What is Glaucoma?<br />Glaucoma is a series of conditions, characterized by a particular form of optic nerve damage that i...
Risk Factors for Glaucoma<br />Increased IOP<br />Age <br />Family History<br />Race <br />Diabetes<br />Previous Eye Inju...
Goals of Glaucoma Management<br />Treatment<br /><ul><li> Lower IOP
Control of IOP fluctuation for a full 24 hours
 Preserve Vision</li></ul>Quality of Life Considerations<br /><ul><li> Long Term Impact of Medications
 Balance of Efficacy and Side Effects</li></li></ul><li>Medical Treatments<br />Prostaglandin Analogues- work by increasin...
Medical Treatments<br />Beta Blockers<br /><ul><li>Most common is timolol- work by decreasing production of aqueous humor ...
Side effects may include low blood pressure, slow heart rate and general fatigue</li></li></ul><li>Medical Treatments<br /...
Alcon’s Promoted Glaucoma Products <br />
TRAVATAN ZThe Only First Line PGA that Provides Proven, Stable 24 Hour IOP Control without the Harmful Effects of BAK on t...
 A Look at the Past…<br />Travatan Classic Benefits:<br />Clinical studies show travoprost lowers IOP better than latanopr...
The Body of Evidence Suggests Travoprost Demonstrates Control That Lasts<br />
The Body of Evidence Suggests Travoprost Demonstrates Control That Lasts<br />
Travatan Z <br />The Only First Line PGA that Provides Proven, Stable 24 Hour IOP Control without the Harmful Effects of B...
A Novel ApproachTo Ocular SurfacePreservation<br />Ocular Surface Disease (OSD) or Dry Eye  has a Significant Presence in ...
Glaucoma Patients and Ocular Surface Disease are At Greater Risk<br /><ul><li>Elderly (Decreased Tear Secretion)
Multiple Topical Ophthalmic medications
Ocular Surface Disease Symptoms May Contribute to Poor Patient Compliance
May Need Surgery Down the Road</li></li></ul><li>Common Dry Eye Symptoms<br /><ul><li>Painful or Sore Eyes
Burning / Stinging
Foreign Body Sensation
Blurred or Poor Vision
Tired Eyes</li></ul>Leung, et al. Prevalence of Ocular Surface Disease in Glaucoma Patients. J Glaucoma 2008;17:350–355<br />
BAK Impact on Ocular Surface Health<br /><ul><li>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</li></ul>Whitson ,et al. Glaucoma Drugs and The Ocular Surface, Review of Ophtha...
Travoprost 0.004% BAK-Free (n=322 PP)<br />Travoprost 0.004%  (n=339 PP)<br />Mean IOP (mm Hg)<br />Efficacy: Travoprost 0...
TM<br />Polyols<br />Zinc<br />Borate<br />An Alternative Preservative<br />Unique Ionic Buffer System<br />
When TRAVATAN Z® Solution comes in contact with ions such as potassium and sodium in the eye, <br />the ionic buffer prese...
DuoTrav(Travoprost 0.004%/Timolol 0.5% Ophthalmic Solution<br />
What Are The Benefits Of DuoTrav® Solution?<br />DuoTravallows for continued IOP success <br />Enhanced efficacy – two med...
49%<br />Compliant<br />(n=41)<br />32%<br />Compliant<br />(n=31)<br />Two Meds<br />One Med<br />Managing Number of Bott...
DuoTrav Summary<br />DuoTrav® Solution is an ideal ‘single bottle’ alternative for glaucoma <br />Once daily dosing with t...
AZARGA® <br />(Brinzolamide / Timolol) Ophthalmic Suspension<br />
AZARGA® <br /><ul><li>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 w...
In clinical trials the mean IOP-lowering effect of AZARGA® Suspension was 7 to 9 mmHg 1,2
Dosed twice daily</li></li></ul><li>AZARGA®<br />The Studies<br /><ul><li> 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</li></li></ul><li>Why is comfort important?<br />The degree of ocular comfort can have an impact...
AZARGA® Suspension Clinical Study Summary<br /><ul><li>AZARGA® Suspension produces IOP-lowering efficacy that is statistic...
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</li></li></u...
A significantly higher percentage (49%), on AZARGA® Suspension experienced no burning or stinging compared to patients on ...
Of those patients (n=106) expressing a preference, AZARGA® Suspension was preferred by 79% of patients, while only 21% of ...
