eye. He wore glasses for reading and had a myopic prescription of -2.75. He wanted a wide range of vision for snooker, from near to far, but his corneal topography showed issues in the right eye. While he may be lefteye dominant, he didn’t use his right eye much. Higher-order aberrations were at 0.7. The challenge was to address his vision needs and decide on the appropriate treatment, potentially considering options like multifocal or accommodating IOLs. Dr. Bala used the T2 PanOptix (trifocal) in this case. The audience supported the choice, with 54% voting to opt for Trifocal (PanOptix) for both eyes for this patient. The patient now has a 6/6 vision; he is happy, and he can read and can read at 5, so he has decided to defer his other eye surgery. In Dr. Bala’s practice, Vivity grew from 7% in 2020 to 66% in 2023, mainly due to a monofocal IOL drop. The same is true of most surgeons in Australia, who flipped towards Vivity.

Vivity IOL: The balance of clarity and extendeddepth-of-focus Designed to strike a perfect balance between extended-depth-offocus (EDoF) and excellent visual acuity, Vivity provides patients with clear visual acuity across varying distances. This innovative lens minimizes the potential for visual disturbances, a critical consideration for patients seeking optimal vision.

Dr. Ahmed pointed out that technology has made modern IOLs more forgiving and precise. This advancement allows surgeons to use these lenses in a larger range of patients, opening up possibilities for those who may not have been candidates for trifocal lenses in the past. “I think increasingly it’s important to understand and be comfortable with these lenses,” he said. “Patients would want to go to surgeons who are well aware of the options. “Patients are also increasingly informed about their options, and many are willing to invest in technology that can reduce or eliminate their dependence on glasses,” Dr. Ahmed said. Mr. Cummings added that often (surgeons) incorrectly assess the patient’s willingness to pay. “We make those judgments, but it’s not our judgment to make. Hearing aids cost four times what these IOLs do, and these IOLs remain in your eye for life; they’re not exchanged every four years, so cost is relative.” Survey Data shows that 3 in 4 patients agree they are willing to pay for a lens that is likely to eliminate the need for glasses after surgery.1

The increasing acceptance of presbyopia-correcting IOLs The session also addressed the growing acceptance of presbyopiacorrecting IOLs (PCIOLs) among both

As for the patient who cared mostly about distance? “She’s wearing a + 1 for piano and +2 for reading, and she’s very happy,” Dr. Bala said.

Case 2: I want everything2 The second patient was a 64-yearold semi-professional snooker player

Dr. Ike Ahmed

CAKE MAGAZINE | November 2023

Mr. Arthur Cummings

patients and surgeons. As the panel discussed, the perception of these lenses has shifted dramatically over the years. Dr. Bala highlighted the changing mindset among surgeons, particularly new graduates, who are more open to incorporating presbyopia-correcting IOLs into their practice. Technology has made these lenses more accessible and precise. “In 2021, there was a survey done, and 66% of doctors wanted to put in an EDoF lens in the next five years,”3 Dr. Bala said. “And I think that number is going to shift further and further.”

Personalized solutions for complex cases The panel emphasized the

importance of personalized solutions for complex cases. Each patient presents a unique set of challenges and requirements, and selecting the right IOL is crucial for their visual satisfaction. Mr. Cummings noted that even practices with a high volume of monofocal cataract surgeries should consider presbyopia-correcting IOLs for their patients. The goal is to provide patients with the opportunity to consider these lenses, ensuring that they are well-informed about their options. “The biggest point is whether or not you have a very high-end practice, there are always patients in our practices that are candidates for these lenses, and I think that’s important for us to note,” he said.

Dr. Ahmed added, “Particularly for new graduates, the mindset has changed. The other phenomenon we are seeing is that the barrier to entry (for new graduates) has reduced with newer IOLs, making it easier for surgeons to jump in. These lenses are easy to use, more forgiving, and can be used in a broader range of patients, and technology allows them to be more precise.”

Elevating Presbyopia Correction with AcrySof IQ Vivity® • AcrySof IQ Vivity®: A presbyopiacorrecting IOL with X-WAVE™ technology and a proven low rate of visual disturbances.4-7 • Simplifying presbyopia correction: Vivity offers extended vision and simplifies the presbyopiacorrecting experience for surgeons and patients while delivering monofocal-like certainty.4-10

(L to R): Mr. Arthur Cummings, Dr. Giacomo Savini, Dr. Ike Ahmed and Dr. Chandra Bala at the Alcon Eye to Eye-Elevating Presbyopia Correction session.

• Expanding candidate pool: Vivity broadens options for patients who were previously excluded from multifocal IOLs.11 • Superior halo profile: Vivity stands out among diffractive EDoF lenses, providing excellent vision with minimal glare and halos. 6,7,11

References 1. Cataract Research Survey 2023 – Global Survey Report 2. 2023 Alcon Inc. 9/23 EMEA-VIV-2300020 3. ESCRS Clinical Trends Survey 2021 Results (Page 6). Available at: https://www.escrs.org/media/ s5dlnraf/2021_escrs_clinical_survey_supplement.pdf Accessed on 26 September 2023.

• High satisfaction: 9 in 10 patients are highly satisfied and would recommend it to others.12

4. AcrySof IQ Vivity® Extended Vision IOL Directions for Use 5. Alcon Data on File, US Patent 9968440 B2, May 15, 2018 6. Bala C, Poyales F, Guarro M, et al. Multicountry clinical outcomes of a new nondiffractive presbyopia-correcting IOL. J Cataract Refract Surg. 2022;48(2):136-143. 7. McCabe C, Berdahl J, Reiser H, et al. Clinical outcomes in a U.S. registration study of a new EDOF intraocular lens with a non-diffractive design. J Cataract Refract Surg. 2022;48(11):1297-1304. 8. Baur ID, Auffath GU, Yan W, Labuz G, Khoramnia R. Visualization of Ray Propagation through Extended Depth-of-Focus Intraocular Lenses. Diagnostics (Basel). 2022;12(11):2667 9. Ligabue E, et al. ACRYSOF IQ VIVITY: Natural vision at a range of distances provided by a novel optical technology. Cataract & Refractive Surgery Today. April 2020. 10. Ahmed IK, et al. The Vivity Extended Depth of Focus IOL: Our Clinical Experience. Cataract & Refractive Surgery Today. February 2021. Available at: https://crstoday.com/wp-content/uploads/ sites/4/2021/02/0221CRST_Alcon-Vivity-2_ROB.pdf Accessed on 25 October 2023

Editor’s Note The 41st ESCRS Congress was held in Vienna, Austria, from September 8 to 12, 2023. Reporting for this story took place during the event. A version of this article was first published on cakemagazine.org.

11.Kohnen T, Berdahl JP, Hong X, Bala C. The Novel Optical Design and Clinical Classification of a Wavefront-Shaping Presbyopia-Correcting Intraocular Lens Clin Ophthalmol. 2023:17:2449-2457 12. Reus NJ, Kooijman M, Perez-Vives C. Overall Visual Outcomes from a Real-world Study of Presbyopia-correcting IOLs in a Large Population. Presented at the European Society of Cataract and Refractive Surgery (ESCRS) Annual Meeting; 8-12 Sept, 2023; Vienna, Austria.

IMG-VIV-2300048

CAKE MAGAZINE | November 2023

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DEMODEX BLEPHARITIS

XDEMVY vs. Tea Tree Oil A closer look at Demodex blepharitis solutions

by Rich Carriero

In July 2023, the FDA approved the first pharmaceutical treatment for Demodex blepharitis, irritation of the eyelids caused by face mites. This groundbreaking development has generated interest in the industry, and we explore the issue further here.

he mere mention of a mite infestation is enough to give most people the ick— and those that cause Demodex blepharitis are no different. Good news, then, for those with mites on their mind (or their eyelids). In July of this year, the FDA approved XDEMVY (lotilaner ophthalmic solution 0.25%; Tarsus Pharmaceuticals, United States), the first medication that treats Demodex blepharitis at the source.

