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Catch up on the top stories in optometry during the week of March 31-April 4.

Takeaways from this week in optometry: March 31 - April 4

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The new lenses are designed for young presbyopes, ranging in age from their late 30s to mid-40s, who may be either existing spectacle wearers or non-wearers.

HOYA launches new advanced focus spectacle lenses for younger patients with presbyopia

Management strategies for patients with ocular syphilis primarily involve antibiotic treatment achieved using high-dose intravenous or intramuscular penicillin.

Timely diagnosis and management of ocular syphilis to prevent permanent visual loss

Pantheon Vision’s bioengineered corneal implant aims to tackle issues with the success rate of human donated tissue.

Pantheon Vision and Eyedeal Medical enter collaborative agreement to develop bioengineered corneal implant

The leading source of breaking news, news analysis, and emerging research reports in optometry, Optometry Times® disseminates practical content by optometrists for optometrists that can be immediately applied to improve the clinical experience.

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The California Optometric Association and the Los Angeles County Optometric Society have compiled resources for optometrists to get involved in continuing relief efforts.

How ODs are helping with Los Angeles wildfire cleanup

Agatha Sleboda, OD; Arti Shah, OD, FAAO; and Kent J. Nozaki, OD provide the best tips that they give to their patients during natural disasters events in light of the recent Greater Los Angeles wildfires. 

What patients should know about eye protection during natural disasters

Optometrists local to the Los Angeles area overview their efforts to continue providing support to patients affected by January's wildfires. 

Eye care organizations, practices provide vision care amid the Greater Los Angeles wildfires

 is a common ocular condition marked by a loss of homeostasis anywhere in the cycle, causing or worsening tear film instability, hyperosmolarity, and inflammation of the ocular surface.

 This condition significantly impairs visual quality, leading to challenges in daily activities such as driving, reading, and computer use.

 Addressing DED is crucial for improving patient satisfaction and quality of life and maintaining practice efficiency.

Supportive care often falls short for patients with DED

Patients with DED frequently report symptoms including burning, stinging, grittiness, foreign body sensation, light sensitivity, ocular pain, and blurred vision.

 These symptoms negatively impact quality of life and may also reduce visual function and productivity.

 If left untreated, DED may lead to recurring patient complaints,

 persistent discomfort, and long-term ocular damage.

 Early diagnosis and intervention are essential to prevent these adverse outcomes and improve the patient’s visual function and overall well-being.

DED can be identified through comprehensive evaluations, including clinical assessments like corneal staining

Management strategies often include artificial tear supplements, prescription therapies targeting various causative factors, and lifestyle modifications.

Proactive management can alleviate symptoms, enhance visual function, and reduce risk of increased follow-ups.

DED is commonly categorized as aqueous deficient, evaporative, or mixed. Excessive tear evaporation due to meibomian gland dysfunction is the leading cause, affecting approximately 90% of patients with DED.

Prescription treatments target the insufficient tear production, inflammatory pathways, or excessive evaporation that perpetuate DED. Cyclosporine-based therapies (Restasis, AbbVie; Cequa, Sun Ophthalmics; Vevye, Harrow) act by inhibiting T-cell activation through the calcineurin-phosphate pathway, resulting in increased tear production and protection of conjunctival goblet cells.

 Cequa employs nanomicellar technology to enhance cyclosporine delivery

 whereas Vevye uses a semifluorinated alkane (SFA), perfluorobutylpentane (PFBP or F4H5), as a vehicle.

Lifitegrast ophthalmic solution 5% (Xiidra; Bausch+Lomb) addresses ocular inflammation through mechanisms such as inhibiting T-cell activation, blocking T-cell recruitment to the ocular surface, and reducing inflammatory cytokine secretion.

Lifitegrast binds to lymphocyte function-associated antigen-1, a protein found on the surface of leukocytes, preventing its interaction with its ligand intercellular adhesion molecule-1.

Perfluorohexyloctane ophthalmic solution (Miebo; Bausch+Lomb) targets the evaporative aspect of DED.

 Composed entirely of perfluorohexyloctane (PFHO or F6H8), Miebo reduces tear evaporation by forming a stable monolayer on the tear film and has a prolonged ocular surface residence time due to its low volatility.

