How I Met Your Cornea

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Elvin Preston
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Throat 10,604 Podiatrists 7,260 Allergists 4,521 Pediatric Ophthalmologists 470 Copyright 2014 Carl Spear, April Jasper Total Distinctive Strategies and Leadership LLC 769,337 and All Unmet Needs &

1 Prescribed an ophthalmic drug once in the past year How I Met Your Cornea Carl H. Spear, OD, FAAO Pensacola, Florida COPE GO All Other Specialties 427,479 Primary Care 190,885 Pediatricians 49,400 Optometrists 31,620 Veterinarians 23,816 Ophthalmologists 19,876 Ear Nose & Throat 10,604 Podiatrists 7,260 Allergists 4,521 Pediatric Ophthalmologists 470 Copyright 2014 Carl Spear, April Jasper Total Distinctive Strategies and Leadership LLC 769,337 and All Unmet Needs & New Horizons for Vision Correction Is it a good time to be an optometrist? Would you tell your children to become an optometrist? % of US Population (w/vision Correction Needs) 100% 80% 60% 40% 20% Vision Correction and Eye Care Need States Presbyopia Astigmatism Myopia Conjunctivitis Allergies Dry Eye Glaucoma AMD Cataract 0% < Age of Population Opportunity: Treatment of Eye Care Conditions Opportunity and New Horizons for Vision Correction Key Solutions for Contact Lens Drop Out # of Doctors 50K 40K 30K 20K 10K Mil 40Mil 30Mil 20Mil 10Mil # Eye care Conditions % of US Population (w/vision Correction Needs) Myopia Prevention Breakthrough Health & Comfort Breakthrough Dry Eye & Presbyopia Contact Lenses Wear Vision Correction Dry Eye & Presbyopia Growth Cataract < # Ophthalmologist # Optometrist Age of Population Source: US Dept. of Distinctive Labor, US Strategies Dept. Health, and Education Leadership & Welfare, LLC All and Review of Ophthalmology * Select Eye Conditions are Diabetic Rights Retinopathy, Reserved AMD, Glaucoma, and Cataracts Source: Internal CIBA Vision Data Contact Lenses Vision Correction 1

Leveraging Contact Lens Innovation So Why Dry Eye?

0 Billion $5.7 Billion* *Data from 2010 Oct GfK. Assumes spherical annual purchase value of $59.66, of $115.32 and $181.37 New Horizons $2.

Population 19% 25% Spherical 56% Spherical Dry Eye 1.7 billion dollar market with artificial teas being nearly 1 billion in the U.S. Growing 10-11% per year $3.0 Billion $5.

2 Leveraging Contact Lens Innovation So Why Dry Eye? 4% ACTUAL Current Vision Correction by Contact lens type 16% 80% Spherical Spherical OPPORTUNITY Vision Correction Required by Contact lens Wearing Population 19% 25% Spherical 56% Spherical $3.0 Billion $5.7 Billion* *Data from 2010 Oct GfK. Assumes spherical annual purchase value of $59.66, of $ and $ New Horizons $2.7Bil fitting with the Optomized Modality 16% ACTUAL Current Vision Correction by 4% Contact lens type 16% 80% Spherical Spherical OPPORTUNITY Vision Correction Required by Contact lens Wearing Population 19% 25% Spherical 56% Spherical Dry Eye 1.7 billion dollar market with artificial teas being nearly 1 billion in the U.S. Growing 10-11% per year $3.0 Billion $5.7 Billion* *Data from 2010 Oct GfK. Assumes spherical annual purchase value of $59.66, of $ and $ Brands Purchased Most Often Recent Gallup Study of Dry Eye Sufferers Doctor Diagnosed (45%) Self Diagnosed (55%) 33% of dry eye patients diagnosed by a doctor purchase either a store brand or a redness reliever like Visine*. 1 Professional Brands Consumer/ Consumer/ Store Brands 66% Store Brands Professional 67% Brands 34% drops the wrong type of drop for dry eye 33% relief. 1 50% of dry eye sufferers choose redness relievers or allergy (n=338) (n=451) Based on third-party industry report, 2008-December 2013; Alcon data on file. Consumer/Store Brands include Private Label, Visine*, Clear Eyes*, Murine Tears* Multi-Sponsor Surveys, Inc. The 2008 Gallup Study of Dry Eye Sufferers: Distinctive Summary Strategies Volume. August and Leadership LLC All 2

this same thing 15 years ago Rumpakis J. New data on contact lens dropouts: an international perspective. Rev Optom. 2010;4:47-57.

