Eyeworld

EW NEWS & OPINION 18 Considering the relatively young population that has elected to undergo this procedure from pre- vious studies (i.e., mean age of 35.93 years with range of 26–52 years 9 and mean age of 39.2 years with range of 22–77 years 4 ), the concern for addi- tional and long-term complications exists as well. We hope the informa- tion presented in this alert will help clinicians better understand the risks of performing this procedure and educate their patients about those risks and other safer, more conservative treatment options that are available. EW References 1. Kim B-H. Regional conjunctivectomy with postoperative mitomycin C to treat chronic hyperemic conjunctiva. Cornea 2012; 31:236–244. 2. Boxer Wachler B. I-BRITE Eye Whitening. Boxer Wachler Vision Institute and MedNet Technologies Inc., 2014. Available at: www.boxerwachler.com/whiteeyes. Accessed March 19, 2014. 3. Caceres V. An eye-opening look at eye brightening procedures. EyeWorld October 2013, pages 60–61. Available at: digital.eyeworld.org/i/194331/62. Accessed March 19, 2014. 4. Lee S, Go J, Rhiu S, Stulting RD, Lee M, Jang S, Lee S, Kim HJ, Chung ES, Kim S, Seo KY. Cosmetic regional conjunctivectomy with postoperative mitomycin C application with or without bevacizumab injection. Am J Ophthalmol 2013; 156:616–622.e3. 5. Hayasaka S, Iwasa Y, Nagaki Y, Kandoi C, Matsumoto M, Hayasaka Y. Late complications after pterygium excision with high dose mito- mycin C instillation [letter]. Br J Ophthalmol 2000; 84:1081–1082. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1723 650/pdf/v084p01075h.pdf. Accessed March 19, 2014. 6. Dunn JP, Seamone CD, Ostler HB, Nickel BL, Beallo A. Development of scleral ulceration and calcification after pterygium excision and mitomycin therapy [letter]. Am J Ophthalmol 1991; 112:343–344. 7. Saifuddin S, el Zawawi A. Scleral changes due to mitomycin C after pterygium excision: a report of two cases. Indian J Ophthalmol 1995; 43:75–76. Available at: www.ijo.in/text. asp?1995/43/2/75/25262. Accessed March 19, 2014. 8. Fujitani A, Hayasaka S, Shibuya Y, Noda S. Corneoscleral ulceration and corneal perfora- tion after pterygium excision and topical mito- mycin C therapy. Ophthalmologica 1993; 207:162–164. 9. Rhiu S, Shim J, Kim EK, Chung SK, Lee JS, Lee JB, Seo KY. Complications of cosmetic wide conjunctivectomy combined with post- surgical mitomycin C application. Cornea 2012; 31:245–252. 10. Kim B-H. Surgical treatment of necrotic scleral calcification using combined conjuncti- val autografting and an amniotic membrane inlay filling technique. Eye 2011; 25:1484– 1490. Available at: www.ncbi.nlm.nih.gov/ pmc/articles/PMC3213665/pdf/eye2011209a. pdf. Accessed March 19, 2014. 11. Kwon HJ, Nam SM, Lee SY, Ahn JM, Seo KY. Conjunctival flap surgery for calcified scle- romalacia after cosmetic conjunctivectomy. Cornea 2013; 32:821–825. 12. Leung TG, Dunn JP Jr, Akpek EK, Thorne JE. Necrotizing scleritis as a complication of cosmetic eye whitening procedure. J Oph- thalmic Inflamm Infect 2013; 3:39. Available at: www.ncbi.nlm.nih.gov/pmc/articles/ PMC3605078/pdf/1869-5760-3-39.pdf. Accessed March 19, 2014. Editors' note: This ASCRS clinical alert is provided for informational and educational purposes only. It is not intended to mandate or establish a specific standard of care or dictate the treatment of any particular patients. ASCRS members must make independ- ent judgments about the treatment of their patients based on all the facts and circumstances relating to each patient's condition. Contact information Cindy Sebrell: csebrell@ascrs.org April 2014 BRIEF SUMMARY OF PRESCRIBING INFORMATION INDICATIONS AND USAGE ILEVRO™ Suspension is indicated for the treatment of pain and inammation associated with cataract surgery. DOSAGE AND ADMINISTRATION Recommended Dosing One drop of ILEVRO™ Suspension should be applied to the aected eye one-time-daily beginning 1 day prior to cataract surgery, continued on the day of surgery and through the rst 2 weeks of the postoperative period. An additional drop should be administered 30 to 120 minutes prior to surgery. Use with Other Topical Ophthalmic Medications ILEVRO™ Suspension may be administered in conjunction with other topical ophthalmic medications such as beta-blockers, carbonic anhydrase inhibitors, alpha-agonists, cycloplegics, and mydriatics. If more than one topical ophthalmic medication is being used, the medicines must be administered at least 5 minutes apart. CONTRAINDICATIONS ILEVRO™ Suspension is contraindicated in patients with previously demonstrated hypersensitivity to any of the ingredients in the formula or to other NSAIDs. WARNINGS AND PRECAUTIONS Increased Bleeding Time With some nonsteroidal anti-inammatory drugs including ILEVRO™ Suspension, there exists the potential for increased bleeding time due to interference with thrombocyte aggregation. There