Friday, October 30, 2015

Coming soon to an ECP near you: Cheaper Lipiflow?

Seems probable...

TearScience® Announces New Pricing Strategy For Core LipiFlow®Technology Used For Treatment Of Dry Eye From Meibomian Gland Disease (MGD)


MORRISVILLE, N.C.--10/28/15 - ()--TearScience, a privately held medical device company, has announced a 50% price cut, effective immediately, on the single-use activators used with the LipiFlow treatment platform for Meibomian Gland Disease (MGD). The move is just one component of an overall strategy to make the LipiFlow and LipiView® Technologies more accessible to Eye Care Professionals (ECPs), who can then, in turn, use them to evaluate and intervene earlier in MGD for the benefit of the millions of individuals suffering from this chronic and progressive obstructive gland disease.

After recent unprecedented growth in use of its LipiFlow technology, TearScience is achieving the economies of scale necessary to reorganize and expand its supply and manufacturing capabilities. Furthermore, TearScience brought on board a new management team with a renewed mission to meet a market need of technology and treatment accessibility. Earlier this year, TearScience lowered the price of its technologies and removed imaging fees....

Wednesday, October 28, 2015

Way to save money on eyedrops?

SimplyTouch eyedrop applicator...

$12.50 is awfully steep for a little bitty thing. On the other hand, if you're spending $300 a month on Restasis, it could pay for itself on the very first use....


Better symptom results from latest study of Shire's Lifitegrast dry eye drug

Shire will be resubmitting its application to the FDA early next year on the strength of these improved results.

Shire's OPUS-3 Phase 3 Trial with Lifitegrast Meets Primary and Key Secondary Endpoints, Significantly Reducing Patient-Reported Symptoms for Dry Eye Disease


...."The results from OPUS-3, where lifitegrast demonstrated symptom improvement as early as two weeks, provide compelling efficacy data that contribute to the totality of evidence from the lifitegrast clinical development program, now the largest for an investigational stage compound in dry eye disease with more than 2,500 patients," said Philip J. Vickers, Ph.D., Head of Research & Development, Shire. "We believe the data from OPUS-3 will satisfy the FDA's request for an additional clinical study. We welcome the opportunity to share these positive data with the regulatory authorities."

Recent study: TBUT lower in women with PCOS

Eur Rev Med Pharmacol Sci. 2015 Oct;19(19):3556-62.

Abstract

OBJECTIVE:

Complaints of dry eye are prevalent worldwide and are known to be associated with insulin resistance (IR) and hyperandrogenism. However, dry eye is often overlooked in the context of polycystic ovary syndrome (PCOS). The aim of the present study was to evaluate whether or not there is any relation between tear functions and PCOS, which is a multifaceted disorder associated with IR or hyperandrogenism.

PATIENTS AND METHODS:

A total of 35 women with polycystic ovary syndrome (PCOS) were enrolled in this study, along with 27 healthy controls. Body mass index (BMI), follicle-stimulating hormone (FSH), luteinizing hormone (LH) and free testosterone levels on the third day of menstruation were recorded, as well as hirsutism score (using the Ferriman Gallwey scoring system), insulin resistance (homeostasis model assessment), neutrophil-to- lymphocyte ratios (NLR), platelet-to-lymphocyte ratios (PLR), and mean platelet volumes (MPV). A complete ocular examination was followed by administration of the ocular surface disease index (OSDI) questionnaire and Schirmer and tear break-up time (TBUT) tests.

RESULTS:

Schirmer and OSDI results were similar between groups, but TBUT was significantly lower in the PCOS group (p = 0.002). There were negative correlations between FG score and TBUT test (r = -0.406, p = 0.001) and between NLR and Schirmer test (r = -0.294, p = 0.025).

CONCLUSIONS:


Although subjective dry eye symptoms do not present in all patients, these results confirm that tear reduction, which can cause further complications in patients with PCOS, can be detected by careful examination and sensitive tests.

PuriLens Plus in place of Unisol 4

Just a quick update to my last - 

There is a product that is apparently identical to the quickly-disappearing Unisol 4: 

PuriLens Plus. 
Sold in a 4 oz bottle. 
$2.95 to $3.95 depending on quantity.

