COVID-19'S IMPACT

EARN 2 CE CREDITS: Maximizing OCT in the Diagnosis of Glaucoma, p. 76

May 15, 2020 www.reviewofoptometry.com COVID-19’s IMPACT …and How Optometry Can Bounce Back THERE’S RELIEF AND THEN THERE’S Its disruptions were swift and seismic, but ODs are ready to move on.

• Planning for Post-COVID Life, p. 3 • Patient Care Morphs During COVID-19, p. 30 • 20 Tips FORFor Reopening DRY, Amid COVID-19, IRRITATED p. 36 EYES.

The only family of products in the U.S. with CMC, HA (inactive ingredient), and HydroCell™ technology.

ALSO: 21st Annual Dry Eye Report, begins p. 42 refreshbrand.com/doc Statins and the Eye: What You May Not Know, p. 62 © 2020 Allergan. All rights reserved. All trademarks are the property of their respective owners. REF127591 08/19 Five Cases You Shouldn’t Refer, p. 68

EARN 2 CE CREDITS: Maximizing OCT in the Diagnosis of Glaucoma, p. 76

May 15, 2020 www.reviewofoptometry.com COVID-19’s IMPACT …and How Optometry Can Bounce Back Its disruptions were swift and seismic, but ODs are ready to move on.

• Planning for Post-COVID Life, p. 3 • Patient Care Morphs During COVID-19, p. 30 • 20 Tips For Reopening Amid COVID-19, p. 36

ALSO: 21st Annual Dry Eye Report, begins p. 42 Statins and the Eye: What You May Not Know, p. 62 Five Cases You Shouldn’t Refer, p. 68 INTRODUCING VISUAL FIELD SUITE M&S | Melbourne Rapid Fields (MRF)

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© 2020 M&S Technologies, Inc. Smart System and M&S are registered trademarks of M&S Technologies. All rights reserved. M&S holds US Patents 7,354,155; 7,926,948; 8,425,040; 8,167,429; 8,419,184; 8,550,631; 10,244,938 and 10,182,713. Other Patents Pending. NewsNews ReviewReview

VOL. 157 NO. 5 n MAY 15, 2020

IN THE NEWS Practices Plan for A recent study found that pharmacological pupil dilation worsened Post-COVID Life angle closure in half of untreated acute primary angle closure (APAC) patients ECPs look to make a return to normalcy an with narrow angles. Swept-source OCT immediate reality. By Mark De Leon, Associate Editor captured 360-degree scans of the angles of 106 APAC patients older than age 50 tate-mandated shutdowns en- distance, by relying on phone calls before and one hour after dilation. Angle acted as the coronavirus spread (78.6% of respondents) and video or narrowing was also associated with a Sacross the United States have photo consultations (81.6%). This shallower anterior chamber and a bigger left the eye care profession largely on correlates with a similar increase lens vault. hiatus since mid-March, but prac- in patients’ curiosity in accessing Narayanaswamy A, Baskaran M, Tun TA, et al. Effect of tices are now prepping to reopen, remote services, as 41.4% of respon- pharmacological pupil dilatation on angle configuration in untreated primary angle closure suspects: a swept source albeit with downscaled services and dents reported their patients current anterior segment optical coherence tomography study. J Glaucoma. March 27, 2020. [Epub ahead of print]. realistic ambitions for the near term. express interest, compared with After restricting services to emer- 17.3% at the start of the crisis. A recent study found that patients gency appointments only, attempt- Optometrists have gotten used to with mild cognitive impairment and ing telemedicine consults and using billing telehealth consultations as Alzheimer’s disease experienced unconventional methods to stay in well, as the initial 26% who were anatomical and functional retinal touch with patients, optometrists comfortable with billing telehealth changes, including reductions in have resumption of business on their in mid-March has grown to about nerve fiber layer thickness, arterial mind but are unsure on how to put 70% of respondents who report blood flow, arterial vessel diameter and arteriovenous difference in oxygen that into action. having done so in the past two saturation. “This indicates alterations in To track both the sentiment weeks (Figure 1). Those doing so are retinal oxygen metabolism in patients and circumstances of a profession starting to feel more confident with with neurodegenerative disease,” the operating in crisis mode, Jobson the process, with only 25.2% saying researchers concluded in their paper. (publisher of Review of Optometry) they needed help in mid-April vs.

Szegedi S, Dal-Bianco P, Stögmann E, et al. Anatomical and launched a weekly survey in mid- 32.4% one month prior. functional changes in the retina in patients with Alzheimer’s March. Data through late April (Continued on p. 7) disease and mild cognitive impairment. Acta Ophthalmo- logica. March 25, 2020. [Epub ahead of print]. show eye care practitioners (Wave Source: Jobson ECP Coronavirus Survey 7) (ECPs) still reeling—respon- Fig. 1. Have You Billed for Telehealth Services in the Last Two Weeks? Researchers recently found that the dents pegged their career- trajectory of functional decline in eyes related stress at 7.0 on a treated for wet AMD was greater than 1-10 scale—but ready to what has been reported. After monitor- rebound. ing patients for approximately three years, the team reported a median dis- Open to Telehealth tance visual acuity (DVA) of 58.0 letters, The crisis continues to push which decreased by 4.3 letters per year. doctors to offer telehealth This rate was not influenced by injection rate after adjusting for key covariates. services. According to the DVA was similar among patients, regard- most recent Jobson ECP less of whether they switched between Coronavirus Survey (Wave ranibizumab and aflibercept. 7), optometrists are still

Evans RN, Reeves BC, Phillips D, et al. Long-term outcomes keeping up with patients of usual care in patients with neovascular age-related while maintaining their macular degeneration in the IVAN trial. Ophthalmology. March 27, 2020. [Epub ahead of print]. NEWS STORIES POST EVERY WEEKDAY MORNING AT www.reviewofoptometry.com/news

REVIEW OF OPTOMETRY MAY 15, 2020 3 Help your patients with DIABETIC RETINOPATHY (DR), and HELP DRIVE PATIENT OUTCOMES Through early detection, monitoring, and timely referral, you can play a pivotal role in managing your DR patients’ vision1-3

IF YOU SEE OR SUSPECT DR:

Educate your patients Refer Follow up about living with DR and DR patients for timely to ensure they potential treatment options2,3 intervention have visited a • According to the AOA, you retina specialist should refer patients with2,3 – Severe nonproliferative DR (NPDR) within 2 to 4 weeks – Proliferative DR (PDR) within 1 week

INDICATIONS AND IMPORTANT SAFETY INFORMATION EYLEA® (aflibercept) Injection 2 mg (0.05 mL) is indicated for the treatment of patients with Neovascular (Wet) Age-related Macular Degeneration (AMD), Macular Edema following Retinal Vein Occlusion (RVO), Diabetic Macular Edema (DME), and Diabetic Retinopathy (DR). CONTRAINDICATIONS • EYLEA is contraindicated in patients with ocular or periocular infections, active intraocular inflammation, or known hypersensitivity to aflibercept or to any of the excipients in EYLEA. WARNINGS AND PRECAUTIONS • Intravitreal injections, including those with EYLEA, have been associated with endophthalmitis and retinal detachments. Proper aseptic injection technique must always be used when administering EYLEA. Patients should be instructed to report any symptoms suggestive of endophthalmitis or retinal detachment without delay and should be managed appropriately. Intraocular inflammation has been reported with the use of EYLEA.

References: 1. Early Treatment Diabetic Retinopathy Study Research Group. Fundus photographic risk factors for progression of diabetic retinopathy. ETDRS report number 12. Ophthalmology. 1991;98(5 suppl):823-833. 2. Care of the Patient With Diabetes Mellitus: Quick Reference Guide. American Optometric Association website. http://bit.ly/2M22OUJ. Accessed August 7, 2019. 3. Ferrucci S, Yeh B. Diabetic retinopathy by the numbers. Rev Optom. June 15, 2016. http://bit.ly/2KNNJ4E. Accessed August 7, 2019.

EYLEA is a registered trademark of Regeneron Pharmaceuticals, Inc.

Visit diabeticretinaldisease.com for additional information and useful patient resources

Continue to monitor The more you know about emerging clinical your patients with DR2,3 science about anti-VEGF and other potential therapies • The AOA recommends frequent for DR, the better you can help inform your patients monitoring of patients2 about how treatment may be able to help – At least every 6 to 8 months in Refer patients to a retina specialist patients with moderate NPDR who can treat DR2,3 and more frequently for patients with greater disease severity2

WARNINGS AND PRECAUTIONS (cont’d) • Acute increases in intraocular pressure have been seen within 60 minutes of intravitreal injection, including with EYLEA. Sustained increases in intraocular pressure have also been reported after repeated intravitreal dosing with VEGF inhibitors. Intraocular pressure and the perfusion of the optic nerve head should be monitored and managed appropriately. • There is a potential risk of arterial thromboembolic events (ATEs) following intravitreal use of VEGF inhibitors, including EYLEA. ATEs are defined as nonfatal stroke, nonfatal myocardial infarction, or vascular death (including deaths of unknown cause). The incidence of reported thromboembolic events in wet AMD studies during the first year was 1.8% (32 out of 1824) in the combined group of patients treated with EYLEA compared with 1.5% (9 out of 595) in patients treated with ranibizumab; through 96 weeks, the incidence was 3.3% (60 out of 1824) in the EYLEA group compared with 3.2% (19 out of 595) in the ranibizumab group. The incidence in the DME studies from baseline to week 52 was 3.3% (19 out of 578) in the combined group of patients treated with EYLEA compared with 2.8% (8 out of 287) in the control group; from baseline to week 100, the incidence was 6.4% (37 out of 578) in the combined group of patients treated with EYLEA compared with 4.2% (12 out of 287) in the control group. There were no reported thromboembolic events in the patients treated with EYLEA in the first six months of the RVO studies. ADVERSE REACTIONS • Serious adverse reactions related to the injection procedure have occurred in <0.1% of intravitreal injections with EYLEA including endophthalmitis and retinal detachment. • The most common adverse reactions (≥5%) reported in patients receiving EYLEA were conjunctival hemorrhage, eye pain, cataract, vitreous detachment, vitreous floaters, and intraocular pressure increased. Please see Brief Summary of Prescribing Information on the following pages.

