JIM MAZZO UNDERSTANDS THE LANDSCAPE OF EYE CARE in a way that makes him one in a million. He is a consummate professional, has an impeccable work ethic, and is a relationship builder between doctors as well as between clinicians and industry. His insights are on target, and we are fortunate to have Jim’s perspective on the growing technologies in the presbyopia market. Take a look at Jim’s refreshing input!

Presbyopia Physician: Is it helpful, or confusing, to doctors, to have not only expanding options of intraocular lenses (IOLs) but also enhancement options within each class, such as extended depth of focus (EDOF), toric, refractive, pinhole, etc.? And can these options be utilized to work well together?

James Mazzo: We’re at a point today where we need to manage the entire patient experience. When a practitioner understands and appropriately addresses a patient’s disease state, then a realistic expectation can be set for the best IOL option.

Historically, industry often overpromised, but couldn’t deliver on these promises, and saw it as an all or nothing approach. Everyone should use ReZoom, ReSTOR, Tecnis Multifocal, or Crystalens. But now doctors understand the segmentation in the companies much better. If you look at RxSight, for example, they have a very good technology coming to market, but it won’t be a solution for everyone. It has limitations due to capital costs for the doctor and pricing for the patient. But for certain patients, it will provide an excellent opportunity for care.

PP: Are doctors showing interest in using these newer options? What can you do to increase their interest in trying them?

JM: I give both the doctors and industry a lot of credit because they have been able to crystallize a strategy for how new options fit into a practice. Doctors must develop a plan for selling the product without reimbursement. But the environment has been very supportive, and COVID actually accelerated the penetration of these products into practices. In the US, there has been consolidation of private equity, and the pandemic accelerated revenue in practices despite there being fewer procedures. So the understanding and the resistance for these product lines have actually increased.

Positioning, education, and practice expansion of these products have been instrumental for increasing the network. Really great practices have clearly identified the available modalities, resulting in additional success.

These modalities now include a trifocal, from Alcon, and there will be others. There is RxSight with the Light Adjustable Lens and various media for EDOF. STAAR has introduced their phakic to the US market, and we’re soon going to have the small aperture IC-8 from AcuFocus, which will be placed in one eye and then complemented with a monofocal in the other.

For all these technologies there is a cost, and a patient mindset must be understood to successfully penetrate the market. EDOF lenses may have a bigger opportunity than the more specialized lenses because they create a broader range. Clearly, positioning of each product will be important.

But when you talk about refractive IOLs, still the greater growth engine on a pure number is toric. The rest of these IOLs have some compromise because they’re not mimicking the natural eye. Toric lenses have improved, and we’re starting to see growth with these options, which is a patient pay product line.

We can no longer look at these modalities in a singular fashion. They’re complemented by products, practice, and position. And of course, it’s no longer just about IOLs and contact lenses when we talk about this market. We now have presbyopic drops, and these drops need to be positioned.

PP: How will the pharmacologic drops fit in? Do you think the addition of pharmacologic treatments will drive the surgical side?

JM: I believe presbyopic drops are excellent for the marketplace, and it provides another option for patients to have spectacle independence. This will drive surgical procedures, and some practices are positioning clearly for use as indicated. But doctors are also using the drops to help their IOL growth. A patient receives the drops, which gives them their spectacle independence, and they’re able to read the restaurant menu or drive their automobile, but it doesn’t last forever. When the patient tells the doctor how much they love the drops, the doctor can offer a permanent solution with an IOL.

PP: What are the challenges that will impede the growth of this market?

JM: One challenge that I want to emphasize is that we are not spending enough time on the external ocular environment of dry eye. If a practitioner has not clearly identified the dryness of the ocular environment of a patient, then a refractive IOL is not going to meet the needs of that patient. If that ocular environment is dry, and it has corneal edema, it will be difficult to manage that patient to the best degree. But I still don’t see this addressed on a consistent basis.

I would like to see more dry eye medications. Right now, we only have 2 on the market. Over the counter drops are good but not great, and we need a couple more diagnostic tests on the market to help identify the problems with the ocular environment. Without proper identification and treatment of those problems, the success ratio of these other great products is limited.

In this armamentarium of IOLs, presbyopic drops, and including LASIK and SMILE, have dry eye mechanisms as part of the treatment. We have great products, like TearLab’s osmolarity test, which was one of the first diagnostics. We’re getting better capital equipment to check the cornea, and better modalities, such as the heat environments, but I still see this disjointed in a practice, meaning they have dry eye in one place and refractive IOLs in another. They should be in the same modality.

And the other major barrier I would point out is more patients with fewer doctors, so the practice needs to be set up with an administrative team to create a positive and efficient patient experience.

PP: What do you see as the future of monovision? Maybe using a monofocal in one eye and something else in the other?

JM: The term monovision means a lot of different things to people. I don’t refer to it as monovision but as a customization of the ocular environment. Doctors are understanding what the best modality is for a patient and deciding if they can mix and match options. For example, do you put the IC-8 in one eye and a monofocal in the other eye? Do you overcorrect in one eye and undercorrect in the other in a SMILE or LASIK procedure? I really like what the practitioners are thinking about now, and companies are doing a great job of customization too.

Contact lenses are still an important part of our business. Great practices have an OD/MD relationship and are using contact lenses. So we’re seeing enhancements to these, the IC-8s of the world, and RxSight, who are locking in each eye differently. And then you can do a little mix and match. There are many technologies entering into what I call customization.

PP: What is on the horizon that you’re excited about?

JM: Another piece on the medical side is genetic testing. Avellino has the first genetic test in ophthalmology. I was CEO of this company and am now an advisor, and I think genetic testing is going to be the next big opportunity in our space.

They have a test for keratoconus, AvaGen. If you’re a keratoconus patient, your cornea may be too compromised to have a refractive IOL procedure. AvaGen can identify if a patient’s children have it, so the condition can be managed from an early age, which can allow the patient to have the benefits of refractive IOLs when they’re ready.

We’re going to have genetic testing in glaucoma, and we’ll have it in age-related macular degeneration (AMD), which is a contraindication for refractive IOLs. Again, looking at the holistic approach, a patient needs to be able to count on their physician to provide the best procedure. This needs to include a genetic test when available, dry eye testing and management of any ocular surface issues, and then correctly managing refractive issues.

With that approach, I truly believe what these great companies and great doctors are doing with the proliferation of new products will allow this category to double. But if we don’t manage conditions up front, with the proper diagnostics and identification of the patient’s genetic structure, we won’t harbor the opportunity to really make an impact.

PP: What other opportunities are coming?

JM: We’re still on the frontier of several serious diseases that we’re trying to treat. Glaucoma, AMD, and macular telangiectasia are good examples. There are great companies developing technologies to address these. Going back to the holistic approach, we have to manage the patient and the patient’s family, and we can no longer think that we’re only doing it product by product.

Another very important part of this is the digital side. I’ve always said he or she who captures the data will win, and digital is flipping the equation. Digital will allow a patient to walk into a doctor’s office, and that doctor will already have the patient history to help evaluate treatment and management options. Artificial intelligence is also providing practitioners with information on how patients in the same demographic categories are being treated.

With doctors looking at glaucoma and retina and other conditions, digital becomes the real critical component because products will follow suit with what the patient state is telling us. ■

James V. (Jim) Mazzo is executive chairman of Neurotech, a retinal implant company; an advisor for Zeiss, Bain Consulting, and Avellino; and executive chair for Centricity Vision and TearLab. He is one of the ophthalmic industry’s best-known and most respected business leaders with more than 40 years of proven experience and a global reputation for building and running world-class organizations.