Within her practice, Selina McGee, OD, estimates at least 86% of patients have evaporative dry eye disease (DED) and suggests that in some clinical settings, that number rises to 100%.
Considering these staggering statistics, optometrists are always looking for additional treatment options to add to their armamentarium.
In May 2023, MIEBO (Bausch & Lomb) gained FDA approval as the first and only dry eye disease treatment to target tear evaporation directly.1
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Overview of MIEBO
Indicated for the treatment of the signs and symptoms of dry eye disease, MIEBO (perfluorohexyloctane ophthalmic solution) can form an anti-evaporative layer on the ocular surface to potentially inhibit evaporation and promote healing.2,3
MIEBO can mimic the functions of the natural meibum, using a water-, steroid-, and preservative-free formulation, which distinguishes it from other topical ophthalmic treatments for dry eye disease.
Screening for evaporative dry eye disease
To establish which patients are candidates for MIEBO, Dr. McGee recommends utilizing a validated dry eye questionnaire such as SPEED (Standard Patient Evaluation of Eye Dryness), which assesses dry eye symptoms through eight questions that cover the severity and frequency using a numeric scale.
The questionnaire serves as an entry point for Dr. McGee’s evaluation at the beginning of the appointment. Depending on the answers, she might decide whether further testing is warranted.
Additional tests that could aid in the proactive identification of dry eye may include:
- Tear osmolarity: To determine the tear film integrity or homeostatic balance by measuring the salinity of the tears.
- MMP9: To measure the qualitative level of matrix metalloproteinase 9 (MMP-9) in the tear film, which can often correlate to ocular surface inflammation.4
- Tear breakup time (TBUT): To assess tear film stability.
- Corneal staining: Using fluorescein sodium (NaFl) to assess the viability of the epithelium. Lissamine green might be employed to assess the quality of the ocular surface further.
Ideal candidates for MIEBO
Dr. McGee identifies three groups of patients that make prime candidates for treatment with MIEBO.
These include individuals who are:
- Treatment-naïve
- Undergoing interventional treatments
- Already being treated for dry eye disease
For the treatment-naïve patient
Dr. McGee encounters many patients who are not privy to their condition and the availability of prescription treatments. She explained, “Most people don't come in saying, ‘My eyes are dry, and I think my tears are evaporating. Can you help me with that?”
However, the answers elicited from the questionnaire allow the eyecare provider (ECP) to gauge the most common patient complaints of fatigue, visual fluctuations, and discomfort (e.g., burning, grittiness, itchiness, soreness, and irritation) while gleaning whether they have previously tried or are currently using over-the-counter drops.
Additional questioning often reveals their symptoms are the result of sitting in front of a computer—perhaps even looking at 2 screens—for 10 to 14 hours a day. In these individuals, corneal staining frequently confirms a very rapid TBUT.
These are patients with “supply and demand” issues, whose ocular surface system simply cannot keep up with their high-level visual needs throughout the day. Dr. McGee has found that MIEBO can be a treatment option for this population.
MIEBO in conjunction with interventional therapies
Patients who are at risk of excessive evaporation and are already undergoing interventional in-office therapies, such as intense pulsed light (IPL), radiofrequency (RF), or meibomian gland expression, comprise the second group who can benefit from MIEBO.
As perfluorohexyloctane can mimic the qualities of natural meibum, it works in conjunction with these procedures to potentially prevent evaporation. In Dr. McGee’s professional opinion, this treatment approach could have a complementary effect to possibly further reduce DED symptoms and signs.
Adding MIEBO to a treatment regimen
A third group that might benefit from MIEBO is patients who are already on an immunomodulator. As a result of this chronic therapy, they tend to have a normalized osmolarity and a reduction in symptoms but still suffer from a low TBUT. MIEBO could fill an unmet need in this population of patients.
This group also contains those who might be positively responding to neurostimulation and making their own tears. However, they could be rewarded from these tears remaining on the surface longer, allowing the cornea to reap the benefits of the 2,000 different components that make up natural tears.
Fitting MIEBO into your practice
According to Dr. McGee, as most dry eye patients have some form of evaporative dry eye in addition to aqueous deficiency,5 MIEBO has its place in many practices that treat DED.
When adding MIEBO to your treatment arsenal, Dr. McGee suggests considering all of the different scenarios and finding the individuals within your patient population who could benefit from perfluorohexyloctane’s unique properties.
Success starts with patient education
There are a few key points that are imperative strategies when introducing MIEBO to patients. First and foremost, make sure they are aware that MIEBO is not mistaken for just an improved artificial tear. Point out that, though they may appear similar—both come in a bottle and are applied as a drop to the ocular surface—that is where the similarities end.
It can be helpful to explain that perfluorohexyloctane is an entirely different molecule that has a novel design where the therapy rests on the surface of the eye with the goal of potentially preventing tear evaporation.
Secondly, it is crucial to let patients know what to expect when instilling the drop. As this molecule is a mere 11 microliters, as opposed to a 30- to 50-microliter water-based drop, patients will not always feel MIEBO when it hits the eye.
In Dr. McGee’s experience, this can lead to individuals dispensing too much of the drop and using up their month-long supply in 2 weeks or less. The bottle should afford 4 drops per day for 4 weeks. Also, it is recommended to stress that the drop will feel “silky” or “oily,” as there is no water in it.
Arming patients with this knowledge can help to eliminate the common problem of overdosing.
Sample patient script to prevent overdosing:
“To ensure you don't utilize your whole therapy before your month is out and you can get your refill, just tip the bottle and tap instead of squeezing when you administer the drop.”
Professional pearls for MIEBO
Through her experience using MIEBO, Dr. McGee extracted three additional pearls.
1. Choose your pharmacy wisely.
Avoid sending a MIEBO prescription to a typical box store. Dr. McGee has found the least amount of friction using BlinkRX, which can fill the order and then ship it directly to the patient.
Your Bausch & Lomb representative can help you locate a suitable pharmacy.
2. Opt for noninvasive tear breakup time testing.
In traditional tear breakup time, fluorescein mixes with our natural tear film. However, because perfluorohexyloctane and fluorescein do not mix, if you are depending on an invasive assessment at the slit lamp, there is a tendency to observe false readings during your ocular surface evaluation.
Instead, use a noninvasive test method when possible.
3. Follow-up to assess progress.
Schedule patients for a follow-up visit in 4 to 5 weeks to evaluate progress and reassess their symptomology using a secondary questionnaire and whatever additional testing you deem medically necessary.
Final thoughts
With the widespread prevalence of ocular surface disease and evaporative DED in particular, another effective and well-tolerated therapy is always welcomed.
The keys to an optimal outcome include proactive identification via appropriate evaluation and testing, thorough patient education, and timely follow-up.
By taking these steps, ECPs can empower patients by helping to address an unmet need in DED treatment and management with MIEBO.