Tuesday, October 6, 2015

Unisol 4 being discontinued

Alert for PROSE & scleral lens users who use Unisol 4 to fill their lenses:

I had been getting reports from customers that Unisol 4 is getting scarce or has been discontinued. I called Alcon today to get the skinny. They said yes, it is being discontinued, officially as of December this year and at this time they have no plans for a replacement.

Obviously it's already disappearing from shelves. Those who use it... it's definitely time to stock up unless you have an acceptable alternative that you already know of.

I have a couple of alternatives in the DryEyeShop - Addipaks (5mL), and Modudose (5mL and 15mL) which I sell in small quantities for people to try. If you need a Unisol replacement though be sure to check with your eye doctor first.

Thursday, August 27, 2015

Ointment recall alert: Refresh PM, Lacri-Lube, FML, Blephamide



FOR IMMEDIATE RELEASE - Dublin, Ireland – August 24, 2015 – Allergan plc, today announced that it is conducting a voluntary recall down to consumer level of specific lots of its REFRESH® Lacri-Lube® 3.5g and 7g for dry eye, REFRESH P.M.® 3.5g for dry eye, FML® (fluorometholone ophthalmic ointment) 0.1% (sterile ophthalmic ointment topical anti-inflammatory agent for ophthalmic use, 3.5g), and Blephamide® (sulfacetamide sodium and prednisolone acetate ophthalmic ointment, USP) 10%/0.2% sterile topical ophthalmic ointment combining an antibacterial and a corticosteroid, 3.5g.
Allergan chose to initiate this recall based on a small number of customer complaints which reported a small black particle at the time of use. This black particle, which is part of the cap, can be created by the action of unscrewing the cap from the aluminum tube, and potentially introduced into the product. Reported adverse events include Foreign Body in Eye (12), Eye Irritation (2), Ocular Discomfort (2), Product Contamination (2), Superficial Injury of Eye (2), Eye Pain (1), Eye Swelling (1) and Vision Blurred (1).
Specific lots are being voluntarily recalled in the interest of patient safety. If the particle gets into the eye, potential adverse events may include eye pain, eye swelling, ocular discomfort or eye irritation. Please contact your physician or healthcare provider if you have any of these symptoms when using these products. The lot number and expiration date may be found on the bottom flap of the carton with the safety seal and on the crimp seal of the product tube.
Specific information on product and lots that are being voluntarily recalled are below:
NDCDescriptionLot NumberExpiration Date
0023-0312-04REFRESH® Lacri-Lube® 3.5 g84746 Apr-17
0023-0312-04REFRESH® Lacri-Lube® 3.5 g84987May-17
0023-0312-04REFRESH® Lacri-Lube® 3.5 g85087May-17
0023-0312-04REFRESH® Lacri-Lube® 3.5 g85359Jun-17
0023-0312-04REFRESH® Lacri-Lube® 3.5 g85721Jul-17
0023-0312-04REFRESH® Lacri-Lube® 3.5 g86045Aug-17
0023-0312-04REFRESH® Lacri-Lube® 3.5 g86406Sep-17
0023-0312-04REFRESH® Lacri-Lube® 3.5 g86594Oct-17
0023-0312-04REFRESH® Lacri-Lube® 3.5 g87021Nov-17
0023-0312-07REFRESH® Lacri-Lube® 7g86470Sep-17
0023-0312-07REFRESH® Lacri-Lube® 7g86829Oct-17
0023-0312-07REFRESH® Lacri-Lube® 7g87105Nov-17
0023-0240-04REFRESH P.M.® 3.5 g85165May-17
0023-0240-04REFRESH P.M.® 3.5 g85228May-17
0023-0240-04REFRESH P.M.® 3.5 g85244Jun-17
0023-0240-04REFRESH P.M.® 3.5 g85351Jun-17
0023-0240-04REFRESH P.M.® 3.5 g85374Jun-17
0023-0240-04REFRESH P.M.® 3.5 g85397Jun-17
0023-0240-04REFRESH P.M.® 3.5 g85561Jul-17
0023-0240-04REFRESH P.M.® 3.5 g85676Jul-17
0023-0240-04REFRESH P.M.® 3.5 g85694Jul-17
0023-0240-04REFRESH P.M.® 3.5 g85834Aug-17
0023-0240-04REFRESH P.M.® 3.5 g85977Aug-17
0023-0240-04REFRESH P.M.® 3.5 g85985Aug-17
0023-0240-04REFRESH P.M.® 3.5 g86073Aug-17
0023-0240-04REFRESH P.M.® 3.5 g85599Sep-17
0023-0240-04REFRESH P.M.® 3.5 g86290Sep-17
0023-0240-04REFRESH P.M.® 3.5 g86325Sep-17
0023-0240-04REFRESH P.M.® 3.5 g86411Sep-17
0023-0240-04REFRESH P.M.® 3.5 g86427Sep-17
0023-0240-04REFRESH P.M.® 3.5 g86506Sep-17
0023-0240-04REFRESH P.M.® 3.5 g86515Sep-17
0023-0240-04REFRESH P.M.® 3.5 g86517Sep-17
0023-0240-04REFRESH P.M.® 3.5 g86746Oct-17
0023-0240-04REFRESH P.M.® 3.5 g86792Oct-17
0023-0240-04REFRESH P.M.® 3.5 g86789Oct-17
0023-0240-04REFRESH P.M.® 3.5 g86809Oct-17
0023-0240-04REFRESH P.M.® 3.5 g86822Oct-17
0023-0240-04REFRESH P.M.® 3.5 g86822AOct-17
0023-0240-04REFRESH P.M.® 3.5 g86932Nov-17
0023-0240-04REFRESH P.M.® 3.5 g87100Nov-17
0023-0240-04REFRESH P.M.® 3.5 g87068Nov-17
0023-0240-04REFRESH P.M.® 3.5 g87156Dec-17
0023-0240-04REFRESH P.M.® 3.5 g87261Dec-17
0023-0240-04REFRESH P.M.® 3.5 g87493Jan-18
0023-0240-04REFRESH P.M.® 3.5 g87494Feb-18
0023-0240-04REFRESH P.M.® 3.5 g87731Feb-18
0023-0240-04REFRESH P.M.® 3.5 g (Professional Sample Pack)85165May-17
0023-0240-04REFRESH P.M.® 3.5 g (Professional Sample Pack)86789Oct-17
0023-0316-04FML® (fluorometholone ophthalmic ointment) 0.1%, 3.5 g
 
