narrow angles

What is Glaucoma?

Glaucoma is a series of conditions, characterized by a particular form of optic nerve damage that is often-but

not always- associated with elevated IOP.

The American Academy of Ophthalmology now defines glaucoma as “a group of diseases with certain features

including an intraocular pressure that is too high for the continued health of the eye.”

Risk Factors for Glaucoma Increased IOP

Age Family HistoryRace DiabetesPrevious Eye Injury

Goals of Glaucoma ManagementTreatment

• Lower IOP

• Control of IOP fluctuation for a full 24 hours

• Preserve Vision

Quality of Life Considerations

• Long Term Impact of Medications

• Balance of Efficacy and Side Effects

Medical Treatments Prostaglandin Analogues- work by increasing flow of

aqueous humor via the uveoscleral pathway out of the eye, thus lowering IOP

Uveoscleral Pathway: Aqueous humor flows through spaces of the iris and ciliary body under the sclera and drains via blood vessels. Some of the aqueous is absorbed directly through the blood vessels of the coroid

Dosed once a day- side effects may include hyperemia which is redness of the eye- usually mild and subsides within a few weeks of treatment

Medical Treatments Beta Blockers

Most common is timolol- work by decreasing production of aqueous humor which lowers IOP

Side effects may include low blood pressure, slow heart rate and general fatigue

Medical Treatments Alpha Agonists- dosed 3 times per day- cause increase in outflow as well as a decrease in production of aqueous humor to lower IOP ie. Alphagan

Side effects may include ocular allergies and drowsiness

Carbonic Anhydrase Inhibitors- 2 or 3 times per day dosing- lower IOP by decreasing production of aqueous humor ie. Azopt, Trusopt

Alcon’s Promoted Glaucoma Products

TRAVATAN ZThe Only First Line PGA that Provides Proven, Stable 24 Hour IOP Control without the Harmful Effects of BAK on the Ocular Surface

A Look at the Past…

Travatan Classic Benefits:Clinical studies show travoprost lowers IOP better than

latanoprost1,2 for a full 24 hours3

Travoprost has demonstrated a flattening of the 24 hour IOP fluctuations

.

.

The Body of Evidence Suggests Travoprost Demonstrates Control That Lasts

Study Author Result

Netland PA et al. - Travoprost vs. latanoprost and timolol in OAG and OH

Indicate that the IOP-lowering efficacy of travoprost was enhanced over the day from 8am to 4pm and was significantly better compared with latanoprost at 4pm.

Maul E. A - Six-week double-masked study – travoprost vs. latanoprost followed by a six-week open-label treatment on travoprost

Statistically significantly greater IOP-lowering efficacy compared to latanoprost at 5PM, which was approximately 20 hours post dose.

Konstas A et al. - 24 Hour IOP efficacy and safety of latanoprost vs. travoprost in exfoliative glaucoma.

Significantly better IOP reduction than latanoprost at the end of the day. Over the 24-hour curve, Travatan also offered a statistically lower IOP than latanoprost.

Sit AJ, Weinreb RN et al - Sustained effect of travoprost on diurnal and nocturnal intraocular pressure

IOP lowering persisted after omission of one to two doses. Between 41 to 63 hours after the last dose, diurnal IOP reductions was attenuated, but noturnal IOP reduction sustained.

The Body of Evidence Suggests Travoprost Demonstrates Control That Lasts

Study Author Result

Dubiner HB et al. - Comparison of the diurnal OH efficacy of travoprost and latanoprost over a 44-hour period in patients with elevated intraocular pressure

Reductions in IOP that may be sustained up to 84 hours after dosing…. significantly lowers IOP vs. latanoprost at the end of the day and provides excellent diurnal IOP control throughout a 24-hour period

Garcia-Feijoo J et al. - IOP lowering efficacy of travoprost vs. latanoprost over a 24 hour period.

Longer lasting IOP-lowering efficacy over latanoprost throughout 24 hours. The same effect was maintained for up to 48 hours.

Konstas A et al. – 24 Hour intraocular pressure control obtained with evening - vs morning – dosed travoprost in POAG

Both morning and evening dosings of travoprost provide effective 24-hour IOP reduction.

