1. 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.”

2. Risk Factors for Glaucoma Increased IOP Age Family History Race Diabetes Previous Eye Injury

4. Control of IOP fluctuation for a full 24 hours

9. Alcon’s Promoted Glaucoma Products

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

11. A Look at the Past… Travatan Classic Benefits: Clinical studies show travoprost lowers IOP better than latanoprost1,2 for a full 24 hours3 Travoprosthas demonstrated a flattening of the 24 hour IOP fluctuations . .

12. The Body of Evidence Suggests Travoprost Demonstrates Control That Lasts

13. The Body of Evidence Suggests Travoprost Demonstrates Control That Lasts

14. 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

15. A Novel ApproachTo Ocular SurfacePreservation Ocular Surface Disease (OSD) or Dry Eye has a Significant Presence in The Glaucoma Population

17. Multiple Topical Ophthalmic medications

18. Ocular Surface Disease Symptoms May Contribute to Poor Patient Compliance

20. Burning / Stinging

21. Foreign Body Sensation

22. Blurred or Poor Vision

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

25. Epithelial Barrier is Compromised

26. Healing is Impaired

27. Increases Conjunctival Inflammatory Cells1

28. Loss of Goblet Cells1

29. Reduction in Tear Function2

30. Decreases Tear Film Break Up Time (TBUT)1Whitson ,et al. Glaucoma Drugs and The Ocular Surface, Review of Ophthalmology, November 2006 Leung, et al. Prevalence of Ocular Surface Disease in Glaucoma Patients. J Glaucoma 2008;17:350–355

31. Travoprost 0.004% BAK-Free (n=322 PP) Travoprost 0.004% (n=339 PP) Mean IOP (mm Hg) Efficacy: Travoprost 0.004% Solution With and Without BAK 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.

32. TM Polyols Zinc Borate An Alternative Preservative Unique Ionic Buffer System

33. 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.

34. DuoTrav(Travoprost 0.004%/Timolol 0.5% Ophthalmic Solution

35. What Are The Benefits Of DuoTrav® Solution? DuoTravallows for continued IOP success Enhanced efficacy – two medications in a single bottle (travoprost + timolol) Enhanced convenience to improve compliance Excellent tolerability to lower IOP and preserve visual field

36. 49% Compliant (n=41) 32% Compliant (n=31) Two Meds One Med Managing Number of Bottles is a Challenge for Clinicians Non-Compliance Increases With the Number of Bottles Multiple Medications are a Treatment Norm Percentage of treated patients at 60 months Kass MS, Heuer DK. Arch Ophthalmol. 2002;120:701-713 Patel SC, Spaeth GL. Ophthalmic Surg. 1995;26(3):234-236

37. 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

38. AZARGA® (Brinzolamide / Timolol) Ophthalmic Suspension

40. 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

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

43. AZARGA® Suspension vs. AZOPT® Suspension vs. Timolol1

44. AZARGA® Suspension vs. COSOPT*2

45. Comfort

46. AZARGA® Suspension vs. COSOPT*3

47. Comfort Study

48. AZARGA® Suspension vs. COSOPT*4

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

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

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

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

57. Glaucoma types: stats In US Open angle glaucoma 80% Angle Closure Glaucoma 20% 50% from narrow angles 40% from plateau 10% from lens rise

58. 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.

59. Narrow Angles relative pupillary blockis most common cause aqueous pressure behind the iris plane forces the iris anteriorlygiving it the typical convex appearance Indentation gonioscopy will flatten iris and open angle Definitive treatment is peripheral laser iridotomy

60. Relative Pupillary Block

61. Plateau Iris Not all angle-closure is caused by relative pupillary block Patients 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.

62. Plateau Iris Plateau 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

63. Plateau Iris When 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.

64. Plateau Iris Plateau 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

65. ALP: Argon Laser Peripheral Iridoplasty the 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

66. Lens Intumescence..Lens Rise A 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 lensectomy More and more lensectomies are taking the place of chronic glaucoma therapy for these patients

67. 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 41

68. TREATMENT OF INFLAMMATION IN THE ANTERIOR SEGMENT OF THE EYE TOPICAL OPHTHALMIC CORTICOSTEROID THERAPY

69. A Focus on Loteprednol Etabonate 43

70. Topical Ophthalmic Steroids Ester Loteprednol Ketone Steroids Higher-risk Dexamethasone Betamethasone Prednisolone Difluprednate Lower-risk Fluorometholone Medrysone Rimexolone 44 McGhee CN, Dean S, Danesh-Meyer H. Locally administered ocular corticosteroids: benefits and risks. Drug Saf. 2002;25:33-55.

