Hot topics
During a symposium that addressed hot topics across various specialties, Steven Wilson, MD, presented on topical losartan for corneal scarring.
Dr. Wilson described studies that he has done so far, mostly in rabbit models, looking at losartan after descemetorhexis, alkali burn injury, PRK late haze, simulated blast injury, and corneal incision/laceration (in review). Dr. Wilson also shared several case reports where losartan had been successfully used to help with issues like dislocated LASIK flap, scarring fibrosis years after RK, and scarring fibrosis after treated Acanthamoeba.
Losartan works on the development and persistence of myofibroblasts, he said, adding that topical losartan will likely be effective for prophylaxis to prevent fibrosis and treatment when scarring fibrosis is already present.
Topical losartan could likely be effective in other corneal disease, Dr. Wilson said, including thermal and chemical corneal burns, bacterial, fungal, and Acanthamoeba corneal infections concurrent with topical antibiotics and scars from prior treated keratitis, HSV keratitis concurrent with antivirals, and herpes zoster keratitis with antivirals and treatment of existing scars. It could potentially have applications for ocular cicatricial pemphigoid, Stevens-Johnson syndrome, and graft vs. host disease.
Dr. Wilson offered several topical losartan recommendations for trials. He stressed not to exceed 0.8 mg/mL losartan in balanced salt solution until studies in rabbits and trials show that higher concentrations are safe. He also said that using this dosage six times a day topically is critical. Many patients do not show slit lamp changes in scarring fibrosis until 4–6 months. Frequently, patients reported vision improvement before slit lamp changes were noted.
Dr. Wilson also said it’s important to continue treatment months after fibrosis is gone, and that it’s not effective for conditions where corneal haze is caused by corneal fibroblasts (like normal PRK haze and normal corneal crosslinking haze). At present, topical losartan is only available from compounding pharmacies, Dr. Wilson said.
Also in the session, Sumit “Sam” Garg, MD, highlighted modular shape-changing IOLs. Modularity, he said, makes the IOL exchange easier/safer/more predictable, maintains the physiologic integrity of the capsule, preserves the benefits of small incision cataract surgery, promotes the stability of the IOL in the capsule, reduces fibrosis and PCO, and enables future IOL upgrades, exchange, and other options.
Dr. Garg shared various products that are currently in development in this space: the Harmoni Modular IOL (Alcon), Gemini Refractive Capsule (Omega), OmniVu (Atia Vision), Juvene (LensGen), and an IOL/drug product from SpyGlass.
The Harmoni is a modular two-component hydrophobic acrylic IOL, with an optic that can be exchanged. The Gemini has modular technology that allows for placement of IOLs, drug delivery, or sensors. The OmniVu modular IOL has a fixed-power front optic and a fluid-filled changing base lens. The Juvene option is a modular lens with a base optic that fills the capsular bag and has a fluid lens that you tab into the base lens. Finally, the SpyGlass product is a combination IOL/drug delivery that is a standard cataract lens but with drug-eluting bimatoprost pads.
Editors’ note: Dr. Wilson has financial interests related to his work with losartan. Dr. Garg has financial interests with SpyGlass and LensGen.
Low-dose atropine for myopia
Michael Repka, MD, spoke about studies that looked at low-dose atropine for myopia control worldwide. He sought to describe current data on low-dose atropine for myopia control and to place these results into perspective. There is no cure for this, he added.
Dr. Repka first mentioned data from the ATOM studies in Singapore and LAMP in Hong Kong.
He moved on to discuss two U.S. studies. The first, the CHAMP study, is a study of NVK-002 in children with myopia. It used two low-dose atropine concentrations of 0.01% and 0.02%, as well as a placebo. Compared with placebo, the low-dose atropine 0.02% did not increase the responder proportion, did not slow mean SER progression but did slow mean axial elongation. Compared to placebo, the low-dose atropine 0.01% increased responder proportion, slowed mean SER progression, and slowed axial elongation.
Dr. Repka said the randomized clinical trial found that 0.02% atropine did not significantly increase the proportion of participants’ eyes responding to therapy, but there was suggested efficacy for 0.01% atropine across all three main endpoints compared with placebo. “The efficacy and safety observed suggest that low-dose atropine may provide a treatment option for childhood myopia progression,” he said.
