Allergic conjunctivitis is reported to affect about 40% of the population,

 are associated with a significant economic burden as well as quality-of-life concerns. 

The global allergic conjunctivitis market was valued at $2.50 billion in 2019 and is predicted to reach $3.05 billion by the end of 2027 on the strength of a 5.4% growth rate.

The combination of the condition’s high prevalence, new treatment options, and large investments in clinical trials is driving market growth, according to analysts.


The eyes offer conjunctival clue to COVID-19

They note that with changing weather and worsening air pollution in some areas, the potential patient population will continue to expand.

One trend that has been changing the allergy landscape is the FDA’s Rx-to-over the counter (OTC) switch process. In 2006, Alcon’s ketotifen product Zaditor became the first allergy drop to switch from prescription to OTC status. 

All 3 of that manufacturer’s olopatadine formulations are also available without a prescription: Pataday Once Daily Relief Extra Strength (olopatadine 0.7%, formerly prescribed as Pazeo); Pataday Once Daily Relief (olopatadine 0.2%); and Pataday Twice Daily Relief (olopatadine 0.1%).

“Approval of a wider range of nonprescription drugs has the potential to improve public health by increasing the types of drugs consumers can access and use that would otherwise only be available by prescription,” the FDA said in a statement

Novel research is under way, and at the same time, manufacturers are seeking to reformulate available drugs. 

Researchers eye cure, diagnostics for adenoviral conjunctivitis



Because the eye’s anatomy presents physiological limitations on drug bioavailability, there is much interest in new drug delivery technology. Here is a review of current drug categories and a selection of agents in the pipeline.

Antihistamines target a key factor in allergic conjunctivitis and have therefore been widely available on the market. 

Systemic antihistamines historically used for ocular allergy control have different affinities to various antihistamine receptors. H1 are largely responsible for pruritus, whereas H2 leads to vasodilation.

Efficacious antihistaminic treatments continue to be developed; the comfort of topical drops is a key concern. Some patients require the concomitant use of lubricating eye drops and oral antihistamines to maximize control of ocular allergy symptoms.


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 Approved for the treatment of allergic rhinitis and urticaria in 2011, bilastine is undergoing allergic conjunctivitis clinical trials as a drop (NCT03479307). 

The ophthalmic solution 0.6% is being compared with ketotifen ophthalmic solution 0.025% for the treatment of the signs and symptoms of allergic conjunctivitis. 

As a second-generation, selective H1-antihistamine, bilastine avoids the sedative effects of first-generation agents.


New molecule for allergic conjunctivitis makes debut

 (Zerviate, Eyevance Pharmaceuticals) was recently approved in the United States for topical ophthalmic use. Cetirizine has been used for many years as the oral OTC drug Zyrtec. 

Clinical trials of the prescription drop showed significantly decreased ocular itch with a rapid onset of action lasting for 8 hours in moderate and severe patients.

Mast cell stabilizers include drugs like cromolyn or nedocromil; however, they are rarely used as monotherapy.

 

This class prevents degranulation of mast cells, the release of preformed inﬂammatory mediators, and the synthesis of additional inﬂammatory mediators. 

These agents block both early and late phases of the ocular surface’s allergic response, reducing hyperemia, itching, and irritation, with differing efﬁcacy among the various agents. 


Where to start with treating OSD patients


Mast cell stabilizers are most effective when administered prophylactically, requiring a several week loading period for optimal beneﬁt which decreases patient compliance. 

They are generally safe and have minimal ocular adverse effects, although they can cause transient burning or stinging on application.


Combination mast cell inhibitor, antihistamine agents work via inhibition of mast cell degranulation and competitive binding of the H1 receptor to block histamine binding. 

Other cytokines that amplify the inflammatory cascade are also released by mast cells. 



Ocular surface inflammation: Vicious cycle of ocular surface disruption


Dual-acting agents usually work quickly, typically within 30 minutes of instillation, have better compliance compared with mast cell-stabilizing agents, and generally provide relief of the itching associated with ocular allergy.

 

Combination products are the most commonly prescribed drugs as first-line treatment; side effects are generally mild.

—originally a prescription drop and now OTC—was the first dual-acting eye drop to be FDA approved, and thus considered the “gold standard.” Now it has been joined by prescription agents azelastine, bepotastine (Bepreve, Bausch + Lomb), epinastine, and

alcaftadine (Lastacaft, Allergan). Alcaftadine differs from olopatadine and bepotastine as it possesses an affinity 10 times greater to both H1 and H2 receptors.

