Recently, a few new medications have hit the eyecare market that may affect the business of contact lenses going forward.

Presbyopia Correction

The first new product is a 1.25% topical pilocarpine drop. Approved by the U.S. Food & Drug Administration (FDA) for the treatment of presbyopia, this drop is aimed at the emerging presbyope (FDA, 2021a). A muscarinic cholinergic agonist, pilocarpine increases the depth of focus of the eye by inducing pupillary miosis. This pharmaceutical can provide about half of the accommodative demand through this increased depth of focus.

Obviously, this new therapeutic agent has significant implications for how and when to prescribe multifocal contact lenses. When one might want to push plus to delay the introduction of multifocal lenses (something we are doing less and less), this new product might be used to provide the help needed in the early days of presbyopia.

One might think of a few creative off-label uses for this drug. All of us have had that patient who needed a low cylinder toric lens in only one eye, but has also objected to the comfort difference between a toric and a sphere, likely due to the lid-lens edge interaction with the toric design. Practitioners can now think about trialing this new medication on the eye with the low cylinder and continuing to wear the sphere—just an idea.

This drug will last about six hours. You should not give it to someone who is at risk for retinal detachment or has iritis. Use of this drug may be limited because most insurance plans are not likely to cover its cost at present. That fact notwithstanding, this drug has the potential to alter the way we prescribe lenses to presbyopes and astigmats.

Increased Tear Production

The second drug that has the potential to change the contact lens market is FDA approved for the treatment of dry eye. This nicotinic cholinergic agonist is formulated as a nasal mist that delivers the therapeutic agent in each dose. It is dosed twice per day with a single mist in each nostril.

The main side effect of this drug, by far, is sneezing. Other potential side effects are coughing and irritation of the throat and nasal passages. The best way to minimize these adverse reactions is to dose the mist against the lowest temporal aspect of each nostril.

This drug activates the trigeminal parasympathetic pathway, resulting in increased production of aqueous tear film as a treatment for dry eye disease (FDA, 2021b). In our patients who are struggling with dry eye and contact lens wear and are refractory to supplementation, this agent could be a significant adjunct therapy for improving tear film support for contact lens wearers (off-label).

I always tell my patients, “The tear film is the oil in the contact lens engine. If you give someone a Ferrari, but drain the oil out of it, you can only drive the car two blocks—even with arguably the best engine in the world.” The same is true of contact lenses. We can give someone a Ferrari of a contact lens, but without an adequate tear film, the patient will not succeed.

Eyecare practitioners lived for many years under the mantra “Change the solution, change the lens, change the patient,” in that order. However, in the past decade, eye care has moved to dealing with the patient first. It has become obvious that this is the best approach. There has been of focus on the meibomian glands recently; it is nice to have something that can stimulate aqueous production. CLS

References

1. U.S. Food and Drug Administration (FDA). New Product Application (NDA) 214028. Available at https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/214028s000lbl.pdf . Accessed May 5, 2022.
2. FDA. NDA 213978. Available at https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/213978s000lbl.pdf . Accessed May 5, 2022.