BLOG: Who cares about dilation reversal? Patients do
Occasionally, treatments come along that are of greater interest to patients than to doctors.
Drops for treating presbyopia are one example. Arguably, two others are medications for dry eye and injections for the geographic atrophy type of macular degeneration.
The most recent treatment that has been met with patient acceptance and doctor ambivalence is phentolamine ophthalmic solution 0.75%, also known as Ryzumvi from Viatris, which has been approved for reversal of pharmacologic mydriasis. There is a high reward for patients to take this drop even though physician practices are reluctant to implement it. Let’s talk about that reluctance and why practices might want to overcome it.
Phentolamine was FDA approved in September 2023 following a successful clinical trial sponsored by Ocuphire, with subsequent licensing to Viatris. In the trial, Ryzumvi returned many patients’ pupils to pre-dilation diameter as soon as 60 to 90 minutes after dilation. A similar topical version of this drug is in the approval process for presbyopia correction.
The challenge with implementing phentolamine is its pricing. Each bilateral dose costs more than $10. Very few doctors can afford to give away a drug of this cost to each dilated patient just for goodwill. Of course, we can pass the cost along to patients, but in my own practice of about 20 doctors, we hesitated to create a new service item that required charge tracking, collections, inventory management, training of our large staff, etc.
Besides, we thought, would anybody really want reversal of dilation? We dilate many patients every day. Does anybody really mind? Some of us remember Rev-Eyes (dapiprazole hydrochloride ophthalmic solution, Angelini Pharmaceuticals), which was available in the 1990s for reversal of mydriasis. It was very uncomfortable for patients and didn’t work that well. It was used by just a few practices and eventually was taken off the market.
When we started asking patients, we realized that dilation is indeed a big deal. One patient told me she loses the rest of the workday after dilation, and she’d gladly pay $75 to $100 to gain even part of it back. Patients having Light Adjustable Lens (RxSight) surgery and postop adjustments get repeatedly dilated. Several have told me they would take no issue with paying extra at each visit for a quicker recovery. And maybe the biggest impact is for latent hyperopes who lose not just reading but also distant vision with dilation.
Now, my practice has taken a measured approach with phentolamine. We’ve placed a sign in each exam room declaring the availability of phentolamine with the cost. When patients inquire, we explain that it works for about 80% of patients. Instead of 6 to 8 hours of dilation, it can reduce the time to about 3 hours, sometimes less. Redness is the only occasional side effect, occurring in about 5%. Most patients are happy to pay when they check out for the cost of the drug with a small margin. Most have given us very good feedback that they regain function in just a couple of hours, exceeding the expectations we have set.
We have found a greater interest in phentolamine than we ever expected. Our technicians seem happy to talk with patients about it and put it in the room for us to administer when we are finished with our exam. Several patients have given me positive reports about how improved the office experience is with dilation reversal.
From a high level, reversal of dilation with phentolamine works well, has few side effects and is reimbursed, and patients are highly motivated to have it. Doesn’t that make us better doctors for embracing this new treatment? Shouldn’t we all consider it?
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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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