Eyeworld

WINTER 2024 | EYEWORLD | 69 C good option because it has a tremendous track record of safety and efficacy, he said. "Due to hyper concentration unachievable by oral anti-microbial medications, any antibi- otic in the tear film many times supersedes the minimum inhibitory concentration sensitivity threshold. Often, I'll have a patient treated for an acute ulcer, doing well with infiltrate reso- lution but delayed epithelialization, and I want to accelerate surface healing but prevent any future infections. I will frequently use a bandage contact lens," Dr. Sheppard said. It's important to consider intermediate-term antibiotic pro- phylaxis, and moxifloxacin is a well-matched partner for the clinician and the patient. An- other example, he said, is Eysuvis (loteprednol etabonate 0.25%, Alcon), which is indicated for intermittent treatment of episodic dry eye disease. Chronic diseases are notoriously age relat- ed, recalcitrant, and incurable, but they benefit from long-term therapy, Dr. Sheppard said. The classic examples are glaucoma and dry eye, and many in this cohort also have cataracts. These patients require intervention for long periods of time, and continuous use of preserved glaucoma medications are known to create changes in the ocular surface. He added that infiltration of inflammatory cells into the conjunctiva can cause a hyper- sensitivity reaction that can be exacerbated by the preservative themselves. Patients who have sensitivities to the active ingredient may become even more sensitive because the preservative is a well-known way to enhance permeability, so medications with continuous insult to the ocular surface are more efficacious because they enter the corneal or conjunctival tissues more readily. On the other hand, you have to be very cautious in this population because they tend to be older, and therefore more likely at risk for dry eye dis- ease and trabecular meshwork outflow damage. There are many choices to address this, Dr. Sheppard said. You can use artificial tears for dry eye, and most brands have single-dose dis- penser options that allow for preservative-free preparation. There's also a growing menu of multidose, preservative-free dry eye tear re- placements for chronic use. The tears that patients will most likely choose over the counter are less likely to be preservative-free and more likely to be store brand, which are produced in the most cost-ef- fective manner with the least efficacious but still FDA acceptable ingredients, Dr. Sheppard said. The patient, when ill-advised and self-directed, will most likely pick an inferior product based on store name brand promotion and eye level display. Therefore, it is incumbent upon eyecare practitioners to provide the education to make patients with chronic ocular surface disease aware of the relative disadvantages of over-the- counter medications and the need to have a proper diagnosis from an eyecare professional. Virtually all prescription medications for dry eye are preservative-free, except Eysuvis, he said. Dr. Pflugfelder said preservative-free for- mulations are available for certain glaucoma drops (timolol, dorzolamide-timolol, tafluprost, latanoprost). "Typically, the preservative-free formulations are more expensive, and they may not be covered by the patient's prescrip- tion plan," he said. "Other strategies are to use combination glaucoma drops versus the individ- ual agents. This will decrease the BAK burden." Central corneal fluorescein staining in patient with aqueous deficient dry eye and history of using latanoprost for glaucoma for 5 years; corneal staining and vision improved when latanoprost was exchanged for preservative-free tafluprost Source: Stephen Pflugfelder, MD continued on page 70

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