71. Topical Ophthalmic Corticosteroids With a Ketone at C-20 Hydrocortisone Prednisolone Rimexolone Difluprednate Fluorometholone Dexamethasone 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.

72. Corticosteroids Inhibit Initiation Points of the Inflammatory Cascade Mast Cell Membrane Phospholipids Corticosteroids Membrane Stabilization Phospholipase A2 Arachidonic Acid Tryptase Chymase Heparin Histamine PAF Lipoxygenase Cyclo-oxygenase Hydroperoxides Cyclic endoperoxides Porstacyclin (PCI2) Thromboxane A2 (TXA2) Leukotrienes (LTC4, LTD4, LTE4, LTB4) Prostaglandins (PGF2, PGD2, PGE2) Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112.

73. Loteprednol Etabonate Unique Ester Steroid Highly lipophilic….penetrates well into eye High Receptor binding affinity leading to increased site activity and reduced free floating metabolites Rapidly esterified into inactive moities resulting in less residual active molecule 47

74. 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.

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

77. Single step leads to an inactive metabolite and low risk of adverse events1,2

78. Significantly reduced incidence of IOP increase1,2

79. Lack of C-20 at Ketone formation which has been implicated in cataract formation31. 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. Novack GD, et al. J Glaucoma. 1998;7:266-269. Howes J, Novack GD. J Ocul Pharmacol Ther. 1998;14:153-158. Manabe S, et al. J Clin Invest. 1984;74:1803-1810.

80. LOTEPREDNOOL ETABONATE Site active Corticosteroid.. In the ocular tissues! Designed to achieve efficacy with a low incidence of side effects Therapeutic effect after application Followed by single step deactivation 51

81. LOTEMAXTM LOTEPREDNOL ETABONATE OPHTHALMIC SUSPENSION 0.5%

82. Post op inflammation With newer technology less post op inflammation Trend was away from topical steroids and use of NSAIDS Rebound iritis common Continuing need for effective and safe suppression of inflammation 53

83. LotemaxTM: Post-operative Inflammation Study 1 Results 1. Stewart R, et al. J Cataract Refract Surg. 1998;24:1480-1489.

84. Summary: Loteprednol Etabonate 0.5%: An Advanced-Generation Corticosteroid The only ester ophthalmic corticosteroid* Therapeutic effect after application followed by a predictable, single-step deactivation Lower propensity to induce IOP elevation and cataract *C-20 position of the basic steroid structure 55

85. Other uses for Lotemax Anterior uveitis HZV keratouveitis Episcleritis and mild forms of scleritis Thygesons SPK Rosacea keratitis Dry Eye GPC SAC Post PKP/graft rejection chronic use Post Trab 56

86. ALREX® LOTEPREDNOL ETABONATE OPHTHALMIC SUSPENSION 0.2%

88. Most commonly affected: eyelids, conjunctiva, cornea 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 Abelson MB, et al. Ocul Surf. 2003;1:127-149. Chambless SL. Curr Opin Allergy Clin Immunol. 2004;4:431-434.

89. Corticosteroids Inhibit Initiation Points of the Inflammatory Cascade Mast Cell Membrane Phospholipids Corticosteroids Membrane Stabilization Phospholipase A2 Arachidonic Acid Tryptase Chymase Heparin Histamine PAF Lipoxygenase Cyclo-oxygenase Hydroperoxides Cyclic endoperoxides Porstacyclin (PCI2) Thromboxane A2 (TXA2) Leukotrienes (LTC4, LTD4, LTE4, LTB4) Prostaglandins (PGF2, PGD2, PGE2) Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112.

90. Corticosteroids Inhibit Multiple Early Points of the Inflammatory Cascade Mast CellMembrane Phospholipids Early-Phase Mediators Phospholipase A2 Activity Arachidonic Acid Cyclooxygenase Pathway Heparin Histamine PAF Proteases (tryptase, chymase) Lipoxygenase Pathway Hydroperoxides (5-HPETE) HHT, MDA Prostaglandins(PGF2α, PGD2, PGE2) Prostacyclin(PGI2) Thromboxane A2(TXA2) Leukotrienes(SRS-A, LTB4) Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112.

