EyeWorld Asia-Pacific March 2020 Issue

FEATURE 14 EWAP MARCH 2020 the instillation of the eye drops.” They also found no statistically significant change in OSI, while there was significant change in pupil size between photopic and scotopic conditions. In terms of safety, Dr. Alió and Dr. Vargas also evaluated endothelial cell count and the ocular surface 1 month after instillation of FOV Tears and found no changes nor evidence of tachyphylaxis. “The only side effect was headache, which was reported in 10% of the patients,” they wrote. Dr. Vejarano himself wrote that he has been taking the drops daily for 10 years. “Until now, I don’t have any secondary effect that cause any risk for the normal health of the eye or put in jeopardy the visual capacity,” he wrote. “I see 20/20 for far and near, and I am 52.” Revitalizing the crystalline lens In contrast, working with the standard theory of presbyopia as described by Dr. Vejarano, Novartis has been developing UNR844. Derived from EV06, a lipoic acid choline ester, Dr. Hovanesian said the drop is intended to increase the flexibility of the aging crystalline lens. A principal investigator for Novartis, Dr. Korenfeld wrote that UNR844 “is designed to reduce the disulfide bonds that form between proteins within the crystalline lens. Crosslinking of these proteins constrains their movement, one relative to the other, and this results in reduced deformability of the lens when it is acted upon by the forces produced by ciliary muscle tone variations, and conveyed to the lens via the zonules. This pharmacologic approach does not go away in less than a day, and in studies done so far, the effect after 90 days of dosing can last up to 7 months later without additional dosing.” Given that the mechanism of action of UNR844 is on the crystalline lens itself, essentially reversing the aging process of which cataract formation is a part, could these drops delay or even prevent cataract formation? UNR844, Dr. Korenfeld said, “has that potential, but it has not been studied yet.” In practice These drops will most likely play a role in the younger, phakic, pre-cataract group of presbyopes. This group includes emmetropes who’ve had great vision their whole life or those with previous LASIK, and who, in either case, became frustrated needing reading glasses. “It’s interesting that we don’t really have a good surgical option for the emmetropic presbyope,” Dr. Hovanesian said. The drops may fill that niche—at least until the patient develops a cataract and needs surgery anyway. Certainly, Dr. Vejarano sees these drops as occupying a space in practice entirely their own. Ultimately, Dr. Hovanesian sees these drops as working synergistically with other treatment modalities. He expects that people who develop the need for reading glasses “will gravitate toward these drops as they become available, as a way to sort of test the waters.” “I think a fairly large number of people are going to enjoy the benefits of the drops, but probably not like either the side effects of the drops or just their need to continue taking them, and then they’ll probably gravitate towards surgery,” he said. Furthermore, the drops can also be used in preparation for other interventions, such as monovision. Rather than using a contact lens to test a patient’s receptivity to monovision, instead they could try pharmacological monovision. In that sense, Dr. Hovanesian said, the drops will “propel surgery forward.” “In my practice, we want to be identified as a presbyopia- treating practice—we already are for lens implants, but we want people who are younger than cataract age to come to us,” Dr. Hovanesian said. “Think about it from the strategic standpoint. You want patients in their pre-cataract years to come to you for visual solutions so that they stay with you when they need cataract surgery.” Dr. Alió and Dr. Vargas continue to see a role for the drops even in patients who have already had cataract surgery. “They are a good option for young presbyopes, patients with previous PresbyLASIK or monovision who are not satisfied with their near vision, or they can also be used in patients who had already been implanted with a monofocal IOL and wish to improve their near vision,” they wrote. “The drops have the advantage of being noninvasive, reversible, and with few side effects, distance vision remains stable after their use, which is an advantage over PresbyLASIK and LASIK monovision, and there is no need for neuroadaptation unlike multifocal IOL implantation.” In any case, Dr. Hovanesian said, “we should be open to these. Let’s be open to these kinds of treatments and see how they work.” EWAP Reference 1. Vargas V, et al. Near vision improvement with the use of a new topical compound for presbyopia correction: A prospective, consecutive interventional non- comparative clinical study. Ophthalmol Ther. 2019 March;8(1):31–39. Editors’ note: Dr. Alió is affiliated with the University Miguel Hernandez, Vissum Instituto Oftalmologico, Alicante, Spain, and declared no relevant financial interests. Dr. Hovanesian is affiliated with Harvard Eye Associates, Laguna Hills, California, and has relevant financial interests with Refocus Group, Novartis, and Allergan. Dr. Korenfeld is affiliated with Comprehensive Eye Care Ltd., Washington, Missouri, and has relevant financial interests with Encore Vision, Novartis, Allergan, and Orasis. Dr. Vargas is affiliated with the University Miguel Hernandez, Vissum Instituto Oftalmologico, and declared no relevant financial interests. Dr. Vejarano is affiliated with Fundación Oftalmológica Vejarano, Popayán, Colombia, and declared no relevant financial interests. 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