Do you expect that drops for presbyopia will decrease demand for surgical procedures?
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Increased demand for refractive cataract surgery
With the forthcoming FDA approval and commercialization of eye drops that improve near vision, the presbyopia market is on the cusp of a pharmaceutical revolution.
Although it is difficult to predict the market penetration of any new product, we know for sure that the presbyopia market, with nearly 2 billion presbyopes today, is one of the largest in the world.
One question that remains is who will prescribe these medications and how. Although ophthalmologists and optometrists will likely both prescribe presbyopic eye drops, I believe that optometrists will do it more often because, at least in the United States, they are usually in the forefront for refractive error and see the vast majority of patients when they start to become presbyopic. The ability of companies to provide patient-friendly and doctor-friendly solutions to access these eye drops will be among the key differentiators, in addition to tolerability, efficacy and safety.
Another question is how this new incoming option will affect other solutions for presbyopia, including surgical options such as monovision and refractive lens exchange or cataract surgery with presbyopia-correcting IOLs. My prediction is that presbyopic eye drops will actually encourage many patients to permanently solve their presbyopic situation surgically. Many of them might not seek surgery if they are happy with the drops, but once cataract develops, I suspect they will be more motivated to ask for a presbyopia-correcting lens because they will not like to give up the advantages of spectacle-free vision that they have experienced through the use of drops. So, if on one hand the demand for surgery in the early stages of presbyopia might drop to some extent, I expect that this will be compensated by an increased demand for refractive cataract surgery later on.
This is an exciting time for presbyopia, as we have more good solutions than we ever had in the past.
John P. Berdahl, MD, is OSN Refractive Surgery Section Editor.
Decreased demand for laser surgery
I do believe that drops will reduce the demand for surgery, and I am tempted to say: Why not? Patients are looking for safe options for this frustrating problem, and we do not have much to offer. In the U.S., many of us do not do advanced laser ablations such as PresbyLASIK. We do have corneal inlays, but we are now aware of the complications associated with them.
Eye drops are likely to reduce surgical demand for three main reasons. First, they are a reversible treatment that can be stopped at any time if patients are not fully satisfied. Drops can be used on demand, not necessarily every day, and will come in a wide range of formulations to suit different needs.
The second reason is that they are safe. Pilocarpine, which is the active agent of several drops, can be associated with eye redness, headaches or myopic shifts, but if someone experiences these side effects, they just need to wait for the drops to wear off and that will be the end of it. If there are visual disturbances related to corneal laser ablation, or scarring or haze related to inlays, those effects are permanent.
Third, drops leave the eye intact for refractive cataract later in life, while previous laser surgery would disqualify many patients from having advanced-technology IOLs. Having laser refractive surgery, particularly hyperopic ablation, can exaggerate the dysphotopic aberrations associated with current multifocal IOL technology. Currently, hyperopic LASIK is 15% to 20% of total LASIK cases, and most of the people who are asking for hyperopic LASIK are those who have just started to experience presbyopia. As far as inlays are concerned, many of the drops that are currently in development achieve the same pinhole effect in a safe and reversible manner.
Here in the U.S., ophthalmic medications can be prescribed by both optometrists and ophthalmologists and by any medical doctor with a prescribing license. Because presbyopia is primarily a refractive problem, optometrists will partake in the care of these people. It is also conceivable that other doctors, such as general practitioners, might be enlisted to treat this growing population of presbyopes. For many surgeons, this might not be a negative change but rather a convenient division of tasks, which will give us more time to take care of surgical patients.
Lorenzo J. Cervantes, MD, is from Connecticut Eye Specialists in Shelton, Connecticut.
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