Cornea: YES Connect
Winter 2024
by Ellen Stodola
Editorial Co-Director
We are fortunate to be practicing at a time with so many dry eye treatment options to help our patients. Within the past year alone, we have added several new therapies targeting specific types of dry eye disease, including Demodex blepharitis and evaporative disease. As cornea specialists, we often must put on our detective caps to determine the specific etiologies of a patient’s ocular surface disease. There is surely no “magic bullet,” and it more often than not takes a multi-therapy approach to address the many facets of a patient’s dry eye syndrome. The more tools in the toolbox, the better we can tailor individual treatments for these complex patients. I am excited to have two phenomenal cornea and dry eye specialists, Elvia Canseco, MD, and Shaily Shah, MD, share their early personal experiences and thoughts on several of these new options with the greater YES community.
Mina Farahani, MD, YES Connect Editor
Previous issues of EyeWorld have discussed dry eye in detail, including the many options available for treatment and management. It continues to be an important topic because of the many patients impacted and different ways it can present. In this issue’s YES Connect column, Elvia Canseco, MD, and Shaily Shah, MD, highlight some of the newer treatment options in the dry eye armamentarium and how they are handling dry eye in their practice, including how they have updated their approach with experience.
Source: Elvia Canseco, MD
Dr. Canseco frequently manages dry eye in her practice. “In my practice, dry eye is very common; more than half of the patients I see have some version of dry eye, and I think it’s important to mention that it’s not one specific [type of] patient,” she said, adding that she sees these issues with patients she evaluates for cataract surgery, those on glaucoma medications, etc. “We’re talking about patients who might show up for routine eye exams or have been referred due to autoimmune disease, graft vs. host disease, or maybe a prior injury of the eye has left them with lagophthalmos or cicatricial changes.”
It’s important to partner with patients to help them understand this is a chronic problem, Dr. Canseco said. “There’s nothing that can completely cure dry eye, but we can make patients feel better, function well, and get through each day. It’s important as ophthalmologists to let patients know that there are changes we can incorporate into their daily routines that can make a difference,” she said, adding that environmental modifications for some patients are often key to successful treatment.
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—lipid-based 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 immune-modulating 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. It provides a thin and smooth coating to the superficial layer on the ocular surface. “I have had patients say they see better when using MIEBO. It’s easy to use and well tolerated, and patients get relief quickly.”
Similarly, Dr. Canseco said she has had a good experience with VEVYE; she said this is a well tolerated product. “One thing we struggle with when we use cyclosporine for inflammatory dry eye treatment is it’s a little uncomfortable,” she said. “Patients can have burning or stinging. Getting patients to stick to the regimen can be a challenge because they’re already uncomfortable from the disease, then they’re using a drop that might not be super comfortable in the beginning.” Dr. Canseco said it’s a good option for those who are comfortable treating patients who would benefit from cyclosporine treatment. “It’s a great option for patients who might need a more comfortable immune-modulating drop from the get-go,” she said.
Dr. Shah has similarly been pleased with many of the new options in dry eye therapy. “So many patients suffer from a condition that, until recently, had very limited treatment options.”
Dr. Shah has found that MIEBO works particularly well in her patients with more obvious evaporative dry eye and in those patients who have failed OTC lubricants but do not have the signs or symptoms to warrant immune modulators or other prescription treatments. “Patients find MIEBO incredibly soothing upon instillation, and the symptom relief seems to last longer for many of my patients.”
She also thinks that VEVYE is a great new form of cyclosporine. “I love that it has perfluorobutylpentane as its vehicle; it provides similar soothing effect and immediate relief upon instillation as MIEBO but also carries the immune modulating effect of cyclosporine that we are all familiar with,” she said. She finds that patients with more symptomatic inflammatory dry eye (those with burning and irritation especially on instillation of eye drops) tend to tolerate VEVYE sooner than expected and often without the need for concomitant steroid treatment.
Dr. Shah said XDEMVY is the first treatment option that is uniquely dedicated to the eradication of Demodex. “I’ve been able to complete treatment courses for several patients now and have seen remarkable results—complete resolution of visible collarettes and great symptom relief. It’s been a game changer, particularly for those patients who have suffered for years without much relief from traditional treatment options such as doxycycline, tea tree oil scrubs, or other topical or systemic anti-parasitic treatment options.
“My approach to dry eye has and continues to evolve significantly over time,” Dr. Shah said. “I think early on in my training, I failed to recognize just how seriously dry eye should be taken. Patients with dry eye suffer in a multitude of ways, ranging from mild irritation to severe burning, redness, blurry vision, and often prolonged and severe pain,” she said. “I think dry eye has to be approached from a place of empathy. Often, these patients have been suffering for years, dismissed as having a ‘less serious’ condition, or just not found great treatment options for their particular form of dry eye. Leading with empathy and reassuring patients that I will work my hardest to find a solution for them is of utmost importance.” Dr. Shah added that she has developed a general algorithm for implementing treatment options depending on presenting history and exam, “etiology” of the dry eye, and what treatments have been tried and failed already. “I also try to always stay up to date on the latest treatment options so that I can offer my patients something that is tailored specifically to their needs.”
Dr. Canseco said her biggest shift in approaching dry eye has been to adjust her thinking and realize that there are many different etiologies that result in dry eye. “I need to address the specific problems, or I won’t really help the patient,” she said. Rather than just relying on certain treatments, Dr. Canseco tries to ensure that she’s looking at the whole picture. She spends time figuring out the goal for each individual patient.
Dr. Canseco said that there are many ways for eyecare professionals to learn about these new options for treatment and stay up to date. “With all these advances in the management and treatment of ocular surface technology and management, we encourage people to attend conferences [and] seek local opportunities to learn so we can provide relief to patients.”
About the physicians
Elvia Canseco, MD
Opia Vision Center
Houston, Texas
Shaily Shah, MD
Northern California
Cornea Associates
Walnut Creek, California
Relevant disclosures
Canseco: Tarsus
Shah: None
Contact
Canseco: cansecoelvs@gmail.com
Shah: shailys123@gmail.com
