Mile Brujic, OD, Talks Dry Eye, Presbyopia Ahead of SECO 2023

Optometrists from all over the country are preparing to attend the 2023 SECO conference in Atlanta, GA. Optometry Advisor spoke with Mile Brujic, OD, one the meeting’s top speakers, to discuss recent advances in dry eye and presbyopia treatment, as well as scope of practice changes affecting the profession. 

Dr Brujic will be presenting on “Paradigm Shifts in Presbyopia: Understanding Advances in Topical Treatment Innovations” on Thursday March 2, and “Learning About the Lid: Optimizing Recognition, Diagnosis, and Treatment of Demodex Blepharitis & Blepharoptosis” on Saturday, March 4 in Atlanta.

It appears that a lot of dry eye treatments have been developed within a relatively short amount of time and more drops are making their way through the 2023 pipeline. Is there a treatment you’re particularly excited about?  

Dr Brujic: First and foremost, we now have an established platform of treatments both pharmaceutical and what I’ll call “procedural based” treatments, which is good. It’s given a lot of people a lot of new options and opportunities, but there are some really interesting things that are coming down the pipe in 2023, 2024, and 2025. The one that’s most recent — there are 2 —  Aldeyra has a [reactive aldehyde species] RASP inhibitor that I think they’ve officially submitted for a new drug application to the FDA, and Bausch + Lomb has a new medication which, if it gets approved, could be the first one for meibomian gland dysfunction and treating that condition. So there’s real interesting innovation in the pharmaceutical space and things that seem to look, just from a mechanism of action perspective, very different from what we currently have. They’re not what I would consider “me too” technologies  — they’re really challenging the status quo. 

Pilocarpine treatment for presbyopia is a relatively new concept. Do you find that some individuals with presbyopia may respond better to this treatment than others? 

Dr Brujic: One hundred percent. So the ideal candidate for the presbyopia drops are those individuals who do not require any type of distance correction or have an insignificant amount of distance correction, and all they require is some type of near power or near add because of presbyopia. These patients absolutely love the drops. The benefit to them is that they work. The disadvantage is that they have some endpoint, meaning throughout the day at some point the drops will “wear off.” 

My second (if you’re putting them on a tiered priority list) favorite patients [for presbyopia drop treatment] are those individuals with low levels of either myopia or uncorrected astigmatism. Oftentimes, these individuals will say, “Wow, these drops not only make my near vision better, but they also make my distance vision better.” 

My third category includes individuals who are in contact lenses and maybe haven’t responded well to multifocal lenses. There’s now an option for these individuals where we can correct their distance vision. After they’ve placed the drop in their eyes, it gives them an alternative as well, so there’s all these facets for patients with this drop. But again, just like everything, you have to balance that with both the benefits against the potential risks and also some of the disadvantages as well. And that requires a little bit of a discussion in the exam room with patients. 

And what would you say are some of the risks and disadvantages? 

Dr Brujic: If somebody says, “I want to use 1 drop and I want it to last all day,” that’s going to be a very tough bar to meet — and they will likely be dissatisfied. In our experience, the drops last anywhere from 4 to 10 hours for patients, so at some point, you will see a reduction in efficacy. The other thing is, as is true with any miotic, the increased risk seems to be a retinal detachment. So one of the things we need to make sure that we’re doing clinically, which isn’t anything outside the realm of optometry or ophthalmology, is just making sure these individuals have healthy retinas. If there are any types of underlying risk factors for retinal detachment, proceed with those individuals very cautiously. Some of those underlying risks are lattice degeneration, any type of thinning of the peripheral retina, any previous history of tears or holes, or diabetic retinopathy. These are really drops that are built for the healthy individual, the nondiseased patient. 

Optometry’s scope of practice legislation has changed in the last few years, with some states allowing optometrists to perform certain laser procedures and prescribe oral medications. How has this affected optometry’s status as a medical profession? 

Tremendously. We are very quickly not only putting our stake in the ground as a key profession, but deepening the stake within the health care space and also really understanding our role within health care. We’re clarifying that more. Ophthalmology, at this point, is seemingly wanting to spend more time in the operating room, for the need that’s there. The baby boomers are needing cataract surgery at high clip. And because of that, they need to be spending more time in the surgical suites. And that means that a lot of the other care is going to be taken over by other individuals, including optometry. So what I feel we’re doing is really stepping up to the challenge and saying, “Yup, this is something that we’ve been trained for.” We just need to make sure that the scope appropriately represents how we’ve been trained in the states that we practice. And that’s why I think it’s really interesting for optometry, because I think that during my lifetime, I will practice in a world where all states have minor surgical privileges and all states will likely have some form of laser privileges. 

What’s next on the horizon for scope of practice changes and where may we see these changes implemented?

Dr Brujic: What I would tell you is that, for the states that currently have expanded scope for minor surgical procedures and lasers, take a look at those states. All of the states that don’t have those privileges are actively looking into acquiring those privileges. So, I think that it’s going to be much more uniform moving forward in the next 10 to 20 years with respect to what optometry’s scope is, because you can literally walk over a state line and you would lose your ability to do several things. You walk back over that state line, and you can do whatever you want to, and that’s nonsensical. It’s a line that draws a difference in law, but the practitioner hasn’t changed, so I think that really needs to change, and I think it will. But again, just take a map of the current state laws and wherever they’re limited. All of those states are likely looking to increase scope and putting efforts towards that.  

Disclosure: Mile Brujic, OD, has received honoraria from Aldeyra and Bausch + Lomb Health.