Inflammation Panorama - New York Eye and Ear Infirmary

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Inflammation Panorama - New York Eye and Ear Infirmary

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CME Monograph

New Evidence and Insights on the

Inflammation

Panorama

From Ocular Surface Disorders to Surgery

Highlights from a Continuing Medical Education Symposium held

during the American Academy of Ophthalmology 2012 Meeting*

ORIGINAL RELEASE: March 15, 2013

LAST REVIEW: February 22, 2013

EXPIRATION: March 31, 2014

Jointly sponsored by The New York Eye and Ear Infirmary

and MedEdicus LLC

This continuing medical education activity is supported through an

unrestricted educational grant from Bausch + Lomb Incorporated.

Distributed with

*This CME symposium was not affiliated with the official program of the AAO/APAO Joint Meeting.


Faculty

Richard L. Lindstrom, MD

(Program Chair and Moderator)

Founder and Attending Surgeon

Minnesota Eye Consultants, PA

Bloomington, Minnesota

Adjunct Professor Emeritus

Department of Ophthalmology and Visual Neurosciences

University of Minnesota

Minneapolis, Minnesota

Eric D. Donnenfeld, MD

Ophthalmic Consultants of Long Island

Rockville Centre, New York

Clinical Professor of Ophthalmology

New York University

New York, New York

Trustee

Geisel School of Medicine at Dartmouth

Hanover, New Hampshire

Stephen S. Lane, MD

Medical Director

Associated Eye Care

Stillwater, Minnesota

Adjunct Professor

University of Minnesota

St. Paul, Minnesota

Terrence P. O’Brien, MD

Professor of Ophthalmology

Charlotte Breyer Rodgers Distinguished Chair in Ophthalmology

Director, Refractive Surgery Service

Bascom Palmer Eye Institute

Palm Beach Gardens, Florida

Learning Method and Medium

This educational activity consists of a supplement and ten (10) study questions.

The participant should, in order, read the learning objectives contained at the

beginning of this supplement, read the supplement, answer all questions in

the post test, and complete the Activity Evaluation/Credit Request form. To

receive credit for this activity, please follow the instructions provided on the

post test and Activity Evaluation/Credit Request form. This educational

activity should take a maximum of 1.5 hours to complete.

Content Source

This continuing medical education (CME) activity captures content from a

CME symposium held on November 10, 2012, in Chicago, Illinois.

Target Audience

This activity intends to educate ophthalmologists.

Learning Objectives

Upon completion of this activity, participants will be better able to:

• Summarize key efficacy and safety attributes of new anti-inflammatory

agents

• Demonstrate best-practice regimens for reducing inflammation risk for

patients undergoing cataract, refractive, or glaucoma procedures

• Demonstrate best-practice regimens for the management of inflammation in

patients with inflammatory conditions such as dry eye, blepharitis, allergy,

and/or anterior uveitis

• List anti-inflammatory therapies in development

Accreditation Statement

This activity has been planned and implemented in accordance with the

Essential Areas and Policies of the Accreditation Council for Continuing

Medical Education (ACCME) through the joint sponsorship of The New York

Eye and Ear Infirmary and MedEdicus LLC. The New York Eye and Ear

Infirmary is accredited by the ACCME to provide continuing medical

education for physicians.

AMA Credit Designation Statement

The New York Eye and Ear Infirmary designates this enduring material for

a maximum of 1.5 AMA PRA Category 1 Credits. Physicians should claim

only the credit commensurate with the extent of their participation in

the activity.

Grantor Statement

This continuing medical education activity is supported through an

unrestricted educational grant from Bausch + Lomb Incorporated.

Disclosure Policy Statement

It is the policy of The New York Eye and Ear Infirmary that the faculty and

anyone in a position to control activity content disclose any real or apparent

conflicts of interest relating to the topics of this educational activity, and also

disclose discussions of unlabeled/unapproved uses of drugs or devices during

their presentation(s). The New York Eye and Ear Infirmary has established

policies in place that will identify and resolve all conflicts of interest prior to

this educational activity. Full disclosure of faculty/planners and their

commercial relationships, if any, follows.

Faculty Disclosures

Eric D. Donnenfeld, MD, had a financial agreement or affiliation during the

past year with the following commercial interests in the form of Consultant/

Advisory Board: Abbott Medical Optics; AcuFocus, Inc; Alcon, Inc; Allergan, Inc;

AqueSys, Inc; Bausch + Lomb Incorporated; Better Vision Network; Cataract

and Refractive Surgery Today; ELENZA, Inc; Glaukos Corporation;

LacriPen/LacriSciences LLP; LenSx Lasers/Alcon Inc; Merck & Co, Inc;

NovaBay Pharmaceuticals; Odyssey Pharmaceuticals; Pfizer Inc; PRN Physician

Recommended Nutriceuticals; QLT Inc; SARcode Bioscience, Inc; TearLab

Corporation; TLC Laser Eye Centers; TrueVision; and WaveTec Vision.

Richard L. Lindstrom, MD, had a financial agreement or affiliation during

the past year with the following commercial interests in the form of

Consultant/Advisory Board: Abbott Medical Optics; AcuFocus, Inc; Adoptics;

Advanced Refractive Technologies; Alcon, Inc; AqueSys, Inc; Bausch + Lomb

Incorporated; Bio Syntrx, Inc; Calhoun Vision, Inc; Clarity Ophthalmics;

Clear-Sight Inc; CoDa Therapeutics, Inc; EBV Partners; EGG Basket

Ventures; ELENZA, Inc; Encore; e-Vision Photography, Inc; Eyemaginations,

Inc; Foresight Venture Fund #3; ForSight Labs; Glaukos Corporation; High

Performance Optics; Hoya Surgical Optics; Improve Your Vision, LLC; ISTA

Pharmaceuticals, Inc; LensAR; LenSx Lasers, Inc; LifeGuard Health LLC;

Lumineyes, Inc; Minnesota Eye Consultants, PA; NuLens Ltd; Ocular Optics

Co, Ltd; Ocular Surgery News/Slack Inc; Ocular Therapeutix, Inc; OmegaEye

Health; Omeros Corporation; PixelOptics, Inc; Quest; Refractec, Inc;

RevitalVision, LLC; Schroder Life Science Venture Fund; Seros Medical, LLC;

Sightpath Medical; Strategic Pharmaceutical Advisors; Surgijet/Visijet; 3D

Vision Systems LLC; TLC Vision Corporation; TearLab Corporation; Tracey

Technologies; Transcend Medical, Inc; TrueVision Systems, Inc; Versant

Corporation; and Vision Solutions Technologies; Ownership Interest: Abbott

Medical Optics; AcuFocus, Inc; AqueSys, Inc; Bausch + Lomb Incorporated;

Bio Syntrx, Inc; Calhoun Vision, Inc; Clarity Ophthalmics; Clear-Sight Inc;

CoDa Therapeutics, Inc; Confluence Acquisition Partners I, Inc; CurveRight

LLC; Cxl Ophthalmics, LLC; EBV Partners; EGG Basket Ventures; Encore;

e-Vision Photography, Inc; Evision Medical Laser; Eyemaginations, Inc;

