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Raman Bhakhri, OD, FAAO, breaks down the complex process of diagnosing inherited retinal diseases.

AAOpt 2024: Utilizing technology to diagnose inherited retinal diseases

Raman Bhakrhi, OD, FAAO, said that optometrists' collaboration with primary care physicians and other medical professionals can help minimize the chance for retinal damage caused by medications.

AOA 2024: Catching toxicity in the retina before it is too late

Patient Case 1: Delaying Cataract Surgery to Prioritize Aggressive Treatment of Ocular Surface Disease, Including Demodex Blepharitis

A panelist discusses how prioritizing aggressive treatment of ocular surface disease, particularly Demodex blepharitis, before proceeding with cataract surgery can lead to better surgical outcomes and patient satisfaction.

Video Series

Preoperative Ocular Surface Disease Algorithm Overview

A panelist discusses how evaluating and treating ocular surface disease before cataract or refractive surgery through a systematic algorithm improves surgical outcomes and patient satisfaction.

This poll is for optometrists and eyecare professionals, only. It will close on Friday, November 5, 2021.

Poll: What pipeline presbyopia treatment are you most looking forward to?

-In the midst of its contentious merger offer from Novartis, Alcon Inc. announced it will acquire the rights to three products from Tampa, FL-based Sirion Therapeutics Inc. 

On Jan. 18, Alcon said it would acquire the U.S. rights to two FDA-approved products-difluprednate ophthalmic emulsion (Durezol) 0.05%, an ophthalmic corticosteroid in drop form for the treatment of inflammation and pain associated with eye surgery, and ganciclovir ophthalmic gel 0.15% (Zirgan), which the FDA approved on Sept. 17 for treating acute herpetic keratitis. In April 2007, the FDA had granted the gel orphan drug status. 

The acquisition also gives Alcon nearly global rights, excluding Latin America, to cyclosporine (Zyclorin), an investigational drug being developed to treat dry eye and other ocular surface diseases. The deal is expected to close by the end of Q1 2010, and hinges on customary closing conditions and required regulatory approvals. 

"While the potential Novartis deal is certainly an issue for us, our leadership is focused more on continuing to build Alcon's commercial capabilities and research pipeline," MacHatton said. "The Sirion deal is a good example of that, as it brings a currently marketed product in Durezol, the recently approved orphan drug Zirgan that will be launched soon, and a potential dry-eye treatment for our pipeline." 

MacHatton declined to say the cost of the acquisitions. 

Sirion spokeswoman Erin Parsons said the deal is "totally separate" from Alcon's discussions with Novartis. "We are certain this will not affect the completion of the deal between Alcon and Sirion," she said. 

In the midst of the contentious merger offer from Novartis, Alcon Inc. announced it will acquire the rights to three products from Tampa, FL.-based Sirion Therapeutics Inc.

Alcon acquires rights to three Sirion products

A large international study conducted by the LHON Study Group reported that a unilaterally administered gene therapy to treat Leber hereditary optic neuropathy (LHON) caused by the 

gene variant resulted in bilateral improvement in visual acuity with improved quality of life and good overall tolerability up to 5 years after treatment.

The first study author, Patrick Yu-Wai-Man, MD, PhD, and colleagues commented, “These results demonstrated the persistent benefit over time from 1 dose of lenadogene nolparvovec (rAAV2/2-ND4, Lumevoq, GenSight Biologics SA), which is promising for the use of gene therapy in LHON due to the 

gene variant,” the most common cause of LHON.

Yu-Wai-Man is from the Cambridge Centre for Brain Repair and MRC Mitochondrial Biology Unit, Department of Clinical Neurosciences, University of Cambridge, and the Cambridge Eye Unit, Addenbrooke’s Hospital, Cambridge University Hospitals, both in Cambridge, United Kingdom; and Moorfields Eye Hospital, and the Institute of Ophthalmology, University College London, both London.

LHON, a genetic disease that affects the retinal ganglion cells,

results in severe bilateral sequential vision loss.

The investigators explained, “Lenadogene nolparvovec, an adeno-associated virus (AAV)–based ocular gene therapy, was developed to treat patients carrying the m.11778G>A mitochondrial DNA gene variant. Its efficacy and safety have been evaluated in four clinical studies that showed an improvement in best-corrected visual acuity (BCVA) up to 2 years after administration and a good safety profile.

The multinational, multicenter, prospective RESTORE Study is the 5-year follow-up study of the phase 3 clinical RESCUE and REVERSE Studies of lenadogene nolparvovec to treat vision loss from LHON due to the 

 mutation. The RESCUE Study evaluated the treatment up to 6 months after the onset of LHON

 and the REVERSE Study did the same from 7 months to 1 year.

In the RESCUE and REVERSE Studies, the patients were treated with a intravitreous injection in 1 eye and a sham injection in the other eye. The main outcome measures were the best-corrected visual acuity (BCVA), quality of life using the National Eye Institute visual functioning questionnaire 25, and adverse events.

The RESTORE Study included 62 of 76 patients who were included in the RESCUE ad REVERSE Studies; 55 patients completed the 5-year examination. The investigators reported that the patients “sustained bilateral improvement in visual acuity with improved quality of life and good overall tolerability up to 5 years after unilateral lenadogene nolparvovec intravitreal administration in patients with LHON due to the 

The investigators concluded, “In this analysis of the RESTORE trial, the follow-up of patients with LHON due to the 

 gene variant unilaterally treated with lenadogene nolparvovec demonstrated a sustained bilateral improvement in BCVA and a good safety profile up to 5 years after treatment. This evidence of persistent benefit over time is promising for the use of gene therapy in these patients.”

