45 EyeWorld Asia-Pacific | September 2024 CORNEA Dr. Beckman said he thinks the difference for Vevye could be in the vehicle, which is a water-free solution that could help the drug stay on the surface of the eye longer. “Cyclosporine has the longest track record of this immunomodulator to quiet down inflammation on the ocular surface and increase tear production. So right away we have a tried and true, proven product,” Dr. Beckman said. He added that the vehicle could provide “greater bioavailability of the active ingredient, so it’s staying on the eye for a long time and it gives more ability for the cyclosporine to penetrate.” Miebo (perfluorohexyloctane ophthalmic solution, Bausch + Lomb) This topical drop was approved to treat the signs and symptoms of dry eye disease in May 2023. It is the first prescription drop approved to target tear evaporation. Dr. Beckman said this product is indicated for all types of dry eye and is helpful even if evaporative dry eye is not the main subtype. He said there are often cases where patients might have normal tear production, tear breakup time, and tear components, but “their evaporation exceeds their supply.” Their tears, for various reasons such as a decreased blink from Parkinson’s, might still be evaporating too quickly relative to their blink rate, thus they might respond well to Miebo. Dr. Beckman added that the mechanism of action for Miebo is different. It’s not increasing tear production, but rather delaying evaporation by replicating what a healthy meibum would do. He said it forms a monolayer along the air-tear interface, creating a barrier on the surface. With a low surface tension, he said it seems to reduce surface friction, creating a silky feeling, which Dr. Beckman said patients like. Dr. Rapuano said that Miebo doesn’t get to the root of any meibomian gland dysfunction, although it can really help their symptoms. Patients with meibomian gland dysfunction will still need lid scrubs and other mechanical treatments to address the root cause. As with many of these new products, Dr. Beckman said it doesn’t have great insurance coverage yet, but the company utilizes a third-party pharmacy to provide the first prescription for free and assist with prior authorizations for future use. XDEMVY (lotilaner ophthalmic solution, 0.25%, Tarsus Pharmaceuticals) Unlike Miebo and Vevye, which are specifically for dry eye, XDEMVY targets Demodex mites, which cause blepharitis that can lead to irritating ocular surface issues. Dr. Beckman said that once he started looking for Demodex by having patients look down and evaluating the base of the lashes on their upper lid (looking for cylindrical sleeves around the lash, called “collarettes” by the company), he realized how prevalent it was. He said that if the patient is symptomatic (itchy eyelids), he’ll treat them with XDEMVY. He also said that it’s critical to look for Demodex if dry eye patients have failed on multiple therapies. “The reason they may have failed is they have a comorbidity. A lot of them might have thyroid eye disease, a lot of them might have Demodex. I think it’s critical when you’re treating a dry eye patient to look for the sleeves, look for cylindrical collarettes,” he said. Prior to XDEMVY becoming available, Dr. Rapuano said there wasn’t an effective and user-friendly treatment for symptomatic Demodex blepharitis. XDEMVY, he said, does a good job reducing the number of Demodex or eliminating them entirely, resulting in a decrease of symptoms. As a cornea specialist, having a treatment like this has made him more aware of looking at the lashes for Demodex. “In my experience, it has been well tolerated by patients. I’ve had essentially all my patients come back looking better and feeling better. In general, it seems to be well tolerated and quite effective,” he said. Whether the Demodex will come back, Dr. Rapuano said it’s been suggested that every 6–24 months patients may need another course of XDEMVY, but that’s not entirely known yet. The trials were done with just one 6-week course. When he spoke with EyeWorld, Dr. Rapuano said he had prescribed Miebo numerous times, and while he hasn’t seen all of these patients back to the office yet, patients describe it as feeling silky and cool.
RkJQdWJsaXNoZXIy Njk2NTg0