 (ketotifen, Alcon) was the first dual-acting drop to be switched from prescription to OTC status. 

Bausch + Lomb recently received approval for its non-preserved ketotifen formulation, Alaway (OTC), representing the first dual-acting agent approved in the United States as a non-preserved formulation.



Study: Innovative dexamethasone formulation shows efficacy, safety

 Pall and colleagues recently reported on a study of 244 patients evaluating the efficacy and safety of a Johnson & Johnson Vision product consisting of the OTC antihistamine/mast cell inhibitor ketotifen delivered via a contact lens for ocular allergy.

 

Results using the Ora-CAC® Conjunctival Allergen Challenge Model were comparable to direct topical drug delivery and suggest that the lens / ketotifen combination can provide a means of simultaneous vision correction and treatment for lens wearers with ocular allergies, the investigators wrote.

Contact lenses containing epinastine and olopatadine are being studied as well.


Topical nonsteroidal anti-inﬂammatory drugs (NSAIDs) improve ocular itching and reduce mucus secretion, cellular inﬁltration, erythema, and chemosis. They work by inhibiting the cyclooxygenase pathway, and thus blocking prostaglandin production.

Antibiotic-steroid combination boosts confidence with delivery


Ketorolac was the ﬁrst to be approved for quieting the ocular itch associated with allergy; however, it may be associated with discomfort on instillation and is indicated for use for no longer than 2 weeks. 

NSAIDs have been associated with cases of corneal melt and are not typically used in clinical practice for allergic conjunctivitis as other drugs remain better options.

 Drugs which inhibit phosphodiesterase IV are being investigated for their effects on suppressing activation of the inflammatory cascade. Three PDE4 inhibitor drugs currently approved for the treatment of skin or lung diseases are apremilast, crisaborole, and roflumilast.

Reproxalap is a novel small-molecule immune-modulating covalent inhibitor of reactive aldehyde species (RASP), which are elevated in ocular and systemic inflammatory disease.

Aldeyra Therapeutics is studying 0.25% reproxalap ophthalmic solution in phase III clinical

trials for the treatment of dry eye disease and allergic conjunctivitis (ClinicalTrials.gov identifier: NCT03404115). The company reported statistically significant and clinically relevant improvements in subject-reported ocular itching and tearing and investigator-assessed ocular redness.


Topical corticosteroids provide the most robust relief from allergic conjunctivitis, effectively relieving a broad range of signs and symptoms.



Patients who report excessive and persistent signs and symptoms that severely interfere with quality of life can be treated in “bursts.” 

Ophthalmic steroids should be used judiciously along with steroid-sparing dual-activity agents, and patients must be monitored for well-known steroid-related side-effects such as elevated IOP and cataract development.



FDA approves topical corticosteroid for treatment of dry eye disease


Newer, safer and C-20 ester-based corticosteroids appear to have an improved IOP side effect profile.1 Loteprednol 0.02% (Alrex; Bausch + Lomb) is indicated for the treatment of seasonal allergic conjunctivitis with only 1% of patients demonstrating an IOP rise of at least 10 mm Hg.

Drug delivered via intracanalicular insert.

 Ocular Therapeutix has reported topline results from its phase 3 clinical trial to evaluate the safety and efficacy of Dextenza intracanalicular insert (dexamethasone 0.4 mg) for the treatment of ocular itching associated with allergic conjunctivitis.

 

The potential “hands-free” therapy would be administered in the office setting. The bioresorbable insert is designed to release corticosteroid to the ocular surface for up to 30 days. 

Dextenza met all pre-specified primary endpoints as demonstrated by a statistically significant mean change in ocular itching from baseline, on a subject-reported 5-point scale, at three time points on day 8, the company stated.


Topical immunomodulators are currently used in severe allergic ocular conditions, such as vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC). The two most well studied and commonly used are cyclosporine A and tacrolimus, available only as compounded agents

 

They work by inhibiting T-cell activation. Other immunomodulatory agents are being investigated; however, use is limited by their low water solubility and lipophilic nature.


Corticosteroids and Immunomodulators for the treatment of dry eye


Immunobiological modulation, to date, has centered on managing asthma and atopic dermatitis. Omalizumab (Xolair; Genentech), not approved for ocular allergy, may show promise for treatment resistant VKC and AKC.

