Optometry dominates in ophthalmic drug prescribing, as is evident by the fact that only 18% of prescriptions for Vuity (pilocarpine 1.25%, Allergan)—the new presbyopia eye drop—have come from ophthalmologists. It’s not as uncommon as you might think. Xiidra (lifitegrast ophthalmic solution 5%, Novartis) prescriptions for dry eye disease have been written from more than two-thirds of optometrists and almost all topical ophthalmic agents approved in the last few years have more prescriptions from optometrists as well. Let’s look at conditions where the power of the pen can be applied.
Recent years have seen a new class of medications (the ROCK inhibitors Rhopressa and Rocklatan, both by Aerie), a prostaglandin analog (Vyzulta; Bausch + Lomb) with nitric oxide-releasing technology and a new focus on sparing the ocular surface. ROCK inhibitors have significant IOP reduction capability and make an ideal second-line treatment in either moving a patient on prostaglandin analogs to Rocklatan or replacing them with Rhopressa. Vyzulta, with its nitric oxide release, delivers additional IOP lowering of more than 2mm Hg in 42% of patients, more than 3mm Hg in 30% and 5mm Hg in 12% compared to latanoprost.
With more states allowing optometrists to perform laser procedures, we can greatly assist our glaucoma patients with selective laser trabeculoplasty as a first-line treatment. Durysta (Allergan), a new sustained-release delivery system, provides a slow release of bimatoprost once the device is placed in the anterior chamber. What’s most impressive is that it dissolves in about three months, but most patients see 18 to 24 months of IOP lowering effect, equivalent to dosing topical bimatoprost QHS.
Dry Eye Disease
Patients with significant staining are best treated with short-term steroids, such as Eysuvis (Kala Pharmaceuticals) on-label or Lotemax SM (Bausch + Lomb) off-label, and then saving them for future flare-ups. Cyclosporine and lifitegrast are good long-term inflammation treatments, as well as omega fatty acids. But you have to treat the cause, and for most dry eye that’s blepharitis—either MGD, Demodex, bacterial or a mixture.
A new lipid-solubilizing topical pharmaceutical that targets MGD may be available soon—NOV03 (Bausch + Lomb.) It notably achieved sign and symptom endpoints in only two FDA pivotal trials.
TP-03 (Tarsus) recently completed its Phase III pivotal trial to treat Demodex blepharitis. If the data comes anywhere near the success of the first Phase III trial, we’ll have our first therapy for eradication of the Demodex mite- in 2023.
Don’t forget about these, as all but two states have recognized that systemic meds for ocular indications are essential to optometry’s role. Low-dose doxycycline or azithromycin is helpful for conditions ranging from blepharitis to ocular rosacea and even recurrent corneal erosion. Hordeola, preseptal cellulitis and non-responsive bacterial conjunctivitis require medications like Keflex (Advancis Pharmaceutical) or Augmentin (GSK). Oral steroids such as Medrol Dosepak (Pfizer) can help with severe allergies around the eye and Evoxac (cevimeline) can benefit Sjögren’s syndrome patients.
Armed with this information, prescribing these therapeutics will greatly help your patients achieve successful outcomes for their ocular conditions.
Dr. Karpecki is medical director for Keplr Vision and the Dry Eye Institutes of Kentucky and Indiana. He is the Chief Clinical Editor for Review of Optometry and chair of the New Technologies & Treatments conferences. A fixture in optometric clinical education, he consults for a wide array of ophthalmic clients, including ones discussed in this article. Dr. Karpecki's full list of disclosures can be found here.