Michael R. Robinson, MD, vice president, Global Therapeutic Area Head, Ophthalmology at Allergan, an AbbVie company, discusses the results from a presentation titled, "Two Phase b Study Results for the Development of a Proprietary Formulation for the Treatment of Presbyopia," presented during the virtual AAO 2020 meeting.

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Michael R. Robinson, MD, Allergan, discusses the results from a study analyzing an investigational ophthalmic solution for treatment of symptoms associated with presbyopia presented during the virtual AAO 2020 meeting.

Analysis of an investigational ophthalmic solution for treating presbyopia-related symptoms

Tanner Ferguson, MD, an ophthalmology resident at the Cleveland Clinic's Cole Eye Institute, discusses findings from the study "Trabecular Micro-bypass Stent Implantation (iStent)" + Phacoemulsification in PXG: Six-Year Outcomes," during the virtual AAO 2020 meeting. 


Tanner Ferguson, MD, Cole Eye Institute, discusses findings from the study "Trabecular Micro-bypass Stent Implantation (iStent)" + Phacoemulsification in PXG: Six-Year Outcomes," during the virtual AAO 2020 meeting. 

Evaluating long-term safety for micro-bypass implant + phaco in PXG


John A. Hovanesian, MD, clinical instructor, UCLA Jules Stein Eye Institute, Laguna Hills, CA, discusses the highlights of his presentation titled "The D3 Study: Drug Delivery vs Drops — A Prospective Clinical Study Evaluating Dexycu vs Prednisolone Acetate 1% in Controlling Post-operative Pain and Inflammation in Patients Undergoing Sequential Cataract Surgery," during the virtual 2020 American Academy of Ophthalmology (AAO) meeting. 

John A. Hovanesian, MD, discusses the highlights of his presentation on a clinical study evaluating dexamethasone vs prednisolone acetate 1% in controlling postop pain/inflammation in sequential cataract surgery patients.

Controlling postop pain, inflammation in cataract patients: drug delivery vs drops



Robert Weinstock, MD, director of Cataract & Refractive Surgery, The Eye Institute of West Florida; the Weinstock Laser Eye Center, presents real-world data from a retrospective multicenter study focusing on the efficacy of dexamethasone intraocular suspension 9% delivered at the time of cataract surgery.

Weinstock notes that research shows the injections can decrease inflammation and control IOP.

Robert Weinstock, MD, presents data from a retrospective multicenter study focusing on the efficacy of dexamethasone intraocular suspension 9% delivered at the time of cataract surgery. 


AAO: Study outlines use of injectable intraocular steroid over drops

Physicians at Kaiser Permanente have been using a prophylactic drop-free drug regimen before cataract surgery for more than a decade. 

Their regimen is so streamlined that the only drop that patients receive in anticipation of cataract surgery is a supplemental dilation drop instilled preoperatively while they are still in the holding area, according to Neal H. Shorstein, MD, who discussed the topic at the American Academy of Ophthalmology’s virtual 2020 annual meeting.

Dr. Shorstein is an ophthalmologist, researcher and associate chief of quality at Kaiser Permanente Medical Center in Walnut Creek, CA.

This more efficient approach seems highly beneficial for patients because drop instillation is associated with a few risks, i.e., prescription error, failure to pick up the prescription, failure to adhere to the instillation instructions, and stopping the drops prematurely. 

If only the correct instillation is considered, 93% of drop-naive patients have been reported to instill drops incorrectly. In addition, the bottle tip can become contaminated and it can cause microtrauma. 

The resistance of bacteria to topical antibiotics is another issue, such that instillation periods that are too short or too long or repeated over time can result in bacterial resistance. Finally, and not to be overlooked, the drugs can be expensive.


The regimen begins with an injection of LidoPhen 1%/1.5% (cyclopentolate/tropicamide, VNH Pharmaceuticals Pvt, Ltd.) at the beginning of the surgery.

The surgery ends with an injection of at least 0.5 ml of intracameral moxifloxacin 0.1%. 

However, 0.1 ml of cefuroxime 1% can be substituted in place of the moxifloxacin. Moxifloxacin also can be used for stromal hydration because recent data have indicated that the antibiotics remain in the wound for about 24 hours.