 In doing so, PFHO compensates for deficiencies in meibum and stabilizes the lipid layer of the tear film, which results in improved tear film homeostasis.

 Although both Miebo and Vevye contain an SFA (chemically inert molecules consisting of a fluorocarbon segment and a hydrocarbon segment),

 their physiochemical properties lead to distinct functionalities. The SFA in Vevye’s formulation (PFBP) serves as a vehicle to solubilize cyclosporine better than PFHO yet does not inhibit evaporation.

 In contrast, Miebo (PFHO) exhibits antievaporative effects due to its unique chemical structure.

 The longer chain length of PFHO enables the formation of a stable monolayer at air-liquid interfaces.

 Additionally, PFHO’s higher boiling point

(indicating lower volatility) ensures slower evaporation and prolonged ocular surface residence time.

 Unlike PFBP, PFHO was shown to stabilize the tear film lipid layer in a 7-day study in rabbits.

Varenicline nasal spray (Tyrvaya; Viatris) stimulates tear production via the trigeminal parasympathetic pathway.

 Varenicline, a nicotinic acetylcholine receptor agonist, activates this pathway when administered intranasally.

Symptom reduction as a key differentiator among treatments

Clinical trials evaluating cyclosporine-based treatments for DED include randomized, vehicle-controlled studies of Restasis,

 Across these studies, cyclosporine-based eye drops showed significantly greater improvements in DED signs (eg, corneal staining, Schirmer test) compared with vehicle controls.

 However, reductions in DED symptoms were generally similar between the active treatment and control groups.

 For Restasis, no significant differences were observed between the treatment and control groups for symptoms such as eye dryness, sandy/gritty sensation, burning, stinging, itching, and pain, although a notable improvement in blurred vision was observed.

 For Cequa, changes in the global symptom score were comparable to the vehicle.

 For Vevye, the primary symptom end points (Ocular Surface Disease Index score in ESSENCE-1 and eye dryness in ESSENCE-2) were not met, although secondary analyses showed a significantly greater reduction in eye dryness for Vevye compared with vehicle in ESSENCE-1.

Lifitegrast was assessed in 4 randomized, placebo-controlled trials (phase 2, OPUS-1, OPUS-2, OPUS-3).

 Pooled results from these trials demonstrated that lifitegrast effectively addressed both prespecified end points: signs (corneal staining) and symptoms (eye dryness and discomfort) of DED, with improvements in eye dryness as early as 2 weeks after treatment initiation.

PFHO was found to deliver rapid and sustained improvements in both signs (corneal staining) and symptoms (eye dryness, burning/stinging) of DED, with consistently greater effects than a hypotonic saline (0.6%) control in 2 randomized controlled trials (GOBI, MOJAVE).

Both signs and symptoms were improved by the earliest assessment time point of day 14. A postmarketing study recently demonstrated relief of patients’ symptoms as early as day 3 of treatment.

In randomized, vehicle-controlled studies (ONSET-1, ONSET-2), varenicline nasal spray outperformed the vehicle in improving Schirmer test scores, consistent with its mechanism of action), and significantly reduced eye dryness at most assessments in ONSET-1.

Identifying and appropriately treating DED is vital to ensure patient comfort and visual quality and function. Treatment decisions should consider disease etiology, symptom burden, and patient preferences. For aqueous-deficient DED, cyclosporine-based products or varenicline nasal spray may be appropriate, with patient choice guiding between a drop or nasal spray. PFHO is particularly effective for evaporative DED, whereas lifitegrast may be favored in cases involving inflammation. Products that alleviate symptoms, such as lifitegrast and PFHO, may be preferable for patients most troubled by discomfort. A personalized approach to therapy selection can optimize outcomes for individuals with DED.

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Villani E, Barabino S, Giannaccare G, Di Zazzo A, Aragona P, Rolando M. From symptoms to satisfaction: optimizing patient-centered care in dry eye disease. 

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Verjee MA, Brissette AR, Starr CE. Dry eye disease: early recognition with guidance on management and treatment for primary care family physicians. 

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Bartlett JD, Keith MS, Sudharshan L, Snedecor SJ. Associations between signs and symptoms of dry eye disease: a systematic review. 

