As we gain greater understanding of mechanisms that affect corneal health, and awareness of the effect of even mild corneal dysfunction on vision and lifestyle, I believe three fundamental changes will continue to happen in eye care in the coming years.
1. Glaucoma will increasingly become a surgical disease. Many European countries have already moved to the early surgical treatment of glaucoma, primarily with trabeculectomy, which has a success rate approaching 90% in low-risk patients with an experienced surgeon. Compared to the alternative, a lifetime of eye drops when a "conservative" approach is taken, early surgery is both cost-effective and kind to the ocular surface.
With increasing frequency, cornea specialists are detecting and treating cases of intractable ocular surface disease characterized by limbal stem cell deficiency among patients treated with long-term topical glaucoma therapy. The costs of this, both personal and financial, far exceed those of surgery. I am also increasingly concerned about the role in glaucoma treatment of generic medications, which are only minimally regulated in the United States for their content of preservatives and "insipient" ingredients that can have long-term toxic effects.
Additionally, new surgical approaches such as the Glaukos iStent and others, may greatly simplify the surgical treatment of glaucoma, making our threshold lower and our comfort level higher for these procedures.
2. Generic medications will come under much greater scrutiny. Generic medications are often safe and much less expensive alternatives to brand-name medications, but some disturbing trends are emerging that are based on the faulty assumption that generics are always equivalent. The ocular surface and the skin are the two target organs where medications are delivered directly on the organ's surface and are therefore most sensitive to toxic "inactive" ingredients (such as preservatives) that can vary widely in generics, which must meet a standard of "equivalence" only for their active ingredients.
Still, third-party payers are using increasingly effective means of pushing patients toward generic medications, whether or not they are a good choice for the patient. Insurance carriers regularly offer cash incentives to pharmacists who switch patients from brand name to generic drugs. In some states, pharmacists can legally switch a patient from one medication to another (in the same drug class) without informing the physician.
At the same time, problems with some generic drugs will become increasingly apparent to physicians, as case reports appear regularly in the peer-reviewed literature. In ophthalmology, this is most notable with corneal melting and toxicity from generic NSAIDs. In large measure, physicians bear the liability for these complications since a 2011 Supreme Court ruling that indemnified drug makers from liability for the unique complications that arise from generic products.
As more of our mainstream ophthalmic drugs go generic, this "push" for generics will grow. Rare will become the class of eye drugs that is available only in a branded form because of the increasing cost to industry of bringing a new drug class to market.
As a profession bearing liability and no control over what is dispensed, physicians will be forced to demand either indemnification for patient outcomes or authority over what medications are actually dispensed. The FDA will also face public outcry over
its simultaneously granting carte blanche approval to generics while stonewalling innovation of new drug classes. In the interest of public safety, the FDA will direct more resources toward the regulation of generics and the close tracking of their side effects.
3. The number of new treatments for dry eye will increase dramatically. Our profession is already increasingly aware of the importance of dry eye and its prevalence among the growing aging population. The severe visual impact of even moderate dry eye in active older adults will drive innovation and approaches that we cannot even yet imagine. Treatments like the LipiFlow system from TearScience, the Maskin meibomian gland probe (Rhein Medical), and intense pulsed light will have a good deal of company, with more effective treatments crowding out their less successful counterparts.
If we truly hope to achieve useful vision in aging adults, ocular surface disease simply cannot be ignored. Our profession is already shifting its attention toward dry eye as a cause of significant ocular morbidity, and this trend has every reason to continue in the future.
- Disclosure: Dr. Hovanesian is a consultant to Essex Woodlands Health Ventures, Fera Pharmaceuticals, Glaukos, IOP, Ista Pharmaceuticals, Ocular Therapeutix, Ivantis, Sight Sciences, and TearScience.
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