Diabetes and Aboriginal vision health Le diabète et la santé oculaire des Autochtones

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Diabetes and Aboriginal vision health Le diabète et la santé oculaire des Autochtones

                                              VOL 72 NO 4 AUGUST / AOÛT 2010

Diabetes and Aboriginal vision health
Le diabète et la santé oculaire des Autochtones


October is Eye Health Month
Diabetes and Aboriginal vision health Le diabète et la santé oculaire des Autochtones
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Diabetes and Aboriginal vision health Le diabète et la santé oculaire des Autochtones
CaNadiaN JourNal of optometry
reVue CaNadieNNe d’optométrie
Vol 72, No 4
august/août 2010
(Date of issue: August 2010)
(Date de parution: août 2010)
ISSN 0045-5075
                                                                                    CANADIAN JOURNAL OF OPTOMETRY REVUE CANADIENNE D’ OPTOMÉTRIE

The Canadian Journal of Optometry is the official publication of the
Canadian Association of Optometrists (CAO) /
La Revue canadienne d’optométrie est la publication officielle de
l’Association canadienne des optométristes (ACO) :
234 Argyle Avenue, Ottawa, ON, K2P 1B9. Phone 613 235-7924 /
888 263-4676, fax 613 235-2025, e-mail info@opto.ca,
website www.opto.ca. Publications Mail Registration No. 558206 /                     President’s Podium / Mot du président
Envoi de publication – Enregistrement no. 558206.
The Canadian Journal of Optometry / La Revue canadienne d’optométrie                 Celebrate Eye Health Month / Célébration du mois de la santé de l’œil
(USPS#0009-364) is published six times per year at CDN$55, and CDN$65
for subsriptions outside of Canada. Address changes should be sent to
                                                                                     Dr. Kirsten North . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
CAO, 234 Argyle Avenue, Ottawa, ON K2P 1B9.


The CJO*RCO is the official publication of the CAO. However, opinions and            Diabetes and Aboriginal vision health / Le diabète et la santé oculaire
commentaries published in the CJO*RCO are not necessarily either the
official opinion or policy of CAO unless specifically identified as such.
                                                                                     des Autochtones
Because legislation varies from province to province, CAO advises
optometrists to consult with their provincial licensing authority before
                                                                                     Dr. Paul Chris. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
following any of the practice management advice offered in CJO*RCO.
    The CJO*RCO welcomes new advertisers. In keeping with our goal of
advancing awareness, education and professionalism of members of the
CAO, any and all advertising may be submitted, prior to its publication,
for review by the National Publications Committee of the CAO.                        Aboriginal preschool vision screening in BC – closing the health gap
CAO reserves the right to accept or reject any advertisement submitted
for placement in the CJO*RCO.                                                        Donna Atkinson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

La CJO*RCO est la publication officielle de l’ACO. Les avis et les
commentaires publiés dans la CJO*RCO ne répresentent toutefois pas
                                                                                     Our Aboriginal relations – When family doctors and Aboriginal patients meet
nécessairement la position ou la politique officielle de l’ACO, à moins
qu’il en soit précisé ainsi. Étant donné que les lois sont différentes d’une
                                                                                     Catherine T. Elliott MD MHSc CCFP & Sarah N. de Leeuw MA PhD . . . . . . . . . . 26
province à l’autre, l’ACO conseille aux optométristes de vérifier avec
l’organisme provincial compétent qui les habilite avant de se conformer
aux conseils de la CJO*RCO sur la gestion de leurs activités.
    La CJO*RCO est prête à accueillir de nouveaux annonceurs. Dans
l’esprit de l’objectif de la CJO*RCO visant à favoriser la sensibilisation,
la formation et le professionnalisme des membres de l’ACO, on pourra
soumettre tout matériel publicitaire avant publication pour examen par
le Comité national des publications de l’ACO. L’ACO se réserve le droit
d’accepter ou de refuser toute publicité dont on a demandé l’insertion               Cover & page 9, photographs: Fred Cattroll.
dans la CJO*RCO.                                                                     Fred, is a nationally recognized photographer, with an extensive list of clients, including the National
                                        •                                            Gallery of Canada, the New York Times, the Washington Post, and the National Arts Centre. His lifetime
                                                                                     work of negatives, slides, prints and digital files, was recently requested by the Canadian Museum of
Chair, National Publications Committee / Président,
                                                                                     Civilization. His work is regarded as a national treasure. A permanent exhibition of his work is in the
Comité national des publications : Dr Paul Geneau
                                                                                     First Peoples Hall at the Museum of Civilization.
Academic Editors / Rédacteurs académiques :
University of Waterloo, Dr B. Ralph Chou
Université de Montréal, Dr Claude Giasson

Advertising Coordinator / Coordonnatrice des publicités ;
Managing Editor / Rédactrice administrative :
Leslie Laskarin

Editorial/Production Assistant / Adjoint de production et réviseur :
Tony Gibbs

Printing Consultant / Impression : Vurtur Communications
                                                                                     Uniform requirements for manuscripts: login to the member site at opto.ca
Translation / Traduction:                                                            or contact CAO.
Tessier Translations / Les Traductions Tessier
                                                                                     Exigences uniformes pour les manuscrits: voir sur le site des membres à
Translation Editor / Réviseure des traductions :
Claudette Gagnon
                                                                                     opto.ca ou contacter l’ACO.

       CaNadiaN JourNal              of    optometr y | reVue            C a N a d i e N N e d ’o p t o m é t r i e                            Vol 72 | No 4 August / Août 2010                 1
Diabetes and Aboriginal vision health Le diabète et la santé oculaire des Autochtones
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Diabetes and Aboriginal vision health Le diabète et la santé oculaire des Autochtones

Celebrate Eye Health Month
          Célébration du mois de la santé de l’œil

T        his issue of CJO includes a member ‘toolkit’
         for October’s Eye Health Month and the 2010
         theme, Seeing Smart – Make your Child’s First
Exam an Eye Exam. The toolkit provides an overview
                                                                                          membership. By entering the ‘Eye Dare You’ contest,
                                                                                          you also have the opportunity to win a prize.
                                                                                            Eye Health Month has been celebrated in Canada
                                                                                          for the past 12 years. Prior to that, CAO celebrated
of the national public relations campaign as well as                                      Save Your Vision week during the same timeframe as
ideas and resources for CAO members.                                                      the American Optometric Association campaign. The
  CAO members play an important role in mak-                                              decision to adopt a month long program in October
ing Eye Health Month a success. Promotion in your                                         was made to differentiate Canadian Optometry and to
practice and community has a cumulative effect and                                        have our ‘own’ campaign.
complements what is done at a national and provincial                                       Eye Health Month has become firmly established on
level.                                                                                    the health awareness calendar resulting in queries from
  Your participation also supports your provincial                                        the media, health units, and government agencies. It
association’s effort to show that it has the most active                                  also has the unintended consequence of others within

   SeeingSmart•VoirPrévoir                                  their eyes deserve an optometrist • Leurs yeux méritent un optométriste

                                                                      Eye Dare You Win an Apple iPad
                                                               Je vous mets au défi Gagner un iPad d’Apple
                                                            Take the EYE DARE YOU challenge                 Prenez le DÉFI pour promouvoir la
                                                            to promote eye health awareness                 sensibilisation de la santé de l’œil dans
                                                            in your area and you could win an               votre communauté et courez la chance
                                                            Apple iPad.                                     de gagner un iPad d’Apple.

