VIDEO: Treatment options in dry eye

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We are living in an age now where we have a number of different diagnostic and treatment options for our patients. And I think it behooves us now because we have so many options to, first of all, not ignore ocular surface disease. It’s extremely prevalent in our patient population, from kids all the way to adults. And as a glaucoma specialist, I see a number of patients who have concomitant glaucoma and being treated for glaucoma as well as ocular surface disease. And so I luckily now utilize a number of different treatment options that we have. So, we have kind of the pharmaceutical side and the nonsurgical or non-procedure side, and then we have the procedure side.

In the last few years, we’ve had a number of different products that have come out to help us with the dry eye state in terms of pharmaceuticals. For instance, now recently in the last year, we have a new, first and  only treatment for evaporative disease, which we never had before, and that’s this new drop called perfluorohexyloctane, also known as Miebo by Bausch + Lomb. And the idea of this product is it actually helps prevent evaporation. The molecule is, as it kind of forms a monolayer, that monolayer allows us to actually prevent evaporation for up to 6 hours. So, you take it three or four times a day, and it gives you that kind of protection that our [meibum], in fact, phase 1 and 2 in vitro data really show us that it does prevent evaporation better than even our own [meibum] itself. So, it’s pretty powerful medication and can be utilized along with other dry eye treatments.

We also have new products in the form of cyclosporine. We have a number of different companies. We have, of course, Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) and cyclosporine in the form of Klarity-C from Imprimis, and we also have Cequa (cyclosporine ophthalmic solution 0.09%, Sun Ophthalmics) as well as Restasis and Vevye (cyclosporine ophthalmic solution 0.1%, Novaliq) recently. Vevye is also a semifluorinated alkane. Little different properties than Miebo, but it does solubilize cyclosporine very well, helps absorption and again does not have significant side effect profiles. So, we have a number of different products from the cyclosporine world that allow us to, again, help improve the goblet cell density, help improve tear production as well as help decrease the inflammatory cascade that we know happens in ocular surface disease.

We have another product that is something that we had kind of ignored for many years, and for me, I’ve seen this so much more now, which is Demodex blepharitis. For so long, we kind of ignored Demodex because all we had was tea tree oil and hot compresses, and they didn’t really work well, and patients were unhappy. And now we have a treatment, Xdemvy (Tarsus Pharmaceuticals), which is lotilaner, which allows us now, can be any dosing for 6 weeks to actually help eradicate those mites that are living on our lid margin. We see those collarettes, and this is an actual condition, I think, that we not only underdiagnosed but underappreciated the impact that it had on just general ocular surface disease, meibomian gland, blepharitis, etc. For a lot of my patients who aren’t doing well with the typical ocular surface treatments with, let’s say, cyclosporine or lifitegrast, which is Xiidra (Bausch + Lomb), or we have even Miebo, etc, why are they not getting better? A lot of times we forget that there’s these mites and collarettes. So, the simplest diagnostics you can ever do in your practice is look down, and that’s it. Tell a patient look down, and if you see those collarettes, that’s pathognomonic for Demodex. And what’s nice now is that the 6-week course shows significant eradication rates decreasing collarettes. Even without 100% eradication of the collarettes, you see significant improvement in symptoms of patients, and it’s very well tolerated, so that’s something that I think that I see a lot more. As a glaucoma specialist, when I have patients on topical prostaglandins, we have the environment that I think is suitable for these mites to kind of form and to overpopulate. Again, anything more than 10 collarettes is considered an infestation. And so we see a number of these patients who look down, collarettes all over the place, and on topical prostaglandin agents as well. Sometimes I’ll just use Xdemvy, and you see a lot of more tolerability, less hyperemia, and patients are able to stay on their topical medications as well. So, we have a number of different products on the surface as well.

We also have something new coming out called Lacrifill (Nordic Pharma), which is a kind of viscoelastic that maintains blockage of the punctum. So we used a punctal plug to keep the tears in the eye longer for many, many years — we have dissolvable and non-dissolvable plugs. And now we have this new product, hopefully coming out soon, that allows us to actually fill the lacrimal system inferiorly and superiorly and allows us to block the expression, or keep the tears in the eye longer rather, for patients without having to worry about a foreign body like a plug that has to stay in the eye. So, it’s another product that’s coming out, hopefully soon as well.

And then in the pipeline, a number of other products from the pharmaceutical side that allow us to help with RASP inhibitors, mycophenolate, there’s a number of different products working on the inflammatory cascade and helping us decrease fibrosis on  the surface of the eye that causes all those loss of goblet cells and other cells on the surface of the eye. My point is, we have a lot of options, no right or wrong, but I think it’s important for us to not ignore it because now we do have ways to help on the surface of the eye.

And of course there’s tears. Artificial tears are medicines, so we can’t forget that we have great preservative-free artificial tears. iVIZIA (Théa Pharma) is one of them that has povidone as well has the cellulose material as well, trehalose rather, that allows us, this sugar help allows us to coat the eye very nicely, helps osmolarity. We have many other different products, Systane (Alcon), Refresh (Allergan), you name it. These are all products that do actually treat the ocular surface disease, so we can’t forget the impact of ocular surface tears as well.

 And also, we have non-topical drop formulations of ocular surface disease treatments. In fact, we have something called varenicline, which is Tyrvaya (Viatris), which allows us to simulate the parasympathetic pathway and help the whole lacrimal functional unit, allows us to stimulate the lacrimal gland, the meibomian glands, the goblet cells all in one. So instead of putting a drop in the eye, we can use a nasal spray that allows us to stimulate that whole pathway. And that can be in an adjunct to other treatments that we do on the ocular surface. So, for people like me who have glaucoma patients who are on topical drops already, adding more drops can be difficult while having a nasal spray that stimulates the whole functional unit naturally. Again, we’re not stimulating just one component of the ocular surface tear film, we’re using multiple components, so meibomian glands, the goblet cells, as well as a lacrimal gland as well. So, it’s another nonsurgical option, but in a non-drop formulation as well.