Old habits die dry: Philosophical considerations of dry eye disease

Don’t try to convince yourself otherwise. We are all guilty. Much of our clinical practice of eye care is deeply entrenched in habit — and for good reason.

Habits are what allow us to survive a busy day at the office. They are formed out of experience, intuition and maybe even a little bit of scientific evidence. Clinical habits are what guide us along our office day as we encounter the expected and the unexpected, the routine follow-up and the complex referral. We are a highly patterned professional group that neatly fits clinical presentations into categories we know and with which we are comfortable. We reflexively recommend treatments based on what has worked or, as is often the case, what has worked efficiently within our office schedule.

But occasionally, habits fail us. For the general eye care professional (ECP), it is difficult to think of a better perpetuator of habit than dry eye disease (DED). With a prevalence in our office topped only by refractive errors, DED is a fertile breeding ground for routine and for reflex, for deeply ingrained habits used to both identify and treat the disease. And why not? For a disease state whose risk factors are so numerous that it is more difficult to find a patient without them than with them, for a disease state that can serve as a default diagnosis for the most common everyday complaints doctors encounter, and for a disease state that is just as likely to be underdiagnosed as it is overdiagnosed, bring on the habits. Bring on the artificial tears, warm compresses and lid scrubs.

Enter cyclosporine. Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) was approved by the FDA in 2003, and by the time of the Ocular Surface Disease Index in 2005, it had already reshaped how doctors think about the management of DED and began to create habits that persist today. Admittedly, in the early 2000s, when the mainstay of treatment was artificial tears, ointments and plugs, the introduction of an immunomodulator to treat DED was anything but habit. But through the powers of marketing and education, doctors gradually signed on, establishing the consensus that still exists today regarding the inflammatory basis of chronic DED.

Now, more than 2 decades after the introduction of Restasis, we have four more versions of branded cyclosporine available for DED. In 2017, we saw the release of Klarity-C (cyclosporine 0.1%, ImprimisRx) featuring a version of cyclosporine compounded in chondroitin sulfate. In 2018, Sun Pharma announced the approval of Cequa (cyclosporine ophthalmic solution 0.09%) featuring a nanomicellar formulation designed to improve penetration of the drug through the aqueous tears. In 2021, Santen delivered Verkazia (cyclosporine ophthalmic emulsion 0.1%, now Harrow), produced in a cationic delivery system intended for once-daily dosing. And the latest innovation to the cyclosporine arsenal is Vevye (cyclosporine ophthalmic solution 0.1%, Harrow), with the active ingredient dissolved in an inactive ingredient similar to but not identical to Miebo (perfluorohexyloctane ophthalmic solution, Bausch + Lomb). Sound like a lot of choices? That does not even include the myriad of generic cyclosporine options that adorn our pharmacy shelves.

Perhaps we can a learn lesson from Forrest Gump’s unforgettable aplomb as he sat through Bubba’s recitation of the many ways his family prepares shrimp. Or we can just do what so many ECPs do and take shelter under the protection of habit, justifying our neglect of detail by claiming our primary focus is affordability for our patients — a common habit, no doubt. Of course, affordability matters. But unfortunately, so many of us (and our sales reps) have become cost and coverage commandos, focusing exclusively on why a medication is affordable instead of why we should prescribe a certain medication. No one would deny we have patients who cannot afford certain options, and for those patients, something may be better than nothing. But no practicing ECP would deny that we have many patients who can afford the medication but do not want to buy it. What is our obligation to them if the details do matter?

Stick to your DED habits, and you may never know. Before you reach for your “old trusty,” before you activate your brain’s automated DED circuit, before you consider prior authorizations and Part D coverage, why not consider if you actually believe in the innovation of a new drug? Could your DED patient get an improved result with a fresh strategy? Do you believe drug delivery and formulation matter? Do you believe innovation can improve tradition? Or do you recite the cranky-doc creed: “They are similar enough! As long as I am giving something, I am doing something! I don’t want to deal with callbacks! If it ain’t broke, don’t fix it!”

If you truly believed “if it ain’t broke, don’t fix it,” then you would not believe in improvement. Or worse, you would only believe in improvement if something broke. That is not the way we practice eye care; that is the way we practice habits.

With the recent availability of Vevye, the latest in the distinguished genealogy of cyclosporine options, why not attempt to break habit? Vevye was designed to address three things: the onset of action of cyclosporine, the tolerability of cyclosporine and the bioavailability of cyclosporine. Why not take a look at the evidence from the two phase 3 ESSENCE trials and the 52-week open-label extension study and see if you believe your patients may benefit, that something need not “break” before we fix it. Ultimately, it is beliefs that drive behavior. And it is only the belief in the value of something new that can deliver us from the mind-numbing ways of old.

Failing this, I fear old habits will continue to die dry.

• For more information:
• Richard Adler, MD, FACS, director of ophthalmology services at Azman Eye Care Specialists and assistant professor of ophthalmology at Wilmer Eye Institute, can be reached at richardadlermd@outlook.com.

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Disclosures:
Adler reports speaking and consulting for AbbVie, Bausch + Lomb, Harrow, Lumenis, Sun Pharma, Tarsus and Viatris.

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