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Transcript of Narrow angles
What is Glaucoma?
Glaucoma is a series of conditions, characterized by a particular form of optic nerve damage that is often-but
not always- associated with elevated IOP.
The American Academy of Ophthalmology now defines glaucoma as “a group of diseases with certain features
including an intraocular pressure that is too high for the continued health of the eye.”
Risk Factors for Glaucoma Increased IOP
Age Family HistoryRace DiabetesPrevious Eye Injury
Goals of Glaucoma ManagementTreatment
• Lower IOP
• Control of IOP fluctuation for a full 24 hours
• Preserve Vision
Quality of Life Considerations
• Long Term Impact of Medications
• Balance of Efficacy and Side Effects
Medical Treatments Prostaglandin Analogues- work by increasing flow of
aqueous humor via the uveoscleral pathway out of the eye, thus lowering IOP
Uveoscleral Pathway: Aqueous humor flows through spaces of the iris and ciliary body under the sclera and drains via blood vessels. Some of the aqueous is absorbed directly through the blood vessels of the coroid
Dosed once a day- side effects may include hyperemia which is redness of the eye- usually mild and subsides within a few weeks of treatment
Medical Treatments Beta Blockers
Most common is timolol- work by decreasing production of aqueous humor which lowers IOP
Side effects may include low blood pressure, slow heart rate and general fatigue
Medical Treatments Alpha Agonists- dosed 3 times per day- cause increase in outflow as well as a decrease in production of aqueous humor to lower IOP ie. Alphagan
Side effects may include ocular allergies and drowsiness
Carbonic Anhydrase Inhibitors- 2 or 3 times per day dosing- lower IOP by decreasing production of aqueous humor ie. Azopt, Trusopt
Alcon’s Promoted Glaucoma Products
TRAVATAN ZThe Only First Line PGA that Provides Proven, Stable 24 Hour IOP Control without the Harmful Effects of BAK on the Ocular Surface
A Look at the Past…
Travatan Classic Benefits:Clinical studies show travoprost lowers IOP better than
latanoprost1,2 for a full 24 hours3
Travoprost has demonstrated a flattening of the 24 hour IOP fluctuations
.
.
The Body of Evidence Suggests Travoprost Demonstrates Control That Lasts
Study Author Result
Netland PA et al. - Travoprost vs. latanoprost and timolol in OAG and OH
Indicate that the IOP-lowering efficacy of travoprost was enhanced over the day from 8am to 4pm and was significantly better compared with latanoprost at 4pm.
Maul E. A - Six-week double-masked study – travoprost vs. latanoprost followed by a six-week open-label treatment on travoprost
Statistically significantly greater IOP-lowering efficacy compared to latanoprost at 5PM, which was approximately 20 hours post dose.
Konstas A et al. - 24 Hour IOP efficacy and safety of latanoprost vs. travoprost in exfoliative glaucoma.
Significantly better IOP reduction than latanoprost at the end of the day. Over the 24-hour curve, Travatan also offered a statistically lower IOP than latanoprost.
Sit AJ, Weinreb RN et al - Sustained effect of travoprost on diurnal and nocturnal intraocular pressure
IOP lowering persisted after omission of one to two doses. Between 41 to 63 hours after the last dose, diurnal IOP reductions was attenuated, but noturnal IOP reduction sustained.
The Body of Evidence Suggests Travoprost Demonstrates Control That Lasts
Study Author Result
Dubiner HB et al. - Comparison of the diurnal OH efficacy of travoprost and latanoprost over a 44-hour period in patients with elevated intraocular pressure
Reductions in IOP that may be sustained up to 84 hours after dosing…. significantly lowers IOP vs. latanoprost at the end of the day and provides excellent diurnal IOP control throughout a 24-hour period
Garcia-Feijoo J et al. - IOP lowering efficacy of travoprost vs. latanoprost over a 24 hour period.
Longer lasting IOP-lowering efficacy over latanoprost throughout 24 hours. The same effect was maintained for up to 48 hours.
Konstas A et al. – 24 Hour intraocular pressure control obtained with evening - vs morning – dosed travoprost in POAG
Both morning and evening dosings of travoprost provide effective 24-hour IOP reduction.
