Ocular surface disease (OSD) is right in front of us. Perhaps you have to express meibomian glands and have patients look down so you can scan their eyelids and instill fluorescein dye, but that’s less complex than managing other ocular diseases, and new therapeutics have made the task even easier. Now is the time to “show up” to manage OSD patients and challenge yourself by taking your practice to another level.

New FDA Approvals

Here are recently developed therapeutic agents that target unmet OSD needs:

• Miebo (perfluorohexyloctane 100%, Bausch + Lomb). This is the first dry eye treatment that targets evaporation; it has been shown to inhibit evaporation four times more than healthy meibum can.1 It works best when patients have MGD but are not completely lipid deficient—meaning, avoid the evaporative dry eye train wrecks with severe meibomian gland atrophy. Fortunately, these types are extremely rare, but Miebo requires some lipid secretions, even dysfunctional, to anchor the alkanes that make up a key part of the drug chemistry. Miebo was shown to create a monolayer barrier for up to six hours.2 

Although listed as QID, most of my patients are experiencing impressive results, including corneal staining clearing, symptom resolution and improved vision with either BID or TID dosing. Miebo has almost no side effects except slight blur upon instillation (then super-clear vision minutes later) or patients stating they can’t feel the drop upon instillation. This could be because there are no preservatives, as it’s a single agent drop and each is only 11µL compared to the 30µL to 50µL typical for most drops.

• Xdemvy (lotilaner 0.25%, Tarsus Pharmaceuticals). This is the first and only drug approved for Demodex blepharitis, a condition that is likely present in at least 20 million people, with few effective treatments available.3 Patients suffering from itching, dry, gritty or red eyes are often treated with dry eye therapies when they actually had Demodex blepharitis, most likely due to doctors not having patients look down while at the slit lamp and scanning the upper eyelid margins for collarettes, which are composed of mite waste products and is a sign of Demodex blepharitis.

Xdemvy is dosed BID for six weeks. I’ve found complete resolution of collarettes in as little as one week by having patients instill the drop and then rub the excess liquid into their lashes and adnexa. But, six weeks of treatment is required because the life cycle of the mites is roughly 16 to 18 days and the mites and eggs will have another potential 18 days. The drop is generally comfortable, with less than 10% of patients in the clinical trials stating burning upon instillation, although I haven’t had a patient express these symptoms.

• Vevye (0.1% cyclosporine A, Novaliq). As we’ve seen with Cequa (0.9%), higher concentrations of cyclosporine with novel vehicles do much better. The unique vehicle for Vevye is another semi-fluorinated alkane, perfluorobutylpentane. While this doesn’t have the extended duration on the ocular surface as Miebo, it will increase bioavailability and comfort, and is also water- and preservative-free.

Don’t Forget Glaucoma Patients

As much as we think patients are compliant with their meds, prostaglandin analogs and preservatives are toxic and inflammatory and some patients with OSD stop using their glaucoma drug due to pain and discomfort. New products like Iyuzeh, a preservative-free latanoprost, or Zioptan (tafluprost) are needed. Other options include selective laser trabeculoplasty as a first-line therapy and the most effective PGAs, like Vyzulta (latanoprostene bunod), which can minimize the need for two medications. Preservative-free Simple Drops from Imprimis Pharmaceuticals offer a triple drop (timolol, bromonidine, dorzolamide) and a quad drop (timolol, brimonidine, dorzolamide, latanoprost), both of which allow patients to avoid multiple meds and preservatives.

It’s an exciting time for OSD management, and these new innovations have made it well worth showing up! 

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.

1. Krösser S, Spencer E, Grillenberger R, et al. Ocular and systemic distribution of 14-C perfluorohexyloctane following topical ocular administration to rabbits. Invest Ophthalmol Vis Sci. 2018;59:2656.

2. Sheppard JD, Nichols KK. Dry eye disease associated with meibomian gland dysfunction: focus on tear film characteristics and the therapeutic landscape. Ophthalmol Ther. 2023;12(3):1397-418.  

3. Schaumberg DA, Nicholas JJ, Papas EB, et al. The international workshop on MGD: report of the subcommittee on the epidemiology of and associated risk factors for MGD. Invest Ophthalmol Vis Sci. 2011;52(4):1994-2005.