Meet the mighty mites Demodex is a genus of modified arachnids that live as ectoparasites. Two types are specific to humans: folliculorum and brevis—better known as the face mites. Though we’re not born with them, nearly all people who live beyond middle age will eventually acquire face mites through close contact with others. Most folks become a bit squeamish upon learning that their faces are host to a breeding population of baby (sort of) spiders. But the truth is these mites have been our lifelong companions. In fact, they are so common that, like lice, Demodex have been used by anthropologists

to chart past human demographic changes. Unlike their pesty cousins, however, the nigh-microscopic Demodex enjoy a commensal relationship with humans. They live brief lives, quietly consuming our natural oils and dead skin cells— they don’t drink our blood or poison us. So long as the immune system keeps their numbers in check, mites cause little bother. Among the elderly and immunocompromised, however, Demodex populations have a way of becoming unruly. Mites are believed to be responsible for or an aggravating factor in 60% or more of blepharitis cases in these groups.1 Demodex involvement is most easily diagnosed from the presence of tell-tale collarettes (cylindrical plugs made of mite eggs and waste products) around the base of the lashes. Demodex folliculorum, which preferentially infests the eyelashes, is particularly known for leaving behind these little calling cards. In addition to severe itching in the anterior lid, folliculorum infestation causes follicle distention and misdirected lashes. Demodex brevis, meanwhile, is known for afflicting the posterior eyelid. Burrowing into the meibomian glands, brevis mites can disrupt oil

CAKE MAGAZINE | November 2023

secretion, resulting in watery tears and dry eye.

The lowdown on XDEMVY To the relief of blepharitis sufferers, Tarsus Pharmaceuticals announced FDA approval of XDEMVY (formerly known as TP-03) early this year. An eye drop delivered twice daily for a period of six weeks, XDEMVY contains lotilaner, which kills Demodex mites by inhibiting the action of GABA neurotransmitters. To get a better sense of XDEMVY’s significance, we reached out to Dr. Elizabeth Yeu, president of the American Society of Cataract and Refractive Surgery (ASCRS). “XDEMVY is one of the most specific isoxazolines for ectoparasites,” she said, commenting on the drug’s formulation and mechanism of action. “Exposure results in paralysis and death of the Demodex mite. Lotilaner is also highly lipophilic, making it well-suited to reach the oily lash follicles where mites reside.” During a double-blind study, XDEMVY patients showed a reduction of collarette density and blepharitis symptoms in as little as two weeks. In some cases, complete eradication was achieved. Notable side effects included stinging at the administration site (10% of patients) and chalazia (2%).2 Dr. Yeu added, “A majority of patients do find this drop to be very comfortable to neutral. The blur that is experienced is no more than that of a large clear tear that lasts seconds.”

Tea tree oil: More harm than good? A repeated selling point in XDEMVY literature and endorsements is that the new treatment is the first FDAapproved medicine for Demodex blepharitis. Though true, this claim might be misconstrued to suggest that no effective countermeasure existed before XDEMVY hit the market. “Various OTC products and inoffice procedures have been used with variable efficacy for Demodex blepharitis. Tea tree oil and its derivatives (including terpinen 4-ol or T4O) have demonstrated

acaricidal properties, although the exact mechanism of action against Demodex viability has not been identified,” Dr. Yeu explained. Leading theories regarding tea tree oil’s mite-smiting properties generally focus on the active compounds terpinen-4-ol and 1,8-cineole, which are said to kill mites by disrupting cell membranes. Tea tree oil is also believed to be an irritant, causing mites to migrate out of pores and crevices for easier removal. Finally, tea tree oil also has anti-inflammatory and antibacterial properties, which can help to reduce blepharitis symptoms.3 There are many commercially available treatments for blepharitis that include tea tree oil, such as I-Lid’n Lash PRO from I-med Pharmaceuticals Canada and Oust Demodex Swabstix from Ocusoft (USA). As patients may require a topical anesthetic before treatment, these products are typically available for in-office use only. A popular home-use remedy, however, is Cliradex, produced by Biotissue (USA), one of the only OTC offerings to include terpinen-4-ol.4 Among other drawbacks, tea tree oil is toxic if ingested and can cause allergic reactions as a topical agent. On the ocular surface, it can cause irritation and tissue damage. To underscore this point, Dr. Yeu cited data from a recent study on tea tree oil. “Recently, an in vitro study found that even very low 0.1% and 0.01% concentrations of T4O are toxic to human meibomian gland epithelial cells,”5 she shared.

The verdict? Both XDEMVY and tea tree oil products address the root cause of Demodex blepharitis—they kill face mites. Unlike XDEMVY, tea tree oil may also offer immediate symptom relief. As an herbal remedy, tea tree oil may also appeal to consumers who are leery of traditional pharmaceuticals (like arachnid neurotoxins). However, compared with XDEMVY drops, tea tree oil topicals are difficult to apply, and the consequences of misuse are greater than any currently known side effects of Tarsus’ new drug.

Dr. Yeu is cautiously optimistic about the new drug. “In my own clinical practice, I treat asymptomatic patients very frequently, particularly because I have a highly refractive surgical practice. I am using XDEMVY pre-operatively when I see at least about 1/5 to 1/4 of the upper lash cuffed with collarettes, the pathognomonic sign for collarettes, and other signs. While only time will tell, it is very encouraging to know that the long-term data does demonstrate that the Demodex blepharitis-mitigating effects are quite durable with XDEMVY,” she concluded.

Contributing Doctor Dr. Elizabeth Yeu earned her medical degree through the combined undergraduate/ medical school program at the University of Florida College of Medicine, Gainesville, FL, USA. She completed her ophthalmology residency at Rush University Medical Center in Chicago, IL, USA, where she served as Chief Resident (2006–7). Dr. Yeu is fellowship-trained in Cornea, Anterior Segment and Refractive surgery from the Baylor College of Medicine, Houston, TX, USA (2007–8), where she served as an Assistant Professor of Ophthalmology (2008-13). Dr. Yeu is a partner at Virginia Eye Consultants, having joined in 2013, and also serves as an Assistant Professor of Ophthalmology at the Eastern Virginia Medical School, Norfolk, VA. Dr. Yeu is the current President of the American Society of Cataract and Refractive Surgery (ASCRS, 2023-4) and serves as the Chair for the American Academy of Ophthalmology (AAO) Refractive Surgery Annual Meeting Program Planning committee. She is the medical director for the CVP Mid-Atlantic Surgery Center for the clinical practice, and also sits on the Board of Directors for the Virginia the Virginia Eye Foundation.

References 1. Rhee MK, Yeu E, Barnett M, et al. Demodex Blepharitis: A Comprehensive Review of the Disease, Current Management, and Emerging Therapies. Eye Contact Lens. 2023;49(8):311-318. 2. Tarsus Pharmaceuticals Press Release. Available at: https://ir.tarsusrx.com/newsreleases/news-release-details/fda-approvesxdemvytm-lotilaner-ophthalmic-solution-025 Accessed on 27 October 2023 3. Shah PP, Sten RL, Perry HD. Update on the Management of Demodex Blepharitis. Cornea. 2022;41(8):934-939. 4. Contact Lens Update. Available at: https:// contactlensupdate.com/2015/12/07/ everything-you-wanted-to-know-and-wereafraid-to-ask-about-demodex/ Accessed on 27 October 2023 5. Chen D, Wang J, Sullivan DA, et al. Effects of Terpinen-4-ol on Meibomian Gland Epithelial Cells In Vitro. Cornea. 2020;39(12):15411546.

