Eyeworld

80 | EYEWORLD | SPRING 2026 C ORNEA by Liz Hillman Editorial Co-Director About the physicians Winston Chamberlain, MD, PhD Affiliate Professor of Ophthalmology Northwest Permanente, P.C. Casey Eye Institute Oregon Health & Science University Portland, Oregon Anat Galor, MD Professor of Ophthalmology Bascom Palmer Eye Institute Miami, Florida Stephen Pflugfelder, MD Professor and James and Margaret Elkins Chair in Ophthalmology Baylor College of Medicine Houston, Texas B iologics may dominate in the retina subspecialty, but cornea is beginning to see interest with these products as well, especially for immune-mediated or severe ocular surface diseases and even corneal dystrophies. "Pharmacological options to date, such as corticosteroids, have limited scope of action in reducing inflammation. On the other hand, biologics can replace diseased or damaged cells or can supplement natural pathways, and they have the potential to heal, restore, or regenerate the cornea," said Stephen Pflugfelder, MD. "I think it is the consequence of greater knowledge about cornea physiology, cellular constituents, and pathways that promote homeostasis, heal- ing, and suppress damaging inflammation." Biologics are already being used for some conditions affecting the cornea, but many of them are systemic or subconjunctival. The emer- gence of topical biologics for conditions affect- ing the cornea is exciting, said Anat Galor, MD. "They're going for diseases that we cur- rently use topical therapy for but may not be super happy with the options we have, like dry eye disease and chronic uveitis," Dr. Galor said, explaining that chronic use of steroids, for ex- ample, is not ideal, and having a steroid-sparing option for conditions like chronic uveitis would be great. "We need to find biologics that work and make them accessible and affordable. The benefit will be that they will be more target- ed approaches to disease. A lot of the current therapies we throw at the ocular surface fall into categories of either generating tears or suppressing inflammation, which are shotgun approaches," said Winston Chamberlain, MD, PhD. If dry eye/ocular surface disease is the target issue, Dr. Chamberlain acknowledged that while inflammation is a strong component, there are multiple other variables that could drive symptoms. "What's appealing about bio- logics is that we may be targeting very specific chemical pathways in certain patients, which may reduce ocular side effects and be more tar- geted to actually address the needs of patients." While biologics for ocular surface disease are attractive for their potential to target root causes, there are some hurdles that need to be overcome. Dr. Chamberlain said biologics are usually macromolecules, recombinant proteins, or "soups of proteins" that can have storage challenges, delivery issues due to the mucosal surface of the eye, especially in drop form. In addition, they're expensive to produce. "I think refrigeration is a key component that would be required for some of the biologic therapies that we consider," Dr. Chamberlain said. "Then there are other variables like overall stability … the kind of material they're stored in and how that might interact with the biolog- ic's chemistry. … How easy is it for a patient to acquire, store and administer the medications?" He gave the example of cenegermin (Ox- ervate, Dompé), which is a recombinant nerve growth factor that is shipped to patients period- ically over the 8-week course of treatment. "Pa- tients get two to three shipments directly from a distribution pharmacy during that time, so there's logistical issues associated with applying those, getting them to the patient, and keeping them stable so that they're effective when the patient uses them in their eye," Dr. Chamberlain said. Then there's the issue of diagnostics—is diagnostic technology advanced enough to detect the very specific pathways that would make biologics beneficial? According to Dr. Chamberlain, "we're getting there, but we certainly aren't there yet for many aspects of ocular surface disease. There are still aspects of disease that we don't understand. Molecular and cellular mechanisms may not be obvious from patient complaints or what we're seeing on the surface." Dr. Chamberlain said there are modalities that can help piece together some of the diag- nostic deficiencies on the surface, such as tear film osmolarity, interferometers that can detect how much lipid is in the tear film, meibomian gland imaging, and infrared imaging that can look at healing processes. "I think we're getting better at making observations about deficien- cies, but we still don't have a great understand- ing of what some of the underlying cellular and molecular mechanisms are that drive symptoms in a particular patient," he said. Early momentum in biologics for corneal conditions continued on page 82

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