EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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EW FEATURE 44 well as for the cornea itself and the intraocular component. The OPD is also an aberrome- ter, a function utilized in a program called OPD CATz, Dr. Waring said, using software that combines wave- front-guided and topography-guided algorithm treatment. This is used internationally and is expected in the U.S. in the future. Dr. Waring warned that wave- front-guided treatments can see changes to the lens over time, and aberrometry measurements and treatments are limited to a 6–7 mm pupil. He said the advantage of CATz over what is currently available is mainly the topographic-guided, large aspheric treatment zone that is customized to the patient's corneal shape that produces a more regular symmetrical cornea, and that pres- ents a simulated target topographic outcome. Best candidates Dr. Rocha said that most patients would benefit from the newer tech- nologies. "There have been studies demonstrating that even for lower correction levels, the improvements in quantity and quality of vision are significant." He said there has been evidence of better results in the extreme corrections, including mod- erate to high myopia or hyperopia and higher levels of astigmatism. Dr. Hamilton said that these new technologies might be partic- ularly useful for older patients. For example, he said for a 50-year-old myopic patient who comes in, he may want to do LASIK but perhaps not a wavefront-guided treatment. Topography-guided treatment tries to maintain the best possible shape of the cornea, which won't change throughout life. He added that as topography- guided treatment is explored more, it may be used more often. "We may end up using it as a standard treatment for everybody," he said, adding that it will take a while to get nomograms developed. Current limitations for SMILE arise if a patient needs further en- hancements. The other limitation is that the visual recovery is slower than with LASIK, he said. It takes a few days for the vision to reach that "wow" factor and possibly even a month for vision to stabilize. The iDesign is the next step in wavefront technology, Dr. Vukich said, indicating its use to drive standard corrections. Meanwhile, topographic-driven corrections may have more benefit for patients who have atypical corneas, he said. Dr. Waring said the Nidek technology works for a wide variety of patients. EW Editors' note: Dr. Hamilton has financial interests with AMO and Alcon. Dr. Vukich has financial interests with AMO and STAAR Surgical (Monrovia, Calif.). Dr. Rocha has financial interests with AMO. Dr. Waring has financial interests with Nidek. Contact information Hamilton: Hamilton@jsei.ucla.edu Rocha: rochag@wcgwave.ca Vukich: javukich@gmail.com Waring: drgeorge@georgewaring.com BRIEF SUMMARY OF PRESCRIBING INFORMATION INDICATIONS AND USAGE ILEVRO® Suspension is indicated for the treatment of pain and inflammation associated with cataract surgery. DOSAGE AND ADMINISTRATION Recommended Dosing One drop of ILEVRO® Suspension should be applied to the affected eye one- time-daily beginning 1 day prior to cataract surgery, continued on the day of surgery and through the first 2 weeks of the postoperative period. An addi- tional 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 inhibi- tors, 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 demon- strated hypersensitivity to any of the ingredients in the formula or to other NSAIDs. WARNINGS AND PRECAUTIONS Increased Bleeding Time With some nonsteroidal anti-inflammatory drugs including ILEVRO® Suspen- sion, there exists the potential for increased bleeding time due to interference with thrombocyte aggregation. There have been reports that ocularly applied nonsteroidal anti-inflammatory 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-inflammatory drugs (NSAIDs) including ILEVRO® Sus- pension, 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 Effects 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), rheuma - toid arthritis, or repeat ocular surgeries within a short period of time may be at increased risk for corneal adverse events which may become sight threat- ening. 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 reflect the rates observed in practice. Ocular Adverse Reactions The most frequently reported ocular adverse reactions following cataract sur- gery 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 proce - dure. 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 Effects. 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 ap- proximately 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 benefit justifies the potential risk to the fetus. Non‐teratogenic Effects. Because of the known effects 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 excret- ed in human milk, caution should be exercised when ILEVRO® Suspension is administered to a nursing woman. Pediatric Use The safety and effectiveness of ILEVRO® Suspension in pediatric patients below the age of 10 years have not been established. Geriatric Use No overall differences in safety and effectiveness have been observed be- tween 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‐inflammatory drugs (NSAIDs). Avoiding Contamination of the Product Patients should be instructed to avoid allowing the tip of the dispensing con- tainer 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 © 2014 Novartis 3/14 ILV14041JAD Keratorefractive surgery August 2014 New technologies continued from page 43