03/2020 anti-VEGF = anti–vascular endothelial growth factor; AOA = American Optometric Association. EYL.20.02.0082 BRIEF SUMMARY—Please see the EYLEA Table 2: Most Common Adverse Reactions (≥1%) in RVO Studies full Prescribing Information available CRVO BRVO on HCP.EYLEA.US for additional EYLEA Control EYLEA Control Adverse Reactions (N=218) (N=142) (N=91) (N=92) product information. Eye pain 13% 5% 4% 5% Conjunctival hemorrhage 12% 11% 20% 4% Intraocular pressure increased 8% 6% 2% 0% 1 INDICATIONS AND USAGE Corneal epithelium defect 5% 4% 2% 0% EYLEA is a vascular endothelial growth factor (VEGF) inhibitor indicated for the treatment of: Vitreous floaters 5% 1% 1% 0% Neovascular (Wet) Age-Related Macular Degeneration (AMD); Macular Edema Following Retinal Vein Occlusion (RVO); Diabetic Ocular hyperemia 5% 3% 2% 2% Macular Edema (DME); Diabetic Retinopathy (DR). Foreign body sensation in eyes 3% 5% 3% 0% 4 CONTRAINDICATIONS Vitreous detachment 3% 4% 2% 0% 4.1 Ocular or Periocular Infections Lacrimation increased 3% 4% 3% 0% EYLEA is contraindicated in patients with ocular or periocular infections. Injection site pain 3% 1% 1% 0% 4.2 Active Intraocular Inflammation Vision blurred 1% <1% 1% 1% EYLEA is contraindicated in patients with active intraocular inflammation. Intraocular inflammation 1% 1% 0% 0% 4.3 Hypersensitivity Cataract <1% 1% 5% 0% EYLEA is contraindicated in patients with known hypersensitivity to aflibercept or any of the excipients in EYLEA. Hypersensitivity Eyelid edema <1% 1% 1% 0% reactions may manifest as rash, pruritus, urticaria, severe anaphylactic/anaphylactoid reactions, or severe intraocular inflammation. Less common adverse reactions reported in <1% of the patients treated with EYLEA in the CRVO studies were corneal edema, retinal 5 WARNINGS AND PRECAUTIONS tear, hypersensitivity, and endophthalmitis. 5.1 Endophthalmitis and Retinal Detachments. Intravitreal injections, including those with EYLEA, have been associated with endophthalmitis and retinal detachments [see Adverse Diabetic Macular Edema (DME) and Diabetic Retinopathy (DR). The data described below reflect exposure to EYLEA in 578 patients Reactions (6.1)]. Proper aseptic injection technique must always be used when administering EYLEA. Patients should be instructed with DME treated with the 2-mg dose in 2 double-masked, controlled clinical studies (VIVID and VISTA) from baseline to week 52 and to report any symptoms suggestive of endophthalmitis or retinal detachment without delay and should be managed appropriately from baseline to week 100. [see Patient Counseling Information (17)]. Table 3: Most Common Adverse Reactions (≥1%) in DME Studies 5.2 Increase in Intraocular Pressure. Acute increases in intraocular pressure have been seen within 60 minutes of intravitreal injection, including with EYLEA [see Adverse Baseline to Week 52 Baseline to Week 100 Reactions (6.1)]. Sustained increases in intraocular pressure have also been reported after repeated intravitreal dosing with vascular EYLEA Control EYLEA Control endothelial growth factor (VEGF) inhibitors. Intraocular pressure and the perfusion of the optic nerve head should be monitored and Adverse Reactions (N=578) (N=287) (N=578) (N=287) managed appropriately. Conjunctival hemorrhage 28% 17% 31% 21% 5.3 Thromboembolic Events. There is a potential risk of arterial thromboembolic events (ATEs) following intravitreal use of VEGF inhibitors, including EYLEA. ATEs Eye pain 9% 6% 11% 9% are defined as nonfatal stroke, nonfatal myocardial infarction, or vascular death (including deaths of unknown cause). The incidence of Cataract 8% 9% 19% 17% reported thromboembolic events in wet AMD studies during the first year was 1.8% (32 out of 1824) in the combined group of patients Vitreous floaters 6% 3% 8% 6% treated with EYLEA compared with 1.5% (9 out of 595) in patients treated with ranibizumab; through 96 weeks, the incidence was Corneal epithelium defect 5% 3% 7% 5% 3.3% (60 out of 1824) in the EYLEA group compared with 3.2% (19 out of 595) in the ranibizumab group. The incidence in the DME Intraocular pressure increased 5% 3% 9% 5% studies from baseline to week 52 was 3.3% (19 out of 578) in the combined group of patients treated with EYLEA compared with 2.8% (8 out of 287) in the control group; from baseline to week 100, the incidence was 6.4% (37 out of 578) in the combined group of Ocular hyperemia 5% 6% 5% 6% patients treated with EYLEA compared with 4.2% (12 out of 287) in the control group. There were no reported thromboembolic events Vitreous detachment 3% 3% 8% 6% in the patients treated with EYLEA in the first six months of the RVO studies. Foreign body sensation in eyes 3% 3% 3% 3% 6 ADVERSE REACTIONS Lacrimation increased 3% 2% 4% 2% The following potentially serious adverse reactions are described elsewhere in the labeling: Vision blurred 2% 2% 3% 4% • Hypersensitivity [see Contraindications (4.3)] Intraocular inflammation 2% <1% 3% 1% • Endophthalmitis and retinal detachments [see Warnings and Precautions (5.1)] • Increase in intraocular pressure [see Warnings and Precautions (5.2)] Injection site pain 2% <1% 2% <1% Eyelid edema <1% 1% 2% 1% • Thromboembolic events [see Warnings and Precautions (5.3)] 6.1 Clinical Trials Experience. Less common adverse reactions reported in <1% of the patients treated with EYLEA were hypersensitivity, retinal detachment, retinal Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug tear, corneal edema, and injection site hemorrhage. cannot be directly compared to rates in other clinical trials of the same or another drug and may not reflect the rates observed Safety data observed in 269 patients with nonproliferative diabetic retinopathy (NPDR) through week 52 in the PANORAMA trial were in practice. consistent with those seen in the phase 3 VIVID and VISTA trials (see Table 3 above). A total of 2980 patients treated with EYLEA constituted the safety population in eight phase 3 studies. Among those, 2379 patients 6.2 Immunogenicity. were treated with the recommended dose of 2 mg. Serious adverse reactions related to the injection procedure have occurred in <0.1% As with all therapeutic proteins, there is a potential for an immune response in patients treated with EYLEA. The immunogenicity of intravitreal injections with EYLEA including endophthalmitis and retinal detachment. The most common adverse reactions (≥5%) of EYLEA was evaluated in serum samples. The immunogenicity data reflect the percentage of patients whose test results were reported in patients receiving EYLEA were conjunctival hemorrhage, eye pain, cataract, vitreous detachment, vitreous floaters, and considered positive for antibodies to EYLEA in immunoassays. The detection of an immune response is highly dependent on the intraocular pressure increased. sensitivity and specificity of the assays used, sample handling, timing of sample collection, concomitant medications, and underlying Neovascular (Wet) Age-Related Macular Degeneration (AMD). The data described below reflect exposure to EYLEA in 1824 patients disease. For these reasons, comparison of the incidence of antibodies to EYLEA with the incidence of antibodies to other products with wet AMD, including 1223 patients treated with the 2-mg dose, in 2 double-masked, controlled clinical studies (VIEW1 and VIEW2) may be misleading. for 24 months (with active control in year 1). In the wet AMD, RVO, and DME studies, the pre-treatment incidence of immunoreactivity to EYLEA was approximately 1% to 3% across Safety data observed in the EYLEA group in a 52-week, double-masked, Phase 2 study were consistent with these results. treatment groups. After dosing with EYLEA for 24-100 weeks, antibodies to EYLEA were detected in a similar percentage range of patients. There were no differences in efficacy or safety between patients with or without immunoreactivity. Table 1: Most Common Adverse Reactions (≥1%) in Wet AMD Studies Baseline to Week 52 Baseline to Week 96 8 USE IN SPECIFIC POPULATIONS. 8.1 Pregnancy Active Control Control Risk Summary EYLEA (ranibizumab) EYLEA (ranibizumab) Adequate and well-controlled studies with EYLEA have not been conducted in pregnant women. Aflibercept produced adverse Adverse Reactions (N=1824) (N=595) (N=1824) (N=595) embryofetal effects in rabbits, including external, visceral, and skeletal malformations. A fetal No Observed Adverse Effect Level Conjunctival hemorrhage 25% 28% 27% 30% (NOAEL) was not identified. At the lowest dose shown to produce adverse embryofetal effects, systemic exposures (based on AUC for Eye pain 9% 9% 10% 10% free aflibercept) were approximately 6 times higher than AUC values observed in humans after a single intravitreal treatment at the recommended clinical dose [see Animal Data]. Cataract 7% 7% 13% 10% Animal reproduction studies are not always predictive of human response, and it is not known whether EYLEA can cause fetal harm Vitreous detachment 6% 6% 8% 8% when administered to a pregnant woman. Based on the anti-VEGF mechanism of action for aflibercept, treatment with EYLEA may Vitreous floaters 6% 7% 8% 10% pose a risk to human embryofetal development. EYLEA should be used during pregnancy only if the potential benefit justifies the Intraocular pressure increased 5% 7% 7% 11% potential risk to the fetus. Ocular hyperemia 4% 8% 5% 10% All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. The background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth Corneal epithelium defect 4% 5% 5% 6% defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively. Detachment of the retinal pigment epithelium 3% 3% 5% 5% Data Injection site pain 3% 3% 3% 4% Animal Data Foreign body sensation in eyes 3% 4% 4% 4% In two embryofetal development studies, aflibercept produced adverse embryofetal effects when administered every three days Lacrimation increased 3% 1% 4% 2% during organogenesis to pregnant rabbits at intravenous doses ≥3 mg per kg, or every six days during organogenesis at subcutaneous Vision blurred 2% 2% 4% 3% doses ≥0.1 mg per kg. Intraocular inflammation 2% 3% 3% 4% Adverse embryofetal effects included increased incidences of postimplantation loss and fetal malformations, including anasarca, umbilical hernia, diaphragmatic hernia, gastroschisis, cleft palate, ectrodactyly, intestinal atresia, spina bifida, encephalomeningocele, Retinal pigment epithelium tear 2% 1% 2% 2% heart and major vessel defects, and skeletal malformations (fused vertebrae, sternebrae, and ribs; supernumerary vertebral arches Injection site hemorrhage 1% 2% 2% 2% and ribs; and incomplete ossification). The maternal No Observed Adverse Effect Level (NOAEL) in these studies was 3 mg per kg. Eyelid edema 1% 2% 2% 3% Aflibercept produced fetal malformations at all doses assessed in rabbits and the fetal NOAEL was not identified. At the lowest Corneal edema 1% 1% 1% 1% dose shown to produce adverse embryofetal effects in rabbits (0.1 mg per kg), systemic exposure (AUC) of free aflibercept was Retinal detachment <1% <1% 1% 1% approximately 6 times higher than systemic exposure (AUC) observed in humans after a single intravitreal dose of 2 mg. 8.2 Lactation Less common serious adverse reactions reported in <1% of the patients treated with EYLEA were hypersensitivity, retinal tear, and Risk Summary endophthalmitis. There is no information regarding the presence of aflibercept in human milk, the effects of the drug on the breastfed infant, or the effects of the drug on milk production/excretion. Because many drugs are excreted in human milk, and because the potential for Macular Edema Following Retinal Vein Occlusion (RVO). The data described below reflect 6 months exposure to EYLEA with a absorption and harm to infant growth and development exists, EYLEA is not recommended during breastfeeding. monthly 2 mg dose in 218 patients following CRVO in 2 clinical studies (COPERNICUS and GALILEO) and 91 patients following BRVO in The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for EYLEA and any one clinical study (VIBRANT). potential adverse effects on the breastfed child from EYLEA. 8.3 Females and Males of Reproductive Potential Contraception Females of reproductive potential are advised to use effective contraception prior to the initial dose, during treatment, and for at least 3 months after the last intravitreal injection of EYLEA. Infertility There are no data regarding the effects of EYLEA on human fertility. Aflibercept adversely affected female and male reproductive systems in cynomolgus monkeys when administered by intravenous injection at a dose approximately 1500 times higher than the systemic level observed humans with an intravitreal dose of 2 mg. A No Observed Adverse Effect Level (NOAEL) was not identified. These findings were reversible within 20 weeks after cessation of treatment. 8.4 Pediatric Use. The safety and effectiveness of EYLEA in pediatric patients have not been established. 8.5 Geriatric Use. In the clinical studies, approximately 76% (2049/2701) of patients randomized to treatment with EYLEA were ≥65 years of age and Manufactured by: approximately 46% (1250/2701) were ≥75 years of age. No significant differences in efficacy or safety were seen with increasing age Regeneron Pharmaceuticals, Inc. Issue Date: 08/2019 in these studies. 777 Old Saw Mill River Road Initial U.S. Approval: 2011 Tarrytown, NY 10591 17 PATIENT COUNSELING INFORMATION Based on the August 2019 In the days following EYLEA administration, patients are at risk of developing endophthalmitis or retinal detachment. If the EYLEA is a registered trademark of Regeneron EYLEA® (aflibercept) Injection full eye becomes red, sensitive to light, painful, or develops a change in vision, advise patients to seek immediate care from an Pharmaceuticals, Inc. Prescribing Information. ophthalmologist [see Warnings and Precautions (5.1)]. © 2019, Regeneron Pharmaceuticals, Inc. Patients may experience temporary visual disturbances after an intravitreal injection with EYLEA and the associated eye examinations All rights reserved. EYL.19.07.0306 [see Adverse Reactions (6)]. Advise patients not to drive or use machinery until visual function has recovered sufficiently. News Review

Meeting New COVID Challenges (Continued from p. 3) Currently, 74.5% of respondents On the Road Again Slowly But Surely would greatly appreciate guidance Educational events large and small have A question on ECPs’ minds is when on reopening, a steady increase from been postponed, curtailed or canceled they can resume business as usual— the 48.2% who said the same at since social distancing policies began in as usual as possible, at least. Many the start of the weekly survey series. mid-March. The majority of ECPs surveyed continue rescheduling appointments Almost 58% are now working on feel ready to attend events within driving for either May or June. a written plan for reopening their distance by the fall of this year (25.5%) The latest survey cut to the chase practice, and many intend to use or sometime in 2021 (25.1%). As for air and asked practice owners how phone calls, social media and email travel, 33.1% of respondents will feel many more weeks they thought their to communicate to patients when comfortable going to meetings by plane businesses could survive with their their practice has re-opened. sometime in 2021. However, respon- doors shuttered. Most respondents When their practices do reopen, dents to the most recent survey believe believed they could tough it out for 41% of respondents believe they that travel both within driving and flying one or two more months (34.3%), will resume at their normal schedule, distance will occur most likely sometime while 30.2% could only plausibly while 33.8% believe they’ll initially in 2021 (31.7% and 38%, respectively). do another three or four weeks. The operate with shortened hours and survey also asked how soon they 15.7% expect to put in longer hours practitioners what personal pro- would expect to be up and running to compensate for the additional tective equipment (PPE) they will after being allowed to reopen. A re- time needed per patient encounter. implement and maintain for them- sounding 41.2% answered immedi- selves and their colleagues (Figure 2). ately, with 29.9% saying they would Safety First While the majority of respondents open within a week. Despite an eagerness to get things believe they will require all staff back in motion, ECPs understand members to wear masks and gloves Reality of Layoffs resuming business necessitates in some capacity, they also intend for Another unfortunate impact on businesses conducting it as safely as possible. doctors to wear masks, gloves, face is staff downsizing. By late April, about Asked what changes they will imple- shields, gowns and goggles. For visit- 60% of ECPs in the survey had admitted ment upon returning to routine ing patients, many practice owners to letting go or laying off staff, a sizable in-person care, 87.1% said they believe they will only require them increase from 40.8% at the end of March. will reduce the number of people in to wear masks. About 15% of respondents said they were the office at the same time, 85.4% Cautiously and with a fair share recently furloughed or laid off, and 89.6% will change sanitization processes of anxiety, optometrists and other of them have applied for unemployment. and 83.9% will screen patients for ECPs nationwide seem ready to The federal Coronavirus Aid, Relief and COVID-19 exposure. interact with patients face to face Economic Security (CARES) Act is a relief The most recent survey also asked again. package looking to make an estimated (Wave Source: Jobson ECP Coronavirus Survey 7) $153.5 billion available to the public Fig. 2. What PPE Do You Plan to Require, and for Who? health sector, another $377 billion to small businesses and $500 billion to large corporations. Depending on the practice, optometry may fall into any of those three categories. About 83% of practice owners said they have applied for aid through the relief package.

Snell K. What’s inside the senate’s $2 trillion coronavirus aid package. National Public Radio. www.npr. org/2020/03/26/821457551/whats-inside-the-senate- s-2-trillion-coronavirus-aid-package. March 26, 2020. Accessed April 30, 2020.

REVIEW OF OPTOMETRY MAY 15, 2020 7 News Review For more, visit www.reviewofoptometry.com/news FA Detects DR Microaneuryms ltra-widefield fluorescein as mild, one to three fields were Overall, UWF-FA microaneurysm angiography (UWF-FA) may deemed moderate and four or more counts were 3.5-fold higher than Ube a more precise method for were considered severe. those found in UWF-CI. Specifically, finding microaneurysms than ultra- In 193 patients (288 eyes), 2.4% they were 3.2 times higher in ET- widefield color imaging (UWF-CI) had no DR, 29.9% had mild non- DRS fields and 5.3 times higher in when grading diabetic retinopathy proliferative DR (NPDR), 32.6% extended ETDRS fields, in addition (DR) severity, a study in the British had moderate NPDR, 22.9% were to being higher in Type 1 diabetes Journal of Ophthalmology reports. classified as having severe NPDR compared with Type 2. The investigation found UWF-FA and 12.2% had proliferative DR. In 246 NPDR eyes graded with

was able to detect three to five times Photo: UWF-CI, UWF-FA found 1.6 times

more microaneurysms than UWF-CI Erik Hanson, to 3.5 times more fields with 20 or and identify up to 3.5 more fields more microaneurysms. affecting DR severity. The study found fair agreement The retrospective study included MD between imaging modalities, patients with Type 1 or 2 diabetes although differences at all DR mellitus who had UWF-FA and severity levels limited direct UWF-CI done within a two-week comparison between the modalities, timeframe. The investigators manu- the researchers noted. However, ally counted microaneurysms in correcting UWF-FA microaneurysm individual Early Treatment Diabetic counts substantially improved DR Retinopathy Study (ETDRS) and severity agreement between the extended ultrawide field zones. The modalities, they added. study determined DR severity based UWF-FA may detect more scattered Ashraf M, Sampani K, AbdelAl O, et al. Disparity of micro-aneu- on fields with 20 or more microan- microaneurysms, compared with rysm count between ultra-wide field color imaging and ultra-wide field fluorescein angiography in eyes with diabetic retinopathy. Br eurysms. Zero fields were classified ultrawide field color imaging. J Ophthalmol. February 28, 2020. [Epub ahead of print].