The degree of ocular comfort can have an impact on patient adherence to IOP-lowering medication regimens.3-6
Generally well tolerated</li></li></ul><li>Spring Optometric Learning Series<br />2012<br />
Glaucoma types: stats <br />In US <br />Open angle glaucoma 80%<br />	Angle Closure Glaucoma 20%<br />50% from narrow angl...
Evaluating Angles <br />Most important anatomic landmark is the scleral spur<br />can be seen an the innermost point of th...
Narrow Angles <br />relative pupillary blockis most common cause <br />aqueous pressure behind the iris plane forces the i...
Relative Pupillary Block <br />
Plateau Iris<br />Not all angle-closure is caused by relative pupillary block<br />Patients with plateau iris tend to be f...
Plateau Iris<br />Plateau Iris is due to anteriorly positioned ciliary processes, which hold the peripheral iris forward<b...
Plateau Iris<br />When indentation gonioscopy is performed, the double-hump sign is seen.<br />The more peripheral hump is...
Plateau Iris<br />Plateau iris syndrome is characterized by persistent angle occludability (spontaneous, in the dark, or a...
ALP: Argon Laser Peripheral Iridoplasty<br />the procedure of choice to effectively open an angle that remains occluded af...
Lens Intumescence..Lens Rise<br />A large, intumescent lens or forward lens movement due to zonular laxity or dehiscence m...
New Advances<br /> in the Treatment of Ocular Inflammatory Diseases<br />Theodore Rabinovitch MD FRCSC<br />Assistant Prof...
TREATMENT OF INFLAMMATION IN THE ANTERIOR SEGMENT OF THE EYE <br />TOPICAL OPHTHALMIC CORTICOSTEROID THERAPY<br />
 A Focus on Loteprednol Etabonate<br />43<br />
Topical Ophthalmic Steroids<br />Ester<br />Loteprednol<br />Ketone Steroids<br />Higher-risk<br />Dexamethasone <br />Bet...
Topical Ophthalmic Corticosteroids With a Ketone at C-20<br />Hydrocortisone <br />Prednisolone<br />Rimexolone<br />Diflu...
Corticosteroids Inhibit Initiation Points of the Inflammatory Cascade<br />Mast Cell<br />Membrane Phospholipids<br />Cort...
Loteprednol Etabonate <br />Unique Ester Steroid<br />Highly lipophilic….penetrates well into eye<br />High Receptor bindi...
2. Lipophilicity of LE Facilitates Optimal Ocular Tissue Penetration<br />Howes JF. Pharmazie. 2000;55:178-183.<br />Alber...
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  • Key Discussion PointsThe corticosteroids available for topical ophthalmic use are based on the hydrocortisone molecule Most of the available agents have a ketone group at location C-20, as does the original hydrocortisone molecule The newer agent difluprednate also has a ketone group at C-20 ReferencesNational 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.
  • Key Discussion PointsOcular allergy—specifically, seasonal allergic conjunctivitis—shares many features of underlying inflammation with other forms of ocular surface inflammatory disease1While it is typically not vision-threatening, SAC can cause considerable discomfort and, in some patients, morbidity and lost productivity2References Abelson MB, Smith L, Chapin M. Ocular allergic disease: mechanisms, disease sub-types, treatment. Ocul Surf. 2003;1(3):127-149. Chambless SL, Trocme S. Developments in ocular allergy. Curr Opin Allergy Clin Immunol. 2004;4(5):431-434.