Foresight Venture Fund #3; FzioMed; Glaukos Corporation; Healthcare

Transaction Services; HEAVEN Fund; High Performance Optics; Improve

Your Vision, LLC; LensAR; LenSx Lasers, Inc; LifeGuard Health LLC;

Minnesota Eye Consultants, PA; Nisco; NuLens Ltd; Ocular Optics Co, Ltd;

Ocular Therapeutix, Inc; OmegaEye Health; OnPoint Medical Diagnostics,

Inc; One Focus Ventures; PixelOptics, Inc; Quest; Rainwater Healthcare, Inc;

Refractec, Inc; ReVision Optics, Inc; RevitalVision, LLC; Sarbox NP, Inc;

SARcode Bioscience, Inc; Schroder Life Science Venture Fund; Sightpath

Medical; SolBeam, Inc; Surgijet/Visijet; 3D Vision Systems LLC; TLC Vision

Corporation; TearLab Corporation; Tracey Technologies; Transcend Medical,

Inc; TriPrima Inc; TrueVision Systems, Inc; Viridax Corporation; Vision

Solutions Technologies; and Wavefront Systems Ltd; Medical Director:

Refractec, Inc; Sightpath Medical; and TLC Vision Corporation.

Stephen S. Lane, MD, had a financial agreement or affiliation during the

past year with the following commercial interests in the form of Honoraria:

Alcon, Inc; and Bausch + Lomb Incorporated; Fees for promotional, advertising

or non-CME services received directly from commercial interest or their Agents

(eg, Speakers Bureaus): Alcon, Inc; and Bausch + Lomb Incorporated.

2


Terrence P. O’Brien, MD, had a financial agreement or affiliation

during the past year with the following commercial interests in the form of

Consultant/Advisory Board: Alcon, Inc; Allergan, Inc; Abbott Medical

Optics; Bausch + Lomb Incorporated; and ISTA Pharmaceuticals, Inc.

Peer Review Disclosure

Ted Gerszberg, MD, has no relevant commercial relationships to disclose.

Editorial Support Disclosures

Cheryl Krader Guttman; Cynthia Tornallyay, RD, MBA, CCMEP;

Kimberly Corbin, CCMEP; Barbara Aubel; and Vivian Fransen, MPA,

have no relevant commercial relationships to disclose.

Disclosure Attestation

The contributing physicians listed above have attested to the following:

1) that the relationships/affiliations noted will not bias or otherwise influence

their involvement in this activity; 2) that practice recommendations given

relevant to the companies with whom they have relationships/affiliations will

be supported by the best available evidence or, absent evidence, will be

consistent with generally accepted medical practice; and 3) that all reasonable

clinical alternatives will be discussed when making practice recommendations.

Off-Label Discussion

This educational activity includes off-label discussion of topical azithromycin

for meibomian gland dysfunction (MGD), loteprednol etabonate gel and

ointment for inflammation other than that related to cataract surgery, and

doxycycline for MGD.

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CME Provider Contact Information

For questions about this activity, call 212-979-4383.

To Obtain AMA PRA Category1 Credit

To obtain AMA PRA Category 1 Credit for this activity, read the material in

its entirety and consult referenced sources as necessary. Complete the

evaluation form along with the post test answer box within this supplement.

Remove the Activity Evaluation/Credit Request page from the printed

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Disclaimer

The views and opinions expressed in this educational activity are those of the

faculty and do not necessarily represent the views of The New York Eye

and Ear Infirmary, MedEdicus LLC, Bausch + Lomb Incorporated, or

Ophthalmology Times. Please refer to the official prescribing information

for each product for discussion of approved indications, contraindications,

and warnings.

Introduction

A recent case-based continuing medical education

symposium focused on a spectrum of inflammatory

disorders that can compromise the success of cataract and

laser vision correction surgery. This continuing medical

education monograph includes the cases presented and

highlights from the faculty’s discussions covering the

diagnosis, treatment, and prevention of various

inflammatory disorders. We hope the information it

contains will be helpful to clinicians as they strive to

minimize surgical complications and optimize outcomes

for their patients.

—Richard L. Lindstrom, MD

Case 1: Cystoid Macular

Edema Prophylaxis

—Richard L. Lindstrom, MD

A 73-year-old male presents with a chief complaint of decreased

visual acuity and vision difficulty while driving and reading. He

has an 18-year history of diabetes that is controlled with oral

medication. Best corrected visual acuity (BCVA) is 20/60 OU,

and ophthalmic examination shows bilateral 3+ nuclear sclerotic

cataracts and 1+ background diabetic retinopathy.

The patient undergoes uneventful cataract surgery and is

prescribed a topical fluoroquinolone for 2 weeks plus

prednisolone acetate 1% 4 times a day for 2 weeks, then

prednisolone acetate 1% twice a day until gone. BCVA improves

initially to 20/25, but at 1 month postoperatively, the patient

presents with BCVA of 20/40 and reports he ran out of his

medication 1 week earlier. Central foveal thickness on optical

coherence tomography (OCT) is 543 microns (Figure 1).

Figure 1. Case 1: Optical coherence tomography image with readily apparent

macular thickening.

Photo courtesy of Richard L. Lindstrom, MD

Dr Lindstrom: Is fluorescein angiography needed to diagnose

cystoid macular edema (CME) in this patient?

Dr Lane: The risk of postcataract surgery CME is increased in

patients with diabetes. So, in this case, the patient’s history and

OCT seem sufficient for diagnosing CME.

Dr Lindstrom: What about the differential diagnosis? Is there

anything that might have been missed preoperatively?

This continuing medical education activity is copyrighted to MedEdicus LLC ©2013.

All rights reserved.

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Dr O’Brien: Surgeons should maintain suspicion for subtle

vitreomacular interface abnormalities, including epiretinal

membrane and vitreomacular traction, in patients with diabetes.

Since the cataract can obscure visualization, it is useful to

perform OCT prior to surgery.

Dr Lindstrom: This patient may have had edema from

diabetic macular edema or possibly an epiretinal membrane

preoperatively. Possible causes for decreased or blurry vision

after cataract surgery include ocular surface disease, regular and

irregular astigmatism, and age-related macular degeneration.

Since this patient ran out of his steroid early, postcataract

surgery CME was diagnosed and treated as such.

Do you modify your medication regimen for cataract surgery

patients at high risk for CME?

Dr O’Brien: Yes. These individuals at higher risk for CME

need a longer duration of treatment with a nonsteroidal

anti-inflammatory drug (NSAID) preoperatively and

postoperatively. 1,2 I instruct the patient at higher risk for CME to

initiate the NSAID 1 week preoperatively and continue it for at

least 6 to 8 weeks after surgery and sometimes, when indicated,

even as long as 3 months.

Dr Lindstrom: My bias is that if we are going to give the

antibiotic plus NSAID preoperatively, there is no reason not to

start the steroid at the same time. I think it helps clean up the

ocular surface, and the more anti-inflammatory therapy on

board at the time of the surgical insult, the better. The steroid

also seems to protect the corneal endothelium. Dr Donnenfeld,

please tell us about your research in that area.

