It’s an exciting time for optometrists prescribing therapeutics. A number of blockbuster topical ophthalmic drugs should become available within a year and can potentially make a big impact for you and your patients. We’ll revisit a few significant recent approvals along with what’s on the horizon.

Recent Advances

Three therapeutics come to mind that you should consider:

• Oxervate (Dompé) for neurotrophic keratitis has changed the usual progression of the disease from punctate keratitis to eventual corneal perforation. In clinical studies, 72% of patients went from persistent corneal epithelial defects or ulcers to complete corneal clearance after two months of therapy, with 80% remaining that way one year later.
• Upneeq (RVL Pharmaceuticals) has done wonders for patients with ptosis. Patients showed a lift in their eyelids that corresponds to a statistically significant increase in visual fields plus the aesthetic effects.
•  Tyrvaya (Viatris Pharmaceuticals) has shown a significant improvement in basal tear production of all three contributing glands, including the lacrimal glands, meibomian glands and the mucin-producing goblet cells.

In the Pipeline

One of the first is a lipid layer enhancing topical agent called NOV03 (Bausch + Lomb) or perfluorohexaloctane, which remains in the meibomian glands for over 24 hours and on the ocular surface for four to six hours after a single drop. It appears to interdigitate with an existing dysfunctional lipid layer to stabilize and enhance it, preventing evaporation by more than that of our existing lipid layer. Since 86% of all dry eye disease (DED) involves meibomian gland dysfunction, this could be the first topical agent targeting that critical layer.

Around the same time, its sister product, CyclASol, which contains 0.1% cyclosporine, may be approved. Up to 86.5% of patients considered CyclASol comfortable and 99.8% reported no or mild instillation site pain, leading to very low discontinuation rates. This drug may be ideal for patients with ocular surface staining and aqueous deficient dry eye.

A third dry eye drug, Reproxolap (Aldeyra Pharmaceuticals), works by inhibiting reactive aldehyde species, or RASP, which is found to be highly elevated in patients suffering from DED (and allergic conjunctivitis). Reproxolap showed almost immediate positive effects in tear production as well as long-term effects on DED patients with inflammation. It has a unique mechanism beyond inflammation control that could significantly help DED sufferers.

Demodex blepharitis will have its first prescription foe this fall. TP-03 (Tarsus Pharmaceuticals) achieved a clinically meaningful collarette cure rate of almost 90% and statistically improved lid erythema and mite eradication rates when used BID for six weeks. These impressive results were without any eyelid rubbing.

Although I see success with manuka honey extract, coconut oil and aloe (MyboClean, Danelli Ocular Creations), as well as intense pulsed light with low laser light treatment and blepharoexfoliation, we need a powerful prescription product like TP-03.

A New Shot at Presbyopia

CSF-1 (Orasis Pharmaceuticals) is a new, low-dose pilocarpine that has an optimized formulation at the lowest effective dose, 0.4%—which is one-third less than the currently available presbyopia drop—a near-neutral pH, is preservative-free and has two lubricating agents. In clinical studies, two thirds of patients gained three lines or more on day 15 (two hours post dose two) with over half maintaining a two-line gain eight hours after instillation.

Optometry is the number one prescribing profession of topical agents for everything from DED to presbyopia. Pharmaceuticals will be optometry’s focus in 2023 as these exciting topical agents lead the way. Start preparing your practice and your patients for these new therapeutics that target DED in novel ways, battle blepharitis for the first time and offer a new approach to presbyopia. 

Dr. Karpecki is medical director for Keplr Vision and the Dry Eye Institutes of Kentucky and Indiana. He is the Chief Clinical Editor for Review of Optometry and chair of the New Technologies & Treatments conferences. A fixture in optometric clinical education, he consults for a wide array of ophthalmic clients, including ones discussed in this article. Dr. Karpecki's full list of disclosures can be found here.