This article was reviewed by John M. Nolan, PhD

At least 700 carotenoids are found in nature. About 50 are included in a typical human diet, 15–16 of which make their way to the circulatory system, but remarkably only 3 are found in the eye, where they are highly concentrated at the macula.

These yellow macular pigments—lutein, zeaxanthin and meso-zeaxanthin—have powerful antioxidant properties and play essential roles in filtering high-energy, short-wavelength blue light and in minimizing the oxidative stress that is known to be a significant factor in age-related eye disease.

John M. Nolan, PhD, has spent 20 years researching the macular pigments–measuring them and monitoring their effects on health. 



Photobiomodulation shows the power of light


He says that “the general population is highly deficient in these; even the healthiest person you know is deficient. Nobody is eating enough.” 

A deficiency in macular pigments has a real and tangible impact on day-to-day quality of life in terms of vision and cognitive function.



Everybody who works in eye care is aware that visual acuity does not describe the whole of visual performance, which is multifaceted and also incorporates aspects of processing speed, contrast sensitivity, glare, and visual adaptation.

Nolan’s European CREST trials, supported by a European Research Council Starting Grant, demonstrated that each of these individual visual functions is significantly improved by enriching the macular pigments by means of an oral supplement, not only in patients with early age-related macular degeneration but also in healthy study participants.

Blue light is a problem for visual performance and increasing its filtration—by increasing macular pigment—reduces visual discomfort and glare disability and improves photostress recovery. 





Another important aspect of vision is the speed of visual processing, which is strongly modifiable by increasing macular pigment.

For every 0.1 increase in macular pigment optical density, roughly 1 millisecond of reaction time can be gained.

 Increased contrast sensitivity can hugely improve a patient’s quality of life and how they feel about their vision. 

A patient with a medium or high level of macular pigments can develop macular degeneration, but nutrition can counterbalance genetic factors and optimize their individual disease trajectory.



It is important to measure the concentration of macular pigment in the eye itself because retinal levels correlate only weakly with levels in the blood; availability of the fat-soluble carotenoids at their target tissue depends on a patient’s body mass index amongst other factors. 

Until fairly recently, it had been possible to quantify retinal concentrations using psychophysical methods only, which are known to be highly subjective and variable and also have the disadvantage of measuring at only 1 point in the eye.



Autologous retinal transplant for larger macular holes gaining traction

Nolan has worked with Heidelberg Engineering to develop an experimental software add-on to the Spectralis system, which uses a dual-wavelength autofluorescence system to measure the “optical volume” of the macular pigments

 

They have developed and validated macular pigment optical volume (MPOV) as an arbitrary unit that provides a measure of the concentration of the pigments within every pixel of the image, across the entire macula, thus allowing the distribution of the pigments to be mapped. 

It is now possible to examine a patient and compare their MPOV with that of the general population average in terms of low or high levels of pigment. 


Nolan’s current research interest is dementia and cognitive function. It has become clear that the levels of macular pigment measured in the eye correlate with their levels in the brain; it has been demonstrated further that these levels correlate directly with cognitive function.

The population of individuals with Alzheimer’s disease is the most deficient Nolan has encountered and he is currently conducting an interventional study in these patients.

This would not have been possible previously, as people with this dementia are not able to cooperate with psychophysical testing. 



Study results link frequent anti-VEGF injections, risk of cognitive impairment


The Spectralis system makes it possible to quickly and simply measure their macular pigment.

A cross-sectional observation study with 4000 participants in the Republic of Ireland demonstrated that individuals who had high levels of pigment outperformed everybody else in all measures of cognitive abilities.

 

Interventional trials found that memory and cognition in healthy patients improved on supplementation with the 3 macular pigments.


It is possible in principle to improve one’s levels of macular pigment by eating significant portions of plants such as spinach, kale and corn. 

Good nutrition is a baseline and the first step Nolan takes with his trial patients is to optimize their nutritional profile via diet.