Dr Donnenfeld: Traditionally, NSAIDs are used preoperatively

and steroids are used postoperatively. However, based in part

on evidence from randomized controlled clinical trials of patients

undergoing various major surgical procedures that preoperative

administration of a steroid has benefits for reducing edema and

pain, 3 we conducted a study comparing difluprednate 0.05%

and prednisolone acetate 1% in which both medications were

started 2 hours prior to cataract surgery, pulse dosed in the

perioperative period, and then tapered. 4 The steroid was started

2 hours preoperatively since its mechanism is to inhibit the

release of arachidonic acid that only occurs after there has been

tissue damage. The pulse dosing regimen was used because the

effect of the steroid is dose-dependent, and then it is tapered

quickly after surgery.

Eyes treated with difluprednate had clearer corneas on day 1

postoperatively, less CME at 2 and 4 weeks, and higher

endothelial cell density at 4 weeks, as compared to eyes not

treated with difluprednate.

A topical corticosteroid also helps control pain after cataract

surgery. 5 Patients can have 20/20 vision on day 1

postoperatively, but if they are uncomfortable, they view the

surgery as a failure.

Dr Lindstrom: The difluprednate-treated patients in your study

also had better vision on the first day postoperatively, and

anecdotally, I think the preoperative use of a steroid with an

NSAID helps to maintain pupillary dilation intraoperatively.

We agree that patients at high risk for CME should be treated

with a steroid preoperatively and be treated for a longer duration

with an NSAID. My short list of patients at high risk for CME

includes those with diabetes, vascular occlusion, epiretinal

membranes, a history of uveitis, CME in the same or fellow eye,

previous ocular surgery, prolonged operating time, and vitreous

loss. However, sometimes you do not know preoperatively who

is at high risk for CME. So, do you use an NSAID in all patients?

Dr Lane: You can get an idea about the risk for CME from the

patient’s history, but in the United States, most cataract

surgeons are routinely using an NSAID.

It is useful to have 2 regimens—1 for “routine patients” and

another for the group of patients at high risk for CME who use the

same medications, but more intensively. Since you do not always

know who the patient at high risk for CME is, having some

coverage with both the NSAID and steroid makes good sense.

I use difluprednate with an NSAID for controlling inflammation

after cataract surgery in the eyes of patients at high risk for

CME, but loteprednol combined with an NSAID is my treatment

of choice in routine cases. In a study we conducted with Edward

J. Holland, MD, in which patients who were having routine

cataract surgery received an NSAID postoperatively and were

randomized to prednisolone acetate 1% or loteprednol

etabonate 0.5% suspension, inflammation control was

equivalent in the 2 groups, but the loteprednol-treated group

had less intraocular pressure (IOP) fluctuation than the

prednisolone-treated group. 6

Dr Lindstrom: If you see a patient who had CME after his or

her first eye cataract surgery, what will you do differently when

operating on the second eye?

Dr Donnenfeld: Patients are counseled about their risk for CME

and told what will be done to try to give them the best possible

surgical outcome. I would obtain a preoperative OCT, and if

there is significant macular edema, I would refer the patient to a

retinal surgeon for possible intravitreal steroid injection prior

to surgery.

If the CME was not significant, I would treat the patient before

surgery with an NSAID plus a steroid. I use bromfenac 0.09%,

which is recommended for once-daily dosing, but I would

prescribe it for use twice a day in a patient with diabetes,

starting 1 week preoperatively and continuing it for 2 to

3 months postoperatively. I would also have the patient start

difluprednate 1 day before surgery and, importantly, begin pulse

dosing difluprednate right before surgery. The patient should be

followed closely postoperatively.

If there is any intraoperative complication, I like to use

intracameral triamcinolone acetonide, not only to recognize

vitreous loss, but also to reduce inflammation. I am very

aggressive with the use of steroids in these patients.

Dr O’Brien: I would agree and also have a low threshold for

intraocular corticosteroid therapy. I use intracameral preservativefree

dexamethasone in patients at risk for CME and intravitreal

preservative-free triamcinolone acetonide in patients who have

complications or are at high risk for CME. Perhaps in the near

future, we will have sustained-delivery vehicles for the longer-term

release of corticosteroids with zero-order pharmacokinetics to

control inflammation for an extended period.

Dr Lindstrom: The point here is that steroids work

synergistically with NSAIDs to minimize postoperative

inflammation and thus can be used aggressively.

4


CME is more common than people think. If postcataract surgery

CME is defined as any leakage or thickening of the retina on

OCT, its rate is near 90% in patients having uneventful cataract

surgery, according to a study by Lobo and colleagues. 7 Among

the 32 eyes included in the trial, 88% of the eyes had evidence

of retinal vascular leakage at 12 weeks postoperatively.

If the goal of cataract surgery is to provide patients with the best

possible visual acuity, surgeons need to focus on preventing

CME. OCT is becoming a critical tool for identifying patients at

high risk for CME, and we have drugs that work synergistically

to help prevent CME.

slit-lamp reveals trace collarettes and scales on the lashes. She

has a clear cornea, rapid tear break-up time (TBUT), and foamy

tear film (Figure 2), along with a 2+/3+ nuclear sclerotic

cataract and 1+ posterior capsular cataract OU. The fundus

examination is unremarkable, and the patient wants a

presbyopia-correcting intraocular lens (IOL).

A

B

Dr Lane: Something I have come to realize in treating patients

with CME is that while visual acuity usually comes back to

20/20, visual quality may still be reduced. Since we do not

know who is going to develop CME, the use of medications to

prevent CME makes good sense.

C

D

Dr Donnenfeld: My partner, John Wittpenn, MD, was the lead

author of a paper that provided evidence-based information in

this area. 8 He and his colleagues randomized approximately

550 cataract surgery patients to receive a steroid alone or

combined with an NSAID postoperatively. Retinal thickening of

more than 10 microns occurred in twice as many eyes in the

steroid-only group than in the NSAID-plus-steroid group, and

having more than 10 microns of retinal thickening was

associated with lower contrast sensitivity.

Extrapolating these data to the more than 3 million cataract

surgeries performed in the United States annually suggests

about 150,000 patients would suffer visual deficit if they were

not treated with this combination of an NSAID plus steroid.

That is a staggering number.

Dr Lindstrom: Indeed, we must think about the prevention of

CME, and today we have more effective steroid options than in

the past for controlling postoperative inflammation with

difluprednate 0.5% emulsion as well as loteprednol 0.5%, which

now includes preservative-free ointment and a gel formulation in

addition to the suspension. Our NSAID options have also been

expanding with the development of formulations that have

reduced dosing frequency relative to their predecessors. In

addition to once-daily bromfenac 0.09%, there has been the

introduction of ketorolac tromethamine 0.45% solution, which

is preservative-free and has a dosing frequency of twice-daily

administration. Nepafenac 0.3% suspension was very recently

approved by the US Food and Drug Administration with a oncedaily

regimen for the treatment of pain and inflammation

associated with cataract surgery, and it received approval in

Europe for the prevention of CME in patients with diabetes. In

addition, a New Drug Application has been filed for a lowerconcentration

preparation of bromfenac that was shown

effective as a once-daily treatment for pain and inflammation

associated with cataract surgery. 9

Case 2: Preoperative Management

of Comorbidities in Cataract

Surgery—Blepharitis and Dry Eye

—Stephen S. Lane, MD

A 75-year-old female who had been using artificial tears 5 times

a day for comfort presents with a complaint of decreased visual

acuity. BCVA is 20/80 OD and 20/70 OS. Examination at the

Figure 2. Case 2: Slit-lamp findings in a patient with combined anterior and

posterior blepharitis show scurf at the base of the lashes (A), inspissation and

plugging of the meibomian glands (B), foam in the tear film (C), and irregular

tear film break-up (D).