The other U.S. study he discussed was the Myopia Treatment Study I. This study randomized (2:1) using atropine 0.01% daily and placebo. Myopia progression adjusted mean (95% CI) changes were –0.82 (–0.96 to –0.68) D and –0.80 (–0.98 to –0.62) D in 0.01% atropine and placebo groups. The axial length adjusted mean (95% CI) changes in axial length were 0.44 (0.39 to 0.50) mm and 0.45 (0.37 to 0.52) mm in 0.01% atropine and placebo groups.
Dr. Repka also drew attention to two additional low-dose atropine studies, one in Western Australia, which used 0.01% atropine vs. placebo, and the MOSAIC (Myopia Outcome Study of Atropine in Children), which included 250 European children and looked at placebo vs. 0.01% atropine. There are a number of ongoing studies in the U.S., as well as an ongoing European study.
Dr. Repka also highlighted some of the important issues with compounded low-dose atropine. Side effects are usually minimal, typically stinging, usually at the beginning of treatment. But he did note that this currently lacks FDA approval, and it would need to be compounded. The duration of treatment is unknown, as is the durability of treatment, and it’s not covered by insurance.
There is remarkable widespread interest in myopia control, Dr. Repka said, but low-dose atropine eye drops study outcomes in Western children have not been impressive (refraction and axial length effects have been modest, and effective concentration is still sought). He said that combination therapy needs to be studied but currently lacks evidence.
Editors’ note: Dr. Repka has no relevant financial interests.
Ocular imaging
During a session on ocular imaging, Michael Chiang, MD, discussed AI and imaging. There are a number of unanswered research questions in AI, he said. There are a variety of findings in individual patients. The performance of AI systems improves as the task narrows, Dr. Chiang said, but diagnosis involves many parallel tasks, which include multiple diseases and findings, and you have to integrate image and clinical data.
One of the needs is building large AI-ready datasets, he said, describing several projects in the works to attempt to build these large datasets. He specifically mentioned the Bridge2AI and AIM-AHEAD projects.
Another thing we need is imaging standards, Dr. Chiang said, adding that this goes back to the concept of image data as basis of AI and of clinical care. These data are in devices, and the devices generate pictures and numbers. But you can’t get data easily out of devices, noting the need to often maintain multiple image management systems.
Imaging and AI has transformed clinical practice, Dr. Chiang said. Imaging device standards and interoperability for clinical care and research is important, and the community must work together for data sharing and collaboration for knowledge discovery and avoidance of bias. Dr. Chiang said he is looking forward to this community working together to advance the field.
Editors’ note: Dr. Chiang has no relevant financial interests.
Secondary dry eye
During a cornea session, Anat Galor, MD, discussed secondary dry eye. Dry eye is not one disease, she said. Patients come in with different phenotypes, which can lead to different pathophysiology and the need for different treatments.
Dr. Galor noted that primary dry eye may be identified as involving abnormalities in the lacrimal gland, meibomian glands, and goblet cells. But she said there are other factors that can give symptoms and signs of dry eye. Dr. Galor highlighted abnormal anatomy, toxicity, and nerve abnormalities as causes of secondary dry eye.
With abnormal anatomy, she said to restore the anatomy if you can. She recommended always looking under the lid. But she said you can’t fix all anatomical abnormalities.
Toxicity also causes secondary dry eye. This could be from something on the ocular surface or the environment. Dr. Galor showed a patient with dry eye who had a 15-year history of using IOP-lowering medications. She also showed a case of a patient who had dry eye symptoms because of mold in the home and had to move to finally relieve the symptoms. We often forget environmental contributors, she said.
The last secondary dry eye cause she discussed was nerve abnormalities. How do you check nerves? Dr. Galor likes to use dental floss but said cotton tips and tissue paper also work as well. You’re looking for abnormal sensation. Every dry eye evaluation should include a sensation check.
Editors’ note: Dr. Galor has financial interests with several companies.
EyeWorld Onsite is a digital publication of the American Society of Cataract and Refractive Surgery.
For sponsorship opportunities or membership information, contact: ASCRS • 12587 Fair Lakes Circle • Suite 348 • Fairfax, VA 22033 • Phone: 703-591-2220 • Fax: 703-591-0614 • Email: ascrs@ascrs.org
Opinions expressed in EyeWorld Onsite do not necessarily reflect those of ASCRS. Mention of products or services does not constitute an endorsement by ASCRS.
Click here to view our Legal Notice.
Copyright 2023. All rights reserved.
