Experienced clinicians offer advice on working new agents into existing therapeutic regimens

Leo P. Semes, OD: This discussion will focus on drugs that have been introduced during the past 24 months. Let's start with Trusopt (dorzolamide, Merck). The indicated dosing is three times a day for glaucoma. Has anybody gone away from that? Has anybody decided to stick with that? Do you prescribe it differently as an additive medication? Has anybody used it for a first-line medication?

Bruce E. Onofrey, OD, RPh: We waited a very long time for Trusopt to come out, and we had great expectations. My experience with Trusopt has been such that I found it to be a hot and cold drug. When it works, it works quite well, and when it fails, it fails miserably. And, it fails miserably a fair percentage of the time.

I am also concerned by some of the anecdotal reports about corneal edema and cystoid macular edema (CME) associated with the drug. It is also a sulfonamide, so there is an allergy potential. With this particular agent, because it has potential for failure, I have tended to stick to the three times daily dosage scheme, which is not a real advantage today within the paradigm of drugs that have the ability to be used less frequently. So, this is probably a second- to third-line drug in my opinion.

David Sendrowski, OD: I agree. In a clinical setting, Trusopt is usually an additive medication; and in such a role, we use it in a twice daily administration, not three times daily. In about 30% to 40% of patients on Trusopt as initial glaucoma therapy, we did not see a good lowering effect from the drug.

We use it in clinical situations in which we want just a small additive effect with the present medications the patient is on. The patients who do get that added effect get the additional lowering effect that we were looking for.

Carl Spear, OD: Trusopt was just a good drug at a bad time. It never got any kind of real hold in the marketplace. Then, better drugs came along quickly. So, we never did end up using it very much.

Bobby Christensen, OD: We have used it for patients on pilocarpine and Timoptic (timolol maleate, Merck), and it seems to work well as additive therapy with Timoptic. Coming off pilocarpine, you get about the same response. So, at least you can go from a four times daily drug to a three times daily drug with about the same results, and patients can see better at night.

Dr. Semes: So, you use Trusopt mostly as a replacement for pilocarpine?

Dr. Christensen: I use it a lot as a replacement. My long-term pilocarpine patients have been doing well, but Trusopt is an easier drug to use.

Dr. Semes: That is interesting because they have somewhat separate mechanisms of action. You're still seeing efficacy with that?

Dr. Christensen: It works well, and studies have shown that to be the case, also. A clinical study comparing Trusopt with 2% pilocarpine showed almost exactly the same percent lowering effect. (Strahlman E. The use of dorzolamide and pilocarpine as adjunctive therapy to timolol in patients with elevated intraocular pressure. Ophthalmol. 1996;103(8).)

Dr. Onofrey: They do have different mechanisms. Trusopt inhibits production, and pilocarpine increases outflow, so they could even be additive. Does anybody believe that Trusopt is a drug of primary choice? Would anybody start a patient on this drug as an initial treatment?

Dr. Christensen: In some cases yes, you consider the health problems the patient has against him or her. If he or she has congestive heart failure and starting cataract, it gives you an option. So, I would use Trusopt as my first-line drug, but it is not one we go to every time.

Shift from beta blockers

Dr. Semes: In terms of replacing drugs, do you see a shift away from beta blockers as a primary or initial treatment for glaucoma?

Dr. Onofrey: Absolutely. Beta blockers are still quite cost effective and, as a group, they are quite efficacious. However, they have significant potential side effects, and they are suspect in inhibiting flow to the optic nerve. A study comparing Betoptic (betaxolol HCl, Alcon) to Timoptic showed that Timoptic was better at lowering pressure over a 3-year period. However, Betoptic was shown to preserve greater optic nerve function.

This is not something we should all follow, because it's one study that suggests drugs that protect the optic nerve head by preserving ocular blood flow may be the way to go.

I have a tendency to lean toward those types of drugs in treating my patients. That's why I have leaned toward drugs like Alphagan (brimonidine, Allergan) in many cases instead of a beta blocker. Studies with Alphagan have suggested that it does not inhibit blood flow to the optic nerve. Therefore, I think that's why people have a tendency to select a safer and more effective drug as their initial treatment of choice over a beta blocker.

Dr. Semes: Blood flow to the optic nerve is really high profile right now. In the past 9 to 12 months, there has been a lot in the literature about this issue. Does that influence your prescribing decisions?