91. Corticosteroids Inhibit Multiple Early Points of the Inflammatory Cascade Mast CellMembrane Phospholipids Early-Phase Mediators Mast Cell Stabilizers (MCS)1 Work Here Phospholipase A2 Activity Most Combination Antihistamines/MCS1 Work Here Arachidonic Acid Cyclooxygenase Pathway Heparin Histamine PAF Proteases (tryptase, chymase) Lipoxygenase Pathway Hydroperoxides (5-HPETE) Antihistamines1 Work Here HHT, MDA Prostaglandins(PGF2α, PGD2, PGE2) Prostacyclin(PGI2) Thromboxane A2(TXA2) Leukotrienes(SRS-A, LTB4) Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112.

92. Corticosteroids Inhibit Multiple Early Points of the Inflammatory Cascade Mast CellMembrane Phospholipids Late-Phase Mediators Early-Phase Mediators Mast Cell Stabilizers (MCS)1 Work Here Phospholipase A2 Activity Most Combination Antihistamines/MCS1 Work Here Arachidonic Acid Cyclooxygenase Pathway Heparin Histamine PAF Proteases (tryptase, chymase) Lipoxygenase Pathway Hydroperoxides (5-HPETE) Antihistamines1 Work Here HHT, MDA Prostaglandins(PGF2α, PGD2, PGE2) Prostacyclin(PGI2) Thromboxane A2(TXA2) Leukotrienes(SRS-A, LTB4) Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112.

93. Corticosteroids Inhibit Multiple Early Points of the Inflammatory Cascade Mast CellMembrane Phospholipids Late-Phase Mediators Early-Phase Mediators Mast Cell Stabilizers (MCS)1 Work Here Phospholipase A2 Activity Most Combination Antihistamines/MCS1 Work Here Arachidonic Acid Cyclooxygenase Pathway Heparin Histamine PAF Proteases (tryptase, chymase) Lipoxygenase Pathway NSAIDs Work Here Hydroperoxides (5-HPETE) Antihistamines1 Work Here HHT, MDA Prostaglandins(PGF2α, PGD2, PGE2) Prostacyclin(PGI2) Thromboxane A2(TXA2) Leukotrienes(SRS-A, LTB4) Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112.

94. Corticosteroids Inhibit Multiple Early Points of the Inflammatory Cascade Mast CellMembrane Phospholipids Late-Phase Mediators Early-Phase Mediators Corticosteroids Mast Cell Stabilizers (MCS)1 Work Here Phospholipase A2 Activity Most Combination Antihistamines/MCS1 Work Here Arachidonic Acid Cyclooxygenase Pathway Heparin Histamine PAF Proteases (tryptase, chymase) Lipoxygenase Pathway NSAIDs Work Here Hydroperoxides (5-HPETE) Antihistamines1 Work Here HHT, MDA Prostaglandins(PGF2α, PGD2, PGE2) Prostacyclin(PGI2) Thromboxane A2(TXA2) Leukotrienes(SRS-A, LTB4) Adapted with permission from Slonim CB. Rev Ophthalmol. 2000:101-112.

95. 65 Treatment of Seasonal Allergic Conjunctivitis Signs 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.

96. Alrex® (loteprednol etabonate ophthalmic suspension 0.2%)Clinical Efficacy and Safety in Seasonal Allergic Conjunctivitis 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 Dell SJ, et al. J Allergy Clin Immunol. 1998;102:251-255. Shulman DG, et al. Ophthalmology. 1999;106:362-369.

97. Significant Resolution of Ocular Allergy Signs and Symptoms With Alrex® Significant ReductionAfter Using Alrex Signs and Symptoms P Itching1 Redness1 Discomfort1 Erythema2 Foreign body sensation2 Burning/stinging2 Tearing2 <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. 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.

99. 1 patient in each group experienced IOP elevation ≥10 mm Hg

100. Alrex: n = 133

101. Placebo: n = 135SAC = Seasonal allergic conjunctivitis Alrex (loteprednol etabonate ophthalmic suspension 0.2%) Product Monograph. Bausch & Lomb Inc.; Dec. 22, 2008

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

104. Since the Crystalens AO is aberration free, patients can enjoy best-potential vision quality with enhanced contrast sensitivity 2

107. As a result, objects at intermediate distances are as clear as objects that are near or far 4

110. As a result, objects at intermediate distances are as clear as objects that are near or far 4

112. Patients can see near, intermediate and distant objects with equal clarity

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

114. Both the natural lens and the Crystalens AO also arch, or change their radius of curvature, to increase their accommodation

115. Both move anteriorly and flex or arch to increase their focusing power in the intermediate and near ranges 13

116. Integrated Eye Care vs Co-management integrated 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

117. Advantages of Integrated Eye Care Optometrists have readily available access to specialty care for their patients The 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