EyeWorld Asia-Pacific June 2018 issue

June 2018 70 EWAP PHARMACEUTICALS a couple of weeks, as opposed to 3 months for cyclosporine,” he said. In his experience, lifitegrast begins to work in the first cou- ple of weeks. “We were part of the masked safety trial with the drug, and it was evident even at that early stage of treating which patients were getting benefit; they were getting it significantly and they were getting it right away,” Dr. Hovanesian said. 1 Dr. Matossian finds that for those who have failed with cyclosporine use, the addition of lifitegrast to the armamentarium gives them new hope. She also has a smaller cohort of patients who are on both lifitegrast and cyclosporine. “These are my more severe keratoconjunctivitis sicca patients,” Dr. Matossian said. How- ever, this group is under 25 pa- tients at this point. Such patients use each of the drugs twice a day, staggering them, she explained. Dr. Holland finds he is more likely to use a steroid as his second drop here. “If there was severe in- flammation, I might start lotepre- dnol on the onset with lifitegrast,” he said. “To me it makes more sense to add an effective steroid like loteprednol than to add a sec- ond drug that works on a similar pathway.” As for the lifitegrast itself, this may be good for more than just the signs and symptoms of dry eye disease. Dr. Holland also uses this off-label in cases of corneal inflammation, in patients with vernal keratoconjunctivitis and atopic disease because those have a T-cell ideology that he finds the lifitegrast works well on. “I add it to the regimens of my high risk corneal transplant patients he said, adding that he also uses this on ocular surface stem cell patients. Dr. Hovanesian thinks that over time other uses for lifitegrast will emerge, such as for those with conditions like conjunctival chalasis, superior limbic kerato- conjunctivitis, and other sources of ocular surface pain where there is inflammation. However, the key area for this drug will remain dry eye. “I don’t think that it has a lot of additional roles beyond dry eye, but dry eye is such a big area of need that it’s an important drug on that basis alone,” he concluded. EWAP Reference Donnenfeld ED, et al. Safety of lifitegrast ophthalmic solution 5.0% in patients with dry eye disease: A 1-year, multicenter, ran- domized, placebo-controlled study. Cornea. 2016;35:741–8. Editors’ note: Dr. Holland and Dr. Matossian have financial interests with Shire. Dr. Hovanesian has finan- cial interests with Shire and Allergan. Contact information Holland: eholland@holprovision.com Hovanesian: johnhova@gmail.com Matossian: cmatossian@matossianeye. com for medications, and most of the insurances will just cover generic NSAIDs such as a generic ketorol- ac,” Dr. Mamalis said. “I know that it may burn a little, but that’s what my patient base ends up using. Patients use this four times a day for 2 weeks in standard cases, then depending on their condition may use this longer.” Currently, he limits his injec- tions to intracameral antibiotics. “There are various combinations that are being done through com- pounding pharmacies that will have an antibiotic and a steroid injected either through the zonules or more posteriorly rather than intracamerally in the anterior chamber,” Dr. Mamalis said. How- ever, he still doesn’t think there’s good evidence that this approach has any distinct advantages over a simple intracameral injection of an antibiotic. What’s more, there can be a downside. “There have been some outbreaks of inflam- mation inside the eye from these transzonular or posterior injections that have been made from vari- ous compounding pharmacies,” he said. “I think the jury is still out regarding those.” Dr. Mamalis thinks more surgeons are going to use intraca- meral antibiotics in their cataract surgery regimens going forward. “The evidence is clear that it pre- vents endophthalmitis,” he said. One current shortcoming in the U.S., however, is the fact that there is no approved single-use injec- tion for antibiotics. “An ASCRS counsel has been put together to try to coordinate large nationwide studies to look at questions like this,” Dr. Mamalis said. “The first thing we are tackling is postopera- tive intracameral antibiotics versus topical antibiotics.” He thinks this could be a game changer. “Then we would have an FDA-approved medication that can be used for intracameral injection that I think all surgeons would consider using,” he said. EWAP References 1. Shorstein NH, et al. Comparative ef- fectiveness of three prophylactic strategies to prevent clinical macular edema after phacoemulsification surgery. Ophthalmol. 2015;122:2450–6. 2. Wielders LHP, et al. Prevention of macular edema after cataract surgery. Curr Opin Ophthalmol . 2018;29:48–53. 3. Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons. Prophylaxis of postoperative endophthalmi- tis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg. 2007;33:978–88. 4. Shorstein NH, et al. Decreased postop- erative endophthalmitis rate after institution of intracameral antibiotics in a Northern California eye department. J Cataract Refract Surg. 2013;39:8–14. Editors’ note: Dr. Talley Rostov has financial interests with Allergan, Bausch + Lomb, and Sun Pharma- ceutical Industries (Mumbai, India). Dr. Mamalis and Dr. Shorstein have no financial interests related to their comments. Contact information Mamalis: nick.mamalis@hsc.utah.edu Shorstein: nshorstein@eyeonsight.org TalleyRostov: ATalleyRostov@nweyes.com Zeroing in – from page 69 Eyes on the perioperative – from page 66