Eyeworld

SEPTEMBER 2023 | EYEWORLD | 43 R Contact Dell: steven@dellmd.com Loh: jenniferlohmd@gmail.com Rebenitsch: Dr.Luke@ClearSight.com Relevant disclosures Dell: LENZ, Allergan Loh: Allergan, Orasis, Visus Rebenitsch: None be perfect, but I am excited that in the next 3–5 years, we should have something that works better." Dr. Loh noted that the Orasis product in development is a lower dose pilocarpine that she said doctors might be more comfortable prescribing. She's interested to see if this is as effective. "The mechanism of action of the drops from Visus Therapeutics and LENZ Therapeutics are interesting to me as well," Dr. Loh said. With the Visus product, there are two ingredients, bri- monidine and carbachol, involved to help create and sustain the miosis by enhancing bioavail- ability. For the LENZ product, they report that the product, which contains aceclidine, helps with miosis but doesn't cause as much ciliary body contraction that is common with other miotics and that's thought to lead to some of the negative side effects, such as the myopic shift. She added that the Ocuphire Pharma prod- uct is interesting from a mechanism of action standpoint, too, because of the two separate components, phentolamine and low dose pilocarpine, that patients can use. The phen- tolamine helps inhibits the iris dilator in order to help potentiate the effect of the low dose pilocarpine miosis. "I think the barriers are making sure that eyecare professionals are comfortable using it," Dr. Loh said. "That's the issue now—how to get eyecare providers comfortable prescribing it, then patients demanding it." When Vuity was launched, Dr. Loh said she noticed pushback from doctors over the fact that it was "just" pilocarpine. "Unfortunately, the at- mosphere among many was, 'Let's just prescribe generic pilocarpine,'" she said. "I wonder if the newer products with different mechanisms of action that we're not as familiar with might in- cite more interest because eyecare professionals may think they're more novel." Dr. Loh also noted that one concern voiced from many physicians is the risk for a retinal de- tachment. "We know from evidence that there's not a strong causation, and the Vuity clinical trial did not have any retinal detachments in the study population, but it unfortunately has been imprinted on people's minds now." This is an exciting field that can help patients before they are ready for presbyopia surgical options, she said. It can help bridge that gap because some of the most unhappy pa- tients are those entering the age of presbyopia. "I'm grateful that the companies are working on solutions because before it was disheartening to tell patients there was nothing to be done but wear glasses," she said. "Now at least there's something to talk about that opens the conver- sation for future options, too." Dr. Dell also mentioned the product being developed by LENZ, which is an aceclidine- based formulation. "Aceclidine is unique among the various products in development in that it is what I refer to as a 'pupil selective miotic,'" he said. "Aceclidine is excellent at creating a sub-2 mm pupil for about 10 hours, but it is quite bad at stimulating the ciliary muscle. That's a desirable combination that effectively decouples miosis from ciliary spasm, myopic shift, and vitreoretinal traction." Dr. Dell said he regards all the compounds containing pilocarpine as roughly equivalent to Vuity, and the data bears that out. "A carbachol- based formulation in development was unable to consistently achieve a sub-2 mm pupil, and we know carbachol is unfortunately quite good at stimulating the ciliary muscle," he added. A presbyopia-correcting drop is a huge unmet need, Dr. Dell said. "The launch of Vuity was handled masterfully, and I have never seen a better development of consumer awareness of an entirely new category of drug in ophthal- mology," he said. "Despite these considerable efforts, our patients didn't like this particular drug very much. We need stronger pupil selec- tive miotics that last all day with a single dose. These are on the way."

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