Vevye and the multifaceted world of treating dry eye

With many dry eye disease (DED) treatment options on the market, it may be difficult for eye care providers to decide on the best eye drop to prescribe their patients. Marc R Bloomenstein, OD, FAAO, discusses that Vevye brings a unique option to consider when making these decisions in an exclusive interview with Optometry Times.

Video transcript

Editor's note - This transcript has been edited for clarity.

Emily Kaiser Maharjan:

I'm here with Dr Marc Bloomenstein to chat about dry eye management and Vevye as a treatment for dry eye. So welcome Dr Bloomenstein. I'm so glad you could join us.

Marc R Bloomenstein, OD, FAAO:
Hey, thanks for having me. I'm excited to be here, sitting in my office, talking to you.

Kaiser Maharjan:
A fun place to be. So first, can you tell us a little bit about your history of treating dry eye?

Bloomenstein:
Yeah, I mean, to be really sincere with you, anybody who's ever listened to me talk knows that I hate the term dry eye because I think it's very ambiguous. I think that as optometrists, every person that walks into our exam lane, we have to ensure that the quality of their tear film, the optical surface that resides on the epithelial tissue of the cornea, is going to be able to meet their demands. Interesting enough, over the last 30 years that I've been practicing, we really, really, really stressed and I mean, when I say stress, we put a lot of stress on our patients, quality of tears, and the ability to make tears. So I kind of feel like I've been managing and treating dry eye since literally the minute I started practicing optometry and I would challenge every doctor out there who works with patients who want to see better, or want us to tell them if they're doing enough so they can see better, that you're managing dry eye the same.

So to expand on that a little bit, the term dryness really kind of is almost like anti-moist. And yet, when we think about patients who have dry eye, it's more a state of being: their eyes are tearing, they're not dry. That scratchy, irritated feeling that we anticipate when somebody says I have dryness, we don't always get that. The first symptom that I look for with patients is that I just don't think I'm seeing as well. Especially now, as much time we spend on computers, on phones, tablets, where we're really stressing that tear film, and we're not blinking. We blink 1 third of the amount of time, we're seeing more evaporation, and we're inducing a lot more inflammation. We're kind of capitulating this cycle that, at some point, as eye care clinicians, we have to go in and break that.

So I feel like every interaction that I have with the patient is a learning experience for me to see what's going on, see what their lifestyles like. But it's a learning experience for that patient to draw back to what we can do to help stabilize the quality of their tears, and more importantly, give them sustainable relief from the symptoms that I think they're having, and then also to alleviate the signs that we often times can see with these patients.

Kaiser Maharjan:

Yeah, so kind of piggybacking off of that, at what point do you escalate from patient education of management into the prescription era.

Bloomenstein:

Honestly, we could probably spend the rest of our careers just talking about the differences between clinicians and when they decide today's the day. I mean, back from the Game of Thrones days, what do we say to death? Not today. To me, I look at everybody's eyes, and I say, "At what point am I going to wait for these patients to become extremely symptomatic? Not today."

So when a patient's already utilizing a lubricating drop, when they already feel the need, the desire, they've gone to the store, bought something over the counter (hopefully not the ones that the FDA has basically just said, "Don't use those"), a branded, good quality lubricating drop, then I already know this patient perceives they have an issue. If I feel that I have to tell a patient, "Look, you need to keep your eyes more lubricated," we now have opportunities to help our patients, neurostimulate the production of a natural tear. We now have better quality, preservative-free, multidose bottles that we can prescribe for patients. So I'm always looking to see what's going to be the most convenient for the patient. But when I start seeing overt, more signs or more symptoms that are correlated to my patient's lifestyle, then I'm very, very aggressive about prescribing something that is going to help manage their condition, but better yet, to be proactive, to prevent it from getting worse. So when you ask me at what point do I pull the trigger, I'm ready to pull the trigger pretty much every time I see a patient who I think is going to benefit from either you know, an immunomodulating agent or an anti-inflammatory or a neurostimulator or even something that is going to help stabilize the evaporative aspect of their tear film.

Kaiser Maharjan:

Absolutely, so kind of dipping into that and dipping into the territory of Vevye, What makes that particular drop stand out from the crowd when you're considering all your treatment options?