Photos courtesy of Stephen S. Lane, MD

What are the striking findings in her slit-lamp images?

Dr O’Brien: She exhibits typical signs of combined anterior

blepharitis and posterior blepharitis with inflammation at the

anterior lid margin, collarettes, and crusting, along with a

glistening from oil reflection of light off the lid skin and lid

margin telangiectatic vessels.

Dr Donnenfeld: The soap-like material along the lid margin is

the result of saponification. It is caused by lipase hydrolysis of

the meibomian gland lipids to soaps and fatty acids, and those

breakdown products cause burning and tear film instability with

a shortened TBUT. Inspissation of the glands is also present and

is pathognomonic for meibomian gland dysfunction (MGD).

Normally, the meibum has an olive oil-like appearance, but with

MGD, the thickened secretions block the glands.

Dr Lane: We do corneal topography routinely for patients

receiving advanced technology IOLs to check the ocular surface.

This patient has irregular astigmatism secondary to an irregular

ocular surface (Figure 3).

Figure 3. Case 2: Corneal topography with irregular astigmatism.

Photo courtesy of Stephen S. Lane, MD

Dr Donnenfeld: There are a few things that can account for the

type of topographic irregularity seen in this patient, but it is

important not to operate in this situation because the

keratometry will be irregular and result in IOL power selection

error. The black areas seen at the bottom of the topographic

image represent frank dropout because of the surface

5


irregularity. That should tell a surgeon there is a problem that

needs to be rectified before operating.

Dr O’Brien: The quality of the topographic image is adversely

impacted in this patient by the film instability and overall poor

quality of the tear lake, and the use of the information obtained

will lead to spurious keratometry and inaccurate IOL power

selection. This is a clear case of the “garbage in will yield

garbage out” principle in terms of IOL power selection and

refractive outcome.

Dr Lane: Yes. Implanting a multifocal IOL in this patient is a

formula for disastrous results. Not only will the IOL power be

wrong, but the image quality will be reduced postoperatively

because of the tear film irregularity (Figure 4). MGD needs to

be treated aggressively prior to surgery.

Figure 4. Reduction in visual quality due to tear film abnormality.

Photo courtesy of Stephen S. Lane, MD

Do patients present with pure MGD, pure aqueous deficient dry

eye, or pure anterior blepharitis?

Dr Lindstrom: There certainly are cases of true aqueous

deficient dry eye, as in patients with Sjögren’s syndrome.

However, according to a study by Lemp and colleagues, 10 86%

of dry eye is evaporative, and it is also my impression that more

patients have MGD with secondary evaporative dry eye than

true aqueous deficient dry eye, especially seniors.

Dr O’Brien: With respect to the lid margin disease, some

patients have a clearly defined clinical picture where the anterior

lid margin is principally involved, and others have involvement

that is more exclusively limited to the posterior lid margin.

However, the majority of the patients have a combination of

anterior and posterior lid margin involvement, and both

components need to be addressed for effective control. The

involvement of the posterior lid margin adds to the poor quality

of meibum, an unstable lipid layer, and accelerated evaporative

tear loss with resultant aqueous tear layer insufficiency.

Dr Donnenfeld: I have found an overwhelming association

between a chief complaint of tired eyes and MGD or dry eye

disease. The reason is that as these patients attempt to maintain

image quality, they may double or triple their blink rate.

Consequently, the levator muscles tire. Other than a slightly

shortened TBUT, they may have no other signs of dry eye.

However, their borderline condition may be converted to an

acute dry eye state after surgery. Then, they might be very upset

and blame the surgery for a preexisting problem that was

marginally compensated.

Dr Lane: I think we would all agree to postpone surgery in

these patients. How should they be managed?

Dr Lindstrom: Because MGD is so common, all patients deserve

what I call “ocular surface preparation.” The regimen I use is

influenced by a study in which Dr Lane was an investigator that

showed improvements were achieved in patients with moderateto-severe

blepharitis/blepharoconjunctivitis after 1 week of

treatment with a fixed combination of topical antibioticcorticosteroid.

11 My approach is to use a fixed combination

antibiotic-corticosteroid, tobramycin-loteprednol, or tobramycindexamethasone,

together with lid hygiene and artificial tears for

1 week prior to surgery.

I think these eyes remain more vulnerable to intraoperative

trauma, and so I put some dispersive viscoelastic on the eye for

protection during surgery. For long-term maintenance therapy, I

am a big advocate of omega-3 fatty acids, but there is no reason

not to start that preoperatively.

Dr. O’Brien: I certainly agree that particular attention to and

proper preparation of the ocular surface preoperatively can lead

to less instability and faster recovery postoperatively from the

stress that cataract surgery inevitably poses to any ocular

surface. One cautionary note about viscous surface protectants

is to be certain to apply the antiseptic and antibiotic agents for

antimicrobial prophylaxis prior to placing the viscous agent.

This order of use allows sufficient time for effective antimicrobial

action that can be blocked by the viscous lubricant substance.

Ocular nutriceuticals, including sources of essential omega-3

fatty acids and related nutrients, play an important role in ocular

surface management, but may require a more extended course

to achieve significant and lasting improvements of the tear film

and ocular surface. Cyclosporine may also take several weeks to

months to gain control of ocular surface inflammation. Thus, a

corticosteroid preparation that is ocular surface friendly,

effective, and safe provides a tool to rapidly reduce ocular

surface inflammation preoperatively.

Dr Lane: Many patients are already taking omega-3 fatty acids,

but often it is not the right kind or enough. The preparation

needs to contain the triglyceride form to assure good

absorption. 12 Results of a randomized clinical trial of patients

with blepharitis and MGD showed improvements in objective

and subjective measures after 1 year of treatment with

approximately 3 g/d of omega-3 fatty acids. 13

To treat MGD and ocular surface disease prior to surgery, I like

to use a fixed combination of loteprednol-tobramycin because of

the safety of loteprednol. Loteprednol ointment might also be

considered to decrease inflammation when initiating treatment

for more severe inflammatory anterior blepharitis and MGD.

It is a nice formulation because it is not greasy and contains

no preservatives.

To decrease inflammation related to MGD, cyclosporine might

also be considered.

Dr Donnenfeld: Patients coming for surgery want something

that is rapidly effective, and they do not want to wait 3 months

for the benefit from omega-3 fatty acids. For these patients,

loteprednol rapidly optimizes the ocular surface, 14 has a good

safety profile, and works synergistically with cyclosporine, which

also has a delayed onset of efficacy and causes irritation. We

found starting loteprednol first and initiating cyclosporine after

6


1 to 2 weeks increases the patient’s comfort and tolerability with

cyclosporine. 15 I start loteprednol 4 times a day for 2 weeks,

then twice a day for 2 weeks.

Dr Lindstrom: A lot of patients are unhappy if they are started

on cyclosporine alone. I tell my patients that if we start

cyclosporine, it is a lifetime treatment, but I find I can sometimes

go from twice-a-day to once-a-day administration after 6 to 12

months. In a randomized study, Su and colleagues reported that

most patients with dry eye disease treated with cyclosporine

twice a day for a year could maintain control when switched to

once-daily dosing. 16

Dr Donnenfeld: We also decrease the dosing frequency of

cyclosporine to once a day for some patients with dry eye.

