EyeWorld Asia-Pacific June 2020 Issue

PHARMACEUTICALS EWAP JUNE 2020 53 by Maxine Lipner EyeWorld Senior Contributing Writer The dry eye pharmacologic zone Contact information Galor: AGalor@med.miami.edu Sheppard: jsheppard@vec2020.com This article originally appeared in the April 2020 issue of EyeWorld . It has been UNKIJVN[ OQFKƂGF CPF CRRGCTU JGTG YKVJ permission from the ASCRS Ophthalmic Services Corp. W hen it comes to dry eye treatment, physicians have three FDA-approved prescription medications, but a variety of other possibilities are in development. The three FDA-approved drugs are Restasis (cyclosporine, Allergan), 8ˆˆ`À> ˆwÌi}À>ÃÌ] œÛ>À̈î] and Cequa (cyclosporine, Sun Pharmaceutical). Technically, Cequa and Restasis are approved for increased tear production and, therefore, directly for patients with >µÕiœÕà Ìi>À `iwVˆi˜VÞ] Ã>ˆ` John Sheppard, MD. Xiidra is ̅i wÀÃÌ] >˜` VÕÀÀi˜ÌÞ ̅i œ˜Þ] dry eye medication approved for both signs and symptoms, ëiVˆwV>Þ vœÀ iÞi `ÀޘiÃà >à well as punctate keratopathy, Dr. Sheppard said. While both Restasis and Cequa have a cyclosporine Vœ“«œ˜i˜Ì] ̅i ˆwÌi}À>ÃÌ molecule in Xiidra was computer modeled and designed in a test tube to inhibit the immunologic handshake between LFA-1 and ICAM-1, Dr. Sheppard explained. “That cell surface interaction causes T cells to activate, proliferate, and secrete cytokines,” he said. Cyclosporine prevents the activation of T cells, which can then take up to 6 weeks to die off. One of the big differences among the three drugs is the vehicle used. “Restasis has an emulsion vehicle, Cequa a nanoparticle vehicle, and Xiidra a saline vehicle,” Dr. Sheppard said. With the nanoparticle vehicle, attaining a higher concentration of cyclosporine is possible, and there seems to be less burning and stinging with Cequa than with the other two, according to Dr. Sheppard. Autologous products The dry eye treatment arsenal also includes products made from the patient’s own blood, like autologous serum eye drops and platelet-enriched plasma drops. Anat Galor, MD, said these are currently not regulated by the FDA because “there’s no pathway to do so for autologous products.” -̈] Åi w˜`à ̅>Ì >Õ̜œ}œÕà serum eye drops are useful in certain dry eye patients. º-«iVˆwV>Þ] ̅i œ˜ià ÕÃi them for are people who have immune-mediated dry eye,” she said, including patients with Sjögren’s disease and graft-versus-host disease for whom FDA-approved products have failed. “I generally use autologous serum tears in a concentration from 20–50%. If they don’t do well, I switch them to platelet-enriched plasma.” Platelet-enriched plasma is like autologous serum tears but at a 100% concentration instead of 20–50%, Dr. Galor said. Off-label possibilities Some medications used off- label, like steroids, could be used short term to reduce both aqueous and evaporative dry eye as well as manage blepharitis initially, Dr. Galor said. She also uses antibiotics, such as doxycycline, minocycline, and azithromycin, orally and topically in patients with evaporative dry eye when trying to improve meibomian gland function. “We think that the antibiotics have an effect on the meibocytes,” she said, explaining that the goal is to make overall oil quality better. One downside of azithromycin drops is that they have preservatives, and they’re thick without much product in the bottle, Dr. Sheppard said. Still, he said he’s been able to use the oral antibiotics successfully, capitalizing on their anti- “ˆVÀœLˆ>] >˜Ìˆ‡ˆ˜y>““>̜ÀÞ] and meibomian-regenerative activity. Doxycycline supports corneal epithelial adhesion by downregulating MMP-9 as well as collagenases. There’s also a minocycline gel for ocular surface disease and meibomian gland disease in clinical trials, Dr. Sheppard said. Demodex , mites that live at the base of the lashes, are Fluorescein negative staining with recurrent paracentral corneal epithelial orasion. Source: John Sheppard, MD