86258Sep-17
0023-0316-04FML® (fluorometholone ophthalmic ointment) 0.1%, 3.5 g
 
87189Dec-17
0023-0316-04FML® (fluorometholone ophthalmic ointment) 0.1%, 3.5 g
 
87514Feb-18
0023-0313-04Blephamide® (sulfacetamide sodium and prednisolone acetate ophthalmic ointment, USP) 10%/0.2%, 3.5 g86430Sep-17
0023-0313-04Blephamide® (sulfacetamide sodium and prednisolone acetate ophthalmic ointment, USP) 10%/0.2%, 3.5 g87806Feb-18
0023-0313-04Blephamide® (sulfacetamide sodium and prednisolone acetate ophthalmic ointment, USP) 10%/0.2%, 3.5 g88147Mar-18
Allergan has informed the U.S. Food and Drug Administration of this voluntary recall. The recall only applies to specific lots of the REFRESH® Lacri-Lube®, REFRESH P.M. ®, FML® (fluorometholone ophthalmic ointment) 0.1%, Blephamide® (sulfacetamide sodium and prednisolone acetate ophthalmic ointment, USP) 10%/0.2%. This recall does not affect any other REFRESH or Allergan product.
Allergan is contacting retailers and wholesalers who have been shipped affected product lots to initiate the recall and is informing them of the steps needed to return affected product.
The company is asking consumers who currently have product from any of the affected lots of REFRESH® Lacri-Lube®, REFRESH P.M. ®, FML® (fluorometholone ophthalmic ointment) 0.1% , Blephamide® (sulfacetamide sodium or prednisolone acetate ophthalmic ointment, USP) 10%/0.2%, to stop using the product and return it to Allergan.
If there are questions or if assistance is required in response to this recall, please use the contact information below.
CONTACT INFORMATION  
Product Returns
Contact GENCO at:
877-674-2087
7 am to 5 pm CST
Credit/Reimbursements
Contact Allergan at:
1-800-811-4148
7am to 5pm PST
Allergan
Medical Inquiries
:

1-800-433-8871 option 2 8am - 5pm PST

Adverse Events/Products Complaints:

1-800-624-4261 Option 3 (8am - 5pm CST)
FDA contact information for reporting adverse events/quality complaints:
Online at www.fda.gov/medwatch/report.htm or call FDA at 1-800-FDA-1088
 


Tuesday, October 29, 2013

How local rags are reporting on Lipiflow

Classic example below… Same old same old.... New eye treatment comes along, doctors who invest in it drum up publicity. They used to do the same thing with every new version of LASIK that came along. Still, I thought there were a few interesting (albeit more or less predictable) features….