Good nutrition optimizes ocular surface in premium cataract patients

A cost–benefit analysis that Nolan published in the 

 showed clearly that across a 5-year period, in the population of the Republic of Ireland, using these supplements as standard could save over 250 million Euros from the health budget. 


Prof. Nolan of the Nutrition Research Centre Ireland, School of Health Science, Waterford Institute of Technology, was recently awarded the Heidelberg Engineering Xtreme Research Award 2020 for his research on macular pigment for vision health and as a biomarker for brain nutrition and function. He has no financial interest in the subject of this article.

1. Akuffo KO, Beatty S, Peto T, et al. The impact of supplemental antioxidants on visual function in nonadvanced age-related macular degeneration: a head-to-head randomized clinical trial.

2. Nolan JM, Power R, Stringham J, et al. Enrichment of macular pigment enhances contrast sensitivity in subjects free of retinal disease: central retinal enrichment supplementation trials – report 1.

3. Bovier ER, Hammond BR. A randomized placebo-controlled study on the effects of lutein and zeaxanthin on visual processing speed in young healthy subjects. 

4. Green-Gomez M, Bernstein PS, Curcio CA, et al. Standardizing the assessment of macular pigment using a dual-wavelength autofluorescence technique.

5. Feeney J, O’Leary N, Moran R, et al. Plasma lutein and zeaxanthin are associated with better cognitive function across multiple domains in a large population-based sample of older adults: findings from the Irish longitudinal study on aging.

Articles

Higher levels of 3 macular pigments minimize risk of age-related disease. 

Dietary supplement can improve measurable visual outcomes

This article was reviewed by Netan Choudhry, MD, FRCSC



YAG laser vitreolysis is a less-invasive option than pars plana vitrectomy for patients who are affected by vitreous opacities (floaters), according to Netan Choudhry, MD, FRCSC, of Vitreous Retina Macula Specialists of Toronto. 

Although floaters are typically clinically inconsequential, a small subset of patients have debilitating symptoms that interfere with their vision and require treatment.



During the American Society of Retina Specialists virtual annual meeting, co-author Collier Jiang, MD, University of Calgary Department of Ophthalmology, presented outcomes from the VOYAGE study evaluating the impact the surgical procedure has on visual outcomes and on optical coherence tomography (OCT) imaging in patients with symptomatic vitreous floaters. 

As background, Jiang said few publications exist on the treatment since it is so new, and those that have been published have shown varying degrees of visual function improvement after the procedure.

“Up to this point, we really haven’t had an objective way of evaluating the opacity, what it looks like, where is it, what is it doing?” Choudhry said. “And then what is the end point for treatment?”



In the VOYAGE study, 35 patients (mean age 59; 43% female) with symptomatic floaters (n=40 eyes) were treated with YAG laser vitreolysis. 

All patients had a dilated eye examination to confirm the floaters as well as pre- and post-treatment ultra-widefield imaging. 





Best corrected visual acuity (BCVA) was measured and swept-source OCT was conducted prior to and after treatment. Jiang noted 5 patients received bilateral YAG laser vitreolysis due to symptomatic vitreous floaters in both eyes.

All treatments were performed by a single surgeon using the Ultra Q Reflex Laser (Ellex) after dilation and anesthesia, using a single mid-vitreous contact lens that was applied to the cornea using GenTeal ointment (Alcon).

“The energy level was initially set for 5 mJ and titrated up to a maximum of 20 mJ to achieve plasma formation with the creation of bubbles and opacity destruction,” Jiang said.

Patients were re-treated if they reported ongoing symptoms during follow-up; 37% of eyes required a second treatment and 35% required a third treatment to resolve symptoms.



Celebrating a pivotal moment in laser-vision correction history

Overall, patients experienced an improvement in mean BCVA after the first YAG treatment compared with baseline (0.14 ±0.20 logMAR units vs 0.11 ±0.20 logMAR units, respectively), however BCVA was not significantly different after the second and third treatments compared with baseline. 