 An IL-4 and IL-13 pathway inhibitor, dupilumab (Dupixent; Regeneron), is being looked at for the treatment of signs and symptoms of AKC in a multicenter, double-masked, randomized, placebo-controlled, parallel-group, efficacy, safety, and tolerability study (NCT04296864).


The ideal allergic conjunctivitis topical agent is a comfortable drop that has a rapid onset of action, is effective, and long lasting. It is also important that there is not a rebound effect like that seen with long-term use of vasoconstrictors. 

Cost considerations will always come into play, although this issue may be shifting as more and more agents move from prescription to over the counter. 

While there are many competing first-line, dual-acting agents in this category, the reality is that most eye care specialists stick to 2 or 3 agents in clinical practice that they feel work the best in their hands.

Within the dual-acting agent class, I do not believe that there is a significant benefit to using a prescription product versus an OTC agent, when the former’s superiority has not been proven in the clinic. 

I do not think eye care specialists can easily justify using a prescription agent if it costs more than an OTC option. If patients fail to get relief with an OTC combination drop, then I consider alternatives.

Confocal microscopy: Seeing what does not meet the eye

For patients with recalcitrant ocular allergy or other 

 that is thought to be in part related to preservatives, I favor a preservative-free compounded version of 0.01% dexamethasone that I have been using for more than 10 years. My colleagues and I have reported its safety and efficacy.



Steroids, in my opinion, are really underutilized in chronic ocular surface disease. The proper use of these agents, particularly low dose and unpreserved, can make a huge difference for our patients.


Although undertreated ocular allergy does not usually pose serious consequences for the patient, it does lead to poorer quality of life and decreased satisfaction with outcomes. 

More treatment options have become available for the acute management of ocular allergic symptoms with many agents moving from prescription to OTC and a number more being looked at in clinical trials. 

Although most patients with allergic conjunctivitis will find reasonable relief using currently available topical agents; a segment of this population remains unsatisfied.



Therefore, there is a need for the development of safer, more effective anti-inflammatories. 

Udell is the emeritus chairman of ophthalmology at Long Island Jewish Medical Center and North Shore University Hospital, and professor of ophthalmology at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. The author wishes to acknowledge Conni Bergmann Koury for providing editorial assistance.

1. Kimchi N, Bielory L. The allergic eye: recommendations about pharmacotherapy and recent therapeutic agents. 

2020, 20:414–420. DOI:10.1097/ACI.0000000000000669

2. Kimchi N; Bielory , et al. ICON: Diagnosis and management of allergic conjunctivitis.

2020;124(2):118-134. doi: 10.1016/j.anai.2019.11.014

3. Allergic Conjunctivitis Market to Exhibit 5.4% CAGR and Reach $3.05 Billion by 2027; Massive Investments in Clinical Trials to Boost Growth. https://tinyurl.com/y3cqryul.

4. Abelson MB, Udell IJ. H2-receptors in the human ocular surface. 

. 1981;99(2):302-304. doi: 10.1001/archopht.1981.03930010304018.

5. Meier EJ, Torkildsen GL, Gomes PJ, Jasek MC. Phase III trials examining the efficacy of cetirizine ophthalmic solution 0.24% compared to vehicle for the treatment of allergic conjunctivitis in the conjunctival allergen challenge model. 

6. Pall B, Gomes P; Yi F, Torkildsen G. Management of ocular allergy itch with an antihistamine-releasing contact lens. 

. 2019;38(6):713-717. doi: 10.1097/ICO.0000000000001911

7. Guidera AC, Luchs JI, Udell IJ. Keratitis, ulceration, and perforation associated with topical nonsteroidal anti-inflammatory drugs. Case Reports. 

. 2001;108(5):936-44. doi: 10.1016/s0161-6420(00)00538-8

8. Maguire JI, Rapuano CJ, Udell IJ. Clinical Update. Cornea. Topical NSAIDs: Best practices for safe use. Eyenet. July 2013. https://www.aao.org/eyenet/article/topical-nsaids-best-practices-safe-use

9. Phillips JE. Inhaled phosphodiesterase 4 (PDE4) inhibitors for inflammatory respiratory diseases. 

 2020;11:259. doi: 10.3389/fphar.2020.00259

10. Aldeyra to present new reproxalap data from Phase 2 clinical trial in allergic conjunctivitis at American Academy of Ophthalmology 2020 Annual Meeting. https://tinyurl.com/y2z2mle9