Ocular Antibiotic Resistance Still Prevalent ntibiotic therapeutics are Staphylococcus aureus, coagulase- older patients more likely to have used to treat confirmed negative staphylococci (CoNS), resistance than pediatric patients. Abacterial cases and, in some Streptococcus pneumoniae, However, the study shows, cases, mere suspects as well. How- Pseudomonas aeruginosa and even for pediatric patients, the ever, liberal use of them can result Haemophilus influenzae collected mean percentage of antibiotic in antibiotic resistant strains of between 2009 and 2018. resistance—including methicillin bacteria and, eventually, untreatable Specifically, the research team resistance among staphylococcal disease. The research community note in the study, S. aureus and isolates—was notable. is on the watch for that eventuality CoNS isolates were most methicil- The study did show that P. ae- and an update to the well-known lin resistant and more likely to be ruginosa and H. influenzae isolates Antibiotic Resistance Monitoring in concurrently resistant to macro- have low resistance overall. Ocular Microorganisms (ARMOR) lides, fluoroquinolones and amino- Although resistance is high, the study shows that bacteria continue glycosides compared with methicil- researchers note that the resistance to win the war. lin-susceptible isolates. Multidrug profiles were mostly unchanged Methicillin resistance and resistance was observed among during the 10-year study period. multidrug resistance are prevalent methicillin-resistant S. aureus. among staphylococci, according Differences in antibiotic Asbell P, Sanfilippo C, Sahm D, et al. Trends in antibiotic resistance among ocular microorganisms in the United States to the investigators. They looked resistance were found among from 2009 to 2018. JAMA Ophthalmol. April 9, 2020. [Epub into more than 6,000 isolates of isolates by patient age, with ahead of print].

8 REVIEW OF OPTOMETRY MAY 15, 2020 THERAPY FOR YOUR EYES

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References: 1. Ngo W, Srinivasan S, Houtman D, Jones L. The relief of dry eye signs and symptoms using a combination of lubricants, lid hygiene and ocular nutraceuticals. J Optom. 2017 Jan-Mar;10(1):26-33. 2. Jones L, Downie L, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. Jul 2017;15:575-628. © 2020 Akorn Consumer Health | A Division of Akorn, Inc. | M16-040-01 News Review For more, visit www.reviewofoptometry.com/news

Glaucoma Index Finds VF Progression Earlier isual field (VF) progression is eyes) were treated at a tertiary glau- guided progression analysis. often a key clue for clini- coma center. Additional data was The glaucoma rate index showed Vcians to decide on the right collected from 391 participants (472 the shortest median time to progres- course of therapy for their glaucoma eyes) in the Advanced Glaucoma sion at 8.8 years compared with patients. A new study in JAMA Intervention Study. The data was guided progression analysis and Ophthalmology found one tracker— collected from 1988 to 2004 and pointwise linear regression, which the glaucoma rate index—was able analyzed from 2018 to 2019. both showed a rate of more than to detect long-term VF progression The study compared estimates 16 years. The subgroup with likely earlier than two other methods: of VF progression using each of progression had similar results. pointwise linear regression or guided the three methods in addition with For that subgroup, the progression analysis. a subset of patients with likely VF proportions of progressing eyes The study also found the glau- progression and likely VF stability. were 73.7% for guided progression coma rate index maintained a low Baseline mean deviation was analysis, 81.4% for pointwise rate of false-positive estimates, and about -6.7 and patients were fol- linear regression and 92.9% for agreement among all three tested lowed up at around nine years. the glaucoma rate index. The methods was moderate at best and The proportion of eyes labeled as pairwise difference for the glaucoma showed differences, depending on progressing was 27.7% in guided rate index vs. pointwise linear baseline severity. progression analysis, 33.5% in regression was 11.5%, 19.2% for Researchers looked at the three pointwise linear regression and the glaucoma rate index vs. guided different measures to detect VF highest at 52.9% in the glaucoma progression analysis and 7.7% progression in 729 eyes of 567 rate index. The pairwise difference for pointwise linear regression primary open-angle glaucoma for glaucoma rate index vs. point- compared to the guided progression patients. wise linear regression was 20%, analysis. Patients in the study had six VF 25% for the glaucoma rate index vs. Salazar D, Morales E, Rabiolo A, et al. Pointwise methods tests performed within about three guided progression analysis and 6% to measure long-term visual field progression in glaucoma. years. A total of 176 subjects (257 for pointwise linear regression vs. JAMA Ophthalmol. April 2, 2020. [Epub ahead of print]. OCT Matches Ultrasound in Pre-op Evaluation efore their patients go in for from 67 patients—60 males and UBM, they were 70.4% and 73.3% any surgeries, optometrists seven females, with a mean age of respectively.1 Bshould have as complete a 34 (±14 years). All the patients had Investigators say these numbers picture of their patient’s eye health a traumatic cataract severe enough show that both imaging techniques as possible. This includes traumatic to prevent slit lamp evaluation of are effective. SS-OCT is at least cataract patients, who first need the PC. They were evaluated under comparable, or superior in some to be evaluated for any posterior both 50MHz UBM and SS-OCT ways, to UBM in detecting preop- capsule (PC) defect. Traditionally, before surgery. All underwent the erative post-traumatic PC rupture. this is accomplished using same surgical technique.1 That team recommends preop- ultrasound biomicroscopy (UBM), Evaluation of the patients showed erative assessment of all traumatic but new research is suggesting the sensitivity (96.8%), specificity cataracts with SS-OCT as a part of that swept-source OCT (SS-OCT) (66.7%) and accuracy (82%) values surgical planning.1 n works just as well.1 That’s good for SS-OCT. For UBM, the sensitiv- news for patients, as UBM, while ity, specificity and accuracy values 1. Tabatabaei S, Soleimani M, Etesali H, Naderan M. Accuracy of swept source optical coherence tomography and ultra- technically noninvasive, can be were 82.6%, 57.9% and 71.4% sound biomicroscopy for evaluation of posterior lens capsule uncomfortable and requires the eye respectively. Positive predictive in traumatic cataract. Am J Ophthalmol. April 2, 2020. [Epub 2 ahead of print]. to be anesthetized. and negative predictive values for 2. Wills Eye Hospital. www.willseye.org/treatment/ultrasound. Researchers looked at 67 eyes SS-OCT were 75% and 95.2%. For Ultrasound. Accessed April 30, 2020.

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PreserVision is a trademark of Bausch & Lomb Incorporated or its afﬁ liates. AREDS and AREDS2 are registered trademarks of the United States Department of Health and Human Services (HHS). © 2020 Bausch & Lomb Incorporated or its afﬁ liates. PN09465 PVN.0096.USA.19 Contents Review of Optometry May 15, 2020

21st ANNUAL DRY EYE REPORT 42 Treat the Front Before the Cut The surgeon will remove the patient’s cataract, but it’s your job to make sure the eye is healthy enough for surgery, or COVER FOCUS: COVID 19 else to help get it there. By Thomas Chester, OD Patient Care Morphs 48 Diet: Why Dry Eye 30 During COVID-19 Hangs in the Balance From telemed to ER visits, doctors and hospitals are What we eat—and don’t eat—is impacting our ocular health. finding creative ways to take care of those in need. Here’s what you need to know. By Jane Cole, Contributing Editor By Katherine Sanford, OD

20 Tips For Reopening 56 Don’t Overlook 36 Amid COVID-19 Aqueous-deficient Dry Eye Here’s advice on how you can hit the ground running Familiarize yourself with this subset so that you’re better and thrive in a world with coronavirus. able to detect and manage it if it does present. By Jane Cole, Contributing Editor By Candice Tolud, OD

ALSO INSIDE: 62 Statins and the Eye: 68 Top Five Cases You Shouldn’t Refer What You Might Not Know Don’t be afraid to keep these patients in your practice; you have the skillset and scope of practice to help them. These lipid-altering drugs are changing lives for the better, but the optometrist is responsible for monitoring their many By Laine S. Higa, OD impacts—good and bad—on ocular health. By Richard Zimbalist, OD, Angella Gentry, OD, and Carrie Ho, OD

Earn 2 CE Credits: 76 Maximizing OCT in the Diagnosis and Management of Glaucoma This technology has become an integral part of glaucoma care, and optometrists must understand how to accurately use it. By Danica Marrelli, OD

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3 News Review 16 Outlook Adapt and Overcome JACK PERSICO BUSINESS OFFICES 19 CAMPUS BLVD., SUITE 101 18 Through My Eyes NEWTOWN SQUARE, PA 19073 2020: The Year Of COVID-19 PAUL M. KARPECKI, OD CEO, INFORMATION SERVICES GROUP MARC FERRARA (212) 274-7062 • [email protected] 20 Chairside PUBLISHER Time Is On My Side JAMES HENNE MONTGOMERY VICKERS, OD 22 (610) 492-1017 • [email protected]

REGIONAL SALES MANAGER 22 Clinical Quandaries MICHELE BARRETT Slice of Life (610) 492-1014 • [email protected] PAUL C. AJAMIAN, OD REGIONAL SALES MANAGER MICHAEL HOSTER 24 Urgent Care (610) 492-1028 • [email protected]

Unmask This Cancer Imposter VICE PRESIDENT, OPERATIONS JIM WILLIAMSON, OD, CASEY FOSTER ABBEY KIRK, OD, AND (610) 492-1007 • [email protected]

RICHARD MANGAN, OD VICE PRESIDENT, CLINICAL CONTENT PAUL M. KARPECKI, OD, FAAO 28 Coding Connection [email protected] Ocular Surface Coding Potpourri PRODUCTION MANAGER JOHN RUMPAKIS, OD, MBA FARRAH APONTE 24 (212) 274-7057 • [email protected] 86 Cornea + Contact Lens Q&A SENIOR CIRCULATION MANAGER Running Out of Options HAMILTON MAHER (212) 219-7870 • [email protected] JOSEPH P. SHOVLIN, OD CLASSIFIED ADVERTISING 88 The Essentials (888) 498-1460 Track the Hill of Vision SUBSCRIPTIONS BISANT A. LABIB, OD $56 A YEAR, $88 (US) IN CANADA, $209 (US) IN ALL OTHER COUNTRIES.

90 Therapeutic Review SUBSCRIPTION INQUIRIES (877) 529-1746 (US ONLY) Managing Neovascular Glaucoma OUTSIDE US CALL: (845) 267-3065 JOSEPH W. SOWKA, OD CIRCULATION PO BOX 81 92 Review of Systems CONGERS, NY 10920 A Common Denominator 90 TEL: (TOLL FREE): (877) 529-1746 CARLO J. PELINO, OD, AND OUTSIDE US: (845) 267-3065 JOSEPH J. PIZZIMENTI, OD CEO, INFORMATION SERVICES GROUP 94 Retina Quiz MARC FERRARA Repairing a Misdiagnosis SENIOR VICE PRESIDENT, OPERATIONS RAMI ABOUMOURAD, OD, AND JEFF LEVITZ

MARK T. DUNBAR, OD VICE PRESIDENT, HUMAN RESOURCES TAMMY GARCIA

96 Advertisers Index VICE PRESIDENT, CREATIVE SERVICES & PRODUCTION MONICA TETTAMANZI

97 Classifieds CORPORATE PRODUCTION DIRECTOR JOHN ANTHONY CAGGIANO 98 Diagnostic Quiz A Bumpy Ride VICE PRESIDENT, CIRCULATION 98 EMELDA BAREA ANDREW S. GURWOOD, OD

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EDITORIAL OFFICES Adapt and Overcome 11 cAmpUS Blvd., SUite 100 newtown SqUAre, pA 19073 The work of re-engaging with patients while maintaining