Furthermore, just over half of the patients (55%) reported an improvement in their symptoms after their final YAG treatment, Jiang said.

“Overall, this study showed a significant improvement in mean BCVA after the first YAG laser vitreolysis treatment compared to baseline,” he said. “Ninety percent of patients reported resolution of their symptomatic visual disturbance after the final treatment session. There were no retinal detachments or retinal tears.”



Persistent retinal detachment connected to retinoblastoma


The VOYAGE study “used a variety of novel imaging techniques to quantify and follow changes in the vitreous opacities,” Jiang said, adding that scanning laser ophthalmoscopy and dynamic OCT visualization were particularly useful tools. 

For example, he said by increasing the gain by 55% to 75% from an unaltered swept-source OCT scan, clinicians are able to view the opacities that were previously unable to be imaged.

Furthermore, “dynamic OCT imaging can capture the movement of the patient’s vitreous in real time and help localize vitreous opacities during treatment,” he said.

The VOYAGE study used swept-source OCT, which provided the clinicians with a greater field of view.

“OCT can provide useful information,” Jiang said. “When the depth is increased to 6 mm, we can identify some vitreous opacities that may have been missed with the standard 3 mm depth.”



OCT: Illuminating the retina layer by layer

Carl Regillo, MD, FACS, Wills Eye Hospital, led the paper discussion, and noted that about two-thirds of patients needed re-treatments.

“Why aren’t we doing this across the board? Most vitreoretinal surgeons are not doing YAG vitreolysis. Is it time consuming? Is it challenging?” he asked.

“These procedures can take some time, probably 10 to 15 minutes,” Choudhry said. “The reason that it was broken up into, on average, 2 sessions, was because after a certain amount of power was administered to the eye, there was a risk of an increase in IOP. We wanted to limit all complications or [adverse] effects.”

Choudhry elaborated on the unique imaging used, noting that swept-source OCT was vital to “identify the opacities that the patients were complaining about and then titrate the treatment to the end point of the disappearance of those opacities, to know that we’ve hit an end point for the therapy.”



Real-world experience of OCT-A for retinal diagnoses and management

In terms of clinical practice implementation and patient selection, Choudhry noted that clinicians cannot forget that not every patient who has floaters needs treatment.

“I have been doing [YAG vitreolysis] for the past year-and-a-half successfully in the patients [who] really need it,” he said. “Of course, in the world of optics, the definitive result will always be with the complete clearing of the vitreous, but if we can avoid vitrectomy and the small risk of complication from vitrectomy in those patients [who] are good for this procedure, then why not?”

Choudhry did note, however, that vitrectomy is the first and only option for certain opacities of the amorphous variety or multiple diffuse floaters. 



Choudhry has no financial disclosures related to this content.

1. Ivanova T, Jalil A, Antoniou Y, et al. Vitrectomy for primary symptomatic vitreous opacities: an evidence-based review. 

Study evaluates the impact of surgical procedure on visual outcomes in patients.

Treating vitreous opacities with YAG laser vitreolysis


This article was reviewed by Nancy J. Newman, MD

The developer of a gene therapy for patients with Leber hereditary optic neuropathy (LHON) caused by a mutation in the 

 gene applied for European marketing authorization of the therapy in September 2020. 

According to the company, GenSight, LUMEVOQ (GS010; lenadogene nolparvovec) targets LHON by specifically targeting the 

 mitochondrial gene mutation, which is the most common cause of the disease.

Investigators evaluated LUMEVOQ in the RESCUE and REVERSE trials. The 2 studies found that in 76% of the patients in the RESCUE study and 71% of those in the REVERSE study, there was a “rate of clinically meaningful improvement from a nadir of at least 0.3 [logarithm of the minimum angle of resolution],” which translates to at least 3 lines of Snellen visual acuity, GenSight reported.



Gene therapy zeroes in on LHON treatment 

These findings are especially important considering the nature of LHON, a genetic disease that affects patients bilaterally. Spontaneous recovery of LHON is rare in those with a mutation in the ND4 gene. 

