Teprotumumab, Enhanced Monofocal IOLs Among Hot Topics at AAO 2021

During a session on hot topics, speakers presented the most cutting-edge technologies from across subspecialties at the American Academy of Ophthalmology 2021 annual meeting.

In January 2020, the FDA approved teprotumumab, sold as Tepezza, the first therapy for thyroid eye disease (TED), an autoimmune disorder that can cause vision loss. In the past, patients with TED have been treated with steroids, radiation, immunosuppression, and surgery, explained Anne Barmettler, MD, associate professor, director of oculoplastic surgery, Albert Einstein College of Medicine, Montefiore Medical Center.

During her presentation, Barmettler provided insights what clinicians have learned since teprotumumab’s approval and compared real-life experiences from around the country with the outcomes from the study.

Most patients are showing improvements in real life after being treated with teprotumumab for TED, especially with proptosis, she said. The therapy also has been shown to help in cases of chronic noninflammatory thyroid eye disease.

However, the improvements are not 100%. For instance, while proptosis is markedly improved, it may still be there. “With that information, it’s not surprising that some patients will still go on to need surgery after infusions and some patients are recurring,” Barmettler said.

In addition, the therapy is expensive. The full treatment for a patient is more than $300,000. As a result, there is an extensive prior authorization (PA) process that takes a lot of time to get through, she said. Insurance may require certain criteria be met, such as a clinical activity score of greater than 4 or that the patient fail on prior steroid therapy.

As an infused therapy, there is also the logistics of treatment. It can be infused at the hospital, an infusion clinic, or at home. But once the PA goes through, it’s specific to the infusion location, Barmettler explained. If you need to change the location of infusion, you need to start the PA process all over again.

“Teprotumumab can improve most of your patients but it’s very, very expensive, and you have to time the infusions,” she said. “And because of prior authorizations and logistics, it does take a while to start. This delay should be considered while planning this.”

Another presentation during the hot topics session focused on enhanced monofocal intraocular lenses (IOLs), which has seen a lot of change recently in the extended depth of focus (EDOF) category, explained William F. Wiley, MD, medical director, Cleveland Eye Clinic.

“I feel like we’ve seen more lenses come to market in the past 2 years than we’ve seen in the past 10 years,” Wiley said. “So, it’s an exciting time to be in ophthalmology.”

For monofocal lenses, there is great, high-quality vision, because they focus all of the light to the back of the eye, but minimal focus. On the other hand, multifocal lenses have high quantity of vision, but low quality. These lenses cause glare, halo, and other unwanted side effects, he explained.

“I see the extended depth of focus category sort of bridging the gap between that monofocal and multifocal IOLs,” Wiley said. “In general, it's designed to increase the depth of focus by minimizing the side effects.”

There are a few different EDOF categories. First is spherical aberration. Instead of pushing all the light onto the retina, this extends the light in front of or behind the retina, which extends the depth of focus. Both the cornea and lens contribute to spherical aberration, so ophthalmologists have to look at the total eye and choose a lens based on the cornea to match, contribute, or negate some of the corneal spherical aberration, Wiley noted.

For diffractive optics, there is EDOF, but there tends to also be negative dysphotopsia—when a dark rounded bar or shadow appears in the visual field. This also occurs with multifocal lenses.

There are a few lenses in the zonal optics category. These lenses have the ability to extend the depth of focus while limiting the side effects that occur with multifocal IOLs.

Finally, aperture optics is a category that Wiley hopes to see in the United States in the next year. This uses pinhole technology to extend the depth of focus and has application in more complicated eyes.

All of the EDOF lens categories strike some sort of balance, Wiley said. While these are exciting times, ophthalmologists should proceed with caution and consider certain questions before proceeding. For instance, will the lens decenter? Are the patient expectations appropriate? What will you gain or lose?

“I think it's great to have so many IOL options; I think we should understand our patient's goals, choose an opportunity to increase visual function, understand that what the technology can and can't do, and understand there are advantages and disadvantages to all these lenses,” he concluded.