Alcon introduces multiple innovations in ophthalmology

There have been a number of recent advances in ophthalmology that are leading to improved care and enhanced outcomes for patients undergoing refractive surgery, cataract removal with IOL implantation, and those with ocular hypertension and glaucoma.

At Innovations in Ophthalmology, an Alcon Laboratories-sponsored medical education program, a faculty of renowned experts reviewed these developments and their applications in clinical practice.

Stephen G. Slade, MD, spoke on "Setting the Bar Higher with LADAR6000; High Speed Ablation and Advanced Registration Technologies." He told attendees that the new LADAR6000 platform is essentially a new device with more than 80% new parts. Its innovations have resulted in high satisfaction for the surgeon, the refractive surgery staff, and patients.

The advantages of the LADAR6000 include improved patient flow, a new laser cavity that is more reliable and allows for fewer gas changes, a better illumination system, and a highly user friendly console. The ablations are performed 50% faster, include the widest approval range for any laser platform, and can be done with an increased physician offset adjustment.

A number of enhancements will be available in the future. On Nov. 6, Alcon received approval for Advanced Assisted Registration. In addition, scleral registration with no eye marking and undilated eye tracking are in development.

"Alcon has responded well to all of its users' needs. The LADAR600 is a new and better laser that is yielding very positive early results in worldwide experience and leading to happier surgeons, staff, and patients," said Dr. Slade, director, Laser Center of Houston, Texas.

Robert N. Weinreb, MD, discussed the topic of "24-hour Intraocular Pressure." He described findings from studies performed at the sleep laboratory of the Hamilton Glaucoma Center, University of California San Diego. Relevant to patient care, those investigations revealed that IOP is usually highest at night, whether measured in normal eyes or those affected by ocular hypertension or glaucoma.

"Therefore, a single measurement of IOP during usual office hours is insufficient for glaucoma management," said Dr. Weinreb, director, Hamilton Glaucoma Center, and professor of ophthalmology, University of California San Diego.

He recommended the diagnosis and treatment of glaucoma should include measurements of IOP at various times throughout the day and at night if possible. In lieu of nocturnal measurements, peak IOP may be predicted by measurements obtained during the day in the office after the patient has been set back into the supine position for several minutes.

Knowing that peak IOP occurs at night, it is also important to consider the efficacy of antiglaucoma medications for lowering IOP over 24 hours. Studies from the sleep laboratory have also shown there are differences between different classes of medication in that regard. Prostaglandin analogues, including latanoprost (Xalatan, Pfizer) and travoprost (Travatan, Alcon) have been shown to reduce nocturnal and diurnal habitual IOP whereas timolol controls IOP during the day but not at night. In addition, travoprost was found to have an enduring effect on 24-hour IOP control even when a dose was omitted.

"These differences in activity are not surprising given the different mechanisms of action of these different classes of drugs," observed Dr. Weinreb.

Continuing with information relevant to glaucoma, Terrence P O'Brien, MD, addressed the issue of "Ocular Surface Disease and the Glaucoma Patient." He pointed out that ocular surface disease has a significant presence in the glaucoma population. In fact a survey of glaucoma patients indicated that about 40% may have some component of coexisting dry eye disease. However, signs and symptoms of ocular surface disease are often underappreciated by the treating physician who is focusing on IOP control and preventing disease progression.

Research on the underlying causes of dysfunctional tear states has improved understanding of factors that can precipitate or exacerbate dry eye, including the role of topical medications containing preservatives that can be toxic to the ocular surface. Benzalkonium chloride (BAK) is the leading ophthalmic medication preservative and is found in many glaucoma products in a range of concentrations.

"Studies of patients started on glaucoma medications containing BAK show there is significant upregulation of markers of ocular surface inflammation. That suggests the need for alternative formulations that can protect multidose medications against microbial contamination while preserving the ocular surface," observed Dr. O'Brien, professor of ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine.

Therefore, the recently approved benzalkonium-free formulation of travoprost (Travatan Z) is an important development in glaucoma management. It contains a novel, proprietary ionic buffer system (SofZia) that breaks down into inert, nontoxic ingredients when the drop contacts the ocular surface. Travatan Z has been shown to be as effective as the BAK-preserved Travatan in clinical trials and to have safety advantages compared with the commercial preparation of latanoprost in experimental models.

"Glaucoma medications containing BAK have deleterious effects on superficial eye tissue that are dose and time dependent, may be reversible, but are clinically important. Travatan Z is an exciting new development as the first and only IOP-lowering prostaglandin analogue without BAK," Dr. O'Brien said.

The evening concluded with a series of presentations focusing on lens removal and IOL surgery. Speaking about "Optimizing Outcomes With Presbyopia-Correcting IOLs," Richard J. MacKool, MD, provided a few tips to increase success with use of the apodized diffractive IOL, the AcrySof ReSTOR.

