BAK-induced Ocular Surface Changes in Patients With Glaucoma:
New Evidence, New Management Strategies

This educational activity is jointly sponsored by the New York Eye & Ear Infirmary and cme², an independent subsidiary of Advanstar Communications Inc, publisher of Ophthalmology Times.

This continuing medical education activity is supported through an unrestricted educational grant from Alcon Laboratories, Inc.

Target Audience
This activity is designed for physicians treating patients with glaucoma.

Statement of Need and Activity Description
Patients with glaucoma are faced with long-term treatment regimens and ones consisting of multiple medications. Side effects of these medications have generally been viewed as a necessary component of treatment, and current strategies to manage them center on altering medications or having patients accept these side effects. Evidence of side effects and occurrence of ocular surface changes caused by preservatives in these medications is emerging. Ophthalmologists must be aware of the risks of preservatives, especially of benzalkonium chloride (BAK, BAC), in their patients with glaucoma. To assist these physicians in recognizing the signs and symptoms of toxicity due to BAK, a roundtable forum with a panel of well-known glaucoma and corneal specialists was assembled. Diagnosis and management options were emphasized.

Learning Objectives
Upon completion of this activity, the participant should be able to:

• Evaluate the prevalence of ocular surface damage in patients with glaucoma
• Explain the role of BAK in antiglaucoma medications and its link to ocular surface damage in long-term management of glaucoma
• Recognize the signs and symptoms of BAK-induced ocular surface damage in patients with glaucoma
• Discuss options for managing and preventing BAK-induced ocular surface damage in patients with glaucoma

Accreditation Statement
This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of The New York Eye and Ear Infirmary and cme², an independent subsidiary of Advanstar Communications Inc, publisher of Ophthalmology Times. The New York Eye and Ear Infirmary is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation
The New York Eye and Ear Infirmary designates this educational activity for a maximum of 0.5 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Mission Statement
It is The New York Eye and Ear Infirmary Institute for Continuing Medical Education's stated mission to create medical education activities that will serve to increase the knowledge, skills, professional performance, and relationships that a physician uses to provide services for patients, the public, or the chosen profession.

Learning Method and Medium
This educational activity consists of an online program and 4 study questions. The participant should, in order, read the learning objectives contained at the beginning of this activity, listen to the activity, answer all questions in the post test, and complete the evaluation form. To receive credit for this activity, please follow the instructions provided on the post test and evaluation form. This educational activity should take a maximum of 0.5 hour to complete.

Content Source
This activity is based on a roundtable discussion that took place in Del Mar, California, in June 2006.

Disclosure Policy Statement
The New York Eye and Ear Infirmary requires that each teacher/contributor in a CME-accredited educational activity disclose the existence of any financial interest and/or other relationship(s) (eg, paid speaker, employee, paid consultant on a board and/or committee for a commercial company) that would potentially affect the objectivity of his/her presentation. Teachers/Contributors are also asked to make a disclosure that a product is still investigational when an unlabeled use of a commercial product or an investigational use, not yet approved for any purpose, is discussed during an educational activity. The disclosed information in no way presumes to assess the contributor's qualifications or suitability. The intention is to provide full disclosure of any potential conflict of interest, real or apparent, which is related to a specific educational activity. Course faculty who neglect to provide information about relationships with commercial companies will be removed from the educational activity. Full disclosure of faculty and commercial relationships is included below.

Faculty and Disclosure Statements

Program Chair and Moderator
Robert N. Weinreb, MD
Distinguished Professor of Ophthalmology
Director, Hamilton Glaucoma Center
University of California, San Diego
La Jolla, California

Dr. Weinreb has disclosed that he has served as either an advisory board member or a paid consultant for Alcon Laboratories, Inc; Allergan, Inc; Merck & Co, Inc; Novartis Pharmaceuticals Corporation; and Pfizer Inc during the past year. Dr. Weinreb indicated that neither he nor any members of his family have any investments in any company that might give rise to a real or perceived conflict of interest, and that he has no other relationships with any commercial companies. Dr. Weinreb's section will not include discussion of investigational products or products not labeled for use.

