Behold, the Power to Reverse Mydriasis Is Here!

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Mydriasis Reversal Drop Now Available in US

Viatris has announced the US commercial launch of phentolamine ophthalmic solution 0.75% (Ryzumvi) to treat pharmacologically induced mydriasis produced by adrenergic agonists (eg, phenylephrine) or parasympatholytic (eg, tropicamide) agents.

Initially FDA-approved in September, Ryzumvi was evaluated across two random, vehicle-controlled, double-masked MIRA-2 and MIRA-3 clinical trials. The drug’s onset of action was found to occur in roughly 30 minutes. Ninety minutes after administration, 49% and 58% of patients who were administered two drops of Ryzumvi returned to < 0.2 mm of baseline pupil diameter compared with 7% and 6% who were administered a placebo, respectively.

My Two Cents

It will be wonderful to tell patients that we do in fact have “that drop that reverses dilation.” After being routinely asked for this drop for the past 11 years of clinical practice, I’ll finally have an answer that patients will appreciate.

I do, however, have a few questions about the product. First off—and it’s probably a dumb question, as I usually seem to have, but—I noticed the indication for the drop is “for the treatment of pharmacologically induced mydriasis produced by adrenergic agonists or parasympatholytic agents.” What about hydroxyamphetamine hydrobromide and tropicamide (Paremyd, Akorn) drops or compounded combination drops (such as the ones we get from Imprimis) that have phenylephrine and tropicamide? Would this drop be considered “off label” to reverse patients dilated with combination drops? Also, what’s the price point? Do practices bear this cost, or do we charge patients for the dilation reversal? If that’s the case, how will patients feel about us dilating them and then “selling them the antidote?” Lots of questions about a fascinating product. Great job, Viatris! I can’t wait to learn more.

OUTSIDE THE LANE

Private Equity Under the Microscope

The Private Equity State Risk Index revealed the significant influence of private equity (PE) firms on various sectors, including health care. Over the past decade, the PE firms analyzed spent $1 trillion (with a “t”) acquiring health care companies across the United States, often loading them up with substantial debt in an effort to sell them at a profit within 3 to 5 years. Critics of PE argue that this drive for profit conflicts with proper patient care and has led to recently increased scrutiny from legislators, anti-trust enforcers, and patients.

One example given in an NBC News article is Conemaugh Health System, a hospital chain in Pennsylvania that was acquired by the large PE firm Apollo Global Management in 2018. The article profiles patients who state that the care at the health system since that ownership transfer has declined. These patients report experiencing overnight waits in the ER and difficulty getting through to anyone who can answer billing questions, among other issues.

The study also highlights the broad reach of PE firms beyond just health care, including areas such as grocery stores/supermarkets, child care, senior living centers, fast food operations, rental housing, and veterinarians. These PE groups' involvement in different industries is extensive; NBC News recently estimated that staffing companies owned by PE firms operated 40% of the nation’s emergency departments. Quite stunningly, by 2030, according to a MetLife estimate, companies backed by PE may own 40% of the nation’s single-family homes.

The impact of all such acquisitions has also come under more scrutiny recently, with two Senate inquiries focused on whether such financial deals may be harming the American public, specifically their health care.

CAN YOU RELATE

Medical and vision insurance providers sure are getting crafty at avoiding paying for services and medications for their patients/enrollees. Recently, I had a few scripts for cenegermin-bkbj ophthalmic solution 0.002% (Oxervate, Dompé) denied because I didn’t perform a corneal sensitivity test with an actual corneal esthesiometer, such as the hand-held Cochet-Bonnet device. After exhausting my contacts to find one of these instruments, I took to LinkedIn, where I encountered roadblock after roadblock trying to purchase one. I was still without a corneal esthesiometer and had patients calling my team and my office, blaming us for the delay in their payments.

As you can imagine, I was so excited to learn that the global pharmaceutical company Brill plans to launch its noncontact, portable Corneal Esthesiometer Brill in May. This device uses a controlled puff of air and patient feedback to determine the presence of reduced corneal sensitivity/neurotrophic keratitis. The handheld machine could be a game-changer in the Williamson clinics, not just my dry eye clinic. Our glaucoma doctors could use it to test baseline corneal sensitivity before beginning their patient on topical pressure-lowering meds, our refractive surgeons could use it to determine if there is any reduced sensitivity before surgery, and, of course, every patient with dry eye should be tested.

Now, the elephant in the room is reimbursement. There is no CPT code for corneal sensitivity, although it very clearly deserves one. With medical insurance demanding that the test be performed with an expensive machine, insurance companies should be willing to pay us for this extra clinical expense and time. If they want us to run a test to prove that a patient has a disease, they should help us provide the best patient care.