                                                            Send in details of your October                 Envoyez un bref compte rendu de
                                                            Eye Health Month project to                     votre projet du Mois de la santé de
                                                            eyedareyou@opto.ca                              l’œil en octobre à defi@opto.ca
                                                            For more information call                       Pour plus d’information, contactez-nous
                                                            888 263-4676 ext. 213.                          à 888 263-4676 poste 213.

CaNadiaN JourNal   of   optometr y | reVue   C a N a d i e N N e d ’o p t o m é t r i e                              Vol 72 | No 4 August / Août 2010   3
Diabetes and Aboriginal vision health Le diabète et la santé oculaire des Autochtones
the eye care sector celebrating Eye Health Month as            Le Mois de la santé de l’œil est célébré au Canada
    their own. While some may see this as an infringe-             depuis 12 ans. Auparavant, l’ACO célébrait la Se-
    ment, most see it as flattery that reflects the legitimacy     maine de la vision en même temps que la campagne
    of optometry’s annual campaign.                                de l’American Optometric Association. La décision
      This year’s theme of children’s vision is a natural          d’adopter en octobre une programmation s’étendant
    choice. We can point to the need for comprehensive             sur tout le mois est guidée par votre volonté de dif-
    eye care for children, gaps in awareness and provin-           férencier l’optométrie canadienne et de nous doter de
    cial coverage, and the important relationship between          notre « propre » campagne.
    vision and learning. Provincial programs such as Eye              Les requêtes des médias, des unités sanitaires et des
    See, Eye Learn can be profiled with pride.                     organismes gouvernementaux ont contribué à ancrer
      To manage the campaign, CAO retained a Toronto               solidement le Mois de la santé de l’œil dans le calen-
    based public relations firm. The cost of the campaign          drier des activités de sensibilisation à la santé oculaire.
    is supported by funds from Eye Health of Canada                Le Mois de la santé de l’œil est également célebré par
    industry partners. In addition, CAO solicited the co-          d'autres du secteur de la santé oculaire; une con-
    chairs of the National Public Education Committee              séquence inattendue de ce succès. Si certains voient
    and Children’s Vision Committee to capably assist in           en cette appropriation un manque de respect, la plu-
    the review of key messages and strategies. We also             part s’en estiment flattés et estiment que cela reflète la
    have a group of media spokespeople, many of whom               légitimité de la campagne annuelle de l’optométrie.
    have volunteered for this task each year. Thank you               Le thème retenu cette année pour la vision des
    to all!                                                        enfants s’est imposé de manière naturelle. Il va nous
      I encourage each of you to review the Eye Health             permettre d’attirer l’attention sur la nécessité de
    Month toolkit and to participate in this year’s cam-           prodiguer aux enfants des soins oculo-visuels com-
    paign. Make us proud!                                          plets, de combler les écarts qui existent en matière de
                                                                   sensibilisation et de couverture au niveau provincial
                                                                   et de mettre en avant la relation essentielle entre la
                                                                   vision et l’apprentissage. Nous pourrons décrire avec
                                                                   fierté des programmes provinciaux comme Eye See,

    L        e présent numéro de la RCO comprend une
             « trousse » pour les membres pour le Mois
             de la santé de l’œil en octobre et le thème
    de l’année 2010, Voir Prévoir – Faites vérifier la vue
    de votre enfant en bas âge. Cette trousse offre une
                                                                   Eye Learn.
                                                                      Pour gérer cette campagne, l’ACO a retenu les
                                                                   services d’une entreprise de relations publiques de
                                                                   Toronto. Cette campagne est supportée financière-
                                                                   ment par des fonds provenant de partenaires de
    présentation générale de la campagne nationale de re-          l’industrie de la santé oculaire au Canada. Par ailleurs,
    lations publiques ainsi que des idées et des ressources        l’ACO a brigué les coprésidences du Comité national
    pour les membres de l’ACO.                                     d’éducation publique et du Comité de la vision pour
      Les membres de l’ACO ont un rôle important à jouer           les enfants pour pouvoir contribuer à l’analyse des
    pour assurer le succès du Mois de la santé de l’œil. Sa        stratégies et des messages clés. Nous disposons égale-
    promotion dans votre cabinet et dans communauté a              ment d’un groupe de porte-paroles auprès des médias,
    un effet conjugué et vient compléter les actions qui sont      la plupart desquels se portent chaque année volon-
    menées aux niveaux national et provincial.                     taires pour occuper cette tâche. Qu’ils en soient tous
      Votre participation soutient également l’effort con-         remerciés!!
    senti par votre association provinciale pour afficher le          J’invite chacun de vous à passer en revue la trousse
    plus grand nombre de membres actifs. En participant            du Mois de la santé de l’œil et à participer à la cam-
    au concours « Je vous mets au défi », vous avez égale-         pagne de cette année. Nous devons en être fiers!
    ment la possibilité de gagner un prix.