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    1. 1. What is Glaucoma?<br />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. <br />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.” <br />
    2. 2. Risk Factors for Glaucoma<br />Increased IOP<br />Age <br />Family History<br />Race <br />Diabetes<br />Previous Eye Injury<br />
    3. 3. Goals of Glaucoma Management<br />Treatment<br /><ul><li> Lower IOP
    4. 4. Control of IOP fluctuation for a full 24 hours
    5. 5. Preserve Vision</li></ul>Quality of Life Considerations<br /><ul><li> Long Term Impact of Medications
    6. 6. Balance of Efficacy and Side Effects</li></li></ul><li>Medical Treatments<br />Prostaglandin Analogues- work by increasing flow of aqueous humor via the uveoscleral pathway out of the eye, thus lowering IOP<br />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<br />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<br />
    7. 7. Medical Treatments<br />Beta Blockers<br /><ul><li>Most common is timolol- work by decreasing production of aqueous humor which lowers IOP
    8. 8. Side effects may include low blood pressure, slow heart rate and general fatigue</li></li></ul><li>Medical Treatments<br />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<br /><ul><li>Side effects may include ocular allergies and drowsiness</li></ul>Carbonic Anhydrase Inhibitors- 2 or 3 times per day dosing- lower IOP by decreasing production of aqueous humor ie. Azopt, Trusopt<br />
    9. 9. Alcon’s Promoted Glaucoma Products <br />
    10. 10. TRAVATAN ZThe Only First Line PGA that Provides Proven, Stable 24 Hour IOP Control without the Harmful Effects of BAK on the Ocular Surface<br />
    11. 11. A Look at the Past…<br />Travatan Classic Benefits:<br />Clinical studies show travoprost lowers IOP better than latanoprost1,2 for a full 24 hours3<br />Travoprosthas demonstrated a flattening of the 24 hour IOP fluctuations<br />.<br />.<br />
    12. 12. The Body of Evidence Suggests Travoprost Demonstrates Control That Lasts<br />
    13. 13. The Body of Evidence Suggests Travoprost Demonstrates Control That Lasts<br />
    14. 14. Travatan Z <br />The Only First Line PGA that Provides Proven, Stable 24 Hour IOP Control without the Harmful Effects of BAK on the Ocular Surface <br />
    15. 15. A Novel ApproachTo Ocular SurfacePreservation<br />Ocular Surface Disease (OSD) or Dry Eye has a Significant Presence in The Glaucoma Population<br />
    16. 16. Glaucoma Patients and Ocular Surface Disease are At Greater Risk<br /><ul><li>Elderly (Decreased Tear Secretion)
    17. 17. Multiple Topical Ophthalmic medications
    18. 18. Ocular Surface Disease Symptoms May Contribute to Poor Patient Compliance
    19. 19. May Need Surgery Down the Road</li></li></ul><li>Common Dry Eye Symptoms<br /><ul><li>Painful or Sore Eyes
    20. 20. Burning / Stinging
    21. 21. Foreign Body Sensation
    22. 22. Blurred or Poor Vision
    23. 23. Tired Eyes</li></ul>Leung, et al. Prevalence of Ocular Surface Disease in Glaucoma Patients. J Glaucoma 2008;17:350–355<br />
    24. 24. BAK Impact on Ocular Surface Health<br /><ul><li>Decreases Epithelial Cell Integrity1
    25. 25. Epithelial Barrier is Compromised
    26. 26. Healing is Impaired
    27. 27. Increases Conjunctival Inflammatory Cells1
    28. 28. Loss of Goblet Cells1
    29. 29. Reduction in Tear Function2
    30. 30. Decreases Tear Film Break Up Time (TBUT)1</li></ul>Whitson ,et al. Glaucoma Drugs and The Ocular Surface, Review of Ophthalmology, November 2006<br />Leung, et al. Prevalence of Ocular Surface Disease in Glaucoma Patients. J Glaucoma 2008;17:350–355<br />
    31. 31. Travoprost 0.004% BAK-Free (n=322 PP)<br />Travoprost 0.004% (n=339 PP)<br />Mean IOP (mm Hg)<br />Efficacy: Travoprost 0.004% Solution With and Without BAK <br />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.<br />
    32. 32. TM<br />Polyols<br />Zinc<br />Borate<br />An Alternative Preservative<br />Unique Ionic Buffer System<br />
    33. 33. When TRAVATAN Z® Solution comes in contact with ions such as potassium and sodium in the eye, <br />the ionic buffer preserving system becomes inactive, providing a solution that is safe and gentle on the eye.<br />
    34. 34. DuoTrav(Travoprost 0.004%/Timolol 0.5% Ophthalmic Solution<br />
