Eyeworld

3 P U 1:25 PM EW CATARACT 22 June 2014 related to cataract treatment. The basic part of the IOL is to replace the lens removed during cataract surgery, and the extra de- sign feature is for a different service to correct either presbyopia or astig- matism. We further explain that if the patient chooses an ATIOL, he or she will be undergoing two services. The cataract service is covered and will be submitted to the patient's insurer, but the presbyopia or astig- matism correction will be billed entirely to the patient because it is a service that is not covered. CMS issued rulings on the non- covered aspects of ATIOLs in 2005 and 2007 and issued guidance on femtosecond lasers in 2012. Those two documents acknowledge that one technology offers certain char- acteristics unique in the treatment of cataract and other characteristics distinctly different for the correction of refractive errors. The cost of using imaging and the incremental cost of the ATIOL above that of a conven- tional IOL are both components of the facility's total cost of goods for the noncovered service of presby- opia correction and/or astigmatism correction. While the documents from CMS are specifically about ATIOLs and lasers, facilities do not have to bill patients in a manner that assigns charge amounts specifi- cally to the noncovered aspect of an ATIOL or to the imaging function of a femtosecond laser. It is optional— but not required—to list individual items used in the noncovered serv- ice. To generate less patient confu- sion, many surgeons simply bill for the total of the refractive service being provided rather than for various items used to perform the service. Millions of patients each year choose surgical procedures that are not covered by insurance. Most of them want a general understanding of how the procedure will be performed, the risks, and the total amount they will be expected to pay. Cosmetic surgeons typically do not submit separate bills for implants used in surgery; it is more common to submit one comprehen- sive bill for the entire service. For patients who choose an ATIOL, this approach works well for the noncov- ered service, even though the cov- ered service is billed to the patient's insurance in the normal fashion. Refractive strategies applied during cataract surgery, including ATIOLs, offer many patients the opportunity to have excellent visual acuity while minimizing the need for spectacles. The discussion be- tween patient and doctor describing the features, advantages and disadvantages of refractive cataract strategies is one most surgeons are comfortable with. However, discus- sions regarding out-of-pocket pay- ments associated with these services are often confusing for both the sur- geon and patient. This can lead to apprehension and fear on the part of the patient, which can break down the confidence of the physician-pa- tient relationship. Surgery—espe- cially eye surgery—is an anxious and often frightening experience for patients. Tools that simplify the process such as that described here are useful adjuncts in minimizing these concerns and aid in creating an atmosphere of honest disclosure and reassurance. EW Editors' note: Dr. Lane is a clinical professor of ophthalmology at University of Minnesota, Minneapolis. He has financial interests with Alcon (Fort Worth, Texas). Look for addi- tional information on this topic in "Dispelling misconceptions: Experts discuss the CMS rulings for advanced technology IOLs and the CMS guidance for femtosecond lasers," in the July issue of EyeWorld. Contact information Lane: sslane@associatedeyecare.com 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 Distinguishing continued from page 20 20-31 Cataract_EW June 2014-DL_Layout 1 6/3/14 12:20 PM Page 22

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