SUBSCRIPTION INQUIRIES healthy boundaries is remaking the optometric practice. 1-877-529-1746 CONTINUING EDUCATION INQUIRIES 1-800-825-4696 n the fall of 2001, a few weeks rejiggering your exam techniques after the September 11th attacks, to minimize proximity to patients, EDITOR-IN-CHIEF • JAck perSico President Bush addressed a dumb- mastering the arcana of coding for (610) 492-1006 • [email protected] I founded nation to explain how we’d telemedicine, and so on. There are MANAGING EDITOR • reBeccA Hepp (610) 492-1005 • [email protected] respond. America would get through plenty of new things to master—let SENIOR EDITOR • Bill kekeviAn it by “the patient accumulation of these small victories build momen- (610) 492-1003 • [email protected] successes,” he said. These would tum and motivation. Combined, they ASSOCIATE EDITOR • cAtHerine mAntHorp (610) 492-1043 • [email protected] happen on many different fronts— begin to solve the inherent paradox ASSOCIATE EDITOR • mArk de leon some overt and public, others less so. optometry practices now face: bring- (610) 492-1021 • [email protected] Some successes would come quickly, ing in enough people to thrive finan- SPECIAL PROJECTS MANAGER • Jill gAllAgHer (610) 492-1037 • [email protected] others frustratingly late, if ever. cially, but also few enough to keep ART DIRECTOR • JAred ArAUJo I think everyone, regardless of everyone safe from exposure. (610) 492-1032 • [email protected] their political opinions, can agree That challenge is upending DIRECTOR OF CE ADMINISTRATION • reginA comBS that was the right way to frame it. decades of traditional habits. Among (212) 274-7160 • [email protected] Without a nation-state enemy that respondents to the Jobson survey, EDITORIAL BOARD could be decisively defeated, Ameri- 84% plan to take temperatures of CHIEF CLINICAL EDITOR • pAUl m. kArpecki, od cans were told to brace for an uncon- patients, 62% will limit dispensary ASSOCIATE CLINICAL EDITORS • JoSepH p. SHovlin, od; AlAn g. kABAt, od; cHriStine w. Sindt, od ventional, unpredictable era. access and 61% will ask contact lens DIRECTOR OPTOMETRIC PROGRAMS • ArtHUr epStein, od The response to COVID-19 will wearers to do their own insertions. CLINICAL & EDUCATION CONFERENCE ADVISOR also follow a tenuous and gradual And optometry practices will be pAUl m. kArpecki, od path. Plans will be provisional, prog- awash in personal protective equip- CASE REPORTS COORDINATOR • Andrew S. gUrwood, od ress will be fitful and daily life will ment (PPE). Almost nine out of 10 CLINICAL CODING EDITOR • JoHn rUmpAkiS, od, mBA continue to be laden with anxiety. doctors plan to use gloves, masks, COLUMNISTS Such is the unenviable environ- face shields, gowns and goggles, as CHAIRSIDE • montgomery vickerS, od ment optometrists find as many well as offer masks and gloves to CLINICAL QUANDARIES • pAUl c. AJAmiAn, od return to their offices this month. staff and patients when appropriate. CODING CONNECTION • JoHn rUmpAkiS, od No surprise, then, that tensions are If there’s any silver lining to all CORNEA & CONTACT LENS Q+A • JoSepH p. SHovlin, od running high. Eyecare practitioners that PPE and precaution, maybe it’s DIAGNOSTIC QUIZ • Andrew S. gUrwood, od THE ESSENTIALS • BiSAnt A. lABiB, od (two-thirds of them ODs, the rest that more patients—and, dare I say, FOCUS ON REFRACTION • mArc tAUB, od; mostly opticians) responding to a more ophthalmologists?—will per- pAUl HArriS, od survey conducted by Jobson rated ceive you as a frontline medical pro- GLAUCOMA GRAND ROUNDS • JAmeS l. FAnelli, od their stress level when thinking about fessional and not just the place to go NEURO CLINIC • micHAel trottini, od; micHAel delgiodice, od their businesses at a 7 on a 1-10 to buy a pair of glasses. Your practice OCULAR SURFACE REVIEW • pAUl m. kArpecki, od scale. Asked how much longer their is going to look and feel a lot more RETINA QUIZ • mArk t. dUnBAr, od practices could survive the shutdown, medical, regardless of how many REVIEW OF SYSTEMS • cArlo J. pelino, od; 43% answered just a month or less. drug prescriptions you write. JoSepH J. pizzimenti, od Clearly, the desire to get on with How long these new protocols will SURGICAL MINUTE • derek n. cUnningHAm, od; wAlter o. wHitley, od, mBA life is compelling. But, when reopen- be needed is anyone’s guess. Until THERAPEUTIC REVIEW • JoSepH w. SowkA, od ing, don’t set the bar at “business as there’s a lower rate of transmission, THROUGH MY EYES • pAUl m. kArpecki, od usual.” Instead, be content with the or a vaccine developed and widely URGENT CARE • ricHArd B. mAngAn, od string of small successes that come available, they seem prudent. For the as you learn to adapt: working out near term, “back to business” won’t JOBSON MEDICAL INFORMATION LLC a disinfecting protocol that’s easy to mean “back to normal.” Just take it perform a dozen or more times a day, one day, and one success, at a time. n

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2020: The Year Of COVID-19 We were all so excited about the year of vision—then, in an instant, everything changed. By Paul M. Karpecki, OD, Chief Clinical Editor

ith COVID-19 sending tact lenses, for free, to patients’ revenue stream. Companies such as the world into lockdown, homes, and it has increased prac- Science Based Health, MacuHealth, Wthe main goal for many is titioner rebates. Pristine and Pharmanex all have simply survival. Despite high hopes • Imprimis can ship compounded excellent products we can provide our for the year of optometry, 2020 has drops to patients. patients. Bruder Healthcare initiated quickly become the most challenging • Allergan has eliminated copays a program for dry eye patients during time the profession has ever faced. on all of its ophthalmic drugs. this downturn. ‘Storefront’ options, Hopefully the COVID-19 curve And that’s just a sampling. such as those offered by Allergan will flatten with social distancing, and We can also use this downtime to and myoasis.com, allow you to sell several potential treatments are in participate in educational webinars, over-the-counter products online that the works. Optometry practices will stay in contact with staff and prepare appear to be coming directly from survive this period and be stronger to return stronger than ever. your office or website. While these because of it, but there is no denying resources won’t replace the revenue the challenges. Takeaways from seeing patients, they at least Optometry will find revenue streams provide some steady income. What To Do Now beyond seeing patients in the office. Even where you see patients will Back in April, federal crisis relief Telemedicine will become part of how change. People are staying away from legislation went into place, including we practice, although it will require crowded stores and hospitals, which the CARES program, business loans, HIPAA-compliant platforms after leads to new Rx opportunities such as unemployment and upfront CMS the pandemic subsides. A virtual visit LeGrandeRx. Patients will be increas- Medicare payments. I commend the can’t replace the initial exam or glau- ingly hesitant to have cataract surgery AOA on providing timely informa- coma/retina evaluations, but it could in a hospital or ambulatory surgery tion and resources on these programs be great for a one-month follow-up center, and practices that have office- and COVID-19 updates. for a dry eye patient not on steroids, based surgery suites such as iOR Part- Still, to survive, optometry prac- contact lens and prescription refills ners may be a safer option. tices must embrace telemedicine. and many other follow-up exams. Optometry has one of the best plat- Home diagnostics will become Pent-up Demand forms available through EyeCare essential to expanding telehealth. The profession must adapt, and the Live. CMS and other medical insur- AtHome (iCare) IOP monitoring new model will provide eye care dif- ance companies pay the same for tele- allows patients to check their own ferently. For one, ODs should wear medicine visits as in-office visits. IOP for interim telemedicine visits, surgical masks, even after the pan- But telemedicine is only successful and ForeSeeHome (Notal Vision) demic (iOR Value, a division of iOR if you already have a medical model. provides at-home AMD monitoring. Partners, sells them at cost to ODs). If you don’t, Optometric Medical An online contact lens distribution The demand for eye care services Solutions (OMS), which specializes avenue that generates revenue for the is currently pent up. By re-posi- in transforming optometry practices practice will be valuable. Companies tioning our practices, creating new into medical eye care practices, is a with sound online distribution chan- revenue sources and adapting to the key resource. Telasight also provides nels (e.g., Hubble) are already suc- changes, optometry won’t just sur- consultative clinical support for those cessfully partnering with some within vive, it will eventually thrive. n pursuing medical eye care. the optometric profession. Note: Dr. Karpecki consults for A few other tools can help: Likewise, recurring sales from companies with products and ser- • Bausch + Lomb can ship con- over-the-counter products is another vices relevant to this topic.

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Time is on My Side If there’s one thing certain about a global pandemic, it is this: Nothing is actually certain, ever. By Montgomery Vickers, OD

n mid-April, as I sit here in more details related to my four can do whenever we can do it, to Lewisville, Texas, more or less years playing baritone horn for the protect our patients and to be there Ion house arrest with my wife “Magnificent 70 Marching Band” for them now, in emergencies and, as my terrifyingly effective war- at the now-defunct Montgomery later, when our country will need us den, how I spend my time during High School in Montgomery, West to get the whole healthcare system COVID-19 has been whittled down Virginia. Ahh, yes, the Magnificent back in gear. to just a few things. Four, actually: 70. All 40 of us. No wonder I had My friends, you have a mission, 1. I start my day with medita- trouble with physiological optics at and it’s not loafing around eating tion and yoga. By meditation Pennsylvania College of Optometry. too many cookies out of boredom. and yoga I mean I spend two Ciphering was not a strong subject Be ready. Make sure your practices hours yawning and complain- in the Fayette County coalfields. survive and especially make sure ing about my stiff back while you are ready to thrive again soon. on hold waiting for a very My Calling, Revealed Be hopeful, love on your family pleasant but hapless IRS agent In truth, I only know how to be an members, friends, staff members to come on and tell me, again, optometrist. I only know how to and colleagues… whether or not that they cannot discuss my help patients. With my two Texas they are hiding the cookies from deceased mother’s missing offices closed except for emergency you. It’s for your own good. 2017 tax refund because they care (it’s not my turn to help yet), I You should be proud of what haven’t received the form I miss my patients, my coworkers and you contribute to our country. submitted three times. Did I my colleagues—the OD business And, well, try to laugh as much mention I have two separate owners who are, no doubt, strug- as you can each day. I’ll do my letters from the IRS thanking gling to keep the offices above water. best to help you laugh again with me for submitting the forms These fine young doctors are not “Chairside” as soon as I get off the that have not been received? wearing hazmat equipment dealing phone with the IRS. n 2. After my meditation and with critical life-and-death decisions yoga, I stare at my phone. at one of our overwhelmed hospi- 3. Once I have completed that tals and nursing facilities. However, critical task, I stare at my within the sphere of health care that computer. resides behind the front lines of this 4. Whew! All done and war, the optometrists, dentists, chi- exhausted. Time for either a ropractors and all the others have nap or a Bloody Mary. So far, their own—our I haven’t chosen a nap. I also own—mission: am not infected with COVID- do what- 19, so my Bloody Mary ever we vaccinations are apparently working. The CDC has not returned my calls. Now, back to optometry. Remember optometry? After several weeks of a forced furlough from private practice, I actually recall

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Slice of Life Keep calm when dealing with conjunctival lacerations and be mindful of the extent of the damage. Edited by Paul C. Ajamian, OD

I have a patient who was breaks or detachment, vitreous Q moving metal sheets and one hemorrhage and intraocular foreign slipped and caught him in the eye. body,” Dr. Bozung says. In cases How do I handle this case? that sustain focal trauma to the Ocular trauma can be very globe, pay special attention to the A concerning, and even the corresponding area of the retina. smallest abrasion or subconjunc- Note changes such as commotio tival hemorrhage can be alarming retinae or retinal hemorrhage. for our patients. “When addressing ocular trauma, our initial goal is to Treatment assess the extent of damage,” says Treating conjunctival lacerations is Alison Bozung, OD, who is on staff quite simple in most cases. Often, at Bascom Palmer Eye Institute in small lacerations will heal without Miami, specializing in ophthalmic When assessing conjunctival laceration, surgical intervention. Dr. Bozung emergencies. subconjunctival hemorrhage may limit will typically prescribe a prophylac- view of the sclera. tic broad-spectrum topical antibiotic Examination drop or ointment four times daily Evaluate the eyelids and periocu- look for a Seidel sign, as you would until the defect has closed. “Remind lar structures first. Full-thickness with a corneal wound leak. Instilling patients not to rub their eye and to eyelid lacerations, for example, can fluorescein will also highlight any temporarily discontinue contact lens indicate likely globe damage. Next, corneal or conjunctival abrasions. wear, as this mechanical irritation address the ocular surface including “When the extent of tissue viola- may impede healing,” she says. the conjunctiva and cornea. If there tion anywhere is still unclear, you A plastic shield at night is a good is a subconjunctival hemorrhage, may want to gently explore the tis- way to prevent accidental rubbing or closer inspection will often reveal a sue with a cotton-tipped applicator pressure on the traumatized eye. In conjunctival laceration as well. moistened by sterile water or saline,” the case of an extensive conjunctival In dealing with eye injuries, rule Dr. Bozung suggests. Be on the look- laceration, consider referral. When out open globes first, according out for any residual foreign matter. surgical repair is indicated, absorb- to Dr. Bozung. When assessing a If a deep or non-mobile foreign body able sutures are typically used. The conjunctival laceration, the subcon- is present, or if any uveal tissue is surgeon typically exercises care junctival hemorrhage may limit your showing, refer this patient to an to ensure a sterilized wound with view. “Be particularly mindful of the anterior segment or orbital special- properly apposed edges while taking possibility of a scleral rupture in the ist for further globe exploration and care to avoid capture of subjacent presence of a complete subconjuncti- possible CT imaging. Tenon’s capsule. val hemorrhage obscuring the entire A dilated fundus exam is a “Fortunately, superficial conjunc- sclera,” Dr. Bozung warns. critical part of an ocular trauma tival lacerations, such as with this Most commonly, scleral ruptures assessment. Only avoid dilation in patient, are often self-limiting and of from blunt trauma will occur at the very specific circumstances, such as minimal consequence,” Dr. Bozung limbus or posterior to muscle inser- when there is uveal tissue prolapsed says. “A thorough examination can tions. If defect depth is not particu- through a wound, a foreign body rule out more dangerous complica- larly obvious, anesthetize the eye in the anterior chamber or obvious tions of ophthalmic trauma and and use a fluorescein strip to paint globe disorganization. “Use fundus ensure our patients’ visual health is over the area of concern in order to examination to rule out retinal not compromised.” n

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Unmask This Cancer Imposter This suspicious lesion isn’t malignant—but fools most. Here’s how to distinguish it. By Jim Williamson, OD, Abbey Kirk, OD, and Richard Mangan, OD

ntraocular malignant neo- mass with acoustic orbital shadow- plasm is one of the most feared ing (Figure 3). Idiagnoses an OD may have to make. The visual prognosis of this Discussion ocular cancer is usually poor, and SCC is a deposition of calcium the potential for systemic involve- within the sclera. They present ment is worrisome. However, what as single or multiple, round focal may at first glance appear to fit the lesions along the superior temporal bill may be an imposter syndrome. arcades and are most commonly Making the correct assessment seen in the elderly as an incidental before sending the patient out for finding.2-4 SCCs appear pale yel- further testing is imperative to low, white or orange and can be distinguish intraocular malignant flat or up to 6mm in height.5 A neoplasms from these other dis- Fig. 1. The blue arrow in this fundus 2015 study analyzed 179 eyes of orders that only masquerade as a photo points to a subretinal lesion in the 118 patients with SCC and found malignancy. right eye’s superior temporal quadrant. the vast majority in Caucasians Here, we review the case of a (98%) with a mean age of 69 and 69-year-old Caucasian male who Cozaar (losartan, Merck), met- a 60:40 female-to-male ratio.1 was ultimately diagnosed with formin and Flomax (tamsulosin, Laterality approached 50% for all sclerochoroidal calcification (SCC). Boehringer Ingelheim). His social categories: unilateral vs. bilateral, This condition is correctly diag- history was positive for tobacco and right eye vs. left eye.1 nosed and referred by only 5% of (half a pack of cigarettes per day) The term SCC is actually a mis- practitioners.1 Here’s how to be and recreational marijuana use. nomer, as the calcification repre- among them and avoid superfluous His best-correct visual acuities sents a scleral mass. There are four testing and patient anxiety. were 20/20 OD, OS with +0.75- recognized types: Type 1 “flat,” 0.50x120 OD and +0.25-0.50x115 Type 2 “rolling,” Type 3 “rocky- Examination OS and a +2.50 add. Chair skills rolling” and Type 4 “table moun- Our patient presented for follow- were unremarkable. Slit lamp bio- tain.”6 “Rocky-rolling” represents up of mild-stage primary open- microscopy showed a pinguecula the most common type and causes angle glaucoma, age-related nuclear OU and NC2 OU as graded by the the most thinning of the overly- cataracts and an area of retinal lens opacities classification sys- ing choroid, which in turn leads to pigment epithelium (RPE) dropout tem (LOCS) III. A dilated fundus a greater possibility for adjacent superiorly in the right eye. His examination revealed a cup-to-disc retinal pigment epithelium (RPE) medical history included Type 2 ratio of 0.70V/0.65H OD and 0.50 and outer retinal changes (Figure diabetes, essential hypertension, OS, along with a yellow subretinal 4).6 The hill-like elevation in this hyperlipidemia, coronary artery lesion outside the superior tempo- patient characterizes a Type 2 disease, congestive heart failure, ral arcade (Figure 1). “rolling” SCC (Figure 2). benign prostatic hyperplasia and Enhanced-depth imaging optical obstructive sleep apnea. His sys- coherence tomography (EDI-OCT) Making the Call temic and ocular medications through the area demonstrated Differentiating SCC from more included Lipitor (atorvastatin, choroidal thinning above the lesion insidious lesions is key to prevent- Pfizer) carvedilol, insulin, Vyzulta (Figure 2). B-scan ultrasonography ing superfluous testing. Fundus- (latanoprost, Bausch + Lomb), highlighted an echo-dense placoid copy alone can diagnose SCC,

