Talk to anyone in the contact lens business about the latest trends and extended depth of focus and myopia management will be close to the top of the list.

Sitting at the confluence of these two swelling streams is an emerging force in the contact lens business, Visioneering Technologies Inc (VTI). The idea for VTI was born in 2008 when Nasa aerospace engineer Dr Richard Griffin designed a contact lens for presbyopes that creates a virtual pinhole. Dr Stephen Snowdy came into contact with that idea and the fledgling firm while working for a US investment organisation designed to help entrepreneurs and start ups achieve commercial success. He led the company’s first institutional round of financing in 2008, joined its board that year and became CEO in 2013.

Dr Snowdy’s path to venture capital came via neurobiology, in which he holds a PhD and an MBA in finance. ‘I’ve always had an interest in things that happen above the neck and with the science and finance combination went into medical venture capital management,’ he says. The combination was to prove crucial in VTI’s development. In 2008 VTI was an embryonic idea of a business built around an extended depth of focus contact lens design. ‘It was barely a company at all,’ says Dr Snowdy. ‘When I came across it, as a venture capitalist, there was no product.’ A couple of experimental lenses had been tried in clinic on some presbyopic patients, those trials had worked well but the company simply consisted of the technical founder, he adds.

‘As a venture capitalist and someone who is interested in anything that affects the brain, especially vision, I said why don’t we just get this thing started proper.’ After securing the finance the next years were spent ‘iterating that design’ and sorting out manufacture. FDA approval for NaturalVue was achieved in 2015. ‘It’s gone from a back-of-the-envelope idea to a small global operation. It’s been quite a journey,’ says Dr Snowdy.

Shift to myopia

VTI initially started with a focus on presbyopia. ‘There was a need in the market for a multifocal contact lens that delivered less compromise between distance and near vision. What ended up happening at VTI is common at early-stage companies; medical need and the market showed us another opportunity,’ he continues. NaturalVue MF has the highest amount of peripheral add power available in a mass produced multifocal so practitioners adopted it to manage paediatric myopia. ‘In 2017 a group of practitioners published the first peer-reviewed data on NaturalVue, covering a case series of 32 children, demonstrating the potential as a tool in managing paediatric myopia. ‘We then used that data as a jumping off point to get a CE mark for myopia progression control in Europe, to get approved in Singapore and Australia and Canada, and registered in Hong Kong all with myopia progression control as a labelled indication.’

In 2016 VTI had a single product, NaturalVue MF, with $200,000 in revenue and 10 employees. This year it expects $7m in revenue with just over 20 employees, and has added sphere lenses and orthokeratology to its products available in the US through a tie up with Menicon. VTI’s soft lens products are now sold in the US, Europe, Canada, Singapore, Hong Kong and Australia. ‘We are still quite early in our launch and growth,’ adds Dr Snowdy.

The lens is quite different from other multifocal designs as it is a centre distance progressive design, he explains. ‘In other words, the distance correction is in the centre of the lens, and the relative plus power is introduced and increased smoothly as one goes from the centre of the lens. The distance and relative plus powers are not arranged in concentric rings, as is the case in other multifocal or EDOF designs. The lens was designed this way because the sharp optical edges between the powers in a concentric ring design may contribute to diffraction and diminished performance.’

Although NaturalVue MF was designed for presbyopia, practitioners who were at the cutting edge of myopia management saw greater potential. ‘People like Thomas Aller, Jeff Cooper, and Brett O’Connor, understood that a centre distance lens with high amounts of relative plus in the periphery may be helpful in managing progressive myopia in kids, and there was no reason to not try it given that the vision reported in children wearing NaturalVue MF is comparable to that of a sphere. The Eye and Contact Lens paper that was published in 2017 showing the potential of NaturalVue MF in a small group of children formed the foundation of a five-year data set showing long-term and continuing benefit in a larger group of children with no device-related adverse events.’

While some ECPs are happy to try it because: ‘You have to correct the myopia so why not?’, some are still looking to see more data and some will never be satisfied and that is what practitioners are like in any field, he says. ‘That’s where we tend to see the pushback.’

The efficacy of the lens in presbyopia has been easy to prove but myopia control is a tougher nut to crack. EDOF is very easy to prove to presbyopes, he says. You have a distance centre lens and as you move away from that you have a progressive add periphery. ‘It goes up very quickly and very high, starting off slow but then very quickly creating an area of blur around a central area of clarity. The visual cortex suppresses that blur and creates an area of central focus. Practitioners can test that quite quickly, so it’s not hard to overcome opposition to the concept.’ However, when it comes to myopia control that is a much harder concept to get across.