Travatan Z
The Only First Line PGA that Provides Proven, Stable 24 Hour IOP Control without the Harmful Effects of BAK
on the Ocular Surface
A Novel ApproachTo Ocular Surface
Preservation
Ocular Surface Disease (OSD) or Dry Eye has a Significant Presence
in The Glaucoma Population
Glaucoma Patients and Ocular Surface Disease are At Greater Risk
• Elderly (Decreased Tear Secretion)
• Multiple Topical Ophthalmic medications
• Ocular Surface Disease Symptoms May Contribute to
Poor Patient Compliance
• May Need Surgery Down the Road
Leung, et al. Prevalence of Ocular Surface Disease in Glaucoma Patients. J Glaucoma 2008;17:350–355
Common Dry Eye Symptoms
•Painful or Sore Eyes
•Burning / Stinging
•Foreign Body Sensation
•Blurred or Poor Vision
•Tired Eyes
BAK Impact on Ocular Surface Health
•Decreases Epithelial Cell Integrity1
• Epithelial Barrier is Compromised
• Healing is Impaired
•Increases Conjunctival Inflammatory Cells1
•Loss of Goblet Cells1
•Reduction in Tear Function2
•Decreases Tear Film Break Up Time (TBUT)1
1. Whitson ,et al. Glaucoma Drugs and The Ocular Surface, Review of Ophthalmology, November 2006
2. Leung, et al. Prevalence of Ocular Surface Disease in Glaucoma Patients. J Glaucoma 2008;17:350–355
Lewis RA, Katz G, Weiss MJ et al. Travoprost 0.004% with and without benzalkonium chloride: a comparison of safety and efficacy. Journal of Glaucoma. 2007;16:98-103.
Travoprost 0.004% BAK-Free (n=322 PP)
Travoprost 0.004% (n=339 PP)
Mea
n IO
P (m
m H
g)
Efficacy: Travoprost 0.004% Solution With and Without BAK
Unique Ionic Buffer System
An Alternative Preservative
When TRAVATAN Z® Solution comes in contact with ions such as potassium and sodium in the eye,
the ionic buffer preserving system becomes inactive, providing a solution that is safe and gentle on the eye.
DuoTrav (Travoprost 0.004%/Timolol 0.5% Ophthalmic Solution
What Are The Benefits Of DuoTrav® Solution?DuoTrav allows for continued IOP success
1. Enhanced efficacy – two medications in a single bottle (travoprost + timolol)
2. Enhanced convenience to improve compliance
3. Excellent tolerability to lower IOP and preserve visual field
Managing Number of Bottles is a Challenge for Clinicians
60% 40%
1 Medication2 or More Medications
Kass MS, Heuer DK. Arch Ophthalmol. 2002;120:701-713
Percentage of treated patients at 60 months
0%
10%
20%
30%
40%
50%
60%
32%Compliant
(n=31)
Two Meds
49%Compliant
(n=41)
One Med
Multiple Medications are a Treatment Norm
Non-Compliance Increases With the Number of Bottles
Patel SC, Spaeth GL. Ophthalmic Surg. 1995;26(3):234-236
DuoTrav Summary
DuoTrav® Solution is an ideal ‘single bottle’ alternative for glaucoma
Once daily dosing with the advantages of increased compliance and less preservative exposure
Increased power and endurance of the travoprost ingredient
AZARGA®
(Brinzolamide / Timolol) Ophthalmic Suspension
AZARGA®
• Fixed combination of brinzolamide 1%/timolol 0.5%
• Indication: Decrease of intraocular pressure (IOP) in adult patients with open‑angle glaucoma or ocular hypertension for whom monotherapy provides insufficient IOP reduction and when the combination therapy is appropriate
• In clinical trials the mean IOP-lowering effect of AZARGA® Suspension was 7 to 9 mmHg 1,2
• Dosed twice daily
AZARGA® The Studies
– Efficacy•AZARGA® Suspension vs. AZOPT® Suspension vs. Timolol1
•AZARGA® Suspension vs. COSOPT*2 – Comfort
•AZARGA® Suspension vs. COSOPT*3 Comfort Study
•AZARGA® Suspension vs. COSOPT*4 Patient Preference Study
Why is comfort important?
