Behind the lens

Excerpted from page 18 of the September/October 2021 edition of AOA Focus.

Simple curiosity may compel Mile Brujic, O.D., who practices in Ohio, to make a beeline to the popular and brightly lit exhibits at conferences showcasing what is new in optometry or to seek out online the latest buzz on innovation in contact lens. Dr. Brujic is naturally curious about new things.

But he is primarily drawn because the innovation can make a difference to his patients.

While giving contact lens manufacturers their due for the “utterly unbelievable” innovations in the industry since he graduated from New England College of Optometry 19 years ago—doctors of optometry have many more options for daily disposable silicone hydrogel lens than they once did, he notes—Dr. Brujic speaks earnestly about what he refers to as the “gaps” that remain when it comes to patient care needs and the opportunity.

Forty-five million Americans are wearing contact lens, according to the Centers for Disease Control and Prevention. However, lots of people “drop out” after trying them.

“Innovation and technology give us the ability to close up these gaps to help better care for our patients,” says Dr. Brujic, a member of the AOA Contact Lens & Cornea Section. “The best companies look at gaps. They listen to clinicians when we say, ‘I wish we had x, y, z’ or ‘I wish we could do this,’ and they challenge themselves to build something to meet that void.

“I’m not naïve,” he adds. “I know it’s a business opportunity, but they deserve the credit that they receive if they do fill a void. There are a lot of people listening to clinicians right now, and they are taking the time to do the research and develop technology. And clinicians are always interested in finding out about what’s new in the industry and what’s good for patient care.”

What doctors want

Doctors of optometry provide feedback to contact lens manufacturers through all manner of channels via surveys, focus groups and advisory boards, as well as casual conversations with manufacturers’ reps at conferences.

Those representatives then carry that feedback back to their respective companies—whether its ideas about enhancements to existing products or new ones—sharing with the professionals who work in their research and development (R&D) divisions.

“They want product performance,” says Michele Andrews, O.D., CooperVision vice president, professional and government affairs-Americas. “What that means is great vision—first and foremost, great comfort and ocular health. Great advanced materials, breathability and lens design that provides the patient with great ocular health and wearing experience.

“Then they (eye doctors) look at it from the perspective of how easy the contact lenses are to fit,” Dr. Andrews says. “This would typically come into play for products such as toric and multifocal lenses. They want a lens that is easy for them to fit, which means it settles properly. They want the fitting guide to take them to the best lens option as quickly as possible so there is the least amount of chair time for the doctors.”

Time is a factor for doctors and patients.

“Chair time has always been critical to doctors, but it’s even more critical in the space we are in today,” says Dr. Andrews, who adds that the same was true for patients. “People have a different appreciation of time coming out of COVID-19. People are choosing to do things in different ways to maximize the time they have available. I would also add another consideration for doctors: how easy it is for patients to apply and remove the lens.”

What doctors know about patient care plays a critical role in research and development, says Andy Pawson, president and general manager of global vision care at Alcon.

“We rely on their involvement in product development and testing through clinical trials,” Pawson says. “We utilize feedback from eye care professionals to ensure our products are meeting the unique needs of patients.”

Says Kurt Moody, O.D., director, North America, professional education, Johnson & Johnson Vision: “Doctors definitely want to keep their patients happy. The benefit of a happy patient is two-fold. They will continue to come back to a practice and, probably more important, they’re going to recommend other patients.”

What patients need

Dr. Brujic relates the story of a patient of his, to whom he posed two questions years ago, and was rather surprised by her answers. He asked her: 

• What was her level of comfort in her contact lens five to 10 minutes after she put them in each morning? At the beginning of the day, the woman, a -6.00, ranked them 10 out of 10. “She loved her contact lenses,” Dr. Brujic says.
• How did her eyes feel five to 10 minutes after she took her lens out at the end of the day? Three or four out of 10, he recalls her saying. She was willing to put up with any discomfort—but Dr. Brujic wasn’t.