4    Vol 72 | No 4 August / Août 2010                            CaNadiaN JourNal   of   optometr y | reVue   C a N a d i e N N e d ’o p t o m é t r i e
Diabetes and Aboriginal vision health Le diabète et la santé oculaire des Autochtones
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Diabetes and Aboriginal vision health Le diabète et la santé oculaire des Autochtones
Vision Institute of Canada   Annual Fall Conference and Trade Show
                             October 22 – 24, 2010
                               The Vision Institute of Canada will be      to raise awareness of
                               holding its Annual Fall Conference and      eye health among this
                               Trade Show on October 22nd, 23rd,           population.
                               and 24th at the Hilton Suites Hotel
                               in Markham, Ontario. This event will        The Vision Institute has
                               provide 20 hours of excellent continu-      an extraordinary line-up
                               ing education including nine hours of       of speakers, including
                               TPA related lectures from Dr. Lou           Dr. Ann Macaulay, CM, MD, FCFP, who
                               Catania, OD, Dr. Larry Alexander, OD,       holds the Order of Canada for her
                               and Dr. David Chow, MD.                     work on Aboriginal health, and Dr. Jay
                                                                           Wortman, MD, a Metis physician from
                               More importantly, this conference will      BC who is featured in the documentary
                               also include a unique Aboriginal Vision     My Big Fat Diet. Mr. Angus Toulouse,
                               Health Lecture Series on Friday, October    Ontario Regional Chief of the Assembly
                               22nd which you are encouraged you to        of First Nations will be one of many
                               attend. Co-sponsored by the Canadian        special guests attending from various
                               Association of Optometrists, this day       aboriginal organizations to meet
                               of lectures for optometrists and staff      members of the optometry profession
                               is part of a special two day Aboriginal     and to learn about eye health and the
                               Vision Health Conference for Aboriginal     vision care services. The Aboriginal
                               health workers and policy makers to         Peoples Television Network will be in
                               help raise awareness about the soaring      attendance to document this confer-
                               rates of diabetes-related blindness         ence and help deliver this eye health
                               facing Canada's native population.          awareness message.
                               The National Collaborating Centre for
                               Aboriginal Health has called this a         The Vision Institute has an ambitious
                               conference of "national significance" for   plan to make 2011 Aboriginal Vision
                               the Aboriginal community. It represents     Health Awareness Year to help educate
                               an opportunity for optometry to dem-        Aboriginal people with diabetes about
                               onstrate its concern and readiness to       the need for yearly comprehensive
                               respond to this emerging health crisis      eye examinations. The importance of
                               and, together with the Aboriginal com-      comprehensive eye exams for native
                               munity, develop a communication plan        children will also be promoted.

       20 Hours of Continuing Education, with a special one day Aboriginal Vision Health Lecture Series
                                                             PLUS The Annual Meeting of the College of Optometrists of Ontario,
Diabetes and Aboriginal vision health Le diabète et la santé oculaire des Autochtones
Please join the Vision Institute, in            Or contact:
     October, for its most important                 Vision Institute, 16 York Mills Road,
     program in three decades. The Vision            Suite 110, Toronto, Ontario M2P 2E5
     Institute is a non-profit charitable            Tel: 416-224-2273 or 1-800-969-8617
     organization. The funds raised from             Fax: 416-224-9234                                     The Vision Institute of Canada is a
     their conferences support the Vision            Or E-mail us at:                                      non-profit charitable organization
     Institute’s educational and charitable          visioninstitute@globalserve.net                       dedicated to eye health education,
     clinical work. Your support is vital to
                                                     Room reservations may be made at the                  research, and specialized clinical services.
     ensure continued success.
                                                     Hilton Suites Hotel, 1-800-668-8800                   The funds we raise from our educational
                                                                                                           programs support the clinical and
     For more information and
                                                                                                           charitable work of the Institute.
     to register, please visit:

                                                                                                                       OUR EDUCATIONAL
                                               Lecture Topics
                                                                                                                       Ontario Association
        Session 1                        Session 4                            Session 6                                of Optometrists
        Improving Aboriginal Health:     Understanding Diabetic               Annual Meeting of the College            Canadian Association
        How Can Health Care              Retinopathy                          of Optometrists of Ontario               of Optometrists
        Professionals Contribute?        Dr. Chris Hudson, OD, PhD            with a special lecture by                The National Collaborating
                                                                              Dr. Marlee Spafford, OD, PhD             Centre for Aboriginal Health
        Dr. Ann C. Macaulay, MD
                                         Epidemiology of Vision Health                                                 Johnson & Johnson
                                                                                                                       Vision Care
        Traditional Aboriginal Diets     Disorders in Aboriginal People
        “My Big Fat Diet”                Dr. Barbara Robinson, OD, MPH, PhD   Session 7                                Alcon Canada

        Dr. Jay Wortman, MD                                                   Retinal Disease:                         Bausch & Lomb Canada
                                                                              From Nutrition to Genetics               Bochner Eye Institute
                                         Session 5                            Dr. David Chow, MD                       Cooper Vision
        Session 2                        Cultural Relevance in Eye
                                                                                                                       Essilor Canada
        Diabetes: The Low-Carb Diet      Examinations
        Debate “Good Calories,           Dr. Graham Strong, OD, MS            Session 8 & 9                            Novartis
        Bad Calories”                                                         Glaucoma Diagnosis
        Mr. Gary Taubes                  Social Determinants in               and Treatment
                                         Aboriginal Diabetes                  Dr. Larry Alexander, OD
                                         Dr. Jeffrey Reading, PhD
        Session 3
        Diabetic Retinopathy:                                                 Session 10 & 11:
        Telemedicine and Remote                                               Anterior Segment Disease
        Northern Communities                                                  and Treatment
        Dr. Alan Cruess, MD                                                   Dr. Lou Catania, OD

15 Hours of CAO Approved Education for Certified Optometric Assistants, Eye Health Book Store & Silent Auction
Diabetes and Aboriginal vision health Le diabète et la santé oculaire des Autochtones

      Diabetes and Aboriginal vision health
            Le diabète et la santé oculaire des Autochtones

