JAN 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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58 EW MEETING REPORTER January 2013 Reporting continued from page 57 Reporting live from the 2012 Asia Cornea Society meeting, Manila of ophthalmology, focusing on the groundbreaking work of two giants of modern ophthalmology: Ramon Castroviejo, M.D. (1903-1987), and Max Fine, M.D. (1908-1989). Dr. Fine, who had been a mentor and sometime colleague of Dr. Abbott, was the first to perform penetrating keratoplasty in the Western United States in 1937, using the technique of square keratoplasty advocated by his friend and rival, Dr. Castroviejo. Having dug up old film reels made by Dr. Fine in the 40s and 60s, Dr. Abbott had the films restored and converted to a digital format, which he then presented to the audience at the opening ceremony of the meeting. The differences between now and then are fascinating and educational: In his life, Dr. Fine worked barehanded—never once performing surgery wearing surgical gloves, believing they impaired his performance. And yet he achieved remarkably clear corneas and good outcomes for the time. Where do you draw the line between using a new technology and what's good for the patient? There is no definite answer, but, said Dr. Abbott, it is the responsibility of surgeons to ask the question. "Our role is to pick and choose [the best option for our patients]," he said. Innovation is clearly a necessity, but the bottom line is whether a particular development is good for the patient. Editors' note: Dr. Abbott has no financial interests related to his lecture. Destigmatizing corticosteroids Editors' note: This Meeting Reporter contains original reporting by the EyeWorld news team from the 2012 Asia Cornea Society meeting in Manila. Ophthalmologists today have a number of options for managing ocular surface and corneal inflammatory disease, including nonsteroidal anti-inflammatory drugs (NSAIDs), antihistamines, mast cell stabilizers, combination antihistamine/mast cell stabilizers, immunotherapy, and corticosteroids. Each agent has its own set of limitations, mostly inherent in their mode of action—antihistamines reduce itching but not redness, vasoconstrictors reduce redness but not itching, and corticosteroids bear the stigma of their safety profiles. This is unfortunate, because, said Edward J. Holland, M.D., Cincinnati, they are the most effective anti-inflammatory agents, offering a broad spectrum of activity that provides the most comprehensive coverage of the inflammatory cascade of any available agent. These agents suppress the migration of polymorphonuclear leukocytes (PMNs) and the reparative processes and functions of fibroblasts, reverse enhanced capillary permeability, and stabilize lysosomes. Ophthalmologists have come to fear the elevation of IOP, risk of formation of posterior subcapsular cataracts, aggravation of infectious disease states, and delay in the normal course of healing that has been associated with corticosteroids. This, said Dr. Holland, has resulted in the suboptimal treatment of active disease and the failure to prevent recurrent disease. The solution may come in the form of the first and, to date, only ester steroid: loteprednol etabonate. Loteprednol, said Dr. Holland, has been shown to be 10 times more lipophilic and have 4.3 times the glucocorticoid receptor binding affinity of dexamethasone—characteristics that significantly alter the safety profile of the drug. While as effective as the current "gold standard" for steroid therapy—prednisolone—Dr. Holland said that loteprednol has significantly less IOP response, making it ideal for long-term use. Ophthalmologists, said Dr. Holland, need to rethink their aversion to corticosteroids, listing dry eye inflammation, meibomian gland disease, chronic conjunctival inflammation, immune stromal keratitis, and even adenoviral ocular infection as indications for corticosteroid use. Corticosteroids, he said, are the most effective way of avoiding the corneal scarring and pain that are sure to result from undertreating chronic inflammatory eye conditions, complications that are at least commensurate—and also far more likely to occur—than the cataract, glaucoma, and steroid dependence that can be avoided through appropriate and judicious use of available agents. Engineered against resistance? In managing keratitis, said John D. Sheppard, M.D., Norfolk, Va., ophthalmologists should consider some important associations: pseudomonas for contact lens ulcers, MRSA/MRSE for at-risk patients, protozoans for unresponsive cases. Basically, he said, it is often best to expect the worst possible bugs when deciding on treatment. The "worst" includes consideration for growing microbial resistance around the world. There is, said Dr. Sheppard, a growing population of baseline methicillin-ciprofloxacin resistant bugs. At the rate microbial resistance is rising, it is entirely possible that all bugs are methicillin resistant within the decade. Amid these rising resistance rates, Dr. Sheppard touted a new option for antimicrobial treatment, the first chlorofluoroquinolone: besifloxacin. Bausch + Lomb's formulation of the drug, Besivance (besifloxacin ophthalmic solution 0.6%, Rochester, N.Y.) delivers the drug in a mucoadhesive vehicle of DuraSite, which helps keep the drug on the eye. The molecular characteristics that make besifloxacin what it is— including a chloride in its structure —mean the drug delivers the most balanced inhibition of microbial DNA gyrase and topoisomerase II action, for a lowered probability of allowing mutant survivors to develop resistance. In 696 conjunctival isolates, he said, he has seen no incidence of resistance to besifloxacin. The drug, he said, offers potent, bactericidal coverage over a broad spectrum of microbes that includes resistant strains. Safety with contact lenses Given the ubiquity of contact lens use, the incidence of contact lens-related microbial keratitis—that such

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