Peer-to-peer education and the downstream excellence of patient care are core drivers for Dr. Yeu. Dr Yeu has authored hundreds of publications and has similarly delivered hundreds of invited lectures, internationally recognized in her expert areas of refractive cataract surgery, complex lensbased surgeries, and ocular surface disease management. She co-chairs the International Keratoconus Academy (IKA) Annual Meeting, in addition to serving on program planning committees for premier peer meetings, including, Hawaiian Eye, Telling It Like It Is and Ocular Surgery News NYC. For fun, she “edu-tains” by co-hosting a podcast/webcast series known as Ophthalmology Quicksand Chronicles, currently in Season 3. Innovation in eye care is of utmost importance to Dr. Yeu. Since 2019, she has served as the Chief Medical Advisor for Tarsus Pharmaceuticals. She serves on the Board of Directors for Tarsus Pharmaceuticals, STAAR Surgical, Avellino USA and OSRX Pharmaceuticals. Dr. Yeu is married to a general surgeon, Stephen Lin, and they are busy raising two pre-teens, ages 12 and 11. During her free time, she enjoys traveling with family, watching live theatre and musicals, and reading with her children. eyeulin@gmail.com

CAKE MAGAZINE | November 2023

nterior Segment

DRY EYE

Quenching Dry Eye with Dr. Tina Khanam A welcome voice demystifies dry eye disease treatment approaches in the modern era by Rich Carriero

Dr. Tina Khanam has more experience with dry eye disease than most. As an alum of the prestigious Moorfields Eye Hospital and the head of a leading British research team, she’s battled it for years. Dr. Khanam took time out to discuss her insights into this often-idiopathic disorder and her hopes for the future of DES treatment.

ry eye disease (DED) presents in a variety of ways, affecting a wide range of patients, ranging from mild sufferers to those with severe dysfunction. But one doctor is bringing a refreshing approach to this enigmatic condition. Though there’s no silver bullet for DED, Dr. Tina Khanam, a British consultant ophthalmologist with Centre for Sight UK, Spire Healthcare Group, and My-iClinic, argues that human behavior often plays a pivotal role in both onset and progression. Thus, for many patients, the symptoms of dry eye can be greatly mitigated by implementing a few simple lifestyle changes. Dr. Khanam takes a holistic view of DED, recognizing the importance of genetics and outside factors like pollution. But for her, the role of patient lifestyle choices remains the focus.

“Dry eye is a multifactorial condition, so it can be difficult to sort out. But if patients have lots of tools under

seeks to educate patients on anterior segment health and preventable DED risk factors. As proof of concept, a few of her tips offered below have helped countless clients improve their quality of life.

Screen timeout While the exponential jump in screen consumption has become the hobbyhorse of professionals— from teachers to sociologists, its detrimental effects on the human eye are incontrovertible. Dr. Khanam suggests that the prolonged fixed gaze associated with heavy screen use significantly contributes to dry eyes. “What we tend to do when we use monitors is stare at the monitor and not blink for a long while,” said Dr. Khanam. Her advice to patients is straightforward: “You need to take regular breaks while using monitors. Exercise your eyes and make sure you’re blinking regularly and fully— not halfway. Your monitor’s not going anywhere.” One tip for computer designers and software engineers? Apps that remind users to blink!

Makeup malfeasance From arsenic eye-shadow to radium face cream, human beings have historically made questionable beauty choices. It should, therefore, come as no surprise to find makeup another major culprit in the growing incidence of dry eye syndrome. As Dr. Khanam explained, “Half the population is female, many of whom are putting toxic cosmetic products on their eyelids. Raising awareness on that front is really important. What are you putting on your eye and around your eye? What can potentially go into your eye?”

their belt, they can manage it or comanage it with their physician and surgeon,” she said. To that end, she

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Dr. Khanam acknowledges that swearing off makeup is a non-starter for many, herself included. “I really love eyeliner products,” she said. When consulting with patients, she instead opts for more modest

recommendations, like going organic or preservative-free. Despite the elevated cost, such minimalist, eco-friendly products are readily embraced by a large segment of modern beauty consumers. Underscoring this, Dr. Khanam cites the growing number of green cosmetics startups as proof. She stresses, however, that consumers need to do more than avoid unpronounceable ingredients—pH awareness is critical. “The active ingredient in eyeliner is usually charcoal, which is alkaline. And alkaline injury is the worst kind of injury to the surface of the eye. It can kill off a lot of cells very, very quickly.” For a pH-balanced alternative, she suggests cocoa. Finally, Dr. Khanam emphasizes the need for more ophthalmologicfocused testing. “I think ophthalmologists should really lead this. They should be in the conversation with the industry so that products are ophthalmology tested. Just like you have skin products, which are dermatology tested,” she continued.

Hygienic habits Noting the incidence of dry eye among contact wearers, Dr. Khanam bemoans the consistent misuse of soft lenses. “Some people wear contact lenses far too long and they don’t look after the lens hygiene well. It’s really important to educate patients. For example, none of the ophthalmologists I know advise monthlies or fortnightlies. We recommend daily disposables, eight hours or less. Never shower or swim with them on,” she stressed. Any contact wearer who’s suffered an ocular infection has learned these lessons the hard way. There remains, however, an information disconnect when it comes to ophthalmic

hygiene. While many patients know to switch their contacts regularly or not share mascara, lid hygiene is still a foreign concept. To dispel that ignorance, Dr. Khanam educates dry eye patients on measures to prevent meibomian gland dysfunction. “Look after your eyelids and the oil that you produce in the eyelid. Use a warm compress

We asked Dr. Khanam about her hopes for the future of DED treatment. “My goal would be to reach out to as many dry eye patients as I can and to really say that we have great tools under our belts now to help these patients,” she enthused. “It’s really important to get to grips with educating the patient as well as making the shared decision of how we can manage this together. It’s a chronic condition and, you know, we’re in it for the long haul with our patients.”

Contributing Doctor

or eye beads and get heat on the eyelid. Also, massage your eyelids: top lid down, bottom lid up. Really squeeze out those pores and make sure they’re not blocked. That’s the best thing you can do,” she shared.

New hopes Dr. Khanam acknowledges that DED—much like IBS, migraine or fibromyalgia—remains an elusive problem. “Some patients look like they’re okay in terms of the anatomy, but physiologically they’re really suffering.” By the same token, she feels optimistic about new approaches to preventing dry eye or alleviating its symptoms. She cited the advent of autologous serum eyedrops, a treatment born out of the use of blood to ameliorate severe DED among patients in the developing world. “Just like you take a drop of blood to check your blood sugar, if you put it on your eye, you treat your dry eyes.” Dr. Khanam also pointed to the comparatively recent adoption of Ikervis for DED of suspected autoimmune etiology after the drug’s successful use in veterinary medicine.

Dr. Tina Khanam, MBBS, MSc, FRCOPhth, Cert LRS, PG Dip CRS, is a consultant ophthalmologist based in London with over 15 years of experience in the field. A graduate of University College London and member of the Royal College of Ophthalmologists UK, Dr. Khanam specializes in anterior segment, with a special interest in cataract, refractive and corneal pathologies. Formerly of Moorfield’s Eye Hospital London, she currently works with Centre for Sight UK, Spire Healthcare Group and MyiClinic. Dr. Khanam has long put education at the forefront of her career and research, with ongoing investigations into the improvement of corneal transplant surgeries (DMEK and DALK) wetlab and skills transfer courses. She is also a longstanding Examiner for the Royal College of Ophthalmologists UK, and served as the Training Programme Director of Education for Trainee Ophthalmologists at Health Education England. Dr. Khanam is passionate about charity work and is the Founder and serving member of the Board of Trustees of the Mannan Foundation Trust, a UK-based organization with missions around the globe dedicated to erasing inequality in health, education and human rights with an emphasis on empowering women and the less fortunate. t.khanam1@nhs.net

CAKE MAGAZINE | November 2023

Cover Story

by April Ingram

The cornea is remarkably strong and resilient; it can heal itself and even outlast the lifetime of its original owner. However, corneal injuries, diseases, or degeneration can lead to corneal fibrosis, scarring, clouding, or structural damage— which could potentially result in impaired vision, and in some cases, permanent damage. Second only to cataracts, corneal blindness is a leading cause of vision loss globally, resulting in 2 million new cases of unilateral blindness each year.