Travatan Z

The Only First Line PGA that Provides Proven, Stable 24 Hour IOP Control without the Harmful Effects of BAK

on the Ocular Surface

A Novel ApproachTo Ocular Surface

Preservation

Ocular Surface Disease (OSD) or Dry Eye has a Significant Presence

in The Glaucoma Population

Glaucoma Patients and Ocular Surface Disease are At Greater Risk

• Elderly (Decreased Tear Secretion)

• Multiple Topical Ophthalmic medications

• Ocular Surface Disease Symptoms May Contribute to

Poor Patient Compliance

• May Need Surgery Down the Road

Leung, et al. Prevalence of Ocular Surface Disease in Glaucoma Patients. J Glaucoma 2008;17:350–355

Common Dry Eye Symptoms

•Painful or Sore Eyes

•Burning / Stinging

•Foreign Body Sensation

•Blurred or Poor Vision

•Tired Eyes

BAK Impact on Ocular Surface Health

•Decreases Epithelial Cell Integrity1

• Epithelial Barrier is Compromised

• Healing is Impaired

•Increases Conjunctival Inflammatory Cells1

•Loss of Goblet Cells1

•Reduction in Tear Function2

•Decreases Tear Film Break Up Time (TBUT)1

1. Whitson ,et al. Glaucoma Drugs and The Ocular Surface, Review of Ophthalmology, November 2006

2. Leung, et al. Prevalence of Ocular Surface Disease in Glaucoma Patients. J Glaucoma 2008;17:350–355

Lewis RA, Katz G, Weiss MJ et al. Travoprost 0.004% with and without benzalkonium chloride: a comparison of safety and efficacy. Journal of Glaucoma. 2007;16:98-103.

Travoprost 0.004% BAK-Free (n=322 PP)

Travoprost 0.004% (n=339 PP)

Mea

n IO

P (m

m H

g)

Efficacy: Travoprost 0.004% Solution With and Without BAK

Unique Ionic Buffer System

An Alternative Preservative

When TRAVATAN Z® Solution comes in contact with ions such as potassium and sodium in the eye,

the ionic buffer preserving system becomes inactive, providing a solution that is safe and gentle on the eye.

DuoTrav (Travoprost 0.004%/Timolol 0.5% Ophthalmic Solution

What Are The Benefits Of DuoTrav® Solution?DuoTrav allows for continued IOP success

1. Enhanced efficacy – two medications in a single bottle (travoprost + timolol)

2. Enhanced convenience to improve compliance

3. Excellent tolerability to lower IOP and preserve visual field

Managing Number of Bottles is a Challenge for Clinicians

60% 40%

1 Medication2 or More Medications

Kass MS, Heuer DK. Arch Ophthalmol. 2002;120:701-713

Percentage of treated patients at 60 months

0%

10%

20%

30%

40%

50%

60%

32%Compliant

(n=31)

Two Meds

49%Compliant

(n=41)

One Med

Multiple Medications are a Treatment Norm

Non-Compliance Increases With the Number of Bottles

Patel SC, Spaeth GL. Ophthalmic Surg. 1995;26(3):234-236

DuoTrav Summary

DuoTrav® Solution is an ideal ‘single bottle’ alternative for glaucoma

Once daily dosing with the advantages of increased compliance and less preservative exposure

Increased power and endurance of the travoprost ingredient

AZARGA®

(Brinzolamide / Timolol) Ophthalmic Suspension

AZARGA®

• Fixed combination of brinzolamide 1%/timolol 0.5%

• Indication: Decrease of intraocular pressure (IOP) in adult patients with open‑angle glaucoma or ocular hypertension for whom monotherapy provides insufficient IOP reduction and when the combination therapy is appropriate

• In clinical trials the mean IOP-lowering effect of AZARGA® Suspension was 7 to 9 mmHg 1,2

• Dosed twice daily

AZARGA® The Studies

– Efficacy•AZARGA® Suspension vs. AZOPT® Suspension vs. Timolol1

•AZARGA® Suspension vs. COSOPT*2 – Comfort

•AZARGA® Suspension vs. COSOPT*3 Comfort Study

•AZARGA® Suspension vs. COSOPT*4 Patient Preference Study

Why is comfort important?

The degree of ocular comfort can have an impact on patient

adherence to IOP-lowering medication regimens.1-4

1. Tsai JC, McClure CA, Ramos SE, et al. 2003. Compliance barriers in glaucoma: a systematic classification. J Glaucoma, 12:393-8.2. Day DG, Sharpe ED, Atkinson MJ, et al. 2006. The clinical validity of the treatment satisfaction survey for intraocular pressure in ocular hypertensive and glaucoma patients. Eye,

20:583-90.3. Konstas AG, Maskaleris G, Gratsonidis S, et al. 2000. Compliance and viewpoint of glaucoma patients in Greece. Eye, 14:752-6.4. Nordmann JP, Auzaneau N, Ricard S, et al. 2003. Vision related quality of life and topical glaucoma treatment side effects. Health Qual Life Outcomes, 1:75.