Faculty

Donald L. Budenz, MD, MPH
Professor, Ophthalmology, Epidemiology, and Public Health
Bascom Palmer Eye Institute
University of Miami Miller School of Medicine
Miami, Florida

Dr. Budenz has disclosed that he has served as either an advisory board member or a paid consultant for Alcon Laboratories, Inc; Carl Zeiss Meditec; and Pfizer Inc during the past year. Dr. Budenz has served on the speakers bureau for Carl Zeiss Meditec and Pfizer Inc during the past year. Dr. Budenz has disclosed that Carl Zeiss Meditec has either directly or indirectly supported some of his research activities during the past year. Dr. Budenz indicated that neither he nor any members of his family have any investments in any company that might give rise to a real or perceived conflict of interest. Dr. Budenz's section will not include discussion of investigational products or products not labeled for use.

Anne L. Coleman, MD, PhD
Frances and Ray Stark Professor of Ophthalmology
Professor of Ophthalmology and Epidemiology
Jules Stein Eye Institute
University of California, Los Angeles
Los Angeles, California

Dr. Coleman has disclosed that she has served as either an advisory board member or a paid consultant for Allergan, Inc, during the past year. Dr. Coleman has disclosed that Alcon Laboratories, Inc, and Pfizer Inc have either directly or indirectly supported some of her research activities during the past year. Dr. Coleman indicated that neither she nor any members of her family have any investments in any company that might give rise to a real or perceived conflict of interest. Dr. Coleman's section will not include discussion of investigational products or products not labeled for use.

Ronald L. Gross, MD
Professor, Ophthalmology
The Clifton R. McMichael Chair in Ophthalmology
The Cullen Eye Institute
Baylor College of Medicine
Houston, Texas

Dr. Gross has disclosed that he is either currently receiving or has in the past year received an honorarium or other financial benefit from Alcon Laboratories, Inc; Allergan, Inc; Merck & Co, Inc; and Pfizer Ophthalmics, and that he has served as either an advisory board member or a paid consultant for Alcon Laboratories, Inc; Allergan, Inc; and Pfizer Ophthalmics within the past year. Dr. Gross has disclosed that Alcon Laboratories, Inc; Allergan, Inc; and Pfizer Ophthalmic, have either directly or indirectly supported some of his research activities during the past year. Dr. Gross indicated that neither he nor any members of his family have any investments in any company that might give rise to a real or perceived conflict of interest, and that he has no other relationships with any commercial companies. Dr. Gross's presentation will not include discussion of any investigational products or products not labeled for use.

Terrence P. O'Brien, MD
Professor of Ophthalmology
Charlotte Breyer Rodgers Distinguished Chair in Ophthalmology
Director of the Refractive Surgery Service
Bascom Palmer Eye Institute at Palm Beach Gardens
University of Miami Miller School of Medicine
Palm Beach Gardens, Florida

Dr. O'Brien has disclosed that he has served as either an advisory board member or a paid consultant for Alcon Laboratories, Inc; Allergan, Inc; Bausch & Lomb; Inspire Pharmaceuticals Inc; ISTA Pharmaceuticals; and Santen Inc during the past year. Dr. O'Brien indicated that neither he nor any members of his family have any investments in any company that might give rise to a real or perceived conflict of interest, and that he has no other relationships with any commercial companies. Dr. O'Brien's section will not include discussion of investigational products or products not labeled for use.

Douglas J. Rhee, MD
Assistant Professor, Ophthalmology
Massachusetts Eye and Ear Infirmary
Harvard Medical School
Cambridge, Massachusetts

Dr. Rhee has disclosed that he has not served as either an advisory board member or a paid consultant for any commercial company during the past year. Dr. Rhee has disclosed that no commercial company has either directly or indirectly supported his research activities during the past year. Dr. Rhee indicated that neither he nor any members of his family have any investments in any company that might give rise to a real or perceived conflict of interest, and that he has no other relationships with any commercial companies. Dr. Rhee's section will not include discussion of investigational products or products not labeled for use.

