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Emerging Technology In Eyecare

Dave Anderson, OD [email protected] Tim Fries, OD, MBA, MPH [email protected] Jason Miller, OD, MBA [email protected] www.theweyesguys.com wEyes Guys Tim, Jason and Dave Optometrists helping Optometrists DISCLOSURES DAVE ANDERSON, OD BUSINESS CONSULTANT, WEYES GUYS MANAGEMENT KOL, ESSILOR CONTRIBUTING AUTHOR, REVIEW OF OPTOMETRIC BUSINESS IDOC MEMBER DIRECTOR CONTACT CLINICAL INVESTIGATOR BAUSCH & LOMB JNJ VISION CARE ALCON TIM FRIES, OD, MBA BUSINESS CONSULTANT, WEYES GUYS VSP AMBASSADOR IDOC MEMBER DIRECTOR CONSULTANT SPEAKER - OPTOS CONSULTANT SPEAKER - NEUROLENS DISCLOSURES JASON MILLER, OD, MBA BUSINESS CONSULTANT, WEYES GUYS CONTRIBUTING AUTHOR, REVIEW OF OPTOMETRIC BUSINESS ADVISORY BOARD SUN PHARMA ALLERGAN ALCON CLINICAL INVESTIGATOR BAUSCH & LOMB JNJ VISION CARE ALCON NEW TECHNOLOGY IS IT WORTH THE INVESTMENT OF TIME, MONEY AND STAFF TRAINING? TECHNOLOGY IN LECTURE FORM

TEXT: DAVIDANDERSO446 (O NOT ZERO) TO THE NUMBER: 22333

Emerging Technology Objectives

• Cover common patient complaints that have no easy answers and the new technology that can help diagnosis and treat them

• Headache and eye misalignment

• MGD and new treatment options

• drops

• Genetics in eyecare Contoured Prism What is different about neurolens®

• A proprietary lens technology Neurolenses Standard integrating a contoured prism Traditional Prism Lenses design in conjunction with the Lenses patient’s refractive prescription. • Contoured prism technology enables practitioners to relieve binocular misalignment detected at distance, intermediate, and near in a single lens. • Research indicates that over 90% of patients experience a larger misalignment when fusing at near than at distance.1

1. Oculomotor Functions & Neurology-Indiana School of Optometry Millions of Units 1500 2250 3000 750 0 2000 Personal Computers 2002 2004 2006 2008 Smartphones Contoured Prism Contoured 2010 2012E The Digital 2014E Tablets 2016E Transformation

Billions 2.25 6.75 4.5 0 9 2005 2006 2007 Mobile-cellular subscriptions Population 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Trigeminal Dysphoria

• Proprioceptive fibers innervating the provide afferent feedback to the brain about the location of each eye. • This feedback is required to avoid binocular misalignments. • These proprioceptive signals are transmitted through the ophthalmic branch of the trigeminal nerve, which is responsible for detecting sensation and reporting pain. • It appears that these signals play a large role in the stimulation of the trigeminal nerve, resulting in symptoms associated with Trigeminal Dysphoria.

American Optometric Association (AOA Clinical Care Group). . April 1997. Leigh, R., Zee, D. The Neurology of Eye Movements. . Weir, C., Journal of Neuro-. . Vol. 26, No. 2. 2006. The Vision Council. Accessed April 2018.

J Neuro-Ophthalmol 2018; 38: 237-243 Symptoms of Trigeminal Dysphoria

Symptomatic patients shared a common trait: a misalignment in their vision*

*Results from a series of clinical studies on headache patients Eye Tracking and Independent Displays

Purkinje Case Study

65YO Female

Symptoms: Tired, dry eyes daily and severe motion sickness for many years. Motion sickness so bad she has not been able to ride in a car for more than a few minutes/miles at a time. She is unable to drive, her husband has to do all the driving.

RX OD +4.00 -0.50 x 095 OS +4.75 -0.50 x 075 +2.50 add current PAL wearer x many years.

Demo 1BI and 1.5 BI flippers, decided to RX a 1.3 BI

Meibomian Gland Treatment

Maintenance/home care: heat masks (many options), lid hygiene including hypochlorous acid for Demodex, tea tree oil, diet/supplement changes

Manual: Miboflow, TearCare, iLux, IPL

Doctor is able to visualize the oil glands function and composition during/after treatment

Automated: Lipiflow

Set it and forget it Tear Function and MGD

Most studies suggest nearly 70% of dry eye has some form of MGD leading to the

Evaporative dry eye is most common cause of dry eye Improving Signs

Clin Ophthalmol. 2018; 12: 683–694 Improving Symptoms

Clin Ophthalmol. 2018; 12: 683–694. Mibo Thermoflo

Ultrasonic heat applied to through ultrasonic gel

Temperature maintained at 108.5 degrees

Cost $18,000, but no cost per use

Uses heat inducer that is antimicrobial, and is cleaned either with alcohol or hydrogen peroxide

Meibography can be added to aid treatment (MiboCam - cost approximately $9000)

Requires 20-30 minute tech time, and approximately 10 minutes of doctor time expressing glands, each eye is treated separately

