AOA 2024: Early adoption and utilization of perfluorohexceloctane (Miebo) for dry eye disease

As the only evaporative dry eye treatment on the market, Miebo provides another option for relief to the nearly 90% of patients that have an evaporative component to their dry eye disease, according to Adam Alexander, OD. He details what he and the team at Bausch + Lomb discovered in observing Miebo's first 90 days on the commercial market in his AOA Optometry's Meeting e-poster. His presentation can be watched here.

Video transcript

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

Jordana Joy:

Hi everyone. I'm here today with Dr. Adam Alexander, director of Medical Affairs at Bausch + Lomb. He's here to chat about a poster presentation he gave on the early adoption and utilization of perfluorohexceloctane for dry eye disease in part of the AOA Optometry's Meeting ePoster Session on May 29 and 30. So thank you very much for being here today, Dr. Alexander. It's a pleasure to have you.

Adam Alexander, OD:

Thanks for having me.

Joy:

Awesome. So first, could you give us an overview of the poster presentation that you gave?

Alexander:

Yeah, absolutely. So this was a poster that was done in combination with our [Health Economics and Outcomes Research, or] HEOR department at B+L to say this was essentially looking at the first 90 days that perfluorohexloctane, or Miebo, was commercially available in the US to say, what type of patients were being prescribed Miebo, how likely were those patients to then refill in around 60 days or so after they got their first prescription, did they have a dry diagnosis, those sort of things. So general demographics, but also just helps us understand who was getting it, how likely were they to then refill and maybe help us as we move forward with Miebo as a product down the line?

Joy:

So what are the characteristics of those best candidates for Miebo?

Alexander:

Sure, so obviously, I mean, Miebo's approved on label for treatment of signs and symptoms of dry disease. So anybody with dry disease, obviously, can be a candidate for Miebo. The interesting thing about Miebo is we know 86% of patients or so have an evaporative component to their dry eye disease. Miebo is the first and only prescription eye drop that actually directly targets evaporation. So partly what we want to understand: were are these patients getting, say, an ICD-10 code diagnosis for evaporative dry eye or that indicated evaporative dry eye? Those sorts of things. When we look in the study, patients were largely females, sort of around 60. I mean, these are sort of normal population demographics for patients with dry eye disease. So it really is a great drug for anyone with the disease, but we wanted to see, you know, how likely were they, in part of this, to be specifically targeting of operation at least in their ICD-10 code or their medical claim.

Joy:

Sure, absolutely. So how has Miebo changed really the approach to dry eye care and how do you see it impacting future innovations in that care?

Alexander:

Well, I think dry eye right now is a great space to be because there's lots of innovations happening beyond just Miebo. I mean, it's nice to have, obviously, the first and only product that directly targets evaporation. I think what, in theory, what eye care should be going for with with dry eye is more sort of precision medicine, precision management, right? You know, we only had 1 treatment option for a decade, and then another treatment option, and obviously, more and more have come along. And I think now we can sort of speak as optometrists, you know, the patient that's sitting in my chair, do I think they're more evaporative? Do I think they're maybe somewhat mixed or they lean more to the aqueous component? And depending on where they are in that disease cascade, you know, I could start them with Miebo if they're evaporative, or Xiidra if they're more inflammatory, those sorts of things. We have lots and lots of options, and knowing that the disease is going to change and evolve over the patient's lifespan as well.

Joy:

For sure, absolutely. So do we have any better of an understanding of the mechanism of action behind Miebo, since it's been launched.

Alexander:

Yeah, Miebo's an interesting drug in that it's not, you know, it's inert. It's not creating any sort of physicochemical reaction at the surface, right? It's forming this physical barrier to evaporation. So, you know, it's a molecule that has 14 carbons in the backbone. Eight of those carbons are protonated, or surrounded by hydrogen atoms, 6 of the carbons are fluorinated, or surrounded by fluorine atoms. And we know that those 8 protonated carbons, want to embed and anchor in the outer lipid layer of the tear film, and those 6 fluorinated carbons want to then orient themselves away from that into the air. The fluorine is like air, they really hate lipid, they really hate aqueous, so they're very lipophilic, very hydrophobic, but they are aerophilic. So you have this lipophilic hydrocarbon segment that embeds there and the fluoridated segment that's aerophilic and puts itself in the air. And then it just forms this nice barrier, it spreads very rapidly, there's low surface tension to the drop itself. So it's spreading rapidly, obviously, when it hits the surface, and then in between blinks as well, and just forming this physical barrier to evaporation.