    35. 35. What Are The Benefits Of DuoTrav® Solution?<br />DuoTravallows for continued IOP success <br />Enhanced efficacy – two medications in a single bottle (travoprost + timolol)<br />Enhanced convenience to improve compliance<br />Excellent tolerability to lower IOP and preserve visual field<br />
    36. 36. 49%<br />Compliant<br />(n=41)<br />32%<br />Compliant<br />(n=31)<br />Two Meds<br />One Med<br />Managing Number of Bottles is a Challenge for Clinicians<br />Non-Compliance Increases With the Number of Bottles<br />Multiple Medications are a Treatment Norm<br />Percentage of treated patients at 60 months<br />Kass MS, Heuer DK. Arch Ophthalmol. <br />2002;120:701-713<br />Patel SC, Spaeth GL. Ophthalmic Surg. 1995;26(3):234-236<br />
    37. 37. DuoTrav Summary<br />DuoTrav® Solution is an ideal ‘single bottle’ alternative for glaucoma <br />Once daily dosing with the advantages of increased compliance and less preservative exposure<br />Increased power and endurance of the travoprost ingredient<br />
    38. 38. AZARGA® <br />(Brinzolamide / Timolol) Ophthalmic Suspension<br />
    39. 39. AZARGA® <br /><ul><li>Fixed combination of brinzolamide 1%/timolol 0.5%
    40. 40. 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
    41. 41. In clinical trials the mean IOP-lowering effect of AZARGA® Suspension was 7 to 9 mmHg 1,2
    42. 42. Dosed twice daily</li></li></ul><li>AZARGA®<br />The Studies<br /><ul><li> Efficacy
    43. 43. AZARGA® Suspension vs. AZOPT® Suspension vs. Timolol1
    44. 44. AZARGA® Suspension vs. COSOPT*2
    45. 45. Comfort
    46. 46. AZARGA® Suspension vs. COSOPT*3
    47. 47. Comfort Study
    48. 48. AZARGA® Suspension vs. COSOPT*4
    49. 49. Patient Preference Study</li></li></ul><li>Why is comfort important?<br />The degree of ocular comfort can have an impact on patient adherence to IOP-lowering medication regimens.1-4<br />Tsai JC, McClure CA, Ramos SE, et al. 2003. Compliance barriers in glaucoma: a systematic classification. J Glaucoma, 12:393-8.<br />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.<br />Konstas AG, Maskaleris G, Gratsonidis S, et al. 2000. Compliance and viewpoint of glaucoma patients in Greece. Eye, 14:752-6.<br />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.<br />
    50. 50. AZARGA® Suspension Clinical Study Summary<br /><ul><li>AZARGA® Suspension produces IOP-lowering efficacy that is statistically superior to both AZOPT® Suspension and timolol 0.5%1
    51. 51. AZARGA® Suspension lowered IOP by as much as 9.1 mmHg(35%)2
    52. 52. AZARGA® Suspension produced clinically meaningful IOP reductions from baseline which were similar to COSOPT*2</li></li></ul><li>AZARGA® Suspension Clinical Study Summary<br /><ul><li>AZARGA® Suspension is significantly more comfortable than COSOPT*1-2
    53. 53. A significantly higher percentage (49%), on AZARGA® Suspension experienced no burning or stinging compared to patients on COSOPT* (15%) (p=0.0004)1
    54. 54. Of those patients (n=106) expressing a preference, AZARGA® Suspension was preferred by 79% of patients, while only 21% of patients preferred COSOPT*2
    55. 55. The degree of ocular comfort can have an impact on patient adherence to IOP-lowering medication regimens.3-6
    56. 56. Generally well tolerated</li></li></ul><li>Spring Optometric Learning Series<br />2012<br />
    57. 57. Glaucoma types: stats <br />In US <br />Open angle glaucoma 80%<br /> Angle Closure Glaucoma 20%<br />50% from narrow angles<br />40% from plateau<br />10% from lens rise<br />
    58. 58. Evaluating Angles <br />Most important anatomic landmark is the scleral spur<br />can be seen an the innermost point of the line separating the ciliary body and the sclera.<br />The trabecular meshwork is located directly anterior to this structure. <br />
    59. 59. Narrow Angles <br />relative pupillary blockis most common cause <br />aqueous pressure behind the iris plane forces the iris anteriorlygiving it the typical convex appearance<br />Indentation gonioscopy will flatten iris and open angle<br />Definitive treatment is peripheral laser iridotomy<br />
    60. 60. Relative Pupillary Block <br />
    61. 61. Plateau Iris<br />Not all angle-closure is caused by relative pupillary block<br />Patients with plateau iris tend to be female, in their 30-50s, hyperopic, and often have a family history of angle-closure glaucoma<br />Slit lamp examination of patients with plateau iris usually shows normal anterior chamber depth with a flat or slightly convex iris surface. <br />On gonioscopy, the angle is extremely narrowed or closed, with a sharp drop-off of the peripheral iris.<br />