3 Comfort...Unmet Medical Need History 35 year old white female Presents with FB sensation and general ocular irritation for 3 days Started in OD then OS History of this same thing 15 years ago Rumpakis J. New data on contact lens dropouts: an international perspective. Rev Optom. 2010;4: Do You Give a Recommendation or Just a Free Sample? Do Recommendation Leads to Purchase! 14% No 86% Yes Patient Stated They Received a Recommendation? 81% No There is a need to encourage ECPs to recommend the brand of the free kits they distribute. Nearly 60% Patients received a free kit sample but only 19% cite a recommendation was made. Symptoms FB Sensation No Pain Some Watering OD No redness or discharge Source: Q OPTI-FREE Brand Activation Consumer Survey Results, Steve Jagger Case 1 OD: Biomicroscopy Central diffuse epithelial opacities A/C Clear Slight FL Staining OS: Central diffuse epithelial opacities A/C Clear Slight FL Staining 3

Keratitis (Corneal infiltrate) Treatment / Management What would you do?

4 Biomicroscopy Treatment / Management What would you do? DDX Viral Keratoconjunctivitis (EKC) CLAARE Thygeson s Infiltrative Keratitis (Corneal infiltrate) Treatment / Management What would you do? Artificial Tears Steroid Restasis?? Bandage Lens Diagnosis What is the etiology? Thygeson s SPK 4

History of Dry Eye Eyes Red and Light Sensitive Symptoms FB Sensation Moderate pain Redness but no discharge Light

5 Case 2 OD: Biomicroscopy Central diffuse epithelial opacities A/C Clear Slight FL Staining OS: Central diffuse epithelial opacities A/C Clear Slight FL Staining History Biomicroscopy 42 year old white female Presents with FB sensation OU History of Dry Eye Eyes Red and Light Sensitive Symptoms FB Sensation Moderate pain Redness but no discharge Light sensitive DDX Viral Keratoconjunctivitis (EKC) CLAARE Thygeson s Infiltrative Keratitis (Corneal infiltrate) Filamentary Keratopathy 5

Diagnosis Filamentary Keratopathy What is the etiology?

Bacterial Keratitis Holly B. Hindman, MD; Sheel B. Patel, MD; Albert S.

ARCHOPHTHALMOL.COM 97 Treatment / Management What would you do?

Occlusion CONTROVERSIES The Case Against the Use of Steroids in the

6 Diagnosis Filamentary Keratopathy What is the etiology? Dry Eye Syndrome SLK RCE Treatment / Management What would you do? CONTROVERSIES SECTION EDITOR: LEE M. JAMPOL, MD Rationale for Adjunctive Topical Corticosteroids in Bacterial Keratitis Holly B. Hindman, MD; Sheel B. Patel, MD; Albert S. Jun, MD, PhD (REPRINTED) ARCH OPHTHALMOL/VOL 127 (NO. 1), JAN Treatment / Management What would you do? Debridement Artificial Tears Bandage Lens Acetlycysteine Punctal Occlusion CONTROVERSIES The Case Against the Use of Steroids in the Treatment of Bacterial Keratitis Elisabeth J. Cohen, MD (REPRINTED) ARCH OPHTHALMOL/VOL 127 (NO. 1), JAN

Steroids for Corneal Ulcers Trial (SCUT) NEI Study The pilot study showed better visual acuity and smaller infiltrate/scar size but longer re-epithelialization time with steroids treatment.

7 Steroids for Corneal Ulcers Trial (SCUT) NEI Study The pilot study showed better visual acuity and smaller infiltrate/scar size but longer re-epithelialization time with steroids treatment. All the adverse outcomes took place in the placebo group. However, none of the results were statistically significant due to small sample size. Two Red Eyes Steroids for Corneal Ulcers Trial (SCUT) The study is a randomized, double-masked, placebo-controlled trial to determine whether adding topical steroids to antibiotic treatment improves the outcomes of bacterial corneal ulcers. Bacterial corneal ulcers presenting to the Aravind Eye Hospital, the UCSF Proctor Foundation, and the Dartmouth-Hitchcock Medical Center will be randomized to receive antibiotic (moxifloxacin) plus steroid (prednisolone phosphate) or antibiotic plus placebo. They will be followed closely until re-epithelialization and then rechecked three weeks and three months later. Clinical Light Bulbs Don t Play Alphabet Soup CLAARE CLPU ARE MK TLS CLOS Infection or Inflammation? Look at tear meniscus SCUT Update CONCLUSIONS: We found no overall difference in 3-month BSCVA and no safety concerns with adjunctive corticosteroid therapy for bacterial corneal ulcers. CASE 3 History: Young female presents to the office with excruciating pain, photophobia and decreased vision in OD. Arch Ophthalmol Feb;130(2): doi: /archophthalmol Epub 2011 Oct 10. Pt. was getting ready for work and slipped with her curling iron. Hit cornea and lid. 7

