Merge Ahead: Where the Parallel Tracks for Future Innovations in Presbyopia May Meet

Innovations for treating presbyopia are moving on two parallel tracks: accommodative intraocular lenses (IOLs) that are both reversable and exchangeable, and pharmaceutical drops to temporarily reverse the effects of presbyopia. The latter may serve as a crossover to the former, and delivering the story of these solutions directly to consumers is going to be important in building those connections.

That was the message two panels delivered at last week’s OIS Presbyopia Innovation Showcase: a panel of clinicians; and another comprising industry leaders. Much of the focus was on the new pharmaceuticals poised to hit the market this year and the need for IOL options with fewer trade-offs.

IOL Outlook
Clinical panelists noted that true accommodative approaches and reversibility of effect or exchangeability are key considerations for future IOLs. Age plays a part in determining whether a cornea- versus lens-based solution is best, noted Thomas John, MD, clinical associate professor at Loyola University, Chicago. Approaches need to be personalized, he said. “I think implants aiming toward accommodating technology will give us something that acts more like the natural lens and provides patients with a quality of vision that can range from distance to near, and everything in between,” Dr. John said.

The panelists pointed to Juvene (LensGen) and SC9 (Bausch + Lomb) IOLs as examples of new accommodative technology. “[Juvene] certainly has huge potential and I think it’s on the cutting edge of accommodating lens technology,” said Kendall Donaldson, MD, medical director at Bascom Palmer Eye Institute in Plantation, FL.

Juvene, a curvature-changing fluid-filled lens, is impressive because it also has potential for upgradability of optics, noted John Hovanesian, MD, who’s conducting clinical trials for SC9. “This lens is seeking approval as an extended-depth-of-focus (EDOF) lens; it is bag-based with large haptics that place it posteriorly,” said Dr. Hovanesian, who practices at Harvard Eye Associates in Laguna Beach, CA.

“It seems to deliver high-quality vision and extended depth of focus, nearing the level of vision that we’d expect from a full-accommodating lens. The more players we have in the market, the more the potential, the better for everyone,” he added.

The LensGen concept is not unlike that of Omega Ophthalmics‘ implant, the brainchild of Gary Wortz, MD. The three-dimensional implant goes into the capsular bag, keeping it open. The implant accepts an exchangeable optic, and maintains space for drug delivery, biometric sensors, and additional lens technologies. “Keeping the capsular bag open is really a key insight in terms of taking presbyopia-correcting lenses, especially the accommodating lenses, to the next level,” said Dr. Wortz, who also practices at Commonwealth Eye Surgery in Lexington, KY.

Until then, however, success with presbyopia-correcting IOLs still depends on setting expectations. The surgeons emphasized the importance of intermediate vision and that EDOF lenses have helped give surgeons confidence because they allow for some flexibility and they provide utility in mixing and matching implants.

“The mix and match is clearly a good option because it covers the intermediate distance, and also you get the advantage of the near,” noted Dr. John. “I think most importantly the patient expectations – patient selection – always takes the center stage.”

Pharmaceutical Options
Presbyopia-correcting drops are showing promise, and those products that make it to market will be the most patient-friendly formulations, explained Dr. Hovanesian, who is involved in some of the clinical trials. “We’re going to learn what patients really want,” he continued. “Different formulations matter. A number of the products depend upon constricting the pupil, but not all. Duration of effect, tolerability, and price, of course, are going to influence how well they do in the market.”

Dr. Kendall also believes price will be a big driver in the adoption of presbyopia-correcting drops. She sees the drops as a bridge to get presbyopes through to a lens-based surgery. “Even in some pseudophakic patients, the drops may provide a little extra range of vision,” she noted.

“There is a place for these pharmaceutical drops,” added Dr. Wortz. “I think they will boost the adoption of presbyopia IOL technologies in the future.”

Taking the Message Directly to Consumers
In preparation for the emerging pharmaceutical treatments for presbyopia, companies developing these treatments are exploring direct-to-consumer (DTC) education. Participants on the industry perspective panel agreed on the importance of targeting patients – that is, existing presbyopes – who are receptive to the message.

What the panel didn’t agree on was what to call presbyopia to make it more “consumer friendly.”

“The majority of patients realize what they have is presbyopia, but most don’t know what it’s called,” said Glen Curran, VP, anterior segment, Allergan. “In fact, research we’ve done shows that 80% of the patients knew the issue was related to aging. It’s not so much about defining the condition, but more about giving it a name,” he said.

Advertising has to be connected to professional acceptance, said Rayner CEO Tim Clover. “It’s not going to work if a bunch of patients turn up to doctors saying, ‘Give me that presbyopia treatment’ and doctors say, ‘No, I don’t really believe in it,'” he said. “We need insightful data to prove that patients have successful outcomes that have an impact on their lives. This will convince doctors.”

The gap between when a patient visits an optometrist and then visits an ophthalmologist for cataract surgery can also be an issue, noted MK Raheja, head, surgical vision R&D, Johnson & Johnson Vision. “It’s 15, 20 years where sometimes this discussion falls through,” he said. “How do we capture our consumer there and how do we educate them? Drops can bridge the gap.”

Robert Kissling, VP, medical affairs, Bausch + Lomb, believes the key to this market in the future is an over-the-counter pharmacologic agent. Raheja agreed, adding, “But there’s another channel: the optometry channel. There are 100 million eye exams a year happening in the US. A partnership between optometry and ophthalmology allows the permeation of some of these unique products.”

Industry and clinicians alike are excited to witness how presbyopia-correcting technologies can be paired together, attacking the problem from different angles, as well as the ongoing development of approaches that can be adjusted as patients’ needs change.

“We can really learn more about the presbyopia patient,” Rayner’s Clover said. “Patient selection is going to be critical, and determining who will benefit from what modality. This area is going to be very exciting in the next few years.”