I recently took my daughter to urgent care for an upper respiratory infection and the doctor recommended OTC decongestants; I was miffed. I informed him that I had already tried OTC products and that’s why we scheduled this visit. He then prescribed a medication but, rest assured, I’d never go back to that clinic. I often wonder if that’s the same for optometry when we choose OTC products alone as treatments for dry eye, blepharitis and other conditions. How many of those patients feel the same way and go on to find another optometrist?

Several new therapeutic agents have become available, and note that the lowest price a patient will pay for an ophthalmic medication is when it first comes on the market. Keep in mind that new medications require e-scribing to a specialty pharmacy and proper ICD-10 codes greatly help. The minor but important insights listed below should help you power-up your prescribing.


The first prescription drop approved for Demodex blepharitis is extremely effective and works faster than I anticipated. By having patients instill Xdemvy (lotilaner ophthalmic solution, 0.25%, Tarsus Pharmaceuticals) in their eye twice a day and gently rubbing any excess drop into the base of their lashes, I’m seeing impressive results within a week or two. Since Demodex mites feed on oils, the use of a surfactant lid wipe (e.g., OcuSoft Lid Scrub Plus) to remove dysfunctional oils is a good use of OTC products but must accompany Xdemvy. If you only use wipes or microblepharoexfoliation (which I recommend), you are essentially removing the sawdust but not killing the termite. I’ve also learned that patients must continue the medication for the entire six weeks; one bottle has more than sufficient drops.

As for helping your patients obtain Xdemvy, e-prescribe to one of four specialty pharmacies: Alliance Rx Walgreens, BlinkRx, Carepoint or CVS Specialty. Most patients pay $50 or less. To help get the drug to the patient, include both ICD-10 codes: H01.00 (unspecified blepharitis) and B88.0 (other acariasis). If a PA is needed, the pharmacy will initiate the PA form with CoverMyMeds. The office must complete it with the doctor signing it and submitting it to the PA. Inform the patient that they will hear from the specialty pharmacy, often by text, within 48 hours and to respond—otherwise the medication will not be shipped. These pharmacies are also trained specifically on this drug and affordable options for Medicare patients.

Semi-fluorinated Alkane Drugs

Miebo (perfluorohexyloctane, Bausch + Lomb) and VeVye (cyclosporine 0.1%, Harrow Health) are very effective. Both deliver a drop about one-fourth of the typical drop size and, because they are incredibly comfortable agents, it can be difficult for patients to feel the drop going in. Miebo resides in the tear film at least six hours and in the meibomian glands for more than 24 hours. It creates a monolayer that prevents evaporation at a rate that is four times greater than our own healthy meibum. The drug can be administered up to four times per day.

VeVye has a sister SFA vehicle plus 0.1% cyclosporine, which is the highest concentration of CsA available in an ophthalmic drop. It’s dosed BID and was assessed on primarily aqueous deficient dry eye patients.

Like Xdemvy, these drugs are best prescribed through a specialty pharmacy: BlinkRx for Miebo and PhilRx for VeVye. Most patients are receiving the first drug for free (often after a PA) and this includes Medicare patients. Many commercial patients continue to get Miebo for $0, but it can depend on a patient’s choice of insurance plans. Should a patient choose a high deductible insurance plan to save on premiums, they may have a higher cost, which should easily be offset with their insurance cost savings. VeVye has a buydown program in place where no patient should pay over $79 and most pay $0.

While optometrists write about two-thirds of all new drug prescriptions, we could still use these insights to improve prescribing results. 

Dr. Karpecki is medical director for Keplr Vision and the Dry Eye Institutes of Kentucky and Indiana. He is the Chief Clinical Editor for Review of Optometry and chair of the New Technologies & Treatments conferences. A fixture in optometric clinical education, he consults for a wide array of ophthalmic clients, including ones discussed in this article. Dr. Karpecki's full list of disclosures can be found here.