    62. 62. Plateau Iris<br />Plateau Iris is due to anteriorly positioned ciliary processes, which hold the peripheral iris forward<br />The anteriorly placed ciliary body forces the peripheral iris into the angle.<br />In Plateau Iris, the angle remains occludable with a patent iridotomy<br />
    63. 63. Plateau Iris<br />When indentation gonioscopy is performed, the double-hump sign is seen.<br />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.<br />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.<br />More force often is needed to open the angle on indentation gonioscopy than on pupillary block angle closure.<br />
    64. 64. Plateau Iris<br />Plateau iris syndrome is characterized by persistent angle occludability (spontaneous, in the dark, or after dilation) in an eye with a patent iridotomy<br />More commonly, the diagnosis of plateau iris configuration is made on routine examination.<br />Plateau iris syndrome usually is recognized in the postoperative period when the angle remains persistently narrow in an eye after iridotomy<br />
    65. 65. ALP: Argon Laser Peripheral Iridoplasty<br />the procedure of choice to effectively open an angle that remains occluded after successful laser iridotomy<br />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<br />Peripheral location of long-duration, low-power, large spot size laser burns is essential for success<br />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<br />ALPI is highly effective, and the effect is maintained for years<br />
    66. 66. Lens Intumescence..Lens Rise<br />A large, intumescent lens or forward lens movement due to zonular laxity or dehiscence may cause mechanical crowding of the angle<br />Diagnosis is based on shallow AC, narrow angles, Patent PI, narrow AC and short AXL in hyperopic individuals<br />Treatement is clear lensectomy<br />More and more lensectomies are taking the place of chronic glaucoma therapy for these patients<br />
    67. 67. New Advances<br /> in the Treatment of Ocular Inflammatory Diseases<br />Theodore Rabinovitch MD FRCSC<br />Assistant Professor of Ophthalmology<br />University of Toronto, Department of Ophthalmology<br />Head, Humber Eye Division<br />North Toronto Eye Care<br />41<br />
    68. 68. TREATMENT OF INFLAMMATION IN THE ANTERIOR SEGMENT OF THE EYE <br />TOPICAL OPHTHALMIC CORTICOSTEROID THERAPY<br />
    69. 69. A Focus on Loteprednol Etabonate<br />43<br />
    70. 70. Topical Ophthalmic Steroids<br />Ester<br />Loteprednol<br />Ketone Steroids<br />Higher-risk<br />Dexamethasone <br />Betamethasone <br />Prednisolone<br />Difluprednate<br />Lower-risk<br />Fluorometholone<br />Medrysone<br />Rimexolone<br />44<br />McGhee CN, Dean S, Danesh-Meyer H. Locally administered ocular corticosteroids: benefits and risks. Drug Saf. 2002;25:33-55.<br />
    71. 71. Topical Ophthalmic Corticosteroids With a Ketone at C-20<br />Hydrocortisone <br />Prednisolone<br />Rimexolone<br />Difluprednate<br />Fluorometholone<br />Dexamethasone<br />National Library of Medicine, Current Medication Information. Available at: http://dailymed.nlm.nih.gov/dailymed/about.cfm. Accessed May 16, 2009. <br />Durezol (difluprednate ophthalmic emulsion) 0.05% [package insert]. Tampa, Fla: Sirion Therapeutics, Inc.; 2008.<br />
    72. 72. Corticosteroids Inhibit Initiation Points of the Inflammatory Cascade<br />Mast Cell<br />Membrane Phospholipids<br />Corticosteroids<br />Membrane<br />Stabilization<br />Phospholipase A2<br />Arachidonic Acid<br />Tryptase<br />Chymase<br />Heparin<br />Histamine<br />PAF<br />Lipoxygenase<br />Cyclo-oxygenase<br />Hydroperoxides<br />Cyclic endoperoxides<br />Porstacyclin<br />(PCI2)<br />Thromboxane A2<br />(TXA2)<br />Leukotrienes<br />(LTC4, LTD4, LTE4, LTB4)<br />Prostaglandins<br />(PGF2, PGD2, PGE2)<br />Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112.<br />
    73. 73. Loteprednol Etabonate <br />Unique Ester Steroid<br />Highly lipophilic….penetrates well into eye<br />High Receptor binding affinity leading to increased site activity and reduced free floating metabolites<br />Rapidly esterified into inactive moities resulting in less residual active molecule<br />47<br />
