Anterior Segment Advances That ‘Won’ 2020 and Those Poised To Disrupt the Future

2020 was a challenging year for ophthalmic surgeons, but an array of device and pharma developments helped them get through it, while other advances are poised to disrupt how they perform surgery in the near future. At last week’s OIS Anterior Innovation Showcase, a panel of high-volume ophthalmic surgeons highlighted the advances that made a difference in their practices during the past year and the ones they are most looking forward to in the next year and beyond. Videos from the Showcase are available here.

Critical Advances in 2020
Cathleen M. McCabe, MD, pointed to Alcon’s AcrySof IQ Vivity intraocular lens (IOL) and continued developments that provide an alternative to drops as standouts in 2020. “Vivity has really expanded the number of patients to whom I can offer a premium lens and presbyopia-correcting technology,” noted the CMO of Eye Health America and medical director at The Eye Associates in Sarasota, FL.

In terms of reducing the burden of glaucoma drops, she said, “Durysta [bimatoprost implant 10 mcg, Allergan/AbbVie] has been nice … it is an easily accepted way of helping our patients to avoid the negatives that are associated with their drops.”

Rosa Braga-Mele, MD, MEd, FRCSC, a professor of ophthalmology at the University of Toronto, concurred about Vivity. “I have been using it now for six months and it has changed the face of extended-depth-of-focus (EDOF) IOLs,” she said. “The lens provides a little bit of mini monovision with a range of vision.”

Additionally, Dr. Braga-Mele pointed to Alcon’s hybrid Intrepid phacoemulsification tip with a polymer coating as another significant advance in her practice, “which allows for a safer procedure, particularly in the setting of resident teaching.”

Innovating Visits for COVID-19
Owing to COVID-19, Robert Weinstock, MD, noted that innovations that help to mitigate risk for patients took center stage for him in 2020. “We are now doing day-one post-op visits for routine cataract surgery virtually,” said Dr. Weinstock, director of cataract and refractive surgery at the Eye Institute of West Florida. “That has really helped us streamline our processes; and we also do e-visits for surgical counseling to limit people’s exposure.”

Also, a digital surgical platform has given him a new appreciation for the variation in a patient’s anatomy. “As a heads up surgeon, having 3-D visualization of the angle with immersive technology is powerful,” Dr. Weinstock added.

For William Wiley, MD, telehealth became central to his practice, albeit somewhat unexpectedly, he admitted. “Telehealth was definitely new to us a year ago,” said the medical director of the Cleveland Eye Clinic. “I would’ve never thought we’d be doing any type of consults virtually.”

IOLs and Other Emerging Tech
As for IOLs, the Alcon Vivity and the Tecnis Eyhance IOL from Johnson & Johnson Vision are working their way into his practice, Dr. Wiley added. Of note, he said that more patients are making lifestyle changes with refractive surgery becoming an even larger part of his practice with an increase in procedures like small-incision lenticule extraction, or SMILE.

“We also tried the new miPORT from Zeiss to go along with miLOOP,” Dr. Wiley said. “This is a simple, single-use technology that enables cataract removal without phaco. It could be a very disruptive technology.”
Panel moderator William Trattler, MD, stated that getting new IOLs is always exciting. “With Vivity and Eyhance we have even more choices,” said the president of the Center for Excellence in Eye Care in Miami. “I enjoy figuring out which technology best suits our patients.”
One such technology is iTEAR 100 (Olympic Ophthalmics) neurostimulation to increase tear production in dry eye. “It works really well for me and my patients,” Dr. Trattler added.

He noted that although he’s been using steroids for dry eye “forever,” the approval of Eysuvis (loteprednol etabonate ophthalmic suspension 0.25%, Kala Pharmaceuticals) helps ophthalmologists to “really understand that it’s safe to use steroids for dry eye, and will help our patients across the board.”

To Come: Presbyopia Drops, Small Aperture IOL Pique Interest
Presbyopia-correcting eye drops are generating a buzz among panel members, with pinhole optics playing a role in that category as well, as in the small-aperture IOLs like the IC-8 from AcuFocus.

The panel agreed that pinhole technology is a great way to help extend depth of focus, and the surgeons said that pharmaceuticals are a “stepping stone” to a surgical procedure in the future. It’s kind of like the interplay between drops and MIGS (minimally invasive glaucoma surgery), Dr. Wiley said, but he cautioned that over time, nobody really likes taking drops day in and day out.

“I’ve had the luxury of being able to use the IC-8 in the FDA study and the results are quite good,” Dr. Wiley explained. “The patients are very happy; this is the one solution that tends to take away side effects like glare and halo. We can improve outcomes with aberrated eyes, so I think it’s a great technology.”

Dr. Braga-Mele said IC-8’s potential as a presbyopia-correcting solution in challenging corneas makes it promising – particularly with its improved side-effect profile compared with current refractive IOL technology.

She noted that dry eye is an even bigger problem now than ever before. “Many of those patients are difficult to achieve success for with presbyopia-correcting technology,” Dr. Braga-Mele explained. In terms of the pharmaceutically induced pinhole effect, such as with Visus Pharmaceuticals‘ Brimochol carbachol-brimonidine combination, “It is a very novel idea, but I worry about the cornea with the use of drops.”

Although drops for presbyopia are exciting, “There’s always a compromise with just about every technology, whether it’s an IOL – multifocal, EDOF, or pinhole aperture – or an eye drop,” Dr. Weinstock said. “We just don’t know about these things until we’ve really started using them in our patients,” he added. “Just like everything else, the FDA trials are great, but once in our hands we will find out the real story.”

Combination Devices, New Role for Femto
Lensar is working on technology that combines femtosecond laser with phacoemulsification. Dr Weinstock has consulted with the company on the device and noted that, “You can really customize the phaco parameters based on the femtosecond analysis, which will automate a lot of decision making to where you are optimizing the functionality for each particular patient.”

Femtosecond laser may be coming to glaucoma treatment with the image-guided surgical system from ViaLase, which he noted is similar to “SLT plus” (selective laser trabeculoplasty) – that is, with superior visualization.

“The imaging part [of glaucoma procedures] is so critical to make sure that you’re getting the treatment where it needs to be,” noted Dr. McCabe. “[Advanced imaging capabilities] would even be an asset for some of the other devices we’re using.” She imagined having MIGS, phaco, and femto all together. “Let’s just push it all together and have it all integrated.”