The degree of ocular comfort can have an impact on patient
adherence to IOP-lowering medication regimens.1-4
1. Tsai JC, McClure CA, Ramos SE, et al. 2003. Compliance barriers in glaucoma: a systematic classification. J Glaucoma, 12:393-8.2. Day DG, Sharpe ED, Atkinson MJ, et al. 2006. The clinical validity of the treatment satisfaction survey for intraocular pressure in ocular hypertensive and glaucoma patients. Eye,
20:583-90.3. Konstas AG, Maskaleris G, Gratsonidis S, et al. 2000. Compliance and viewpoint of glaucoma patients in Greece. Eye, 14:752-6.4. Nordmann JP, Auzaneau N, Ricard S, et al. 2003. Vision related quality of life and topical glaucoma treatment side effects. Health Qual Life Outcomes, 1:75.
AZARGA® Suspension Clinical Study Summary• AZARGA® Suspension produces IOP-lowering
efficacy that is statistically superior to both AZOPT® Suspension and timolol 0.5%1
• AZARGA® Suspension lowered IOP by as much as 9.1 mmHg(35%)2
• AZARGA® Suspension produced clinically meaningful IOP reductions from baseline which were similar to COSOPT*2
AZARGA® Suspension Clinical Study Summary• AZARGA® Suspension is significantly more comfortable than
COSOPT*1-2
• A significantly higher percentage (49%), on AZARGA® Suspension experienced no burning or stinging compared to patients on COSOPT* (15%) (p=0.0004)1
• Of those patients (n=106) expressing a preference, AZARGA® Suspension was preferred by 79% of patients, while only 21% of patients preferred COSOPT*2
• The degree of ocular comfort can have an impact on patient adherence to IOP-lowering medication regimens.3-6
• Generally well tolerated
Spring Optometric Learning Series2012
Glaucoma types: stats In US Open angle glaucoma 80% Angle Closure Glaucoma 20%
50% from narrow angles40% from plateau10% from lens rise
Evaluating Angles Most important
anatomic landmark is the scleral spur
can be seen an the innermost point of the line separating the ciliary body and the sclera.
The trabecular meshwork is located directly anterior to this structure.
Narrow Angles
relative pupillary block is most common cause
aqueous pressure behind the iris plane forces the iris anteriorly giving it the typical convex appearance
Indentation gonioscopy will flatten iris and open angle
Definitive treatment is peripheral laser iridotomy
Relative Pupillary Block
Plateau IrisNot all angle-closure is caused by relative pupillary
blockPatients with plateau iris tend to be female, in their
30-50s, hyperopic, and often have a family history of angle-closure glaucoma
Slit lamp examination of patients with plateau iris usually shows normal anterior chamber depth with a flat or slightly convex iris surface.
On gonioscopy, the angle is extremely narrowed or closed, with a sharp drop-off of the peripheral iris.
Plateau IrisPlateau Iris is due to
anteriorly positioned ciliary processes, which hold the peripheral iris forward
The anteriorly placed ciliary body forces the peripheral iris into the angle.
In Plateau Iris, the angle remains occludable with a patent iridotomy
Plateau IrisWhen indentation gonioscopy is performed, the double-
hump sign is seen.The more peripheral hump is determined by the ciliary
body propping up the iris root, and the more central hump represents the central third of the iris resting over the anterior lens surface.
The space between the humps represents the space between the ciliary processes and the endpoint of contact of the iris to the anterior lens capsule.
More force often is needed to open the angle on indentation gonioscopy than on pupillary block angle closure.
Plateau IrisPlateau iris syndrome is characterized by persistent
angle occludability (spontaneous, in the dark, or after dilation) in an eye with a patent iridotomy
More commonly, the diagnosis of plateau iris configuration is made on routine examination.