For patients who experience visual loss when they are age 15 years or older, the percentage who have some visual recovery is only 11.3%, according to a recent meta-analysis published in the 

The challenge for physicians has been to estimate the rate of visual recovery given the small numbers of affected patients, which usually ranges from about 800 to 1200 new cases annually in the United States and Europe.

The investigators, led by Nancy J. Newman, MD, pointed out that visual prognosis associated with LHON is generally poor, with most patients’ visual acuity worsening to at least 20/200. 

In addition, there are few treatments for LHON, and clinical trials are hampered because there is little information about the natural history of vision loss and recovery. In light of this information gap, researchers conducted a meta-analysis with the hope of expanding the body of information about LHON with this mutation.

Newman is from the departments of ophthalmology, neurology, and neurological surgery at the Emory School of Medicine in Atlanta, Georgia.



Research shows promising results for LHON gene therapy 


Investigators were able to identify 12 retrospective studies and 3 prospective studies that, in total, provided visual function information on 695 patients with LHON caused by the m.11778G>A mutation. 

Of these patients, the investigators found that “100 (14.4%) … were reported to have ‘recovered’ some vision, although definitions of ‘recovery’ varied among studies.”

When they considered the age at which the vision loss began and those who were at least 15 years of age, the investigators noted “meaningful visual recovery occurred in 23 of 204 (11.3%) patients. 

A younger age at onset, especially less than 12 years, portends a better visual prognosis and a different natural history of visual loss progression and recovery than in adults.”

Gene panel offers expanded diagnostic capability of inherited retinal diseases


The key findings of the meta-analysis, which provided an actual picture of the course of visual function in these patients, were as follows. 

The classic presentation of LHON in which patients with the m.11778G>A mutation have a severe loss of vision with rare or poor recovery from the nadir is true for most of the patients.

According to the team of investigators, among the patients aged 15 years and older, the percentage of patients who experience meaningful visual recovery “likely occurs in less than 20% of patients, irrespective of how recovery is defined, and ultimate visual acuities of better than 20/200 are rare.”



The investigators noted the importance of future prospective studies with enough genotypically homogeneous untreated patients with LHON.



Ocular gene therapy offers hope for inherited retinal disease

The studies that would yield the best information are those that the patients are stratified by age, enrolled immediately upon becoming symptomatic, and then followed regularly for a sufficiently long time during which they undergo consistent measures of visual function with standard definitions of visual improvement to clarify the natural order of the disease.

GenSight pointed out that the findings of the meta-analysis lend weight to the findings of the trials in which LUMEVOQ was evaluated. 



Newman is a consultant for GenSight, Santhera Pharmaceuticals, and Stealth BioTherapeutics, and reported receiving research support from GenSight and Santhera Pharmaceuticals.


1. Newman NJ, Carelli V, Taiel M, Yu-Wai-Man P. Visual outcomes in Leber hereditary optic neuropathy patients with the m.11778G>A (MTND4) mitochondrial DNA mutation. 

A new gene therapy for this patient population targets the ND4 gene mutation.

Leber hereditary optic neuropathy: Outlining disease’s natural course

Any time we perform ocular surgery—whether 

, oculoplastic, or any other ocular procedure—we want to set the patient up for success. 

Part of that is addressing any potential sources of infection, inflammation, and ocular surface disease that could complicate the postoperative course. It is common to see patients with meibomian gland dysfunction (MGD), dry eye disease (DED), and blepharitis.

For long-term efficacy, therapeutic choices are focused on the underlying cause or causes of the problem. 



Considering Demodex infestation and cataract surgery

 was 1 potential cause that we tended to overlook or ignore, because there was little we could do to address the specific problem of 

 mite infestation. 

Now we are beginning to understand the role of 

 in blepharitis and inflammatory DED, and the treatment outlook has markedly improved.


 is the presence of collarettes, or cylindrical dandruff, at the base of the eyelashes.

