The dry eye decade that was
Over the last 10 years, the diagnosis and treatment of dry eye disease has taken eye care by storm.
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Man, that went fast. It seems like only yesterday it was 2011, and here we are at the end of 2020. The “year of the eye doctor” that never really happened.
I know that some people count their decades from the 00 to 09; it just seems right and proper to use 2020 as the last year of the decade. You know, to leave it behind and all.
Still, when you think about it, the decade we bring to a close this month was another in a series of epic decades in eye care. You could make a case that it was the Dry Eye Decade (and I am about to make that declaration), but other major areas of eye care also saw paradigm-shifting, earthshaking innovations. My other two areas of interest fairly exploded with new stuff. Cataract surgery in the twenty-teens continued its streak of convention-shifting innovations. Where once we had only the Crystalens (Bausch + Lomb), we now have any number of multifocal bifocal, trifocal and extended depth of focus options available for patients wishing to have spectacle independence (thanks to Andy Corley for this entire field’s existence). And come on, just look at the havoc treating astigmatism has wrought upon the landscape. Can you say femtosecond laser limbal relaxing incisions? Without astigmatism, would we even have femtosecond laser-assisted cataract surgery?
Laser refractive surgery has seen a similar explosion of innovation. I was part of the first tranche of American refractive surgeons to transition from RK to the excimer laser in 1994. This past decade saw the demise of the keratome, the instrument that made LASIK a reality. It was left behind following the introduction of the femtosecond laser. With the advent of SMILE, refractive surgeons now have a way to bypass the ocular surface when treating ametropia. Where my dry eye disease interests intersect with refractive surgery lies the possibility that I, and many like-minded refractive surgeons, will return to the surface and do some version of PRK rather than any incisional procedure.
And how about those crazy retina folks? Can I get a “yowza” for them? What we do in terms of restoring sight or enhancing the vision of our patients is cool, to be sure. But retina actually walks some of these people back from the land of the blind. Anti-VEGF injections were certainly around before 2011, but this last decade has brought about the introduction of two viable alternatives, Eylea (aflibercept, Regeneron) and Beovu (brolucizumab, Novartis), to the incumbents Lucentis (ranibizumab, Genentech) and Avastin (bevacizumab, Genentech). Not only that, but our nerdy retina compadres rocked industry by doing a randomized controlled trial proving the effectiveness of compounded Avastin that costs one-tenth as much as other brands. All of that is as close as medicine gets to being miraculous; we tip our hats to our back-of-the-eye colleagues.
But because this is a dry eye column, let us get back to the matter at hand: Over the last 10 years, the diagnosis and treatment of DED has taken eye care by storm. And not just ophthalmology, mind you. When we talk about DED, we must take into account the fact that almost everything we can do as ophthalmologists can also be done by a majority of optometrists in the U.S. Indeed, one can argue that the only thing that has had a greater impact on OD’s ability to provide medical care in their offices was the first wave of diagnostic scope of practice laws that allowed them to use topical anesthetics and dilating drops.
While Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) was initially approved in October 2003 and became widely available in 2004, it was in 2011 that it really began to hit its stride. If memory serves, it was around this time that the Joe Schultz-led eye care division at Allergan began to actively promote not only Restasis but also the benefits that accrued to practices that cared for patients with DED. This was my first exposure to a “disease awareness” marketing program. Along with this very public position, there was a quiet “behind the scenes” acceptance that Restasis was a tough treatment to initiate. Again, to its credit, the management at Allergan did not interfere with frontline DED docs who identified clinical challenges and then found ways to overcome them.
Restasis proved that pharmaceutical treatment of DED could be good business. The wholesale acquisition cost of Restasis increased 92% between 2011 and 2017, when topline sales reached $1.4 billion in the U.S. Did you know that from 2015 to 2017, Restasis accounted for 30% of all dollars spent on ophthalmic prescription drugs? I do not know about you, but it was definitely Restasis that taught me about pharmacy benefit managers and discounts as I struggled to figure out why my patients spent so much more on their DED care in 2020 than they did in, say, 2015. Good business led to good science; we now have two new immunomodulators we can prescribe for DED.
Who would have thought in 2011 that DED would become a procedural subspecialty? I never thought about it in that way in the days when the only thing we could do in the office was put in punctal plugs. TearScience (now Johnson & Johnson Vision) ushered in a new era with the introduction of a test, LipiView, that could objectively diagnose meibomian gland dysfunction (MGD). You could then use its companion treatment, LipiFlow, to heat the lids and express the melted meibum. These innovations were followed in the clinic by TearCare (Sight Sciences) to provide precisely directed thermal therapy and iLux (Alcon) with which the lids can be simultaneously manually heated and expressed. Perhaps the most impactful therapeutic procedure may turn out to be intense pulsed light (IPL). Developed and husbanded to acceptance by Rolando Toyos, MD, the twenty-teens saw a veritable explosion of IPL uptake in both the MD and OD communities of DED doctors.
It has been a heck of a ride, this decade. From near obscurity — I described DED as the red-headed stepchild of eye care — DED has become an area of interest that now affects almost everything we do. Over these last 10 years, it has become huge business with multiple new drugs and devices entering the marketplace. Despite all of this, we still have frontiers left to discover and conquer. If the twenty-teens were the decade of anti-inflammatories and MGD, perhaps the ’20s will be the decade of the goblet cell and neuromodulators.
Buckle up: 2021 is here to start another decade.
- Reference:
- Chen EM, et al. Ophthalmology. 2020;doi:10.1016/j.ophtha.2020.04.037.
- For more information:
- Darrell E. White, MD, can be reached at SkyVision Centers, 2237 Crocker Road, Suite 100, Westlake, OH 44145; email: dwhite@healio.com.
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