Bloomenstein:

You are asking some really great questions. Part of the problem is, is that we're not a monolith. I mean, every patient is different, and what patients can experience, what patients can carry, what patients can tolerate. So we've known for almost over 20 years that cyclosporine has been an effective anti-inflammatory immunomodulator. Allergan was the was the first billion dollar medication. Optometry embraced that, but we also know that not every patient stayed on it. We also know that having adherence to a drop is also different than being compliant and patients would not adhere because it burned or irritated them, or the challenge of the multi doses, or the single vial uses.

The other thing that really happens also is, is that we start losing the ability to make decisions that we think is in our patient's best interest because of coverage, because they don't have accessibility to it. Fortunately, we have the opportunity to look at different options. Knowing that cyclosporine works really well for a lot of our patients, it's nice to be able to couple patients who have had sensitivities, or have had challenges with preservatives, patients who felt that they're burning, stinging or having a challenge to get like a large drop in their eye. So as we've watched the evolution of cyclosporine become a different iterations, we have to remember too, that, you know, the mechanism of the action of the molecule is only as good as the delivery.

What Vevye has done is they've taken a perfluoro, I think it's butylpentane, which is the vehicle, which is a semifluorinated alkyne. We have another semifluorinated alkanes, which, they're not the same, on the market. The density of the medication, the spreadability, how deep it penetrates into the eye is a lot different, but the vehicle that carries this .1% cyclosporine, makes Vevye a very unique opportunity. And the reason why I say that is is that it's a very small dose, it's like 10 microliters, which is about 1 third to 1 fifth the normal size of a drop. So for patients who have a hard time getting a drop in, it's a lot more convenient. Because it's waterless it's preservative free. It's the first medication or first cyclosporine, we've had that comes in and multidose bottle that doesn't have any preservative in it that's water free, I should say, because of the vehicle. In their clinical trials and my patient experience in using this, it's been a very, very neutral drop.
So it gives me an opportunity to provide a medication where I feel I'm going to get better compliance with patients. It also gives me an opportunity to help manage that inflammation without having to talk to them about some of the sequelae, the secondary, or the side effects that might happen with the older medications that we've been using.

Kaiser Maharjan:

So what patient do you think would be a good fit for Vevye?

Bloomenstein:

That's a really interesting point. As I mentioned before, I mean, I feel that when I look at patients, I'm always looking for an opportunity to help be proactive, to prevent things from getting worse. So for somebody that is asymptomatic, they don't feel that they have a problem, but I can foresee they do or I watch the quality of their tears evaporating, I'm seeing inflammation that's on the eye, some injection, some inflammation, I would consider absolutely using immunomodulator anti-inflammatory. Using one where I feel it's more comfortable and neutral, the accessibility of it, I would absolutely consider you know, Vevye.

I mean, I'm not naive, though. I mean, oftentimes I'm restricted by what my patient's accessibility is. But [ophthalmic healthcare market] Harrow has made it really easy right now and made an opportunity for patients to be able to get this as low as 0 dollars, pay no more than maybe 79 I'd see, and they have a money back guarantee, which helps me also to talk to patients about using it. A class of patients that I really, really, really try to find the most neutral comfortable job is ones that are already on multiple drugs, so for example, a glaucoma patient. We see a tremendous amount of dry with our glaucoma patients and a lot of it has to do with the preservatives that we see in there other medications. So finding something that's going to be neutral, that's going to have accessibility that's also going to penetrate and is also demonstrated to work very quickly. Vevye has been put into my armamentarium, if you will.

Kaiser Maharjan:

Yeah, absolutely. It's a great addition to the optometrists' toolkit. It's good to have options.

Bloomenstein:

Yeah, definitely.

Kaiser Maharjan:

Alright. Is there anything else that you'd like to talk about that we haven't touched on?

Bloomenstein:

I think that, you know, for my colleagues, and for me, it's not 1 size fits all. So it's great to have options and often times we trial something as opposed to throwing the baby out with the bathwater, or maybe all we need to do is do an added medication. Or the bigger thing, though, is just finding what's going to be the right fit for your patients. I think that, you know, you don't know until you've tried it with your patients, and I think that Vevye fits nicely in there because of its unique qualities that will give us an opportunity to see what's going to help our patients.

Kaiser Maharjan:

That sounds fantastic. So thank you so much for taking the time to chat today. I really appreciate you sharing your knowledge Dr Bloomenstein.

Bloomenstein:

Your welcome, anytime, anytime. Let's do this again.

Kaiser Maharjan:

Absolutely. Sounds good.