Plateau iris syndrome usually is recognized in the postoperative period when the angle remains persistently narrow in an eye after iridotomy
ALP: Argon Laser Peripheral Iridoplastythe procedure of choice to effectively open an angle that
remains occluded after successful laser iridotomy The procedure consists of placing laser burns on the surface
of the peripheral iris to contract the iris stroma between the site of the burn and the angle
Peripheral location of long-duration, low-power, large spot size laser burns is essential for success
The result is iris stromal tissue contraction and compaction that physically widens the angle and prevents the apposition of the peripheral iris against the trabecular meshwork
ALPI is highly effective, and the effect is maintained for years
Lens Intumescence..Lens RiseA large, intumescent lens or forward lens movement
due to zonular laxity or dehiscence may cause mechanical crowding of the angle
Diagnosis is based on shallow AC, narrow angles, Patent PI, narrow AC and short AXL in hyperopic individuals
Treatement is clear lensectomyMore and more lensectomies are taking the place of
chronic glaucoma therapy for these patients
41
New Advances in the Treatment of Ocular
Inflammatory Diseases
Theodore Rabinovitch MD FRCSC
Assistant Professor of Ophthalmology
University of Toronto, Department of Ophthalmology
Head, Humber Eye Division
North Toronto Eye Care
TOPICAL OPHTHALMIC CORTICOSTEROID THERAPY
TREATMENT OF INFLAMMATION IN THE ANTERIOR SEGMENT OF THE EYE
43
A Focus on Loteprednol Etabonate
44
Topical Ophthalmic SteroidsKetone Steroids
Higher-risk Dexamethasone Betamethasone Prednisolone Difluprednate
Lower-risk Fluorometholone Medrysone Rimexolone
EsterLoteprednol
McGhee CN, Dean S, Danesh-Meyer H. Locally administered ocular corticosteroids: benefits and risks. Drug Saf. 2002;25:33-55.
DifluprednateDexamethasone
Topical Ophthalmic Corticosteroids With a Ketone at C-20
Hydrocortisone Rimexolone
Fluorometholone
National Library of Medicine, Current Medication Information. Available at: http://dailymed.nlm.nih.gov/dailymed/about.cfm. Accessed May 16, 2009. Durezol (difluprednate ophthalmic emulsion) 0.05% [package insert]. Tampa, Fla: Sirion Therapeutics, Inc.; 2008.
Prednisolone
Corticosteroids Inhibit Initiation Points of the Inflammatory Cascade
Corticosteroids
Mast Cell
Membrane Phospholipids
Phospholipase A2
Arachidonic Acid
Cyclo-oxygenase
Cyclic endoperoxides
Porstacyclin(PCI2)
Prostaglandins(PGF2, PGD2, PGE2)
Lipoxygenase
Hydroperoxides
Leukotrienes(LTC4, LTD4, LTE4, LTB4)
Thromboxane A2
(TXA2)
MembraneStabilization
TryptaseChymase
Heparin Histamine PAF
Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112.
Loteprednol Etabonate 1. Unique Ester Steroid
2. Highly lipophilic….penetrates well into eye
3. High Receptor binding affinity leading to increased site activity and reduced free floating metabolites
4. Rapidly esterified into inactive moities resulting in less residual active molecule
47
2. Lipophilicity of LE Facilitates Optimal Ocular Tissue Penetration
Howes JF. Pharmazie. 2000;55:178-183.Alberth M, et al. J Biopharm Sci. 1991;2:115-125.
3.Greater Binding Affinity
Receptor binding affinity is 4.3 times that of dexamethasone 3
Druzgala P, et al. J Steroid Biochem Molec Biol. 1991;38(2):149-154.
1. Druzgala P, et al. J Steroid Biochem Molec Biol. 1991;38(2):149-154.
4. RAPID ESTERIFICATION
• Safety benefits – Single step leads to an inactive metabolite and low risk of
adverse events1,2• Significantly reduced incidence of IOP increase1,2
• Lack of C-20 at Ketone formation which has been implicated in cataract formation3
1. Novack GD, et al. J Glaucoma. 1998;7:266-269. 2. Howes J, Novack GD. J Ocul Pharmacol Ther. 1998;14:153-158.3. Manabe S, et al. J Clin Invest. 1984;74:1803-1810.
