Emerging dry eye therapies and co-managing MGD: Ping Moore, OD

In this Q&A, Ping Moore, OD, of Emory Eye Center discusses where the dry eye treatment pipeline is heading and how the field's growing emphasis on disease subtyping is shaping day-to-day clinical decisions.

Moore points to selenium sulfide (AZR-MD-001; Azura Ophthalmics), now in the phase 3 ASTRO trial, as a therapy to watch for meibomian gland dysfunction (MGD). If approved, it would be the first ointment designed specifically to clear meibomian gland obstruction, building on the known link between MGD and seborrheic dermatitis. Moore also discusses the expanding role of topical cyclosporine formulations, including cyclosporine ophthalmic emulsion (Restasis; Allergan), cyclosporine 0.09% (Cequa; Sun Pharmaceutical Industries), and cyclosporine 0.1% (Vevye; Harrow), alongside lifitegrast (Xiidra; Bausch + Lomb) as a non-cyclosporine alternative for patients who don't respond to immunomodulatory therapy or face coverage barriers.

Beyond the pipeline, Moore emphasizes that identifying each patient's underlying etiology, whether inflammatory, evaporative, or aqueous-deficient, determines whether treatment should start with anti-inflammatory therapy, punctal plugs, or a combination approach. Moore credits the recently published TFOS DEWS III report with reinforcing this subtype-driven framework, noting the report's emphasis on the overlapping factors, from systemic disease to environmental triggers to medication side effects, that compound dry eye severity over time.

The conversation also addresses collaborative care at Emory, where Moore manages residual dry eye symptoms following cataract and LASIK surgery and co-manages patients with thyroid eye disease alongside the oculoplastics team. Moore describes how surgical interventions, including orbital decompression and entropion or ectropion repair, address underlying anatomic causes of chronic dryness, after which patients return for continued medical management, illustrating a model of coordinated care between optometry and ophthalmology at an academic medical center.

There's a lot happening in the dry eye pipeline—agents targeting neuropathic ocular pain, novel MGD ointments like selenium sulfide, neuromodulators. What emerging therapy has you most excited, and why does it address a gap you're actually seeing in your patients?

Moore: I'm excited about the growing number of treatments available, and those currently being evaluated in clinical trials. One promising example is selenium sulfide (AZR-MD-001; Azura Ophthalmics), an ingredient commonly found in products used to treat dandruff and seborrheic dermatitis. Because we know there is an association between meibomian gland dysfunction (MGD) and seborrheic dermatitis, it's an interesting area of research.

The ASTRO study is currently in phase 3 multicenter clinical trials evaluating the selenium sulfide ointment for MGD. If approved, it would be the first ointment specifically designed to treat MGD by helping unclog the meibomian glands. Although the product is not yet available, I'm looking forward to seeing how it could expand treatment options and influence clinical practice.

Over the past several years, new topical cyclosporine medications have also become increasingly valuable in managing dry eye disease. Cyclosporine is not a neuromodulator but an immunomodulator, and these medications are excellent for patients who have been living with chronic dry eye. Cyclosporine has been available for more than 20 years, and now newer formulations with higher concentrations have demonstrated both safety and improved efficacy. Cyclosporine ophthalmic emulsion (Restasis; Allergan) was the first approved, followed by more recent higher-concentration options such as cyclosporine 0.09% (Cequa; Sun Pharmaceutical Industries) and cyclosporine 0.1% (Vevye; Harrow). Lifitegrast (Xiidra; Bausch + Lomb), while not a cyclosporine, belongs to a different drug class and promises to provide relief within a shorter period. It offers an excellent alternative, particularly for patients who don't respond to cyclosporine or when insurance coverage makes one medication more accessible than another.

In an academic setting, physicians from other specialties often ask whether these medications are safe to use in the eye. They're familiar with similar drugs taken orally or applied to the skin, where side effects can differ significantly. For FDA-approved ophthalmic medications, the dose and concentration have been specifically studied and shown to be safe for ocular use while providing meaningful clinical benefit.

That said, no single treatment is right for every patient. The key is identifying the underlying cause of the disease. Does the patient have significant inflammation requiring control first with a short course of a low-dose steroid before transitioning to artificial tears? Or is the primary issue reduced aqueous tear production, where punctal plugs may provide substantial benefit by helping retain tears?

