Slide 1. Slide 2. Slide 3. Current Trends in Medical Management. Financial Disclosure. Antibiotics - Systemic

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1 Slide 1 Current Trends in Medical Management Ron Melton, OD, FAAO Randall Thomas, OD, MPH, FAAO Slide 2 Financial Disclosure Dr. Ron Melton and Dr. Randall Thomas are consultants to, on the speakers bureau of, on the advisory committee of, or involved in research for the following companies: Allergan, ICARE, Shire, and Valeant. Slide 3 Antibiotics - Systemic Penicillins Cephalosporins Tetracyclines Macrolides Fluoroquinolones

2 Slide 4 Amoxicillin/Clavulanic Acid (Augmentin) Clavulanic acid enables amoxicillin to be bactericidal against common gram positive pathogens Useful in treating soft tissue infections Cannot use if patient is allergic to penicillin Tx: 250, 500 & 875 (generic) or 1000 mg (branded only) tablet q 12 hrs x 7-10 days Can be taken with meals Slide 5 Cephalexin (Keflex) Cephalexin - 1st generation cephalosporin Effective against most gram positive pathogens Some earlier generation cephalosporins share about a 1% cross-allergenicity to PCN Usual dosage: 500 mg bid x 1 week Useful in soft tissue staph infections, such as internal hordeola, preseptal cellulitis, etc. Slide 6 Pre-symptomatic Age and Lifestyle Related Diminution of MG Function Improper Volume and Integrity of the Lipid Layer Symptomatic Rapid Break-up Time Increased Tear Osmolarity Increased Inflammation Patient Presents with Scratchy, Burning, Sandy, Gritty Complaints

3 Slide 7 Lipid-Based Artificial Tears (For Evaporative Dry Eye) Vast majority of dry eye patients have MGD Meta-stable emulsions are optimum Tx Rapidly provides a protective lipid barrier Reduces harmful evaporation to prevent tear loss Replenishes the complete tear film Systane Balance emulsion (10 ml) Alcon Refresh Optive Advanced (10 ml) Allergan Soothe XP (15ml) B + L Retaine MGD - OCuSOFT Slide 8 Aqueous-Based Artificial Tears (For Aqueous Deficient Eye) Relatively uncommon cause of dry eyes Aqueous-based solutions are 2nd choice Rapidly provides ocular surface hydration Main ingredients commonly include Cellulose Glycerin Polyethylene Glycol Propylene Glycol Soothe Xtra Hydration (15 ml) B+L Systane Ultra (15 ml) Alcon Optive (15 ml) - Allergan Blink (15 ml) AMO FreshKote (15 ml) Focus Labs Slide 9

4 Slide 10 Lifitegrast Ophthalmic Solution 5.0% for Treatment of Dry Eye Disease New class integrin antagonist Works by blocking the chronic inflammation mediated by T-cells central to dry eye disease Phase 3 studies met primary objectives and demonstrated superiority with placebo and reduced conjunctival lissamine staining at day 84; secondary endpoints showed improvement in symptoms and lack of improvement in signs Onset of action 2-4 weeks Administered BID for months Packaged in PF unit-dose by Shire Pharmaceuticals Sheppard, JD et al. Lifitegrast ophthalmic solution 5.0% for treatment of dry-eye disease: results of the OPUS-1 phase 3 study. Ophthalmology. Feb, 2015 Slide 11 Alternative Supplementation Orally administered omega-3 essential fatty acids May take 4-6 months to obtain a significant clinical effect Liquid formulations are available for those patients who have difficulty swallowing large capsules. Slide 12 Lacrisert A sterile, translucent, rod-shaped, water-soluble, ophthalmic insert (1.27 mm x 3.5 mm) made of hydroxypropyl cellulose 5 mg For moderate to severe dry eye sufferers Insert into inferior cul-de-sac of eye beneath base of tarsus Supplied by Valeant Pharm. in packages containing 60 unit doses, two reuseable applicators and a plastic storage container for applicators after use.