Dr. Sendrowski: No, it doesn't. Until those studies are fairly conclusive, I don't let them influence me. However, I feel the beta-blockers are falling out of favor with patients in terms of the ocular side effects; it is certainly not our first drug of choice. When we switch patients who are on beta blockers like Timoptic, one of the drastic differences they notice is that they don't get the common ocular side effects. So we're using it, but down the line more and not as a first-line drug for glaucoma.

First-line glaucoma treatment

Dr. Semes: What are you starting folks on?

Dr. Sendrowski: The two top medications that we're presently using are Xalatan (latanoprost, Pharmacia & Upjohn) and Alphagan. Our biggest problem with glaucoma patients is noncompliance. Alphagan's twice daily administration is nice and Xalatan administered once daily is also favorable to many of our patients. We find that compliance is better and side effects are much lower.

Alphagan, certainly, can be both a first-line and second-line drug along with Xalatan. We found them to be good first-line anti-hypertensive medications that we use on a lot of our patients.

Dr. Christensen: There are many variables to consider. If the patient is healthy, young and does not smoke, I use Betoptic S. I like a selective beta blocker just because it is easy to get. It is on most of the formularies, we have used it for many years and it has worked well. If you have someone with health problems, that's probably not going to be the choice.

Dr. Onofrey: I lean toward Alphagan. If a patient is already on a beta blocker and hasn't reached his or her target pressure, I will reduce the beta blocker, keep it going and add Alphagan to the therapy. So, I use Alphagan as a primary drug of choice. I like the efficacy of the drug and I like the lack of systemic side effects associated with it. And, these side effects can be significant even in younger individuals, producing impotence, headache and depression. These are not issues with the clonidine derivatives.

I don't ever stop using beta blockers unless patients have significant side effects. However, I will, instead of increasing a concentration from 0.25% to 0.5% or from once a day to twice a day, almost always add Alphagan to that therapy.

I always use Alphagan in its full twice-a-day dosage. You can sometimes get away with using beta blockers once a day, but I have found problems with using Alphagan once a day.

Dr. Semes: When you talk about reducing beta blocker applications, are you talking about reducing concentration as well as frequency of dosage?

Dr. Onofrey: I rarely use the 0.5%. When I talk about reducing it, most of these patients come in on monotherapy: 0.25% beta blocker twice a day. And if I find that's not adequate, I don't go up. I actually go down to once a day, but add Alphagan to that.

Dr. Spear: I still lean toward a beta blocker as a first-line medication unless there is a frank contraindication. It has been around, and it is on all the formularies. Although the side effects are there, I still lean toward a beta blocker. Second-line medication is either Xalatan or Alphagan.

J. James Thimons, OD: Most patients still receive beta blockers as the primary drug for several reasons: the general comfort with what the drug's going to do, the predictable intraocular pressure reductions and the modest side effects. If you exclude patients with obvious contraindications, there are not a lot of problems with patients on beta blockers.

But, we have started to look at the issue of cost. Xalatan is significantly more expensive per unit dose than any other drug on the market. It is very difficult for me to justify that in a population of patients where cost issues are a concern. It also affects compliance.

Both Alphagan and Xalatan show excellent additive properties to beta blockade. I am developing a pattern in a large number of patients of adding either Alphagan or Xalatan as my second drug to an existent beta blockade therapy in successful patients who we need further control of.

Dr. Semes: In our clinic, we've probably had 20% to 30% of the patients started on Alphagan develop topical allergic responses.

Dr. Sendrowski: I have seen similar experience with Alphagan. Approximately 10% of our patients come back with a topical allergy from the medication.

Dr. Thimons: From my clinical experience, which would be about 800 patients on the drug, fewer than 100 have had a problem.

Dr. Onofrey: The studies with Alphagan show that 18% of patients experienced allergic reactions. However, it is probably less than 18% in most clinical practices.

Dr. Thimons: We have had several patients complain of fatigue on Alphagan. Some improved, and others persisted and we discontinued. Has anybody else had that experience?

Dr. Christensen: Yes. It is not a high incidence, but we've kept patients on it, and it seems to get a little better, but it is just too early using Alphagan to tell.

Dr. Thimons: Have you discontinued anybody?

Dr. Christensen: I have not discontinued them for that. However, it's a question we need to ask. It is not in our repertoire of questions at the 3-month visit, but we should ask, because patients may think the fatigue is caused by something else.