However, it depends on the underlying etiology, and patients

have to be monitored for potential worsening that would

necessitate a return to twice-daily dosing.

Dr Lane: In terms of the patient in this case, surgery was

postponed, and the patient was instructed to perform lid

hygiene and to start omega-3 fatty acids at 3 g/d. Treatment

also included loteprednol 0.5% ointment since the inflammatory

component of the mixed blepharitis was significant enough to

necessitate a steroid, and she started taking doxycycline. There

was a significant improvement after 2 weeks. The patient had

surgery and did well. For long-term control, she was started on

maintenance therapy with topical azithromycin every other

month and continued oral omega-3 fatty acids supplementation

and lid hygiene.

Dr Lindstrom: I also find topical azithromycin effective for

long-term maintenance therapy in patients with MGD.

Dr O’Brien: Azithromycin, an advanced macrolide agent,

is well-suited for MGD management because it has both

immunomodulatory properties conferring anti-inflammatory

activity and is antimicrobial. Anterior blepharitis is not an

infectious process, but it is associated with excessive

bacterial colonization.

For lid hygiene, I like to use a foaming lid scrub that contains

linalool, a tea tree oil derivative that has some anti-inflammatory

and antimicrobial properties, including activity against methicillinresistant

Staphylococcus aureus and Staphylococcus epidermidis. 17

We also caution the sometimes obsessive-compulsive patients

with MGD blepharitis to not use detergent-containing lid scrubs

excessively as this may result in further breakdown of abnormal

meibum into free fatty acids, and triglyceride soaps may also add

to the ocular surface irritation.

Case 3: Ocular Allergy and

Ocular Surgery

—Terrence P. O’Brien, MD

A 61-year-old male presents with IOPs of 36 mm Hg OD and

38 mm Hg OS as well as early glaucomatous changes in his

visual field and retinal nerve fiber layer. Previously, he had been

a suspect for primary open-angle glaucoma with a cup-to-disc

ratio of 0.7 OU, borderline high IOP, and a family history of

glaucoma. He is a patient with a moderately high degree of

myopia who has worn rigid gas-permeable contact lenses

successfully for many years.

He was placed on a prostaglandin analogue once nightly. IOP

decreased only to the mid-20s, and an alpha adrenergic agent

(brimonidine) was added twice a day. The patient complained of

itching, occasional redness, and episodic mucus discharge, and

he was developing contact lens intolerance. Photographs from

his external examination are shown in Figure 5. What is your

diagnosis?

Figure 5. Case 3: Clinical findings of giant papillary conjunctivitis with tarsal

hyperemia in a patient with long-term rigid gas-permeable contact lens wear.

Fluorescein sodium outlines the giant papillae on the upper eyelid.

Photos courtesy of Terrence P. O’Brien, MD

Dr Donnenfeld: Given the appearance and history of contact

lens wear, I would diagnose giant papillary conjunctivitis.

Dr O’Brien: Talking in general about patients with glaucoma

plus ocular surface disease, what are the issues to consider when

using topical medications?

Dr Lane: IOP-lowering agents can be a double-edged sword

because of the risks for an allergic reaction to some medications

and for toxicity from the medications themselves or from

preservatives, especially benzalkonium chloride. 18,19 In this

patient who needs a steroid to treat inflammation, the potential

for an IOP response also needs to be considered.

Dr O’Brien: How do you differentiate whether the conjunctival

redness in this patient is a sign of allergy or irritation?

Dr Donnenfeld: With a prostaglandin analogue, there can be

irritation from the preservative or from the active ingredient.

Switching to a preservative-free medication might be a reasonable

thing to try. Sometimes I prescribe an oral glaucoma medication

for a few weeks to treat the IOP and leave such patients on 1

topical medication in 1 eye only. If the redness in the fellow eye

improves, I know which topical medication was the cause.

Brimonidine can cause allergic reactions. 20 Patients with an

allergic reaction to brimonidine tend to rub their eyes a lot. The

rubbing perpetuates the redness by causing mast cell

degranulation, and the rubbing is also detrimental in patients

with glaucoma because the rubbing increases IOP.

Dr Lindstrom: When a patient has an allergic reaction, there is

itching, often right over the caruncle, and there might be some

erythema of the skin as well. Blepharitis burns, and dry eyes

typically are associated with a foreign body gritty sensation.

Dr O’Brien: To manage this patient, we suspended the contact

lens wear and treated him with a pulse dosing regimen of

loteprednol etabonate 0.5%. Loteprednol has a safety

advantage in the patient with glaucoma because it has a reduced

potential for IOP elevations relative to other steroids, 21 and this

case was managed using the suspension formulation. Now,

7


however, loteprednol gel 0.5% is available and would have been

a good choice because it contains 70% less preservative than

the suspension, 0.003% vs 0.01%. Therefore, it is friendlier to

the ocular surface. The vehicle is a “smart” polymer and

contains the demulcents polyethylene glycol and glycerin. It

dispenses as a liquid and converts to a gel on the eye, but causes

minimal blur.

Tear film

dysfunction

Infectious

Red eye

Suspected

allergy

Autoimmune

Vasomotor

Dr Lane: I think gel formulations are going to bring a paradigm

shift in treating ocular surface disease because of their potential

for increased dwell time on the ocular surface.

Visual disturbance

Ocular pain

Photophobia

Chronic contact lens wearer

History

Rhinitis

Asthma

Sinusitis

Atopic dermatitis

Urticaria/Angioedema

Dr Lindstrom: The gel formulation of loteprednol etabonate is

also a non-settling suspension so that a uniform dose is

delivered with each drop and without a need for shaking.

Ophthalmologist

Crosstalk

Allergist/

Immunologist

Dr O’Brien: That is an excellent point as, despite frequent

instruction, few patients properly agitate the eyedrop bottle to

achieve a uniform suspension of the active ingredient with

drop delivery. 22

In addition to loteprednol etabonate 0.5%, this particular patient

was also started on a dual-acting anti-allergy agent (olopatadine)

twice daily and was switched to daily disposable soft contact

lenses. Brimonidine was stopped. The patient’s IOP increased

to above 30 mm Hg, but was controlled with the addition of a

beta-blocker. The patient did well but returned 14 months later

with even worse dryness, irritation, itching, hyperemia, and

mucus discharge.

We referred this patient for consultations with both the

refractive surgery and glaucoma services, hoping that refractive

surgery would eliminate his need for contact lenses and the

glaucoma surgery would minimize the need for topical

medications. He was also restarted on a pulse dosing regimen of

loteprednol 0.5%. He continued the anti-allergy agent, used

preservative-free artificial tears, and returned for a refractive

surgery evaluation after 6 weeks.

At the Bascom Palmer Eye Institute, we developed an

algorithmic approach to rationally manage the candidate for

LASIK (laser-assisted in situ keratomileusis) who has comorbid

allergy (Figure 6). 23 Just as it is important to control

inflammatory conditions prior to performing cataract surgery, it

is important to have ocular allergy under control prior to LASIK.

