Myriad applications for new ptosis drug
Bacharach is co-director of the glaucoma division at California Pacific Medical Center, San Francisco, and founding partner at North Bay Eye Associates, Sonoma County, Calif.
Disclosures: Bacharach reports he is a consultant/advisor to Aerie, Allergan, Bausch + Lomb, Eyepoint, Eyevance, Glaukos, Humphrey-Zeiss, Imprimis, Injectsense, Iridex, New World Medical, Ocular Therapeutix, Omeros, Osmotica/RVL, Santen, Topcon and Vertical; receives lecture fees from Aerie, Allergan, Bausch + Lomb, Bryn Mawr Communications, Evolve, Iridex, Sun and Vindico; receives grant or research support from Aerpio, Biorasi, Equinox, Eyepoint, Glaukos, Injectsense, Insite Vision, Kala, Lexitas, Nicox, Novartis, Ocular Therapeutix, Oculis, Oculos, Ocuphire, Ora, Orasis, Osmotica/RVL, Perrigo, Salvat, Santen, Sight Science, Sun, Surface, Tarsius and Trefoil; and has equity/stock ownership in OnPace.
In July 2020, the FDA approved Upneeq for acquired blepharoptosis in adults. After having participated in the clinical trials, I am now finding it has significant clinical utility in my everyday practice — see my previous blog on Upneeq.
At first, I saw it as a drug that would mainly be used by oculoplastic surgeons, but now I understand that the applications are tremendous. A large population of patients with lid droop are eager to try this product — from younger people to seniors to everyone in between. For example, with the explosion of Zoom meetings during the pandemic, many patients have requested the drop to help look more alert on the computer screen.
The on-label application for Upneeq (oxymetazoline hydrochloride ophthalmic solution 0.1%, RVL Pharmaceuticals) applies to a vast patient population, and the almost instant lid lift makes a big difference to them. The clinical trial participants could not wait to have access to the product once it was commercialized. Now with more experience, I am identifying more opportunities to implement it in practice.
Often after cataract or glaucoma surgery, patients will develop postoperative ptosis. We may examine the patient in the lane and tell them their visual acuity is 20/20 and the surgery was a success, but they have a droop. Traditionally we had to tell patients to wait 6 months to a year to see if it will resolve, and if not, refer to an oculoplastic surgeon. Patients who have spent significant money out of pocket for a premium lens might wind up with great vision, but they have a droopy eyelid. That is going to temper their enthusiasm and great Yelp reviews. By using Upneeq in these postoperative ptotic eyes, we can help make a patient much happier and less concerned with the total surgical result. Even if the result is not permanent, it can get patients through to when they can have a more definitive correction if desired or needed. I think Upneeq offers a huge clinical opportunity for doctors to manage a postoperative pickle. One of the resident surgeons from California Pacific Medical Center and I put a case series together utilizing Upneeq for postoperative ptosis and published it online in the Journal of Cataract and Refractive Surgery.
This novel on-label treatment option is easy to prescribe because it is supplied through a specialty pharmacy, RVL Pharmaceuticals, owned by Osmotica. There is no insurance involved, and the company has set a reasonable price point. The company contacts the patient directly, removing some of the hassles with prior authorization and substitutions. It streamlines operations for our office.
Clearly this drug has applications outside of ophthalmology and could be important to a variety of subspecialties like aesthetics and dermatology. When RVL launched Upneeq, the company made the intentional decision to work with eye care practitioners first as its primary target audience. It wants to develop those relationships because it believes that we, as a profession, can be great partners and help introduce Upneeq to the rest of medicine.
Ophthalmologists are innovative, and we will find applications for the drug beyond what was included in the clinical trials. RVL Pharmaceuticals has hired a top-notch team to roll the product out, and it is growing the company around the asset.