Finally, at least 4 mg of subconjunctival triamcinolone acetonide is injected at least 5 mm inferior to the inferior limbus. No perioperative topical nonsteroidal anti-inflammatory drug (NSAID) or steroid is used, Dr. Shorstein explained.


The use of moxifloxacin in the manner described for stromal hydration and in an intracameral injection has been associated with low endophthalmitis infection rates. 

This was supported by a meta-analysis that concluded that there was no supporting evidence that any postoperative use of topical antibiotics lowered the risk of endophthalmitis. 

Another study found no difference in the endophthalmitis rates with or without the use of short-term topical antibiotics in conjunction with a regimen of intracameral antibiotics, according to Dr. Shorstein.

A look at the studies that evaluated triamcinolone injections during cataract surgery showed that similar or better control of inflammation was achieved with subconjunctival injection compared with topical steroid instillation or with a steroid plus an NSAID in the 2017 PREMED Study. 

In the latter, the inflammation was well controlled in patients with diabetes who did not develop cystoid macular edema, but the intraocular pressure (IOP) was higher because of a higher subconjunctivally injected steroid dose, he pointed out.

That result leads to consideration of the importance of dose and injection site.

“Location is everything,” Dr. Shorstein said. “Injecting steroid closer to the limbus produces a higher concentration of the steroid in the aqueous and a higher mean IOP at 3 months compared with the same dose injected more posteriorly resulting in a lower aqueous concentration and a lower mean IOP.”

There is a tradeoff when injecting the drug more anteriorly. Pain and iritis are addressed but it carries the increased risk of higher IOP. Injecting more posteriorly should be more beneficial to the macula with less chance of IOP spikes ,but perhaps at the expense of enhanced pain and iritis control.

Initially, Dr. Shorstein reported, the drop-free regimen included the concentrated form of triamcinolone that resulted in some IOP spikes; with the same dose but injecting a greater volume (0.4 mL) of the dilute form of drug (10 mg/mL), fewer IOP spikes occurred and the physicians adhere to this practice.

“The most common problem associated with steroid injections is conjunctival hemorrhage that results from nicking a blood vessel during the injection,” he said. “This can be minimized by visualizing the needle tip and avoiding large vessels.”

Rarely, self-limited late hemorrhages months after the injections have been observed.

Drug reflux is another problem that can be avoided by tunneling the needle 2 to 4 mm under the conjunctiva and injecting slowly.

Dr. Shorstein also advises physicians to educate patients about the presence of the depot white spot and that it generally resolves in about 1 to 2 months and that, while IOP spikes occur infrequently, patients should have a checkup 1 month postoperatively.

Finally, when adhering to the dropless regimen, Dr. Shorstein noted the importance of instilling povidone-iodine 5% solution for 3 to 5 minutes, careful wound construction, leaving a relatively firm eye at the end of the surgery, and use of stromal hydration with an antibiotic.

Dr. Shorstein has no financial interest in this subject matter. The drugs mentioned are used off-label.

Articles

During AAO 2020, Neal H. Shorstein, MD, explains how physicians at Kaiser Permanente have a streamlined regimen using a prophylactic drop-free drug before cataract surgery for more than a decade. 

AAO: Drop-free prophylaxis regimen before cataract surgery lowers treatment burden with caveats

The first-line treatment for multiple sclerosis (MS), fingolimod 0.5 mg (Gilenya, Novartis), reduces both the number of relapses and disease progression in patients with relapsing-remitting MS and may reduce the incidence of uveitis, which is higher in this patient population compared with the general population. 

However, the downside is that the drug can cause fingolimod-associated macular edema (FAME), and patients require close observation.

The drug works by blocking movement of central memory T-cells from the lymph nodes to the blood stream and has been shown to have a favorable effect on murine models of experimental autoimmune uveitis, according to Bradley Smith, MD, and Scott Sonne, who discussed the topic during a presentation at the American Academy of Ophthalmology’s virtual 2020 annual meeting.

Dr. Smith is a physician partner at The Retina Institute in St. Louis and an instructor in Clinical Ophthalmology & Visual Sciences at the Washington University School of Medicine in St. Louis, MO. Sonne is from the St. Louis University School of Medicine in St. Louis.