24 REVIEW OF OPTOMETRY MAY 15, 2020

Urgent Care

abdominal pain, polyuria and psychiatric symptoms, such as depression, anxiety, insomnia, cognitive dysfunction and possibly coma.9 Bartter’s syndrome represents a group of inherited primary renal tubular electrolyte transport disorders. Of the three phenotypes, only two—classic Bartter’s and Gitelman’s—are associated with SCC.8 Both of these closely-related autosomal recessive diseases share the characteristics of renal salt Fig. 2. Above, EDI-OCT imaging wasting and hypokalemic hypo- through the SCC reveals a Type chloremic metabolic alkalosis.10 A 2 “rolling” lesion. The red arrow manifestation of Gitelman’s syn- points to an area of choroidal drome—which is more common thinning above the lesion. and presents later in childhood or Fig. 3. At left, the red arrow adulthood—includes hypomagne- shows an echo-dense placoid semia.11 Magnesium ions increase lesion while, the blue shows calcium pyrophosphate dihydrate acoustic orbital shadowing on crystal solubility. Therefore, hypo- this B-scan ultrasound. magnesemia could lead to deposition of those calcium crystals in given its characteristic appearance, which is detectable only with ultra- joints and the sclera.11 demographic, and predilection sonography or CT exam.1 SCCs are usually benign and for the superior temporal loca- Approximately 80% of SCCs are similar to a Cogan or senile tion. With EDI-OCT, an SCC will are primary or idio- appear as a scleral (not choroidal) pathic.1,6 Secondary plaque with secondary compression causes result from of the choroid.3,7 B-scan ultraso- hypercalcemia due nography shows a highly-reflective, to hyperparathyroid- echo-dense plaque unlike a cho- ism, parathyroid roidal metastasis, which would adenomas, hyper- likely exhibit low-to-medium vitaminosis D, cal- reflectivity. The majority of SCCs cium pyrophosphate exhibit homogeneous hyperauto- dihydrate deposition, fluorescence with fundus autofluo- hypomagnesemia, rescence, and hyperreflectivity on diuretic use, chronic Fig. 4. Another SCC patient exhibits a Type 3 “rocky- infrared imaging.7 SCCs also lack kidney disease and, rolling” appearance. The red arrow shows the extensive vasculature on a fluorescein or rarely, renal disorders, choroidal thinning above the scleral mass. indocyanine green angiography. On including Bartter’s computed tomography (CT) scans, syndrome.2,5,8 Fig. 5. This CT scan SCCs appear as highly-attenuated Patients with demonstrates SCC in objects similar to bone. The CT hyperparathyroidism the right eye (blue scan easily confirmed the right eye display the mnemonic arrow) and a subtle SCC in this patient, and surpris- “stones, bones, one in the left eye ingly picked up a subtle one in the groans, thrones and (red arrow), which left eye, which was not viewed psychiatric over- was not visible on clinically (Figure 5). This likely tones” due to kidney clinical exam. represents a Type 1 “flat” lesion, stones, bone pain,

26 REVIEW OF OPTOMETRY MAY 15, 2020 scleral-calcified plaque, which 4. Leys A, Stalmans P, Blanckaert J. Sclerochoroidal calcifications of sclerochoroidal calcifications. JAMA Ophthalmol. tion with choroidal neovascularization. Arch Ophthalmol. 2019;137(1):111-2. occurs near the horizontal rectus 2000;118:854-7. 9. Sugarman J, Douglass A, Say E, Shields C. Stones, bones, muscle insertions. Some researchers 5. Wong C, Kawasaki B. Idiopathic sclerochoroidal calcification. groans, thrones and psychiatric overtones: Systemic asso- Optom Vis Sci. 2014;91(2):32-7. ciations of sclerochoroidal calcification. Oman J Ophthalmol. speculate that SCCs may be their 6. Hasanreisoglu M, Saktanasate J, Shields P, Shields C. Clas- 2017;10(1):47-9. counterparts at the oblique muscle sification of sclerochoroidal calcification based on enhanced depth 10. Fulchiero R, Seo-Mayer P. Bartter Syndrome and Gitelman insertions where chronic forces imaging optical coherence tomography “mountain-like” features. Syndrome. Pediatr Clin North Am. 2019;66(1):121-34. Retina. 2015;35:1407-14. 11. Bourcier T, Blain P, Massin P, et al. Sclerochoroidal calcifica- induce both primary and second- 7. Fung A, Arias J, Shields C, Shields J. Sclerochoroidal calcification associated with Gitelman syndrome. Am J Ophthalmol. ary calcifications.5 Rarely, SCCs tion is primarily a scleral condition based on enhanced depth 1999;128(6):767-8. imaging optical coherence tomography. JAMA Ophthalmol. 12. Bessette AP, Singh AD. Multimodal imaging of choroidal may lead to a secondary choroidal 2013;131(7):960-3. neovascularization associated with sclerochoroidal calcification. neovascular membrane (CNV). 8. Goerlitz-Jessen M, Ali M, Grewal D. Rare complica- Ocul Oncol Pathol. 2016;2(4):234-8. Researchers recommend periodi- cally monitoring SCC patients for CNV development with a dilated exam and EDI-OCT.2,9 If a CNV presents, observation may be the best initial course of action, given the more peripheral location to the macula.12 Intravitreal anti-vascular endothelial growth factor injections or argon laser may also be approri- ate.12 SCCs can impersonate various Proven Occlusion Therapy. intraocular tumors and are frequently misdiagnosed.2,5,9 Typically, Enough Said. they represent an idiopathic inci- Collapsible Tip for Superior Retention dental finding, but their discovery and Improved Patient Comfort does warrant appropriate systemic testing to rule out underlying conditions. This may include a complete metabolic panel, parathyroid Punctal Occlusion is 76.8% and renal function testing.7 Medi- effective between 2-4 weeks at cations should also be reviewed as treating the symptoms *of Dry Eye associated with: diuretics can lead to a loss of meta- 1 Ǣ✓ bolic parameters. More impor- ...... Seasonal Allergies tantly, however, is making the right ...... Ǣ.✓ . Contact Lens Wear diagnosis and avoiding unnecessary Ǣ✓ ■ Aging ...... testing. Ǣ✓ Dr. Williamson is the residency Medications ...... Ǣ✓ supervisor at the Memphis VA Computer/Cell Phone Use . . . . .Ǣ✓ Medical Center and is an adjunct LASIK/Refractive Surgery faculty at multiple optometry schools. Dr. Kirk is a resident at the Memphis VA medical center.

1. Shields CL, Hasanreisoglu M, Saktanasate J, et al. Sclero- chroidal calcification: clinical features, outcomes, and relationship with hypercalcemia and parathyroid adenoma in 179 eyes. Retina. 2015;35:547-54. PUNCTAL OPENING SIZE PART NO. 2. Ali ZC, David VP. Sclerochoroidal calcification associated with 0.2mm to 0.3mm X-Small 2003 hypovitaminosis D. Can J Ophthalmol. 2017;52(4):e121-2. (800) 367-8327 0.3mm to 0.5mm Small 2005 3. Honavar S, Shields C, Demirci H, Shields J. Sclerochoroidal E-mail: [email protected] 0.6mm to 0.8mm Medium 2008 calcification: Clinical manifestations and systemic associations. www.lacrimedics.com Arch Ophthalmol. 2001;119:833-40. ©2020 Lacrimedics, Inc. 0.9mm to 1.0mm Large 2010 *http://www.ncbi.nlm.nih.gov/pubmed/11862081 Coding Connection

Ocular Surface Coding Potpourri Keep this compendium handy when treating your dry eye patients. By John Rumpakis, OD, MBA, Clinical Coding Editor ne of the fastest growing with their own coding rules. Intense-pulsed light (e.g., areas of optometry is dry BlephEx, or mechanical debride- Lumenis) does not have its own CPT Oeye. For those of you ready ment of the eyelids, currently doesn’t code, so 17999, unlisted procedure, to build a dry eye subspecialty, you have a code. Nonetheless, you still skin, mucous membrane and sub- also need to know how to code for have to code it. Just because a spe- cutaneous tissue, would be the most it, including office visits, procedures cific technology or procedure doesn’t appropriate. and technologies. Here are the have a specific CPT code assigned Unlisted codes do not have any basics for coding dry eye visits: to it doesn’t alleviate the medical RVUs attached to them, and no Office visits. In general, the E&M record documentation or coding of standard coverage or reimburse- codes (992XX) are the most appro- it. Fortunately, the CPT allows for ments exist. Most are patient-paid. If priate for dry eye–related visits. The this situation with unlisted codes. you are submitting an unlisted code, 92012 intermediate ophthalmic code CPT code 92499, unlisted ophthal- the claim should include a letter of can also be used if the CPT defini- mological service or procedure, is medical necessity, a specific descrip- tion is followed. From a telehealth designed for situations where an tion of the procedure and justifica- perspective, G2010 (recorded image ophthalmic procedure is performed tion of your charges. evaluation and interpretation), but doesn’t have its own code. This G2012 (virtual check-in) and 99421- would be the most appropriate code CLIA-waived POC Tests 423 (online digital evaluation) may to use for a BlephEx procedure. Testing osmolarity and MMP-9 be appropriate. Thermal lid procedures such as is now commonplace for dry eye. Meibography vs. photography. iLux (Alcon) would also fall into this Getting your CLIA waiver is easy, as In January 2019, meibography was category. Some argue that 67999, is coding for the tests. given a new category III code of unlisted procedure-eyelids, would The TearLab osmolarity system 0507T, defined as near infrared dual be the proper code; however, the is best described using CPT 83861, imaging (i.e., simultaneous reflective code begins with “67,” designating microfluidic analysis using an inte- and transilluminated light) of meibo- it as a surgical procedure. Because grated collection and analysis device, mian glands, unilateral or bilateral, these tools are not surgical in nature, tear osmolarity. It is a unilateral or with interpretation and report. 92499 is the most appropriate. single-unit test, so billing one test for Category III codes, by definition, LipiFlow (Johnson & Johnson each eye is appropriate. are rarely covered by third-party car- Vision Care) and TearCare (Sight InflammaDry (Quidel) is best riers and are generally patient-paid. Sciences) are different because they described using CPT 83516, immu- Anterior segment photography have their own category III codes: noassay for analyte other than infec- remains the same, CPT 92285, • LipiFlow (0207T) – evacuation tious agent antibody or infectious defined as external ocular photogra- of meibomian glands, auto- agent antigen, qualitative or semi- phy with interpretation and report mated, using heat and intermit- quantitative, multiple step method. for documentation of medical prog- tent pressure, unilateral. It also is a unilateral or single-unit ress (e.g., close-up photography, slit • TearCare (0563T) – evacu- test and follows the same billing lamp photography, goniophotogra- ation of meibomian glands, method for each eye. phy, stereo-photography). using heat delivered through If you know the basics for specific Both procedures require proper wearable, open-eye eyelid treat- procedures using CPT and category medical necessity to perform, and ment devices and manual gland III codes, you can protect your prac- interpretation and report. expression, bilateral. tice’s finances and compliance. n Lid procedures. Numerous new The definition of each code is Send your coding questions to lid procedures are available, each unique to the technology. [email protected].