      C        anada is home to an
               Aboriginal population of
               over 1.2 million people,
      of whom 61% are First Nations,
      34% are Métis (mixed native-
                                            population (243,000), fol-
                                            lowed by BC (196,000), Alberta
                                            (188,000), Manitoba (175,000),
                                            Saskatchewan (142,000), and
                                            Quebec (108,000). The remain-
                                                                                          One of the most significant
                                                                                        consequences of the “psycho-
                                                                                        social stress” associated with
                                                                                        colonization and the loss of
                                                                                        traditional foods and lifestyles is
      European descent), and 5% are         ing 25,000 live in the other                the epidemic of diabetes that is
      Inuit. These three distinct groups    provinces and territories.3                 eroding the health and lives of
      all have unique “local geographic       The Aboriginal community is               Aboriginal people. The extent
      and linguistic heritages, cultural    also the largest growing segment            to which Aboriginal people have
      practices and spiritual beliefs.”     of the Canadian population, in-             been affected is both complex
      Slightly more than half live in       creasing at a rate six times faster         and astonishing. This is a phe-
      urban areas but maintain strong       than non-Aboriginal people.                 nomenon affecting indigenous
      connections to their communi-         Almost half the native popula-              people worldwide. The long-
      ties of origin.1 Although there has   tion is below 25 years of age,              term complications associated
      been an increase in the number        compared to 40 years for the                with diabetes, such as blindness,
      of Aboriginal people living in        non-native population.                      heart disease, kidney disease,
      urban areas, there has actually         Aboriginal history in Canada re-          infectious disease and amputa-
      been a net migration back to First    flects years of government forced           tions, are an emerging public
      Nations communities in the last       assimilation and colonization               health crisis.5
      40 years.2 There are 615 native       efforts with the “appropriation of            Before 1950, diabetes was
      communities (reserves or bands)       land and loss of traditional liveli-        rare in native communities.6
      in Canada. British Columbia has       hoods.” The residential school              Diabetes was not detected in
      the largest number of reserves at     system, established in 1892,                1500 First Nations people who
      198 followed by Ontario with 153.     resulted in the mandatory removal           underwent a tuberculosis survey
      Ontario has more remote First         of children from their homes                in Saskatchewan in 1937.7 Today
      Nations communities than any          and their placement in boarding             twenty percent of the Canadian
      other region.                         schools where they were “for-               Aboriginal population lives with
        Aboriginal people make up           bidden to speak their own lan-              diabetes, a number that has
      3.8% of the Canadian popula-          guages.” Many suffered emotional,           doubled in the last two decades,
      tion, ranking second in the           physical, and sexual abuse, turning         most likely due to environmental
      world to New Zealand, where           to drugs and alcohol in later life to       (nutrition and lifestyle) factors.6, 7
      the Maori people make up 15%          deal with their trauma. The atten-          Across Canada, type 2 diabetes
      of the population. In the United      dant loss of self-esteem and the            is three to five times higher in
      States and Australia, approxi-        destruction of family bonds and             Aboriginal people than in the
      mately 2% of the general popula-      parenting skills have caused a cul-         general population. According
      tion is Aboriginal.2 According to     tural shock resulting in ill health,        to a Saskatchewan study
      the 2006 Aboriginal Census,           poverty and family breakdown.4              published in January 2010,
      Ontario has the largest native                                                    the rate of diabetes among

8      Vol 72 | No 4 August / Août 2010                       CaNadiaN JourNal   of   optometr y | reVue   C a N a d i e N N e d ’o p t o m é t r i e
Photo: Fred Cattroll
Aboriginal women of child-                        diabetic retinopathy in Aboriginal        A more recent report from
bearing age is four times greater                 Canadians. A study published            2007, the Southern Alberta Study
than women in the general popu-                   that year involving the Sandy           of Diabetic Retinopathy, showed
lation. Native women also have                    Lake First Nations community in         that prevalence rates of diabetic
much higher rates of gestational                  Northern Ontario reported the           retinopathy in type 2 diabetes in
diabetes, which dramatically                      following prevalence rates: non-        native and non-native subjects
increases a woman’s risk of                       proliferative diabetic retinopathy      were identical, with a prevalence
developing diabetes later in life,                24% (NPDR), macular edema               rate of 40%, “far higher” than
and also makes her offspring                      (5%) and proliferative diabetic         the Sandy Lake study. Native
more prone to the disease.7                       retinopathy 2% (PDR).9                  subjects also tended to have more
  Diabetes is the leading cause                     These findings were consistent        advanced retinopathy changes
of adult blindness in Canada.                     with an earlier study in 2002 by        indicating that Aboriginal ethnicity
According to one report, the                      Maberley, et al.10 The authors of       does play a role in the severity of
rate of progression and severity                  the 2005 study suggested that the       retinal complications.11
of diabetic retinopathy, unlike                   relatively low prevalence rates of        Despite conflicting research,
kidney disease, is no greater in                  macular edema and PDR “pos-             what is clear is that with the
Aboriginal people than that of                    sibly reflect low median duration       disproportionate and increasing
the general population.8 As re-                   of diabetes or the presence of          number of native people with
cently as 2005, there was limited                 protective genetic factors.”9           diabetes, and its occurrence at a
data on the prevalence of                                                                 much early age than the general

CaNadiaN JourNal   of   optometr y | reVue   C a N a d i e N N e d ’o p t o m é t r i e         Vol 72 | No 4 August / Août 2010                          9
published data on the relation-            Aboriginal vision health.
       n   74 percent of people who have         ships between diabetic retinopathy,         Optometry, its partners and
           diabetes for 10 years or more will    macular edema severity and visual          professional organizations, need
           develop some form of diabetic
                                                 acuity. 13                                 to work with Aboriginal people
                                                    In the United States the                and their organizations to create
       n   Approximately 14 percent of
           people with diabetes have diabetic    National Eye Institute was                 an effective Canadian communi-
           macular edema and prevalence          created by Congress in 1968 as             cation strategy to help educate
           increases to 29 percent for people    part of the National Institutes of         Aboriginal health care workers
           with diabetes who use insulin for
                                                 Health. In 1991 it established the         and eye care professionals about
           more than 20 years.
                                                 National Eye Health Education              Aboriginal eye health issues and
       n   Left untreated, 25 percent of
           people with diabetic macular          Program which released a report            the importance of annual dilated
           edema will develop moderate           in 2004 titled: American Indian and        eye exams for native Canadians
           vision loss within three years.       Alaska Native Diabetic Eye Disease         living with diabetes.
       n   Estimates of the rate of annual       Communication Plan. This com-
           eye exams vary greatly by country
                                                 munication plan was designed               1 Macaulay AC. Improving aboriginal health:
           and study, but the rate of screen-                                                 How can health care professional contribute?
           ing is generally fairly low (from     to improve the eye health of
                                                                                              Can Fam Phys. Vol. 55: April 2009
           40 to 65 percent).                    American Indians and Alaska
       n   Worldwide guidelines (for people      Natives with diabetes and to raise         2 Bailey S; Native population growing.
           with diabetes) recommend              awareness about the importance               The Canadian Press; Jan 15, 2008
           annual screenings with a dilated
                                                 of annual dilated eye exams in             3 Atkinson DL Preschool Vision
           eye exam from an eye care
           specialist. 12                        this population.14                           Screening and Aboriginal Eye Health:
                                                    An environmental scan pro-                An Environmental Scan and Literature
           – International Diabetes Federation   duced in 2007 by the National                Review. BC Initiatives; April 2007
                                                 Collaborating Centre on Aboriginal         4 Macaulay AC. Improving aboriginal
                                                 Health based at the University               health: How can health care professional
     population, diabetes will lead              of Northern British Columbia,                contribute? Can Fam Phys. Vol 55: April
     to a more significant burden                                                             2009
     of preventable vision loss in                  “…a review of the international         5 Hanley AJ. Diabetes in Indigenous
     Aboriginal communities than in              literature suggests that Canada              Peoples: Medscape Diabetes and
     non-Aboriginal groups.                                                                   Endocrinology. July 2006; http://cme.
                                                 is well behind other countries in
        There are few statistics available       addressing Aboriginal eye health
     to show the rate of annual dilated          and vision care services. Both the         6 Young TK, et al. Type 2 diabetes
     eye examinations being received                                                          mellitus in Canada’s First Nations: status
                                                 United States and Australia have
     by Aboriginal Canadians. If trends                                                       of an epidemic in progress. CMAJ;
                                                 developed innovative, Aboriginal
                                                                                              September 5, 2000; 163 (5)
     from other services are any indica-         specific, community-controlled
     tion, access to annual dilated eye          programs and promotional                   7 Dyck R, et al. Epidemiology of diabetes
     exams for many Aboriginal people                                                         mellitus among First Nations and non-
                                                 material…” 15
                                                                                              First Nations adults. CMAJ February
     with diabetes is limited by geog-              Canada has a larger native                23, 2010 182(3)
     raphy and the availability of an            population, by percentage, than
     optometrist or ophthalmologist.                                                        8 Harris SB. Diabetes in indigenous
                                                 the United States but is indeed well
                                                                                              peoples: Program and abstracts of the
     Several telemedicine projects               behind in addressing the Aboriginal          American Diabetes Association 66th
     using digital retinal cameras have          vision health issues that are be-            Scientific Sessions; June 9-13, 2006;
     been established but are not                coming an emerging public health             Washington, DC.
     filling the need for the diagnostic         crisis. More Canadian funding and          9 Hanley AJG, et al. Complications of
     vision care services that is re-            research are required to fill the            Type 2 Diabetes among Aboriginal
     quired. There is also a lack of             gap in scientific knowledge about            Canadians Prevalence and associated risk