5 Slide 13 Doxycycline versus Azithromycin for MGD Patients (110) with MGD received oral azithromycin (500mg day one, then 250 mg/d 4 days) vs one month oral doxycycline (200 mg/day) x 1 month After 2 months both groups significant improvement; % of clinical improvement significantly better for azithromycin; less GI SE with azithromycin (4% vs 26%); azithromycin less expensive. Kahului MB et al. Oral azithromycin versus doxycycline in meibomian gland dysfunction. Br J Ophthalmol. Feb Slide 14 Dermatologists Prescribing for Acne Minocycline 44.4% Doxycycline 40.5% Azithromycin 3.2% Reference: J Am Acad of Dermatology, October 2015 Slide 15 Brimonidine Dermatologic Gel Used to address the erythema and flushing commonly expressed in facial and eyelid rosacea Causes microvascular vasoconstriction Comes in a 30 gram tube applied once daily Provides a somewhat effective clinical response Available as a.33% gel by Gladerma Reference: The Medical Letter, October 2013

6 Slide 16 Eye Whitener Luminese Dilute alpha-1 receptor agonist Causes rapid and sustained whitening of the bulbar conjunctival microvasculature 0.025% brimonidine is the effective dilution Does not cause rebound hyperemia like tetrahydrozoline Prior to commercialization of Luminese, inoffice dilution can be done Use a 3 ml sample bottle of aqueous artificial tear, and using a sterile syringe, place 1 ml of 0.1% Alphagan-P into the artificial tear bottle to achieve a 0.025% solution Use once daily, usually in the morning, to achieve protracted eye whitening. Slide 17 Anti-Viral Medicines Topical Trifluridine Ganciclovir Viroptic Zirgan Oral Acyclovir Valacyclovir Famciclovir Zovirax Valtrex Famvir - These are anti-herpetic drugs and are ineffective against the various adenoviral serotypes - Slide 18 Trifluorothymidine (Trifluridine) A halogenated pyrimidine analog of thymidine Inhibits both virally-infected and non-infected cells Possesses good activity against both HSV-I and HSV-II Approved down to age 6 Penetrates into epithelium, stroma, and aqueous Once dispensed by pharmacy, refrigeration not required Heals most herpetic ulcers in 5 to 8 days Use q 2h for first 4 to 5 days, then taper PRN Marketed as: Viroptic 1% (7.5 ml) by Monarch Pharmaceuticals and generic

7 Slide 19 Topical Ganciclovir Used systemically to treat CMV retinitis A new topical pro-drug for treating epithelial HSV Only acts on virally infected cells Used 5 x D for 4 to 6 days, then tid for 3 to 4 more days Is a 0.15% ophthalmic gel-drop with BAK Marketed as Zirgan ophthalmic gel Comes in a 5 gram tube Marketed by B+L Pharmaceuticals Slide 20 Topical Antiviral Options Trifluridine Old drug Indiscriminate expression Potentially toxic More frequent dosing Refrigerate until opened Thimerosal preserved Solution (7.5 ml bottle) Viroptic and generic Ganciclovir Recently approved Infected cell-specific Minimally toxic Less frequent dosing No refrigeration needed BAK preserved Gel (5 gram tube) Zirgan by B+L Slide 21 Acyclovir (ACV) Analog of guanosine Specifically targets virally-infected cells Minimally toxic to uninfected cells Best to initiate therapy within 72 hours Tx: 800 mg by mouth 5 x D for 7 days for HZO; 400 mg 5 x D for 7 days for HSK Main side effect: occasional nausea Use with caution in kidney disease Available generically

8 Slide 22 Valacyclovir Prodrug of acyclovir - greater bioavailability and longer half-life Rapidly and completely converted to acyclovir after oral administration Can be taken without regard to meals Side effects: nausea / headache Best to initiate therapy within 72 hours Tx: 1,000 mg caplet tid x 7 days for HZO; 500 mg tid x 7 days for HSK Use with caution in kidney disease Valtrex by Glaxo Wellcome and generically Slide 23 Famciclovir Prodrug of penciclovir, the active antiviral drug Intracellular half-life of 7-10 hours Active against HSV and VZV Best to initiate therapy within 72 hours Can be taken without regard to meals Side effects: minimal/rare - mostly nausea Dosage: 500mg q 8 hrs x 7 d for HZO; 250 mg q 8 hrs x 7 d for HSK Use with caution in kidney disease Marketed as Famvir by Novartis and generic Slide 24 Valacyclovir vs. Acyclovir for Recurrent HSV One-year suppression therapy with oral valacyclovir (500-mg tablet daily) was shown to be as effective and as well-tolerated as acyclovir (400- mg tablet twice daily) in reducing the rate of recurrent ocular HSV disease. SOURCE: Miserocchi E, Modorati G, Galli L, Rama P. Efficacy of valacyclovir vs. acyclovir for the prevention of recurrent herpes simplex virus eye disease: A pilot study. Am J Ophthalmol, Oct. 2007

