Miebo: A comfortable, effective option for dry eye disease
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Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
Our monthly column focuses on a novel topical treatment for dry eye disease approved by the FDA in May 2023. Miebo (perfluorohexyloctane ophthalmic solution, Bausch + Lomb) is the first eye drop that directly targets tear evaporation, and according to many practitioners who have tried it, it may transform the treatment of dry eye. Douglas Katsev, MD, will tell us more.
Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor
I have been using Miebo for a few months now, and I am impressed beyond expectations. It is a tiny drop, so gentle and comfortable, that goes into the eye almost unnoticed.
And it works: More than 70% of my patients have reported a marked improvement of dry eye symptoms as compared with previous treatments, and nobody has complained of any side effects.
Miebo mimics the action of natural meibum. It coats the tear film and prevents evaporation, which is the leading cause of discomfort and visual problems in dry eye disease (DED). All types of dry eye include evaporation. Whether it is not producing enough tears or whether the tears are draining away too quickly, anything that protects the tear film from excess evaporation is going to preserve the ocular surface from stress and damage. The efficacy of Miebo was demonstrated in two large phase 3 studies in which it showed rapid, sustained improvement in the signs and symptoms of DED with a significant difference from controls. I also did my own little study: I had to fly across the country to give a lecture, and my eyes always get dry on a plane. I put a drop of Miebo in only one eye and did the same to the person sitting next to me. At the end of the flight, I took a picture of us both, and we could clearly see that the eye with the drop was less red than the other eye.
One of the unique things about this drop is that it has no downsides. It does not hurt; there is no burning or stinging sensation on instillation. Nobody feels any discomfort; some do not even notice that it has landed on the surface, and quite a few people report a nice sensation as it goes in. On your hands, if you touch it, it has an oily feel — it feels as if it might be good for the skin around the eyes. Many other drugs have side effects, such as stinging when placed in the eye, and this often stops people from using them. So far, none of my patients have stopped using Miebo because they had a problem. And it really helps in the open air and in dry environments when you need to prevent evaporation.
The recommended dosage is four times a day because that is the schedule used in the studies. However, I tend to tell my patients to use it as needed, up to four times a day. Most of them feel comfortable with three times a day; several use it twice daily and are happy with it, also reducing the cost.
Miebo is a great first-line treatment and may be the only therapy needed by quite a few of our patients. But it can also work hand in hand with other products, including anti-inflammatory eye drops such as Xiidra (lifitegrast ophthalmic solution 5%, Bausch + Lomb), Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) or Cequa (cyclosporine ophthalmic solution 0.09%, Sun Pharmaceutical). It is great to use with punctal plugs because the plug blocks the tears from draining and the drops prevent them from evaporating. That double improvement is a synergistic action. In addition, it makes punctal plug implantation easier: I put a drop in the eye first, and then the punctal plug slides into position smoothly and comfortably.
In essence, this drop has no negatives and achieves positives quickly. That is unusual compared with any other eye drop out there. Most of them take time to work, and most of them have side effects. Alone or in combination with other strategies, Miebo is likely to change the way we treat dry eye.
- For more information:
- Douglas Katsev, MD, founder and director of Santa Barbara Eyecare in Santa Barbara, California, can be reached at katsev@aol.com.
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