October 26, 2013 – DesMoinesRegister.com

Chronic dry eye forced Doug Pagel to shut the overhead vent and make sure fans weren’t blowing on him at work. He’d even tried punctal plugs to reduce symptoms.
Two months ago, he underwent a new procedure at Eye Care of Iowa, where he works as office manager, that helped relieve those problems. The 12-minute procedure, called LipiFlow, helped restore moisture to his eyes and eliminate the hassle of keeping track of a bottle of eye drops. It also has opened up the possibility of him wearing contact lenses.
“I haven’t used any drops since the procedure,” said Pagel, adding that his condition continues to improve….

Ah. I’m happy for Doug, of course. But… now we’re touting Lipiflow as an ALTERNATIVE to eyedrops, and dangling the carrot of renewed contact lens use? Ugh.

….Symptoms of dry eye include watering or a burning, gritty, sandy sensation toward the end of the day. Many times, that is a result of computer vision syndrome, where eyes become strained and tired from staring at a screen all day.
Two main types of dry eye can affect patients. The most common is “evaporative” dry eye, where the eyes make tears, but they don’t last long. Blocked glands can cause the problem and contribute to lipid deficiency in the tears. Others suffer “aqueous deficient” dry eye, where the eyes don’t make enough water.
A variety of traditional treatments are available — eye drops, punctal plugs and lubricants. But research shows that only 15 percent of all dry eye patients benefit from artificial tears and are able to make the oil to prevent evaporation. For the remainder of patients, those with evaporative dry eye, the oil isn’t produced properly….

Well, one must admit the press are at least starting to talk a lot more about evaporative dry eye. Don’t know that I like the price we’re paying for it but at least it’s happening.


….Following treatment, patients are asked to perform daily blinking exercises and take a triglyceride-based fish oil to maintain eye health….
Interesting. But if the point is to get rid of those “annoying” eyedrop bottles (sheesh, as if any of us actually use bottles anyway… it’s handfuls of vials for most), um, I’d be interested to know how happy these patients are about trading drops for blink exercises. Just sayin’. I think the blink exercises are a great idea. I just don’t think people whose only complaint is the “hassle” of using eyedrops are going to be crazy about it. Most people I know who have had Lipiflow got it because they were desperate and in pain and would be happy to use infinite drops if they’d only work. On the other hand, one of my many biases is that… I know far too many desperate dry eye patients.

…. “Anyone who has dry eye is a potential candidate. What we need to do is have them come in and do an evaluation in the office,” he said.
Ward didn’t want to discourage patients by disclosing the cost of the procedure, but noted that it would be less than the average spent to treat dry eye — roughly $2,500 a year. Insurance does not cover the treatment….

Very interesting. I wonder where they came up with the $2500. No casual dry eye patient spends anywhere near that… only the ones who have some seriously bothersome persistent symptoms.


Abstract: Plugs after LASIK

I have a better idea: Don't cut into healthy corneas.


Purpose:
To evaluate the effect of punctal plug use in preventing dry eye after laser in situ keratomileusis (LASIK).
 Materials and Methods:
A randomized clinical trial at a tertiary eye care center, Riyadh, Saudi Arabia. Participants underwent LASIK for myopia in both eyes and a lower punctal occlusion in one eye only while the other eye served as control. Both eyes received the same postoperative medications except for lubricant duration (subject eye: four times per day for one week; control eye: four times per day for 6 months). Participants were evaluated at 1 week, 2, and 6 months after surgery for signs and symptoms of dry eye. The main outcome measures were visual acuity; ocular surface parameters; and Ocular Surface Disease Index questionnaire.
 Results:
Seventy-eight eyes of 39 patients were included in this study. The Ocular Surface Disease Index scores of eyes with punctal plugs were better at all follow-up visits, and the differences between both eyes were statistically significant (1 week, p<0.0001; 2 months, p<0.0001; 6 months, p=0.008). At the final follow-up visit, the percentage of normal eyes was higher in eyes with punctal plugs for all ocular surface parameters (Schirmer 1 test, 94.9%; tear breakup time, 77.8%; punctate epithelial keratitis score, 71.8%) compared to eyes without occlusion (Schirmer 1 test, 92.3%; tear breakup time, 58.3%; punctate epithelial keratitis score, 53.8%); however, such differences were not statistically significant.
 Conclusion:
Punctal plug insertion after LASIK surgeries may minimize the need for frequent lubricant application and hence improve patient satisfaction.