11. Ocular Therapeutix announces topline results of Phase 3 clinical trial of Dextenza for the treatment of ocular itching associated with allergic conjunctivitis. https://tinyurl.com/y5y9c9c8

12. Vichyanond P, Kosrirukvongs P. Use of cyclosporine and tacrolimus in treatment of vernal keratoconjunctivitis. 

13. Wiliams PB, Sheppard JD. Omalizumab: A future innovation for treatment of severe ocular allergy? 

 2006;5(12):1603-1609. DOI: 10.1517/14712598.5.12.1603

14. Jonisch J, Steiner A, Udell IJ. Preservative-free low-dose dexamethasone for the treatment of chronic ocular surface disease refractory to standard therapy. 

. 2010;29(7):723-726. doi: 10.1097/ICO.0b013e3181b765a6

15. Schoemmel E, Raval Y, Gomes PJ. Ocular allergy and quality of life: patient survey 2019. Presented at: ARVO 2020; May 3-7; Virtual

16. Charters L. Examining ocular allergy, quality of life. Sept. 28, 2020. https://www.ophthalmologytimes.com/view/examining-ocular-allergy-quality-of-life

Articles

Growing patient pool is driving clinical trial investment.

The sky is the limit for allergy pipeline

This article was reviewed by William F. Mieler, MD

Of the thousands of available medications, relatively few are known to cause retinal complications at therapeutic dosages, according to William F. Mieler, MD.

Patterns of toxicity include disruption of the retinal pigment epithelium, vascular occlusion, macular and retinal edema, crystalline deposition, and inflammation, said Mieler during a presentation at the American Academy of Ophthalmology (AAO) virtual 2020 annual meeting. Mieler is the Cless Family Professor in Ophthalmology at the University of Illinois College of Medicine in Chicago.

Mieler discussed risk factors for and recognition of retinal toxicity associated with hydroxychloroquine, chloroquine, and pentosan polysulfate sodium (PPS).

“The key factor to not missing any medication-related abnormality is to have a thorough history of the medications that the patient is currently using or has used in the past,” he said. “Then it is imperative to know and to recognize the usual patterns of toxicity that have been described for systemic and topical medications but also to remain alert for new associations involving medications and possible retinal toxicity. Multimodal imaging is very helpful in checking for and documenting possible toxicity as well as in monitoring progression.”


Hydroxychloroquine, and less commonly chloroquine, is widely used by rheumatologists and dermatologists to treat a variety of autoimmune inflammatory diseases. 

Other than the potential for causing maculopathy and retinopathy, hydroxychloroquine has relatively few systemic adverse effects, Mieler said.

The retinal toxicity associated with these drugs that is seen most often on fundus examination is represented by pigment mottling and/or atrophy, rather than a complete bull’s eye maculopathy. 

In non-Asian patients, initial damage typically shows a parafoveal distribution, whereas Asian patients more often exhibit a pericentral pattern of damage.

Research is unfolding the proteins in retinitis pigmentosa

As demonstrated in a case example presented by Mieler, worsening can occur after the patient has stopped the medication.

“It is important to recognize that hydroxychloroquine and chloroquine bind to melanin and are stored in the eye where they can remain indefinitely,” he said. “Toxicity can progress months and years after cessation of the medication.”

Mieler pointed out that the drugs are cleared by both the liver and kidneys so that patients with renal and/or hepatic impairment are at risk for increased blood levels and retinal toxicity.

“Pre-existing maculopathy and concurrent tamoxifen usage may also increase the risk for retinal toxicity with chloroquine and hydroxychloroquine,” he noted.

Adherence to medication dosing recommendations and monitoring with baseline and follow-up multimodal imaging are key elements for preventing irreversible vision loss from the drug-induced retinal toxicity. 

A rift in the retina may help repair the optic nerve

As noted in the most recent AAO-supported recommendations on screening for chloroquine and hydroxychloroquine retinopathy,

 the risk of toxicity is less than 2% at 5 years among patients treated with hydroxychloroquine 5 mg/kg or less, but it increases to greater than 20% at 20 years. 

Therefore, it is recommended that the daily dosage of hydroxychloroquine be kept to less than 5.0 mg/kg real weight (< 2.3 mg/kg chloroquine). In addition, the daily dose should not exceed 400 mg and ideally should be just 200 mg.