CAKE MAGAZINE | November 2023

t is estimated that approximately 3% of all emergency room visits are due to eye trauma, with the majority of cases involving corneal injury. Sadly, the vast majority of these cases were preventable. Most corneal injuries can be categorized as either traumatic (abrasion, foreign bodies) or exposure-related (chemical, thermal, or radiation burns). Morbidities resulting from corneal trauma vary widely, ranging from minor or insignificant injuries to vision-threatening with life-long consequences. Most often, in cases of minor corneal trauma caused by abrasions or foreign bodies, the approach involves managing symptoms using analgesia, removing the foreign object, and treating with topical non-steroidal anti-inflammatory drugs or topical antibiotics. When it comes to major trauma or injury, aggressive measures are required, with the most extreme option being corneal transplant.

The ultimate gift of sight Corneal transplantation, the most commonly performed form of organ transplantation, can be a viable option for individuals who have suffered irreversible corneal damage due to disease or trauma. Currently, over 10 million people worldwide are affected by corneal blindness. The unfortunate reality is that there is a much greater demand for corneal transplants than there are available corneas from donors. However, advancements have been made in reducing transplant rejection rates and enhancing our understanding of the procedure and wound-healing process, resulting in higher success rates for corneal transplants than ever before. This ensures that these valuable donations are put to good use. In a 2016 study evaluating the status of global corneal transplants and eye banking, it was found that for every cornea donated, there was a demand for 70 more.1 They also found that 53% of the world’s population does not have access to corneal transplantation. The authors noted the need for ongoing efforts to encourage cornea donation in all countries.

However, public education programs still face significant challenges in dispelling myths and encouraging individuals to donate their corneas. Among the general public, there is a lack of awareness that only the corneas are donated, not the entire eye. It is important to know that corneal donation can take place within 24 hours of death, and corneal donation will not affect how someone looks at their funeral. Additionally, even if someone had cancer or poor vision during their lifetime, their corneas can still be extremely valuable to someone in need.

The evolution of corneal transplantation Did you know that corneal transplantation has a history dating back almost 120 years? The first corneal transplant was performed by Dr. Eduard Zirm in 1905 on a patient who suffered an alkali chemical injury. Over the decades that followed, there has been an evolution in surgical techniques, suture materials, antibiotics, steroid and tissue storage, and preparation techniques. Indeed, we have moved away from the era of full-thickness transplants, and there is now a shift towards more customized, disease-focused procedures. Nowadays, surgeons determine whether the deficits are in the endothelial layer, requiring endothelial keratoplasty, or if midlayer procedures such as anterior lamellar keratoplasty are required. Endothelial keratoplasty represents a major advancement in corneal transplantation, allowing for the targeted replacement of the diseased corneal endothelium. There are several endothelial keratoplasty techniques that vary in the way the recipient’s endothelium is removed and how the donor tissue is prepared. These techniques include Descemet’s membrane endothelial keratoplasty (DMEK), Descemet stripping endothelial keratoplasty (DSEK), Descemet stripping automated endothelial keratoplasty (DSAEK), and Descemet membrane automated endothelial keratoplasty (DMAEK).

Keys to successful corneal transplantation Prof. Vito Romano, a professor of

ophthalmology at the University of Brescia in Italy and the head of Cornea and Ocular surface service at Spedali Civili di Brescia, is passionate about clinical and translational research. His research is primarily focused on lamellar corneal transplantation and strategies aimed at improving the success of corneal transplantation. Prof. Romano shared the key to successful corneal transplantation. “It is well known that corneal endothelial cell viability is the main predictor for corneal graft survival. Currently, surgeons have no means to assess the endothelial status independently before transplantation,” he said. One of the areas that Prof. Romano’s research focuses on is testing a method that could enhance the standardization of keratoplasty outcomes, improve graft survival, and offer eye banks and surgical teams an accessible tool for validating tissues before transplantation. This initiative aims to reinforce the overall quality of their services.

“It is well known that corneal endothelial cell viability is the main predictor for corneal graft survival. Currently, surgeons have no means to assess the endothelial status independently before transplantation.” — Prof. Vito Romano

Prof. Romano and his colleagues have recently published the protocol for their viability study, which aims to validate a preoperative method of evaluating the endothelial health of donor corneal tissues. This method will enable surgeons to determine the proportion of tissues deemed suitable for transplantation and prospectively record clinical outcomes.2 Prof. Romano’s research is also focused on DMEK, recognizing the difficulty of the procedure and the importance of surgeon training. “Spreading knowledge about a

CAKE MAGAZINE | November 2023

Cover Story

surgical technique with a steep learning curve is of paramount importance,” he shared. “Such techniques often require years of practice and mentorship to master. Sharing expertise accelerates the learning process and reduces the risk of errors and complications associated with novices. Moreover, it promotes standardization and ensures that best practices are consistently applied.”

“Spreading knowledge about a surgical technique with a steep learning curve is of paramount importance.” — Prof. Vito Romano

Prof. Romano and his colleagues have published a useful guide for DMEK learners in the Survey of Ophthalmology. This guide identifies potential limitations and offers alternative approaches and emerging technologies that can speed up the DMEK learning curve.3

Vision-threatening corneal diseases Fuchs’ dystrophy and keratoconus are among the major corneal diseases that may require transplantation. Fuchs’ endothelial corneal dystrophy is a progressive hereditary disease characterized by the dysfunction of the corneal endothelium. It can be classified based on the time of onset — with early-onset cases manifesting in early childhood and progressing into the patient’s 30s, while lateonset cases typically begin in their 40s and 50s. In Fuchs’ dystrophy, the corneal endothelium is unable to properly regulate fluid absorption, resulting in stromal edema, which, in turn, causes hazy or cloudy vision. In addition, there is a progressive loss of endothelium, contributing to an increase in stromal and Descemet’s membrane thickness. This aggravates stromal and epithelial

edema, and in severe cases, can result in the development of epithelial bullae. Patients with Fuchs’ dystrophy often experience fluctuating blurriness in their vision throughout the day, with mornings typically being the worst. One of the most telling clinical signs is the formation of excrescences, known as “guttae,” on the Descemet’s membrane.

Navigating keratoconus Keratoconus, on the other hand, is a devastating, slowly progressive, noninflammatory ectatic corneal disease that affects the corneal collagen structure and organization. Dr. Ashraful Huq Ridoy, a consultant ophthalmologist currently practicing at Bangladesh Eye Hospital and Institute in Dhanmondi and Bangladesh Eye Care Hospital in Zigatola, shared his expertise in diagnosing and managing patients with keratoconus. Dr. Huq explained the features of keratoconus that eye care professionals should take into account, noting that the origins of the condition are not well understood. “Though the exact reason for keratoconus is still unclear, it usually appears at early puberty and might be progressive until the 3rd or 4th decade of life. Keratoconus is usually bilateral, but progression could be asymmetrical. Ocular allergies and eye rubbing secondary to atopy are believed to have a higher incidence of association with keratoconus, along with other few systemic and ocular disease conditions,” he said. He added that awareness is key to timely diagnosis. “In South Asian countries, it is important to prioritize awareness and logistics of keratoconus diagnosis because not all patients exhibit the classical signs of the condition,” he continued. Dr. Huq provided an example of such a non-classical case. “So, when a young patient presents with myopic astigmatism and a history of frequent changes in glass power in recent years, and whose vision cannot be refracted to 20/20, there should always be consideration

CAKE MAGAZINE | November 2023

for keratoconus screening for that patient.” We asked Dr. Huq how he manages a keratoconus patient in his practice.“When keratoconus is diagnosed, treatment will depend on the progression and severity. So, the first part of management is determining whether it is progressive or non-progressive,” he explained. Due to the progressive nature of the disease, once the diagnosis has been confirmed, it is essential to encourage keratoconus patients to establish a long-term relationship with their cornea specialist. This is not always easy, as Dr. Huq emphasized, “The patient should receive empathic counseling about the disease and should be persuaded to commit to long-term follow-up.”