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Patient Care Morphs During COVID-19 From telemed to ER visits, doctors and hospitals are finding creative ways to take care of those in need. By Jane Cole, Contributing Editor

OVID-19 has everything two cohorts of research patients Turning to Telehealth except essential services on who are part of his practice’s dry A series of federal, state and local hold, and it has forced a eye clinical trials. COVID-19 mandates caused Kam- Cmonumental shift in how To ensure proper social distanc- biz Silani, OD, to cease all routine clinicians provide care. While many ing, he teleconferences with patients eye care at his practice, Beverly ODs made the difficult decision to in one study group. The other study Hills Optometry: Advanced Dry put their practices on temporary cohort comes into the office on a Eye Center in Southern California hiatus, some are turning to urgent “one-in, one-out” basis. until further notice. visits or moving to telehealth to Continuing to see patients who Los Angeles County has been serve their patients without sight- called in for urgent issues—some- one of the hardest hit counties in threatening issues. thing his practice was designed to the country, with 22,485 confirmed Other ODs are finding a way handle from day one—fills a criti- cases as of May 1.1 to make a difference by offering cal patient care need and keeps Dr. Although his practice signifi- guidance on how their practices Vollmer’s practice busy. cantly reduced in-office services, can withstand the current crisis and Long before the pandemic, Dr. Dr. Silani and his staff worked to jump-start their offices once their Vollmer had considered moving to reassure patients they would still doors reopen. a large city an hour away and com- be there for them through in-office muting to his practice, he says, but emergency and telehealth visits. Rising to the Occasion he’s thankful he decided against it, “Our practice always considered The coronavirus outbreak has especially now with the high call telehealth in our pipeline,” Dr. forced nearly every practice in the volume that has escalated due to Silani says. “After COVID-19 hit country to adapt, and what that the pandemic. Since he only lives hard, telehealth quickly became a means for most, including Patrick a few blocks away from his clinic, top priority so we could be avail- Vollmer, OD, of the Vita Eye Clinic Dr. Vollmer can get to his office in a able for our patients remotely.” in Shelby, NC, was to eliminate matter of minutes. For his telemedicine platform, routine care. On a typical week, he sees Dr. Silani chose doxy.me, which “We felt this was the best between five and 12 research is HIPAA compliant. Although he recourse despite being considered patients and 20 to 25 emergency says FaceTime and Skype are ade- ‘essential,’” he says. patients—all of whom present one quate during the COVID-19 pan- Dr. Vollmer is keeping his clinic at a time to reduce patient interac- demic since because of temporary open for emergency visits and for tions in the office. HIPAA leniency, he still found it

30 REVIEW OF OPTOMETRY MAY 15, 2020 beneficial to choose a platform that fit into his practice post-pandemic. Finding Purpose in the Chaos His move to telehealth was rela- When Samantha Hornberger, OD, of Bright Family Eyecare in Lawrenceburg, IN, had to tem- tively smooth and provided patients porarily close her office to routine care, she picked up a notebook and pen and started jot- the option to be seen sooner rather ting down a plan. Her brainstorm turned into a comprehensive, step-by-step manual called than waiting to reschedule until the “Office Closure Action Plan: A Plan for COVID-19 Closure” that details what doctors can do to practice fully reopened. best position themselves in this unprecedented time and how to reboot after the pandemic. Telehealth visits do pose some Dr. Hornberger said her brainstorming gave her less anxiety about what was happening. limitations based on the reason “I thought, if this makes me feel better to have an organized plan, it’s going to make others for the patient visit, Dr. Silani feel better too.” says. “We don’t have the ability to Hornberger’s COVID-19 practice roadmap offers immediate and post-pandemic advice for perform contact lens evaluations ODs, including how to continue to generate revenue, reaching out to suppliers and vendors or routine eye care via telehealth about the potential to defer, delay or alter payment arrangements, how to get the word out visits.” Dr. Silani also encourages to the community that you’re still open for emergency visits and tips on sanitizing the office patients to come into the office if and scheduling and launching a telehealth platform. they have sudden vision loss, onset Her guide has already become a valuable resource for hundreds in the profession, as of floaters/flashes or any eye pain. more than 700 eye care practitioners have either downloaded it or connected with her on What does fall under the prac- social media, she says. tice’s telehealth umbrella are dry Dr. Hornberger is currently working on the next update to the manual, which will offer eye consults and mild to moder- suggestions on how doctors can start envisioning practice changes they’d like to make that ate issues such as styes, red eyes, would reduce burnout and stress. watery eyes and ocular irritation. “Honestly, there has never been a better time to think about this, because we won’t go To get the word out about the back to normal right away. Who knows what normal is even going to look like. There will be new telehealth platform, Dr. Silani’s a transition period where you can make the changes you want to make even if they aren’t staff shared the news on the prac- COVID-related.” tice’s social media platforms and In the meantime, Dr. Hornberger encourages her colleagues to persevere and persist, two also as an e-mail campaign to reach traits in which she feels the profession already excels. And during this unprecedented time, current patients. Dr. Hornberger still suggests trying to find small joys throughout the day. “I fully believe we Dr. Silani was quick to hammer are going to find good that’s going to come out of this if we look for it.” out a template for a typical tele- Dr. Hornberger’s guide can be found on her website at themoderneyesite.com. health consult: • When a patient contacts the practice for an appointment, sent to the pharmacy, or if a telehealth visits a week, with the staff offers the option and referral to a specialist, such as hope the number will continue to benefits of booking a tele- a neuro-ophthalmologist, or rise, especially for some out-of- health visit. a retina, cornea or glaucoma town patients and ones who com- • If the patient expresses inter- specialist, is warranted. mute long distances. est, staff books a virtual • Finally, the doctor shares the Looking to the future, he adds: appointment. notes of the visit with the staff “Although COVID-19 presents • Staff sends the patient a con- to upload into the patient’s many challenges to eye care practi- sent form highlighting the fea- chart. tioners, it is key to adapt and pivot. tures, benefits and potential “If eligible for a virtual appoint- Use this added, precious time to risks of telehealth and collects ment, patients enjoy the conve- dabble with new ideas, services, payment via credit card. nience, comfort and safety of this products, update marketing mate- • The doctor and patient engage option,” Dr. Silani says. “After the rial, create a blog or attend virtual in the video visit. At the com- COVID-19 outbreak has ended, we CEs and webinars.” pletion, the doctor determines will certainly continue offering this As New York City became the whether the patient needs to service as an option for our new epicenter of the outbreak in the be seen for a follow-up (either consults and pre-existing patients.” United States with 42,996 con- virtually or in-office), if the Dr. Silani estimates his office is firmed cases in Brooklyn alone as patient needs a prescription currently conducting three to five of May 1, Justin Bazan, OD, of

REVIEW OF OPTOMETRY MAY 15, 2020 31 COVID-19

A COVID-19 Pandemic Transition In Action clinic, and if they can have their questions answered over the phone, By Rebecca Hepp, Managing Editor that’s ideal,” she says. One somewhat unexpected scheduling challenge has been the The optometrists, ophthalmologists, technicians and support staff increase in urgent referrals, as Emory Eye Center is one of the only at Emory Eye Center in Atlanta worked overtime to postpone routine clinics in the area still seeing urgent patients and performing ocular care, kickstart telemedicine and prepare to handle COVID-positive surgeries. Added to that, a significant number of patients present to consults in the hospital. With more than 120,000 patient encounters the emergency room for ocular complaints, or at least they did before annually and five locations, a VA Medical Center, 15 subspecialties the coronavirus hit, Dr. Mileski says. Those numbers have dropped and several hospital locations to cover, it’s no small feat. considerably, and patients are now calling the clinic directly. But they had experience with something like this before, and it’s given them a leg up on at least one aspect of the changes. Telehealth Pros and Cons While the move to telehealth has been touted as the go-to interven- PPE Surprise tion during the pandemic, Dr. Mileski says it’s a complicated decision. All ODs are trained on personal protective equipment (PPE), but it’s a Patients must first have an ocular complaint that is likely easy to rarely used skill, says Kelsey Moody Mileski, OD, an assistant profes- identify with a good patient history and external exam. It’s also work- sor of ophthalmology at Emory Eye Center. In fact, she says getting ing well for some follow ups, she says. used to wearing all of the PPE when seeing a patient has been one of However, “if they need a pupil check, dilation or a refraction, we the most surprising challenges. have to bring them into the clinic if it’s for an urgent complaint or Emory, however, has been ahead of the game when it comes to rescheduled if it’s routine,” she explains. PPE preparedness, she notes. “Emory Eye Care physicians were Another wrinkle: the patients have to be tech savvy enough to use involved both during and after the Ebola crisis, and several Emory their computer or smartphone for the telemedicine visit—something retinal specialists examined Ebola survivors in both Atlanta and the many older patient struggle with. Democratic Republic of Congo and had experience with the necessary PPE required,” she explains. “Due to this, PPE was addressed COVID-19 Encounters immediately within the Eye Clinic to begin training even before the In the clinic, staff ask about COVID symptoms when scheduling every closures started.” appointment and during check-in. Patients who mention suspicious Her team realized quickly that wearing goggles makes BIO signifi- symptoms are asked to not come directly into the eye clinic. cantly easier than it is with a face shield. Also, having two clinicians “The goal is to examine them in the hospital or the designated on a hospital consult is the best way to handle the situation, Dr. COVID clinics they have now set up,” according to Dr. Mileski. Mileski says. Only one OD has contact with the patient, but the two- “Luckily, the hospital’s new COVID-positive clinic now has a telereti- man team makes the extra PPE and sterilization steps much easier. nal camera, so it gives us some information that has been helpful.” As for hospital consults, they noticed early in the pandemic that Scheduling Chess Game only about 1% of COVID-positive patients develop viral conjunctivi- Of course, Ebola never grew to the pandemic we are dealing with tis—and they don’t necessarily need an eye care consult for that. now, and it’s uncharted territory for other aspects of patient care. “However, just because you are COVID-positive doesn’t mean you The biggest challenge, Dr. Mileski says, has been culling through can’t have other ocular issues at the same time that do need to be the appointments to decide who does—and doesn’t—need to be seen,” she emphasized. seen. It took a few changes, but they settled on a system that identi- Dr. Mileski saw her first COVID-positive inpatient for new-onset fies patients as time-sensitive or urgent. The latter patient group is floaters. “I started by triaging her over the phone to get her history either kept on the schedule or rescheduled for a specific day that the so when I got to her room I could get straight to the eye exam,” she provider is in clinic, she explains. notes. To limit the supplies they had to take into the room, they used “The trick is, we don’t know when we will be reopening to routine a paper eye chart they could just throw it away. The same goes for care, so the question is how long can a patient wait, and do we need the eye drops, she adds. to be concerned that they may lose vision within that time,” she says. “The patient who just needs an IOP check could wait one to two Make the Most of a Bad Situation months as long as they have refills of their drops; however, we do not None of this is ideal, but everyone is coming together to make the want them to be rescheduled several months later.” best of what they have. Most of all, Dr. Mileski is pleasantly surprised Even time-sensitive and urgent patients staying on the calendar by the patient response. “You never know how people will react to need to be rescheduled to different days or times, she admits, to limit the situation [...] and it’s been a very positive experience, especially the number of patients in the clinic at one time. when it’s the provider themselves calling,” she says. “This is unprec- “Most of the time, patients are very willing to not come into the edented; we have never had to deal with anything like this before.”

32 REVIEW OF OPTOMETRY MAY 15, 2020 PASSIONATELY AT WORK IN EVERY ASPECT OF EYE HEALTH

At Akorn, eye care is our passion. We are present in all aspects of eye health, from anterior to posterior segments, from diagnosis to treatment to maintenance. Since 1971, we have been building partnerships in the eye care community and supporting you in making a lasting impact in your patients’ lives.

Park Slope Eye in Brooklyn, closed and facilitate the effort when she for the specific tests their doctor his office and headed out of the wasn’t in the clinic, especially since ordered. city to take care of patients through she had some extra time on her The patient generally returns telehealth visits.1 He coordinated hands without routine care visits. home where they will have a tele- with a local practice to handle “The majority of patients have medicine visit with their primary emergency referrals and directed his appointments for labs,” Dr. Sanford care physician to discuss the lab employees to work from home. explains. “They can still go inside results and any other issues. “We wanted to provide help to the hospital to the main lab, but The first day, the lab had 35 people in need, and telemed and we are funneling every visitor and patients, but the hospital is antici- digital communication is the best every employee into one entrance.” pating up to 150 per day. way we can do that right now. In addition to social distancing, the “It’s good to feel like we are pro- We have always answered a lot of drive-through lab provides conve- viding an extra service for the veter- questions and provided advice via nience for those with ambulatory ans,” Dr. Sanford says. n email, so it was an easy and natural issues who would otherwise have to 1. COVID-19 Compiler. https://covid19.topos.com. Accessed progression into using a formal navigate through the building until April 16, 2020.

telemed platform.” they reach the main lab Photos: Memphis VA Medical Center Still, “the amount we are doing is located on the far end of the minuscule compared to our normal hospital, Dr. Sanford says. in-office flow,” he says. Here’s how it works: Dr. Bazan says the learning curve A patient pulls up in for telehealth is very low. He sug- their car to a station for gests ODs test drive a few of the screening questions. Based popular platforms and they can on their answers, hospital watch an American Optometric workers will put a colored Association telemedicine webinar as strip of paper on their wind- a helpful resource if they are con- shield. A red slip indicates sidering this option. a patient may have been exposed to or is exhibiting Drive-through Care symptoms of COVID-19 Working at the front lines at the and hospital staff shouldn’t Memphis VA Medical Center, Kath- approach the vehicle. In this erine Sanford, OD, easily answered case, the individual will be the “all hands on deck” call when redirected to the ER and her hospital decided to roll out its personnel will be notified drive-through lab to promote social so they can take necessary distancing while still providing con- precautions. tinuity of care for veterans. Patients who are asymp- “I live in Memphis, so there’s a tomatic or who indicate lot of diabetes, high blood pressure they were not exposed to and other chronic conditions that anyone with symptoms get need to be monitored,” she says. a green slip of paper, alert- While the hospital had already ing staff that it’s safe to launched an intensive telemedicine approach them. program for primary care visits, the The drive-through lab drive-through for blood work was can handle two cars at a the VA Center’s latest push to take time. When the patient care of patients and ensure their reaches one of two bays, safety during the pandemic. they get out of their vehicle The Memphis VA Medical Center now provides a Although the new lab is phlebot- and enter a side room of convenient drive-through lab to help patients get omy based, Dr. Sanford was eager a large tent where a phle- the labwork they need without risking exposure in to lend a hand in helping organize botomist takes their blood the hospital.