9 Slide 25 Study on Stromal HSK OD response rate, 6% - MD response rate 15% ALL: 95% treated epithelial keratitis correctly For stromal immune keratitis 54% OD correct 74% MD correct 82% corneal subspecialist correct Correct = topical steroids with antiviral cover Correct use of oral antiviral prophylaxis for recurrences 51% - OD, 60% - MD, 62% corneal subspecialist Training was most significant determining factor Reference: Letters Arch. Oph., December 2010 Slide 26 Preventing HSV Disease Recurrences Patients being treated with oral antiviral therapy were 9 times less likely than untreated patients to develop recurrent keratitis Recurrence rates: 27% at 1 year 50% by 5 years 57% by 10 years 63% by 20 years Stromal disease is more likely to recur than epithelial disease Length of prophylaxis: Generally 5 disease-free years Reference: Arch. Oph. January 2010 Slide 27 Zostavax Vaccine for prevention of shingles in adults age 50 and older Marketed by Merck as Zostavax and is given as a single dose by injection Anyone who has been infected by chicken pox (more than 90% of adults in US) is at risk for developing shingles Contraindicated if Hx of allergy to gelatin, neomycin; Hx of acquired immunodeficiency states; pregnancy In landmark Shingles Prevention Study, Zostavax reduced risk of developing shingles by 51% (4 yrs of follow-up) References: FDA News Release, March 24, 2011 FDA approves Zostavax vaccine to prevent shingles in individuals 50 to 59 years of age.

10 Slide 28 Impact of Zostavax Vaccination: per one million vaccine recipients Could prevent: 300,000 outpatient visits 375,000 medication prescriptions 9,700 emergency department visits 10,000 hospitalizations Shingles is a disease with potentially devastating systemic and ocular consequences and physicians, including ophthalmologists (optometrists) and primary care doctors, can and should recommend this vaccine to eligible patients. Reference: AJO, May 2013 Slide 29 Zostavax Efficacy: How Long? After 10 years, vaccination lost most of its power Efficacy against HZ incidence fell from 46% in year 7 to 14% in year 10 and was negligible among 1470 participants who were followed for the 11th year. Vaccination at age 60 is unlikely to confer protection for the duration of a person s life. We foresee new public health recommendations advising re-vaccination after about 8 years. This certainly sounds prudent to us. Reference: Clinical Infectious Disease. March 15, Slide 30 Treatment Options - Ocular Allergy Artificial Tears Mild Vasoconstrictors Decongestant / Astringents Vasoconstrictor / Antihistamines Antihistamines Antihistamine / Mast Cell Stabilizers Mast Cell Stabilizers Non-steroidal Anti-inflammatories Mild Corticosteroids Systemic Antihistamines Potent Corticosteroids Homeopathic Formulations

11 Slide 31 Antihistamine/Mast Cell Stabilizer Highly selective H1 receptor blockers with prolonged receptor binding Good mast cell stabilization All bid dosing, except Pataday, Pazeo and Lastacaft qd Olopatadine 0.1% (Patanol) (5 ml) 0.2% (Pataday) qd (2.5 ml) 0.7% (Pazeo) qd (2.5ml) Bepotastine 1.5% (Bepreve) (5, 10 ml) Epinastine 0.05% (Elestat and generic) 5 ml Alcaftadine 0.25% (Lastacaft) qd (3 ml) Azelastine 0.05% (Optivar and generic) (6 ml) Ketotifen 0.025% (generic and OTC) (Claritin Eye) (5 ml) (Zyrtec Itchy Eye) (5 ml) (Zaditor) (5 ml) (Alaway) (10 ml) (Refresh) (5ml) (TheraTears) (5 ml) Slide 32 Treatment of Ocular Allergies Antihistamine / Mast Cell Stabilizer Smart Steroid Slide 33 Systemic Antihistamines OTC Chlorpheniramine (Chlor-Trimeton) Diphenhydramine (Benadryl) Loratadine (Claritin) - 10 mg qd Fexofenadine (Allegra) - 60 mg bid; 180 mg qd Cetirizine (Zyrtec) - 5 or 10 mg qd Rx Desloratadine (Clarinex) 5 mg qd Levocetrizine (Xyzal) 5 mg qd Metabolized by the liver Excreted in bile and urine (1/2 dose if renal disease)