10    Vol 72 | No 4 August / Août 2010                           CaNadiaN JourNal   of   optometr y | reVue   C a N a d i e N N e d ’o p t o m é t r i e
“     ... a review of the international literature suggests that Canada is well behind other
countries in addressing Aboriginal eye health and vision care services. Both the United
States and Australia have developed innovative, Aboriginal specific, community-controlled
programs and promotional material.
   factors. Diabetes Care; August 2005 Vol          tous des « héritages linguistiques      Manitoba (175 000), la Saskat-
   28 no. 8 2054-2057                               et géographiques régionaux, des         chewan (142 000) et le Québec
10 Maberley D, et al. Digital photographic          pratiques culturelles et des croy-      (108 000). Le restant de cette
   screening for diabetic retinopathy in the        ances spirituelles » qui leur sont      population (25 000) dans d’autres
   James Bay Cree. Ophthalmic Epidemiol             propres. Un peu plus de la moitié       provinces et territoires.3
   9: 169–178, 2002                                 d’entre eux vivent dans des régions       La collectivité autochtone
11 Ross SA, et al. Diabetic Retinopathy in          urbaines et entretiennent des liens     est également le segment de la
   Native and Nonnative Canadians. Exp              étroits avec leur communauté            population canadienne ayant la
   Diab Res. Vol 2007: Article ID 76271             d’origine(1). Bien que le nombre        plus forte croissance, avec un
12 International Diabetes Federation.               d’Autochtones vivant en région          taux six fois plus rapide que celui
   http://www.idf.org/international-                urbaine s’accroisse, les dernières      des personnes non autochtones.
   diabetes-federation website accessed             40 années ont été marquées par un       Près de la moitié de la population
   July 15, 2010.
                                                    solde migratoire positif en faveur      autochtone a moins de 25 ans, un
13 Tucker D, et al. Investigation the links         des communautés des Premières           chiffre à confronter aux 40 ans
   between diabetic retinopathy, macular            nations.2 Le Canada compte              de la population non autochtone.
   edema severity and visual acuity in
                                                    615 communautés autochtones               L’histoire des Autochtones
   patients with diabetes. Expert Review
   of Ophthalmology; Dec 2008 Vol 3 No
                                                    (réserves ou bandes). La Colom-         au Canada est liée à des années
   6 (673-688)                                      bie-Britannique est la province qui     d’assimilation forcée et à des
                                                    compte le plus grand nombre de          entreprises de colonisation
14 National Eye Health Education
                                                    réserves (198) devant l’Ontario         menées par le gouvernement qui
   Program: American Indian and
   Alaska Native Diabetic Eye Disease               (153). L’Ontario a davantage de         ont conduit à « l’appropriation
   Communication Plan. US Department                communautés de Premières na-            de leurs territoires et la perte de
   of Health and Human Services:                    tions isolées que toutes les autres     leurs moyens de subsistance ».
   National Eye Institute; January 2004             régions.                                Le système de pensionnat, mis
15 Atkinson DL. Preschool Vision                      Les Autochtones représen-             en place en 1892, s’est traduit
   Screening and Aboriginal Eye Health:             tent 3,8 % de la population             par des mesures contraignantes
   An Environmental Scan and Literature             canadienne, un chiffre qui les          comme l’enlèvement des enfants
   Review. BC Initiatives; April 2007               classe au second rang mondial           de leur foyer et leur placement
                                                    devant la Nouvelle-Zélande où           dans des pensionnats où il leur
                                                    le peuple Maori représente 15 %         était « interdit de parler leur pro-
                                                    de la population. Aux États-            pre langue ». Nombre d’entre

L       e Canada compte une                         Unis et en Australie, environ           eux ont souffert de violences
        population autochtone                       2 % de la population générale           psychologique, physique et
        qui dépasse 1,2 million de                  est autochtone.2 Selon le recen-        sexuelle et se sont tournés plus
personnes parmi lesquelles 61 %                     sement sur les Autochtones de           tard dans leur vie vers la consom-
sont des membres des Premières                      2006, l’Ontario est la province         mation de drogues ou d’alcool
nations, 34 % des Métis (personnes                  qui abrite la plus grande popula-       pour pouvoir surmonter ces
de descendance mixte autochtone-                    tion autochtone (243 000), suivie       traumatismes. Les pertes d’estime
européenne) et 5 % des Inuits. Ces                  par la Colombie-Britannique             de soi, la destruction des liens
trois groupes distincts présentent                  (196 000), l’Alberta (188 000), le      familiaux et la détérioration des