    74. 74. 2. Lipophilicity of LE Facilitates Optimal Ocular Tissue Penetration<br />Howes JF. Pharmazie. 2000;55:178-183.<br />Alberth M, et al. J Biopharm Sci. 1991;2:115-125.<br />
    75. 75. 3.Greater Binding Affinity<br />Receptor binding affinity is 4.3 times that of dexamethasone 3<br />Druzgala P, et al. J Steroid Biochem Molec Biol.1991;38(2):149-154. <br />Druzgala P, et al. J Steroid Biochem Molec Biol. 1991;38(2):149-154.<br />
    76. 76. 4. RAPID ESTERIFICATION<br /><ul><li>Safety benefits
    77. 77. Single step leads to an inactive metabolite and low risk of adverse events1,2
    78. 78. Significantly reduced incidence of IOP increase1,2
    79. 79. Lack of C-20 at Ketone formation which has been implicated in cataract formation3</li></ul>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.<br />Novack GD, et al. J Glaucoma. 1998;7:266-269. <br />Howes J, Novack GD. J Ocul Pharmacol Ther. 1998;14:153-158.<br />Manabe S, et al. J Clin Invest. 1984;74:1803-1810.<br />
    80. 80. LOTEPREDNOOL ETABONATE<br />Site active Corticosteroid.. In the ocular tissues!<br />Designed to achieve efficacy with a low incidence of side effects<br />Therapeutic effect after application<br />Followed by single step deactivation<br />51<br />
    81. 81. LOTEMAXTM<br />LOTEPREDNOL ETABONATE OPHTHALMIC SUSPENSION 0.5%<br />
    82. 82. Post op inflammation <br />With newer technology less post op inflammation<br />Trend was away from topical steroids and use of NSAIDS<br />Rebound iritis common<br />Continuing need for effective and safe suppression of inflammation<br />53<br />
    83. 83. LotemaxTM: Post-operative Inflammation Study 1 Results<br />1. Stewart R, et al. J Cataract Refract Surg. 1998;24:1480-1489.<br />
    84. 84. Summary: Loteprednol Etabonate 0.5%: An Advanced-Generation Corticosteroid<br />The only ester ophthalmic corticosteroid*<br />Therapeutic effect after application followed by a predictable, single-step deactivation<br />Lower propensity to induce IOP elevation and cataract<br />*C-20 position of the basic steroid structure<br />55<br />
    85. 85. Other uses for Lotemax <br />Anterior uveitis<br />HZV keratouveitis<br />Episcleritis and mild forms of scleritis<br />Thygesons SPK<br />Rosacea keratitis<br />Dry Eye<br />GPC<br />SAC<br />Post PKP/graft rejection chronic use<br />Post Trab<br />56<br />
    86. 86. ALREX®<br />LOTEPREDNOL ETABONATE OPHTHALMIC SUSPENSION 0.2%<br />
    87. 87. Ocular Surface Allergy: Seasonal Allergic Conjunctivitis <br /><ul><li>Allergic hypersensitivity conditions affecting the ocular surface1
    88. 88. Most commonly affected: eyelids, conjunctiva, cornea </li></ul>Seasonal Allergic Conjunctivitis (SAC)2<br />Typically occurs during spring and autumn <br />Itching, burning, redness, eyelid swelling, conunctival hyperemia, chemosis, mucoid or watery discharge <br />Generally mild, non-vision-threatening; considerable discomfort, morbidity, loss of productivity <br />Abelson MB, et al. Ocul Surf. 2003;1:127-149.<br />Chambless SL. Curr Opin Allergy Clin Immunol. 2004;4:431-434.<br />
    89. 89. Corticosteroids Inhibit Initiation Points of the Inflammatory Cascade<br />Mast Cell<br />Membrane Phospholipids<br />Corticosteroids<br />Membrane<br />Stabilization<br />Phospholipase A2<br />Arachidonic Acid<br />Tryptase<br />Chymase<br />Heparin<br />Histamine<br />PAF<br />Lipoxygenase<br />Cyclo-oxygenase<br />Hydroperoxides<br />Cyclic endoperoxides<br />Porstacyclin<br />(PCI2)<br />Thromboxane A2<br />(TXA2)<br />Leukotrienes<br />(LTC4, LTD4, LTE4, LTB4)<br />Prostaglandins<br />(PGF2, PGD2, PGE2)<br />Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112.<br />
    90. 90. Corticosteroids Inhibit Multiple Early Points of the Inflammatory Cascade<br />Mast CellMembrane Phospholipids<br />Early-Phase<br />Mediators<br />Phospholipase A2<br />Activity<br />Arachidonic Acid<br />Cyclooxygenase<br />Pathway<br />Heparin<br />Histamine<br />PAF<br />Proteases (tryptase, chymase)<br />Lipoxygenase<br />Pathway<br />Hydroperoxides<br />(5-HPETE)<br />HHT, MDA<br />Prostaglandins(PGF2α, PGD2, PGE2)<br />Prostacyclin(PGI2)<br />Thromboxane A2(TXA2)<br />Leukotrienes(SRS-A, LTB4)<br />Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112. <br />