Curr Eye Res. 2013 Oct 22. [Epub ahead of print]
Alfawaz AM, Algehedan S, Jastaneiah SS, Al-Mansouri S, Mousa A, Al-Assiri A.
Source
Department of Ophthalmology, College of Medicine, King Saud University , Riyadh , Kingdom of Saudi Arabia .


Wednesday, October 16, 2013

Drug news: Mimetogen MIM-DE enrolling for Phase III

14 October 2013

Mimetogen Pharmaceuticals has started enrolment of patients in its Phase III clinical trial of MIM-D3 ophthalmic solution to treat patients with dry eye syndrome.
The new drug, which is the first in a class of molecules called TrkA agonists, stimulates the production of mucins that are necessary for lubrication, removal of allergen, pathogens and debris, as well as corneal epithelial healing to reduce ocular surface damage.
Additionally, MIM-D3 will help in improving neural function, which might enhance corneal sensitivity and integrity, compared to the existing dry eye therapies.
Around 400 patients will be randomized to receive 1% MIM-D3 ophthalmic solution or placebo twice daily over an eight week period during the trial which is aimed at further assessing the safety and efficacy of the drug.
The safety and comfort of the drug compared to placebo will also be assessed in the trial, while its primary endpoints are corneal fluorescein staining score in the CAESM and ocular dryness....

Abstract: Contacts and tear lipid layer

Thought this abstract from a literature review is a good reminder of how (ahem) healthy contact lenses are for our eyes:


This review describes the impact of contact lens wear on the tear film lipid layer and how changes in the lipid layer might modulate contact lens-related discomfort. Relevant clinical, functional, and biochemical aspects of the tear film lipid layer are reviewed. Contact lens wear modulates these aspects of the lipid layer, specifically the prelens lipid layer thickness is reduced; tear evaporation rate is increased; tear breakup time is reduced; and the concentration of lipid components such as cholesterol esters, wax esters, and phospholipids varies. The full implications of these changes are unclear; however, there is some evidence that contact lens-related discomfort is associated with a thinner prelens lipid layer, increased lipid degradation, and greater secretory phospholipase A2 activity. Certain fatty acids appear to be associated with maintaining the structural stability of the tear film but their role in retarding tear evaporation and modulating contact lens-related discomfort remains to be elucidated.

Eye Contact Lens. 2013 May;39(3):247-53. doi: 10.1097/ICL.0b013e31828af164.
Rohit A, Willcox M, Stapleton F.
Brien Holden Vision Institute, University of New South Wales, Sydney, New South Wales 2052, Australia. a.rohit@brienholdenvision.org.au


Abstract: Autologous serum eyedrops - impact on signs & symptoms of DES



Aim:
To assess the impact of autologous serum (AS) eye drops on the ocular surface of patients with bilateral severe dry eye and to draw a comparison between the clinical and laboratory examinations and the degree of subjective symptoms before and after serum treatment.
 Materials and methods:
A three-month prospective study was conducted on 17 patients with severe dry eye. AS eye drops were applied a maximum of 12 times a day together with regular therapy. Dry eye status was evaluated by clinical examination (visual acuity, Schirmer test, tear film breakup time, vital staining, tear film debris and meniscus), conjunctival impression cytology (epithelial and goblet cell density, snake-like chromatin, HLA-DR-positive and apoptotic cells) and subjectively by the patients.
 Results:
The application of AS eye drops led to a significant improvement in the Schirmer test (p<0.01) and tear film debris (p<0.05). The densities of goblet (p<0.0001) and epithelial cells (p<0.05) were significantly increased, indicating a decrease of squamous metaplasia after AS treatment. A significant decrease (p<0.05) was found in the number of apoptotic, HLA-DR-positive and snake-like chromatin cells on the ocular surface. A significant improvement was found in all evaluated subjective symptoms. Altogether, the clinical results were improved in 77%, the laboratory results in 75% and the subjective feelings in 63% of the eyes.
 Conclusions:
We found that three-month AS treatment led especially to the improvement of ocular surface dryness and damage of the epithelium. The improvement of dry eye after AS treatment correlated well with the clinical, laboratory and subjective findings. From the patients' subjective point of view, the positive effect of AS decreased with time, but still persisted up to three months after the end of therapy.
 