8 Biomicroscopy Corneal Debridement Indications Traumatic Corneal Abrasions Recurrent Corneal Erosions Corneal Burns Following FB Removal Herpes Simplex Keratitis Biomicroscopy What would you do? A. Patch/Antibiotic B. Bandage CL/Antibiotic C. Patch/Combo D. Bandage CL/Combo E. Antibiotic alone F. Combo alone G. Artificial tears Why Debride? Wound Management Increase Healing Reduce RCE 8

9 Procedure Instill Anesthetic Antibiotic NSAID Pull defect toward center Roughen basement membrane Post Debridement Cycloplegic Antibiotic Pressure Patch? Anterior Stromal Puncture Indications Recurrent Corneal Erosion Theory ASP Procedure Debride Cornea Use Anterior Stromal Puncture Needle or 25 ga Needle 9

10 ASP Procedure Start at edge of defect and work toward center Multiple punctures within the area Post ASP Cycloplegic Antibiotic NSAID Pressure Patch Long Term Hyperosmotics Artificial Tears Cornea-Copia Clinical Light Bulbs Corneal Trauma What happens? Prostaglandins and other mediators are released Results in Pain Miosis Decreased IOP 10

11 Pain Management Stop before it starts Topical NSAIDS Oral Analgesics Chemical Burns Immediate Irrigation DO NOT CHECK VA History, History Acids Bases Abrasion Management What do you do? Patch Bandage CLs Collagen shield? Nothing at all Irrigation Saline In Bottles Water Whatever you have Any Indication For Oral Antibiotics? The Morgan Lens History Scleral mold lens Attatches to IV bag Continuous irrigation

12 Chemical Burns After Irrigation Check ph with litmus paper FL stain and evert lids IOP Antibiotic After Irrigation Cycloplegic Pain Management Steroids Anterior Segment Grand Rounds Quick Hitters The Morgan Lens Indications Irrigation of Chemical Burns Delivery of Antibiotics Contraindications Suspected Penetrating FB 12

13 Have You Flipped Your Lid Another One Anything Different? What would we do prior to removal? Have You Flipped Your Lid Another Quick Hitter 7 yo male with this presentation 13

Case Study Treatment Strategy 81 Year Old Female Severe Dry Eye, Exposure Keratopathy (OD>OS) No response to Drops (Restasis ) or Punctal Plugs Treatment

What Are Biologics? 52 year-old female presented with ocular pain and blurred vision (20/200) for 2 weeks.

Treatment Strategy Epithelial debridement to remove loose epithelium (Fig.

14 PROKERA SLIM Incorporates New ComfortRING Technology for an optimal patient experience Slim profile designed to contour to the ocular surface Elegantly designed to move with the eye Maximizes amniotic membrane contact with the cornea, limbus, and limbal stem cells The Sooner the Better Dry Eye with Exposure Case Study Treatment Strategy 81 Year Old Female Severe Dry Eye, Exposure Keratopathy (OD>OS) No response to Drops (Restasis ) or Punctal Plugs Treatment Strategy PROKERA SLIM was inserted OD for 1 week PROKERA SLIM Removed: The eye was quiet, with a crystal clear cornea Recurrent Corneal Erosion Final Cases What Are Biologics? 52 year-old female presented with ocular pain and blurred vision (20/200) for 2 weeks. She had a history of similar attacks & diagnosed as RCE. Epithelial debridement, lubricants and BCL failed to relieve pain and halt recurrence. Treatment Strategy Epithelial debridement to remove loose epithelium (Fig. A, B) followed by placement of PROKERA SLIM On the 2nd day, the patient had no pain. Complete healing occurred within 3 days, resulting in clear cornea and 20/20 vision. A smooth surface remained stable with no recurrence for 13 months follow-up (Fig. C, D) PROKERA should be considered after lubricants have failed 14

15 MEDICARE COVERAGE Thank you for your attention! 15

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