34 REVIEW OF OPTOMETRY MAY 15, 2020 WE’RE SEEING AMAZING RESULTS. AND SO ARE THEY.

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20 Tips For Reopening Amid COVID-19 Here’s advice on how you can hit the ground running and thrive in a world with coronavirus. By Jane Cole, Contributing Editor

OVID-19’s rapid sweep than half (57.9%) are cur- across the country rently working on a written has caused an unprec- reopening plan, nearly double Cedented disruption the amount who said so just to the profession and forced two weeks prior. But everyone optometrists to make quick should be planning, according clinical and practice manage- to practice management con- ment decisions. Many ODs sultant Gary Gerber, OD, of shuttered their practices tem- the Power Practice. It’s critical porarily due to COVID-19, to have a well-thought out while others improvised with framework that touches on urgent appointments only all aspects of the practice and and telehealth. Now that the patient care prior to opening CDC’s nationwide recommen- your doors again for “routine dation to postpone routine eye patient care,” he says. care is no longer in effect, ODs “Many doctors are think- are faced with a new chal- ing, ‘I’m going to reopen, lenge: What should they have Gone are the days of packed waiting rooms. Instead, and it won’t be as busy, so in place before reopening? clinicians should space out seating and scheduling to I’ll just slowly get back into Almost all eye care practi- minimize patient interactions. it,’” Dr. Gerber says. “But it’s tioners (93%) who responded not going to be ‘pre-COVID’ to the 7th wave of Jobson’s (Ed. note: The advice provided slower, it’s going to be slower Coronavirus ECP Survey expect here is from anecdotal sources and and very different. You have to to reopen their practices once may not conform to state or federal walk through simulations with your restrictions are lifted, but they also guidance. Use your own discretion staff prior to reopening.” This is not anticipate they’ll need to imple- whenever contemplating changes to a time to improvise as you go. ment changes to continue social clinical or business practices.) Dr. Gerber suggests all doctors distancing and limit the spread of do a simulation of the patient’s infection. Have a plan. in-office journey prior to reopen- Here’s an array of things you 1Somewhat encouragingly, the ing. “It’s important to do a walk should consider: latest survey of ECPs found more through to determine when and

36 REVIEW OF OPTOMETRY MAY 15, 2020 where you will need PPE or social such guidance may conflict with well as for public perception.” distancing for different situations. If other considerations, including Rely on experts. an optician takes out their tools to what public health data suggests, 3Even if social distancing man- bend a nose pad, for example, what he adds. dates a six-foot radius between are they going to do with that tool? There could also be “herd men- each person, no one should feel Does the tool get disinfected before tality” and pressure to open if other alone. Everyone is in the same boat, they use it again?” It’s critical to offices do so, Dr. Chou says. That and support is available from your have everything mapped out before could lead to hastily prepared plans optometric colleagues and state and you reopen, he says. that may end up being counterpro- national optometric associations. ductive. Bottom line: getting it right The American Optometric Associa- Ignore peer pressure to reopen. matters more than being fast. tion (AOA) released much-antici- 2“The biggest gray area I’m hear- At the time of this writing, pated guidance on how to reopen ing from other doctors is when Dr. Hornberger had her patients during the pandemic (see, “AOA to reopen, when is it safe, when rescheduled starting the first week Provides Reopening Checklist”), is it advised, and there’s no good of May—a date subject to change much of which is reflected here. answer for that,” says Samantha in these shifting times. Hornberger, OD, of Lawrenceburg, Aaron Neufeld, OD, a private Make distancing IN. “This was the same situation practitioner from Los Altos, CA, 4mandatory. for many of us when we decided to and co-founder of ODs on Finance, A recent article published in the close.” hopes to reopen his practice in full Journal of Glaucoma suggests Because reopening dates are when the shelter-in-place rule is efforts to shorten wait times and mostly dependent on individual lifted in his area. lines will be paramount.1 ODs state’s stay-at-home orders, resched- “Our mid-May schedule has should rearrange their waiting uling patients can be a moving tar- already been filling. That being rooms to reduce capacity and get. Most governmental guidance said, there will definitely be changes encourage patients to limit the num- on reopening will be regional, says implemented for the health and ber of people accompanying them.1 Brian Chou, OD, of San Diego. But safety of our patients and staff, as The article also suggests patients in

AOA Provides Reopening Checklist • Continue messaging patients. Reach out to them during As mandatory restrictions begin to lift and optometrists prepare this difficult time to see how they are doing through all to open their doors for routine care, the AOA recently offered relevant communications channels (e.g., website, social guidance on what practices should have in place to reopen. media, email, direct mail, advertising). “The American Optometric Association is committed to helping • Prepare for your staff needs as they assimilate into the our members be prepared for the ‘new normal’ when it’s safe to new working environment. Demonstrate consideration for open practices,” says AOA President Barbara L. Horn, OD. “Doctors the mental health of the staff and team while reestablishing of optometry will be doing things differently in their practices, and the new care delivery flow. the AOA continues to develop helpful guidance supported by the • Contact other medical practices in the area to see when latest information from all federal agencies.” they will be reopening or if they have new protocols in The AOA recommends ODs set their reopen date based on place. federal, state and local guidance—and have a reopen plan that • Post signage in the office of the new protocols to ensure leaves plenty of time to sanitize the office and all equipment. Here maximum safety. are a few steps from the AOA’s “Optometry Practice Reactivation • Use AOA resources such as the AOA COVID-19 Hub Preparedness Guide” to augment what your colleagues have (www.aoa.org/coronavirus). already suggested: • Develop an action plan before opening. Determine To access the AOA’s complete guide, go to www.aoa.org/ priorities for preparing office space and clinical areas based documents/covid-19/aoa-guidance-for-re-opening-practices_ on suggested guidelines for cleaning and sanitizing the office covid-19.pdf. and dispensary, and how long this process may take. Ready for Routine Care? AOA Offers Guidance for Post-COVID-19 Reactivation. www. • Develop a new system for sterilization of the office, aoa.org/news/practice-management/aoa-offers-guidance-for-post-covid-19-reactivation. based on available guidelines. April 23, 2020.

REVIEW OF OPTOMETRY MAY 15, 2020 37 COVID-19

suburban locations may be asked to Some medical authorities advise until 3pm during the first two-to- wait in their cars until they receive a that anyone registering 100.4° or four weeks. “We don’t want our text message from the office.1 higher should be sent home. More- staff travelling in rush hour since “We will likely make changes to over, it has a psychological benefit. they rely on public transportation, avoid having multiple patients in Patients will be more at ease know- and their safety is our first con- the same area at the same time,” ing that everyone who’s currently cern,” Dr. Resnick says. explains Jennifer Stewart, OD, of on the premises or who passed Patients at her practice will be Norwalk, CT. “This may include through that day has been screened. scheduled one per half hour and decreasing the number of patients will alternate between exam rooms. on the schedule, staggering how Conduct histories by phone. Dr. Hornberger believes many they are scheduled, asking patients 8Have a staff member call each doctors will initially schedule to wait in their cars until we are patient a day or two before their at 50% of their previous capac- ready and changing patient flow in exam to obtain all insurance and ity, which poses a different set of our office to minimize crowding.” registration information, plus a full challenges regarding staffing and Letting patients browse about the history. With a lower caseload at the revenue. Prior to COVID-19, Dr. office will have to stop for a while. outset, staff may have time to devote Hornberger scheduled a half hour Some practices will require patients to this task. Patients will appreciate for a complete eye exam, but she is book an appointment for their dis- it both as a safety measure and a now considering allotting an hour pensaries, in 15-minute increments, convenience (no one likes filling out for each appointment to allow with access limited to one individ- forms at the doctor’s office). enough time to clean and disinfect. ual at a time. In addition, her current scheduling Walk before you run. protocol is to ask patients if they are Find hands-free options. 9Susan Resnick, OD, who has in immediate need of contact lenses 5Doctors may want to put large contact lens specialty practices or glasses, if they have issues such as into place methods to reduce in Manhattan and Long Island, has diabetes or glaucoma or any other the amount of surfaces a patient decided to scale down hours and immediate reasons why they need to touches, such as leaving the practice capacity. One doctor will be sched- be seen quickly. “If not, we’re prob- front door open (or even installing a uled at each location from 10am ably looking at August to schedule

motion-activated door), launch- Photo: Jacqueline Lucas, OD those patients.” ing cashless payment systems and encouraging patients to fill Install breath shields. out registration forms online, Dr. 10At the slit lamp, a plexi- Chou says. glass barrier will be a virtual necessity from now on. Either When in doubt, reschedule. purchase one or make your 6Moving forward, patients own (Learn how here: www. won’t want to be near anyone reviewofoptometry.com/article/ who’s visibly unwell, COVID- how-to-make-your-own-slit- related or not. Dr. Stewart will lamp-breath-shield). Consider ask patients who are ill or who adding a similar barrier at the have been in contact with some- front desk to separate office staff one who is sick to reschedule in from patients. two to three weeks. Adjust your exam Take temperatures 11methods. 7of everyone. Prior to closing for routine This goes for both staff and care in March, Dr. Resnick patients. It’s not the most reliable had shifted to more “problem- screening tool, as asymptomatic centric” exams to limit touching individuals can still spread the If you have the right tools, you can make your the patient when possible. For virus, but it might catch some. own slit lamp breath shield. some patients, and when appro-

38 REVIEW OF OPTOMETRY MAY 15, 2020 Photo: Nathan Stevens, OD priate, Dr. Resnick skipped certain Dr. Stewart. “We ask patients pretests that weren’t critical. Going to wash hands when they forward, she says her practice may first enter the office and when forego routine visual fields except moving to different rooms. for glaucoma patients in an effort We’ll continue to wipe down to be selective in her practice’s any patient area, including COVID-19 clinical strategy. counters and doorknobs, fre- Reusable bottles such as dilating quently. In the optical, we’ll drops and topical anesthetics should disinfect frames after patients be stored in a cabinet, instead of on touch them and minimize the counter, to prevent exposure to browsing.” anything aspirated by you or the As part of Dr. Neufeld’s patient. You may also want to wear reopening plan, his office will safety goggles during any up-close implement sterilization pro- contact with the patient. cesses for exam rooms, recep- Tonometers that provide sterile probes for each tion areas and optical/frames. patient, such as the iCare seen here, may be a Rethink tonometry. The latter will include a bin better option for checking IOP. 12Clinicians should consider where “used” frames will replacing their reusable Goldmann be placed and then cleaned before If a patient sees you or staff disin- tonometers with other options such being put back on the frame board. fecting—cleaning the slit lamp with as disposable tonometer prisms alcohol pads or wiping down sur- or single-use protective sleeves.1 Boost patient confidence. faces in the exam room, for exam- Because pneumotonometers and 14Patients are expecting you, ple—it will help reassure the patient air-puff tonometry can presumably the healthcare professional, to set far more than if the tech does this aerosolize the tear film and any an example. “Opening up too early behind closed doors, he adds. viral particles, clinicians should will cast a shadow of social irre- steer clear of these devices when- sponsibility,” Dr. Chou explains. Update your wardrobe. ever possible.1 “I feel it’s more important to com- 15COVID-19 can live on sur- Dr. Hornberger currently uses municate with the patient base faces for hours, so ODs can reduce an iCare rebound tonometer that since uncertainty may lead them the chances of contamination for allows for a sterile probe for each astray to subpar online prescription staff and patients by requiring a patient. “You don’t have the puff renewal.” A patient communica- more sanitary dress code. Dr. Resn- factor, and you don’t have to instill tion system, such as Eyecare Prime, ick’s doctors and staff will now eye drops where you have to get DemandForce or SolutionReach, wear scrubs, which will be put in close to the patient,” she says, will come in handy right about plastic bags after wear and replaced now, he says. (Disclosure: Demand- with new scrubs delivered daily. Disinfect—everywhere, Force is owned by Internet Brands, Everyone in her offices will also 13every time. parent company of the publisher of wear gloves and masks, and she Because of COVID-19’s easy Review of Optometry.) and the other ODs will wear N-95 transmission, cleaning and safety In addition, COVID-19 likely has masks, as they will have longer and precautions will be critical. In Dr. patients hypersensitive about disin- closer interactions with the patients. Resnick’s practice, every exam fection, and any sanitizing activities Most doctors will likely need room will be completely disinfected they see—whether effective or not— more PPE than they think, and before the next patient—a good will be important, Dr. Chou says. prior to reopening, practices need practice for everyone. In addition, He likens this to restaurants that to pinpoint reliable, trusted sup- individuals with suspected ocular give straws with a paper wrapper at pliers and alternate suppliers, Dr. infections will be put in a special the top. “It’s a visual reinforcement Gerber says. Over a three-month containment area. there has been an attempt at sanita- period, he estimates practices may “We already have a strict sanitation, but the truth is, the wrapper need between 1,200 and 8,000 tion and sterilization protocol in probably does little in actually masks, depending on patient vol- place and will continue this,” adds reducing contamination.” ume and number of staff. Doctors

REVIEW OF OPTOMETRY MAY 15, 2020 39 COVID-19 Photo: Suzanne W. Sherman, OD worried about safety issues. routine, no glasses, no contact lens “Your staff might be waiting to vision plan reimbursement indi- go back to work, but not neces- vidual if I’m only seeing one patient sarily for you.” an hour.” With an initially decreased Still, it might not be advisable to schedule, revenue flow will drop vision plans unless a practice’s be a big consideration in how schedule is completely full, Dr. many staff members to bring Chou says. “If you are running at back, Dr. Hornberger says. “A full capacity, that’s when it makes Doctors can keep using telehealth for some lot of doctors like me are in the business sense to pare off the vision conditions easily identified with an external same boat where we weren’t plan that is displacing your ability exam and a good history. This patient was able to get any Paycheck Pro- to see higher-value patients.” diagnosed, via telehealth, with a corneal tection Program funds in the infiltrate due to overnight contact lens wear. first round. So a big question Pass along some costs. is, can we even afford to bring 19Many practices are changing will also need to determine how staff back if we’re not seeing a full fees when they reopen. For the first often they will need to change patient load?” time at Dr. Resnick’s practice, she’ll masks and ensure they have masks Adding to this, many ODs have be charging a nominal no-show on hand when patients show up to furloughed staff currently collecting cancellation fee. It’s justified, she an appointment without one. unemployment, which is enhanced says, because “we’re going to be by $600 a week in Federal Pan- doing concierge, personalized care Keep up with telemedicine. demic Unemployment Compensa- where patients get a half hour to an 16Some doctors turned to tion until July 31, 2020. hour all to themselves.” telehealth out of necessity and look “This means a decent number And with the increased cost to forward to abandoning it once they of staff are getting paid more than practices for PPE and sanitation, a reopen. But it’s probably here to before and not having to work,” modest bump in fees will likely be stay. Take care to master telehealth Dr. Chou says. “So there is an eco- necessary, Dr. Gerber adds. so you can make it a sustainable nomic disincentive for these staff part of your practice. This allows to return, even though one of the Don’t stress. you to see more patients than would conditions of them accepting unem- 20“Obviously easier said than otherwise be possible, extending the ployment insurance is willingness done; however, stressing out does care you provide and adding more to accept work.” Technically if they nothing but add another negative to practice revenue. don’t accept work, they could lose item to deal with on your already Does a conjunctivitis patient all of their unemployment compen- overwhelmingly full plate,” Dr. really need to be in the same sation, he adds. Neufeld says. “This pandemic will physical space as you to make the be over, and life will resume. Look diagnosis? Most laptop and phone Drop cheapskate plans. at ways in which you can run your cameras can give you a decent 18With the downtime, some practice in the leanest way possible enough view. Moreover, “I can get ODs are revisiting their business right now. Slowly we will all be able 90% of the way to the diagnosis decisions when it’s time to reopen, to ramp up to full speed.” from the history alone,” noted Elise including vision plans. Dr. Horn- As practices reopen across the Brisco, OD, of Los Angeles in a berger’s practice currently accepts country, Dr. Hornberger offers this recent webinar on optometric prac- two large vision plans, but since piece of advice: be flexible. “The tice in the COVID-19 era. she will be operating on reduced reopening plan doesn’t have to be availability and revenue, plans with perfect at the beginning. We just Shuffle staffing. lower reimbursement rates may have to get back to taking care of 17Dr. Gerber suggests the staff be dropped, she says. “If I have our patients, and whatever that ends you hire for reopening may not reduced availability, the people up looking like will be okay.” n be the staff you laid off, since they who really need to be seen are in 1. Liebmann JM. Ophthalmology and glaucoma practice in may have found a different job or my chair, and from an economic the COVID-19 era. J Glaucoma. April 14, 2020. [Epub ahead decided not to return if they are standpoint, I can’t afford to see a of print].