12 Slide 34 Intranasal Steroids for Ocular Symptoms in Allergic Rhinitis In a randomized trial, intranasal steroids relieved both nasal and ocular symptoms. Because intranasal steroids are the most effective medications for allergic rhinitis symptoms (especially congestion), guidelines recommend them as first-line agents for moderate-to-severe disease As many as 85% of patients with seasonal allergic rhinitis also have ocular symptoms. For these patients, many clinicians prescribe oral antihistamines or ocular products rather than (or in addition to) intranasal steroids Nasacort and Flonase now OTC Reference: journalwatch.com, June, 2010 Slide 35 Non-Steroidal Anti-Inflammatory Drugs Inhibition of prostaglandin synthesis is the mechanism of action. They specifically inhibit the action of cyclooxygenase, an enzyme vital to prostaglandin synthesis. Prostaglandins are powerful mediators of inflammation. Acular (Ketorolac 0.5%) by Allergan and generic Acular LS (Ketorolac 0.4%)-Allergan Acuvail (Ketorolac PF 0.45%)-Allergan Ocufen (Flurbiprofen 0.03%) by Allergan and generic Profenal (Suprofen 1%) by Alcon and generic Voltaren (Diclofenac 0.1%) by Novartis and generic Bromday (Bromfenac 0.09%) by B+L Nevanac (Nepafenac 0.1%) by Alcon Slide 36 Nepafenac Ophthalmic Suspensions Nevanac 0.1% AND Ilevro 0.3% Indication: Treatment of pain and inflammation associated with cataract surgery Nevanac is dosed tid; Ilevro, once daily Ilevro is to be prescribed the day before surgery, the day of surgery and then 14 more days BAK 0.005%, ph 6.8, pregnancy category C, pediatric use down to age 10 Marketed by Alcon as Ilevro 0.3% ophthalmic suspension 1.7 ml and 3 ml

13 Slide 37 Bromfenac Ophthalmic Solutions Bromday 0.09% and Prolensa 0.07% (22% less concentration) Indication: Treatment of pain and inflammation associated with cataract surgery Both are dosed once daily Both are prescribed the day before surgery, the day of surgery and then 14 more days BAK 0.005% BAK ph 7.8, pregnancy category C, pediatric use down to age 18 Marketed by B&L as Prolensa 0.07% ophthalmic solution (3ml) Slide 38 Antibacterial Medications Sulfa Preparations Erythromycin Bacitracin Bacitracin / Polymyxin B Bacitracin / Polymyxin B / Neomycin Chloramphenicol Gentamicin Tobramycin Trimethoprim / Polymyxin B Fluoroquinolones Azithromycin Oral antibiotics Slide 39 Aminoglycosides Bactericidal Inhibits protein synthesis Effective against most commonly encountered gram positive and gram negative bacteria Available in both solution and ointment form Gentamicin - toxic/allergic reactions do occasionally occur. Pregnancy category C. Tobramycin (80)- resistance, toxic and allergic reactions rare (Pregnancy category B)

14 Slide 40 Trimethoprim with Polymyxin B Trimethoprim, a non-antibiotic antibacterial Bacteriostatic and broad spectrum Inhibits bacterial dihydrofolate reductase Effective against most common ocular pathogens, except pseudomonas species Excellent for bacterial infections in children Haemophilus influenzae and streptococcus pneuomniae Polymyxin B is a highly effective gram bactericidal drug Available as a 10 ml solution (Polytrim (88) and generic) Slide 41 Azithromycin 1% Ophthalmic Solution Topical eyedrop solution of azithromycin Only macrolide eyedrop formulation Spectrum coverage is similar to erythromycin Good tissue penetration; viscous vehicle Dosage: BID for 2 days then QD for 5 days Avoid use if patient is allergic to erythromycin Pregnancy category B; approved down to age 1 Marketed as AzaSite 1% ophthalmic solution in a 2.5 ml opaque bottle by Akorn Slide 42 Moxifloxacin 0.5% Actions: Inhibits topoisomerase type 2 (DNA gyrase) and topoisomerase type 4 Moderately effective against G+ and G bacteria Pregnancy category C Pediatric indication: Vigamox - age 1 Moxeza - age 4 months Xanthan gum prolongs ocular surface contact time, thus a decreased dosing frequency Dosing: Vigamox 0.5% tid x 7 days (ph 6.8) Moxeza 0.5% bid x 7 days (ph 7.4) Vigamox (03)and Moxeza (10) Alcon Systemically available as Avelox