“Most reports of toxicity have occurred in patients on medication for greater than 7 years or having received a total dose of at least 460 g,” Mieler said. “High dosages hasten the accumulation of drug and may enhance the degree of tissue damage. At a daily dose of 400 mg/day, the 460 g cumulative dose would be reached prior to 5 years, which explains the current recommendation to begin annual screening after 5 years.”


Monitoring for retinopathy/maculopathy in patients being treated with hydroxychloroquine/chloroquine aims to detect abnormalities prior to the development of irreversible damage and visual loss. 

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It therefore begins with a complete baseline ophthalmologic examination, including imaging with fundus photography, spectral-domain OCT (SD-OCT), and an automated Humphrey threshold visual field with white 10-2 pattern.

Annual screenings for drug-related toxicity beginning after 5 years should include automated perimetry (generally a Humphrey 10-2 visual field) and SD OCT as the primary tools. 

A combination of results of multiple tests provides the best monitoring because a single screening test, such as SD OCT, may be normal even when a parafoveal ring abnormality might be seen on the visual field, Mieler noted.

“Even subtle changes in the visual field need to be taken seriously. If any abnormalities are seen, SD OCT, fundus autofluorescence, or multifocal electroretinogram should be performed as these tests may be more sensitive than the visual field,” he said.

Mieler added that microperimetry also may be considered, although its role for detecting chloroquine/hydroxychloroquine retinopathy is not fully known. In addition, the test is not uniformly available in all retina specialists’ offices. The utility of OCT angiography is currently being evaluated.

PPS is indicated to treat symptoms of interstitial cystitis, and it is also utilized in the prevention and/or treatment of thrombi and as a disease-modifying drug for osteoarthritis. It was approved for marketing in the United States in 1996.

A preliminary report providing evidence of ocular toxicity associated with its use was published in 2018.

 

A more recent paper provided corroborating evidence and reported a prevalence of 20% in a cohort of 50 patients who had been previously treated with or were currently receiving PPS.3

“Available evidence shows treatment with this drug can cause profound central macular pigmentary change, although the long-term impact is still being investigated,” Mieler said.

Investigators research ocular health after space flight

PPS binds to epithelial cells, including the retinal pigment epithelial cells in the eye. Risk of maculopathy with PPS is related to duration of therapy, daily dose, and total cumulative dose. It generally takes more than 10 years of exposure to the drug to see ocular abnormalities.


Affected patients typically present with central vision impairment and are found on examination to have macular pigment mottling and excrescences on Bruch’s membrane. Anatomic appearance on OCT is generally normal or minimally affected.


e:wmieler@uic.edu
Mieler has no relevant financial interests to report.

1. Marmor MF, Kellner U, Lai TYY, Melles RB, Mieler WF; American Academy of Ophthalmology. Recommendations on screening for chloroquine and hydroxychloroquine retinopathy (2016 revision). 

. 2016;123(6):1386-1394. doi:10.1016/j.ophtha.2016.01.058

2. Pearce WA, Chen R, Jain N. Pigmentary maculopathy associated with chronic exposure to pentosan polysulfate sodium. 

. 2018;125(11):1793-1802. doi:10.1016/j.ophtha.2018.04.026

3. Wang D, Au A, Gunnemann F, et al. Pentosan-associated maculopathy: prevalence, screening guidelines, and spectrum of findings based on prospective multimodal analysis. 

. 2020;55(2):116-125. doi:10.1016/j.jcjo.2019.12.001

Key is to recognize usual patterns for systemic and topical medications.

Risk awareness helps identify medication-induced retinal toxicity


This article was reviewed by Rachel Curtis, MD



A smartphone direct ophthalmoscope attachment (D-EYE) has proved easy to use and successful in visualizing the optic disc compared with the direct ophthalmoscope (DO), according to research presented at the virtual annual meeting of the Canadian Ophthalmological Society.

Data from the prospective, randomly assigned, crossover, educational trial involved 44 first-year medical students not familiar with this type of examination, who looked at measurements such as vertical cup-to-disc ratio, fundus matching using an online program, and identifying whether the state of health of the optic nerve was normal or abnormal, according to Rachel Curtis, MD, a fourth-year ophthalmology resident at Queen’s University in Kingston, Ontario, Canada, and the study’s presenting author.


The value of new diagnostics and personalized medicine

“There is a big push for new technologies and new ways of delivering medical teaching,” Curtis told 

® during an interview. “The whole concept is finding new technologies to teach medical students [how to examine the optic nerve] and ways to integrate these technologies into practice.”