O
O
OO
O
O
HO
Cl
LEloteprednol etabonate
O
O
OHO
O
O
HO
M-COOHLE, 17-acid metabolite
(1-cortienic acid etabonate)(inactive)
O
OH
OHO
HO
1-cortienic acid(inactive)
1. Bodor N. Pharmazie. 2001;56(suppl 1):S67-S74.2. Novack GD et al. J Glaucoma. 1998;7:266-269.3. Howes J, Novack GD. J Ocul Pharmacol Ther. 1998;14:153-158.
LOTEPREDNOOL ETABONATE
Site active Corticosteroid.. In the ocular tissues!
Designed to achieve efficacy with a low incidence of side effectsTherapeutic effect after application
Followed by single step deactivation
51
LOTEPREDNOL ETABONATE OPHTHALMIC SUSPENSION 0.5%
LOTEMAXTM
53
Post op inflammationWith newer technology less post op inflammationTrend was away from topical steroids and use of
NSAIDSRebound iritis common
Continuing need for effective and safe suppression of inflammation
Resolution of Anterior Chamber Inflammation (Sum of Celland Flare Scores) at Each Visit During the Treatment Period – Study 1
Visit Treatment Groupn at Risk
Resolved
P Valuen %
2 (days 2-6)LE 0.5%Placebo
109111
164
15%4%
0.003
3 (days 7-12)LE 0.5%Placebo
10292
4417
43%18%
<0.001
4 (days 13-20)LE 0.5%Placebo
9876
6930
70%39%
<0.001
Final visitLE 0.5%Placebo
109113
7033
64%29%
<0.001
1. Stewart R, et al. J Cataract Refract Surg. 1998;24:1480-1489.
LotemaxTM: Post-operative Inflammation Study 1 ResultsLotemaxTM: Post-operative Inflammation Study 1 Results
55
Summary: Loteprednol Etabonate 0.5%: An Advanced-Generation Corticosteroid
The only ester ophthalmic corticosteroid*Therapeutic effect after application followed by a
predictable, single-step deactivationLower propensity to induce IOP elevation and
cataract
*C-20 position of the basic steroid structure
Other uses for Lotemax
Anterior uveitisHZV keratouveitisEpiscleritis and mild
forms of scleritisThygesons SPKRosacea keratitis
Dry EyeGPCSACPost PKP/graft rejection
chronic usePost Trab
56
LOTEPREDNOL ETABONATE OPHTHALMIC SUSPENSION 0.2%
ALREX®
Ocular Surface Allergy: Seasonal Allergic Conjunctivitis
Seasonal Allergic Conjunctivitis (SAC)2 Typically occurs during spring and autumn Itching, burning, redness, eyelid swelling, conunctival
hyperemia, chemosis, mucoid or watery discharge Generally mild, non-vision-threatening; considerable
discomfort, morbidity, loss of productivity 1. Abelson MB, et al. Ocul Surf. 2003;1:127-149.2. Chambless SL. Curr Opin Allergy Clin Immunol. 2004;4:431-434.
• Allergic hypersensitivity conditions affecting the ocular surface1 – Most commonly affected: eyelids,
conjunctiva, cornea
Corticosteroids Inhibit Initiation Points of the Inflammatory Cascade
Corticosteroids
Mast Cell
Membrane Phospholipids
Phospholipase A2
Arachidonic Acid
Cyclo-oxygenase
Cyclic endoperoxides
Porstacyclin(PCI2)
Prostaglandins(PGF2, PGD2, PGE2)
Lipoxygenase
Hydroperoxides
Leukotrienes(LTC4, LTD4, LTE4, LTB4)
Thromboxane A2
(TXA2)
MembraneStabilization
TryptaseChymase
Heparin Histamine PAF
Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112.
Phospholipase A2
ActivityArachidonic Acid
LipoxygenasePathway
CyclooxygenasePathway
Mast CellMembrane
Phospholipids
HHT, MDA
Hydroperoxides(5-HPETE)
Leukotrienes(SRS-A, LTB4)
Prostaglandins(PGF2α, PGD2, PGE2)
Prostacyclin(PGI2)
Thromboxane A2
(TXA2)
HeparinHistamine PAFProteases (tryptase, chymase)
Early-PhaseMediators
Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112.
