Eyeworld

58 | EYEWORLD | SUMMER 2024 C ORNEA Relevant disclosures Beckman: AbbVie, Alcon, Bausch + Lomb, Tarsus, Sun Ophthalmics, Thea, Viatris Rapuano: Tarsus Contact Beckman: kenbeckman22@aol.com Rapuano: cjrapuano@willseye.org 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 com- ponents, 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 treat- ments to address the root cause. As with many of these new products, Dr. Beckman said it doesn't have great insur- ance coverage yet, but the company utilizes a third-party pharmacy to provide the first pre- scription for free and assist with prior authoriza- tions 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 De- modex if dry eye patients have failed on multi- ple 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 us- er-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 symp- toms. As a cornea specialist, having a treatment continued from page 57 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 treat- ments. Unlike the drops discussed in this article, Tyrvaya delivers its active ingredient (vareni- cline) 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 nos- tril—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.

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