Optometrists handling anterior segment concerns have a few new tools at their disposal lately. Here’s an overview: 

Corneal crosslinking. Still relatively new in the US but a mainstay internationally for more than two decades, this technology can halt progression of ectasia for conditions such as keratoconus. And while this is a wonderful tool, the real key to halting this disease is early diagnosis. 

New imaging technologies such as Visionix and Pentacam can help you detect keratoconus early and find the right treatment path. With today’s advances, these new tools may soon be accompanied by genetic testing. The AvaGen genetic test (Avellino Labs) measures more than 1,000 SNPs across 75 genes associated with keratoconus and numerous corneal dystrophies that may progress or exacerbate with certain surgeries such as LASIK.

Lid ptosis. It’s imperative we start looking closely for this, even if it turns out to be longstanding blepharoptosis or a common acquired ptosis. Sometimes, it aids in the diagnosis of a life-threatening conditions such as an impending aneurysm or an acquired Horner’s secondary to non–small cell lung cancer. In the next few months, the FDA will review clinical trial data for Vertical Pharmaceuticals’ topical drop, RVL1201, for blepharoptosis. RVL1201 is a once-daily ophthalmic formulation of an alpha-1 agonist, which acts directly on Müller’s muscle to elevate the upper eyelid. 

Corneal nerves. Corneal innervation may be the key to numerous disease presentations. With the approval of Oxervate (cenegermin-bkbj ophthalmic solution 0.002%, Dompé), we now have an effective treatment for neurotrophic keratitis, ranging from stage 1 with SPK to stage 3 with corneal ulceration. In clinical trials, Oxervate resulted in no corneal staining for 72% of cases after two months of therapy. One year later, 80% of the patients still had no signs of corneal pathology. 

Another challenging condition to manage is neuropathic pain, or corneal neuralgia. These patients present with intense pain but no stain. The nerves are damaged and confocal microscopy shows ‘burrs’ on the nerve endings and numerous nerve branches—leaving patients prone to chronic pain from corneal nerve firing. Treatments involve topical loteprednol and autologous serum, oral nortriptyline, low-dose naltrexone and dry eye management. 

The ophthalmic branch of the trigeminal nerve is another nerve we can’t lose sight of. New research into trigeminal dysphoria caused by subtle eye misalignment results in frequent headaches, neck stiffness and a dry eye sensation. Research shows measurement and treatment with a spectacle lens called the NeuroLens (eyeBrain) can practically eliminate more than 50% of all frequent headaches and the accompanying dry eye sensation that occurs with most cases of trigeminal dysphoria.

New Solution for Profitability

With just one adjustment, we could add more than $3 billion per year to optometry: prevent contact lens dropout. The average contact lens wearer generates more than $300 annually to a practice (not including spectacle sales). However, statistics show the dropout rate is somewhere between 18% and 24% per year. Assuming the higher 24%, with 43 million people in the US wearing contact lenses, that means nearly 10 million drop out per year, or a loss of close to $3 billion. 

The number one reason for dropout described by patients is dryness and irritation. So it’s time to start treating dry eye and meibomian gland dysfunction early. A single Lipiflow (Johnson & Johnson Vision) treatment resulted in four hours of increased contact lens wearing time. A recent study found the new Eyeleve moist compress (Bruder) can increase contact lens wear time by three hours when used for 10 minutes per day. 

If we focus on the underlying dry eye rather than simply changing lenses, we just may find a way to recoup that lost $3 billion in revenue per year.

It’s time to look at opportunities to diagnose patients early and provide novel therapies to improve vision, stave off pain and keep patients happy in their lenses—true opportunities worth seizing. 

Note: Dr. Karpecki consults for companies with products and services relevant to this topic.