Corticosteroids Inhibit Multiple Early Points of the Inflammatory Cascade
Phospholipase A2
ActivityArachidonic Acid
LipoxygenasePathway
CyclooxygenasePathway
Mast CellMembrane
Phospholipids
HHT, MDA
Hydroperoxides(5-HPETE)
Leukotrienes(SRS-A, LTB4)
Prostaglandins(PGF2α, PGD2, PGE2)
Prostacyclin(PGI2)
Thromboxane A2
(TXA2)
HeparinHistamine PAFProteases (tryptase, chymase)
Antihistamines1
Work Here
Most Combination Antihistamines/MCS1
Work Here
Early-PhaseMediators
Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112.
Corticosteroids Inhibit Multiple Early Points of the Inflammatory Cascade
Mast Cell Stabilizers (MCS)1
Work Here
Phospholipase A2
ActivityArachidonic Acid
LipoxygenasePathway
CyclooxygenasePathway
Mast CellMembrane
Phospholipids
HHT, MDA
Hydroperoxides(5-HPETE)
Leukotrienes(SRS-A, LTB4)
Prostaglandins(PGF2α, PGD2, PGE2)
Prostacyclin(PGI2)
Thromboxane A2
(TXA2)
HeparinHistamine PAFProteases (tryptase, chymase)
Antihistamines1
Work Here
Most Combination Antihistamines/MCS1
Work Here
Late-PhaseMediators
Early-PhaseMediators
Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112.
Corticosteroids Inhibit Multiple Early Points of the Inflammatory Cascade
Mast Cell Stabilizers (MCS)1
Work Here
Phospholipase A2
ActivityArachidonic Acid
LipoxygenasePathway
CyclooxygenasePathway
Mast CellMembrane
Phospholipids
HHT, MDA
Hydroperoxides(5-HPETE)
Leukotrienes(SRS-A, LTB4)
Prostaglandins(PGF2α, PGD2, PGE2)
Prostacyclin(PGI2)
Thromboxane A2
(TXA2)
HeparinHistamine PAFProteases (tryptase, chymase)
NSAIDsWork Here
Antihistamines1
Work Here
Most Combination Antihistamines/MCS1
Work Here
Late-PhaseMediators
Early-PhaseMediators
Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112.
Corticosteroids Inhibit Multiple Early Points of the Inflammatory Cascade
Mast Cell Stabilizers (MCS)1
Work Here
Phospholipase A2
ActivityArachidonic Acid
LipoxygenasePathway
CyclooxygenasePathway
Mast CellMembrane
Phospholipids
HHT, MDA
Hydroperoxides(5-HPETE)
Leukotrienes(SRS-A, LTB4)
Prostaglandins(PGF2α, PGD2, PGE2)
Prostacyclin(PGI2)
Thromboxane A2
(TXA2)
HeparinHistamine PAFProteases (tryptase, chymase)
NSAIDsWork Here
Antihistamines1
Work Here
Most Combination Antihistamines/MCS1
Work Here
Late-PhaseMediators
Early-PhaseMediators
Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112.
Corticosteroids Inhibit Multiple Early Points of the Inflammatory Cascade
CorticosteroidsMast Cell Stabilizers (MCS)1
Work Here
65
Treatment of Seasonal Allergic ConjunctivitisSigns and symptoms of SAC occur after (a)
degranulation and release of preformed mediators from mast cells and (b) ensuing inflammatory cascade due to newly formed mediators
Because corticosteroids have the ability to ameliorate the immediate and secondary effects of mast cell mediators, corticosteroids may be the most effective choice for treating allergic conjunctivitis
Ono SJ, Abelson MB. Allergic conjunctivitis: update on pathophysiology and prospects for future treatment. J Allergy Clin Immunol. 2005;115:118-122.
2 randomized, double-masked, placebo-controlled, parallel-group multicenter studies1,2
268 patients with signs and symptoms of SAC treated bilaterally q.i.d. for 42 days
133 patients treated with loteprednol etabonate 135 patients treated with placebo
Results: Alrex was significantly more effective than placebo
Severity of bulbar conjunctival injection and itching over the first 2 weeks
Alrex® (loteprednol etabonate ophthalmic suspension 0.2%)
Clinical Efficacy and Safety in Seasonal Allergic Conjunctivitis
1. Dell SJ, et al. J Allergy Clin Immunol. 1998;102:251-255.
2. Shulman DG, et al. Ophthalmology. 1999;106:362-369.
Significant Resolution of Ocular Allergy Signs and Symptoms With Alrex®
1. Dell SJ, et al. J Allergy Clin Immunol. 1998;102:251-255.2. Alrex (loteprednol etabonate ophthalmic suspension 0.2%) Product Monograph. Bausch
& Lomb Inc.; Dec 22, 2008.
