Cornea: I wish I had …
Summer 2024
by Liz Hillman
Editorial Co-Director
For years, ophthalmologists had limited prescription options for patients experiencing dry eye and ocular surface disease. In the last decade, the number of available options has grown with several receiving approval in 2023. Now, a year later, Kenneth Beckman, MD, and Christopher Rapuano, MD, are sharing their thoughts and experiences with these new options, in addition to perspectives on where they fit in the growing ocular surface market.
“I’m happy to have more options,” Dr. Rapuano said. “The truth is, we have tons of ocular surface disease patients who are not responding to the current treatments that we have. You do have to try different things. I personally like having the different options.”
Vevye (cyclosporine ophthalmic solution, 0.1%, Novaliq)
Vevye received FDA approval in June 2023 for treatment of signs and symptoms of dry eye. It is the third cyclosporine option in the ocular surface/dry eye market in addition to Restasis (cyclosporine ophthalmic emulsion, 0.05%, AbbVie) and Cequa (cyclosporine ophthalmic solution, 0.09%, Sun Ophthalmics).
Dr. Rapuano said he doesn’t have direct experience with Vevye, but from what he understands, it seems to begin working at 4 weeks, while the other options take a little bit longer. Also compared to Cequa and Restasis, Dr. Rapuano said that Vevye is approved for signs and symptoms of dry eye, whereas Cequa is indicated for increased tear production, and Restasis is indicated to increase tear production in patients with ocular inflammation associated with dry eye.
“As far as I’m concerned that’s for marketing concerns,” Dr. Rapuano said. “The proof will be in the pudding; we’ll see whether it’s better than Restasis, Cequa, or Xiidra [lifitegrast ophthalmic solution, 5%, Bausch + Lomb]. Will it be less irritating? In my experience, Cequa is less irritating, and it’s better tolerated by patients than Restasis. Cequa is almost twice as strong as Restasis, so I do like it a lot. The downside is it’s a newer medication, and it’s harder to get insurance coverage for it than Restasis. Insurance coverage is better than it used to be, but it’s harder to get covered than Restasis.”
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.”
Source: Christopher Rapuano, MD
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 with 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 are a cause of blepharitis that can lead to irritating ocular surface issues.
Dr. Beckman said 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 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.
Coverage challenges and beyond
Dr. Beckman said with all the products discussed in this article, he usually orders them in preference to what the insurance company will cover.
“What every one of these has done is given me one more option because, in reality, they all work well for most people or at least some. There is a good chance that any of them will work well, and it’s not worth the fight with insurance initially. If I write for Xiidra and they get moved to Cequa by insurance, I’m not going to fight to get them on Xiidra when Cequa might work well for them and vice versa. I cross that bridge when they come back,” Dr. Beckman said. “The good news is a lot of these companies have excellent rebate programs. Sometimes we say, ‘This company has a coupon, saying pay no more than X. Are you willing to try that?’ If the patient says yes, we get it.”
Looking forward, Dr. Rapuano said he’d like to see some of the challenges with early coverage become better addressed. He would like to see more options come to market that reduce compliance issues (fewer required doses, etc.). “I have some of patients where it’s basically a full-time job, and they’re doing something every hour. It’s unfortunate, but that’s what they need to make their eyes feel comfortable,” he said.
Article Sidebar
Tyrvaya (varenicline solution nasal spray, 0.03 mg, Viatris)
Though approved in 2021, Dr. Beckman felt it was worth bringing up Tyrvaya in a discussion about recently approved ocular surface treatments. Unlike the drops discussed in this article, Tyrvaya delivers its active ingredient (varenicline) as a nasal spray, stimulating natural tear production.
Dr. Beckman said Tyrvaya is a great option for contact lens wearers who don’t want to have to remove their lenses to administer drops and for patients who have difficulty putting in drops.
“It’s just a different mechanism to stimulate tear production that works well,” he said. “One of the negatives is after you put it in some people start sneezing or they’ll complain that it hurts their throat. What we’ve found is a neat trick.
It does not have to go way up in the nostril. It just needs to hit the nerve endings, which are lower. I instruct my patients to point the tip laterally, so it’s hitting the lateral wall of the nostril—not jamming it way up. Pinch the top of the nose to block it, and don’t inhale. Catch what runs out with a tissue. So they get the effect without the side effects. Since I’ve started telling patients to do this, it’s become much more tolerable. It works quickly. I’ve found with each use it makes the eyes run, and in my experience, those who tolerate it have a nice effect fairly early.”
Dr. Rapuano finds Tyrvaya especially useful in patients who do want to add another topical mediation to their regimen.
Article Sidebar
I wish I had …
Marjan Farid, MD, Cornea Editorial Board member, shared what she wishes she had:
I wish I had an “all in one” diagnostic point-of-care test for dry eye disease that would give me information on multiple markers including osmolarity, MMP-9, lactoferrin, and others.
About the physicians
Kenneth Beckman, MD
Director of Corneal Surgery
Comprehensive Eyecare of Central Ohio
Westerville, Ohio
Christopher Rapuano, MD
Chief of the Cornea Service
Wills Eye Hospital
Philadelphia, Pennsylvania
Relevant disclosures
Beckman: AbbVie, Alcon, Bausch + Lomb, Tarsus, Sun Ophthalmics, Thea, Viatris
Rapuano: Tarsus
Contact
Beckman: kenbeckman22@aol.com
Rapuano: cjrapuano@willseye.org
