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May 2013 Glaucoma February 2011 challenges/MIGS maybe you don't believe that Travatan with SofZia is a viable alternative," Dr. Reynolds said. "Your philosophy may be that if you're going to treat glaucoma topically, you want to use every preservativefree alternative that's out there and use them first line." The rub here, he pointed out, is that most patients seem to "tolerate" generic prostaglandins well. Others stress that when it comes to glaucoma therapy, preservatives such as BAK can pose a particular problem since therapy tends to be ongoing, said Robert J. Noecker, MD, Ophthalmic Consultants of Connecticut, Fairfield. If patients are temporarily exposed to a little bit of BAK, it's no problem, but with glaucoma, unfortunately, there may be no reprieve. "The problem with glaucoma therapy is that you're doing it for so long, day after day, year after year, that there will be a cumulative toxicity to the surface of the eye," Dr. Noecker said. "That can cause problems with the way that the drugs get into the eye, the way that patients feel in terms of how it can affect their vision; there are also some concerns that it can make the glaucoma worse over time." The strongest evidence that preservatives can be problematic comes from laboratory models, he pointed out. There, preservatives can be given to one group and withheld from the other. However, with peo- EW FEATURE ple it can be harder to isolate those exposed to preservatives since patients can have other issues with which to contend, Dr. Noecker said. There is, however, no shortage of anecdotal reports. "We have patients who have such rotten ocular surfaces that one drop of these medications can tip them over the edge," he said. Unfortunately, rehabilitating the surface doesn't happen overnight. In some cases, patients with problematic ocular surfaces have been using preserved medications for years. "It will take some time to unravel those," Dr. Noecker said. "Immediately stopping it you won't see much change, but over time this will restore their normal ocular surface." Also, he said the evidence is shaky as to whether removing the preservatives from just one glaucoma medication will help those who are on several other preserved drops. As a result, Dr. Noecker said that those patients who have never been on preserved glaucoma drops are seen by some as prime candidates for Zioptan. "One of the theories is just don't go there—if you can avoid preservatives, it's better not to have a problem that you have to try to undo," Dr. Noecker said. The fact that Zioptan is a preservative-free prostaglandin may be continued on page 46 Poll size: 190 EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send a four-question online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the current 1,000+ physicians who take a minute a month to share their views, please send us an email and we will add your name. Email daniela@eyeworld.org and put EW Pulse in the subject line—that's all it takes. Copyright EyeWorld 2013 45