“In South Asian countries, it is important to prioritize awareness and logistics of keratoconus diagnosis because not all patients exhibit the classical signs of the condition.” — Dr. Ashraful Huq Ridoy

Dr. Huq also explained the factors that may influence keratoconus progression. “Patient age, ocular allergies, eye rubbing, corneal steepening, its location, and bestcorrected vision play a role in understanding the progression,” he said.

Strategies for high- and low-risk cases If the patient is deemed to be at a high risk of progression, Dr. Huq recommends a specific initial course of action. “Go for collagen crosslinking (CXL) first. Study shows CXL stops the progression in 90% of cases,” he said. “However, CXL has limitations in advanced cases and also won’t work when hydrops or any scar is present in the cornea,” he cautioned. CXL involves topical treatment plus ultraviolet light that adds bonds to

the collagen fibers, improving the strength of the cornea. How about our lower-risk patients? “In cases of low-risk progression, when the patient has good vision with glasses or contact lenses, we typically observe the patient and recommend regular follow-up. Scleral contact lenses are always often the preferred choice for visual rehabilitation in keratoconus patients,” Dr. Huq shared. “CXL only stops the progression,” he added. “Scleral contact lenses are the first choice for visual rehabilitation in post-CXL or lowrisk progression patients.” However, patients also play a crucial role in their treatment. “Patient education on the proper use and storage of scleral contact lenses is another important aspect to consider,” noted Dr. Huq.

Modern approaches to keratoconus management Dr. Huq also discussed additional management options for keratoconus patients. “Topography-guided PRK with CXL can be considered in patients who exhibit no documented progression and have significant higher-order aberrations that are not corrected with contact lenses. Another option for visual rehabilitation in non-progressive cases is the toric implantable contact lens. This involves precise measurement of corneal toricity and best-corrected vision,” he shared. How about those with early to moderate keratoconus? “Intra corneal ring segment is one treatment option to consider when the corneal thickness is 450 microns in the central 6 mm zone,” Dr. Huq explained. “In cases of very thin corneas, hydrops, or post-hydrops scarring, planning for cornea transplantation is the recommended treatment. Deep anterior lamellar

keratoplasty (DALK) is the preferred choice for managing keratoconus, although penetrating keratoplasty remains an option depending on the condition of the host cornea. Many times, keratoplasty induces unpredictable toricity, which may need adjustments with scleral contact lenses.” In the past, treatment options for keratoconus were limited and often resulted in poor outcomes. However, as Dr. Huq explained, this is no longer the case. “Early diagnosis and management are the key to preserving vision and enhancing the quality of life for individuals living with keratoconus.”

Eyes on the future Ongoing research is dedicated to making significant advancements in the management of corneal disease, with a primary focus on reducing the reliance on donated corneal tissue and finding ways to maximize its impact. Recent work exploring the delivery of cultured endothelial cells as an alternative to using corneal tissue has shown promising results. Additionally, a recent program is investigating non-surgical magnetic corneal endothelial cell delivery as a potential approach to treat corneal edema. Despite significant advancements in the understanding and management of corneal diseases and trauma, the cornea remains both delicate and resilient. However, there’s still a shortage of available corneas for those in need of corneal transplants. Hence, encourage your patients to consider cornea donation in your region, sign their donor card, and make their wishes known to their families. Spread the word about one of the most important donations we could ever make—the gift of sight.

References 1. Gain P, Jullienne R, He Z, et al. Global Survey of Corneal Transplantation and Eye Banking. JAMA Ophthalmol. 2016;134(2):167-173. 2. Airaldi M, Zheng Y, Aiello F, et al. Preoperative surgeon evaluation of corneal endothelial status: the Viability Control of Human Endothelial Cells before Keratoplasty (V-CHECK) study protocol. BMJ Open Ophthalmol. 2023;8(1):e001361.

Contributing Doctors Dr. Ashraful Huq Ridoy is a consultant ophthalmologist currently practicing at Bangladesh Eye Hospital and Institute in Dhanmondi and Bangladesh Eye Care Hospital in Zigatola. His practice primarily centers on phaco surgery, LASIK, SMILE, ICL, refractive surgery, keratoconus, and cornea transplant surgery. He has a strong passion for spreading ophthalmic surgery expertise. He has served on the faculty of the Phaco Development Program and is currently working as a faculty in a Cataract Training Program at Bangladesh Eye Hospital and Institute. Dr. Huq has received recognition for his notable contributions to his field of practice. He was honored with the Best Paper Award at the 14th Biannual SAARC Academy of Ophthalmology Conference held in Nepal in 2018 and the Best Young Ophthalmologists Award at the Asia Pacific Academy of Ophthalmology APAO Congress in 2021. drashrafulhuq@gmail.com Dr. Vito Romano is a professor of ophthalmology at the University of Brescia and a consultant ophthalmologist at Spedali Civili di Brescia. He is a prominent specialist in eye surgery, with expertise in cataract and refractive surgery, as well as corneal transplantation. Prof Romano completed his surgical fellowship at the Royal Liverpool University Hospital and Moorfields Eye Hospital in London. He is actively engaged in research and has authored more than 250 research manuscripts in peerreviewed journals. His research focus is on corneal diseases, lamellar corneal transplantation, and strategies to improve graft survival. In 2022, he was added to the list of Top Italian Scientists. He actively serves on both national and international committees and is highly dedicated to teaching and mentorship in his field. vito.romano@gmail.com

3. Parekh M, Ruzza A, Rovati M, et al. DMEK surgical training: An instructional guide on various wetlab methods. Surv Ophthalmol. 2023;68(6):1129-1152.

CAKE MAGAZINE | November 2023

udos

WOMEN IN OPHTHALMOLOGY

Caring with CAIRS Armed with an illustrious career in ophthalmology, Dr. Soosan Jacob offers new approaches to reshaping vision by Chow Ee-Tan

With over 21 years of experience in the fields of refractive surgery, keratoconus management, glaucoma, and complex cataracts, Dr. Soosan Jacob is renowned for her innovative work in ophthalmology. CAKE Magazine sat down with the “Power Lister” ophthalmologist to talk about corneal allogenic intrastromal ring segments (CAIRS), as well as her exemplary contributions to the industry.

r. Soosan Jacob serves as the director and chief of Dr. Agarwal’s Refractive and Cornea Foundation (DARCH) and is a senior consultant at Cataract and Glaucoma Services at Dr. Agarwal’s Group of Eye Hospitals in Chennai, India. A prolific researcher, writer, and keynote speaker, it comes as no surprise that Dr. Soosan Jacob earned recognition and was listed as part of the Top 100 ophthalmologists worldwide.

Conquering keratoconus Dr. Jacob’s primary area of research has been keratoconus, a disease that, she notes, is more commonly prevalent than previously believed. “In the past, the prevalence of keratoconus was thought to be low. However, with the availability of improved diagnostics, it has become evident that its prevalence is actually much higher than we thought it was,” she shared. She cited a study conducted in central India, which showed the high prevalence of keratoconus in patients, including some who are very young. “This is a very common disease, particularly among the young. It affects patients in the prime of their lives, who are actively working and need good vision. Without treatment, this can become a devastating disease,” she continued. However, if the disease is treated properly, it can be controlled effectively, allowing the patient to live an active and fruitful life. Dr. Jacob admits this was the reason she got interested in the disease, because one can really make a lot of difference in the lives of many young individuals.

CAIRS: A new approach to reshaping vision

However, Dr. Jacob shared that she did not actually dream of becoming an ophthalmologist. She did consider pursuing a career in medicine because it seemed to be a secure path toward a stable and fulfilling life.

professor pointed out that she could make use of her hands and brain while performing surgery.

But during her third year at Medical College Kottayam in Kerala, a

“This was probably my ‘eureka moment’ for ophthalmology,”

she shared. “Here was surgery without bloodshed and with instant gratification.” Once her interest was piqued, everything else fell into place—and her journey in ophthalmology had begun.