AZARGA® Suspension Clinical Study Summary• AZARGA® Suspension produces IOP-lowering

efficacy that is statistically superior to both AZOPT® Suspension and timolol 0.5%1

• AZARGA® Suspension lowered IOP by as much as 9.1 mmHg(35%)2

• AZARGA® Suspension produced clinically meaningful IOP reductions from baseline which were similar to COSOPT*2

AZARGA® Suspension Clinical Study Summary• AZARGA® Suspension is significantly more comfortable than

COSOPT*1-2

• A significantly higher percentage (49%), on AZARGA® Suspension experienced no burning or stinging compared to patients on COSOPT* (15%) (p=0.0004)1

• Of those patients (n=106) expressing a preference, AZARGA® Suspension was preferred by 79% of patients, while only 21% of patients preferred COSOPT*2

• The degree of ocular comfort can have an impact on patient adherence to IOP-lowering medication regimens.3-6

• Generally well tolerated

Spring Optometric Learning Series2012

Glaucoma types: stats In US Open angle glaucoma 80% Angle Closure Glaucoma 20%

50% from narrow angles40% from plateau10% from lens rise

Evaluating Angles Most important

anatomic landmark is the scleral spur

can be seen an the innermost point of the line separating the ciliary body and the sclera.

The trabecular meshwork is located directly anterior to this structure.

Narrow Angles

relative pupillary block is most common cause

aqueous pressure behind the iris plane forces the iris anteriorly giving it the typical convex appearance

Indentation gonioscopy will flatten iris and open angle

Definitive treatment is peripheral laser iridotomy

Relative Pupillary Block

Plateau IrisNot all angle-closure is caused by relative pupillary

blockPatients with plateau iris tend to be female, in their

30-50s, hyperopic, and often have a family history of angle-closure glaucoma

Slit lamp examination of patients with plateau iris usually shows normal anterior chamber depth with a flat or slightly convex iris surface.

On gonioscopy, the angle is extremely narrowed or closed, with a sharp drop-off of the peripheral iris.

Plateau IrisPlateau Iris is due to

anteriorly positioned ciliary processes, which hold the peripheral iris forward

The anteriorly placed ciliary body forces the peripheral iris into the angle.

In Plateau Iris, the angle remains occludable with a patent iridotomy

Plateau IrisWhen indentation gonioscopy is performed, the double-

hump sign is seen.The more peripheral hump is determined by the ciliary

body propping up the iris root, and the more central hump represents the central third of the iris resting over the anterior lens surface.

The space between the humps represents the space between the ciliary processes and the endpoint of contact of the iris to the anterior lens capsule.

More force often is needed to open the angle on indentation gonioscopy than on pupillary block angle closure.

Plateau IrisPlateau iris syndrome is characterized by persistent

angle occludability (spontaneous, in the dark, or after dilation) in an eye with a patent iridotomy

More commonly, the diagnosis of plateau iris configuration is made on routine examination.

Plateau iris syndrome usually is recognized in the postoperative period when the angle remains persistently narrow in an eye after iridotomy

ALP: Argon Laser Peripheral Iridoplastythe procedure of choice to effectively open an angle that

remains occluded after successful laser iridotomy The procedure consists of placing laser burns on the surface

of the peripheral iris to contract the iris stroma between the site of the burn and the angle

Peripheral location of long-duration, low-power, large spot size laser burns is essential for success

The result is iris stromal tissue contraction and compaction that physically widens the angle and prevents the apposition of the peripheral iris against the trabecular meshwork

ALPI is highly effective, and the effect is maintained for years

Lens Intumescence..Lens RiseA large, intumescent lens or forward lens movement

due to zonular laxity or dehiscence may cause mechanical crowding of the angle

Diagnosis is based on shallow AC, narrow angles, Patent PI, narrow AC and short AXL in hyperopic individuals

Treatement is clear lensectomyMore and more lensectomies are taking the place of

chronic glaucoma therapy for these patients

41

New Advances in the Treatment of Ocular

Inflammatory Diseases

Theodore Rabinovitch MD FRCSC

Assistant Professor of Ophthalmology

University of Toronto, Department of Ophthalmology

Head, Humber Eye Division

North Toronto Eye Care

TOPICAL OPHTHALMIC CORTICOSTEROID THERAPY

TREATMENT OF INFLAMMATION IN THE ANTERIOR SEGMENT OF THE EYE

43

A Focus on Loteprednol Etabonate

44

Topical Ophthalmic SteroidsKetone Steroids

Higher-risk Dexamethasone Betamethasone Prednisolone Difluprednate

Lower-risk Fluorometholone Medrysone Rimexolone

EsterLoteprednol

McGhee CN, Dean S, Danesh-Meyer H. Locally administered ocular corticosteroids: benefits and risks. Drug Saf. 2002;25:33-55.