May take 3-4 visits, provides 6 months of symptom relief MIBO THERMOFLO • EASY TECHNICIAN USE • COMFORTABLE FOR PATIENTS • EFFECTIVE TREATMENT • COST IS LOW • NO REUSABLES TO PURCHASE MIBOTHERMOFLO TearCare by Sight Sciences

Thermal heat applied to eyelid through small disposable heating pads that are temperature controlled during treatment

Temperature maintained at 108.5 degrees at inner lid, ranges from 106-113, but can be controlled if patient more sensitive

Cost $5500 for starter kit, with $250 per use for each heating pad

Open eye, encouraging blinking during treatment and no heat accumulation to the ocular surface

Both eyes done simultaneously

Requires 15 minute tech time (not continuous), and approximately 10 minutes of doctor time expressing glands

Takes 1 visit, provides 6-12 months of symptom relief TEARCARE • EASY TECHNICIAN USE • COMFORTABLE FOR PATIENTS • EFFECTIVE TREATMENT • COST IS MODERATE TO LOW • OPEN EYE PROCEDURE HAPPY PATIENTS

Beginning of treatment Mid-treatment MG Expression

Treating Presbyopia with Drops

Presbyopia affects more than 1.8 billion people worldwide, 11million in the US Two Kinds of Eyedrops Miotic Drops – Smaller size = “pinhole effect,” greater depth of field Lens-Softening Drops Softens the eye’s aging lens, allowing it to be more flexible and adjust/focus for near vision Treating Presbyopia with Drops

Miotic Drops:

Some companies developing miotic drops:

Allergan

Presbyopia Therapies

Orasis Pharmaceuticals Treating Presbyopia with Drops

Lens Softening Drops: - turn back the clock 10 years

Novartis EV06 ophthalmic solution 1.5% (lipoic acid choline ester) – Phase 2 trials

Best for people without and in early stages of presbyopia Liquid Vision (Presbyopia Therapies)

Marketed as a “Lifestyle Drop” designed to last 5 hours or more

Aceclidine (miotic) & tropicamide (cycloplegic) to create a “superpinhole effect” and moderate

“Lifestyle enhancement” to be used with glasses/ contacts Genetic testing in eyecare

Targeted treatment and care regimen vs. standard of care cook-book care regimen

ARMD

Inherited retinal disorders

Achromatopsia

Keratoconus

Lattice and Granular Corneal Dystrophies Genetics Testing

Spark Invitae genetic test for inherited retinal diseases including RP, Lebers and others

Arctic Macula Risk and Vita Risk genetic tests that assess risk for ARMD progression and best supplement based on genetic profile Invitae genetic test for IRD (Inherited Retinal Disorders)

248 genes tested

RP

Lebers

Stargardts

Rod-Cone Dystrophy

Vitelliform macular dystrophy

Retinal findings associated with Syndromes including Usher, Stickler and many others Other Genetic Tests Spark Retinal

Luxterna (voretigene neparvovec-rzyl)

First FDA approved gene therapy for RPE65 deficiency

Gene is delivered directly into the eye

Cost of the procedure up to $500,000 per eye

Treatment center at Cincinnati Childrens

Also available at Bascom Palmer, Mass Eye/Ear, others Arctic Vita Risk test

Vita Risk is a DNA test measuring the two main genetic variations (three genetic variations in two genes) that interact with common vitamin/mineral supplements containing zinc. People in one genetic group have increased risk of progression of age-related to wet AMD.

Some patients have higher potential for worsening using current AREDS 2 supplements due to higher levels of zinc, most AREDS 2 are 25-80mg/d

15% of patients respond negatively to high levels of zinc Arctic Macula Risk

Macula Risk is a DNA test combining many of the genes (15 genetic variations in 12 genes) associated with the progression of age-related macular degeneration (AMD). The genetic result is integrated into a formula developed from research at Tufts Medial Center and includes a patient’s age, AMD disease status, height, weight, sex, and smoking history, which provides a basis for progression risk.

The report provides a two, five and 10-year prediction of the risk for progression to lost vision from advancing AMD. This test was 89% accurate in its published research. TGFBI Gene Transforming growth factor beta induced

TGFBI is key factor several corneal dystrophies:

Granular , type 2, Reis-Bücklers Corneal Dystrophy, Thiel-Behnke corneal dystrophy, and Lattice corneal dystrophy

Cytogenetic Location: 5q31.1

Avellino Labs USA, Menlo Park, CA - AvaGen

Cost: $8-17, depending on condition evaluated

Screens for and currently FIVE other corneal dystrophies

Uses: Pre-LASIK consult? Newly diagnosed corneal dystrophy, family Hx of “corneal problem” or for future children’s risk

Gene therapy on the horizon for keratoconous and these dystrophies Other New Tech

MiSight - Coopervision Myopia Management Lens

MYOSIGHT - HOYA DIMS (defocus incorporated multiple segment)

Right Eye Vision Training

VR Visual Fields

A-Scan by DGH axial length measure for Myopia Management

wEyes Guys OPTOMETRY CONSULTING

Dave Anderson, OD [email protected] Tim Fries, OD, MBA, MPH [email protected] Jason Miller, OD, MBA [email protected] www.theweyesguys.com