CAKE MAGAZINE | November 2023

In recent years, Dr. Jacob has been actively involved in CAIRS or corneal allogenic intrastromal ring segments. CAIRS, she said, is a procedure in which ophthalmologists place a ring of allogenic tissue into the eye. “Corneal tissue is the most easily available, allogenic source and so we started out with this. It should be noted though that CAIRS can be performed with other sources

as well. CAIRS is inserted into the mid-periphery of the patient's eye in a specific manner and form. This process brings about a change in the shape of the patient's eye,” she explained. According to Dr. Jacob, as keratoconus is a disease characterized by the deformed shape of the cornea, patients would generally have a conical protrusion. This distortion leads to various refractive irregularities across the cornea, resulting in distorted vision, higher-order aberrations, and poor quality of vision. “CAIRS uses the Barraquer thickness law. If you put in tissue in the midperiphery you can achieve a flattening of the center. That's exactly what we try to do,” she explained. “But the challenge lies in the type of material that was being implanted - PMMA used to create synthetic ICRS. This limits going beyond a certain thickness because these [materials] are not biocompatible. If you keep too much of it, especially in patients with pre-existing corneal thinning disorder, it can result in complications, such as extrusions, intrusions, migrations, and so on,” Dr. Jacob continued. This is where CAIRS created a paradigm shift by allowing implantation of allogenic tissue which is extremely biocompatible and takes away many of the risks associated with implanting synthetic tissue. In addition, we also found that CAIRS gives greater effect than synthetic segments like INTACS and others. Following uniform thickness CAIRS, Dr. Jacob developed customized CAIRS, employing a similar technique for cornea treatment, but using customization or personalization for each patient. This journey has been highly rewarding because they have progressed from using a uniform thickness to implementing customized CAIRS—which means they are tailoring the procedure to each patient. “Keratoconus is a disease that exhibits different characteristics among different patients. There is a gradation of powers within the cone, and the position and shape of the cone may differ, along with the morphology and phenotype of the

cone. There are various thicknesses, and each variation is different—thus making each patient unique,” she added. When Dr. Jacob performs customized CAIRS, she tailors the segment for each patient based on factors such as topographic map, refractive error, thickness and so on. “We have finely honed the technique to the point where we can translate it to the patient. We have observed that it really improved the patient's visual quality, which serves as a validation for the techniques we use,” she enthused.

A promising future in eye care Several ongoing studies on CAIRS are published or pending publication. With more than 600 eye patients who have undergone CAIRS, they have managed to obtain a large database of a wide range of keratoconus patients, all of whom will be included in the studies for publication. Dr. Jacob added that CAIRS has an exciting future. So far, the procedure has been accepted by many ophthalmologists all over the world, in multiple centers in the US, Canada, Australia, Lebanon, Turkey, Israel, Germany, South Africa, the Dominican Republic, and Iraq, among many others. “This is very encouraging because it’s one thing to develop a technique, but it takes the game to a completely different level when you find out your colleagues are also doing it on an international scale,” she shared.

“We now have patients who seek out this treatment, having heard about it from peer support groups, or read about the technique. They are part of the younger patient population who are very active online and are actively seeking treatments that can benefit them,” continued Dr. Jacob. There is already a substantial body of literature on CAIRS, both in medical books and online resources. Dr. Jacob has her own YouTube channel where she shares videos, ranging from the beginning of customized CAIRS to the latest video that has won multiple awards at various conferences—providing detailed explanations about customized CAIRS. Looking forward, Dr. Jacob believes ophthalmologists can customize this technique even further and bring it into places where treatments are still not widely available, such as some African countries. In these areas, according to literature, the prevalence of keratoconus is approximately 9% among male patients and around 5% to 6% among female patients. “They may not have femtosecond lasers available in those areas, so this would be a place where we could make manual channel creation even in the remotest of countries or locations. Any well-trained surgeon could then do CAIRS,” she shared. Dr. Jacob has also worked on femtosecond laser cut CAIRS. These, as well as the trephine cut CAIRS with the use of the CAIRS customizer that she designed give great precision to customization. In fact, the trephine cut CAIRS allows the surgeon to exactly plan and translate plans to the patient’s eye.

A true trailblazer When asked about her vision for the future of ophthalmology, Dr. Jacob said several changes are important for the field. These include the need for more inclusivity, increasing diversity, empowering more women, encouraging greater collaboration between various groups, and fostering increased teamwork.

CAKE MAGAZINE | November 2023

udos

WOMEN IN OPHTHALMOLOGY

Dr. Jacob has relished every moment of her journey as an ophthalmologist. Her innovative career has been marked by various accomplishments, ranging from her first innovation which was in the field of oculoplasty (supra-brow single stab incision frontalis sling surgery for enhanced cosmesis) to anterior segment transplantation, and glued capsular hook and supracapsular glued IOL in the cataract field. Her contributions also extend to corneal innovations, such as contact lens-assistedcrosslinking, immediate primary pre-Descemetic deep anterior lamellar keratoplasty (DALK) for acute hydrops, air pump-assisted pre-Descemet endothelial keratoplasty (PDEK), host Descemetic scaffolding, and, of course, CAIRS. “Each of these [endeavors] is like a baby to me, and seeing them help patients brings me immense happiness and pride,” Dr. Jacob concluded.

Contributing Doctor Dr. Soosan Jacob, MS, FRCS, DNB, MNAMS, the director and chief of Dr. Agarwal’s Refractive and Cornea Foundation (DARCF) and a senior consultant at Cataract and Glaucoma Services at Dr. Agarwal’s Group of Eye Hospitals in Chennai, India. She is a renowned speaker widely respected for her innovative techniques and management of complex surgical scenarios. Dr. Jacob has been featured as one of the five most influential female figures in ophthalmology at a virtual roundtable, and has been listed as part of the Top 100 ophthalmologists worldwide. Dr. Jacob has a special interest in cutting-edge cataract, cornea, glaucoma, complex anterior segment reconstruction, and

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refractive surgery. Many of her innovations have earned international awards. She has received numerous prestigious international awards for her surgical videos, as well as Best Paper of Session awards for her innovations at international conferences in the United States and Europe. She is actively involved in conducting courses and delivering lectures at numerous national and international conferences. She has authored over 110 peerreviewed publications and more than 200 chapters in 34 textbooks. Dr. Jacob also serves as the chairperson of the Multimedia Editorial Board AAO-ISRS (American Academy of Ophthalmology - International Society of Refractive Surgery) and council member of many societies and journals. dr_soosanj@hotmail.com

In cataract surgery

CAKE MAGAZINE | November 2023

nlightenment

INDUSTRY UPDATE

array of novel forms—podcasts, videos of all stripes, multimedia articles—all piped in quite literally at the speed of light. Companies like UK-based ophthalmic solution manufacturer Rayner know this. The race is on to adjust, adapt, and ride the crest of this wave to make sure information on their ophthalmic offerings isn’t cast adrift. Rayner’s answer is their allencompassing online clinical program and resource hub, Peer2Peer—and the company’s strategy behind the platform is a bold wager on what’s to come in eye care.

Communication break… up? Rayner’s approach is informed by one peculiar feature of the modern consumer landscape. Buyers are relying on word-of-mouth from colleagues and experts more than ever to evaluate goods and services. For Rayner Vice President of Marketing Christopher Willis, a large part of Rayner’s Peer2Peer path is based on embracing this.

Rayner’s Bet on Ophthalmology’s Digital Future

by Matt Herman

As online eye care resources go parabolic, Rayner’s Peer2Peer platform is positioning itself as a next-gen nexus of premium ophthalmic content.

ord travels differently these days, and the new ways we consume information is now rattling the windows of the ivory tower of ophthalmology. Rayner’s Peer2Peer platform represents the firm’s attempt to provide a forum for doctors to interact with this new world of ophthalmic content. We sat down with Rayner’s Vice President of Marketing Christopher Willis to dissect their unique approach with Peer2Peer and how it fits in with their vision of the industry’s future.

The dissemination of medical information has traditionally been a slow, methodical and calculated drip through the mass of doctors that use it to inform their practice. Not so long ago, the latest news on drugs, devices, tools and procedures was broken along the plodding rhythm of periodicals or spread sluggishly through tight word-of-mouth networks. That drip is now a deluge. Information floods in through the floorboards around the clock and in a dizzying

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“No one wants to hear from the marketing team anymore,” he noted. “They want to hear from their peers about their experience with the latest products and solutions. Peer2Peer gives them the platform to do that.”