CaNadiaN JourNal     of   optometr y | reVue   C a N a d i e N N e d ’o p t o m é t r i e         Vol 72 | No 4 August / Août 2010   11
compétences parentales que tout          population générale. Selon une              RDP « pouvaient refléter de cour-
     cela suppose ont provoqué un             étude réalisée en Saskatchewan et           tes durées moyennes de diabète ou
     choc culturel, à l’origine de pro-       publiée en janvier 2010, le taux de         la présence de facteurs de protec-
     blèmes de santé, de la pauvreté          diabète chez les femmes autoch-             tion génétique ».9
     et de l’éclatement familial.4            tones en âge de procréer est quatre           Un rapport plus récent datant
       L’une des conséquences                 fois supérieur à celui des femmes           de 2007 (Southern Alberta Study
     marquantes de ce « stress                de la population générale. Les              of Diabetic Retinopathy) a montré
     psychosocial », qui s’ajoute aux         femmes autochtones présentent               que le taux de prévalence de la
     effets de la colonisation et à la        également des taux de diabète ges-          rétinopathie diabétique chez les
     perte des nourritures tradition-         tationnel bien supérieurs, lesquels         sujets autochtones et non au-
     nelles et des modes de vie, est          augmentent de façon spectaculaire           tochtones atteints d’un diabète
     l’épidémie de diabète qui mine la        le risque pour une femme de voir            de type 2 était équivalent dans
     santé et la vie des Autochtones.         se développer un diabète plus tard          ces deux populations, soit 40 %,
     Il est stupéfiant de constater à         au cours de sa vie, mais aussi de           un taux « bien supérieur » à celui
     quel point les Autochtones ont           rendre sa descendance plus encline          révélé par l’étude de la com-
     été touchés par cette épidémie           à cette maladie.7                           munauté Sandy Lake. Les sujets
     dont les causes sont complexes. Il         Le diabète est la cause princi-           autochtones sont également plus
     s’agit d’un phénomène qui affecte        pale de la cécité chez l’adulte au          enclins à présenter des évolutions
     tous les peuples autochtones dans        Canada. Selon une étude, la vitesse         de rétinopathie plus rapides, ce qui
     le monde. Les complications à            de progression et la sévérité de            montrerait que leur origine eth-
     long terme associées au diabète,         la rétinopathie diabétique, con-            nique joue un rôle dans la gravité
     comme la cécité, les cardiopathies,      trairement aux néphropathies, ne            des complications rétiniennes.11
     les néphropathies, les maladies          serait pas plus grande parmi les              En dépit de résultats de recher-
     infectieuses et les amputations,         Autochtones que dans la popula-             che contradictoires, il est désor-
     constituent une situation de crise       tion générale.8 Pas plus tard qu’en         mais clair que l’on fait face à un
     naissante en termes de santé             2005, on ne disposait que de peu            nombre croissant et dispropor-
     publique.5                               de données sur la prévalence de             tionné de personnes autochtones
       Avant 1950, le diabète restait         la rétinopathie diabétique chez             atteintes du diabète et, d’autre
     une affection rare dans les com-         les Autochtones du Canada. Une              part, que cette maladie survient
     munautés autochtones.6 Le diabète        étude publiée cette année sur la            à un stade bien plus précoce que
     n’a d’ailleurs pas été détecté parmi     communauté de Premières nations             dans la population générale; on
     les 1 500 membres des Premières          Sandy Lake, située dans le Nord             sait en outre que le diabète va
     nations qui firent l’objet d’un suivi    de l’Ontario, a révélé les taux de          entraîner davantage de cas évi-
     de la tuberculose en Saskatchewan        prévalence suivants : 24 % pour             tables de perte de vision, au sein
     en 1937.7 Aujourd’hui, c’est 20 %        la rétinopathie diabétique non              des communautés autochtones que
     de la population autochtone              proliférante (RDNP), 5 % pour               dans les groupes non autochtones.
     canadienne qui vit avec le diabète,      l’œdème maculaire et 2 % pour la              Il existe peu de statistiques qui
     un pourcentage qui a doublé au           rétinopathie diabétique proliférante        rendent compte du taux annuel
     cours des deux dernières décen-          (RDP).9                                     d’examen de la vision à pupille di-
     nies, vraisemblablement en raison          Ces résultats correspondent à             latée dont bénéficient les Autoch-
     de facteurs environnementaux             ceux d’une étude antérieure menée           tones canadiens. Si les tendances
     (la nutrition et le style de vie).6, 7   en 2002 par Maberley et coll.10             qui émanent d’autres services sont
     Partout au Canada, on constate           Les auteurs de l’étude de 2005 ont          de quelques enseignements, force
     que le taux de diabète de type 2         avancé l’hypothèse que les taux             est de constater que l’accès de
     est de trois à cinq fois plus élevé      de prévalence relativement bas en           nombreux Autochtones atteints de
     chez les Autochtones que dans la         matière d’œdème maculaire et de             diabète aux examens annuels de la

