Recently, Cequa (cyclosporine ophthalmic solution 0.09%) became only the third dry eye medication to be approved by the FDA in the past 19 years. This is exciting for those of us suffering from dry eyes, as well as for those who treat it.

FDA approved to treat dry eye disease by enhancing tear production, it works as an immunomodulator in a similar fashion to its earlier competitor. Like the Restasis that we know all too well, Cequa uses cyclosporine but in a much higher concentration. This higher concentration is also part of a formula that includes nanomicelles. Micelles are gelatinous congregates of hydrophilic and hydrophobic molecules that can help with absorption of a substance. Sun Pharma (the manufacturer of Cequa) says these will help increase the ability of Cequa to penetrate the ocular tissues and overcome any solubility changes.

For the patient, this means a more effective medication, because penetration into the cells of the cornea and conjunctiva will be enhanced. Hopefully, this also means the medication will work more quickly, since it is well known that Restasis can sometimes take six months for the patient to notice changes in their dry eye symptoms.

Cequa was evaluated in two randomized studies with over 1000 patients suffering from dry eye disease. Compared to control at day 84, use of Cequa for 12 weeks showed a statistically significant increase in tear production (measured by Schirmer Score). Corneal and conjunctival staining was evaluated earlier, and positive changes were noted as early as four weeks.

Now available from Sun Ophthalmics in the US, Cequa is dosed just like Restasis and Xiidra twice per day, 12 hours apart, morning and evening. The new medication comes in single-use vials that should be discarded immediately after each use. Each box contains six pouches with 10 vials each, for a one month supply.

Cequa should never be used while wearing contact lenses, and the company advises that dry eye patients should likely not be wearing extended wear contact lenses anyway. If contact lenses are worn, they may be inserted 15 minutes after instillation of the medication. 

Great question! So, you can get Cequa by heading to your optometrist or ophthalmologist and they will write you a prescription for Cequa which is exactly like they would do for Restasis and Xiidra. You take that prescription or they send it over to the pharmacy and you pick it up there. So it's as simple as that, like any other prescription medication.

Most likely, it will be more expensive than Restasis because Restasis has to battle all of these new medications coming out. So, they'll probably lessen their drop price soon if they haven't already. If I'm not mistaken, I believe that at some point there is going to be a generic of Restasis coming out as well. So, if you are a fan of Restasis fan, that will be an option for you. But right now, Cequa is just going to be expensive most likely because it is a new medication.

Doxycycline is an okay medication for ocular rosacea. There are better ones out there if you're going to go the antibiotic route. A Z-Pak has been proven to be just as effective in 7 days, and you don't have to take it long-term like you do doxycycline.

A more natural approach would be an omega-3 supplement, and watery eyes is caused from meibomian gland dysfunction (MGD). Your meibomian glands, 31 on top and 31 on bottom, secrete oil onto your eye. The responsibility of this oil, or meibum, is to keep your tears in place. If you're not getting meibum out onto the eye, then those tears will break up and then your eye feels like it has something in it. So then, it tells your brain to make more watery tears which come from your lacrimal gland. This is different, and so you make more watery tears which makes your eyes water more.  The goal of doxycycline is it helps break down the oils in the meibomian glands. It helps them come out more easily.

More natural remedies for this are an omega-3 supplement like I talked about. You can use a warm compress to help break up those oils and give you a little symptom relief. You can do LipiFlow or you can do an IPL (Intense Pulsed Light). LipiFlow is just a thing that you do in-office and it's pretty much like a warm compress and massage on steroids. IPL is just a light that helps break down the oils in the meibomian glands and it helps them getting working again. Diet, eliminating bad saturated fats like red meat, dairy, cheese, and other things like that, can also help. Eating healthier fats like avocados, nuts, chia seeds and hemp seeds is beneficial. And then, just keeping your eyelids clean. Using our Heyedrate Lid and Lash Cleanser really helps with that. That's a hypochlorous acid based eyelid cleanser. 

We get his question a lot because Lumify is a new medication that is out there as a redness reliever. I recommend Lumify about as much as I recommend Visine. I don't like Visine, obviously, because the more you use it the more red your eyes can get, and we call that rebound redness.

Lumify has been studied and shown to not have that rebound redness effect, but it still contains preservatives. It still contains BAK (benzalkonium chloride) which a lot of people with dry eye just do not handle very well. So I recommend you use Lumify if you want to, only occasionally. I use a similar drop because my eyes are very red and if I have a big meeting or something like that then I will use them.  You don't want to have those red eyes, that's perfectly understandable, but don't expect it to treat your dry eye. It's not a dry eye drop. It's just meant to get rid of that redness and really no more than once a day should you have to use it. 

That’s a great question and we're actually going to be doing a Lumify article and Lumify Dry Eye Show in the near future.

Yes definitely! Medications like that will definitely cause your dry eye to return. If you haven't had LipiFlow in 11 months, you could always do that too and there's so many things that can flare up your dry eye no matter what. It can be the the weather turning cold, it can be allergies of the fall, it can be that you had a bad day of eating and something just caused you to flare up. Flare-ups will occur and you just have to know how to deal with those, and that's when we recommend artificial tears.

