This article was originally published in a sponsored newsletter.

Ocular surface disease (OSD) is a multifactorial condition that is a frequent reason for visits to eye-care providers. OSD can be associated with eyelid-related factors, autoimmune diseases, neurotrophic keratopathy, limbal stem cell deficiency, prior surgery and systemic medications, among others. As a result, it has become increasingly important to approach management in a targeted fashion. In this article, we present two illustrative cases in which the primary etiology for OSD was appropriately identified, and focused approaches were taken for pathology-directed treatment to optimize patient outcomes.

Case 1

A 46-year-old woman experienced three years of bilateral irritation and eyelid itchiness. She was previously treated with cyclosporine 0.05%, preservative-free artificial tears, warm compresses and lid wipes. Examination demonstrated the presence of collarettes on her eyelids, along with bilateral conjunctival injection.

Treatment: The patient was treated with a six-week course of twice daily lotilaner ophthalmic solution 0.25% (XDEMVY, Tarsus Pharmaceuticals) and showed improvement in symptoms and clinical resolution of eyelid collarettes.

Discussion: Demodex blepharitis can be graded based on the number of lashes per eyelid with collarettes¹: 

• Grade 0 includes less than three lashes/eyelid.
• Grade 1 includes three to 10 lashes/eyelid.
• Grade 2 includes more than 10 but less than 1/3 of lashes/eyelid.
• Grade 3 involves greater than or equal to 1/3 to less than 2/3 of lashes/eyelid.
• Grade 4 involves greater than or equal to 2/3 of lashes/eyelid.

Lotilaner 0.25% works by inhibiting Demodex mites’ GABA chloride channels, leading to uncontrolled neuromuscular activity and death. Nearly 90% of patients in the Saturn-2 trial demonstrated a clinically meaningful cure (grade 0 or 1) after treatment.² 

Case 2

A 55-year-old man experienced 10 years of bilateral dryness, foreign body sensation and fluctuation in vision. Prior treatments included lifitegrast 5% (XIIDRA, Bausch + Lomb), topical corticosteroids, preservative-free artificial tears and oral doxycycline, with modest improvement. Examination revealed diffuse punctate epitheliopathy and decreased tear break-up time.

Treatment: This patient was managed with perfluorohexyloctane ophthalmic solution (MIEBO, Bausch + Lomb) four times daily in both eyes. He noted significant improvement in symptoms within weeks of treatment.

Discussion: Perfluorohexyloctane is a well-tolerated treatment that readily incorporates into patients’ tear films, decreases evaporation and stabilizes the tear layer. The drop consistency itself may provide a soothing effect that some patients may find immediately relieving.

The spectrum of OSD is broad and becoming increasingly subdivided as knowledge on underlying etiologies of disease emerges. The future of managing OSD will certainly involve more directed and specific treatments, and our patients have better options than ever before.

References:

1. Martinez-Pulgarin DF, Avila MY, Rodriguez-Morales AJ. Interventions for Demodex blepharitis and their effectiveness: a systematic review and meta-analysis. Cont Lens Anterior Eye. 2021 Dec;44(6):101453. doi:10.1016/j.clae.2021.101453
2. Gaddie IB, Donnenfeld ED, Karpecki P, et al. Lotilaner ophthalmic solution 0.25% for Demodex blepharitis: randomized, vehicle-controlled, multicenter, phase 3 trial (Saturn-2). Ophthalmology. 2023 Oct;130(10):1015-1023. doi:10.1016/j.ophtha.2023.05.030

ZEBA A. SYED, MD is a fellowship-trained ophthalmologist who specializes in cornea, cataract, and refractive surgery. She serves as an Associate Professor of Ophthalmology at Sidney Kimmel Medical College at Thomas Jefferson University and is the Director of the Cornea Fellowship at Wills Eye Hospital.

Cynthia Matossian MD, FACS is the founder of Matossian Eye Associates. She specializes in refractive cataract surgery and dry eye disease. She was named one of Ocular Surgery News' Premier Surgeon 300—an elite group of 300 premium refractive cataract surgeons in the United States. She was the 2017 winner of the Ophthalmic World Leaders Visionary Award. She has been named one of the Top 25 Leading Women Entrepreneurs in New Jersey and one of New Jersey and Pennsylvania’s Best 50 Women in Business. She is a Clinical Assistant Professor of Ophthalmology (Adjunct) at Temple University School of Medicine. She has published numerous articles and participated in national and international meetings in leadership roles.