12    Vol 72 | No 4 August / Août 2010                      CaNadiaN JourNal   of   optometr y | reVue   C a N a d i e N N e d ’o p t o m é t r i e
maculaires et l’acuité visuelle.13       nir de nouveaux problèmes de
  n   74 % des personnes atteintes de                Aux États-Unis, le Congrès a           santé publique. Le Canada doit
      diabète depuis au moins 10 ans               créé en 1968 le National Eye In-         mobiliser davantage de fonds
      vont développer une forme quel-
                                                   stitute comme entité du National         et consentir plus d’efforts de
      conque de rétinopathie diabé-
      tique.                                       Institutes of Health. En 1991,           recherche pour combler son
  n   Environ 14 % des personnes                   cet institut a mis en place le           écart en matière de connaissance
      atteintes de diabète présentent              National Eye Health Education            scientifique sur la santé oculaire
      des œdèmes maculaires d’origine              Program qui a publié en 2004 un          des Autochtones. Le secteur de
      diabétique; cette prévalence
                                                   rapport intitulé : American In-          l’optométrie, ses partenaires et
      s’accroît à 29 % pour les per-
      sonnes atteintes de diabète qui              dian and Alaska Native Diabetic          les organisations professionnelles
      utilisent l’insuline depuis plus de          Eye Disease Communication                doivent travailler de concert
      20 ans.                                      Plan. Ce plan de communica-              avec les Autochtones et leurs
  n   Sans traitement, 25 % des per-               tion a été élaboré pour améliorer        organisations pour développer
      sonnes qui souffrent d’un œdème
                                                   la santé oculaire des Indiens            une stratégie de communication
      maculaire d’origine diabétique
      développeront une perte de vi-               d’Amérique et des Autochtones            canadienne plus efficace. Il s’agit
      sion modérée d’ici à trois ans.              de l’Alaska atteints par le diabète      d’aider à sensibiliser les travail-
  n   Les estimations qui ont été                  et pour sensibiliser davantage           leurs autochtones en soins de
      réalisées sur les taux annuels               ces populations à l’importance           santé, ainsi que les professionnels
      d’examen de la vision varient de
                                                   de subir un examen annuel de la          des soins oculo-visuels aux pro-
      manière importante selon les
      pays et les études, mais le taux de          vision à pupille dilatée.14              blèmes de santé des Autochtones
      dépistage est généralement assez               Voilà ce qu’affirme une ana-           et à l’importance de faire passer
      bas (de 40 à 65 %).                          lyse de la conjoncture réalisée en       un examen annuel de la vision
  n   Les lignes directrices mondiales             2007 par le Centre de collabora-         à pupille dilatée aux Canadiens
      en la matière recommandent
                                                   tion de la santé autochtone abrité       autochtones souffrant du diabète.
      de procéder à des dépistages
      annuels en faisant passer aux                par l’University of Northern
      personnes atteintes de diabète               British Columbia :                       1   Macaulay AC. Améliorer la santé des
      un examen de la vision à pupille               « …une analyse de la littérature           Autochtones : Quelle contribution les
      dilatée, conduit par un spécialiste                                                       professionnels de la santé peuvent-ils
                                                   internationale conduit à penser
      des soins oculovisuels.12                                                                 apporter? Le médecin de famille
                                                   que le Canada se situe loin der-
                                                                                                canadien. Vol. 55 : avril 2009
                                                   rière d’autres pays en ce qui con-
  – Fédération internationale du diabète                                                    2   Bailey S; Native population growing. La
                                                   cerne la prestation de services de
                                                                                                Presse Canadienne; Jan 15, 2008
                                                   santé oculaire et de soins de la
                                                   vue aux Autochtones. Les États-          3   Atkinson DL Preschool Vision
vision à pupille dilatée est limité                                                             Screening and Aboriginal Eye
par la situation géographique et                   Unis et l’Australie ont tous deux
                                                                                                Health : An Aboriginal Eye Health
la disponibilité d’un optométriste                 élaborés des programmes nova-                and Literature Review. BC Initiatives;
ou d’un ophtalmologiste. Plu-                      teurs, dédiés aux Autochtones et             avril 2007
sieurs projets de télémédecine                     gérés par les communautés; ils           4   Macaulay AC. Améliorer la santé des
s’appuyant sur l’utilisation de                    ont également conçus des docu-               Autochtones : Quelle contribution les
caméras rétiniennes numériques                     ments de promotion… »15                      professionnels de la santé peuvent-ils
ont été mis en place, mais ils ne                    Bien que le Canada compte                  apporter? Le médecin de famille
suffisent pas encore à combler le                  une population autochtone plus               canadien. Vol. 55 : avril 2009
besoin en services de diagnostic                   grande qu’aux États-Unis, il se          5   Hanley AJ. Diabetes in Indigenous
et de soins de la vue. Peu de don-                 situe bien derrière son voisin               Peoples : Medscape Diabetes and
nées ont en outre été publiées                     dans le règlement des problèmes              Endocrinology. Juillet 2006; http://
                                                   de santé oculaire des Autoch-                cme.medscape.com/viewarticle/540921
sur les liens entre la rétinopathie
diabétique, la gravité des œdèmes                  tones qui sont en voie de deve-

CaNadiaN JourNal     of   optometr y | reVue   C a N a d i e N N e d ’o p t o m é t r i e          Vol 72 | No 4 August / Août 2010       13
SeaSonal allergic

Treat the Signs and Symptoms
• ALREX® treats the signs and symptoms of seasonal allergic conjunctivitis1
• Proven efficacy with an excellent safety profile1
• Available in 5 mL bottles
ALREX® (loteprednol etabonate) Ophthalmic Solution 0.2% is indicated for temporary short-term relief of the signs and symptoms of seasonal
allergic conjunctivitis.
Alrex® is for ophthalmic, short-term use only (up to 14 days). If Alrex® is used for 10 days or longer, intraocular pressure should be monitored.
Alrex® is contraindicated in suspected or confirmed infections of the eye: viral diseases of the cornea and conjunctiva including epithelial herpes
simplex keratitis (dendritic keratitis), vaccinia, and varicella; untreated ocular infection of the eye; mycobacterial infection of the eye and fungal
diseases of ocular structures; hypersensitivity to this drug or any ingredient in the formulation or container, or to other corticosteroids.
Reactions associated with ophthalmic steroids include elevated intraocular pressure, which may be associated with optic nerve damage, visual
acuity and field defects, posterior subcapsular cataract formation, secondary ocular infection from pathogens including herpes simplex, and
perforation of the globe where there is thinning of the cornea or sclera.
In clinical studies, adverse events related to loteprednol etabonate were generally mild to moderate, non-serious and did not interrupt continuation
in the studies. The most frequent ocular event reported as related to therapy was increased IOP: 6% (77/1209) in patients receiving loteprednol
etabonate, as compared to 3% (25/806) in the placebo treated patients.