Dr. Thimons: We have been getting the fatigue response within 24 to 48 hours. I find that by 7 to 10 days, if patients do get through it, they are over it. If by 1 week they haven't cleared it, they are not going to, and they are getting a clonidine-like effect even though it is supposedly completely selective. Obviously, it is some brain-barrier crossing that is taking place.

Dr. Onofrey: I haven't seen much fatigue, but I have seen dry mouth and headache associated with the drug.

Also, Xalatan has really stormed into the marketplace as a great drug. Does anybody consider it to be a front-line drug?

Dr. Thimons: No.

Dr. Onofrey: Besides iris pigmentation, have you seen any unusual adverse effects in patients taking Xalatan?

Dr. Semes: Yes. Thickening of the eyebrows and eyelashes.

Dr. Onofrey: There is the issue of CME.

Dr. Semes: It is anecdotal and circumstantial, but something probably to be aware of.

Dr. Christensen: What is the percentage of patients who have just had no effect using Xalatan?

Dr. Thimons: It is probably 5%, 7%, maybe even 10%.

Anti-infectives

Dr. Semes: Fluoroquinolones probably represent the most recent foray into the marketplace. What's your favorite fluoroquinolone, and what dosage do you use on corneal ulcers?

Dr. Sendrowski: It goes back and forth between Ocuflox (ofloxacin, Allergan) and Ciloxan (ciprofloxacin HCl, Alcon), those are my two favorite fluoroquinolones. Regarding infectious keratitis, we follow the manufacturer's recommendation, and we find that the fluoroquinolones are very good.

I use the fluoroquinolones for conjunctivitis and keratitis as the first drug of choice. In the clinical setting, we're seeing a wide range of different infectious agents taking over the ocular surface. It's difficult, at times, to determine what's attacking the eye.

So, in a clinical setting, offering the patient a broad-spectrum drug like the fluoroquinolone is effective.

Dr. Semes: Do you distinguish in your use of fluoroquinolones between contact lens related and non-contact lens related?

Dr. Sendrowski: I would sway toward tobramycin for contact lens related infections, just to be protective against Pseudomonas.

Dr. Christensen: I like Ciloxan for surface problems, such as corneal ulcerations and mucopurulent conjunctivitis, which can progress to something worse.

I like Ocuflox after refractive surgery. I don't like the precipitates that may get in the wound after refractive surgery. Also, Ocuflox has better penetration into the cornea, and Ciloxan has a little broader spectrum, so I make a clinical judgment depending on what's happening.

I stay away from aminoglycosides as much as I can. If I think it's Pseudomonas, I'll go with Ciloxan. And for pediatric infections, Polytrim (trimethoprim sulfate, polymyxin B sulfate, Allergan) is a wonderful antibiotic.

Dr. Onofrey: The Ocuflox doesn't leave the crystals behind, but the belief that the crystals are clinically significant is quite controversial. In fact, many believe that the presence of crystals has no effect on wound healing at this time. Also, as Dr. Christensen mentioned, Ocuflox may have better corneal penetration, and Ciloxan has a better spectrum of activity or at least greater efficacy against organisms.

This, in fact, produces a controversy from a marketing point of view for Ocuflox and Ciloxan, one promoting corneal penetration and the other greater efficacy. Recently, ophthalmology has been turning to the inhibitory quotient (IQ), a method of evaluating antibiotic efficacy well known to microbiologists and infectious disease specialists. By integrating both the tissue penetration and the potency, the IQ (penetration in mg/mL divided by the MIC ₉₀) allows the clinician to better predict antibiotic efficacy. The higher the IQ, the greater the probability of reaching a therapeutic drug level in the tissue. Applying the IQ to published penetration studies suggests that Ciloxan may be the better fluoroquinolone.

We must remember that the fluoroquinolone's efficacy, specifically against bacterial keratitis, is somewhat waning, dropping in some studies as low as 82%. As practitioners who deal with severe corneal disease, we must prepare ourselves for situations where fluoroquinolones may not work. And, certain studies suggest that monotherapy for bacterial keratitis is not a standard of care. Combination therapy, combining a fluoroquinolone like Ciloxan along with a fortified cephalosporin like cefazolin, anywhere from 33 to 50 mg/cc, actually has been suggested as standard of care for sight-threatening bacterial keratitis as initial therapy.