Kuldev Singh, MD
Professor, Ophthalmology
Director, Glaucoma Service
Stanford University School of Medicine
Stanford, California

Dr. Singh has disclosed that he has served as either an advisory board member or a paid consultant for Alcon Laboratories, Inc, during the past year. Dr. Singh has disclosed that no commercial company has either directly or indirectly supported his research activities during the past year. Dr. Singh indicated that neither he nor any members of his family have any investments in any company that might give rise to a real or perceived conflict of interest. Dr. Singh's sections will not include discussion of investigational products or products not labeled for use.

Clark L. Springs, MD
Assistant Professor, Ophthalmology
Indiana University Medical Group
Indianapolis, Indiana

Dr. Springs has disclosed that he has served on the speakers bureau for Alcon Laboratories, Inc, during the past year. Dr. Springs has disclosed that no commercial company has either directly or indirectly supported his research activities during the past year. Dr. Springs indicated that neither he nor any members of his family have any investments in any company that might give rise to a real or perceived conflict of interest, and that he has no other relationships with any commercial companies. Dr. Spring's section will not include discussion of investigational products or products not labeled for use.

Angelo P. Tanna, MD
Assistant Professor, Ophthalmology
Director, Glaucoma Service
Northwestern University
Feinberg School of Medicine
Chicago, Illinois

Dr. Tanna has disclosed that he has served as either an advisory board member or a paid consultant for Alcon Laboratories, Inc, and Allergan, Inc, during the past year. Dr. Tanna has served on the speakers bureau for Alcon Laboratories, Inc; Allergan, Inc; and Merck & Co, Inc, during the past year. Dr. Tanna has disclosed that Alcon Laboratories, Inc; Allergan, Inc; Merck & Co, Inc; and Pfizer Inc have either directly or indirectly supported some of his research activities during the past year. Dr. Tanna indicated that neither he nor any members of his family have any investments in any company that might give rise to a real or perceived conflict of interest. Dr. Tanna's section will include discussion of investigational products or products not labeled for use.

Richard W. Yee, MD
Clinical Professor
Director, Corneal and External Diseases and Refractive Surgery
Hermann Eye Center
Joe M. Green, Jr, Endowed Chair in Ophthalmology
University of Texas Health Science Center
Houston, Texas

Dr. Yee has disclosed that he has not served as either an advisory board member or a paid consultant for any commercial company during the past year. Dr. Yee has served on the speaker's bureau for Alcon Laboratories, Inc, during the past year. Dr. Yee has disclosed that Alcon Laboratories, Inc; Allergan, Inc; and Refocus Group have either directly or indirectly supported some of his research activities during the past year. Dr. Yee indicated that neither he nor any members of his family have any investments in any company that might give rise to a real or perceived conflict of interest, and that he has no other relationships with any commercial companies. Dr. Yee's section will not include discussion of investigational products or products not labeled for use.

Disclosure Attestation
Each of the contributing physicians listed above has attested to the following:
1) that the relationships/affiliations noted will not bias or otherwise influence his or her involvement in this activity; 2) that practice recommendations given relevant to the companies with whom they have relationships/affiliations will be supported by the best available evidence or, absent evidence, will be consistent with generally accepted medical practice; and 3) that all reasonable clinical alternatives will be discussed when making practice recommendations.

Disclaimer
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients' conditions and possible contraindications or dangers in use, review of any applicable manufacturer's product information, and comparison with recommendations of other authorities.

Hardware and software requirements:
Windows machine: Sound card, speakers, 450 MHz Intel Pentium II processor (or equivalent) and later, with 128 MB RAM, Internet connection, Internet browser, Macromedia Flash 7.0 or higher

Macintosh machine: Sound card, speakers, 500 MHz PowerPC G3 and later, with 128 MB RAM, Internet connection, Internet browser, Macromedia Flash 7.0 or higher

Additional configurations may also work. Check this site for Internet browser requirements and Flash compatibility of your system: http://www.macromedia.com/software/flashplayer/productinfo/systemreqs/flashplayer7/

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