    91. 91. Corticosteroids Inhibit Multiple Early Points of the Inflammatory Cascade<br />Mast CellMembrane Phospholipids<br />Early-Phase<br />Mediators<br />Mast Cell Stabilizers (MCS)1<br /> Work Here<br />Phospholipase A2<br />Activity<br />Most Combination Antihistamines/MCS1<br /> Work Here<br />Arachidonic Acid<br />Cyclooxygenase<br />Pathway<br />Heparin<br />Histamine<br />PAF<br />Proteases (tryptase, chymase)<br />Lipoxygenase<br />Pathway<br />Hydroperoxides<br />(5-HPETE)<br />Antihistamines1<br /> Work <br />Here<br />HHT, MDA<br />Prostaglandins(PGF2α, PGD2, PGE2)<br />Prostacyclin(PGI2)<br />Thromboxane A2(TXA2)<br />Leukotrienes(SRS-A, LTB4)<br />Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112. <br />
    92. 92. Corticosteroids Inhibit Multiple Early Points of the Inflammatory Cascade<br />Mast CellMembrane Phospholipids<br />Late-Phase<br />Mediators<br />Early-Phase<br />Mediators<br />Mast Cell Stabilizers (MCS)1<br /> Work Here<br />Phospholipase A2<br />Activity<br />Most Combination Antihistamines/MCS1<br /> Work Here<br />Arachidonic Acid<br />Cyclooxygenase<br />Pathway<br />Heparin<br />Histamine<br />PAF<br />Proteases (tryptase, chymase)<br />Lipoxygenase<br />Pathway<br />Hydroperoxides<br />(5-HPETE)<br />Antihistamines1<br /> Work <br />Here<br />HHT, MDA<br />Prostaglandins(PGF2α, PGD2, PGE2)<br />Prostacyclin(PGI2)<br />Thromboxane A2(TXA2)<br />Leukotrienes(SRS-A, LTB4)<br />Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112. <br />
    93. 93. Corticosteroids Inhibit Multiple Early Points of the Inflammatory Cascade<br />Mast CellMembrane Phospholipids<br />Late-Phase<br />Mediators<br />Early-Phase<br />Mediators<br />Mast Cell Stabilizers (MCS)1<br /> Work Here<br />Phospholipase A2<br />Activity<br />Most Combination Antihistamines/MCS1<br /> Work Here<br />Arachidonic Acid<br />Cyclooxygenase<br />Pathway<br />Heparin<br />Histamine<br />PAF<br />Proteases (tryptase, chymase)<br />Lipoxygenase<br />Pathway<br />NSAIDs<br />Work <br />Here<br />Hydroperoxides<br />(5-HPETE)<br />Antihistamines1<br /> Work <br />Here<br />HHT, MDA<br />Prostaglandins(PGF2α, PGD2, PGE2)<br />Prostacyclin(PGI2)<br />Thromboxane A2(TXA2)<br />Leukotrienes(SRS-A, LTB4)<br />Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112. <br />
    94. 94. Corticosteroids Inhibit Multiple Early Points of the Inflammatory Cascade<br />Mast CellMembrane Phospholipids<br />Late-Phase<br />Mediators<br />Early-Phase<br />Mediators<br />Corticosteroids<br />Mast Cell Stabilizers (MCS)1<br /> Work Here<br />Phospholipase A2<br />Activity<br />Most Combination Antihistamines/MCS1<br /> Work Here<br />Arachidonic Acid<br />Cyclooxygenase<br />Pathway<br />Heparin<br />Histamine<br />PAF<br />Proteases (tryptase, chymase)<br />Lipoxygenase<br />Pathway<br />NSAIDs<br />Work <br />Here<br />Hydroperoxides<br />(5-HPETE)<br />Antihistamines1<br /> Work <br />Here<br />HHT, MDA<br />Prostaglandins(PGF2α, PGD2, PGE2)<br />Prostacyclin(PGI2)<br />Thromboxane A2(TXA2)<br />Leukotrienes(SRS-A, LTB4)<br />Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112. <br />
    95. 95. 65<br />Treatment of Seasonal Allergic Conjunctivitis<br />Signs 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<br />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<br />Ono SJ, Abelson MB. Allergic conjunctivitis: update on pathophysiology and prospects for future treatment. J Allergy Clin Immunol. 2005;115:118-122.<br />
    96. 96. Alrex® (loteprednol etabonate ophthalmic suspension 0.2%)Clinical Efficacy and Safety in Seasonal Allergic Conjunctivitis <br />2 randomized, double-masked, placebo-controlled, parallel-group multicenter studies1,2<br />268 patients with signs and symptoms of SAC treated bilaterally q.i.d. for 42 days <br />133 patients treated with loteprednol etabonate <br />135 patients treated with placebo<br />Results: Alrex was significantly more effective than placebo <br />Severity of bulbar conjunctival injection and itching over the first 2 weeks<br />Dell SJ, et al. J Allergy Clin Immunol. 1998;102:251-255. <br />Shulman DG, et al. Ophthalmology. 1999;106:362-369. <br />