DifluprednateDexamethasone

Topical Ophthalmic Corticosteroids With a Ketone at C-20

Hydrocortisone Rimexolone

Fluorometholone

National Library of Medicine, Current Medication Information. Available at: http://dailymed.nlm.nih.gov/dailymed/about.cfm. Accessed May 16, 2009. Durezol (difluprednate ophthalmic emulsion) 0.05% [package insert]. Tampa, Fla: Sirion Therapeutics, Inc.; 2008.

Prednisolone

Corticosteroids Inhibit Initiation Points of the Inflammatory Cascade

Corticosteroids

Mast Cell

Membrane Phospholipids

Phospholipase A2

Arachidonic Acid

Cyclo-oxygenase

Cyclic endoperoxides

Porstacyclin(PCI2)

Prostaglandins(PGF2, PGD2, PGE2)

Lipoxygenase

Hydroperoxides

Leukotrienes(LTC4, LTD4, LTE4, LTB4)

Thromboxane A2

(TXA2)

MembraneStabilization

TryptaseChymase

Heparin Histamine PAF

Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112.

Loteprednol Etabonate 1. Unique Ester Steroid

2. Highly lipophilic….penetrates well into eye

3. High Receptor binding affinity leading to increased site activity and reduced free floating metabolites

4. Rapidly esterified into inactive moities resulting in less residual active molecule

47

2. Lipophilicity of LE Facilitates Optimal Ocular Tissue Penetration

Howes JF. Pharmazie. 2000;55:178-183.Alberth M, et al. J Biopharm Sci. 1991;2:115-125.

3.Greater Binding Affinity

Receptor binding affinity is 4.3 times that of dexamethasone 3

Druzgala P, et al. J Steroid Biochem Molec Biol. 1991;38(2):149-154.

1. Druzgala P, et al. J Steroid Biochem Molec Biol. 1991;38(2):149-154.

4. RAPID ESTERIFICATION

• Safety benefits – Single step leads to an inactive metabolite and low risk of

adverse events1,2• Significantly reduced incidence of IOP increase1,2

• Lack of C-20 at Ketone formation which has been implicated in cataract formation3

1. Novack GD, et al. J Glaucoma. 1998;7:266-269. 2. Howes J, Novack GD. J Ocul Pharmacol Ther. 1998;14:153-158.3. Manabe S, et al. J Clin Invest. 1984;74:1803-1810.

O

O

OO

O

O

HO

Cl

LEloteprednol etabonate

O

O

OHO

O

O

HO

M-COOHLE, 17-acid metabolite

(1-cortienic acid etabonate)(inactive)

O

OH

OHO

HO

1-cortienic acid(inactive)

1. Bodor N. Pharmazie. 2001;56(suppl 1):S67-S74.2. Novack GD et al. J Glaucoma. 1998;7:266-269.3. Howes J, Novack GD. J Ocul Pharmacol Ther. 1998;14:153-158.

LOTEPREDNOOL ETABONATE

Site active Corticosteroid.. In the ocular tissues!

Designed to achieve efficacy with a low incidence of side effectsTherapeutic effect after application

Followed by single step deactivation

51

LOTEPREDNOL ETABONATE OPHTHALMIC SUSPENSION 0.5%

LOTEMAXTM

53

Post op inflammationWith newer technology less post op inflammationTrend was away from topical steroids and use of

NSAIDSRebound iritis common

Continuing need for effective and safe suppression of inflammation

Resolution of Anterior Chamber Inflammation (Sum of Celland Flare Scores) at Each Visit During the Treatment Period – Study 1

Visit Treatment Groupn at Risk

Resolved

P Valuen %

2 (days 2-6)LE 0.5%Placebo

109111

164

15%4%

0.003


10292

4417

43%18%

<0.001


9876

6930

70%39%

<0.001

Final visitLE 0.5%Placebo

109113

7033

64%29%

<0.001

1. Stewart R, et al. J Cataract Refract Surg. 1998;24:1480-1489.

LotemaxTM: Post-operative Inflammation Study 1 ResultsLotemaxTM: Post-operative Inflammation Study 1 Results

