With seven prescription medications, multiple effective in-office procedures and an abundance of understanding, there’s never been a better time to manage ocular surface disease (OSD). Let’s dive into all the noteworthy advancements.

Impressive New Therapeutics

The newest FDA-approved therapies have been nothing less than incredible in managing OSD. The term “magical” for Xdemvy (lotilaner 0.25%, Tarsus Pharmaceuticals) has been often cited by my patients and in my own experience to treat Demodex—a difficult ectoparasite to control. That is no longer the case, as mite eradication with Xdemvy occurs within days, although six weeks of therapy is required to kill the nits that hatch about 18 to 20 days later. I’ve found that adding a surfactant cleaner (e.g., OcuSoft’s Lid Scrub Plus) to remove the dysfunctional oils further speeds the resolution. After six weeks, I’ve had great success in using a Manuka extract lid hygiene product such as MyboClean (Danelli Ocular Creations) for maintenance.

Miebo (perfluorohexyloctane, Bausch + Lomb) does something few drugs can tout, and that is to function better than optimal adult meibum. Studies have shown it prevents evaporation at least four times better by creating a monolayer barrier that lasts about six hours. I tell every patient that this prescription will provide the oil layer you need while we work on enhancing your own oils through hydrating compresses such as the Bruder Moist Heat Eye Compress (Bruder Healthcare), intense pulsed light with low-level light therapy (Espansione from Essilor Instruments) or an in-office procedure such as TearCare (Sight Sciences).

Vevye (cyclosporine 0.1%, Harrow Health) has changed the game with cyclosporine and proven how effective this agent can be in managing dry eye disease (DED). What’s most fascinating is the dramatic and rapid improvement in corneal staining without the burning side effects.

Adjunctive OSD Treatments

When considering the option of punctal occlusion, gone are the days of rigid, irritating surface plugs that have retention issues. Two major advances have changed the field, including the 180-day dissolving plug (Oasis Medical), which tapers to a 0.25mm end in a 0.6mm plug. It fits over 98% of all puncta in my clinic, is easy to insert, doesn’t irritate the ocular surface and provides full occlusion for a minimum of six months.

Then there is Lacrifill (Nordic Pharmaceuticals), which uses crosslinked hyaluronic acid to fill the puncta. The “lacrifiller” is injected into the canalicular system via a 26-gauge canaliculi and avoids surface irritation.  

Inadequate lid seal is easily diagnosed due to morning symptoms and is the number one cause of nonresponsive dry eye in my clinic. If inferior staining is present, the use of preservative-free Lotemax ointment (loteprednol etabonate, Bausch + Lomb) before bed is ideal. Longer term use of RetainePM (OcuSoft) would follow, but for the best results, SleepTite eyelid strips provide 100% resolution. The strips are hypoallergenic, oxygen-permeable, latex-free and don’t stick to eyelashes. Patients who wear these successfully each night typically no longer require other treatments for dry eye.

Allergy Treatment Advances

Three new additions I often use simultaneously have allowed me to gain the upper hand on the severe allergies we experience in central Kentucky. A QD olopatadine now formulated with a cationic vehicle—Retaine Allergy (OcuSoft)—is most favored by my patients. I recommend combining it with Optase Allegro (Scope) as their daily artificial tears. Ectoine, a key component, forms a protective hydration shield around proteins and other molecules like allergens.¹

Because the eyelids protect and prevent allergens from entering the eye, OcuSoft Lid Scrub Allergy with green tea extract for inflammation, tea tree oil for itching and PSG-2 for redness helps to effectively remove allergens while soothing the eyelids.

When I started my first dedicated dry eye clinic, we had artificial lubricants, off-label steroids and punctal plugs. Now, there are a plethora of game-changing products available that have shown that our cup runneth over in managing OSD. 

Dr. Karpecki is Director of Cornea and External Disease at the Kentucky Eye Institute in Lexington KY.   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.