Eyeworld

APRIL 2020 | EYEWORLD | 85 C W hen it comes to dry eye treat- ment, physicians have three FDA-approved prescription medications, but a variety of other possibilities are in devel- opment. The three FDA-approved drugs are Restasis (cyclosporine, Allergan), Xiidra (lifitegrast, Novartis), and Cequa (cyc- losporine, Sun Pharmaceutical). Technically, Cequa and Restasis are approved for increased tear production and, therefore, directly for patients with aqueous tear deficiency, said John Sheppard, MD. Xiidra is the first, and currently the only, dry eye medication approved for both signs and symptoms, specifically for eye dryness as well as punctate keratopathy, Dr. Sheppard said. While both Restasis and Cequa have a cyc- losporine component, the lifitegrast molecule in Xiidra was computer modeled and designed in a test tube to inhibit the immunologic handshake between LFA-1 and ICAM-1, Dr. Sheppard explained. "That cell surface interaction caus- es T cells to activate, proliferate, and secrete cytokines," he said. Cyclosporine prevents the activation of T cells, which can then take up to 6 weeks to die off. One of the big differences among the three drugs is the vehicle used. "Restasis has an emulsion vehicle, Cequa a nanoparticle vehicle, and Xiidra a saline vehicle," Dr. Sheppard said. With the nanoparticle vehicle, attaining a higher concentration of cyclosporine is possible, and there seems to be less burning and stinging with Cequa than with the other two, according to Dr. Sheppard. Autologous products The dry eye treatment arsenal also includes products made from the patient's own blood, like autologous serum eye drops and plate- let-enriched plasma drops. Anat Galor, MD, said these are currently not regulated by the FDA because "there's no pathway to do so for autologous products." Still, she finds that autologous serum eye drops are useful in certain dry eye patients. "Specifically, the ones I use them for are people who have immune-mediated dry eye," she said, including patients with Sjögren's disease and graft-versus-host disease for whom FDA-ap- proved products have failed. "I generally use autologous serum tears in a concentration from 20–50%. If they don't do well, I switch them to platelet-enriched plasma." Platelet-enriched plasma is like autologous serum tears but at a 100% concentration instead of 20–50%, Dr. Galor said. Off-label possibilities Some medications used off-label, like steroids, could be used short term to reduce both aque- ous and evaporative dry eye as well as manage blepharitis initially, Dr. Galor said. She also uses antibiotics, such as doxycy- cline, minocycline, and azithromycin, orally and topically in patients with evaporative dry eye when trying to improve meibomian gland function. "We think that the antibiotics have an effect on the meibocytes," she said, explaining that the goal is to make overall oil quality better. One downside of azithromycin drops is that they have preservatives, and they're thick The dry eye pharmacologic zone by Maxine Lipner Senior Contributing Writer About the doctors Anat Galor, MD Associate professor of ophthalmology Bascom Palmer Eye Institute Miami, Florida John Sheppard, MD Professor of ophthalmology, microbiology, and molecular biology Eastern Virginia Medical School Norfolk, Virginia Relevant disclosures Galor: Allergan, Novaliq, Shire Sheppard: AbbVie, Aldeyra, Allergan, Bausch + Lomb, Novaliq, Noveome, Oasis Medical, Oyster Point Pharma, Novartis, Sun Pharmaceutical Contact Galor: AGalor@med.miami.edu Sheppard: jsheppard@vec2020.com Fluorescein negative staining with recurrent paracentral corneal epithelial erosion Source: John Sheppard, MD continued on page 86 PHARMACEUTICAL FOCUS

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