EyeWorld Asia-Pacific June 2016 Issue

62 EWAP PHARMACEUTICALS June 2016 Francisco, and in private practice, Los Altos, California, continues to routinely place epinephrine in the irrigation bottle to maintain pupil dilation, which he has found to be highly effective. “In 2014 we published our findings 2 that if there is no epinephrine in the bottle, there is a 4–5% rate of severe IFIS and a 12–14% rate of moderate to severe IFIS in patients who’ve never take alpha blockers,” he said. “I do think it is important to add an alpha agonist to the irrigation bottle.” Dr. Chang pointed out that there is a huge cost discrepancy. “Epinephrine costs about [US]$4 per vial, and lacking any evidence that Omidria is superior to epinephrine at maintaining mydriasis, I personally can’t justify using a product that is more than 100 times more expensive,” he said. Although he is glad the Centers for Medicare & Medicaid Services (CMS) has a program to subsidize patient access to newly developed drugs, in this case with a US$4 alternative that he has successfully used for decades, the new Omidria formulation doesn’t address an unmet need in his practice. Intravitreal experience Jeffrey Liegner, MD , Eye Care Northwest, Sparta, New Jersey, who was one of the creators of the Tri-Moxi and Tri-Moxi-Vanc intravitreal approach, explained that the need for this sprang from a confluence of events around 2010. At that time, Medicare had given instructions that all medications be single-use only. “We had to find something in a unit dose, and in the case of vancomycin, the smallest one came in a 500-mg vial. We would use 25 mg and throw out the rest of it—that didn’t make any sense.” The other contributing factor was soaring prices for the topical eye drops. “They were ridiculously expensive, and the prices were going up rapidly, particularly the antibiotics,” Dr. Liegner said. Also, insurance formularies became much more restrictive. “Sometimes without telling us they were forcing us into generics, less functional or lower performing drugs, and that was unacceptable,” he said. Dr. Liegner considered the idea of injecting the medication into the eye and inquired about what the retina specialists were using for patients with infections. “Moxifloxacin was the big one at that time, and vancomycin was always a favorite,” he said, adding that for inflammation they confirmed that they were using triamcinolone. He then set out to create a formulation that was PH proper, which would be held in solution and could be delivered at a dose that cataract surgeons could use. This led to the development of the two intravitreal drugs made by Imprimis, Tri-Moxi and Tri- Moxi-Vanc. The technique takes patient compliance out of the equation. Dr. Liegner wonders whether lack of compliance causes infection or if it may be due to inadequate placement of drops. The intravitreal injection of medication assures physicians that the drugs are delivered exactly where they are needed. There are two primary techniques for using this—pars plana and transzonular. Dr. Liegner estimates that 60% of physicians use a transzonular injection approach, and 40% use the pars plana approach. But it is the transzonular approach that he views as preferable. “People who do transzonular never go to pars plana,” he said. He thinks that the advantage of the transzonular approach is that it takes much less time, and there is no perforation of the eye or broken capillaries, hemorrhages, or pain associated with the injection. While many express concerns about the possibility of elevated intraocular pressure with the approach, Dr. Liegner has not found this to be a big concern. “We have studied this, and there seems to be less than one-tenth of 1% of individuals who have a steroid response of elevated IOP,” he said. Putting the medication in the eye can also fog the vision initially. “For the first 4–8 hours, you’re not going to have that fabulous vision that some surgeons crave,” Dr. Liegner said. Some patients see floaters for 2–3 weeks before the medicine gets absorbed. Dr. Liegner finds that the need for “rescue drops” in cases where intravitreal drugs have been used is dose-dependent. In his practice, the rate is about 2.6% of cases. Dr. Lindstrom views the approach, which costs US$20 for Tri-Moxi and US$25 for Tri-Moxi- Vanc, as a huge financial boon for patients, since this is administered during the procedure and is currently bundled into the facility fee payment. “It saves patients sometimes hundreds of dollars,” he said. Dr. Chang uses intracameral moxifloxacin, but in the absence of clinical studies he prefers topical postoperative anti-inflammatory drops. “Unless you do a fellow eye study comparing intravitreal injection in one eye to topical drops in the other, we simply have anecdotal impressions regarding our anti-inflammatory regimens,” Dr. Chang said. He uses generic topical NSAID and prednisolone acetate twice a day for 4 weeks in most of his cataract patients because it is easy to explain and remember. He refers patients to GoodRx.com to purchase these generics often at lower costs compared to their drug plans. Dr. Chang pointed out that every patient is different. “We published a study 3 showing that younger age and increasing axial length are separate and additive risk factors for a steroid response,” he said. Dr. Chang therefore cautions against injecting triamcinolone in young myopes. “I use loteprednol when the patient has these risk factors or glaucoma and NSAID only for extreme axial myopes.” He also individually varies and adjusts the anti-inflammatory treatment regimen. “I would love to see studies comparing the rates of rebound iritis, subclinical cystoid macular edema (CME), and steroid response with intravitreal Inside look - from page 61