Dr. Spear: We usually use Ocuflox postop with cataract and refractive surgery, and we use Ocuflox a few days before cataract surgery. We also use Voltaren (diclofenac sodium, Ciba Vision) beginning a few days before cataract and refractive surgery.

Anti-inflammatories

Dr. Semes: Anti-inflammatories have been around for a number of years and have recently gained popularity for some new applications. For what sort of applications do each of you employ topical nonsteroidals?

Dr. Thimons: The bulk of my applications are off-label, and they have been derived from communications with other practitioners and articles in the literature. There are very few things that I've used the nonsteroidals for that are actually approved by the Food and Drug Administration (FDA), except for post-refractive surgery. I use Acular (ketorolac tromethamine, Allergan) to treat the glare phenomenon that patients experience following radial keratotomy.

I use Voltaren [now FDA-approved for this indication] specifically as an anti-inflammatory drug in a variety of circumstances. Sometimes, I use it as a replacement drug for steroids. It works particularly well in postoperative patients, especially postoperative cataract patients.

A recent study demonstrated essentially no difference at the 1-week, 3-week and 5-week visits with those two drugs. I think they're relatively interchangeable.

I've also used these drugs in managing patients who have uveitis and are known steroid responders, known glaucoma patients or individuals with discs who are at risk. We want to try to prevent a steroid response regardless of how minimal that opportunity is.

Another use is in IOL patients who have persistent postoperative inflammation.

Dr. Spear: Do you use it for CME?

Dr. Thimons: Yes. I feel you have almost no risk of damage to the patient, whereas oral steroids and deposteroids both have significant side effects and risk with a question as to increased incidence of efficacy.

Dr. Spear: Over the course of 1 year, we went full circle with using Voltaren before cataract surgery. We were using it preoperatively to hold down inflammation during and after surgery.

Then, we went away from it. The reason we went full circle was the patient population. We were using it and getting good results, but then we stopped using Voltaren preoperatively and postoperatively and we went back to Pred Forte (prednisolone acetate, Allergan). One reason was the cost.

Pred Forte is much less expensive and we didn't really see a big difference in inflammation.

Dr. Thimons: Do you use it selectively for patients who are known steroid responders?

Dr. Spear: Even on known steroid responders, we still have a tendency to go with Pred Forte and a beta blocker or Vexol (rimexolone, Alcon) and a beta blocker.

In an advanced glaucoma patient or for patients who have significant postoperative inflammation, we add Voltaren or Acular as a second-line medication. Postoperatively, for patients who are having significant inflammation and are still on Pred Forte, we add Voltaren or Acular as a second-line medication.

Dr. Onofrey: The nonsteroidal anti-inflammatory drugs (NSAIDs) were brought out for one reason: to try to have a stop gap drug that was an anti-inflammatory and was safer than a steroid.

We're always looking for drugs that have the same efficacy as a steroid with greater safety margins. I don't think they meet that criterion.

NSAIDs have two purposes: analgesic and anti-inflammatory effect. I believe that Voltaren, particularly, is an excellent analgesic drug for postop. However, if you want anti-inflammatory effect in spite of the potential complications of steroid response, I, too, would prefer to use a steroid, because that's a better drug.

I would add to it an anti-glaucoma medication. Regarding CME, one study showed that too rapid tapering of topical steroids is one of the prime causes of CME in postop cataracts. So we extend up to 3 months the slow taper of a patient following cataract surgery with topical medication.

Dr. Christensen: We use Voltaren for abrasions, with bandage contact lenses being used less often.

We start out four times daily for a few days and then use it twice daily for a few days. This is an excellent drug for pain from ultraviolet burns.

I also use it on epidemic keratoconjunctivitis and adenoviral infections, for added comfort. We use it once a day, maybe twice a day.

Dr. Sendrowski: My experience using NSAIDs, besides postoperatively, has been to treat abrasions. We have moved away from patching patients and bandage contact lenses to giving patients either Voltaren or Acular along with the antibiotic. The patients are much happier and they respond much quicker.

Dr. Onofrey: We keep coming back to the pain issue, which is a function of what NSAIDs do. They block cyclooxygenase and inhibit prostaglandins, which are the stimulators of peripheral pain receptors. So, we keep coming full circle on it as being a really good analgesic type of medication. I just question its anti-inflammatory effect.