What did Dr. Brujic learn from the long-ago exchange?

“There is massive unmet need and massive opportunity to help some of these patients,” he says, adding that he has put systems in place in his practice to help identify patients feeling discomfort, including asking the right questions.

In a 2020 literature review in PubMed, “ A Review of Contact Lens Dropout,” the authors cite contact lens dropout as a likely “major factor contributing to the near stagnant growth in the CL (contact lens) market,” according to their review of papers on the subject. Patients drop out for a number of reasons, but discomfort was called out most often in the studies reviewed (frequency ranged between 12% and 27.4% in developed countries).

“The top cited reason for CL dropout in established CL wearers was discomfort, while vision was the top reason in neophyte CL wearers,” the review’s authors write. “If given the chance, CL dropouts are often able to successfully resume CL wear up to 74% of the time.”

The game changers

AOA Focus asked leading contact lens makers about what new innovative products are on the horizon.

ALCON: Total30 ^® monthly replacement, water-gradient contact lens

In 2019, Alcon invested $584 million in research and development. Today, it has 1,300 employees dedicated to R&D and more than 110 projects in its development pipeline, Pawson says.

“Alcon is committed to science-based innovation and bringing new products to the market that help consumers see brilliantly,” Pawson says. “We aim to strengthen our portfolio with new products, better lens design and chemistry, and novel technologies.”

Its latest contact lens innovation to be announced this fall: TOTAL30, which Pawson describes as “the first and only monthly replacement, water-gradient lens that feels like nothing, even at day 30.” The lens uses new biomimetic CELLIGENT ^® Technology, which mimics the ocular surface structure to help resist the adherence of bacteria and lipids, Pawson says.

“We estimate that six out of 10 contact lens fits in the U.S. are in a reusable lens, and there has not been meaningful innovation in this category in years,” he says. “The water gradient lens material, first introduced with DAILIES TOTAL1 ^® contact lenses, approaches 100% water at the outermost lens surface so nothing touches the eye but a gentle cushion of moisture. ”

Bausch + Lomb: INFUSE ^® daily disposable contact lens

Launched in August 2020, Bausch + Lomb INFUSE ^®, helps remove the barrier to contact lens dryness—experienced by about a third of contact lens wearers in the U.S, says George Grobe, vice president, R&D, global vision care, Bausch + Lomb.

“These lenses provide a high moisture content and low modulus, maintaining 96% of its moisture for a full 16 hours,” Grobe adds.

During the design process, Bausch + Lomb explored gaps in the current marketplace and found in a survey of its daily disposable users that:

• 53% of users experienced contact lens dryness.
• 69% said they settle for less comfort to wear lenses for the entire day.
• 82% said they would be interested in an option that could help reduce contact lens dryness.

 “With these insights in mind, we developed Bausch + Lomb INFUSE ^® contact lenses with a next-generation material infused with ProBalance Technology™ to help maintain ocular surface homeostasis to aid in minimizing symptoms of contact lens dryness and for a comfortable lens-wearing experience,” says Grobe, noting that market research showed the likelihood of discontinuing contact lens wear had more than tripled from 2004 to 2019.

“Each day, we work with our core functions, including R&D, to identify and address the needs of eye care professionals and their patients all around the world,” Grobe says. “This process is core to everything we do and allows us to continue to deliver on our mission of helping people see better to live better.

“We owe much of our success to the ongoing collaboration and feedback we receive from eye care professionals,” he says. “Their passion and dedication, coupled with patient and data-driven insights, allows us to better understand patients’ needs and to facilitate communication about new areas of eye care. In addition, our internal team of ODs plays an integral part in our R&D process, from lens design to polymer chemistry to clinical research and medical affairs.”

CooperVision: A new MyDay^® daily disposable multifocal lens with the widest parameter yet

In late fall, CooperVision will launch its MyDay daily disposable multifocal lens.

“It will have a wider parameter range when it launches,” Dr. Andrews says. “It will have the widest parameter range of all daily disposal multifocals in the marketplace and give doctors the widest number of prescription options.