"In the U.S. FDA trial, 94% of patients indicated they would have the ReSTOR lens implanted again. However, it is possible to even surpass that impressive satisfaction level with a few simple consideration," said Dr. MacKool, private practitioner, Astoria, NY.

He recommended separating bilateral surgeries by several weeks in order to identify if patients will develop bothersome nocturnal glare and halos. Those events are uncommon, but it is important to identify them and avoid the second eye surgery until it resolves. Very rarely, a patient may have to have an implant exchange. Astigmatic control is also critical for optimal vision outcomes, and Dr. MacKool described his algorithmic approach for correcting various ranges of astigmatism.

The phenomenal uncorrected near vision afforded by this implant is key in its high patient satisfaction. Occasionally patients may not achieve good uncorrected near vision, and usually that is because they have an unusually large pupil when reading. These patients may be screened for preoperatively by measuring the accommodative pupil and counseled that they may need to use a miotic drop, at least temporarily.

"You'll find most patients will not object as they would rather instill a medication up to a few times a day than have to wear reading glasses," Dr. MacKool said.

Kay Coulson advised attendees on "Incorporating Refractive IOLs into Your Practice."She offered two tips to jumpstart the refractive IOL practice.

The first consideration is to block out days dedicated solely to evaluation of cataract patients and to plan to see only 15 to 20 patients on each of those days. The second strategy is to "spread the offense" so that patients are well-educated about the upgraded IOL option before they see the surgeon. Coulson recommended mailing information and a vision preferences checklist to patients prior to their visit, use of complementary materials in the office to remind patients about this option, and playing the Alcon DVD with AcrySof ReSTOR patient testimonials while patients are waiting in the exam lane.

"Although you may be seeing two-thirds fewer patients on your cataract evaluation day, you will find these techniques will increase your IOL upgrade rate so that your income can increase threefold," Coulson said.

Carmen Puliafito, MD, discussed "The Need to Redefine Cystoid Macular Edema (CME)." He said all CME should be considered clinically significant as permanent visual sequelae may follow after even a mild case.

"This is an important concept to consider in the era of refractive IOLs where patient expectations for quality of vision are higher than ever before," said Dr. Puliafito, professor and chairman, Bascom Palmer Eye Institute, University of Miami School of Medicine.

To prevent CME, he recommended a careful macula examination using OCT to identify risk factors, which should be treated if possible prior to surgery. In addition, a topical NSAID should be used pre- and postoperatively as there is mounting evidence it reduces the incidence of CME.

Among the NSAID options, nepafenac 0.1% ophthalmic suspension (Nevanac, Alcon) is an excellent choice. Studies with that agent show it achieves extremely high concentrations in the aqueous humor, is very efficient in reducing inflammation postcataract surgery, and reduces vitreous prostaglandin levels more effectively than ketorolac (Acular, Allergan) in an experimental model. A topical NSAID is also a cornerstone for management of postoperative CME.

Samuel Masket, MD, a private practitioner in Los Angeles, concluded the program by reviewing "Continued Advances in Customized Lens Removal Technologies and Techniques."

"It has been roughly 35 years since Charles Kelman introduced phaco, and we have had a series of incremental advances in the interim. However, only in very recent times have we been able to significantly further reduce incision size, and now we also have a new energy delivery alternative that is kinder to intraocular structures," Dr. Masket said.

Reducing the incision size has value for achieving the goal of astigmatic-neutral surgery. Two options exist: bimanual microincision phaco and coaxial microphaco performed using the UltraSleeve through a 2.2-mm incision and the Alcon Infiniti system that affords necessary excellent fluids and chamber stability. Dr. Masket said the latter has several advantages compared with the bimanual technique, including importantly that it involves little or no learning curve. A study performed by Dr. Masket involving fellow eyes of patients undergoing bilateral surgery showed the 2.2-mm coaxial approach was associated with significantly less surgically-induced astigmatism whether calculated by the algebraic method or with vector analysis.

Regarding reduction of energy exposure during lens removal, torsional (OZil) phaco is a tremendous advantage compared with traditional longitudinal ultrasound. The back and forth movements of the phaco tip that characterize torsional phaco affords a more efficient method of lens removal because it minimizes repulsion of nuclear material. With less total energy used, there is less heat generation and less chance for wound burn. In addition, there is less infused BSS with this technique, reduced chance for posterior capsule rupture, and reduced nuclear chips.

Dr. Masket described his own technique that combines torsional and longitudinal phaco. He begins by dividing the lens into four pieces with chopping using torsional alone, but adds traditional longitudinal ultrasound for removal to help move material along the needle and avoid clogging.