The smartphone direct ophthalmoscope attachment lets physicians record the picture or video and show the anatomy, Curtis said.

“It can improve continuity of care by documenting serial exams,” she explained. “It also helps students identify what they are seeing on examination. Your student or ophthalmology resident can show it to your preceptor. Another advantage is that the images or a video can be uploaded into an electronic medical record.”

Curtis noted that a competent fundus examination is often part of routine clinical evaluation in family practice, the emergency department, and inpatient wards, and is a duty of care in many clinical situations. She added that there has been a decrease in confidence and use of ophthalmoscopy among medical students and physicians.

“It is a difficult skill to use a direct ophthalmoscope, and it is generally not well taught in medical schools,” said Curtis. “This [D-EYE] is a fairly intuitive technology.”

In this study, a fundus photo matching program was utilized to compare the performance of the D-EYE with that of the DO. Students were randomized to initiate the examination with the D-EYE or the DO. 

The 2 cohorts studied over 2 consecutive years—one had 26 students and the other had 18—were similar in terms of mean age and gender distribution. 

Students were given 10 minutes to examine both eyes of 1 patient, with 1 eye dilated and 1 not dilated. They examined multiple patients during the study.

Developing retinal technologies strengthen visualization

After the examination, students were asked to match the patient’s optic nerve to the fundus photograph that was found in a 9-photo collage that had been randomly generated. 

They could make multiple attempts and would receive a message under the image telling them whether their choice was correct or incorrect. If it was incorrect, they would receive a message telling them to try again.

Students were asked to complete a form to indicate their perception of “ease of use” of the device and their confidence in using the device. 

They were also asked to document the vertical cup-to-disc ratio of each eye and to report whether the disc’s state of health overall was normal or abnormal.

Curtis and colleagues found students using the DO needed more attempts (3.57 vs 2.69, 

 = .010) to match the patient’s fundus to the correct photograph and needed more time (197.00 vs 168.02 seconds, 

 = .043, t test) to correctly choose the proper fundus photograph, when compared to the D-EYE device. 

Glaucoma mystery: Focus on deep optic nerve structures

These results were discussed at the Canadian Ophthalmological Society annual meeting as part of a paper abstract presentation, which won a third-prize award.

“The difference was both statistically significant and clinically relevant,” said Curtis. “It took 30 seconds more to identify the correct nerve with the DO. Thirty seconds does not seem like a lot, but in a busy ward or clinic, it does make a difference in efficiency. We found that there was not only less time to match the optic nerve, but it took them less matching [fewer attempts] and there was less guessing involved.”

The investigators observed no statistically significant difference in the accuracy of estimating vertical cup-to-disc ratio in either the right or the left eye, which was the primary outcome of the study, using D-EYE vs DO.

Medical students reported greater ease of use with the D-EYE (6.40 vs 4.79, 

 < .001) as well as overall confidence in the examination (5.65 vs 4.49, 

The technology facilitates examining the optic nerve and being able to distinguish whether its state of health is grossly normal or grossly abnormal, Curtis emphasized.

“That is arguably the most clinically relevant outcome,” she said. “If you are going to send off [the patient] for referral or make an appropriate consult, the thing you need to be able to do is to recognize whether or not this nerve needs to be looked at by an ophthalmologist.”

, the use of the smartphone and direct ophthalmoscope attachment lets clinicians be more physically distant from a patient when performing the examination and adhere to infection-minded prevention.

“With the direct ophthalmoscope, you have to be very close to the patient to get a good view,” Curtis concluded. “In an infection-minded environment, you may want a larger buffer between you and the patient. This [smartphone and direct ophthalmoscope attachment] is a good arm’s-length distance between you and the patient’s eye.” 

Curtis has no financial disclosures related to this content.

Mackay DD, Garza PS, Bruce BB, Newman NJ, Biousse V. The demise of direct ophthalmoscopy: a modern clinical challenge. 

 2015;5(2):150-157. doi:10.1212/CPJ.0000000000000115

Gupta RR, Lam WC. Medical students’ self-confidence in performing direct ophthalmoscopy in clinical training. Can 

Ophthalmology Times: February 15, 2021

The sky is the limit for allergy pipeline

Risk awareness helps identify medication-induced retinal toxicity

Smartphone tech helps visualize optic disc