On the other hand, punctal plugs are generally not the best choice for patients with significant ocular surface inflammation because they can trap inflammatory mediators on the ocular surface, potentially worsening irritation. Those patients are also more likely to rub the plugs out because of discomfort.

Finding the etiology of each dry eye case and providing a tailored treatment plan, whether it's starting with eye lubrication, warm compresses, incorporating immunosuppressants, low-dose steroids, or inserting punctal plugs, or any combination of these, can prevent or alleviate neuropathic ocular pain. For these chronic cases, it takes time, and it's our job as eye care providers to walk patients through these steps so they have guidance during the process.

We already have a wide range of treatment options, and the pipeline continues to grow. It will be exciting to see how these emerging therapies fit into individualized treatment plans and help us better care for patients.

The TFOS DEWS III report, published late last year, puts a strong emphasis on targeting treatment to disease subtypes rather than a one-size-fits-all approach. Has that guidance shifted how you're categorizing patients in your own clinic?

Moore: The TFOS DEWS III report is one of the most comprehensive manuals on dry eye treatment and management available today. It was developed through the collaboration of scientists from around the world who specialize in dry eye therapy and management, and I have a great deal of respect for this publication.

For clinicians who have been treating dry eye for many years, much of the content serves as a valuable review. However, it also covers emerging therapies and new treatment approaches, which I found especially helpful. In addition, it clearly outlines the different categories of dry eye, including meibomian gland dysfunction (MGD), which is just one component of the broader discussion.

The term "dry eye" sounds straightforward, but its underlying causes are often complex. Etiology can include autoimmune disease, allergies, gut health, stress, environmental factors at home or at work, prolonged computer use, dehydration, or mechanical abnormalities of the eyelids that lead to incomplete blinking. Systemic medications, including many cancer therapies and allergy medications, can also contribute. Even some eye drops used to treat dry eye contain preservatives that may worsen ocular surface dryness over time. All these factors need to be considered when evaluating and treating a patient.

One strength of this manual is its emphasis on dry eye rarely stemming from a single factor. More often, it results from multiple overlapping etiologies, which can develop into a cycle of worsening disease. For example, a patient with environmental allergies may develop eyelid inflammation, which impairs meibomian gland function. At the same time, the allergy medication they are taking may further reduce tear production, compounding their symptoms.

This is why taking a thorough case history is so important. Understanding where the problem began and identifying the factors that have contributed since the initial trigger allows clinicians to better understand why a patient's symptoms have progressively worsened and to develop a more targeted treatment plan.

You practice at an academic medical center where optometry and ophthalmology work side by side. Where do you see the biggest gaps in how ODs and MDs are co-managing dry eye patients, and what would better collaboration look like?

Moore: Being at Emory and practicing alongside so many surgical specialists is one of the things I love most about my job. Most of my MD colleagues are surgeons, and because they're focused on other aspects of patient care, they don't usually have the time to also manage comprehensive dry eye therapy. That's where I can help.

I frequently see patients who have had successful cataract or LASIK surgery, both of which can contribute to dry eye symptoms. For most patients, those symptoms resolve within about a year, but some continue to experience dry eye for longer. Being able to co-manage these patients with our MD colleagues is an important part of providing comprehensive care.

Another group of patients I work with has conditions such as Graves disease. Even after their thyroid disease has been successfully treated and their hormone levels have returned to normal, many are left with proptosis, or bulging eyes. In severe cases, the eyelids can no longer close completely, leaving the eyes chronically dry because of constant environmental exposure.

Fortunately, we have an outstanding ocular plastics department. Our oculoplastic surgeons perform procedures such as orbital decompression to reposition the eyes. They also treat conditions like entropion and ectropion, in which the eyelids turn inward or outward. With entropion, the eyelashes rub against the surface of the eye with every blink. With ectropion, the eyelids cannot close properly, leaving the eye exposed. Surgical interventions can address the underlying cause of chronic dry eye associated with these conditions.

Once our surgeons have completed the procedures and no further surgical treatment is needed, the patients return to me, and we continue managing any residual dry eye symptoms with topical medications or other therapies. I always look forward to referring patients for surgery when it's appropriate, and I especially enjoy seeing them afterward because they're always so grateful. For many, surgery has been life-changing. My dry eye patients see me as their primary eye care provider, and I coordinate their care by referring them to the appropriate surgical specialists whenever needed.

Discover our Viewpoints series to hear more expert perspectives on dry eye management, from subtype diagnosis to emerging therapies like Miebo, Vevye, and Tryptyr.