    97. 97. Significant Resolution of Ocular Allergy Signs and Symptoms With Alrex® <br />Significant ReductionAfter Using Alrex<br />Signs and Symptoms<br />P<br />Itching1<br />Redness1<br />Discomfort1<br />Erythema2<br />Foreign body sensation2<br />Burning/stinging2<br />Tearing2<br /><0.001<br /><0.001<br /><0.001<br /><0.001<br /><0.005<br /><0.003<br /><0.011<br />Yes<br />Yes<br />Yes<br />Yes<br />Yes<br />Yes<br />Yes<br />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.<br />1. Dell SJ, et al. J Allergy Clin Immunol. 1998;102:251-255.<br />2. Alrex (loteprednol etabonate ophthalmic suspension 0.2%) Product Monograph. Bausch & Lomb Inc.; Dec 22, 2008. <br />
    98. 98. Alrex Showed a Favourable Safety Profile With IOP Elevations Similar to Placebo<br />Incidence of IOP Elevation<br />>10 mm Hg (%)<br />1%<br />1%<br />Alrex® Clinical Safety vs Placebo <br />in Two 6-week Trials of SAC<br /><ul><li>Rate of IOP elevation similar to placebo
    99. 99. 1 patient in each group experienced IOP elevation ≥10 mm Hg
    100. 100. Alrex: n = 133
    101. 101. Placebo: n = 135</li></ul>SAC = Seasonal allergic conjunctivitis<br />Alrex (loteprednol etabonate ophthalmic suspension 0.2%) Product Monograph. Bausch & Lomb Inc.; Dec. 22, 2008<br />
    102. 102. Accommodation Meets Asphericity in AO<br /> Merging Innovation and Proven Design<br /><ul><li>The Crystalens AO™ brings together Bausch + Lomb’s innovative accommodating lens technology and its proven aspheric lens design
    103. 103. This accommodating aspheric IOL is designed to deliver premium vision at all distances without any intermediate vision compromise
    104. 104. Since the Crystalens AO is aberration free, patients can enjoy best-potential vision quality with enhanced contrast sensitivity </li></ul> 2<br />
    105. 105. Enhanced Vision Under All Conditions<br />Excellent Contrast Sensitivity<br /><ul><li>Patients should experience their best-potential postoperative vision quality with enhanced contrast sensitivity
    106. 106. This is particularly important in low-light or nighttime conditions </li></ul>Uncompromised Intermediate Vision<br /><ul><li>The Crystalens AO is optimized for lifestyle vision
    107. 107. As a result, objects at intermediate distances are as clear as objects that are near or far</li></ul> 4<br />
    108. 108. Enhanced Vision Under All Conditions<br />Excellent Contrast Sensitivity<br /><ul><li>Patients should experience their best-potential postoperative vision quality with enhanced contrast sensitivity
    109. 109. This is particularly important in low-light or nighttime conditions </li></ul>Uncompromised Intermediate Vision<br /><ul><li>The Crystalens AO is optimized for lifestyle vision
    110. 110. As a result, objects at intermediate distances are as clear as objects that are near or far</li></ul> 4<br />
    111. 111. CRYSTALENS AO™:<br />ADVANCING OPTICAL QUALITY<br />Designed to Accommodate for a Complete Range of Vision<br /><ul><li>The Crystalens AO accommodating monofocal lens delivers 100% of available light rays at all distances
    112. 112. Patients can see near, intermediate and distant objects with equal clarity
    113. 113. The IOL, like the natural crystalline lens, can provide accommodation from distance to near vision by moving along the visual axis
    114. 114. Both the natural lens and the Crystalens AO also arch, or change their radius of curvature, to increase their accommodation
    115. 115. Both move anteriorly and flex or arch to increase their focusing power in the intermediate and near ranges</li></ul> 13<br />
    116. 116. Integrated Eye Care vs Co-management<br />integrated eye care model: optometrists, ophthalmic technicians, and ophthalmologists all work under the same roof to provide efficient and effective patient care<br />Co-management model: practices refer patients across boundaries and leave the optometrist as the primary care physician to handle a majority of eye care <br />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<br />
    117. 117. Advantages of Integrated Eye Care<br />Optometrists have readily available access to specialty care for their patients<br />The 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<br />working in an integrated practice can be a great learning experience <br />Since everyone on staff has access to all the charts, there's an immediacy co-managed practices cannot offer.<br />ability to control the quality of care because everyone is under the same roof<br />
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