The outlook for contact lenses

Excerpted from page 18 of the October 2018 edition of AOA Focus.

The fateful clinical/business decision for St. Louis-based The Koetting Associates Eye Center came in 1961.

That's when the long-time practice's owner, Robert Koetting, O.D., spun off­ a portion of the family business into specialty contact lenses, long before other eye doctors saw the writing on the wall. The medical devices are commonplace today—45 million Americans wear contact lenses, according to estimates by the Centers for Disease Control and Prevention. But back then, it was considered risky business.

"It was pretty much unheard of at the time to put all your eggs in one basket," says current owner Carmen Castellano, O.D., who joined the practice about 20 years later fresh out of the Illinois College of Optometry, and later bought it outright.

"At that time, only about 1% of the population wore contact lenses," Dr. Castellano says. "There was only one type of contact lens then, an old type of hard lens. Soft contact lenses were introduced in the '70s and really opened up the market more and more to people. I would say that Dr. Koetting was very much a visionary. The fact that Koetting Associates was a specialty contact lens practice attracted me to it after college."

Today Koetting Associates—built on a solid footing of quality care, customer service and referrals from other practices—remains a community and family fixture, though some things have changed. Dr. Castellano lists some optometric milestones, including the ongoing integration of medical eye care into optometry and the AOA's decades-old struggle-turned-victory for Medicare parity for doctors of optometry. Dr. Castellano's two sons, Joseph Castellano., O.D., and Nicholas Castellano, O.D., have joined him in practice.

About 60% of its revenue comes from selling and fitting contact lenses. The practice draws from a patient base of more than 20,000. What hasn't changed is the practice's fixation on the future of contact lenses. On Dr. Castellano's mind is development of a more patient-friendly solution for presbyopia, especially as the population ages.

"Easy, simple and e­ffective," says Dr. Castellano, who stays current on innovations in contact lens development by keeping up on the literature, attending professional meetings, taking continuing education courses and via a peer-to-peer group he belongs to.

"That's what patients tell us they want," he says. "It's something, as a practice, that we need to keep in mind. We have to provide the services that address their vision needs."

Therapeutics delivery

Thomas Quinn, O.D., serves patients at his Athens, Ohio, practice in two ways: Dr. Quinn and the other doctors there provide eye care and vision health services to their community. The practice also is an investigational site for contact lens studies. As a consequence of being a contact lens test site, and out of his own curiosity, he also keeps a keen eye on developments in the contact lens industry.

Dr. Quinn, a past chair of the AOA's Contact Lens & Cornea Section (CLCS), is excited about what he sees. For example, drug-delivery systems that carry therapies to the eye, making treatments easier and simpler for patients. Being able to develop a more efficient way to deliver medications to the eyes, versus drops—whose effectiveness can vary based on factors such as the patient's tears—has been something the industry has been chasing for at least a decade, Dr. Quinn says. Studies, such as "Ocular Drug Delivery" published September 2010 in the AAPS Journal, say that as little as 5% of drops actually reach their destination—the anterior segment of the eye—due to the eye's protective barriers such as tears and the cornea.

Beyond that, the sheer volume of a typical eye drop is 30 microliters, while the eye's cul de sac can hold about 7 microliters, according to Heather Sheardown, Ph.D., professor of chemical engineering at McMaster University.

A big challenge has been how to release medication to the ocular surface in a controlled way. Simply soaking a contact lens in a medication and placing it on the eye doesn't work well, as the medication tends to be released too quickly. Dr. Quinn likens this approach to "medication by fire hose."

"We've had a hard time controlling the release of medications," Dr. Quinn says. "There have been things we've looked at such as nanoparticles (also nanodrops and nanopackets). These have offered some promise, but they tend to have the character of a thick gel. How is that going to work visually with a contact lens?

"Molecular imprinting technology has been looked at," he says. "It would be like taking a scaffold and putting it in the matrix of the lens and then removing it. What the scaffold leaves behind are little insertion areas that can house the medications. It holds the medication in the matrix of the lens.

