EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/511377
recommended aggressively treat- ing patients from the start with lid hygiene, as well as use of flax seed oil, doxycycline, artificial tears, and Restasis (cyclosporine, Allergan, Irvine, Calif.). "We should get them into the best situation before throwing on all of our other medications, which will exacerbate their disease," Dr. Kammer said. "We should treat them aggressively from the get-go so that they're better able to tolerate these medications once we institute treatment." Avoiding BAK Dr. Kammer tries to take the medica- tions themselves into consideration. This often means focusing on the preservatives used. "Certainly the most common preservative that's used today is BAK and this is a detergent, so it can have a signifi- cant negative effect," Dr. Kammer explained. "Just like it disrupts the bacterial cells or viral cells or fungal cells, it can also disrupt the cells on the ocular surface." This has been seen on a mo- lecular level during in vitro studies and has often been seen clinically as well, he said. That has led to the rise of alter- native medications that have softer preservatives or single-dose preser- vative-free medication, he noted. "Although they still can have some effect on the ocular surface, these aren't quite as harsh as the medica- tions with BAK," Dr. Kammer said. Dr. Parekh concurred that some- times the alternatively preserved and preservative-free agents can help. Such agents include Travatan Z (travoprost, Alcon, Fort Worth, Texas) preserved with SofZia, Alpha- gan P (brimonidine tartrate, Aller- gan, Irvine, Calif.) with Purite, and preservative-free medications such as Timoptic in Ocudose (timolol, Bausch + Lomb, Bridgewater, N.J.), Cosopt PF (dorzolamide/timolol, Merck, Whitehouse Station, N.J.), and Zioptan (tafluprost, Me ck). Dr. Kammer finds that the alternatively preserved agents can be more benign than agents with traditional preservatives. "They're distinguished by these alternative preservatives, which in several clin- ical studies have been shown to be less toxic to the ocular surface," he said, adding that theoretically this can have a positive impact on how people feel on a daily basis and on how they see. He pointed out that practi- tioners are fortunate to have single- dose preservative-free drops from 3 different categories of glaucoma medication—Cosopt PF, a combina- tion beta blocker and carbonic an- hydrase inhibitor, preservative-free Timoptic in Ocudose, a beta-block- er, and preservative-free Zioptan, a prostaglandin analogue. This is something that he views as a real boon for patients. The great thing about this is you can put patients on 3 different glaucoma medications with no preservatives, Dr. Kammer noted. "So for patients who have sig- nificant d y eye symptoms, this can be very beneficial and can make a difference between whether or not they need a surgical procedure or can continue with medication," he said. Looking to the future, there are already some new options in the wings. Among these, Dr. Kammer pointed to an implantable extended- release device that releases micro- particles and nanoparticles as one potential new option. Use of micro- needles to inject medication into a specific spot is anothe , he said. Clinical trials are underway for an intracameral medication that could lower the intraocular pressure. "These options could be helpful to these patients who have signif- icant dry eye symptoms and other ocular surface diseases," Dr. Kammer said. Dr. Parekh agreed that an in- jectable or a longer-lasting glauco- ma medication would be great for circumventing ocular surface issues. However, in his view the "holy grail" would be the advent of a whole new class of glaucoma drugs. EW Editors' note: Dr. Kammer has fina - cial interests with Allergan and Iridex (Mountain View, Calif.). Dr. Parekh has financial interests with Alcon, Allergan, and Bausch + Lomb. Contact information Kammer: jeff.kammer@vanderbilt.edu Parekh: parag2020@gmail.com