Eyeworld

EW CATARACT 40 postop; and many stabilized in their depression symptoms. The patients' day-to-day functioning did not im- prove, however. Surgical tips Although the mental and physi- cal risks of putting someone with dementia through cataract surgery and the risks of anesthesia are legit- imate concerns, the research shows the surgery can be well-tolerated, said Dr. Lerner, who has had cata- ract surgery and said it helped him tremendously. However, he understands why a surgeon might hesitate to perform the procedure if the patient has severe retinal pathology, diabetic retinopathy, or end-stage glaucoma. There are some ways to make cataract surgery easier to manage if the patient has dementia. You may need to slow down and explain what is happening more, as the patient may be confused, Dr. Lerner said. You will probably want to stick with what Dr. Lerner calls "vanil- la" cataract surgery, as asking these patients to neuroadapt to more sophisticated and custom IOLs may be too much for them. Try to get surgery done before the person's mental health is too difficult to manage, Dr. Safran rec- ommended. More advanced demen- tia could lead to a more complex preop evaluation and surgery under general anesthesia. "It's unfortunate when you have patients who cross the threshold to the point where you can't even get them to let you do a slit lamp exam," he said. It's also crucial to check on the patient after surgery more often than usual, Dr. Belkin advised. This patient group, particularly if they have severe Alzheimer's disease, may be more likely to fall out of bed or become combative. Finally, consider how cataract surgery will benefit the patient's overall quality of life. "You have to look at the dementia patient as a whole person. They have a sensory deficit, and we can help them with that," Dr. Belkin said. EW Editors' note: The physicians have no financial interests related to their comments. Contact information Belkin: Julie.belkin@uhhospitals.org Girard: docteur.girard@orange.fr Lerner: alan.lerner@case.edu Safran: safran12@comcast.net February 2015 the Copenhagen meeting; the trial should be completed by June 2015, according to ClinicalTrials.gov. If the final results show a con- tinued benefit from cataract surgery, they should be examined on a larger scale, Dr. Lerner said. A study from 3 years ago also found positive results from cataract surgery. At the 2011 Academy of Ophthalmology annual meeting in Orlando, Fla., Brigitte Girard, MD, assistant professor of ophthalmolo- gy, Tenon Hospital, Paris, reported that patients with mild Alzheimer's disease and cataracts experienced improvements in thinking, sound- er sleep, better mood, and other benefits after surgery. The study included 38 men and women with an average age of 85.6. All but 1 patient had improved vision; 1 in 4 had improvements in thinking and memory skills by 1 and 3 months a few patients who have had an absolutely amazing turnaround in their mental status after surgery for advanced moderate to severe cat- aracts that were causing decreased visual function bilaterally," he said. "The changes can be so rapid, it's like meeting a new person on the first postoperative visit." The clinical trial at Case West- ern Reserve has 43 participants total, according to the abstract from 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 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-inflammatory 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-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® 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 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), 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 reflect 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 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 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 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 excreted 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 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-inflammatory 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 © 2014 Novartis 7/14 ILV14057JAD Study continued from page 38

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