Eyeworld

EW FEATURE 80 World Cornea Congress highlights September 2015 Patients with zoster "do need steroids, and often need steroid drops indefinitely," Dr. Lee said. Some of his patients may only need one drop a week, "but that's what keeps their eye comfortable. It's cru- cial to set the expectation early on that they'll be on steroids for a long time with a very slow taper" and to discuss the potential side effects from long-term steroid use. Debate is ongoing about vac- cination if a patient has developed HZO; Dr. Lee does not recommend vaccination, but others support vac- cination as long as shingles occurred more than 12 months previously. "Immunocompetent patients can recontract shingles or zoster ophthalmicus even shortly after the initial episode, so I personally recommend vaccination in select cases that are at least a year out without signs of ocular disease, even if they've previously developed shin- gles," Dr. Pepose said. "While more studies are indicated, it may lessen the severity of another recurrence, even if it doesn't completely elimi- nate the recurrence. It bolsters im- munity in patients where age is de- pleting natural immunity. It should not be given to immunosuppressed most common cause of suicide due to pain in people 70 years and older, Dr. Cohen said. HZO results in a 4.5-fold increase in the risk of stroke and a 1.3-fold increase in the risk of stroke in patients with zoster in other locations. Further, there is a 9-fold higher risk for cancer within a year of an HZO diagnosis, Dr. Cohen said. Finally, she said, the "most common time" for the eye to become involved is about 2–4 weeks after the rash in the V1 distribution over the eye. For now, Zostavax has yet to af- fect the global epidemiology because of a low uptake in most nations. According to Dr. Cohen, the glob- al incidence is increasing with no clear-cut cause. "Initial studies seem to suggest vaccine efficacy for about 6 years in people older than 60 years," Dr. Pepose said, and this remains a ques- tion the Centers for Disease Control (CDC) is trying to ascertain—along with any recommendations for revaccination. "The vaccine is approved by the FDA for people age 50–59, when it reduces zoster by 70%, but the dura- tion of vaccine efficacy is unknown in this age group," Dr. Cohen said. Treating HZO Within 72 hours of the shingles rash onset, oral antivirals should be prescribed, including valacyclovir 100 mg/3 times daily for 7 days, famciclovir 500 mg/3 times daily for 7 days, or acyclovir 800 mg/5 times daily for 7 days, although the latter is not as effective. And while they reduce chronic eye disease from 50% to 30%, Dr. Cohen said, "they do not reduce PHN." The correct dose is crucial to treating the disease—and this is twice the level as what is used to treat herpes simplex infections. "Antiviral treatment should be given to all people with zoster as soon as possible, since complica- tions typically develop more than 72 hours after onset when treatment should be given, and occur in rela- tively young and healthy people," Dr. Cohen said, who would still implement the antivirals if a patient presented outside that 72-hour win- dow with active disease. Understanding continued from page 78 Daily life: Has an active lifestyle—takes daily walks, gardens, attends weekly bridge games, goes on a yearly vacation with friends Lives on her own. Her daughter helps her from time to time Has an upbeat, independent attitude Health: She is on PGA therapy that has reduced her IOP from 26 mm Hg OU to 18 mm Hg OU for several years She takes a systemic beta-blocker for hypertension IOP status: Recently, her IOP has risen to around 22 mm Hg OU, and optic nerve damage has progressed She is cognizant of the need to work toward a target IOP and a reduction of approximately 5 mm Hg A potential candidate for SIMBRINZA ® (brinzolamide/brimonidine tartrate ophthalmic suspension) 1%/0.2% Meet Ann She has open-angle glaucoma with elevated IOP* Age: 77 years Not actual patient. *Hypothetical patient profi le. Has an active lifestyle—takes daily walks, gardens, attends weekly bridge games, goes on Lives on her own. Her daughter helps her from Has an upbeat, independent attitude She is on PGA therapy that has reduced her IOP from 26 mm Hg OU to 18 mm Hg OU for several years She takes a systemic beta-blocker for hypertension Recently, her IOP has risen to around 22 mm Hg OU, and optic nerve damage has progressed She is cognizant of the need to work toward a target She has open-angle glaucoma SIMBRINZA ® (brinzolamide/brimonidine tartrate ophthalmic suspension) 1%/0.2% is a fi xed combination indicated in the reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension. Dosage and Administration The recommended dose is one drop of SIMBRINZA ® Suspension in the affected eye(s) three times daily. Shake well before use. SIMBRINZA ® Suspension may be used concomitantly with other topical ophthalmic drug products to lower intraocular pressure. If more than one topical ophthalmic drug is being used, the drugs should be administered at least fi ve (5) minutes apart. IMPORTANT SAFETY INFORMATION Contraindications SIMBRINZA ® Suspension is contraindicated in patients who are hypersensitive to any component of this product and neonates and infants under the age of 2 years. Warnings and Precautions Sulfonamide Hypersensitivity Reactions—Brinzolamide is a sulfonamide, and although administered topically, is absorbed systemically. Sulfonamide attributable adverse reactions may occur. Fatalities have occurred due to severe reactions to sulfonamides. Sensitization may recur when a sulfonamide is readministered irrespective of the route of administration. If signs of serious reactions or hypersensitivity occur, discontinue the use of this preparation. Corneal Endothelium—There is an increased potential for developing corneal edema in patients with low endothelial cell counts. Severe Hepatic or Renal Impairment (CrCl <30 mL/min)— SIMBRINZA ® Suspension has not been specifi cally studied in these patients and is not recommended. Acute Angle-Closure Glaucoma—The management of patients with acute angle-closure glaucoma requires therapeutic interventions in addition to ocular hypotensive agents. SIMBRINZA ® Suspension has not been studied in patients with acute angle-closure glaucoma. Contact Lens Wear—The preservative in SIMBRINZA ® Suspension, benzalkonium chloride, may be absorbed by soft contact lenses. Contact lenses should be removed during instillation of SIMBRINZA ® Suspension but may be reinserted 15 minutes after instillation. Severe Cardiovascular Disease—Brimonidine tartrate, a component of SIMBRINZA ® Suspension, had a less than 5% mean decrease in blood pressure 2 hours after dosing in clinical studies; caution should be exercised in treating patients with severe cardiovascular disease. Potentiation of Vascular Insuffi ciency—Brimonidine tartrate, a component of SIMBRINZA ® Suspension, may potentiate syndromes associated with vascular insuffi ciency. It should be used with caution in patients with depression, cerebral or coronary insuffi ciency, Raynaud's phenomenon, orthostatic hypotension, or thromboangiitis obliterans. Contamination of Topical Ophthalmic Products After Use—There have been reports of bacterial keratitis associated with the use of multiple-dose containers of topical ophthalmic products. These containers have been inadvertently contaminated by patients who, in most cases, had a concurrent corneal disease or a disruption of the ocular epithelial surface. INDICATIONS AND USAGE

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