Dual action anti-allergy agents have become our mainstay for

treating ocular allergy. However, it is important to realize that

they may differ in their effects on the tear film due to differences

in histamine receptor binding affinity profiles. 24

Dr Lindstrom: In a contact lens wearer or patient with known

dry eye, I am using bepotastine besilate 1.5%. Bepotastine is a

highly selective H1 receptor antagonist with low binding affinity

for muscarinic receptors, 24 and therefore it has a low likelihood

for exacerbating dry eye.

Loteprednol etabonate 0.2% is also an effective option for ocular

allergy management, 25 and it has been reported to be safe when

used on a long-term basis in patients with chronic allergy. 26

Dr O’Brien: This patient had LASIK performed in 2 stages.

First, the flap was created with a femtosecond laser, but the

excimer laser photoablation was delayed for 6 weeks after

Slit lamp exam

Tear breakup time

Vital staining

(fluorescein, lissamine

green, rose bengal)

Diagnosis

KCS TFD VKC GPC AKC PAC SAC

Lubricants

Antihistamines

Optimization of Ocular Surface

Multiple-action agents

Mast cell stabilizers

Schirmertest

Tear film osmolarity

RPS inflammatory dry eye

Detector

Tear IgE

Conjunctival cytology

Severity-based treatment

Immunomodulators

Steroids/CyA

Re-evaluate Ocular Surface (4 weeks)

Figure 6. Preoperative workup for LASIK candidates with a history of allergy. 23

Reprinted with permission from Lippincott Williams & Wilkins.

Skin test

Atopic evaluation

Rhinoscopy

Peak flow spirometry

Immunotherapy

trabeculectomy with mitomycin-C so that it would correct any

astigmatism induced by the glaucoma surgery.

Postoperatively, the patient had excellent unaided visual acuity,

20/20 OD and 20/15 OS, with very little residual refractive error

and no need for contact lenses. He continued the preservativefree

artificial tears for 6 months and the dual action anti-allergy

agent as needed. The hyperemia and papillae in this patient

gradually improved, although it took about a year, and the

persistence of the papillae can be associated with exacerbations

and recurrences. However, the patient was delighted to no longer

need contact lenses, IOP was controlled in the low teens, and the

visual field and nerve fiber layer were stable.

Dr Donnenfeld: Dr Lindstrom has published on the benefit of

cataract surgery for glaucoma control. 27,28 Therefore,

phacoemulsification, perhaps combined with a trabecular microbypass

stent, might have been an alternative to trabeculectomy

in this patient.

In patients with milder glaucoma who have ocular irritation

associated with their topical medication, laser trabeculoplasty is

also a reasonable procedure for trying to eliminate topical

medication use.

Dr Lindstrom: Most 60-year-olds have early cataracts. If a patient

has what I call the 3G syndrome—glare from cataract, glasses,

and glaucoma—I often think of a refractive lens exchange.

8


Case 4: Inflammation and

Surviving a Toxic Anterior

Segment Syndrome Epidemic

—Eric D. Donnenfeld, MD

A 71-year-old female underwent uneventful cataract surgery in

2005 and received the standard postoperative medication

regimen that included a fourth-generation fluoroquinolone, an

NSAID, and prednisolone acetate 1%. She presents on the first

postoperative day without pain, minimal lid swelling, and a

relatively quiet eye, but complains about decreased vision.

A slit-lamp photo of her eye is shown (Figure 7). What are the

important findings?

Figure 7. Case 4: Sterile hypopyon

in a patient with TASS.

Photo courtesy of

Eric D. Donnenfeld, MD

Dr O’Brien: The corneal edema is diffuse. It is not just adjacent

to the incision, but is limbal to limbal, horizontally and vertically.

That suggests a toxic response.

Dr Lane: However, unless you have a reason to suspect toxic

anterior segment syndrome (TASS) because of an ongoing

outbreak, your first obligation is to rule out infectious

endophthalmitis.

Dr O’Brien: The time course also provides diagnostic clues.

Significant hypopyon within 24 hours of surgery suggests it may

be triggered by a toxic response rather than infection. Despite

these suggestive clues, I certainly agree that it is incumbent upon

the surgeon to perform the requisite diagnostic tests to rule

out infection.

Dr Donnenfeld: TASS was suspected in this patient because I

learned a TASS epidemic had started the day before. Other

patients seen by other surgeons had a similar presentation, and

some had an anterior chamber tap with nothing found on Gram

stain. How do you manage TASS?

Dr Lane: I would do an anterior chamber washout, prescribe an

intracameral antibiotic, and treat TASS with an aggressive

anti-inflammatory regimen.

Dr O’Brien: The possible sequelae of TASS include CME,

endothelial damage, and damage to the trabecular meshwork

leading to uncontrollable glaucoma. The pupil may also be

affected by the toxins and become permanently mydriatic

and nonreactive.

Based on my experience with TASS cases seen on referral, I think

early anterior chamber irrigation plus washout is an important

maneuver to prevent permanent intraocular damage, especially in

this case where the inflammation is so severe. TASS is a toxic

insult to the intraocular milieu, and the solution to pollution is

dilution. We need to be aggressive in irrigating the toxins away

and then start the patient on high-dose corticosteroids.

Dr Lindstrom: I think of TASS in much the same way as I think

of diffuse lamellar keratitis (DLK). If I see DLK on the first day

after LASIK, I do not immediately lift the flap and irrigate, but

usually give patients an opportunity to respond to aggressive

topical steroids while monitoring them very closely.

Dr Donnenfeld: Nick Mamalis, MD, a professor of

ophthalmology at the John A. Moran Eye Center, University of

Utah, Salt Lake City, and co-chairman of the American Society

of Cataract and Refractive Surgery TASS Task Force, is against

using antibiotics, and I think washout is also controversial.

For a mild case, I start treatment for the patient with a potent

topical steroid, but when there is severe corneal edema, I wash

out the eye and inject steroid intracamerally. I use preservativefree

dexamethasone sodium phosphate because it works more

quickly than triamcinolone and does not stay around as long.

Then I start the use of topical difluprednate because of its

potency. In a study of patients with severe anterior uveitis, the

use of difluprednate 4 times a day was more effective than

brand-name prednisolone acetate 1% 8 times a day. 29

This case was part of a nationwide epidemic that included

37 cases at our surgery center over 6 weeks. An investigation

led by Dr Mamalis identified endotoxin in one manufacturer’s

balanced salt solution as the cause. What are some other causes

of TASS?

Dr Lane: Residue in inadequately cleaned reusable cannulas is a

big culprit.

Dr O’Brien: Some detergent residues used in processing

surgical instruments are also a cause.

Dr Donnenfeld: The lessons we learned from this TASS

outbreak were that you have to scrupulously examine the

process of cleaning and processing instruments; document lot

numbers for all products coming in contact with the eye; keep

records of all staff and equipment used; communicate early

within and outside your facility; and identify TASS early, treat

aggressively with steroids, and avoid vitreous taps and

intravitreal antibiotics.

The first 9 cases at our center were sent to a retinal specialist

for evaluation, and the 2 most severe cases had a vitreous tap

with intravitreal antibiotics, but you do not want to do those

maneuvers if you know it is TASS. These patients need to be

watched very carefully, and you have to certainly be willing to

see them every 4 to 5 hours until you know what is going on.