“What we’re excited about is the fact that these lenses and the fitting guide get the product to the doctor and the patient really fast,” Dr. Andrews says. “This should give doctors more confidence to recommend multifocals to their patients because they won’t have a scenario when the patient is coming back three, four or five times for adjustments or they quit.”

CooperVision’s annual report lists its investment in R&D at just over $54 million in 2020.

“CooperVision has a team that is continuously looking at the unmet needs in the marketplace—what do prescribers and their staffs need, what do patients need that’s not out there?” Dr. Andrews says. “They’re looking out many, many years because if we think about the timeline to develop and test a new contact lens, it’s years long, not weeks or months long.

"You have to always be thinking about what’s next,” she says. “What will the contact lens marketplace look like in five or 10 years? Those conversations are happening now from a R&D standpoint.”

Johnson & Johnson Vision: Acuvue Theravision drug-eluding contact lens

When Dr. Moody joined Johnson & Johnson Vision’s R&D division in 2005, a project to develop a drug-eluding contact lens had already started. It takes time to go from understanding the need for a product to how a company can create a product that satisfies that need. From there, it’s a lot of trial and error.

The triumphs and failures keep the innovative process chugging along.

“What we continue to strive for is to find those products that are more transformational vs. just ‘me too,’” he says, citing examples of transformational products that Johnson & Johnson Vision has developed. “Another example of transformational innovation is our newest lens that was just released in Canada this summer (and soon to be launched in Japan).”

The delayed release in the U.S. is due to its different regulatory path. The lens contains the active ingredient ketotifen, an over-the-counter antihistamine eye drop that treats allergy symptoms. A release date had not been set at publication.

“The U.S. FDA has determined it’s a ‘drug lead’ rather than a ‘device’ lead,” Dr. Moody says. “So, we have to go down the regulatory pathway for a drug. It would be the first (mass produced) drug-eluding contact lens in the U.S.

“What’s transformational about it is that we cracked the code on how to do this,” he says. “The manufacturing process to do this was no small feat. We have a separate manufacturing facility (in Ireland) that was created exclusively for a drug-eluding contact lens. And we had to keep that separate from our normal contact lens because the (sterility) requirements are much higher than for a contact lens by itself. But we now have a blueprint and have proven we can do it. So, it really opens the door for a whole new capability for contact lenses.”

That is: Could the contact lens be a vehicle for the other types of drug classes that eye doctors use?

“What we know is that patients struggle sometimes to get an eye drop in,” Dr. Moody says. “Do they use it all the time? Are they compliant with using their drops? All of a sudden, that’s where it opens up the door. You think about glaucoma, about the anti-inflammatories we use and post-cataract surgery.”

At the forefront of innovation

Over time, Dr. Brujic has built up an impressive knowledge of contact lens innovation.

How did he do it?

By reading publications and the bombardment of emails in his inbox on the subject. He strikes up conversations with industry representatives at conferences such as Optometry’s Meeting^®. That has led to other introductions to influencers in various companies.

There are a few ways for doctors to be at the forefront of learning about new releases, according to Dr. Brujic: by leading a clinical trial in their practice; by providing pre-market feedback on products to contact lens makers; and providing post-market feedback.

Innovations are in the pipeline that can shape optometry, says Dr. Brujic, citing a number of potential “game-changers.” What about orthokeratology for myopia management? What about drops for myopia and presbyopia management? If punctal plugs can emit steroids, why can’t they deliver other drugs for other disease states such as glaucoma, he asks. Trials are now underway for a therapeutic for Demodex blepharitis.

We shall see if those can make it to the finish line, Dr. Brujic says. What’s important for doctors to understand is that the innovations are there and being comfortable enough to either utilize them or refer to practitioners who are comfortable using them, he says.

“It’s a really enriching way to practice,” Dr. Brujic says. “We have the ability to change patients’ lives with a single treatment. That’s cool.”