55

Summary: Loteprednol Etabonate 0.5%: An Advanced-Generation Corticosteroid

The only ester ophthalmic corticosteroid*Therapeutic effect after application followed by a

predictable, single-step deactivationLower propensity to induce IOP elevation and

cataract

*C-20 position of the basic steroid structure

Other uses for Lotemax

Anterior uveitisHZV keratouveitisEpiscleritis and mild

forms of scleritisThygesons SPKRosacea keratitis

Dry EyeGPCSACPost PKP/graft rejection

chronic usePost Trab

56

LOTEPREDNOL ETABONATE OPHTHALMIC SUSPENSION 0.2%

ALREX®

Ocular Surface Allergy: Seasonal Allergic Conjunctivitis

Seasonal Allergic Conjunctivitis (SAC)2 Typically occurs during spring and autumn Itching, burning, redness, eyelid swelling, conunctival

hyperemia, chemosis, mucoid or watery discharge Generally mild, non-vision-threatening; considerable

discomfort, morbidity, loss of productivity 1. Abelson MB, et al. Ocul Surf. 2003;1:127-149.2. Chambless SL. Curr Opin Allergy Clin Immunol. 2004;4:431-434.

• Allergic hypersensitivity conditions affecting the ocular surface1 – Most commonly affected: eyelids,

conjunctiva, cornea

Corticosteroids Inhibit Initiation Points of the Inflammatory Cascade

Corticosteroids

Mast Cell

Membrane Phospholipids

Phospholipase A2

Arachidonic Acid

Cyclo-oxygenase

Cyclic endoperoxides

Porstacyclin(PCI2)

Prostaglandins(PGF2, PGD2, PGE2)

Lipoxygenase

Hydroperoxides

Leukotrienes(LTC4, LTD4, LTE4, LTB4)

Thromboxane A2

(TXA2)

MembraneStabilization

TryptaseChymase

Heparin Histamine PAF


Phospholipase A2

ActivityArachidonic Acid

LipoxygenasePathway

CyclooxygenasePathway

Mast CellMembrane

Phospholipids

HHT, MDA

Hydroperoxides(5-HPETE)

Leukotrienes(SRS-A, LTB4)

Prostaglandins(PGF2α, PGD2, PGE2)

Prostacyclin(PGI2)

Thromboxane A2

(TXA2)

HeparinHistamine PAFProteases (tryptase, chymase)

Early-PhaseMediators


Corticosteroids Inhibit Multiple Early Points of the Inflammatory Cascade

Phospholipase A2


LipoxygenasePathway


Mast CellMembrane

Phospholipids

HHT, MDA




Prostacyclin(PGI2)

Thromboxane A2

(TXA2)


Antihistamines1

Work Here

Most Combination Antihistamines/MCS1

Work Here




Mast Cell Stabilizers (MCS)1

Work Here

Phospholipase A2


LipoxygenasePathway


Mast CellMembrane

Phospholipids

HHT, MDA




Prostacyclin(PGI2)

Thromboxane A2

(TXA2)


Antihistamines1

Work Here


Work Here

Late-PhaseMediators





Work Here

Phospholipase A2


LipoxygenasePathway


Mast CellMembrane

Phospholipids

HHT, MDA




Prostacyclin(PGI2)

Thromboxane A2

(TXA2)


NSAIDsWork Here

Antihistamines1

Work Here


Work Here

Late-PhaseMediators





Work Here

Phospholipase A2


LipoxygenasePathway


Mast CellMembrane

Phospholipids

HHT, MDA




Prostacyclin(PGI2)

Thromboxane A2

(TXA2)


NSAIDsWork Here

Antihistamines1

Work Here


Work Here

Late-PhaseMediators




CorticosteroidsMast Cell Stabilizers (MCS)1

Work Here

65

Treatment of Seasonal Allergic ConjunctivitisSigns and symptoms of SAC occur after (a)

degranulation and release of preformed mediators from mast cells and (b) ensuing inflammatory cascade due to newly formed mediators

Because corticosteroids have the ability to ameliorate the immediate and secondary effects of mast cell mediators, corticosteroids may be the most effective choice for treating allergic conjunctivitis

Ono SJ, Abelson MB. Allergic conjunctivitis: update on pathophysiology and prospects for future treatment. J Allergy Clin Immunol. 2005;115:118-122.