Signs and SymptomsSignificant Reduction
After Using Alrex P
Itching 1
Redness 1
Discomfort 1
Erythema 2
Foreign body sensation 2
Burning/stinging 2
Tearing 2
<0.001
<0.001
<0.001
<0.001
<0.005
<0.003
<0.011
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Alrex® Ophthalmic Suspension (loteprednol etabonate ophthalmic suspension 0.2%) is indicated for the temporary short-term relief of the signs and symptoms of Seasonal Allergic Conjunctivitis.
Alrex® Clinical Safety vs Placebo in Two 6-week Trials of SAC
SAC = Seasonal allergic conjunctivitis
Alrex (loteprednol etabonate ophthalmic suspension 0.2%) Product Monograph. Bausch & Lomb Inc.; Dec. 22, 2008
• Rate of IOP elevation similar to placebo
• 1 patient in each group experienced IOP elevation ≥10 mm Hg
– Alrex: n = 133
– Placebo: n = 135 0
1
2
3
4
Alrex Placebo
1% 1%In
cid
enc
e o
f IO
P E
leva
tio
n>
10 m
m H
g (
%)
Alrex Showed a Favourable Safety Profile With IOP Elevations Similar to Placebo
Accommodation Meets Asphericity in AO
• The Crystalens AO™ brings together Bausch + Lomb’s innovative accommodating lens technology and its proven aspheric lens design
• This accommodating aspheric IOL is designed to deliver premium vision at all distances without any intermediate vision compromise
• Since the Crystalens AO is aberration free, patients can enjoy best-potential vision quality with enhanced contrast sensitivity
2
Merging Innovation and Proven Design
4
Enhanced Vision Under All Conditions
Excellent Contrast Sensitivity• Patients should experience their best-potential postoperative
vision quality with enhanced contrast sensitivity
• This is particularly important in low-light or nighttime conditions
Uncompromised Intermediate Vision• The Crystalens AO is optimized for lifestyle vision
• As a result, objects at intermediate distances are as clear as objects that are near or far
4
Enhanced Vision Under All Conditions
Excellent Contrast Sensitivity• Patients should experience their best-potential postoperative
vision quality with enhanced contrast sensitivity
• This is particularly important in low-light or nighttime conditions
Uncompromised Intermediate Vision• The Crystalens AO is optimized for lifestyle vision
• As a result, objects at intermediate distances are as clear as objects that are near or far
CRYSTALENS AO™:ADVANCING OPTICAL QUALITY
• The Crystalens AO accommodating monofocal lens delivers 100% of available light rays at all distances• Patients can see near, intermediate and
distant objects with equal clarity
• The IOL, like the natural crystalline lens, can provide accommodation from distance to near vision by moving along the visual axis
• Both the natural lens and the Crystalens AO also arch, or change their radius of curvature, to increase their accommodation• Both move anteriorly and flex or arch to
increase their focusing power in the intermediate and near ranges
13
Designed to Accommodate for a Complete Range of Vision
Integrated Eye Care vs Co-managementintegrated eye care model: optometrists, ophthalmic
technicians, and ophthalmologists all work under the same roof to provide efficient and effective patient care
Co-management model: practices refer patients across boundaries and leave the optometrist as the primary care physician to handle a majority of eye care
integrated eye care is likened to a vertical integration in the same practice, and co-management comprises different practices where both jointly manage the patient
Advantages of Integrated Eye CareOptometrists have readily available access to specialty care
for their patientsThe patient already knows the practice and doesn't have to
travel further to go see a specialist, or worry about not being familiar with the practice
working in an integrated practice can be a great learning experience
Since everyone on staff has access to all the charts, there's an immediacy co-managed practices cannot offer.
ability to control the quality of care because everyone is under the same roof