Eyeworld

42 | EYEWORLD | SEPTEMBER 2023 R EFRACTIVE spasm is less of an issue, a second dose a few minutes after the first can result in a better ef- fect. Much of the effect of Vuity is gone in a few hours, which is unsurprising considering that pilocarpine was dosed QID for glaucoma." He added that he has not found Vuity to be particularly helpful in screening patients for the IC-8 Apthera (Bausch + Lomb), which can be used in eyes with significantly distorted corneas. "Instead, we simply place a pinhole in the pho- ropter over the patient's refraction to gauge the level of improvement in acuity," he said. Jennifer Loh, MD, said that she is still using Vuity in her practice, but she looks for the ideal patient. This includes someone who is in the 40–50 age range, is an early presbyope, and is looking for relief from glasses. Those patients are usually great at using Vuity because they're early on the journey, she said, adding that the FDA approval of BID dosing has also helped in terms of efficacy. Dr. Loh added that she is cautious to ensure that the patient has no history of retina pathol- ogy, and she discusses the low risk for retinal detachment with use of this drop. She said she acknowledges what the patient might find if they do their own literature search on the in- ternet. "I don't want to shock or surprise them, and I want them to know my thoughts and the background on it and why I think they are a good candidate with a low risk profile for the drop," she said. Presbyopia is a journey, Dr. Loh said. This drop has its uses, but it may not work 100% of the time all day, she said. "I set the expectation that they may need to wear glasses still. I want them to be happy with the medicine and know that it's an adjunct." Luke Rebenitsch, MD, has found these presbyopia drops to not be as effective as he had hoped for patients in his practice. "We were ex- cited about this because it's one more gateway for patients to know that there are solutions for presbyopia," he said. "In our practice, we have tried it in the early presbyope, the one who's not quite ready for blended vision with LVC or refractive lens exchange." Although according to FDA trials there was only a single-digit percentage of people who had a headache, redness, or irritation with the drops, Dr. Rebenitsch said these issues tend to be more significant in his practice, at least early on. "Our biggest issue was that only 30–40% of patients developed a significant enough clinical effect," he said, adding that newer data shows that twice a day dosing is better without signifi- cant differences in adverse effects. He added that he found it challenging to monetize this product in his practice in order to make it profitable. This is never the number one reason we do something, Dr. Rebenitsch said, but in order to run a practice, you have to find a way to make things profitable. The bottom line, he said, is that it worked for a minority of early presbyopes but was not a practice builder. "Even worse, in patients in whom the clinical effect was not sufficient, it caused patients to lose trust in our practice." In terms of other products in development in the presbyopia drop market, Dr. Rebenitsch said a number of these have a similar mecha- nism of action, which is pupillary modulation to introduce depth of focus through a pinhole effect. Dr. Rebenitsch said he is excited about some of the options in development but noted that pilocarpine alone is probably not sufficient. "There are numerous combination drops in development that may allow for an even smaller pupil without a myopic shift or other adverse effect," he said. He said he would be happy to use presby- opia drops in his practice as a bridge for those patients who are not yet ready for surgical treatment. "But it needs to work in a majority of patients, not just in a controlled study environ- ment," he said. Dr. Rebenitsch also said that if these drops could become safe enough to be an over the counter option, this could help the industry in general. "They're not that expensive to produce, and it would create an overall increased aware- ness for presbyopia, but that's probably years in the future and may never happen," he said, noting that it's unlikely that something like Vuity would ever be an over the counter product because of the reports of retinal detachment. Dr. Rebenitsch said he thinks there will be a presbyopia drop that works better in the future. "I think it has everything to do with pupil size, and I think one of these formulations will be more of a silver bullet," he said. "It will never continued from page 41

• Blank Page