have been reports that ocularly applied nonsteroidal anti-inammatory drugs may cause increased bleeding of ocular tissues (including hyphemas) in conjunction with ocular surgery. It is recommended that ILEVRO™ Suspension be used with caution in patients with known bleeding tendencies or who are receiving other medications which may prolong bleeding time. Delayed Healing Topical nonsteroidal anti-inammatory drugs (NSAIDs) including ILEVRO™ Suspension, 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. Corneal Eects 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 ILEVRO™ Suspension 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. Contact Lens Wear ILEVRO™ Suspension should not be administered while using contact lenses. 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 reect the rates observed in practice. 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. Non‐Ocular Adverse Reactions Non‐ocular adverse reactions reported at an incidence of 1 to 4% included headache, hypertension, nausea/vomiting, and sinusitis. USE IN SPECIFIC POPULATIONS Pregnancy Teratogenic Eects. Pregnancy Category C: Reproduction studies performed with nepafenac in rabbits and rats at oral doses up to 10 mg/kg/day have revealed no evidence of teratogenicity due to nepafenac, despite the induction of maternal toxicity. At this dose, the animal plasma exposure to nepafenac and amfenac was approximately 70 and 630 times human plasma exposure at the recommended human topical ophthalmic dose for rats and 20 and 180 times human plasma exposure for rabbits, respectively. In rats, maternally toxic doses ≥10 mg/kg were associated with dystocia, increased postimplantation loss, reduced fetal weights and growth, and reduced fetal survival. Nepafenac has been shown to cross the placental barrier in rats. There are no adequate and well‐controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, ILEVRO™ Suspension should be used during pregnancy only if the potential benet justies the potential risk to the fetus. Non‐teratogenic Eects. Because of the known eects of prostaglandin biosynthesis inhibiting drugs on the fetal cardiovascular system (closure of the ductus arteriosus), the use of ILEVRO™ Suspension during late pregnancy should be avoided. Nursing Mothers ILEVRO™ Suspension is excreted in the milk of lactating rats. It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when ILEVRO™ Suspension is administered to a nursing woman. Pediatric Use The safety and eectiveness of ILEVRO™ Suspension in pediatric patients below the age of 10 years have not been established. Geriatric Use No overall dierences in safety and eectiveness have been observed between elderly and younger patients. NONCLINICAL TOXICOLOGY Carcinogenesis, Mutagenesis, Impairment of Fertility Nepafenac has not been evaluated in long‐term carcinogenicity studies. Increased chromosomal aberrations were observed in Chinese hamster ovary cells exposed in vitro to nepafenac suspension. Nepafenac was not mutagenic in the Ames assay or in the mouse lymphoma forward mutation assay. Oral doses up to 5,000 mg/kg did not result in an increase in the formation of micronucleated polychromatic erythrocytes in vivo in the mouse micronucleus assay in the bone marrow of mice. Nepafenac did not impair fertility when administered orally to male and female rats at 3 mg/kg. PATIENT COUNSELING INFORMATION Slow or Delayed Healing Patients should be informed of the possibility that slow or delayed healing may occur while using nonsteroidal anti‐inammatory drugs (NSAIDs). Avoiding Contamination of the Product Patients should be instructed to avoid allowing the tip of the dispensing container to contact the eye or surrounding structures because this could cause the tip to become contaminated by common bacteria known to cause ocular infections. Serious damage to the eye and subsequent loss of vision may result from using contaminated solutions. Use of the same bottle for both eyes is not recommended with topical eye drops that are used in association with surgery. Contact Lens Wear ILEVRO™ Suspension should not be administered while wearing contact lenses. Intercurrent Ocular Conditions Patients should be advised that if they develop an intercurrent ocular condition (e.g., trauma, or infection) or have ocular surgery, they should immediately seek their physician's advice concerning the continued use of the multi‐dose container. Concomitant Topical Ocular Therapy If more than one topical ophthalmic medication is being used, the medicines must be administered at least 5 minutes apart. Shake Well Before Use Patients should be instructed to shake well before each use. U.S. Patent Nos. 5,475,034; 6,403,609; and 7,169,767. ALCON LABORATORIES, INC. Fort Worth, Texas 76134 USA © 2013 Novartis 2/13 ILV13030JAD ASCRS continued from page 16

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