The investigators conducted a retrospective analysis

 to determine the incidence of uveitis and macular edema in patients with MS who were treated with fingolimod 0.5 mg. The study patients were identified in the electronic health record at The Retina Institute.


A total of 188 patients were included in the study; they had been followed for from 1 to 104 months (mean, 60.9) after treatment with fingolimod.

The authors reported that no patient had or developed uveitis. Acute macular neuroretinopathy developed in 1 patient. Twenty-six (13.83%) patients had a history of optic neuritis and 7 (3.7%) had a recurrence during the study. Fingolimod was discontinued in 3 patients after 57, 43, and 13 months for nonophthalmic reasons.

FAME developed in 3 (1.6%) patients, none of whom had intraocular inflammation or another identifiable cause of the ME.

The authors also reported good visual acuity (VA) results in most patients, i.e., 20/40 or better in 93% of eyes; 5% had a VA ranging from 20/50 to 20/200, and 2% had a VA below 20/200.

“The VA in 2 eyes was worse than 20/400 as a result of optic neuritis. Additional causes of visual loss in the patients with worse than 20/100 were optic neuritis, ischemic optic neuropathy, ruptured globe, keratoconus, macular hole, and amblyopia,” they commented.

It is recognized that uveitis occurs more frequently in patients with MS and develops in from 3.6 to 9 years on average. By contrast, uveitis did not develop in this patient cohort after a mean follow-up exceeding 5 years.

According to the investigators, fingolimod was well tolerated.

“Our retrospective review suggests possible efficacy against the development of uveitis in an at-risk population that is consistent with fingolimod’s anti-inflammatory effect in animal models,” they said. 

However, the investigators concluded that more work will need to be done to confirm or deny this possibility.

“Although there was a higher incidence of FAME, all patients were treated successfully with topical therapy,” they said.


Dr. Smith has no financial interest in this subject matter.

1. Sonne SJ, Smith BT. Incidence of uveitis and macular edema among patients taking fingolimod 0.5 mg for multiple sclerosis. 

 2020 Sep 21;10(1):24; https://doi.org/10.1186/s12348-020-00215-1

Bradley Smith, MD, presents at AAO 2020 on how fingolimod 0.5 mg, a first-line treatment for multiple sclerosis, may reduce both the number of relapses and disease progression in patients with relapsing-remitting MS as well as the incidence of uveitis.

AAO: Fingolimod for MS offers disease control with no development of uveitis


Kristen Brotherson, vice president, US surgical marketing for Alcon, discusses some of the recent advances in cataract surgery-related technologies, including a new advanced lens for patients with presbyopia (AcrySof IQ Vivity IOL).

AAO: Alcon showcases advanced IOL technology for presbyopia


Rudy Nuijts of the University Eye Clinic Maastricht, the Netherlands, discusses the highlights of his AAO 2020 presentation on a combination treatment regimen for lowering the incidence of cystoid macular oedema following category surgery.

AAO: Preventing cystoid macular oedema after cataract surgery


Rick Eiswirth, president and CEO of Alimera Sciences, provides an update on the company’s clinical trial that aims to evaluate its fluocinolone acetonide intravitreal implant 0.19 mg (Iluvien) as a baseline therapy for diabetic macular edema.

AAO: Alimera highlights NEW DAY Study for sustained-release intravitreal implant


Ted Leng, MD, MS, associate professor of ophthalmology with the Byers Eye Institute at Stanford, and medical advisor for Verana Health, talks about data insights for retinal surgeons. Leng is joined by Steven D. Schwartz, MD, the Ahmanson Professor of Ophthalmology and chief-retina division with Stein Eye Institute, UCLA. Schwartz highlights his AAO presentation, “New Insight into Real-World U.S. Injection Data,” which highlights the impact of the coronavirus disease 2019 pandemic on intravitreal injection usage.

Ted Leng, MD, MS, Byers Eye Institute at Stanford, and medical advisor for Verana Health, talks about data insights for retinal surgeons. Steven D. Schwartz, MD, Stein Eye Institute, UCLA, highlights his AAO presentation, “New Insight into Real-World U.S. Injection Data."



AAO