EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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32 EW NEWS & OPINION Honing continued from page 30 from multiple ways. These patients want no drops or plugs, and they want something natural." Although Dr. Latkany warns these patients that taking fish oil for omega-3s won't miraculously cure their dry eye, it can certainly help. "I try to treat the patients as a whole and look at their nutritional intake," he said, in addition to eval- uating patients' environment, co- morbid diseases, and medication use. John D. Sheppard, M.D., pro- fessor of ophthalmology, microbiol- ogy, and immunology, Eastern Virginia Medical School, Norfolk, Va., finds that patients, particularly those with AMD or with family members who have had AMD, want to comply with nutrition advice, but they may not be aware of what they are taking—or should take. "Depending on how you stratify it socioeconomically, I think that the AMD population is well aware of something they're supposed to take for their eyes," Dr. Sheppard. "How- ever, they just know that they need to take the blue pill every morning." They may not necessarily know the specific nutrients from food or sup- plements that will help shield them against certain eye ailments, he said. NEVANAC® (nepafenac ophthalmic suspension) 0.1%, topical ophthalmic Initial U.S. Approval: 2005 Revised: 9/2007 BRIEF SUMMARY 1 INDICATIONS AND USAGE NEVANAC® ophthalmic suspension is indicated for the treatment of pain and inflammation associated with cataract surgery. 2 DOSAGE AND ADMINISTRATION 2.1 Recommended Dosing One drop of NEVANAC® should be applied to the affected eye(s) three-times-daily beginning 1 day prior to cataract surgery, continued on the day of surgery and through the first 2 weeks of the postoperative period. 2.2 Use with Other Topical Ophthalmic Medications NEVANAC® may be administered in conjunction with other topical ophthalmic medications such as beta-blockers, carbonic anhydrase inhibitors, alp ha-agonists, cycloplegics, and mydriatics. 3 DOSAGE FORMS AND STRENGTHS Sterile ophthalmic suspension: 0.1% 3 mL in a 4 mL bottle 4 CONTRAINDICATIONS NEVANAC® is contraindicated in patients with previously demonstrated hypersensitivity to any of the ingredients in the formula or to other NSAID. 5 WARNINGS AND PRECAUTIONS 5.1 Increased Bleeding Time With some nonsteroidal anti-inflammatory drugs including NEVANAC®, there exists the potential for increased bleeding time due to interference with thrombocyte aggregation. There have been reports that ocularly applied nonsteroidal anti-inflammatory drugs may cause increased bleeding of ocular tissues (including hyphemas) in conjunction with ocular surgery. It is recommended that NEVANAC® ophthalmic suspension be used with caution in patients with known bleeding tendencies or who are receiving other medications which may prolong bleeding time. 5.2 Delayed Healing Topical nonsteroidal anti-inflammatory drugs (NSAIDs) including NEVANAC®, may slow or delay healing. Topical corticosteroids are also known to slow or delay healing. Concomitant use of topical NSAIDs and topical steroids may increase the potential for healing problems. 5.3 Corneal Effects Use of topical NSAIDs may result in keratitis. In some susceptible patients, continued use of topical NSAIDs may result in epithelial breakdown, corneal thinning, corneal erosion, corneal ulceration or corneal perforation. These events may be sight threatening. Patients with evidence of corneal epithelial breakdown should immediately discontinue use of topical NSAIDs including NEVANAC® and should be closely monitored for corneal health. Postmarketing experience with topical NSAIDs suggests that patients with complicated ocular surgeries, corneal denervation, corneal epithelial defects, diabetes mellitus, ocular surface diseases (e.g., dry eye syndrome), rheumatoid arthritis, or repeat ocular surgeries within a short period of time may be at increased risk for corneal adverse events which may become sight threatening. Topical NSAIDs should be used with caution in these patients. Postmarketing experience with topical NSAIDs also suggests that use more than 1 day prior to surgery or use beyond 14 days post surgery may increase patient risk and severity of corneal adverse events. 5.4 Contact Lens Wear NEVANAC® should not be administered while using contact lenses. 