 

These waxy collarettes are the waste material of 

 mites living inside the hair follicles. When you regularly look for collarettes, you’ll likely be surprised at how common 

About 84% of people 60 years or older have 

 infestation, as do 100% of patients 70 years or older.

 overpopulation as well, particularly those with MGD and keratitis.

 

The higher incidence in older populations is not well understood. We hypothesize that the natural defenses and skin barrier function may be compromised with age, allowing 

 to gain the upper hand, but we do not know for certain.



Drop shows effectiveness for Demodex blepharitis in phase 2a stud

 can have a spectrum of manifestations, from asymptomatic infestation to significant blepharitis inflammation. 

Generally, significant 

 infestation results in significant inflammation. Patients have classic dry eye and blepharitis symptoms, including dry or gritty feeling, foreign body sensation and fluctuating vision. 

Because mites inside the lash follicles cause the condition, patients also can have follicular distention, hyperplasia, eyelash loss, and eyelid keratinization.

 blepharitis and bacterial blepharitis are also strongly correlated.


Despite its prevalence, there have been few treatments for 

 infestation, and there are no treatments approved for that specific indication. 

Although many patients with 

 infestation come to me having already been prescribed an immunomodulator such as cyclosporine (Cequa; Sun Pharma; Restasis; Allergan) or lifitegrast (Xiidra; Novartis), these medications treat the ocular surface sequelae of 

 infestation rather than the infestation itself. 



Making dry eye manageable for patients working from home


We could hypothesize that these medications might increase the ability to fight 

 by reducing inflammation and improving skin health, but we do not have evidence to support that idea.

Certain comorbidities, such as diabetes, place patients at higher risk for 

 blepharitis, so a primary care physician should help manage any systemic condition that has not been adequately controlled. 

To prepare a patient with 

 infestation for surgery, I usually use a combination of mechanical and chemical methods to remove collarettes, kill mites, and enhance skin barrier function in the patient.



For patients, home maintenance is important to help keep the 

 population under control. It is key to communicate this to patients.

In the office, we can perform microblepharoexfoliation using mechanical tools (AB Max; Myco Industries; BlephEx) or kits that combine tools and agents to treat Demodex (Cliradex; Bio-Tissue; ZEST; Zocular).



Where to start with treating OSD patients

and rosacea, intense pulsed light (IPL) therapy (Optima IPL; Lumenis) can be used to decrease the 

 burden in patients also afflicted with rosacea.

, ivermectin can be prescribed orally or topically (Soolantra; Galderma) to control the facial Demodex burden.


At home, good hygiene is essential to keep 

 under control after in-office treatment, but traditional shampoos are not very effective. 

Cleansing towelettes with 4-terpineol isolate (Cliradex; Bio-Tissue), the miticidal component of tea tree oil, have the highest antidemodectic activity of all the commercial cleansers.


Patients use the towelettes to clean the eyelids, lashes, and face. Hypochlorous acid cleanser (Avenova; NovaBay Pharmaceuticals), which I use for many dry eye patients, has minimal effect on 

but it can be used as a complementary therapy to 4-terpineol isolate.

Patients can also use a device at home that cleans the eyelid margins and stimulates the meibomian glands (NuLids; NuSight Medical), as well as gel cleaner for the eyelids and lashes (ZocuShield; Zocular).


 blepharitis are very new, and more treatments are in development. They are the consequence of our growing understanding of the disease and the pressing need to address it effectively. 

We have gone from strictly mechancal approaches to removing the mites, to chemical options, to the possibility of pharmaceutical options for the treatment of patients with this issue.



Amid pandemic, friendly bugs can help protect the eye from infection

 burden that is driving blepharitis and inflammation is growing rapidly, making it easier than ever to resolve the problem before elective surgery and keep patients on track long term. 




Periman is an ocular surface disease expert and director, dry eye services and clinical research, Periman Eye Institute, Seattle, Washington.