I mean, the way I like to think about it is if you've ever been fishing, you have a fishing bobber, some of it stays above the water, some of it stays below the water, no matter how sort of disrupted the water gets or if it rains on top of it right? It always sits in the exact same spot. Miebo is doing that exact same thing at the surface. So it's very interesting in that it's just having this physical barrier to evaporation, trying to keep your natural tears on the eye as long as possible. We know the 2 things that the lipid layer of the tear film was supposed to do are inhibit evaporation and reduce surface tension at the surface to obviously not have buildup or friction forces from blinking. Miebo was able to do both of those things. So we think it's pretty unique in that sense.

Joy:

Absolutely, that's all very fascinating. But AOA's Optometry's Meeting is coming up right rapidly here in Nashville, what are you most looking forward to this year?

Alexander:

So it'll be great to be back in Nashville. I haven't been back in a couple years, so that'll be that'd be fun to visit. I mean, I'm from the Midwest, so Nashville is sort of a nice place to get to. And Optometry's Meeting in general is a great place to see plenty of colleagues, plenty of people from around the country that I don't get to see very often anymore.

You know, it's nice for B+L to have beyond Miebo other things that are going to be highlighted at the meeting, and certainly other products within the dry eye space that we're going to be talking about, which is exciting, including a nutritional product that that we're very excited about. You know, I'm spending all of my time in sort of dry eye and dry eye research right now, which is fun. But when I come to the meetings, it's nice to get back into things like glaucoma and diabetes. That's where I grew up on eyecare when I was still in clinic full time. And so I like to hear what's happening in those spaces as well. So it'd be a lot of lecture, some meetings, some additional posters and those sorts of things for me, but obviously a very fun and busy meeting in Nashville in a great city to visit.

Joy:

Absolutely. So was there anything else that you wanted to touch on that we haven't gotten to yet?

Alexander:

Yeah, so specifically when we were looking for the dry eye patients in this study, specifically, right — and obviously, I covered it in the poster session, the virtual poster session — but when we look at how likely were people to prescribe or to refill their Miebo versus cyclosporine. And this wasn't a comparator; cyclosporine, both generic and branded, were just included as a sort of descriptor, to say how many patients were getting Miebo in this 90 day period and how many patients are getting cyclosporine. So we just had an idea of, you know, this is a pretty standardized drop in this space, let's at least use that to see what type of patients are getting that drop versus not. The interesting part about the cyclosporine is that within the 90 days, still the majority of those patients were getting a 30 day supply of cyclosporine versus 90 days, which we may think it's the opposite, so most patients were getting a 30 day supply. And obviously, Miebo is pretty much written as a 30 day supply right now. You know, patients that are getting my bo in their 60 day post-treatment period or the 60 days past the time that they got their prescription, about two-thirds of them refilled versus only about a quarter of the cyclosporine patients refilled.

Is that speaking to Miebo is potentially, you know, something that is having some better patient outcomes or patient satisfaction? This study isn't enough to say that, but it's maybe saying that that's something we can continue to look at down the line. And we also want to look and see, like I said, how many of these patients were getting a dry eye diagnosis. The thing that was interesting for me as a clinician, only about 38% of the Miebo patients, and about a third of the cyclosporine patients got any sort of dry eye diagnosis on the day of their prescription or within the 12 months prior. And that's including 110 different ICD-10 codes for ocular surface disease. You know, we're trying to be very inclusive in the study to grab what are the providers that are part of this database, what are they coding for. And really it was under-coded, dry eye was very under-coded, despite the number of prescriptions that are out there.

So the most most patients were getting what we determined to be aqueous deficient dry eye codes. So that dry eye syndrome and bilateral lacrimal glands, that was the most common code you see, and then beyond that was more inflammatory, like keratoconjunctivitis sicca and then meibomian gland disfunction was sort of way down the line. So I think that's sort of ingrained from the way that these type of medications used to be maybe approved on their insurances. You had to have certain ICD-10 code, you had to have certain prescriptions prescribed in the correct order to get things eventually through a prior auth[orization].

I think the thought that I talked about earlier of precision medication or precision medicine with these patients is that we can have more specific codes for the actual disease state or the underlying condition you're seeing in front of you, and hopefully that will help correlate with the prescriptions that are then given out by those those optometrists on the back end. You know, the majority of patients that were getting Miebo were from optometrists, versus cyclosporine was mostly coming from ophthalmology. So certainly optometry is picking this drug up very quickly, or at least it was in the first 90 days. And I think that's continued on since we launched it last September.

Joy:

For sure, it's exciting developments. Thank you very much for taking the time today, Dr. Alexander, we appreciate it.

Alexander:

Of course. Thank you so much.