PERFLUOROHEXYLOCTANE SOLN,OPH
Clinical Criteria Summary
Document 558
Provider Requirements
- Prescribing provider must be a VA/VA Community Care ophthalmologist or optometrist
Diagnosis
- Dry eye disease associated with meibomian gland dysfunction
Prior Therapy Requirements
- Documented lack of therapeutic response to at least two artificial tear agents from different categories OR documented corneal surface damage while frequently using artificial tear agents
- Lack of response to an adequate trial of ophthalmic cyclosporine unless unable to use (e.g., intolerance, etc.)
- Lack of response to an adequate trial of ophthalmic lifitegrast unless unable to use (e.g., intolerance, etc.)
Administration & Counseling Guidelines
- Do not administer while wearing contact lenses; patients must remove contact lenses prior to and for at least 30 minutes after administration
- Wait 10–15 minutes between topical ophthalmic drops; instill aqueous drops first, followed by perfluorohexyloctane
Document 557
Indication & Patient Population
- Treatment of the signs and symptoms of dry eye disease
- Patients with dry eye disease due to meibomian gland dysfunction (MGD) who have not responded to or tolerated treatment with artificial tears, topical cyclosporine, and lifitegrast
Dosing & Administration
- Administered as one drop in each eye four times daily
- Should not be administered while wearing contact lenses; remove contact lenses prior to and for at least 30 minutes after administration
- Wait 10-15 minutes between topical ophthalmic drops; instill aqueous drops first, followed by perfluorohexyloctane
Contraindications & Precautions
- No boxed warnings
- No contraindications listed
- No other warnings/precautions listed
Formulary Status
- Non-formulary (NF)