“We are in the middle of a boom in influencer marketing, and I believe ophthalmology is as much an influencer market as any other.” — Christopher Willis, Vice President of Marketing, Rayner

Most will recognize this as the logic underpinning the modern influencer-dominated marketing economy, and Mr. Willis takes it as gospel that this approach has breached the inner sanctum of eye

care. “We are in the middle of a boom in influencer marketing, and I believe ophthalmology is as much an influencer market as any other,” he observed. “Surgeons want to know what their colleagues are doing—especially those who have a respected reputation with publications and studies,” Mr. Willis continued. “They not only want to know what they’re doing, but how they’re doing it – tips, tricks, suggestions for optimizing technology and maximizing patient satisfaction.”

Rolling the dice on decentralization The knock here would be that the modern consumer has largely wizened up to companies essentially throwing their voice onto an army of paid influencers. But Rayner knows this, and this is where the gambit with Peer2Peer takes shape. According to Mr. Willis, Peer2Peer is a space where clinicians and publicly available data dominate the messaging. “It’s for surgeons, by surgeons,” he stated.

“We host the platform and facilitate the content creation, but it’s the opinion and experiences of the surgeons that can be seen and heard when visiting the platform.” — Christopher Willis, Vice President of Marketing, Rayner

With their concept, Rayner doesn’t dictate what can and cannot appear on the platform. Doctors who use their products are free to create, to comment, to explore. Rayner simply acts as the middle man. “We host the platform and facilitate the content creation, but it’s the opinion and experiences of the surgeons that can

be seen and heard when visiting the platform,” Mr. Willis explained. The end result is a nexus of both clinical and experiential information from some of the top ophthalmic surgeons in the world— all collaborating to cover the topics they see as important to advance their practices. “Peer2Peer is quite a decentralized process at Rayner,” observed Mr. Willis. “Our team members are in the field engaging with key opinion leaders. They’re listening to the market to understand what people either want to talk about or want to hear. Once we have something interesting identified, we look for experts in that field to lead the discussion.”

Star power and style Rayner’s bold approach with Peer2Peer has yielded an impressive haul of content thus far. From webinars recorded at global ophthalmic congresses to clinical research papers and interviews with all-star surgeons in a variety of languages, Peer2Peer is designed with global reach in mind. The key offering for Mr. Willis, however, is the star-studded podcast series. Since launching in January of 2023, Peer2Peer has hosted over 30 podcast episodes, which have racked up a whopping 12,000 listens. “Some of our top-performing episodes have come from significant thought leaders in the field, such as Dr. Damien Gatinel, Prof. Gerd Auffarth, Dr. Roger Zaldivar, and Dr. Eric Donnenfeld, just to name a few,” he said. These big names are bound to explain some of the platform’s early successes. Mr. Willis believes, however, that the philosophy behind the content is what has sustained Peer2Peer in becoming one of the most successful initiatives in eye care. “Peer2Peer is open to all health care professionals,” he said. “This may well be one of the top performing [platforms] in the industry. We see no reason to restrict this content. A lot of what’s on there would be of benefit to every practicing ophthalmologist.”

Just the beginning Despite the runaway successes of Peer2Peer in 2023, Rayner sees the platform as constantly evolving. New features are constantly being incorporated, and the recent Peer2Peer 2.0 launch reflects the ease-of-use and accessibility ethos that defines their renowned line of IOLs. “We have so much content now that we’ve incorporated an enhanced search function,” Mr. Willis said. “There’s also a new feature called KOL Corner, which links timestamped content to frequently asked questions, enabling those who don’t have the time to watch an entire webinar to get to the precise content they’re looking for.” In the end, Rayner’s big bet on Peer2Peer and its unorthodox approach to the corporate relationship to content hinges on two factors. The first is that the flexibility they have built into the platform in its early stages will allow them to quickly respond to trends across the industry. “The beauty of digital is that we will continue to evolve the platform based on what we’re seeing. As habits change, we will continue to change,” Mr. Willis reflected. The second is that the open forum they have created for discussion keeps the messaging around their products positive. But the very existence of the platform, the names attached to the content involved, and its runaway early success reflect not only Rayner’s supreme confidence in what it produces. It is also a testament to the trust thousands of doctors around the world have in the firm, and with Peer2Peer, Rayner is betting it stays that way.

Editor’s Note Christopher Willis is Rayner’s Vice President of Marketing. This article was written based on an interview with Mr. Willis regarding the company’s Peer2Peer platform, for educational purposes.

CAKE MAGAZINE | November 2023

nlightenment

ESCRS 2023

Key Takeaways from ESCRS 2023 Data, connectivity, patients and sustainability were at the heart of the Congress by Roger Lopez – President, International Surgical, Alcon

The 41st Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2023) was yet another landmark event that brought together leading eye care professionals in the fields of cataract and refractive surgery. Held at the Messe Wien Exhibition & Congress Centre in Vienna, Austria, from September 8 to 12, the event was marked by thought-provoking discussions and valuable networking opportunities.

gainst the picturesque backdrop of Vienna, ESCRS 2023 provided a remarkable platform for the exchange of cutting-edge research, insights, and technological innovations among eye care professionals. This event once again proved to be an exceptional opportunity for ophthalmologists and eye care

specialists to stay at the forefront of developments in their field. Below are my top four takeaways from the event.

1. Data is key, and the devil is in the details Strong scientific data is vital to

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validating claims, comparing treatment options and unlocking new possibilities for eye care professionals and their patients. At Alcon, we believe in supporting ethical, independent clinical research conducted by qualified third-party sponsors and investigators. One of the key papers that was presented at the ECSRS 2023 was Where is the Plus in a Monofocal Plus IOL? It mentioned Dr. Morgan Michelleti’s non-interventional study that showed Clareon® monofocal IOL provides excellent distance and intermediate vision that is non-inferior to TECNIS Eyehance monofocal IOL.1,2 In addition, leading ophthalmic surgeons presented the Vivity® Registry Study, which monitored realworld patient experiences for up to 12 months post-cataract surgery with implantation of either AcrySof® IQ Vivity® sphere or Toric.3 Data from 900+ cataract patients demonstrated sustained clinical performance, high patient satisfaction, and reduced dependence upon glasses. Evidence also suggested that AcrySof IQ Vivity can be used successfully in a broad range of patients, including those with mild comorbidities such as dry eye and diabetes, providing surgeons and patients with additional treatment options.

As the ophthalmic community, we must push and prioritize thorough data analysis and precise claims substantiation. The devil is in the details, and by prioritizing accuracy, we can significantly impact innovations and patient outcomes.

2. Patients want more Our recent Alcon’s Eye on Cataract Survey highlighted that three in four patients agree they are willing to pay for a lens that is likely to eliminate the need for glasses after surgery.4 It also highlights that cataract surgery remains the main procedure that people are willing to invest in, among other age-related activities like dental implants, hearing aids, or brainstimulating activities.4 This confirms that patients want—and are willing to pay for—value

3. Integrated connected care is the modus operandi Recent double-blind market research conducted by Alcon in Germany, France and Japan confirmed that connectivity to health record systems and from clinic to operating room is already an expectation from the customer. And, in many cases, it’s being implemented at a certain level.5 Alcon Vision Suite is Alcon’s answer to the customer’s needs. By offering a seamless ecosystem that connects the industry’s most comprehensive operating room suite with clinical diagnostics, digital solutions, and first-class training and services, we

are able to partner with surgeons and care teams for more complete and connected care.6

Editor’s Note

4. Sustainability is not just a “nice to have”

The 41st Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2023) was held at the Messe Wien Exhibition & Congress Centre in Vienna, Austria, from September 8 to 12, 2023. Reporting for this story took place during the event.