The patient was treated with cyclopentolate 1% and

prednisolone acetate because difluprednate was not available at

the time. She did well with the clearing of her corneal edema,

fibrin, and hypopyon over 3 weeks, but she had low-grade

inflammation with chronic iritis, CME, and photophobia, and

was maintained on a long-term basis with loteprednol.

TASS can be associated with long-term smoldering

inflammation. How would you manage this patient who

presents 2 months later with low-grade iritis?

9


Dr Lane: The goal for long-term treatment for low-grade

iritis is to use an agent that is potent enough to control the

inflammation, but has a high enough safety margin so that you

do not have to be concerned about adverse effects of chronic

treatment. Loteprednol fits that description and would be an

appropriate choice. I would start treatment for low-grade iritis

with the gel formulation, taper it to once or twice a day, and

instead of discontinuing the steroid altogether, switch to

loteprednol 0.2% for longer-term use.

There are published reports of patients using loteprednol 0.2%

daily for up to 3 years without developing cataracts or IOP

elevation. 26 I find it is very helpful for managing mild

inflammation for the long term.

Dr Donnenfeld: Loteprednol is a strong steroid with minimal

side effects, and it is my corticosteroid of choice for long-term

maintenance treatment, such as following a penetrating

keratoplasty. I also use loteprednol for everything anterior to

Descemet membrane—anything involving the ocular surface,

anterior cornea, conjunctiva, pterygia, or lid margin. My early

experience with loteprednol gel is that it is even more potent

than the suspension and may be used for intraocular

inflammation. I use difluprednate when I need a potent steroid

for rapid inflammation control. I use it in pulse dosing for TASS,

for acute graft rejection, and in cataract surgery when I want to

completely suppress inflammation.

References

1. Heier JS. Preventing post-cataract extraction CME: early identification of

patients at risk and prophylactic treatment may avert vision loss. Ophthalmol

Manage. October 2004:63-72.

2. O’Brien TP. Emerging guidelines for use of NSAID therapy to optimize cataract

surgery patient care. Curr Med Res Opin. 2005;21(7):1131-1137.

3. Holte K, Kehlet H. Perioperative single-dose glucocorticoid administration:

pathophysiologic effects and clinical implications. J Am Coll Surg. 2002;195(5):

694-712.

4. Donnenfeld ED, Holland EJ, Solomon KD, et al. A multicenter randomized

controlled fellow eye trial of pulse-dosed difluprednate 0.05% versus

prednisolone acetate 1% in cataract surgery. Am J Ophthalmol. 2011;152(4):

609-617.

5. Korenfeld MS, Silverstein SM, Cooke DL, Vogel R, Crockett RS; Difluprednate

Ophthalmic Emulsion 0.05% (Durezol) Study Group. Difluprednate ophthalmic

emulsion 0.05% for postoperative inflammation and pain. J Cataract Refract

Surg. 2009;35(1):26-34.

6. Lane SS, Holland EJ. Loteprednol etabonate 0.5% versus prednisolone acetate

1.0% for the treatment of inflammation after cataract surgery. J Cataract Refract

Surg. 2013;39(2):168-173.

7. Lobo CL, Faria PM, Soares MA, Bernardes RC, Cunha-Vaz JG. Macular

alterations after small-incision cataract surgery. J Cataract Refract Surg.

2004;30(4):752-760.

8. Wittpenn JR, Silverstein S, Heier J, et al. A randomized, masked comparison of

topical ketorolac 0.4% plus steroid vs steroid alone in low-risk cataract surgery

patients. Am J Ophthalmol. 2008;146(4):554-560.

9. Klier SM, Pearce JH, Goldberg DF, Gow JA, McNamara TR, Low-

Concentration, Modified Bromfenac Ophthalmic Solution Once Daily Study

Group. Efficacy of low-concentration, modified bromfenac ophthalmic solution

administered once daily for ocular inflammation and pain associated with

cataract surgery. Poster presented at: Association for Research in Vision and

Ophthalmology Annual Meeting; May 10, 2012; Fort Lauderdale, FL.

Abstract 6684.

10. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of

aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a

retrospective study. Cornea. 2012;31(5):472-478.

11. Torkildsen GL, Cockrum P, Meier E, Hammonds WM, Silverstein B, Silverstein

S. Evaluation of clinical efficacy and safety of tobramycin/dexamethasone

ophthalmic suspension 0.3%/0.05% compared to azithromycin ophthalmic

solution 1% in the treatment of moderate to severe acute blepharitis/

blepharoconjunctivitis. Curr Med Res Opin. 2011;27(1):171-178.

12. Dyerberg J, Madsen P, Møller JM, Aardestrup I, Schmidt EB. Bioavailability of

marine n-3 fatty acid formulations. Prostalgandins Leukot Essent Fatty Acids.

2010;83(3):137-141.

13. Macsai MS. The role of omega-3 dietary supplementation in blepharitis and

meibomian gland dysfunction (an AOS thesis). Trans Am Ophthalmol Soc. 2008;

106:336-356.

14. Pflugfelder SC, Maskin SL, Anderson B, et al. A randomized, double-masked,

placebo-controlled, multicenter comparison of loteprednol etabonate ophthalmic

suspension, 0.5%, and placebo for treatment of keratoconjunctivitis sicca in

patients with delayed tear clearance. Am J Ophthalmol. 2004;138(3):444-457.

15. Donnenfeld E, Sheppard JD, Holland EJ. Prospective, multicenter, randomized

controlled study on the effect of loteprednol etabonate on initiating therapy with

cyclosporine A. Presented at: American Academy of Ophthalmology Annual

Meeting; November 2007; New Orleans, LA.

16. Su MY, Perry HD, Barsam A, et al. The effect of decreasing the dosage of

cyclosporine A 0.05% on dry eye disease after 1 year of twice-daily therapy.

Cornea. 2011;30(10):1098-1104.

17. Gilbard JP, Douyon Y, Huson RB. Time-kill assay results for a linaloolhinokitiol-based

eyelid cleanser for lid hygiene. Cornea. 2010;29(5):559-563.

18. Epstein SP, Chen D, Asbell PA. Inflammatory response by ocular surface

epithelia upon exposure to prostaglandin analogs. Invest Ophthalmol Vis Sci.

2008;49:E-abstract 3820.

19. Baudouin C. Labbé A, Liang H, Pauly A, Brignole-Baudouin F. Preservatives in

eyedrops: the good, the bad and the ugly. Prog Retin Eye Res. 2010;29(4):

312-334.

20. Blondeau P, Rousseau JA. Allergic reactions to brimonidine in patients treated

for glaucoma. Can J Ophthalmol. 2002;37(1):21-26.

21. Comstock TL, Decory HH. Advances in corticosteroid therapy for ocular

inflammation: loteprednol etabonate. Int J Inflam. 2012;2012:789623.

22. Apt L, Henrick A, Silverman LM. Patient compliance with use of topical

ophthalmic corticosteroid suspensions. Am J Ophthalmol. 1979;87(2):

210-214.

23. Bielory BP, O’Brien TP. Allergic complications with laser-assisted in situ

keratomileusis. Curr Opin Allergy Clin Immunol. 2011;11(6):483-491.

24. Wade L. Bielory L, Rudner S. Ophthalmic antihistamines and H1-H4 receptors.

Curr Opin Allergy Clin Immunol. 2012;12(5):510-516.

