Cornea: I wish I had …
Summer 2024
by Liz Hillman
Editorial Co-Director
Who are the best patients? What are the outcomes like? What’s in store for the future? Victor Perez, MD, Stephen Pflugfelder, MD, and Alfonso Sabater, MD, PhD, answered these questions and more as they pertain to platelet-derived ocular surface therapies, giving insights on what they wish ophthalmologists knew about these products.
EyeWorld: When do you think a platelet- derived product is suitable for a patient with dry eye or ocular surface disease?
Dr. Perez: It used to be reserved for more severe cases of ocular surface disease, but now we treat even mild patients. At the beginning, it was patients who had a non-healing ocular surface/cornea problem—that was the first indication. Then it was patients with severe dry eye, pemphigoid, graft vs. host disease, Sjogren’s, where the cornea was really eroded. That’s the type of patient we call severe. It worked very well for those patients.
Now patients who have symptoms of corneal staining that is more advanced … those are candidates for plasma therapy. We have patients with more mild disease, who may have a little corneal erosion, some who have symptoms, we’re starting to use this with these patients. It’s my go-to line of therapy for patients who have ocular pain, ocular sensitivity as well.
Dr. Pflugfelder: I reserve it for moderate to severe dry eye patients who haven’t responded to conventional therapy or aqueous deficient patients with severe corneal epithelial disease.1 It can also be effective for keratoneuralgia.2
Dr. Sabater: I think platelet-derived products are a good option for patients with moderate or severe dry eye disease who do not respond to artificial tears or the current FDA-approved dry eye therapies. Additionally, it is a great option for patients with dry eye disease associated with early stage neurotrophic keratitis (also known as stage I).
Source: Angela Gomez
EyeWorld: What makes these products so effective for certain patients?
Dr. Perez: Years ago, I had been using autologous serum tears for the treatment of ocular surface diseases while at the Cleveland Clinic. Then I moved to Bascom Palmer Eye Institute, and we started collaborating with Dr. Eduardo Anitua, an oral surgeon from Spain, who has extensive experience with the use of platelet-derived products in oral surgery. We demonstrated that these have more growth factors and developed a kit to prepare them for their use in ophthalmology.
Dr. Pflugfelder: It has biologically active constituents including high levels of growth factors.
Dr. Sabater: Platelet-derived products contain a variety of factors that play a role in tissue repair and regeneration, such as growth factors, cytokines, chemokines, or fibrinogen, among others. In addition, they have a potent antinociceptive effect, possibly thanks to peripheral endocannabinoid-mediated mechanisms. These combined properties make platelet-derived products unique when compared to other pharmaceutical treatments.
EyeWorld: What are the special considerations for recommending/prescribing these products for your patients?
Dr. Pflugfelder: Platelet-derived products have the potential to restore comfort, function, and quality vision to patients with severe keratoconjunctivitis sicca. They can also heal sight-threatening persistent corneal epithelial defects and sterile corneal ulcers. Current obstacles to widespread use are availability and cost. Most of the centers that prepare these products are academic centers, although an increasing number of community practices are adopting them.
Dr. Sabater: It is important to evaluate the patient’s medical history and any existing conditions that may affect the safety or efficacy of platelet-derived products. We should provide detailed information to the patients about the procedure, potential risks, benefits, and expected outcomes. Additionally, these products have refrigeration requirements that are critical to preserve their stability and sterility. Therefore, we should make sure that the patient will be able to follow these requirements.
EyeWorld: What has been your experience with prescribing platelet-derived products?
Dr. Perez: I think they’re becoming more popular. As ophthalmologists, we know that they work. The main issue is access. Not everyone has a facility where the patient can go to get blood drawn, etc. It’s a process. Then of course, it’s not easy for the patient. The patient will need therapy for at least 3 months, but they work and patients like them.
Dr. Sabater: I have been prescribing platelet-derived products for more than 10 years to patients with moderate and severe dry eye disease with good results regarding signs and symptom improvement. I prescribe platelet-derived products every week. At Bascom Palmer Eye Institute, we treat more than 2,000 patients yearly with these products.
EyeWorld: Are there any pros/cons/best practices for their use?
Dr. Perez: It was originally thought that patients with autoimmune diseases don’t have good plasma. We’ve done a study where we looked at our patients with autoimmune diseases, and we didn’t see anything; the safety was very good. Patients with poor liver and kidney function and systemic infections are contraindicated for the use of autologous blood products.
Dr. Pflugfelder: Pro: It is highly effective. Con: It is not covered by insurance, so it is moderately costly.
Dr. Sabater: Platelet-derived products are very well tolerated by most patients, compared to other drugs in the market. Additionally, they have a relatively high rate of efficacy in patients with dry eye disease. However, they also have some drawbacks. For example, (1) there is variability in quality due to changes in platelet counts and growth factor content that are influenced by the patient’s age and biological conditions; (2) patients are required to get their blood drawn every few months; (3) they are not FDA approved; (4) they are not covered by insurance companies; and (5) they have strict refrigeration requirements.
EyeWorld: What do you think is the future of these products?
Dr. Perez: Future ideas include can we use blood products from someone else, other healthy individuals? Most of these products as of now are autologous. This is a direction I’m excited about. Then, of course, identifying other indications for plasma and platelet products and identifying who are the responders and who are the non-responders.
Dr. Pflugfelder: I think they will be enduring but won’t be used widely until they become more available to patients.
Dr. Sabater: I hope that in the future we can have access to a standardized FDA-approved allogeneic platelet-derived drug product with no refrigeration requirements. I think new innovations that improve the quality, stability, and accessibility will increase their adoption.
About the physicians
Victor Perez, MD
Professor of Ophthalmology
Director of Cornea Research
Bascom Palmer Eye Institute
Miami, Florida
Stephen Pflugfelder, MD
James and Margaret Elkins Endowed Chair
Director of the Ocular Surface Center
Cullen Eye Institute
Baylor College of Medicine
Houston, Texas
Alfonso Sabater, MD, PhD
Associate Professor of Clinical Ophthalmology
Medical Director of the Ocular Surface Program
Bascom Palmer Eye Institute
Miami, Florida
References
- Soifer M, et al. A multicenter report of the use of plasma rich in growth factors (PRGF) for the treatment of patients with ocular surface diseases in North America. Ocul Surf. 2022;25:40–48.
- Wang M, et al. Initial experiences using plasma rich in growth factors to treat keratoneuralgia. Front Med. 2022;9:946828.
Relevant disclosures
Perez: None
Pflugfelder: None
Sabater: Ocubio
Contact
Perez: vperez4@med.miami.edu
Pflugfelder: stevenp@bcm.edu
Sabater: asabater@med.miami.edu
