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BLOG: Moving away from the surface
As an avowed ocular surface guy (some would say ocular surface obsessed), it’s odd to find that some of the most interesting stuff going on when it comes to the ocular surface is stuff that avoids the surface altogether. I can think of two huge areas of interest to all of us that apply: glaucoma treatment and perioperative cataract surgery care. Traditionally both involve the use of multiple topical medications, often with complex regimens, that can be quite rough on the ocular surface. This in turn can lead to problems with treatment compliance.
Glaucoma care could not be more in the bull’s-eye of medicine’s macro trends. On the plus side, the most ubiquitous generic medication, latanoprost, has almost no deleterious effect on the conjunctiva, cornea or meibomian glands. It may be the only generic conversion to achieve “no-brainer” status in eye care. Even here the problem of preservative allergies visits the ocular surface. Compliance issues and both medication costs and insurance hassles will drive the “glaucoma as a surgical disease” bus. I can’t remember being as excited about a glaucoma treatment as I am about sustained release injectable lipids since, well, the introduction of Xalatan (latanoprost, Pfizer).
No more crusty eyelids and flaming red eyes; compliance assured with every office visit. Big win for the ocular surface.
Cataract surgery is in the early stages of a similar evolution away from topical medications. The intracameral injection of an antibiotic and a steroid at the end of a cataract extraction ensures 100% compliance for those two medications in the 92% or so of patients who do not have an inflammatory “breakthrough.” This leaves only the NSAID unaccounted for. If we are obsessing over a 10-fold decrease in endophthalmitis from 0.03% to 0.003% we would do well to remember a similar decrease in cystoid macular edema (CME) in the 90s from approximately 6% to approximately 0.6% with the use of topical NSAIDs.
What if we find that ketorolac injected into the eye during phacoemulsification not only reduces the incidence of acute floppy iris syndrome, but also blocks all Cox-1 and Cox-2 activity long enough to provide the same anti-CME effect? Without pre- and post-op eye drops? No more stinging and burning for your patients’ eyes and your staff members’ ears (no insurance preauthorization calls).
The move away from the ocular surface is happening.
Disclosure: White reports he is a consultant for Bausch + Lomb, Allergan, Shire and Eyemaginations; is on the speakers board for Bausch + Lomb, Allergan and Shire; and has a financial interest in TearScience.