We don't recommend artificial tears to treat dry eye normally, because they don't treat the issue. They just cover it up. But if you're doing everything right and you've pretty much solved your dry eye issue, you can usually use an eye drop during a flare-up without issues.

Does it feel good because it actually feels good when you put it in, or does it feel good because it makes you look better because it gets rid of the redness? That would be my question to you. Just try to keep it to once a day, and I know they say that you can use it up to four times a day but please don't do that. Once a day is fine to get rid of that redness and, like we said earlier, we'd like to see you use it only as needed. This means for a big meeting or a wedding or something like that because it does contain preservatives, and these preservatives (they're in a lot of eye drops) can react with your eyes and they can be harmful for a lot of people and cause sensitivities. So, just be careful with how much you use it. 

We've had a lot of people that have tried the NuLids device and we've gotten good feedback so far. We've only had one person or so that felt that it just wasn't for them and that it was making things worse. But we've really had some good feedback and a lot of people that have said that it is making their eyes feel better and that it does work. However, I do I tell people there is a learning curve with it, especially with your upper lids because it's a little strange to use the device on your upper lids. It does work, and we have people that have found relief.

If you have meibomian gland dysfunction, it could be something to look into for you. We became NuSight Medical's online retailer for it because a lot of doctors didn't want to carry it in their office because it is expensive to inventory in their office. We've sold close to 20 of them so far, and I would say it works just about as well as every other dry eye product. 10% of people just aren't going to like it and they're not going to feel results from it and that's the same with our spray. That's the same with Restasis, it's more like 50%, and Xiidra is more like 50%, but anything with dry eye usually sees about 10% of people who will just not like it.

If you look at any dry eye products on the market and look at the reviews, even ours on Amazon, you'll see that we have 70% 5 stars and then 10% 1 star reviews, and then everything else is in between. That's because it works so well, but some people either don't give it a chance or they don't use it long enough and they'll just negatively review it and throw it off. So, that's the same with the NuLids because it's more of a long-term product. So again, if you use it you're not going to notice results right away and some people will give up right away. 

Absolutely that is dry eye and I feel you! I had the same thing happens to me, I wake up and oh my gosh my eyes can be so painful sometimes, especially when Travis insists on sleeping with the fan on if it's hot outside. So you can do that... you can avoid sleeping with any fans above you, next to you, even in your room at all.

Hydration is huge. Make sure that you're drinking a lot of water, half your body weight in ounces of water per day. You can always look at using a gel drop at night or an ointment. The reason your eyes are getting dry at night like that is most likely because you sleep with your eyes open a little bit, and that can really dry out the surface of your eye.

This can be a couple different things. Mucus tends to be more allergy based. I'd have to see your eyes, number one, but most likely mucus is from allergies. So, if your eyes are itching a lot you can always try an allergy eye drop. Allergy drops, of course, have preservatives but if you're not sensitive to the preservatives it's usually okay to take once or twice a day. We usually recommend Alaway for that, so try that to see if that will help with the mucus discharge because dry eye doesn't necessarily cause mucus unless it's very, very severe. If it was that severe you'd be on a lot of medications for it. I've only seen that probably once in my career.

This condition is called Mucus Fishing Syndrome. Basically, the more that you try to swipe that mucus out and dig in your eyes and get that white stringy mucus out, the more your eyes are going to produce that. So you really need to keep your fingers out of your eyes and try that allergy eye drop that Travis mentioned and see if that can get it to go away for you. The more you mess with it, the more it can become a problem. If it is MFS, we usually put our patients on a steroid and then they're going to be on Xiidra or Restasis because they have so much inflammation going on. If that's happening, again that's something I've only seen once in my career.

Cequa and it's C-E-Q-U-A. It is a much higher concentration of cyclosporine than what Restasis is so it's possible that if Restasis didn't work for you, that's Cequa will. So Cequa has about double the concentration of cyclosporine, which is the medication in it, than what Restasis does. So it's possible that it could work for you, but the reason it works supposedly better is the delivery system. We're going to start seeing this in healthcare, with medications changing or coming out with different delivery vehicles. There's some really neat technology coming out including nano grade, like remote-control, little bugs that enable the medication to crawl all the way to the site were it's needed.

So this is a great question! We know you're doing things right because you've been with us for a little while and the vitamins and lid cleansers are a great start. That's a great base and this is where we recommend having the artificial tear because there will be the flare-ups. Situations where it is cool and windy are going to cause that, so get yourself a good pair of wrap around sunglasses and have those artificial tears, like Retain MGD, there for you when you do have that problem.

Yes! Floaters are independent of dry eye, and floaters are in the back of the eye in a jelly called the vitreous. Whenever you move your eye, that jelly moves around and they float past your vision. Floaters are actually shadows of little debris in that vitreous. They're very normal, everybody's got them, and it's just who can see them and who can't. And Cequa is used on the front of the eye, so it's not going to cause any harm.