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Uchino M, Yokoi N, Kawashima M, Ryutaro Y, Uchino Y, Tsubota K. Treatment trends in dry eye disease and factors associated with ophthalmic follow-up discontinuation in Japan. 

Pellegrini M, Bernabei F, Moscardelli F, et al. Assessment of corneal fluorescein staining in different dry eye subtypes using digital image analysis. 

Savini G, Prabhawasat P, Kojima T, Grueterich M, Espana E, Goto E. The challenge of dry eye diagnosis. 

Agarwal P, Craig JP, Rupenthal ID. Formulation considerations for the management of dry eye disease. 

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Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. 

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Periman LM, Mah FS, Karpecki PM. A review of the mechanism of action of cyclosporine A: the role of cyclosporine A in dry eye disease and recent formulation developments. 

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Periman LM, Perez VL, Saban DR, Lin MC, Neri P. The immunological basis of dry eye disease and current topical treatment options. 

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Agarwal P, Korward J, Krösser S, Rupenthal ID. Preclinical characterization of water-free cyclosporine eye drops – factors impacting ocular penetration 

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Perez VL, Pflugfelder SC, Zhang S, Shojaei A, Haque R. Lifitegrast, a novel integrin antagonist for treatment of dry eye disease. 

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Zhuang-Yan A, Syed YY. Perfluorohexyloctane ophthalmic solution: a review in dry eye disease. 

2024;84(4):441-448. doi:10.1007/s40265-024-02016-5

Tsagogiorgas C, Otto M. Semifluorinated alkanes as new drug carriers—an overview of potential medical and clinical applications. 

2023;15(4):1211. doi:10.3390/pharmaceutics15041211

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2004;108(35):13403-13411. doi:10.1021/jp0402481

Liang Y, Kociok N, Leszczuk M, et al. A cleaning solution for silicone intraocular lenses: "sticky silicone oil". 

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Agarwal P, Scherer D, Günther B, Rupenthal ID. Semifluorinated alkane based systems for enhanced corneal penetration of poorly soluble drugs. 

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Agarwal P, Khun D, Krösser S, et al. Preclinical studies evaluating the effect of semifluorinated alkanes on ocular surface and tear fluid dynamics. 

2019;17(2):241-249. doi:10.1016/j.jtos.2019.02.010

Pflugfelder SC, Cao A, Galor A, Nichols KK, Cohen NA, Dalton M. Nicotinic acetylcholine receptor stimulation: a new approach for stimulating tear secretion in dry eye disease. 

2022;25:58-64. doi:10.1016/j.jtos.2022.05.001

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Goldberg DF, Malhotra RP, Schechter BA, Justice A, Weiss SL, Sheppard JD. A phase 3, randomized, double-masked study of OTX-101 ophthalmic solution 0.09% in the treatment of dry eye disease. 

2019;126(9):1230-1237. doi:10.1016/j.ophtha.2019.03.050

Sheppard JD, Wirta DL, McLaurin E, et al. A water-free 0.1% cyclosporine A solution for treatment of dry eye disease: results of the randomized phase 2B/3 ESSENCE study. 

2021;40(10):1290-1297. doi:10.1097/ICO.0000000000002633

Akpek EK, Wirta DL, Downing JE, et al. Efficacy and safety of a water-free topical cyclosporine, 0.1%, solution for the treatment of moderate to severe dry eye disease: the ESSENCE-2 randomized clinical trial. 

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Sheppard JD, Torkildsen GL, Lonsdale JD, et al; OPUS-1 Study Group. Lifitegrast ophthalmic solution 5.0% for treatment of dry eye disease: results of the OPUS-1 phase 3 study. 

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Tauber J, Berdy GJ, Wirta DL, Krösser S, Vittitow JL; GOBI Study Group. NOV03 for dry eye disease associated with meibomian gland dysfunction: results of the randomized phase 3 GOBI study. 

2023;130(5):516-524. doi:10.1016/j.ophtha.2022.12.021

Sheppard JD, Kurata F, Epitropoulos AT, Krösser S, Vittitow JL; MOJAVE Study Group. NOV03 for signs and symptoms of dry eye disease associated with meibomian gland dysfunction: the randomized phase 3 MOJAVE study. 

An overview of prescription medications available for DED.

Arti Shah, OD, FAAO

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