15 Slide 43 Gatifloxacin 0.5% Inhibits topoisomerase types 2 and 4 Moderately effective against Gram+ and Gram bacteria FDA-approved for bacterial conjunctivitis Pregnancy category C; pediatric to age 1 BAK preserved Available from Allergan as 0.5% Zymaxid (10) Systemically: Tequin (removed from market) Slide 44 Antibiotic Susceptibilities The efficacy of aminoglycosides has been welldocumented in endophthalmitis. As the use of topical fluoroquinolones has increased, so have the number of reports documenting an increase in bacterial resistance. The 4th generation fluoroquinolones evaluated did not provide much greater coverage than the earlier generation fluoroquinolones. To guard against resistance, eye doctors are discouraged from using antibiotics with EKC, and prophylactic use before intravitreal injections. Reference: Ophthalmology, August 2014 Slide 45 MIC 90 Comparisons for ARMOR Surveillance Study Isolates S aureus (n=1169) MRSA (n=493) Besifloxacin Vancomycin 1 1 Trimethoprim 2 2 Clindamycin 0.12 >2 Oxacillin >2 >2 Moxifloxacin 1 16 Gatifloxacin 2 16 Chlormaphenicol 8 16 Ofloxacin 8 >8 Levofloxacin Ciprofloxacin Tobramycin 1 >256 Azithromycin >512 >512 CoNS (n=992) MRCoNS (n=493) Besifloxacin Vancomycin 2 2 Clindamycin 1 >2 Oxacillin >2 >2 Gatifloxacin 2 32 Tobramycin 4 16 Chlormaphenicol 4 8 Ofloxacin 8 >8 Moxifloxacin 1 32 Ciprofloxacin 8 64 Levofloxacin Trimethoprim 32 >128 Azithromycin >512 >512 Asbell PA et al. JAMA Ophthalmol. 2015:1-10. Asbell PA et al. JAMA Ophthalmol. 2015:1-10.

16 Slide 46 A Novel Fluoroquinolone - Besifloxacin A unique bi-halogenated quinolone New chemical entity: An 8-chlorofluoroquinolone NOT used systemically relative resistance-proof FDA-approved medication: Bacterial conjunctivitis FDA-approved treatment protocol: tid for 7 days Pediatric approval: ages 1 and older Preserved with 0.01% BAK (Durasite vehicle) Marketed as Besivance 0.6% ophthalmic suspension by B&L 5 ml (09) Slide 47 Chloramphenicol Revisited More than 50% of the world uses chloramphenicol as a first-line agent in the treatment of conjunctivitis It is OTC in many countries Approximately a one in 2 million chance of blood dyscrasia If American medicine continues to tilt towards more socialized care and some medications are not available based on cost alone, drugs like chloramphenicol eye drops could be considered as a viable treatment option. Reference: AJO, September 2013 Slide 48 Ester vs Ketone Corticosteroids Ester Loteprednol Ketone Prednisolone Fluorometholone Dexamethasone Rimexolone Difluprednate

17 Slide 49 Difluprednate 0.05% (Durezol) There is increased bioavailability and dose uniformity resulting from the formulation of difluprednate as an emulsion, rather than a suspension. Steroid-induced hypertension seen in 8% of the normal population, and is more common in patients with glaucoma. Steroid-induced hypertension is generally not seen until 3 to 6 weeks of corticosteroid use. Difluprednate was shown to provide better results compared with prednisolone acetate We believe the effects seen are the result of the greater anti-inflammatory potency of difluprednate. AJO, October, 2011 Slide 50 Loteprednol Etabonate Only ester-based, site-specific steroid Works at target tissues, and then is quickly metabolized into inert compounds LE has high intrinsic activity when applied locally 0.5% loteprednol similar in therapeutic equivalence to 1% prednisolone acetate, yet causes little, if any, increase in IOP Available as 0.2% (Alrex) ophthalmic suspension, 0.5% Lotemax ointment and 0.5% Lotemax Gel Slide 51 Fluorometholone Alcohol A progesterone-based steroid Useful in treating mild to moderate ocular conditions Has a reduced potential to increase IOP Available as FML 0.1% suspension and ointment (Allergan) and generic suspensions Also available as FML-Forte, a 0.25% suspension (no increase in efficacy beyond the 0.1%. concentration )

