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From oldest to newest, these are: Maxitrol (neomycin, polymyxin-B and dexamethasone, Novartis), which comes in both suspension and ointment forms; TobraDex suspension and ointment (tobramycin with dexamethasone, Eyevance); and Zylet (tobramycin and loteprednol, Bausch + Lomb), which is only available as a suspension. STRATEGIES FOR SUCCESS HOW IMPORTANT IS IT TO BE “PRESERVATIVE-FREE”? • “Published studies have not demonstrated any clear benefits of the BAK-Free formulations.” • “There is a lack of evidence of clinically significant harm from a small number of BAK preserved drops in patients without OSD. This means that generally more expensive PF glaucoma medications should only be recommended for those on poly pharmacy or those with OSD but are not necessarily required for all patients.” —Br J Ophthalmol, July 2018 12 REVIEW OF OPTOMETRY JUNE 15, 2020 − From least to most expensive, these are: generic Maxitrol (about $25), Zylet (with a coupon it is about $35) and generic TobraDex (about $60-80). These prices may vary depending upon insurance plans and geographic location of the patient. − From safest to least safe (all are relatively safe): Zylet, Maxitrol and TobraDex. All three suspensions need to be shaken before instillation. Regarding antibiosis, these medicines are all clinically effective. There is no debate that Zylet is the “pick of the litter” here, especially for chronic conditions such as staphylococcal blepharitis, because of the ester-based steroid. When cost is truly imperative, generic Maxitrol is the best choice, but only for acute conditions that generally need treatment for no more than seven to 10 days, because of the dexamethasone. These combination drugs are real workhorses in routine clinical care. Do bear in mind, however, that unless there is a breach in the integrity of the corneal epithelium, an antibiotic is generally not needed, and only a straight steroid should be employed. • Intranasal steroids are the treatment of choice for allergic rhinitis in patients over age 12; adding an oral antihistamine confers no benefit. If the intranasal steroid alone does not fully control the allergic response, then “an intranasal antihistamine such as azelastine can be added, albeit at the expense of dysgeusia.”9 • Giant papillary conjunctivitis continues to be a menace. It could be relegated to history if everyone could/ would wear daily disposable contact lenses. For symptomatic patients, such as in the image below, we have them cease contact lens wear for at least a week, and preferably for two weeks. (Every contact lens wearer with a functionally significant prescription needs a backup pair of eyeglasses!) We prescribe Lotemax SM for these patients QID for one to two weeks, then BID for two more weeks. During the last two weeks, we instruct the patient to instill a drop 10 minutes prior to lens application and a second drop at the end of the work or school day when lenses are removed. Getting new lenses and decreasing wear time are significant maneuvers in the ultimate resolution of symptoms. According to Mathea Allansmith, MD, a renowned ocular allergist at Harvard, and our esteemed colleague Jimmy Bartlett, OD (professor emeritus at UAB), loteprednol is the steroid of choice in treating this condition. • An FDA program called “Rx to OTC” recently brought both 0.1% olopatadine (Patanol, Alcon) and 0.2% olopatadine (Pataday, Alcon) OTC. These drops can no longer be prescribed. This will bring two more products onto the already-crowded OTC shelves. Since all these histamine type 1 receptor blockers perform similarly, the advice we give our patients is to select a 10mL bottle when it costs about the same as a 5mL competitor. Use any of these drops BID for a week, then try to drop back to once daily use as needed to control ocular itching. Different insurance plan formularies may mean that, cost-wise, you provide a better service to your patient by prescribing a brand name–protected Rx anti-allergy drop, such as Bepreve (bepotastine, Bausch + Lomb), rather than asking them to purchase an OTC product.
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