MEDICAL SERVICES

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Medical Eye Care: The Next Frontier

A look at where this field may be headed and the O.D.’s role

WALTER WHITLEY, O.D., M.B.A., F.A.A.O., NORFOLK, VA.

With more than 10,000 baby boomers turning age 65 every day, the increase use of digital devices, the diabetes epidemic, including diabetic retinopathy, and the overall increase in our population, the need for medical eyecare is great, and it’s only going to get greater. In fact, medical eyecare services account for 17% of patient visits to optometrists, which is predicted and expected to grow, says Essilor’s Management & Business Academy.

Here, I discuss the three areas of eye care I believe will contribute to this growth and our role in each.

1 Refractive surgery

I think the following three technologies will contributeto an increase in medical eyecare services:

► Presbyopic correction. Starting roughly four years ago, the first of 78 million baby boomers began to transition into retirement. Many want to maintain an active lifestyle with less dependence on glasses, and they are willing to spend their hard-earned dollars on technology that will allow them to do this. This technology is comprised of corneal implants/inlays, intrastromal laser treatments and toric multifocal or toric accommodating IOLs.

Corneal implants and inlays can be implanted into the cornea to either reshape the central cornea or provide enhanced depth-of-focus to provide these patients with clear vision at all ranges.

Also, these devices can be removed if patients are dissatisfied, making them an attractive option for refractive correction. Some of these designs are currently undergoing FDA clinical trials.

Intrastromal laser treatments utilize the femtosecond laser and create a series of concentric rings in the cornea, which add magnifying power for improved near vision. Being a flapless laser procedure, this option may be favorable to presbyopic patients who are familiar with laser eye surgery.

Additionally, some patients may be averse to having foreign materials, such as corneal inlays and implants, in their eye. This technology is not currently available in the United States.

Toric multifocal or toric accommodating IOLs will provide astigmatic cataract patients an opportunity to improve both their quality and quantity of vision as a result of their closer position to the eye’s nodal point. With greater than 35% of the patient population having more than 1.00D of corneal astigmatism, this could be a great option to simultaneously address both astigmatism and presbyopia in one procedure.

Currently, Bausch + Lomb’s Trulign Toric is the only IOL that addresses both astigmatism and accommodation, but several toric/multifocal platforms are currently under FDA investigation. The next promising toric multifocal, which is waiting approval, is Alcon’s AcrySof IQ ReSTOR.

► Corneal collagen crosslinking (CXL). This procedure entails inducing additional cross-links within or among collagen fibers using ultraviolet-A (UVA) light and riboflavin to slow, stop or possibly reverse the progression of several corneal ectasias. Therefore, the procedure could significantly improve the quality of life of patients who have corneal ectasias and keratoconus at any stage of their disease. In fact, clinical studies show that the procedure can increase uncorrected visual acuity by 3.6 lines, reduce maximal keratometry readings by 2.01D and arrest disease progression, reports the Journal of Cataract & Refractive Surgery.

CXL is currently undergoing FDA investigation with promising potential.

► Dropless cataract surgery. To address the cost of medications, patient/pharmacy callbacks and patient non-compliance, some surgeons are implementing dropless cataract surgery, which is a combination of compounded moxifloxacin/triamcinolone and sometimes vancomycin. Intraoperatively, this compound is injected into the anterior vitreous post IOL implantation. Although limited evidence-based literature is available on the procedure, dropless cataract surgery has the potential to become a mainstream technique. One consideration that must be weighed is the safety of dropless cataract surgery vs. the safety of the current peri-operative drop regimen.

The O.D.’s role. Patients view us as the refractive experts. To maintain this title, we, as O.D.s, must keep up to date on these and other future refractive technologies, in terms of the procedures themselves and ideal patient candidates. This way, we can provide clear patient education and appropriate recommendations.

In addition, we will play a role in the peri-operative care of these patients, so we must be well versed in the protocols for positive outcomes. By educating our current patients on what’s in the pipeline, their candidacy and providing exceptional post-op care, we will be able to manage, retain and attract patients.

2 Diagnostic/management/therapeutic innovations

I believe these modernizations are forthcoming:

► Ocular surface disease panel testing. On the heels of ocular surface disease and current point-of-care testing, it makes sense to have an ocular surface disease (OSD) panel that tests for tear osmolarity, lactoferrin levels, IgE antibodies and matrix metalloproteinase-9 (MMP-9) all in one test. Potentially, tests for autoimmune systemic conditions, such as Sjögren’s syndrome, could be added to this panel.

