MAY 2013

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

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44 EW FEATURE February challenges/MIGS May 2013 Glaucoma 2011 Pharmaceutical focus Prostaglandin enters preservative-free zone by Maxine Lipner EyeWorld Senior Contributing Writer For eyes with compromised surfaces, like this one stained with lissamine green, anecdotal reports show that even one drop of preserved medication may be enough to tip them over the edge. Source: Robert J. Noecker, MD P rescribing prostaglandins for glaucoma patients has taken on a new dimension. It's no longer simply a matter of deciding between brand name and generic medications. Practitioners these days have a new type of medication in this prostaglandin class to consider—the preservative-free drug Zioptan (tafluprost ophthalmic solution 0.0015%, Merck, Whitehouse Station, N.J.). Since February 2012 when Zioptan won FDA approval, this new option has given practitioners another tool to wield for glaucoma patients. Zioptan has joined the ranks of other classes of glaucoma drugs with non-preserved options, drugs such as preservative-free timolol (Timoptic, Aton Pharma, Madison, N.J.) and Cosopt PF (preservativefree dorzolamide/timolol, Merck), according to Douglas J. Rhee, MD, associate professor of ophthalmology, Harvard Medical School, Boston. While the preservative-free trend may seem very recent, he pointed out that it is a movement that began some time ago. "The preservative-free agents are an extension of a popularized theory to Monthly Pulse move away from benzalkonium chloride (BAK)," Dr. Rhee said. Initially beginning around 2001, there were alternatively preserved medications such as Alphagan P (brimonidine tartrate ophthalmic solution 0.15%, Allergan, Irvine, Calif.), preserved in Purite, followed by the prostaglandin analog Travatan Z (BAK-free travaprost 0.004%, Alcon, Fort Worth, Texas), preserved in SofZia, in 2006. "There was the beginning of a realization that we should be using something gentler on the eye," Dr. Rhee said. "The natural extension to that are these preservative-free agents." These have all germinated from the notion that the glaucoma agents themselves, as well as the preservatives such as BAK, are causing side effects to the surface of the eye. "They can make the eyes more uncomfortable," Dr. Rhee said. In addition, they can make eyes appear red and feel gritty or sandy. "There is some evidence to show that these changes are long term," Dr. Rhee said. "It's not just a sensation, you're actually changing the conjunctival tissue, specifically the goblet cells." To combat this, the ophthalmic field has pressed to make therapies gentler so that patients would adhere to the prescribed regimen more frequently, he explained. Prostaglandin first Zioptan is the first prostaglandin medication to offer not just a gentler approach but a totally preservativefree option. The vast majority of glaucoma patients tend to be on prostaglandin medication, noted Adam C. Reynolds, MD, Intermountain Eye and Laser Center, Boise, Idaho. "I would say on average in any given glaucoma situation more than 80% of our patients are on prostaglandin analogs," said Dr. Reynolds, who views the prostaglandins as a core medical treatment for glaucoma nowadays. This makes it especially important if patients are intolerant of the BAK preservative in Lumigan (topical bimatoprost, Allergan) or Xalatan (latanoprost, Pfizer, New York), generic latanoprost, or even Travatan Z to have an option where there is no additional agent to contend with. Even if patients can't tolerate these other drops, they may be able to use Zioptan, he said. Weighing the options In some circles, in addition to using this for patients with ocular surface disease, there is the thinking that everyone might do better without preservatives, Dr. Reynolds said. "Maybe you believe that everyone should be on preservative-free therapies because 'BAK is from Satan,' as Dr. (John) Samples likes to say, and Keeping a Pulse on Ophthalmology The EyeWorld Monthly Pulse survey for May focused on glaucoma challenges, including microinvasive glaucoma surgery, or MIGS. A slight majority of respondents (54%) remain concerned about the efficacy of MIGS procedures and cite that as their biggest challenge in beginning to use MIGS. Meanwhile, 25.9% thought that it would be a big step into unchartered territory since they don't currently perform glaucoma surgery. In question 2, 60.7% said they don't wish to use Trabectome and cataract surgery. Many (41.4%) also believed that cataract surgery alone would help a patient whose IOP is 22 mm Hg on max meds with early visual field change. Finally, most responders (68%) agreed that only head-to-head testing will determine which would lower IOP better—a device bypassing the trabecular meshwork or one placed in the suprachoroidal space.

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