Bausch & Lomb Canada Inc., Vaughan, ON L4K 4B4
©2010 Bausch & Lomb Incorporated         ®Denotes trademark of Bausch & Lomb Incorporated or its affiliates
References: 1. ALREX Product Monograph, December 22, 2008
patient should be re-evaluated.
                                                                                             Prolonged use of corticosteroids may result in glaucoma with damage to the optic
                                                                                             nerve, defects in visual acuity and fields of vision, and in posterior subcapsular
   (loteprednol etabonate ophthalmic suspension 0.2% w/v)                                    cataract formation. Alrex® should not be used in the presence of glaucoma or
                                                                                             elevated intraocular pressure, unless absolutely necessary and careful and close
                                                                                             appropriate ophthalmologic monitoring (including intraocular pressure and lens
           Prescribing Summary                                                               clarity) is undertaken.
                                                                                             Corneal fungal infections are particularly prone to develop coincidentally with
           Patient Selection Criteria                                                        long-term local steroid application. Fungus invasion must be considered in any
                                                                                             persistent corneal ulceration involving steroid use. Fungal cultures should be taken
THERAPEUTIC CLASSIFICATION                                                                   when appropriate.
Corticosteroid                                                                               Prolonged use of corticosteroids may suppress the host response and thus increase
INDICATIONS AND CLINICAL USE                                                                 the hazard of secondary ocular infections. In those diseases causing thinning of the
Alrex® (loteprednol etabonate) Ophthalmic Suspension is indicated for temporary              cornea or sclera, perforations have been known to occur with the use of topical
short-term relief of the signs and symptoms of seasonal allergic conjunctivitis              steroids. In acute purulent conditions of the eye, steroids may mask infection or
CONTRAINDICATIONS                                                                            enhance existing infection.
Suspected or confirmed infection of the eye: viral diseases of the cornea and                Use of ocular steroids may prolong the course and may exacerbate the severity of
conjunctiva including epithelial herpes simplex keratitis (dendritic keratitis), vaccinia,   many viral infections of the eye (including herpes simplex). Employment of a
and varicella; untreated ocular infection of the eye; mycobacterial infection of the         corticosteroid medication in the treatment of patients with a history of herpes
eye and fungal diseases of ocular structures; hypersensitivity to this drug or any           simplex requires great caution.
ingredient in the formulation or container, or to other corticosteroids.                     Formulations with benzalkonium chloride should be used with caution in soft
SPECIAL POPULATIONS                                                                          contact lens wearers.
Use in Pediatrics (< 18 years of age):                                                       ADVERSE REACTIONS
Alrex® should not be used in pediatric patients.                                             Overview
Use in Geriatrics:                                                                           Reactions associated with ophthalmic steroids include elevated intraocular pressure,
Alrex® should not be used in geriatric patients. The safety and efficacy of Alrex®           which may be associated with optic nerve damage, visual acuity and field defects,
have not been established in patients > 65 years of age.                                     posterior subcapsular cataract formation, secondary ocular infection from pathogens
Pregnant Women:                                                                              including herpes simplex, and perforation of the globe where there is thinning of
Alrex® should not be used in pregnant women, unless the benefit clearly outweighs            the cornea or sclera.
the risks. Studies in pregnant women have not been conducted.                                In nineteen clinical trials ranging from 1 to 42 days in length, 1,209 patients
Nursing Women:                                                                               received various concentrations of loteprednol etabonate in topical ocular drops
Alrex® should not be used in lactating women, unless the benefit clearly outweighs           (0.005%, 0.05%, 0.1%, 0.2%, 0.5%). Adverse events related to loteprednol
the risks.                                                                                   etabonate were generally mild to moderate, non-serious and did not interrupt
                                                                                             continuation in the studies. The most frequent ocular event reported as related to
           Safety Information                                                                therapy was increased IOP: 6% (77/1209) in patients receiving loteprednol
                                                                                             etabonate, as compared to 3% (25/806) in the placebo treated patients.
WARNINGS AND PRECAUTIONS                                                                     With the exception of elevations in IOP, the incidence of events in the LE group was
General                                                                                      similar to, or less than that of the placebo control groups. Itching was reported as
For ophthalmic, short-term use only (up to 14 days).                                         related to therapy in 3% of the loteprednol treated eyes, injection, epiphora,
The initial prescription and renewal of Alrex® should be made by a physician only            burning/stinging other than at instillation, foreign body sensation, and
after appropriate ophthalmologic examination is performed. If signs and symptoms             burning/stinging at instillation were each reported for 2% of eyes. The most
fail to improve after two days, the patient should be re-evaluated. If Alrex® is used        frequent non-ocular event reported as related to therapy was headache, reported
for 10 days or longer, intraocular pressure should be closely monitored.                     for 1.2% of the loteprednol treated subjects and 0.6% of the placebo treated
Prolonged use of corticosteroids may result in cataract and/or glaucoma formation.           subjects.
Alrex® should not be used in the presence of glaucoma or elevated intraocular                To report an adverse event, contact your Regional Adverse Reaction Monitoring
pressure, unless absolutely necessary and close ophthalmologic monitoring is                 Office at 1-866-234-2345 or Bausch & Lomb at 1-888-459-5000
undertaken. Extreme caution should be exercised, and duration of treatment should
be kept as short as possible.                                                                              Administration
Alrex® should not be used in cases of existing (suspected or confirmed) ocular viral,
fungal, or mycobacterial infections. Alrex® may suppress the host response and thus          One drop instilled into the affected eye(s) four times daily for up to 14 days. If
increase the hazard of secondary ocular infections. The use of Alrex® in patients            scheduled dose is missed, patient should be advised to wait until the next dose and
with a history of herpes simplex requires great caution and close monitoring.                then continue as before.
Alrex® contains benzalkonium chloride.                                                       SHAKE VIGOROUSLY BEFORE USING. Alrex® should be stored upright between
Alrex® has not been studied in pregnant or nursing women, but has been found to              15°–25°C for up to 28 days after first opening.
be teratogenic in animals. Alrex® should not be used in pregnant or nursing women            The preservative in Alrex®, benzalkonium chloride, may be absorbed by soft contact
unless the benefits clearly outweigh the risks.                                              lenses, and can discolour soft contact lenses. Therefore, Alrex® should not be used
Carcinogenesis and Mutagenesis                                                               while the patient is wearing soft contact lenses. Patients who wear soft contact
Long-term animal studies have not been conducted to evaluate the carcinogenic                lenses and whose eyes are not red should wait ten to fifteen minutes after instilling
potential of loteprednol etabonate. Loteprednol etabonate was not genotoxic in vitro         Alrex® before they insert their contact lenses.
in the Ames test, the mouse lymphoma tk assay, or in a chromosome aberration                 Patients should be advised not to wear a contact lens if their eye is red. Alrex®
test in human lymphocytes, or in vivo in the single dose mouse micronucleus assay.           should not be used to treat contact lens related irritation.
Alrex® should be used as a brief temporary treatment. If Alrex® is used for 10 days          SUPPLEMENTAL PRODUCT INFORMATION
or longer, intraocular pressure should be closely monitored. The initial prescription        WARNINGS AND PRECAUTIONS
and renewal of Alrex® should be made by a physician only after appropriate                   Sexual Function/Reproduction
                                                                                             The effects of Alrex® on sexual function and reproduction have not been studied in humans. Treatment of male and
ophthalmologic examination is performed, ie. slit lamp biomicroscopy or fluorescein          female rats with up to 50 mg/kg/day and 25 mg/kg/day of loteprednol etabonate, respectively, (1000 and 500 times
staining if appropriate. If signs and symptoms fail to improve after two days, the           the Alrex® clinical dose) prior to and during mating, was clearly harmful to the rats, but did not impair their copulation
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