Currently, many of these individual point-of-care tests are available individually, but not routinely implemented. The OSD panel would be similar to a comprehensive metabolic panel ordered by primary care physicians to assess the current status of the kidneys, liver and electrolyte and acid/base balance, as well as of blood sugar and blood proteins, which provides information simultaneously to improve diagnostic accuracy and efficiency.

Patients suffering from ocular allergy and/or dry eye disease may greatly appreciate the convenience of a one-and-done test that enables a customized targeted treatment.

► Non-invasive chronic disease management. Contact lenses that contain non-invasive sensors, microchips and other miniaturized electronics are currently in development to monitor a diabetic patient’s blood sugar levels via the tear film and send the data wirelessly to a mobile device for tracking. For example, Novartis recently joined forces with Google to develop this “smart lens” technology. This patient-friendly technology (no more finger pricks to test blood sugar) will no doubt improve patient compliance and data, enabling better disease management and, thus, improve the patient’s overall health. It could also be used in glaucoma patients to monitor IOP or provide extended release of medications, negating the need for the drops patients don’t always comply with.

Another idea in the works is punctal plug technology that could monitor blood sugar levels or IOP via the tear film.

► Eye drops for dry AMD. Several pharmaceutical companies are currently developing complement inhibitor eye drops and have expressed an interest in antioxidants and neuroprotective factors. Eye drops offer significant benefits in terms of cost, convenience and patient adherence vs. the monthly injections, says the Journal of Clinical Ophthalmology.

The O.D.’s role. Chronic disease management falls well within the role of optometry and is something we already do. An OSD panel will provide practitioners more timely information in an efficient manner.

For disease states, such as glaucoma and diabetes, we can help our patients and primary care providers effectively manage these conditions with current modalities that optometry is already accustomed to.

In regard to eye drops for AMD, many patients may benefit from a clinically effective alternative to the traditional invasive injections and could be treated by their optometrist. By having novel diagnostic and treatment modalities at our disposal, optometrists would be better equipped to treat and manage our patients throughout the course of their disease.

3 Drug transmission

I think the following technologies will increase medical eyecare services:

► Contact lens delivery. To overcome the obstacles of effective drug delivery, such as anatomical barriers, patient non-compliance and the long-term impact of pH/preservatives on the ocular surface, it won’t be long before contact lenses will deliver a sustained release of medication into the eye for glaucoma, dry eye disease, allergies and ocular infections. Patients will appreciate this technology, as it will make complying with a medication schedule null and void, while improving their ocular health.

► Punctal plug delivery. The plug will contain a proprietary drug delivery core that can be tailored to deliver a wide range of therapeutic agents through a different time period, again providing patient convenience and improved outcomes.

Several studies are currently underway evaluating punctal occlusion delivery for glaucoma and postoperative inflammation after cataract surgery.

► Transcleral delivery. This route provides medication via biodegradable polymers in a nondestructive, minimally invasive method for sustained drug delivery. Polymers can be localized within the eye and used as a slow-release intraocular implant after simple injection, while other implants would need to be surgically placed. Examples include scleral implants of indomethacin and intrascleral betamethasone, which have been shown to provide sustained drug release.

For optometry, the most promising of the transcleral techniques would be iontophoresis, which is neither an injection nor implant.

This method utilizes a small current that forms an electrical field at the ocular surface with an ocular applicator. The electrical field crosses into the anterior and posterior segments and under the field’s influence, the mobility of charged particles becomes enhanced. Placing drug molecules into the field may lead to substantially higher ocular drug concentrations than achieved with eye drops, providing greater relief to patients.

All the transcleral techniques mentioned provide an alternative route of effective drug administration and penetration while addressing the issues of patient compliance.

The O.D.’s role. Innovations in drug delivery will continuously impact the treatment and management of ocular diseases. Due to the issues of drug penetration, bioavailability and patient compliance, optometrists should be on the lookout for more effective treatment options that will benefit our patients.

We are familiar with many of these technologies in regard to punctal plugs and contact lenses, and they are already well within the optometric scope of practice. These innovations would provide a possibly more effective alternative to traditional eye drop therapy.

Survival

The need for medical eyecare is only going to grow. Those who stay abreast of the latest technologies, educate patients about them and become well versed with their roles in each technology will thrive, as they’ll continue to create a need for their services. OM

Dr. Whitley is the director of Optometric Services at Virginia Eye Consultants in Norfolk, Va. He is affiliated with the Optometric Council of Refractive Technologies and has received funding from Alcon, TearLab and EyeGate Pharma. E-mail him at wwhitley@vec2020.com, or comment online at tinyurl/OMcomment.