Dr. Thimons: For the practicing clinician, it's important to differentiate the inflammation we're discussing. I don't think anybody would feel comfortable putting a patient who came in with a granulomatous uveitis on any of the nonsteroidals and expect him or her to improve; but, postoperative inflammation is a very different process, and NSAIDs work particularly well in postop inflammation management.

Dr. Onofrey: When we see delayed wound healing or infiltrates, the first thing we do is stop the NSAID.

Dr. Semes: Is the use of NSAIDs to treat corneal abrasions universal?

Dr. Thimons: I use it for corneal work. When I do a foreign body removal, I put two or three drops in before the procedure, then put a couple of drops in afterward and send them home with a topical antibiotic.

Anti-allergy

Dr. Semes: Let's move on to anti-allergy, starting with Livostin (levocabastine HCl, Ciba Vision). Does it work? How quickly? What response do you get?

Dr. Onofrey: Livostin is a great drug. It's a breakthrough drug in that it has a high potency, singular effect. You don't have to use a combination of a decongestant sympathomimetic with its potential side effects in combination with the antihistamine effect, which may be all that you really want in this situation.

The normal dosage is three times a day, but it is still an effective maintenance drug at a once- or twice-a-day dosage. In fact, it is a highly effective topical antihistamine drug.

Dr. Spear: It depends on patient presentation. If a patient is in the chair and is complaining of the normal itchy, burning sensation, I give him or her Livostin and tell him or her to take it as needed.

However, if someone comes in with a flaring, allergic-type conjunctivitis, I treat it differently. I give the patient a steroid to quiet it down and then put him or her on Crolom (cromolyn, Bausch & Lomb). If the patient is going to be on something long-term, I prescribe Crolom.

Dr. Onofrey: That's a good point about combination therapy and allergies. We don't start all patients on antihistamine therapy. Allergy must be staged first, and there are a variety of stepwise treatment options available. Artificial tears certainly play a role in treating allergy.

We must build from the bottom up and look at combining a mast-cell inhibitor like Crolom with an antihistamine like Livostin.

Dr. Thimons: To make my selection of an anti-allergy medication, I look at the patient's intensity of initial presentation and assess the patient's general allergy history.

If the patient suffers from allergies during a certain time period each year, Livostin is absolutely ideal. If it's severe, I would add a steroid. However, if a patient needs long-term relief, I would use Patanol (olopatadine, Alcon).

Certainly, you can use Crolom in those instances, but the Patanol really diminishes the itch. I have patients who have been on it for 6 months, and they have done quite well. I don't know what the long-term efficacy is; it hasn't been available long enough to test what occurs at 12 months.

Dr. Onofrey: Patanol has not been out long, but my experience has been similar to Dr. Thimons'. I have had about an 80% significant reduction in both acute symptoms and good control as you would expect with both the mast cell inhibition and the antihistamine effect. So, the only problem with Patanol is its cost. We all like the efficacious drug, but paying $40 to $50 is difficult in my situation.

Dr. Thimons: If you take it down to once a day though, it becomes a very cost-effective drug, and many patients can be managed after an intense treatment period on once-a-day therapy and do quite well.

Dr. Semes: Who is the best candidate for Patanol?

Dr. Sendrowski: I've had a lot of success with Patanol, especially with perennial allergic conjunctivitis patients. Those patients are in long-term therapy and are happier with both the symptomatologic and clinical relief that they get with the drug.

Cost becomes less of a factor because patients are willing to pay for that relief. The twice daily administration is very favorable with our patients and tends to increase patient compliance.

Contact lens patients can use Patanol before contact lens insertion and after removal.

We don't use it on every patient, however. You must take each patient individually.

Dr. Semes: On whom would you not use it?

Dr. Sendrowski: I would not use it on patients who have a severe seasonal allergic conjunctivitis. You can't expect Patanol to work as effectively as an initial dose of steroids.

Dr. Onofrey: I tend to use it in people with primary ocular symptoms. Those who have more diffuse symptoms get oral medications or a nasal steroid inhaler. They're much more effective than antihistamines.

Dr. Onofrey: I use Zyrtec (cetirizine, Pfizer) as my drug of choice for orals. It's safe for children as young as 6, in doses of 5 mg to 10 mg once a day.

Dr. Thimons: You don't use Claritin (loratadine, Schering)?

Dr. Onofrey: My only reason is that Zyrtec is the one on our formulary. Zyrtec and Claritin are drugs of choice.