18 Slide 52 Systemic Prednisone Most common Rx d systemic corticosteroid Common initial dosage mg Available generically in both tablets and DosePaks (5 or 10 mg at 6 or 12 day course) Questions to ask before prescribing? Diabetic? Peptic Ulcer Disease? Tuberculosis? Pregnant? Slide 53 Non-ophthalmic steroid: ointment/cream/lotion Triamcinolone - moderate potency steroid Available in cream, ointment and lotion (0.5%, 0.1%, 0.025%) Our favorite: the 0.1% cream Reference: Drug Facts and Comparisons Slide 54 Anti-infective/Anti-inflammatory Combinations Prednisolone Blephamide Poly-Pred Pred-G Dexamethasone Maxitrol Neo-Decadron TobraDex (ST) Fluorometholone FML-S Hydrocortisone Cortisporin Loteprednol Zylet

19 Slide 55 Tobramycin 0.3% and Loteprednol etabonate 0.5% Excellent coverage against most ocular pathogens with minimal concern of aminoglycoside toxicity Safe, effective suppressor of inflammation Marketed as Zylet Ophthalmic Suspension by B&L Pharmaceuticals Available in 5 and 10 ml bottle Slide 56 Tobramycin and Dexamethasone Excellent coverage against most ocular pathogens with minimal concern of aminoglycoside toxicity Effective suppressor of inflammation Guard against prolonged use with dexamethasone Marketed as TobraDex Suspension and Ointment (tobramycin 0.3% and dexamethasone 0.1%) by Alcon, (suspension available generically) Now available as TobraDex ST (tobramycin 0.3% and dexamethasone 0.05%) by Alcon Slide 57 Neomycin, Polymyxin B, and 0.1% Dexamethasone Excellent coverage against most bacteria Effective suppressor of inflammation Has been a time honored work horse in medical eye care Limit use to 1-2 weeks to guard against ocular hypertension Marketed as Maxitrol and generically Available as both suspension and ointment A very inexpensive medicine

20 Slide 58 Treatment of Blepharitis-Related Dry Eye Antibiotic/steroid combination agents can play an important role in a rational, stepwise dry eye treatment plan. These drugs do not appear to alter meibomian gland secretions. However, they can effectively reduce both bacterial proliferation and inflammation of the lid margins. Treat with combination antibiotic/steroids as needed on a pulsed basis as part of a long-term treatment plan for recalcitrant or recurrent blepharitis. Reference: Refractive EyeCare, December 2011 Obviously, in chronic conditions, an aminoglycoside combined with loteprednol would be the wisest choice Slide 59 Lid and Lash Hygiene New eye care product containing hypochlorous acid.01% in saline Fast-acting cleanser for lids, lashes, periorbital skin with extremely low toxicity Can be used for blepharitis and other conditions of eyelids or eyelashes which often cause inflammation and discomfort Effective against broad range of pathogens usually found on the lids and lashes Dispensed as 40 ml bottle with spray pump by NovaBay Pharmaceuticals Slide 60 Cliradex for Demodex A derivative of Tea Tree Oil ingredients Terpinen-4-ol (T4o) is the most demodexicidal For cleansing the face and eyelid skin Has a transient slight stinging, menthol-like sensation If ocular contact, rinse with saline or artificial tear Must keep eyes closed, and allow to air dry for 1 minute Try this once daily for 6-8 weeks (bid if severe) Available from BioTissue, Doral, Fl See for more information

21 Slide 61 Lid and Lash Hygiene Eye care products containing hypochlorous acid.01% /.02% Fast-acting cleanser for lids, lashes, periorbital skin with low toxicity Used for blepharitis and other conditions of eyelids or eyelashes which often cause inflammation and discomfort Effective against broad range of pathogens usually found on the lids and lashes Available in variety of formulations (solution, gel, spray)