6 ADVERSE REACTIONS Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to the rates in the clinical studies of another drug and may not reflect the rates observed in practice. 6.1 Ocular Adverse Reactions The most frequently reported ocular adverse reactions following cataract surgery were capsular opacity, decreased visual acuity, foreign body sensation, increased intraocular pressure, and sticky sensation. These events occurred in approximately 5 to 10% of patients. Other ocular adverse reactions occurring at an incidence of approximately 1 to 5% included conjunctival edema, corneal edema, dry eye, lid margin crusting, ocular discomfort, ocular hyperemia, ocular pain, ocular pruritus, photophobia, tearing and vitreous detachment. Some of these events may be the consequence of the cataract surgical procedure. 6.2 Non-Ocular Adverse Reactions Non-ocular adverse reactions reported at an incidence of 1 to 4% included headache, hypertension, nausea/vomiting, and sinusitis. See full prescribing information for NEVANAC®. Clinical implications It will take efforts from eye doctors to steer patients toward the right supplements and diet, Dr. Anshel said. The Ocular Nutrition Society does not manufacture supplements, but the group does have sponsors that sell eye health supplements, he said. Patients also need to know that it's not just supplements that will help protect them against dry eye, macular degeneration, or other dis- eases. "You can't throw pills at a bad diet," Dr. Anshel said. "It's a change of lifestyle and diet." Making that change naturally means that eye doctors need to be knowledgeable on this topic and make the time to broach it with pa- tients—two potentially difficult is- sues. "Many [ophthalmologists] are more surgeons and see the eye as something more technical and al- most feel it exists and does not need the rest of the body," Dr. Delcourt said. "I know many French ophthal- mologists are skeptical about this, while others are interested but don't feel comfortable talking with pa- tients about nutrition because they are not trained. There is also a time issue." Basic information at confer- ences or other doctor-geared settings would be a good place to spread ac- curate information about eye health and nutrition, Dr. Delcourt said. A relationship with a local nutri- tionist is another way to bridge the informational gap, Dr. Anshel said. He has referred certain patients with glaucoma, cataracts, and diabetic retinopathy to nutritionists. Dr. Sheppard's practice once considered having a dietician on staff but decided it would not be the right fit. However, Dr. Sheppard sometimes gives out the business card of a trusted local dietician. He also sends letters to patients' in- ternists to recommend changes in nutrition as necessary. ALCON LABORATORIES, INC. Fort Worth, Texas 76134 USA © 2011 Alcon, Inc. 3/11 NPF11500JAD Dr. Latkany occasionally refers patients to nutritionists; those pa- tients usually have rosacea or aller- gies. Dr. Sheppard's office also sells popular ocular nutritional supple- ments; although patients can order those supplements online or buy them at a pharmacy, some prefer to go out of their way and get them right from their doctor's office, he said. Even though chair time is al- ways a concern for doctors, there is a small thing they can do to push eye health and nutrition, Dr. Sheppard said. "I don't believe there is any- thing better we can do than to say to patients that they should take 2,000 mg of omega-3 fatty acids a day. We have 110 employees, and [I bought] each of them a bottle of fish oil for Christmas. It's a no-brainer," he said. EW Editors' note: Dr. Anshel is president of the Ocular Nutrition Society. Dr. Delcourt has financial interests with Bausch + Lomb, Novartis (Basel, Switzerland), and Pfizer (New York). Dr. Latkany has financial interests with Alcon (Fort Worth, Texas). Dr. Sheppard has financial interests with Alcon, Allergan (Irvine, Calif.), Bausch + Lomb, and Vistakon (Jacksonville, Fla.). Contact information Anshel: 760-931-1390 Delcourt: 33-5-57-57-48-95, benedicte.mele@isped.u-bordeaux2.fr Latkany: 212-689-2020, relief@dryeyedoctor.com Sheppard: 757-622-2200, docshep@hotmail.com EyeWorld factoid Zinc is highly concentrated in the eye, mostly in the retina and choroid, and plays a vital role in bringing vitamin A from the liver to the retina in order to produce melanin Source: American Optometric Association March 2012