That's been looked at, but early results indicate that it can change the shape and the diameter of the contact lenses, possibly impacting its fit on the eye. That's been a hurdle to try to get over."

He's also excited about a "sandwich" technology being worked on by a fledgling company in Boston (Theraoptix, one of 123 Harvard University innovation labs). Researchers there are proposing putting two contact lenses together. Between them, Dr. Quinn says, is a thin polymer zone that holds the medication.

The two sides of the sandwich help control the release of the medication, improving therapeutic effectiveness.

"Patients wouldn't have to put drops in their eyes," Dr. Quinn says. "The article said it would be ideal to use after surgery, like cataract surgery, as it releases medication for two weeks. Another thing I heard about is making a 3D-printed microneedle array that causes a really shallow invasion of the tissue that allows for drug delivery. I don't know how that actually sits on the eye. Washington State University is working on that."

Smart contact lenses

Dr. Quinn calls smart contact lenses the next "big thing" in contact lens development, as digital technology will someday enable doctors of optometry to monitor and perhaps co-manage their patients' diabetes, intraocular pressure and even cancer.

"There is actually a digital contact lens that is in use (the "Triggerfish" device in 2016), which measures intraocular pressure indirectly. It measures small changes in the volume (size) of the eyes, as the pressure goes up and down," Dr. Quinn says. "Costs for the Triggerfish technology can be a limiting factor for some practices. It's mostly going to be at tertiary centers and universities. But there are more and more studies I've read that have shown a good association between this product and managing glaucoma patients. Better patient outcomes!"

He also notes new contact lens technology developed by the California Institute of Technology, but not yet approved in the U.S., that emits low levels of light and slows the progress of diabetic retinopathy.

When the FDA cleared the way in early 2018 for Johnson & Johnson to market its light-adapting technology in contact lenses, it became a first-of-its-kind device. They were designed for daily use to correct for nearsightedness (myopia) or farsightedness (hyperopia), plus for people with certain degrees of astigmatism. The contact lenses contain a photochromic additive that adapts the amount of visible light filtered to the eye based on the amount of UV light to which they are exposed. They return to regular tint when exposed to normal lighting. It will hit the market in the U.S. in early second quarter of 2019.

These sorts of developments, Dr. Quinn says, will help influence not only the quality of care to patients, but also the scope of care doctors of optometry will deliver.

"If we can use a contact lens as a tool that will help us monitor or treat eye conditions, this will open us up to a whole other population that might not have ever considered wearing a contact lens. That's exciting to me as a contact lens provider."

Myopia control

This topic is "getting legs right now," says Dr. Quinn, due to the study of myopia progression. Studies have linked both orthokeratology, or corneal reshaping lenses, as well as dual-focus, center distance, multifocal contact lenswear with slowing the progression of myopia.

"There is currently no myopia progression control soft contact lens with FDA approval in the U.S., so we're using center-distance, multifocal contact lenses that are designed to correct presbyopia," he says.

Why it matters

Emerging technologies mean new opportunities for doctors of optometry.

Paul Barney, O.D., who practices in Alaska, is chair of the AOA's New Technologies Committee. Dr. Barney notes that it isn't easy for busy doctors of optometry to track all the emerging technologies, especially because some are developed in secret and others can take years to succeed or fizzle.

Yet, Dr. Barney says, doctors can't afford to ignore the innovation. First and foremost, they must provide the best care possible to their patients, he says. Second, he notes, doctors will need to be able to respond to patients who want to wear the contact lenses that augment reality (AR) by providing wearers with directions to their destinations, improving color vision deficiency or increasing the performance of gamers. Dr. Quinn, who scans patent applications, is curious about innovation to come. He notes Innovega's promise of a "full field of view" AR/virtual reality system that combines media-displaying glasses and contact lenses (emacula.io) as well as patent applications for contact lenses that could potentially solve the challenges of providing better correction for patients with presbyopia.

Adds Dr. Quinn: "The basic contact lens rule still applies. Contact lenses must provide good vision, be comfortable to wear and maintain a healthy ocular surface. Optometry is still important."

Staying abreast of contact lens development keeps doctors of optometry relevant to their patients.

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