Wow factor

Dr Snowdy says there remain practitioners who are not invested in the concept of myopia management, but the industry is working hard to convince parents and practitioners that it is an important thing to do. ‘There are a lifetime of co-morbidities that come with myopia and the earlier you intervene the better; not everybody believes that yet.’ Changing attitudes means using trade shows and academic meetings but also getting into practices and talking to practitioners and creating data. ‘Quite often they [ECPs] will say “wow, I didn’t realise how far the data had come on,” others just want to see more.’

That means building long-term data in real-world settings with tens of thousands of wearers creating good starting points for conversations with practitioners and parents. ‘Adding ortho-k to our product offerings in the US further strengthens our messaging around myopia. We also participate in industry-wide efforts to educate practitioners and parents through organisations like the Global Myopia Awareness Coalition. And lastly, the large companies are making all of this easier through their marketing and educational efforts as they launch their own myopia management brands and portfolios of products for myopia management.’

He says using NaturalVue as a single solution for presbyopes and myopia management is an advantage over parallel branding. ‘I don’t think it’s confusing; it should be less confusing. A single product that can be used in the young, the old, and in the in-between in case of digital eye strain, is super-simple. Making it even easier, NaturalVue MF has a universal add, so the lens is fitted much like a sphere, regardless of the purpose of its use.’ Technically, from a regulatory and commercial point of view, he says, it also makes sense to continue to brand NaturalVue as a single product.

Multifunctional

Having a single product is equally practical from a stock point of view while certification is an important element in building ECP’s confidence. ‘NaturalVue MF contact lenses are CE marked in Europe for the correction of myopia, presbyopia and myopia progression control. That’s quite a bit of utility in a single product, saving space in the office, and simplifying lens selection. Also, given that NaturalVue MF has a universal add, fit sets are no larger than a spherical fit set. Myopia management is growing quickly as a new area of business that is both clinically and financially rewarding to the practitioner.’

‘Myopia is a life-time problem,’ he adds. ‘From myopia progression in the young, to digital eye strain in non-presbyopic adults, to the myopic patient who enters the unavoidable presbyopia. In all these cases there is the need to correct the distance vision, along with a concomitant issue that deserves attention, be it myopia progression, eye strain or near vision. NaturalVue MF is being used to address the needs of patients throughout the age continuum. The lenses are daily-disposable, making lens management as simple as throwing them away and opening a new pair.’

The job for VTI now is getting ECPs to fully embrace the concepts of EDOF and myopia management. On EDOF, Dr Snowdy says: ‘It’s always dicey to assume what people know; no matter what we assume with regard to practitioners’ understanding of specialty products, we’ll be wrong for a large chunk of the community.’ For this reason, VTI requires that practitioners who choose to include NaturalVue MF in their practices go through a training programme on optical design, EDOF concepts, and the fitting and troubleshooting of NaturalVue MF.

The picture is also still emerging on whether ECPs ‘get’ myopia management. ‘The short answer is some yes, many no,’ he admits. ‘Understanding myopia management is like any new skill in patient care; it takes effort on the parts of both industry players and practitioners. Awareness among practitioners of the clinical and practice benefits of myopia management are still early, but rapidly increasing. VTI and other industry and academic participants are busy publishing data, building portfolios of product choices and doing our best to educate practitioners and parents alike on why myopia must be viewed as a lifetime condition deserving of intervention at all of its stages.’

Around the world VTI has its own sales force but in the UK it works with Positive Impact. Lockdowns allowing, he wants to be knocking on as many doors as possible. The pandemic has not been the ideal time to launch something new like myopia management and it has impeded its partner Menicon’s Bloom launches in the UK and Europe. ‘However, we are now starting to see the sun peek above the horizon with opening economies, higher interest in myopia management and increasing sales.’

The UK will see a two-pronged approach with Positive Impact promoting NaturalVue and Menicon launching its Bloom platform across Europe and the UK. NaturalVue makes up half of that platform in the guise of the Bloom Day lens complementing Menicon’s ortho-k product.

Dr Snowdy says such collaborations will become more widespread as optical companies build portfolios of products like CooperVision’s move on Paragon to bring in ortho-k and a deal with Essilor to bring in spectacles. ‘The large companies are building a portfolio of products because one product is not going to fit all patients.’

For those ECPs still dragging their feet, Dr Snowdy has a message: ‘Even if it’s not our product, please do something proactive about myopia in your patients. Dig into the data and you will come away with compelling arguments. Even if you don’t believe the data, you have to correct the vision anyway so why not do it with something that is correcting the peripheral hyperopia and stands a chance of arresting the progress of the disease?’