Yu-Wai-Man P, Newman NJ, Biousse V, et al. Five-year outcomes of lenadogene nolparvovec gene therapy in LHON. 

Published online December 19, 2024. doi:10.1001/jamaophthalmol.2024.5375

Yu-Wai-Man P, Griffiths PG, Chinnery PF. Mitochondrial optic neuropathies—disease mechanisms and therapeutic strategies. 

Vignal-Clermont C, Girmens JF, Audo I, et al. Safety of intravitreal gene therapy for treatment of subjects with Leber hereditary optic neuropathy due to mutations in the mitochondrial ND4 gene: the REVEAL study. 

Newman NJ, Yu-Wai-Man P, Carelli V, et al.; LHON Study Group. Efficacy and safety of intravitreal gene therapy for Leber hereditary optic neuropathy treated within 6 Months of disease onset. 

Yu-Wai-Man P, Newman NJ, Carelli V, et al. Bilateral visual improvement with unilateral gene therapy injection for Leber hereditary optic neuropathy. 

Newman NJ, Yu-Wai-Man P, Subramanian PS, et al.; LHON REFLECT Study Group. Randomized trial of bilateral gene therapy injection for m.11778G>A MT-ND4 Leber optic neuropathy. 

RESTORE study: Unilateral genetic treatment for LHON with positive bilateral results

Dry eye can have debilitating effects on a patient’s vision and their life, depending on how bad the anterior segment problem gets. As optometrists, we can and should be on the front lines of providing not only vision exams and correction but also vision care. It is emotionally rewarding as well as beneficial for the practice and patients.

In 2017, 2 huge reports made me excited about ocular surface treatment: One was the TFOS DEWS II (Tear Film & Ocular Surface Society Dry Eye Workshop II) report, and the other was CEDARS.2, published by the Cornea External Disease and Refractive Society. These reports were the catalyst for me to incorporate dry eye treatment into my practice. Although it took about 2 years to implement it effectively, it was so successful that we opened a whole new facility focusing solely on dry eye treatment.

Three steps to integrating dry eye therapy

We implemented dry eye treatment in phases. Here are my top 3 tips for successfully implementing dry eye treatment into a practice.

1. Ask the right questions and do a screening survey.

These can include the Ocular Surface Disease Index or Standard Patient Evaluation of Eye Dryness questionnaire, which are easy to use and implement in your practice. Patients may not know what dry eyes feel like, so it is best not to ask, “Do your eyes ever feel dry?” because it requires a simple yes or no answer and is ineffective as a conversation starter. Instead, start by discussing the patient’s lifestyle to identify any visual habits that may put them at risk for dry eye. For example, patients who are computer engineers and spend 12 to
15 hours a day on digital devices are at risk for not only dry eye but also eye strain and other visual effects. They may be asymptomatic or believe any irritation or varied vision is due to eye strain when it may be treatable dry eye.

2. Take images—they are worth a thousand words.

We have many imaging options that enable patients to see what is happening with their eyes. For example, fluorescein dye creates a cool neon effect that shows where surface damage is occurring from dry eyes––a powerful image to show the patient. You can demonstrate how quickly it takes for the tears to disappear. This can help the patient connect what they are physically feeling to the diagnosis of dry eye.

3. Understand the different treatment levels for different severities.

Using certain over-the-counter products is a great place to start, as this can help patients develop a routine of putting in drops, keeping their eyes clean, or taking a vitamin supplement. There are many superb pharmaceutical options and also more procedure options available now. Knowing what each option does for each patient based on their dry eye diagnosis is vital to developing effective treatment.

When treating meibomian gland dysfunction (MGD) specifically, there are 3 main areas to target: inflammation, obstruction, and production. Different devices can help fight problems with all 3. For example, intense pulsed light is becoming popular for dry eye and MGD treatment. It has an anti-inflammatory effect that uses light waves to target tissues and calm inflammation so that the glands and surrounding structures can work better. To remove blockages and obstruction, we have blepharo exfoliative treatments for surface eyelid issues to remove biofilm and bacteria from around the eyelid edges. Low-level light therapy, also known as photobiomodulation, helps stimulate cellular activity to effectively have tissues make more of the critical components of our tears. Radio frequency is starting to come into play, which tightens the skin and builds collagen. If the collagen and skin are tighter around the eyes, it allows for a better mechanical blink with more compression, which results in better expression and more tears.

Make it easy for patients to accept your treatment plan

All these procedures and technology are beneficial to patients when they are accessible. Some of the procedures for dry eye are covered by different medical insurances, and some are not. In our practice, we package treatments and offer a percentage discount for bundled items. We also accept, in addition to typical credit cards, the CareCredit health and wellness credit card, which enables patients to pay over time, often with promotional financing.

Finally, my best advice is not to hesitate. You are the front line for patients in all things regarding eye care and correction. Once they know you have treatment options available, you will find that dry eye will become a thriving portion of your practice.

Adding a service to your practice can be scaled to your liking.

Raman Bhakhri, OD, FAAO

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