39 EyeWorld Asia-Pacific | March 2025 CORNEA Dr. Shah has had training in dry eye and ocular surface inflammation. During her fellowship, she learned how much of an impact ocular surface disease can have on patients’ vision, physical comfort, and overall quality of life. “I’ve realized over time just how ubiquitous dry eye is, and in my current practice, I treat dry eye disease every day,” she said. “Typically, I see between three and 10 new consults for dry eye disease or ocular surface inflammation per week (including mild blepharitis, ocular rosacea, concerns for Demodex blepharitis, post-surgical dry eye, etc.); however, like most ophthalmologists (and particularly cornea specialists), I incidentally find and treat dry eye in more than a third of my patients.” With mild or asymptomatic disease, Dr. Shah will typically start with conservative treatments, such as warm compresses, lid hygiene, and OTC artificial tears. “I’ll often tailor the OTC options to the specific patient—lipidbased tears in those with meibomian gland dysfunction or decreased tear breakup time, preservative-free options for those with suspected preservative sensitivities, etc.” In patients with more significant or recalcitrant symptoms that have not responded to OTC treatment or in those with more severe and obvious ocular surface inflammation, Dr. Shah will quickly move on to other treatment options. “For those with low tear lake or significant fluorescein staining, I will often place punctal plugs. For patients with significant inflammation of the ocular surface, I will start an immunemodulating therapy such as cyclosporine or lifitegrast often in conjunction with a short course of steroids. “Other great treatment options available in our armamentarium include Tyrvaya [varenicline, Viatris], which I’ll often use in patients who have multifactorial etiologies for their dry eye or those who cannot tolerate another eye drop on their ocular surface, MIEBO [perfluorohexyloctane, Bausch + Lomb], for those patients who need a little better than OTC lubricant options but may not have severe enough symptoms to warrant immune modulators, or XDEMVY [lotilaner, Tarsus], in patients with more obvious signs or symptoms of Demodex blepharitis. For treatment-resistant dry eye, I will often consider autologous serum tears, and in neurotrophic disease I will reach for Oxervate [cenegermin-bkbj, Dompe]. Lastly, we must not forget options for systemic treatment of ocular surface disease, such as doxycycline in patients with severe meibomian gland disease or ocular rosacea.” As Dr. Shah mentioned, there are various products and treatments available for different stages of dry eye disease, and both Dr. Shah and Dr. Canseco discussed some of the more recent product approvals in this space, including MIEBO, XDEMVY, Lacrifill (Nordic Pharma), and VEVYE (cyclosporine, Harrow). Dr. Canseco has seen a shift in the way physicians can help patients address dry eye. Previously, the physician might have jumped to artificial tears. “We know that didn’t help every patient,” she said. “We now know and understand the pathophysiology behind ocular surface disease and dry eye, and we know there are many different components, and now, we can address the different components of dry eye.” She has found XDEMVY particularly useful in her practice. “We’ve always known about blepharitis as one of the main problems of ocular discomfort,” she said. “Patients complaining of itching, irritation, feeling like there’s something in the eyes, misdirected lashes—with all of these complaints, we’ve tried our best to treat them. My handout still includes ways in which we’ve treated blepharitis before, like cleaning up the lids, using baby shampoo, tea tree oil, etc. It’s awesome that we now have a very specific and effective treatment regimen for patients who are affected by Demodex blepharitis.” Dr. Canseco said results with XDEMVY are great, and it’s well tolerated as opposed to some other regimens where patients complain the treatment itself (tea tree oil) is irritating. XDEMVY specifically kills Demodex mites and gets to the root cause of the problem. “I would challenge physicians to start using it on all patients who have collarettes. What you want to do is have patients look down at the slit lamp so you don’t miss it,” she said. Dr. Canseco has also been excited to incorporate Lacrifill into her practice. “When patients have aqueous deficiency and using tears isn’t feasible, I think using some form of a punctal plug is helpful,” she said. “Lacrifill is the first in its category. [It’s] like a filler, and we fill the lacrimal system,” she said. “We go through the puncta, and one great advantage is we can do all four puncta. The beauty is that it lasts for about 6 months. Patients don’t feel it, and it will conform to their anatomy.” Lacrifill also has elasticity like a gel, so Dr. Canseco said it will fill crevices, getting deep in the canalicular system and providing relief for patients. Dr. Canseco said MIEBO is a new version of a lubricating tear that helps coat the ocular surface. Though she doesn’t have as much experience with MIEBO because of coverage issues, she said it does help patients feel better quickly.
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