ODs will begin to see patients taking new oral MS drug

Optometrists can expect referrals from neurologists who want their patients with multiple sclerosis to be monitored for macular edema that can result from a new medication, according to two presenters here.

Ron Melton, OD, FAAO, and Randall K. Thomas, OD, MPH, FAAO, both PCON Editorial Board members and private practitioners from North Carolina, shared an array of case presentations here at a symposium sponsored by Primary Care Optometry News.

Gilenya (fingolimod, Novartis), the first once daily oral pill for relapsing forms of MS, according to Dr. Melton, has been shown in rare instances to cause macular edema. Optometrists should see MS patients before starting Gilenya to establish a baseline to ensure the retina’s health, then again 3 months later for repeat testing to rule out the presence of macular edema.

“And if there’s no macular edema at 3 months, it’s not going to happen,” Dr. Melton said.

The doctors also discussed the use of the new Lotemax ointment (loteprednol etabonate ophthalmic ointment 0.5%, Bausch + Lomb).

“The official indication for this unique product is for postoperative inflammation and pain after cataract surgery, as opposed to using steroid eye drops four times daily,” Dr. Melton said.

Dr. Thomas advised attendees to decide in which patients to use the agent. “It’s an ester-based steroid,” he said. “Where might we use this? Some patients have trouble putting in loteprednol drops during the day; have them use the loteprednol ointment at bedtime. People with corneal transplants need ongoing anti-inflammatory suppression. Other considerations are blepharitis, giant papillary conjunctivitis, Thygeson’s chronic keratitis, stromal immune herpetic keratitis, corneal erosion. Do what makes sense.”

Topamax (topimarate, RW Johnson) is indicated for the treatment of seizure disorders but is primarily used off-label for migraine headache, weight loss, depression and bipolar disorder.

“A significant minority of these patients will develop transient bilateral blurring and increased IOP,” Dr. Thomas said. “They will have simultaneous bilateral angle closure. This is not a true anatomic angle closure.

“In some predisposed people, the ciliary body complex will swell, which moves the lens forward and induces myopia. This results in the blurred vision complaint, which drives the patient into your office,” he continued.

“You can correct them, so you know it’s not an organic problem, but they have high pressures,” Dr. Thomas said. “Call the prescribing physician and let them know that the Topamax needs to be stopped.”

Dr. Thomas said, “This is not a crisis. Treat it exactly as you would treat angle closure, except you do not use pilocarpine; use a cycloplegic agent. It stabilizes the ciliary body, causing it to de-swell, allowing the iridocorneal angle to open up. Put them on an aqueous suppressant.”

• Disclosures: Drs. Melton and Thomas are consultants to Bausch + Lomb.

Speaker: Use caution when prescribing acetaminophen

Optometrists have a number of options when treating patients for pain, but pay close attention to dosage, even when choosing an over-the-counter agent, according to Primary Care Optometry News Editorial Board member and University of Houston College of Optometry professor Bruce E. Onofrey, OD, RPh, FAAO, FOGS, in a PCON-sponsored course.

“Vicodin (hydrocodone and acetaminophen, Abbott) is a good choice for pain treatment,” Dr. Onofrey said. “It’s a perfect mixture of a very potent opioid (5 mg) with acetaminophen (500 mg).

“But which of these two drugs is most dangerous,” he asked, “hydrocodone or acetaminophen? Acetaminophen has the greatest potential risk for producing liver failure. It’s easy to exceed this dosage because everything contains acetaminophen.

“Opiates also have their own problems,” he continued. “You can’t drink or drive or take other sedatives, and there is a host of antihistamines with sedative effects that you must be aware of. Have a broad view of the range of over-the-counter products a patient could be taking.”

Dr. Onofrey suggested an effective alternative. “Acetaminophen in combination with ibuprofen is an excellent drug that I think is better than Vicodin,” he said. “It’s better for neural or corneal pain.”

He recommended two extra-strength acetaminophen three times a day with 600 mg of a nonsteroidal anti-inflammatory drug three times a day. “If you want a super analgesic, there’s no reason you can’t prescribe Vicodin along with one tablet of ibuprofen,” he said.

“In a normal situation of corneal healing, that will happen within the first 24 hours,” Dr. Onofrey said. “If the pain lasts longer, something else is going on.”

Dr. Onofrey also shared a trial he uses to determine if a patient will benefit from Restasis (cyclosporine A, Allergan) therapy for dry eye.

He gives the patient a 5-cc bottle of a generic steroid such as fluorometholone, prescribing it three times a day for a week, twice a day for a week and then once a day until the bottle is empty. The patient is instructed to return when through with the steroid.

“If they get a benefit from the steroid, I put them on Restasis,” Dr. Onofrey said. “I never use steroids as maintenance therapy. They can be used intermittently as needed for 2 to 3 weeks, which is called ‘pulse’ therapy. Once they are stabilized, they return to cyclosproine A.”

• Disclosure: Dr. Onofrey has no relevant financial disclosures.

Application of evidence-based medicine, imaging improves outcomes

Practitioners who combine the use of new technology and clinical trial results have “an approach to treating a retina patient that is much more definitive and outcomes-based than in the past,” according to a presenter here during a Primary Care Optometry News-sponsored symposium.

Anthony A. Cavallerano, OD, FAAO, PCON Editorial Board member and director of the Store and Forward Boston Training Program at the VA Boston Health Care System, along with Jerry Cavallerano, OD, on staff at Beetham Eye Institute, Joslin Diabetes Center, Boston, presented research results that drive clinical decisions for treating age-related macular degeneration and diabetic retinopathy.

“More and more evidence-based information is available every day to help us understand how we should approach patients,” Dr. Anthony Cavallerano said.

“Advanced imaging technology goes a long way toward providing us with additional information that’s useful in looking at outcomes-based data,” he added.

Prior to the Age-Related Eye Disease Study, “there was a lot of intuitive information and a less-than-scientific understanding that antioxidants and multivitamins may go a long way in helping to at least prevent the progression of the atrophic type of AMD,” Dr. Anthony Cavallerano said. “The AREDS study was invaluable, in that it was the first study that provided us with information on what we might do to treat patients with dry AMD.”

AREDS showed that “with intervention, we can reduce the risk of progression to severe vision loss and severe AMD by about 25%,” Dr. Anthony Cavallerano said. “When you translate that into the number of patients we have at risk for advanced AMD, that’s considerable. The socioeconomic benefit of looking at this data is extraordinary.”

Dr. Jerry Cavallerano said the Diabetic Retinopathy Clinical Research (DRCR) Network is “instrumental for evaluating care.” The group combines data from separate sites, ensures that consistent study protocol is implemented and certifies refractionists and all study personnel.

“There were several misperceptions in our understanding of diabetic macular edema (DME),” Dr. Jerry Cavallerano said. “Based on the results of previous studies, we thought scatter laser might exacerbate macular edema. Based on DRCR.net findings, we find that it doesn’t. We also said laser for DME was not very beneficial in improving visual acuity, but we found that as it was applied in the DRCR.net it was. Previously, the perception was that focal treatment reduced the risk of moderate vision loss, but did not result in vision gain, while in the DRCR study, we saw that vision improved.”

Another study under the DRCR umbrella showed that “intravitreal ranibizumab with prompt or deferred focal grid laser was superior to the focal grid laser alone and superior to triamcinolone in conjunction with laser for diabetic macular edema for patients who met study eligibility criteria,” he said.

• Disclosures: The doctors have no relevant financial disclosures.