Sustainability isn’t just a buzzword anymore; it’s a necessity. The conference emphasized that businesses can no longer treat sustainability as optional. At Alcon, we’re working to reduce waste, emissions, and concerns associated with disposable instruments versus reusable ones, while also ensuring patient safety and optimal results—which remain our top priorities. In one such key initiative, Alcon has partnered with Plastic Bank (Vancouver, Canada) to help improve our plastic impact while continuing to help people see brilliantly. For each ton of plastic used in our IOL delivery systems sold and our leading contact lenses and packaging produced, Plastic Bank collected the same amount of ocean-bound plastic in vulnerable coastal communities.7 In conclusion, ESCRS 2023 left us invigorated and armed with valuable insights. The four takeaways—the pivotal role of data, the growing need for spectacle independence, the prominence of connected care, and the urgency of sustainability—serve as guiding principles as we continue to navigate the ever-evolving landscape of the ophthalmic industry.

GLB/IMG-CLM-2300003

References 1. CRST GLOBAL Europe Edition. Monofocal IOLs: Impact of Optical Design on Intermediate Vision. Available at https://crstodayeurope. com/articles/monofocal-iols-impact-of-opticaldesign-on-intermediate-vision/monofocaliols-impact-of-optical-design-on-intermediatevision. Accessed on October 11, 2023. 2. Clareon IOL Aspheric Hydrophobic Acrylic IOL with the AutonoMe Directions for Use. Available at: https://www.myalcon.com/ international/professional/cataract-surgery/ iols/clareon-monofocal-and-toric/ ; https:// www.myalcon.com/international/professional/ cataract-surgery/delivery-systems/autonome/ Accessed on October 24, 2023 3. Bala et al. Multicountry clinical outcomes of a new nondiffractive presbyopia-correcting IOL. J Cataract Refract Surg. 2022;48(2):136-143. 4. Cataract Research Survey 2023 – Global Survey Report. Available at: https://www. alcon.com/media-release/cataract-surgeryalcons-acrysof-iq-vivity-iols-demonstratessustained-high-patient Accessed on October 24, 2023 5. DHS Business Model Research – 2023 – IPSOS.

Disclaimer

6. Market Scope. 2020 Ophthalmic Diagnostic Equipment Report: A Global Analysis for 2019 to 2025. Available at https://www.myalcon. com/international/professional/events/escrs/ alcon_vision_suite/ Accessed on October 11, 2023.

This content is intended for Healthcare Professionals (HCPs) only. Please note that product-related promotion of Medical Devices to non-HCPs may be subject to restrictions based on local rules and regulations. The content of this article is for informational purposes only. The authors and publishers of this article do not endorse or recommend any specific treatments, procedures, or interventions.

7. Alcon 2022 Social Impact and Sustainability Report. Available at: https://alcon.widen.net/s/ kqj8nqc7vt/social-impact-and-sustainabilityreport-2022 Accessed on October 24, 2023

CAKE MAGAZINE | November 2023

Conference Highlights

ESCRS 2023

Zooming in on Presbyopia Will we ever be free of reading glasses?

by Nick Eustice

As we age, we must all come to terms with the inevitable changes in our bodies. How we deal with these changes is greatly influenced by the treatment options available to us. Among these changes that occur with age, presbyopia, the degeneration of the crystalline lens affecting near-field vision, is one of the most common.

visit to any pharmacy tells the tale of medicinal options, some more effective or more preventative than others. We find anti-aging creams in the skincare aisle and denture adhesive next to the toothpaste. A common sight in nearly every pharmacy is a rack of reading glasses. While these reading glasses provide necessary relief for countless presbyopia sufferers, we often wonder if there

could be a better approach to addressing this problem. This was the issue at hand during the Presbyopia Game Changers symposium at the ESCRS Congress 2023 in Vienna, Austria. As Dr. Elizabeth Yeu emphasized in the opening lecture of the session, it is an issue of significant concern to a vast number of people.

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Dr. Yeu reported that 2.1 billion people worldwide suffer from presbyopia, with an estimated 80% of the population experiencing the condition by the age of 45 to 55. In the US alone, there are about 1.8 million new cases of presbyopia each year. “In fact, 40% of those patients are looking for an alternative beyond glasses, but there are no great solutions,” Dr. Yeu said. She cited census reports of the most impactful age-related ailments, noting that two of the top six were vision-related. “But the number one is loss of near vision,” she continued, “with 60% of patients truly concerned about it.”

Drawbacks of current alternative solutions Dr. Yeu pointed out that “there is no ‘holy grail’ for presbyopia treatment.” In addition to the traditional reading or bifocal glasses, advanced contact lens options have been developed. However, these options come with the inconveniences and challenges associated with lens solutions. They can also lead to a reduction in depth perception over time, as well as adjustment to monovision. Numerous surgical alternatives for presbyopia exist, but each one comes with significant drawbacks. Multifocal

IOLs and refractive lens exchange do not provide a comprehensive solution, and the associated costs and risks likely outweigh the potential benefits. Corneal inlays are both expensive and carry the risk of complications and reduced distance vision. Monovision laser correction is perhaps the most high-risk treatment option, involving irreversible sculpting of the eye. It also carries a number of potential side effects, including the loss of binocularity and depth perception. All in all, surgical treatments often come with complications and risks, which typically outweigh the partial solutions they can provide for presbyopia sufferers. However, all of these treatments are continuously improving and may one day provide a conclusive treatment for presbyopia. As Dr. Yeu revealed, a lot of encouraging results come from the latest developments in pharmacology.

Miotic drops provide a pharmacological alternative “Among the emerging therapeutics, the one that we currently have in the US is pilocarpine 1.25%,” continued

Dr. Yeu. In March of this year, it received FDA approval for B.I.D. usage, a significant development as it extends the ability for patients to use it day to night. But it still allows reversibility, so that the pupil can go back to its nascent state by morning. “The benefits of pilocarpine as a treatment for presbyopia are quite significant,” Dr. Yeu explained. Like all miotic drops, pilocarpine works by triggering a constriction of the pupil, thereby improving depth of focus as a result of small aperture optics. Commonly described as “the pinhole effect,” this reduction in the size of the pupil leads to a sharpening of distant and near images alike. Though pilocarpine 1.25% is currently the only FDA-approved miotic drop, it is by no means the only one currently in the clinical development stage. Various other preparations of pilocarpine, including those prescribed in conjunction with phentolamine, as well as aceclidine and stand-alone phentolamine in a spray formulation, are also currently in the testing phase. These applications aim to improve upon the delivery mechanics of the 1.25% pilocarpine drops, or to reduce the stress placed upon the eye, reducing the chance of harmful side effects.

Another miotic drop preparation could potentially provide an alternative treatment option. Delivering a significantly higher muscarinic agonist potency, Brimochol PF (Visus Therapeutics, WA, USA) drops are also showing great promise in phase 3 studies. These drops bring together the longlasting miotic effect of carbachol with the unique properties of brimonidine tartrate, which has a whitening effect, by inhibiting ciliary muscle contraction, preventing pupil dilation, and acting as a vasoconstrictor.

Cautious optimism The efficacy of the currently available pilocarpine drugs, as well as those potentially in the pipeline, is great news for individuals seeking an alternative treatment for presbyopia. However, Dr. Yeu noted that there are potential side effects that could come from the drop’s incorrect use. “This is not a lifestyle drop that we simply prescribe without doing a proper dilation. This is a medication. We want to know if there is vitreomacular traction. We need to assess for any prolonged axial length,” she cautioned. Careful management of these very effective drugs is vital to their future success. Dr. Yeu concluded by highlighting that the proper use of these therapeutics is something that requires close management within the eye care community in order to ensure a safe and effective alternative treatment for presbyopia. As Dr. Yeu previously mentioned, there is no holy grail or miracle cure. However, these advances in pharmacology could go a long way in liberating millions of presbyopes from their dependence on glasses.

Editor’s Note The 41st ESCRS Congress was held in Vienna, Austria, from September 8 to 12, 2023. Reporting for this story took place during the event.

CAKE MAGAZINE | November 2023