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Ocular surface therapy and mydriasis focus of 2014


An examination of the advancements made in drug therapy this past year includes ocular surface therapy, the approval of an anti-inflammatory mydriatic agent, and several dry eye drugs.

Take Home

An examination of the advancements made in drug therapy this past year includes ocular surface therapy, the approval of an anti-inflammatory mydriatic agent, and several dry eye drugs.


By Lynda Charters; Reviewed by Peter S. Hersh, MD, and Eric D. Donnenfeld, MD

Ocular surface health continues to be an increasingly important topic for refractive and cataract surgeons.

“In general, the ocular surface remains one of the most important aspects of refractive surgery,” said Eric Donnenfeld, MD, clinical professor of ophthalmology, New York University Medical Center; trustee, Dartmouth Medical School, and founding partner, Ophthalmic Consultants of Long Island, Rockville Centre, NY.

In light of this, the therapy that has become increasingly popular in conjunction with serum tears to manage the ocular surface for patients with potential wound-healing problems after refractive procedures and poor epithelial healing.

“Serum tears, which contain components of tears in concentrations that are comparable to the patient’s natural tears as well as a variety of growth factors, are obtained from and processed through the patient’s own blood. They seem to be effective and clinicians are clearly talking more about autologous serum tears as an earlier intervention for patients with ocular surface disease,” said Peter Hersh, MD, professor of ophthalmology at Rutgers New Jersey Medical School, Newark.

Proper management of blepharitis is also important for ocular surface management in patients considering refractive surgery.

Dr. Hersh noted that the use of azithromycin ophthalmic solution (AzaSite 1%, Akorn), has had good effects as an adjunct to aggressive surface management.


“Topical azithromycin, in addition to lid hygiene and non-preserved artificial tears, may be very helpful in patients with meibomitis,” Dr. Hersh said.

The effectiveness of these interventions was evident in a patient of Dr. Hersh whose corneal epithelium was in poor condition secondary to long-term contact lens wear and blepharitis. Aggressive treatment with topical azithromycin, oral doxycycline, cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan), and serum tears resulted in the patient being able to undergo LASIK after 3 months of treatment.

Another way to manage chronic ocular surface conditions is by using amniotic membranes to treat persistent epithelial defects.

“These products have improved our management of these chronic conditions. Prokera and the Prokera Thin (Bio-Tissue) are amniotic membranes that are attached to a contact lens and have made an enormous difference in our ability to treat these conditions,” Dr. Donnenfeld said.

These amniotic membrane onlays have been gaining in popularity. The Prokera products are cryopreserved amniotic membranes that are placed much like a contact lens, Dr. Hersh explained.

Ambiodisc (IOP Ophthalmics) is a dehydrated amniotic membrane that adheres to the area of epitheliopathy and is covered by a therapeutic contact lens.

“These newer amniotic membrane preparations have increased the ease of use of amniotic membranes since they do not require sutures. The amniotic membranes can be very effective for difficult to manage ocular surface problems, in particular, persistent epithelial defects,” Dr. Hersh commented.

Approval of anti-inflammatory mydriatic agent

Another milestone in 2014, according to Dr. Donnenfeld, was the FDA approval of Omidria 1% and 0.3% (OMS302, Omeros), which is the combination of intracameral ketorolac and phenylephrine. The drug is injected into the balanced salt solution during cataract and intraocular surgeries.


“Use of this drug gives surgeons the security of knowing that the pupillary size will be maintained with greater accuracy during cataract and intraocular surgeries. In addition, the non-steroidal anti-inflammatory component of Omidria has a beneficial effect that I believe will be perfect for refractive cataract surgery,” he stated.

The drug is expected to be launched in January 2015.

 “I am looking forward to having an FDA-approved medication for dilating pupils, maintaining mydriasis, and controlling inflammation at the time of surgery,” Dr. Donnenfeld said.

There are also several new dry eye drugs that are in the FDA pipeline, he said.

Lifitegrast (Shire Pharmaceuticals) is an investigational drug that is a T-cell modulator, which works rapidly to treat the inflammatory component of dry eye disease. MIM-D3 (Mimetogen Pharmaceuticals, Inc.) is also a dry eye pharmaceutical with a very different mechanism of action. MIM-D3 is both a mucin secretagogue and improves corneal sensation, he said. 


Eric D. Donnenfeld, MD

E: ericdonnenfeld@gmail.com

Dr. Donnenfeld is a consultant to Omeros and Shire Pharmaceuticals.


Peter S. Hersh, MD

E: phersh@vision-institute.com

Dr. Hersh has no financial interest in any aspect of this report.

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