25. Elion-Mboussa A, Gong L, Roy L, Zhu B, DeCory H, Chu E. Loteprednol

etabonate ophthalmic suspension, 0.2% is as safe as olopatadine hydrochloride

ophthalmic solution, 0.1% with superior relief of signs and symptoms in the

treatment of seasonal allergic conjunctivitis. Presented at: Proceedings of the

Annual Meeting of the American Academy of Allergy Asthma and Immunology;

March 2012; Orlando, FL.

26. Ilyas H, Slonim CB, Braswell GR, Favetta JR, Schulman M. Long-term safety of

loteprednol etabonate 0.2% in the treatment of seasonal and perennial allergic

conjunctivitis. Eye Contact Lens. 2004;30(1):10-13.

27. Poley BJ, Lindstrom RL, Samuelson TW, Schulze R Jr. Intraocular pressure

reduction after phacoemulsification with intraocular lens implantation in

glaucomatous and nonglaucomatous eyes: evaluation of a causal relationship

between the natural lens and open-angle glaucoma. J Cataract Refract Surg.

2009;35(11):1946-1955.

28. Poley BJ, Lindstrom RL, Samuelson TW. Long-term effects of

phacoemulsification with intraocular lens implantation in normotensive and

ocular hypertensive eyes. J Cataract Refract Surg. 2008;34(5):735-742.

29. Foster CS, Davanzo R, Flynn TE, McLeod K, Vogel R, Crockett RS. Durezol ®

(difluprednate ophthalmic emulsion 0.05%) compared with Pred Forte ®

Ophthalmic Suspension in the treatment of endogenous anterior uveitis.

J Ocul Pharmacol Ther. 2010;26(5):475-483.

10


CME Post Test Questions

To obtain AMA PRA Category 1 Credit for this activity, complete the CME Post Test by writing the best answer to each

question in the Answer Box located on the Activity Evaluation/Credit Request form on the following page. Alternatively, you

can complete the CME Post Test online at http://www.MedEdicus.com, Educational Activities tab, and click the Post-Test &

CME Certificate button.

See detailed instructions at To Obtain AMA PRA Category 1 Credit on page 3.

1. All of the following are risk factors for postcataract surgery

cystoid macular edema, except:

A. Diabetes

B. Vitreous loss

C. History of LASIK (laser-assisted in situ keratomileusis)

D. Epiretinal membrane

2. In a published study by Lobo and colleagues of patients

undergoing uneventful cataract surgery, the percentage of

eyes found to have evidence of retinal vascular leakage after

12 weeks was near:

A. 25%

B. 50%

C. 75%

D. 90%

3. In a study by Wittpenn and colleagues comparing postcataract

surgery treatment with a steroid alone or combined with an

NSAID, retinal thickening of more than 10 microns:

A. Occurred more often in the combination treatment

group

B. Was associated with reduced contrast sensitivity

C. Was prevented by combination treatment

D. Was associated with reduced uncorrected visual acuity

4. Depending on the intraocular pressure and other ocular

findings, all of the following might be a reasonable surgical

strategy for minimizing medication use in patients with

glaucoma plus ocular surface disease, except:

A. Trabeculectomy

B. Phacoemulsification

C. Laser trabeculoplasty

D. Any of the above might be reasonable, depending on

individual circumstances

5. All of the following may be signs of meibomian gland

dysfunction, except:

A. Low Schirmer test score

B. Rapid tear break-up time

C. Lid margin telangiectasia

D. Foamy tear film

6. Initial treatment for dry eye associated with meibomian gland

dysfunction might include all of the following, except:

A. Doxycycline

B. Punctal plugs

C. Topical corticosteroid-antibiotic combination

D. Lid hygiene

7. A benefit of using bepotastine besilate to treat ocular allergy

in contact lens wearers is:

A. Its receptor selectivity profile confers a reduced

likelihood of exacerbating dry eye

B. It is recommended for once-daily dosing

C. It contains no preservatives

D. It can be instilled without removing the contact lenses

8. Adverse sequelae of toxic anterior segment syndrome (TASS)

may include all of the following, except:

A. Cystoid macular edema

B. Permanent miosis

C. Glaucoma

D. Endothelial damage

9. Which of the following should be absolutely avoided in an eye

with TASS?

A. Vitreous tap

B. Topical corticosteroid treatment

C. Anterior chamber washout

D. Cyclopentolate

10. All of the following ophthalmic nonsteroidal

anti-inflammatory drugs are recommended for

once-daily dosing, except:

A. Bromfenac 0.09%

B. Ketorolac tromethamine 0.45%

C. Nepafenac 0.3%

D. All 3 products are recommended for once-daily dosing

11


Activity Evaluation/Credit Request

New Evidence and Insights on the Inflammation Panorama: From Ocular Surface Disorders to Surgery

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❏ Yes ❏ No I and/or my family member have a financial relationship with The New York Eye and Ear Infirmary and/or refer Medicare/Medicaid patients to it.

❏ I certify that I have participated in the entire activity and claim 1.5 AMA PRA Category 1 Credits.

Signature Required __________________________________________________________________ Date Completed ______________________________

OUTCOMES MEASUREMENT

❏ Yes ❏ No Did you perceive any commercial bias in any part of this activity? IMPORTANT! If you answered “Yes,” we urge you to be specific

about where the bias occurred so we can address the perceived bias with the contributor and/or in the subject matter in future activities.

_________________________________________________________________________________________________________________________________

Circle the number that best reflects your opinion on the degree to which the following learning objectives were met:

5 = Strongly Agree 4 = Agree 3 = Neutral 2 = Disagree 1 = Strongly Disagree

Upon completion of this activity, I am better able to:

• Summarize key efficacy and safety attributes of new anti-inflammatory agents 5 4 3 2 1

• Demonstrate best-practice regimens for reducing inflammation risk for patients 5 4 3 2 1

undergoing cataract, refractive, or glaucoma procedures

• Demonstrate best-practice regimens for the management of inflammation in patients 5 4 3 2 1

with inflammatory conditions such as dry eye, blepharitis, allergy, and/or anterior uveitis

• List anti-inflammatory therapies in development 5 4 3 2 1

1. Please list one or more things, if any, you learned from participating in this educational activity that you did not already know. ____________________________

_________________________________________________________________________________________________________________________________

2. As a result of the knowledge gained in this educational activity, how likely are you to implement changes in your practice?

4=definitely will implement changes 3=likely will implement changes 2=likely will not implement any changes 1=definitely will not make any changes

5 4 3 2 1

Please describe the change(s) you plan to make: __________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

3. Related to what you learned in this activity, what barriers to implementing these changes or achieving better patient outcomes do you face?

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

4. Please check the Core Competencies (as defined by the Accreditation Council for Graduate Medical Education) that were enhanced for you through participation

in this activity. ❏ Patient Care ❏ Practice-Based Learning and Improvement ❏ Professionalism

❏ Medical Knowledge ❏ Interpersonal and Communication Skills ❏ Systems-Based Practice

5. What other topics would you like to see covered in future CME programs? ___________________________________________________________________________

_________________________________________________________________________________________________________________________________

ADDITIONAL COMMENTS __________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

POST TEST ANSWER BOX

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