A number of recent advances in ophthalmology are leading to improved care and enhanced outcomes for patients undergoing refractive surgery, cataract removal with IOL implantation, and those with ocular hypertension and glaucoma. At "Innovations in Ophthalmology," an Alcon Laboratories-sponsored medical education program, a faculty of renowned experts reviewed these developments and their applications in clinical practice.
Recent industry innovations are bringing important advantages to ophthalmologists and their patients. At a continuing medical education program sponsored by Alcon Laboratories, members of a distinguished faculty reviewed new developments relating to the care of patients with glaucoma, ocular allergy, and those undergoing lens removal surgery.
Richard A. Lewis, MD, discussed the benefits of the new benzalkonium chloride-free formulation of travoprost 0.004% (Travatan Z, Alcon) for the medical management of glaucoma.
He told attendees there is a wide body of evidence suggesting that the chronic application of eye drops is deleterious to the ocular surface. Based on a number of studies, the preservative benzalkonium chloride (BAK) appears to be the culprit rather than the active ingredient.
He reported results of prospective, randomized, double-masked studies demonstrating the BAK-free formulation of travoprost is equivalent to the original formulation in its IOP-lowering efficacy and endurance of the IOP-lowering benefit when it is measured 60 hours after a final dose. In those studies, both agents offered comparably favorable safety profiles.
"BAK has a significant adverse effect on the ocular surface, cellular physiology, and conjunctival cell viability and also causes significant irritation symptoms," Dr. Lewis said. "Although BAK has been shown to improve the ocular penetration of some drugs and was important in the past when pilocarpine was a therapeutic mainstay for glaucoma, the efficacy results of these studies demonstrate BAK is not necessary for travoprost penetration. [Travoprost] represents a beneficial alternative to glaucoma patients."
Mark Abelson, MD, spoke on new horizons in ocular allergies. He reviewed some of the trials that formed the basis for FDA approval of the once-a-day formulation of olopatadine 0.2% (Pataday, Alcon), including findings from vehicle-controlled conjunctival allergen challenge and environmental studies that demonstrated the prolonged duration of activity of once-a-day olopatadine 0.2% and its ability to control itching and conjunctival redness over a 10-week course during allergy season. In addition, he presented data demonstrating significant benefits in patients with more severe allergic reactions related to greater amounts of environmental pollen.
Favorable safety data for olopatadine 0.2% is available from over 1000 participants in more than 10 clinical trials. In those studies, the types and frequency of adverse events were not different between subjects treated with olopatadine 0.2% and placebo controls. In addition, olopatadine 0.2% has been shown to be safe and well tolerated in patients as young as 3 years of age.
"The new 0.2% formulation of olopatadine provides the excellent activity of a medication with dual antihistamine and mast cell stabilizing properties with the convenience of once a day administration," Dr. Abelson said. "It has the potential to make a significant difference in the quality of life for the millions of people around the world who suffer from ocular allergy."
Stephen S. Lane, MD, reviewed the topic of patient selection for premium IOLs with the goal of helping ophthalmologists determine what individuals are the best candidates for those "lifestyle" implants as defined by those who will be truly happy.
He proposed that from an informed consent perspective, surgeons have the obligation to introduce these lenses to all patients undergoing cataract surgery and noted within his practice about 35% of patients receive a premium "lifestyle" IOL.
Successful patient selection takes into account the individual's functional and occupational requirements, preexisting ocular pathology and expectations.
However, Dr. Lane also emphasized that surgeons offering these lenses have responsibilities to become knowledgeable about their benefits and limitations, be willing to commit the necessary chair time to educate, advise and counsel patients pre- and postoperatively, and to strive for accurate biometry, appropriate formulae selection, meticulous surgery, astigmatism control, and adjustment of residual ametropias.
"Education of patients is the cornerstone for success in high technology IOL implantation, but it is also critical for surgeons to do their best surgery," Dr. Lane said.
Continuing on the same theme, Con Moshegov, MD, spoke on multifocal IOLs "in the pursuit of presbyopic correction."
He reviewed the strengths and weaknesses of the various IOL platforms available for providing an extended range of vision for patients with presbyopia, including results achieved with mixing and matching different implants.
He noted the apodized diffractive IOL (ReSTOR, Alcon) has demonstrated very good visual outcomes in the premarketing clinical trials and in clinical experience. In particular it affords excellent near acuity and has the benefits of the AcrySof (Alcon) platform, including its single-piece design, yellow chromophore optic, ease of insertion, and low PCO rates.
"As patients are becoming more educated about the possibility of spectacle independence after cataract surgery, their demand for multifocal implants is increasing," Dr. Moshegov said. "In addition, presbyopia is the most common presenting problem in a refractive surgery office. To meet those patients' needs, the [apodized diffractive] IOL offers familiar and predictable technology."
Wrapping up the symposium, Robert H. Osher, MD, highlighted the benefits of torsional and mcro-coaxial phaco by demonstrating its performance in a video of a very challenging case.
The patient was an older monocular man with a long-standing, dense cataract, a low endothelial cell count, and angle closure glaucoma. Despite encountering difficulties with the incision and capsulorhexis creation as well as a very shallow chamber, Dr. Osher took advantage of the benefits of micro-coaxial phaco and torsional ultrasound to safely remove the lens while maintaining a secure and competent incision. The patient achieved an excellent uncorrected visual acuity outcome on the first day postop.
"Microcoaxial phaco with torsional ultrasound [OZil, Alcon] on the Infiniti [Alcon] platform is as good as it gets," Dr. Osher said. "Multiple surgeons have published papers demonstrating its excellent fluidics, stable chambers, increased efficiency, decreased repulsion and chatter, and safer thermal profile. Thanks to this superb technology, I was able to operate safely in a closed, secure eye in this very challenging case. For surgeons who want to elevate the quality of their procedures to an unprecedented level, microcoaxial phaco with torsional ultrasound is the right choice."