1. Gao YY, Di Pascuale MA, Li W, et al. High prevalence of Demodex in eyelashes with cylindrical dandruff. 

. 2005;46(9):3089-3094. doi:10.1167/iovs.05-0275

2. Liu J, Sheha H, Tseng SCG. Pathogenic role of Demodex mites in blepharitis. 

2010;10(5):505-510. doi:10.1097/ACI.0b013e32833df9f4

3. Liang L, Liu Y, Ding X, Ke H, Chen C, Tseng SCG. Significant correlation between meibomian gland dysfunction and keratitis in young patients with Demodex brevis infestation. 

. 2018;102(8):1098-1102. doi:10.1136/bjophthalmol-2017-310302

4. Fishman HA, Periman LM, Shah AA. Real-time video microscopy of In vitro Demodex death by intense pulsed light. 

2020;38(8):472-476. doi:10.1089/photob.2019.4737

5. Cheung IMY, Xue AL, Kim A, Ammundsen K, Wang MTM, Craig JP. In vitro anti–demodectic effects and terpinen-4-ol content of commercial eyelid cleansers. 

 2018;41(6):513-517. doi:10.1016/j.clae.2018.08.003

6. Kabat AG. In vitro demodicidal activity of commercial lid hygiene products. 

 2019;13:1493-1497. doi:10.2147/OPTH.S209067

New options open possibilities for treatment, resulting in better outcomes for patients.


Treating Demodex blepharitis efficiently before surgery

® reader, Sergio, recently sent me a report on a survey of almost 1300 physicians with the headline “Nearly half of doctors are ‘seriously’ rethinking their careers, finds COVID-19 survey.” 

The article begins with data from the CDC to the effect that 1 in 16 Americans (5.9%) infected to date with 

This rethinking is most common amongst primary care doctors, with 50% of internists and 55% of family physicians described as such.

“Just what the heck is ‘rethinking’” you ask? According to the surveyors, it can mean anything from tweaking your practice to throwing in the towel. The results show:

> 9% of doctors say they are going to retire.

> 6% will “quit medicine and start a new career.”

I find the survey results a tad confusing. The categories strike me as overlapping or poorly defined. 

For example, what is the difference between retiring and closing your practice for good? What is the difference between leaving patient care and quitting medicine and starting a new career? Are some of these people going to become hospital administrators or work in the pharmaceutical industry? 


Planning is important — even when “nobody knows nothing”

If so, they would not be retired, rather they would still be in medicine but no longer caring for patients. Will they be one of those characters who spend their days writing editorials in medical publications instead of doing something that contributes to society?

Whatever the details, the authors concludes that if all these doctors quit clinical practice, the loss of such a large chunk of the medical workforce (9% + 8% + 6% + 3% = 26%) would leave the rest of us doctors overwhelmed.

But with these surveys, as with the polls before Presidential elections these days, you never know.

On a positive note, 49% of responding physicians say they plan to make no significant changes and others plan to “change the practice setting.”

One hospitalist from Iowa, rather than bemoaning his job during the pandemic, said this in the survey: “It has actually galvanized me. I think I am privileged to provide inpatient medicine at just the moment in history when the need is so great.”

Certainly we have known from the earliest days of the pandemic—

when Dr. Li Wenliang died in Wuhan, China after first reporting the outbreak

—that ophthalmologists are at risk from the disease. Will that translate into a fear that leads many of us to quit medicine?

The word “ophthalmologist” doesn’t appear anywhere in the article and there is no breakdown by subspecialty, but I am not seeing or hearing of a mad rush for the exits by my ophthalmologist colleagues. 

® is going to perform a hopefully more valid survey of a large group of the smarter and best-looking ophthalmologists.

Are you, dear reader, planning to respond to 



Read more by editorials by Peter McDonnell

Pandemic forces some to reconsider careers.

Thinking and rethinking ophthalmology: Are you?

This article was reviewed by Edward Holland, MD

The first prescription ocular corticosteroid indicated specifically for short-term treatment of 

 disease (DED)—loteprednol etabonate ophthalmic suspension 0.25% (Eysuvis; Kala Pharmaceuticals)—has received FDA approval, which comes with expectations for providing rapid relief of signs and symptoms of DED.