Dr. Thimons: I'm still using Claritin (10 mg qd) as my drug of choice.

Dr. Onofrey: The only advantage of Zyrtec over Claritin is more flexible dosing. It comes in a 5 mg and 10 mg dose vs. only 10 mg. It's not a big issue, though, because they all come in liquid pediatric dosages.

Dr. Thimons: Claritin is approved in pediatric dose down to age 6.

Dr. Onofrey: It comes in chewable pills, and there is a quick absorption type of Claritin. They're equivalent third-generation nonsedating antihistamines.

Seldane (terfenadine, Marion Merrell Dow), as you know, is dangerous because of its drug interaction with erythromycin and ketoconazole causing cardiac complications. The replacement for Seldane is Allegra (fexofenadine, Hoechst Marion Roussel). Unfortunately, Allegra is the same potency, 60 mg, and it has to be given twice a day. I consider that an obsolete drug when you compare it to Zyrtec and Claritin, which are once-a-day drugs.

Antivirals

Dr. Semes: Regarding new antivirals, which oral medications are you using?

Dr. Thimons: We started using Famvir (famciclovir, SmithKline Beecham), not as a replacement, just as an alternative to acyclovir. So far it has worked well.

Dr. Onofrey: As we all know, it's almost mandatory to put any zoster patient on an oral antiviral to prevent post-herpetic general neuralgia, and Famvir is used three times a day vs. five times a day for acyclovir.

Dr. Thimons: It is also 500 mg.

Dr. Thimons: Have you used Valtrex (valacyclovir, Glaxo Wellcome) at all?

Dr. Onofrey: Yes, and they are all equivalent. Valtrex is still two pills, 1,000 mg three times a day vs. 500 mg twice a day for famcyclovir. So, if you have a choice, I would suggest Famvir.

Dr. Semes: Let's turn our attention to oral antivirals for simplex.

Dr. Spear: In a patient with superficial herpetic keratitis, add acyclovir as part of the treatment regimen. Typically, with patients who had episodes of recurrent herpetic keratitis, we put a few of them on a low maintenance dose to try to prevent the recurrence.

Dr. Thimons: I don't use oral acyclovir on any patient with topical epithelial keratitis unless he or she is nonresponsive to Viroptic (trifluridine, Glaxo). Viroptic is such a well-accepted drug. Its cost is significantly less than the use of acyclovir orally.

But I will add it to that small percentage who are not Viroptic responders. I wish we could get topical acyclovir. That would be an ideal drug.

Dr. Onofrey: I would use acyclovir on anybody who has a history of being immunocompromised, such as HIV-positive patients, people on chronic steroids or any immunosuppressive therapy for organ transplantation, or if they have asthma or arthritis and are on steroids or cancer chemotherapy.

Dr. Thimons: There's a great new adenoviral drug that will soon be available. I have been involved in a peripheral way through patients, direct communications and observation with this drug.

Patient response has been very good. Infiltrates are gone and follicles diminish. It's very exciting. It will hit the market in late 1998 or early 1999. Cidofovir is its chemical name, and it will be manufactured by Storz. n

For Your Information:

• Bobby Christensen, OD, can be reached at 6912 E. Reno, Suite 101, Midwest City, OK 73110; (405) 732-2277; fax: (405) 737-4776. Dr. Christensen has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any company mentioned.
• Bruce E. Onofrey, OD, RPh, can be reached at 9101 Montgomery Blvd., NE, Albuquerque, NM 87111; (505) 275-4226; fax: (505) 275-4023. Dr. Onofrey has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any company mentioned.
• Leo P. Semes, OD, can be reached at 1716 University Blvd., Birmingham, AL 35294-0010; (205) 924-6773: fax: (205) 934-6758. Dr. Semes has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any company mentioned.
• David Sendrowski, OD, can be reached at 2575 Yorba Linda Blvd., Fullerton, CA 92631; (714) 449-7414; fax: (714) 992-7811. Dr. Sendrowski has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any company mentioned.
• Carl Spear, OD, may be contacted at Navarro Family Eye Care, 8485 Navarro Parkway, Navarro, FL 32566; (904) 939-3459; fax: (904) 939-8161. Dr. Spear has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any company mentioned.
• J. James Thimons, OD, can be reached at 100 East 24th St., New York, NY 10010; (212) 780-5012; fax: (212) 780-4980. Dr. Thimons has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any company mentioned.