Curr Eye Res. 2013 Sep 27. [Epub ahead of print]
Jirsova KBrejchova KKrabcova IFilipec MAl Fakih APalos MVesela V.
Laboratory of the Biology and Pathology of the Eye, Institute of Inherited Metabolic Disorders, General Teaching Hospital and First Faculty of Medicine Charles University in Prague , Czech Republic .

Tuesday, September 24, 2013

Dry eye and my spam folder

Just out of curiosity I clicked on something that eluded my spam filter.

Subject line: EyePromise EZ Tears: 30-Day Dry Eye Relief Guarantee


Golly.

Relief in 30 days, guaranteed.

Dry eye omega 3 supplements are a dime a dozen, every huckster has one now. Now, I'm not really bored or twiddling my thumbs, but I guess I must be needing some distraction from a burgeoning list of calls & emails I'm getting behinder on every hour, because I actually clicked on the image to get to the URL

...Where I searched in vain for
a) An ingredient list
b) The terms of the 30 day guarantee offer (n.b. The offer is not for consumers but for eye doctors who want to shill, I mean sell this stuff.)
c) Absolutely any other information about the product or the offer. In fact the only thing there IS on the site is a page to submit your practice information so you can get a free promo kit and $100 per case discount. Even the "Terms of Use" and "Privacy Policy" links at the bottom point back at it.

I googled the company (ZeaVision) and product (EyePromise EZ Tears) and found their main product page. The ingredients list is quite respectable, I must say. The testimonials, hm. Mostly along these lines:
I began taking EZ Tears after visiting their booth in Orlando @ Disney World. I noticed a difference with couple weeks. There is no need for any eye drops. It is the best thing I could ever imagine!!! Thanks soooo much.

Impressively, there are no negative comments from people for whom it didn't work. LOL.

Friday, September 20, 2013

UK dry eye market... someone's noticing us....


I was reminded today of a comic one of my siblings reproduced artistically for one of our parents on their birthday when I was little. I don't remember the picture but the caption read, "If you feel like no one cares you're alive, try missing a few car payments."

Well, UK dry eye patients, if you feel like no one cares about you, (grin) at least the stock pickers do. If your doctor doesn't seem to, find another doctor... thankfully more and more doctors who give a fig for dry eye really are emerging.


By Reportlinker
Published: Tuesday, Sep. 17, 2013 - 7:55 am
NEW YORK, Sept. 17, 2013 -- /PRNewswire/ -- Reportlinker.com announces that a new market research report is available in its catalogue:

Summary
GlobalData has released its new Country report, "PharmaPoint: Dry Eye Syndrome - UK Drug Forecast and Market Analysis to 2022". Dry eye syndrome (DES), or keratoconjunctivitis sicca, is a multifactorial disease of the eye caused by dryness, decreased tear production, or increased tear film evaporation. DES, which is often referred to simply as dry eye, is the most prevalent form of ocular discomfort and irritation. The most common symptoms of DES are ocular irritation and discomfort, foreign body sensation, fatigue, and visual disturbances, which interfere with daily activities. In the elderly population, it is the most common reason for seeking eye care, and this is expected to increase exponentially with an aging demographic.
The DES market in the UK is projected to grow substantially during the forecast period. During the forecast period, the primary growth driver of the DES market in the UK will be the launch of the EU's first prescription product for DES, as well as the rapidly increasing population of DES patients.
Scope
Overview of the DES including epidemiology, etiology, symptoms, diagnosis, pathology and treatment guidelines as well as an overview on the competitive landscape. - Detailed information on the key drugs in the UK including product description, safety and efficacy profiles as well as a SWOT analysis. - Sales forecast for the top drugs in the UK from 2012-2022. - Analysis of the impact of key events as well the drivers and restraints affecting the UK DES market.