2 randomized, double-masked, placebo-controlled, parallel-group multicenter studies1,2

268 patients with signs and symptoms of SAC treated bilaterally q.i.d. for 42 days

133 patients treated with loteprednol etabonate 135 patients treated with placebo

Results: Alrex was significantly more effective than placebo

Severity of bulbar conjunctival injection and itching over the first 2 weeks

Alrex® (loteprednol etabonate ophthalmic suspension 0.2%)

Clinical Efficacy and Safety in Seasonal Allergic Conjunctivitis

1. Dell SJ, et al. J Allergy Clin Immunol. 1998;102:251-255.

2. Shulman DG, et al. Ophthalmology. 1999;106:362-369.

Significant Resolution of Ocular Allergy Signs and Symptoms With Alrex®

1. Dell SJ, et al. J Allergy Clin Immunol. 1998;102:251-255.2. Alrex (loteprednol etabonate ophthalmic suspension 0.2%) Product Monograph. Bausch

& Lomb Inc.; Dec 22, 2008.

Signs and SymptomsSignificant Reduction

After Using Alrex P

Itching 1

Redness 1

Discomfort 1

Erythema 2

Foreign body sensation 2

Burning/stinging 2

Tearing 2

<0.001

<0.001

<0.001

<0.001

<0.005

<0.003

<0.011

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Alrex® Ophthalmic Suspension (loteprednol etabonate ophthalmic suspension 0.2%) is indicated for the temporary short-term relief of the signs and symptoms of Seasonal Allergic Conjunctivitis.

Alrex® Clinical Safety vs Placebo in Two 6-week Trials of SAC

SAC = Seasonal allergic conjunctivitis

Alrex (loteprednol etabonate ophthalmic suspension 0.2%) Product Monograph. Bausch & Lomb Inc.; Dec. 22, 2008

• Rate of IOP elevation similar to placebo

• 1 patient in each group experienced IOP elevation ≥10 mm Hg

– Alrex: n = 133

– Placebo: n = 135 0

1

2

3

4

Alrex Placebo

1% 1%In

cid

enc

e o

f IO

P E

leva

tio

n>

10 m

m H

g (

%)

Alrex Showed a Favourable Safety Profile With IOP Elevations Similar to Placebo

Accommodation Meets Asphericity in AO

• The Crystalens AO™ brings together Bausch + Lomb’s innovative accommodating lens technology and its proven aspheric lens design

• This accommodating aspheric IOL is designed to deliver premium vision at all distances without any intermediate vision compromise

• Since the Crystalens AO is aberration free, patients can enjoy best-potential vision quality with enhanced contrast sensitivity

2

Merging Innovation and Proven Design

4

Enhanced Vision Under All Conditions

Excellent Contrast Sensitivity• Patients should experience their best-potential postoperative

vision quality with enhanced contrast sensitivity

• This is particularly important in low-light or nighttime conditions

Uncompromised Intermediate Vision• The Crystalens AO is optimized for lifestyle vision

• As a result, objects at intermediate distances are as clear as objects that are near or far

CRYSTALENS AO™:ADVANCING OPTICAL QUALITY

• The Crystalens AO accommodating monofocal lens delivers 100% of available light rays at all distances• Patients can see near, intermediate and

distant objects with equal clarity

• The IOL, like the natural crystalline lens, can provide accommodation from distance to near vision by moving along the visual axis

• Both the natural lens and the Crystalens AO also arch, or change their radius of curvature, to increase their accommodation• Both move anteriorly and flex or arch to

increase their focusing power in the intermediate and near ranges

13

Designed to Accommodate for a Complete Range of Vision

Integrated Eye Care vs Co-managementintegrated eye care model: optometrists, ophthalmic

technicians, and ophthalmologists all work under the same roof to provide efficient and effective patient care

Co-management model: practices refer patients across boundaries and leave the optometrist as the primary care physician to handle a majority of eye care

integrated eye care is likened to a vertical integration in the same practice, and co-management comprises different practices where both jointly manage the patient

Advantages of Integrated Eye CareOptometrists have readily available access to specialty care

for their patientsThe patient already knows the practice and doesn't have to

travel further to go see a specialist, or worry about not being familiar with the practice

working in an integrated practice can be a great learning experience

Since everyone on staff has access to all the charts, there's an immediacy co-managed practices cannot offer.

ability to control the quality of care because everyone is under the same roof

narrow angles

Health & Medicine

elevated iop

control of iop fluctuation

risk factors

certain features

group of diseases

intraocular pressure

balance of efficacy

series of conditions