BLOG: Cornea could become the new glaucoma
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Megatrends happen in ophthalmology when new technology addresses existing patient needs and is met with physician acceptance. There’s no better example of this than the current landscape in glaucoma.
A prevalent and vision-threatening condition that was traditionally treated best with eye drops, glaucoma is now best approached by initial treatment with selective laser trabeculoplasty followed shortly by other interventional measures like drug delivery platforms. These include Durysta (bimatoprost intracameral implant) from AbbVie and iDose (travoprost intracameral implant) from Glaukos, as well as angle-modifying instruments (soon to include femtosecond and excimer lasers) or permanent implantable stents. Truly, it has been a renaissance for patients, and it has motivated even further innovation.
In the cover story of this issue of Healio | OSN, we explore a different innovation — epithelial-on corneal cross-linking, which represented a great improvement over traditional treatments for corneal ectasia requiring complete epithelial removal. Roy Rubinfeld, who has been a champion of this cause for 15 years, steadfastly collected data from dozens of surgeons, including myself, that demonstrated that we can cross-link the cornea without taking the risks of epithelial removal.
But there is so much more that can be done with remodeling of the cornea. For almost 30 years, we’ve been aware of chemical cross-linking, in which we can achieve the same effect with no UV light or riboflavin. Even more interestingly, prior to cross-linking, the cornea can be chemically softened by removing glycosaminoglycans, which give the cornea its tensile strength and rigidity. Once reshaped (with contact lenses or other techniques), the cornea can then be cross-linked, making a new shape permanent. While the safety and efficacy of these concepts still require work, they can be applied selectively to steepen or flatten small portions of the cornea. This requires no removal of tissue as with excimer laser or small lenticule extraction but by changing the shape of the tissue itself. The altered shape is permanent, unlike procedures that heat tissue like laser thermal keratoplasty, which because of its short-lived effectiveness has been relegated to the dustbin of history. Selective softening and cross-linking of the cornea can potentially allow high-resolution reshaping both for refractive purposes and for diseases like keratoconus or corneal scars.
If you need another reason to be excited about the future of corneal treatments, consider cell therapies like those being developed for corneal edema. Injected endothelial cells combined with Rho kinase inhibitors (Aurion) or magnetic nanoparticles (Emmecell) can allow minimally invasive treatment of endothelial disease.
And we haven’t even talked about expanding treatments for dry eye, which has a total global market of $7.5 billion, according to Fortune Business Insights. Many of our colleagues haven’t even heard of some of the newest treatments, including a topical skin cream to stimulate tear secretion through the trigeminal nerve (Signal12), a TRPM8 sensor agonist (Alcon), a RASP inhibitor (Aldeyra) and a TNF-alpha blocker (Oculis). Each of these relies on a completely new mechanisms of action, and each will increase our success rate in managing this extraordinarily common group of diseases.
In most fields of medicine, advances happen at a slow, evolutionary pace because once innovators secure funding and navigate technical hurdles, they must struggle for physician acceptance. Ophthalmology, and corneal disease treatments in particular, are privileged to have rapid, revolutionary improvements every few years because we enjoy the combination of high motivation from our patients, rapid adoption of practitioners and a well-rewarded investor community, which fuel innovators to help us realize the dreams of our poorly seeing patients.
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For more information:
John A. Hovanesian, MD, FACS, an ophthalmologist specializing in cataract, refractive and corneal surgery at Harvard Eye Associates in Laguna Hills, California, can be reached at drhovanesian@harvardeye.com.
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