Being the first drug approved in this class for the short-term treatment of DED also implies that it differs from the plethora of DED treatments available. 



Boosting short-term dry eye management in patients



Although cyclosporine ophthalmic emulsion 0.05% (Restasis; Allergan) and lifitegrast ophthalmic solution 5% (Xiidra; Novartis) are good chronic anti-inflammatory medications, the difference is that reaching peak benefit often takes weeks to months.

“With Eysuvis, patients will get immediate relief from the signs and symptoms of 

because of the rapid action of corticosteroids against inflammation,” said Edward Holland, MD, director of Cornea Services at Cincinnati Eye Institute and a professor of ophthalmology at the Univeristy of Cincinnati. “The clinical trials of the drug showed that symptomatic improvement began within 1 or 2 days of instillation of the drop. Having an approved corticosteroid is going to change how we manage dry eye.”

Recently, a realization that has emerged from the study of DED is that most of the patient population experiences flares, on average, 4 to 6 times a year, according to Holland. Moreover, the majority of the 17 million patients with DED say they experience flares vs continuous symptoms. 

For patients who treat flares when they occur, a short-term treatment is probably enough. There are patients who have more severe symptoms and are on chronic medications who will have flares as well and need additional treatment.



As cyclosporine options grow, focus remains on the vehicle



Currently available formulations do not provide relief from these painful episodes. Some patients can be totally asymptomatic in between flares and do not require maintenance therapy, but want to address the flares as they occur. 

Other patients need maintenance therapy, but can experience breakthrough episodes of DED flares despite ongoing treatment.

“Previously, we did not have a therapy that could target the episodes of flares,” Holland said.

AMPPLIFY mucus-penetrating particle (MPP) drug delivery technology developed by Kala Pharmaceuticals seems key to the rapid onset of symptomatic relief experienced by patients. MPP enhances penetration of loteprednol etabonate through the ocular mucous layer, improving drug delivery to ocular surface tissues to target the immune responses that drive acute DED flares.

“Loteprednol etabonate is a very good corticosteroid with good safety profile and high potency,” Holland said. “I think it is going to be very effective and perhaps a first-line prescription therapy for all 


FDA approval was based on the results of 4 clinical trials—1 phase 2 and 3 phase 3 trials—that reported significant improvements in the signs and symptoms of dry eye.

In STRIDE 3 (NCT03616899), the last phase 3 multicenter, randomly selected, double-masked, placebo-controlled, parallel-arm trial, the effects of Eysuvis were compared in 901 patients with DED (447 who received active drug and 454 control patients) who instilled drops 4 times daily for 2 weeks. 

Conjunctival hyperemia improved significantly after 2 weeks of dosing in the phase 3 trials, and in 2 of the 3 phase 3 trials ocular discomfort also improved significantly.

The treatment is approved for a course of up to 2 weeks. Because 

 is characterized by inflammation, the hope is that the inflammation will be knocked down, and the tendency to progress—creating the potential need for chronic therapy—dampened, Holland said.



Myths and misconceptions about autologous serum for dry eye

In all trials, the most common adverse effect was pain associated with drop instillation.

Holland is anticipating a “new era in the treatment of dry eye disease” and says that Eysuvis offers promise to the millions of patients with disease flares.

“For the first time, we will be able to offer 

 patients a therapeutic option that provides rapid relief for both the signs and symptoms of the disease and that is safe and well tolerated,” he said.

Kala Pharmaceuticals plans to launch Eysuvis in the United States by the end of 2020.


Ophthalmology Times: December 2020

Dietary supplement can improve measurable visual outcomes

Treating vitreous opacities with YAG laser vitreolysis

Leber hereditary optic neuropathy: Outlining disease’s natural course

Treating Demodex blepharitis efficiently before surgery

Thinking and rethinking ophthalmology: Are you?

Short-term dry eye treatment option receives FDA approval

Wiping away mask fog