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21st Annual Dry Eye Report Treat the Front Before the Cut The surgeon will remove the patient’s cataract, but it’s your job to make sure the eye is healthy enough for surgery, or else to help get it there. By Thomas Chester, OD

cular surface disease can patient’s ocular surface, before and complicate and, in some after the operation. We will also cases, impede cataract explain how stabilizing the ocular Osurgery. At least one study surface before surgery can impact shows 63% of presurgical cata- post-op satisfaction and reduce the ract patients have a decreased tear chances of possible complications. break-up time (TBUT) of five seconds or less—indicating evaporative Test All, Despite Symptoms dry eye.1 That same research shows Patients who are symptomatic will 77% of patients scheduled for sur- likely be more receptive to dis- gery had corneal staining.1 Other cussing how their DED can affect research indicates that 87% of cata- surgery. Generally speaking, these ract patients use artificial tears one patients may or may not want to month postoperatively.2 have the dry eye treated prior to While dry eye is now a widely surgery but patients may not fully diagnosed disease, the number Eyelid warming devices such as the understand the impact that a com- of actual sufferers is likely even Tearcare system (Sightscience), can help promised ocular surface can have greater since many self treat using express meibmoian glands and prepare on their surgical outcomes. over-the-counter products or under- the patient for refractive surgery. Research clearly shows an report their symptoms. I’ve heard impaired ocular surface affects patients say they believe ocular dry- ation of the ocular surface health of preoperative planning for cataract ness is simply “typical for my age.” every patient planning to undergo surgery.3 Having a poor tear film However, dry eye disease (DED) cataract surgery. This includes gath- can potentially alter the corneal can have significant consequences ering preoperative measurements, surface resulting in reduced repeat- to a patient’s lifestyle as well as on and monitoring postoperative ability of keratometry readings and various aspects of cataract surgery. refractive outcomes. diminished accuracy of intraocular As primary care clinicians, optom- Here, we review how to oversee lens (IOL) calculations.3 The study etrists need to take special consider- the health and stability of a cataract also concluded that diagnosing

42 REVIEW OF OPTOMETRY MAY 15, 2020 These slit lamp images show a patient undergoing the TearCare procedure. Note the visible material being expressed from the glands. and treating dry eye preopera- tionnaires, we are able to determine DED tests can reveal much about tively results in better visual out- the patient’s perspective of their the current homeostasis of the comes.3 However, many patients condition preoperatively. We repeat patient’s tear film, so you’ll want to present asymptomatically. Only the questionnaire at each visit incorporate some of the following approximately 22% of the patients (except day one and week one post- into your preoperative workup. In presenting for surgery had been op). In our clinic, we flag scores our clinic, we have access to both diagnosed with dry eye previously.1 higher than 8 as dry eye suspicious. inflammatory marker measurements However, a 2015 study shows dry This step is important because, as (Inflammadry, Quidel) and tear eye in 54.3% of 400 participants we’ve likely all heard before, “If a osmolarity measurements (Tearlab). older than 40 years.4 Additionally, patient is diagnosed prior to sur- When combined with TBUT, osmo- that study shows the prevalence gery, it is the patient’s problem, if a larity measurements provide an is greatest among participants 71 patient is diagnosed after surgery, it adequate assessment based on the years or older (67.3%), around the is the doctor’s problem.” Tear Film and Ocular Surface Soci- age when many will also be fac- Other measures of subjective ety’s DEWS II definition.7 ing potential cataract surgery.4,5 symptoms include the Dry Eye Tear hyperosmolarity correlates Of those who reported being com- Questionnaire-5 or the Ocular strongly to tear film instability. A pletely asymptomatic, 24.1% had Surface Disease Index. Whichever 2017 study shows patients with dry eye.4 test you employ, this subjective hyperosmolarity had a greater cor- Patients with subclinical DED are information is especially valuable neal variability as measured with just as likely to experience surgical when combined with the same keratometry readings, resulting in complications and return with one results after the procedure. Often, IOL calculation variability as well.8 or more DED symptoms. So, the patients present postoperatively With the addition of this purely importance of dry eye testing using with what they perceive is DED objective data, a provider can effec- both signs and symptoms for every caused by their cataract surgery. By tively identify a significant number cataract surgery candidate can’t be referencing a pre-op questionnaire, of dry eye patients preoperatively. overstated. it frequently reveals that the same Other investigative options can symptoms were present before the include tear film interferometry, tear Create a Testing Protocol procedure as well. It can reassure a clearance assessments (i.e., fluores- Any discussion about how to treat patient to learn that the surgery did cein clearance test, tear function ocular surgery patients with dry not worsen their dry eye, only that index, fluorophotometry) and ocu- eyes needs to begin with identify- they are now more aware of the lar surface damage assessment (i.e., ing the problem. In our clinic, we symptoms. corneal and conjunctival, rose ben- stick close to the American Society Objective tests are also critical in gal, lissamine green staining, cytol- of Cataract and Refractive Surgery identifying patients, especially those ogy), corneal epithelial cell mapping (ASCRS) guidelines.6 By measuring who are asymptomatic. But even if and lipid layer assessments (i.e., patient symptoms via SPEED ques- patients are symptomatic, objective precorneal/meibomian grading).9

REVIEW OF OPTOMETRY MAY 15, 2020 43 Surgical Comanagement

Treatment Protocols7 patients are paying out of pocket and bring higher expectations of Minimal Mild Moderate their surgical results. In attempting Aqueous deficient to meet the higher expectations of Education regarding the condition, Non-preserved ocular Autologous/allogeneic refractive cataract lens patients, its management, potential dietary lubricants to minimize serum eye drops providers should have a healthy modifications (including water preservative-induced ocular surface prior to surgery as a intake), treatment and prognosis toxicity priority in their treatment plans. Modification of local environment Punctal occlusion Therapeutic contact lens Surgical delay. One way to options establish a healthy ocular surface Ocular lubricants of various types Moisture chamber Amniotic membrane is by stabilizing the ocular tear film (if MGD is present, then consider spectacles/goggles grafts while delaying the surgery. Reasons lipid-containing supplements) to delay surgery include corneal Identification and potential Topical corticosteroid abnormality (e.g., dellen, superficial modification/elimination of (limited-duration), punctate keratitis), irregularity in offending medications non-glucocorticoid kerotometry (topography) measure- immunomodulatory ments or fluctuating vision. drugs (such as If delaying the procedure is war- cyclosporine) or LFA-1 ranted, it is important to under- antagonist drugs (such as lifitegrast) stand what is being monitored so Lipid Deficient treatment can be appropriate and an endpoint can be achieved. This Education regarding the condition, Lid hygiene and warm Tea tree oil treatment for its management, potential compresses of various Demodex (if present) process can take two to four weeks dietary modifications (including types or longer to improve adequately oral omega-3s), treatment and enough to proceed with surgery. prognosis Only upon adequate resolution of the signs and symptoms should the Modification of local environment Non-preserved ocular In-office, physical lubricants to minimize heating and expression patient proceed. For most patients preservative-induced of meibomian glands planning to have standard IOLs toxicity with TearCare (Sight implanted, we’ve found that a 70% Sciences), Lipiflow resolution of staining is fine as long (Johnson & Johnson as the central area is cleared. The Vision) or iLux (Alcon) same would apply to symptoms—if Ocular lubricants of various types, Moisture chamber Topical antibiotic or a patient’s symptoms are reduced including more lipid-containing spectacles/goggles antibiotic/steroid comb by 25%, they may be improved options applied to the lid margins enough to proceed, although this for anterior blepharitis (if is not a hard and fast rule as some present) contingencies can impact the deci- Identification and potential Topical LFA-1 antagonist Oral doxycycline (50- sion. modification/elimination of drugs (such as lifitegrast) 100mg po up to bid) or Ocular surface issues have an offending medications azithromycin (Z-pak) outsized effect on the performance of multifocal IOLs, so if your Presurgical Treatment be the best candidate for a multifo- patient is interested in these high- With appropriate identification, cal lens since these lenses typically performance lenses, it is imperative optometrists can customize the require high contrast to maximize that they achieve a healthy tear most appropriate treatment plan the vision. DED identification in film prior to surgery. For example, for each patient. This can help premium IOL patients is not only if a patient with SPK chooses a determine the best procedure as critical for the success of the patient traditional IOL, they may be coun- well as the most appropriate IOL but also for the success of the seled as to the effects of the SPK on for the patient. A patient with sig- refractive cataract surgery portion their vision and it may be treated nificant history of DED may not of the practice since many of these concomitantly. If the same patient

44 REVIEW OF OPTOMETRY MAY 15, 2020 inflammation present. However, if the source is MGD, thermal treatments with expression may be the best option. Doxycycline can also be considered in patients with MGD. If the patient shows This meibography picture demonstrates mild breakdown of the meibomian glands. significant SPK, loteprednol or Classic signs in this image are the lack of parallel meibomian gland structures— lifitegrast may be prescribed or in whether due to angling or breakdown. severe cases an amniotic membrane can be employed. In the least, good desires a multifocal IOL, however, where the patients report transient hygiene and some form of preser- their dry eye will more profoundly decreases in vision that are attribut- vative free artificial tears and/or affect their postoperative vision able to variations in tear film caus- warm compresses can likely be of and should be resolved prior to ing decreased contrast sensitivity.10 help to these patients whether it is surgery. Apply the same rationale Treatment. As their are dif- used prior to surgery, during the to epithelial thickness and keratom- ferent possibilities to treat the postoperative period (excluding etry ocular surface, much depends on warm compresses during the first measurements with an emphasis the etiology. If patients lack suf- week), or for long term mainte- on stability. Take these measure- ficient tear volume—based on tear nance. ments on a serial basis to determine meniscus height in conjunction When performing the biomicros- whether or not the surface is stable. with qualitative analysis of the copy exam, pay special attention to TBUT can create irregular dynamic lipid layer—prescribing a cyclo- corneal and conjunctival structures acuity and becomes a much greater sporine option may be the best to note any staining. Don’t forget concern with multifocal IOLs, option, or punctal occlusion if no to also evaluate the patient’s tear

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meniscus. Additionally, note the Photo: Dan Fuller, OD lid margin health to determine the state of the glands and the status or potential status of any lid infections or inflammations that could potentially disrupt postoperative healing. Meibomian gland expression can be performed using the Meibomian Gland Evaluator (Johnson & John- son Vision) to demonstrate gland function. During the clinical exam the provider should also pay special attention to mechanical or structural abnormalities such as poor lid closure, inadequate lid apposition This Keratograph 5M (Oculus) images is can help establish a patient’s tear break-up or an irregular lid margin. time, which can help prepare them for surgery.

Anterior Healing laser-assisted cataract surgery or exacerbate a patient’s DED. The During the immediate postopera- refractive cataract surgery. How- incision itself can potentially cut tive period, several complications ever, for a patient who was previ- through the nerves that are respon- may arise. These include acute ously diagnosed and treated for sible for innervating the corneal intraocular pressure spikes, endo- DED prior to surgery, the optom- surface and, by doing so, may phthalmitis and cystoid macular etrist needs to educate them about delay the epithelial wound healing. edema. These can occur with any their normal healing course. You’ll Discussing this helps the patient patient—dry eye or otherwise—fol- need to explain that the use of topi- understand that, during the initial lowing traditional cataract surgery, cal antibiotics and antinflammato- healing process, they may have ries and the preservatives located reduced tear production, decreased within them can potentially lead TBUT, decreased mucin produc- to ocular surface agitation, leav- tion increased inflammation and, ing patients with a newly observed ultimately, discomfort.15 This aspect or heightened awareness of DED is relatively temporary and will cor- symptoms.11 rect itself with healing. Counsel patients who traditionally use warm compresses to man- Outcomes age posterior blepharitis or use lid It is not uncommon for a patient scrubs to manage anterior blephari- to have an outstanding surgical tis to withhold these therapies for a procedure, yet be unsatisfied with full week, so as not to compromise the outcome.10 In a 2016 study the new incision and create any of patients who were dissatis- increased risk for infection. Stop- fied, 57% were due to refractive ping these maintenance regimens error and 35% were due to DED. can lead to a potential backslide Patients may also confront post- or relapse of previously managed operative discomfort as a result DED.11 of the previously mentioned post- The iLux (Alcon) can be performed in Exposure to light from the oper- operative drops, but some might the office to help clear the meibomian ating microscope can also be a develop discomfort due to a pre- glands of patients with dry eye due contributing factor to the patients operative refractive miscalculation to meibomian gland dysfunction. This dry eye syndrome.12-14 Optometrists as any residual refractive error can can help set the stage for a successful should explain to patients that even produces eyestrain or create aniso- refractive surgery. the corneal incision can potentially metropia between the two eyes.

46 REVIEW OF OPTOMETRY MAY 15, 2020 These patients can have uncor- minimized or corrected, while for tertiary care center. Oman J Ophthalmol. 2015;8(3):151–6. 5. Kauh C, Blachley T, Lichter P, et al. Geographic variation in rected 20/20 vision, yet exhibit others it may just mean a more the rate and timing of cataract surgery among US communi- “20/unhappy” presentation. Since thorough education on appropriate ties. JAMA Ophthalmol. 2016;134(3):267-76. 6. Starr C, Gupta P, Farid M, et al. An algorithm for the preop- refractive error is closely associated expectations. However, all eye care erative diagnosis and treatment of ocular surface disorders. J with dry eye, it’s worthwhile to providers should be aware of the Cataract Refract Surg. 2019;45(5):669-84. 16 7. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II defini- evaluate the ocular surface. impact this condition can have as tion and classification report. Ocul Surf. 2017;15(3):276-83. It is imperative to reset expecta- well as the resulting consequences 8. Epitropoulos AT, Matossian C, Berdy GJ, et al. Effect of tear osmolarity on repeatability of ketratometry for cataract sur- tions during this timeframe. Missed if they are not dealt with appropri- gery planning. J Cataract Refract Surg. 2018; 44(9):1090-6. refractive errors can be modified, ately. n 9. Kanellopoulos A, Asimellis G. In pursuit of objective dry eye but it is important to correct the screening clinical techniques. Eye Vis (Lond). 2016;3:1 Dr. Chester is a partner at the 10. Gibbons A, Ali T, Waren D, Donaldson K. Causes underlying condition that may have Cleveland Eye Clinic and is active and correction of dissatisfaction after implantation of caused the error. Likewise, if the in training professionals in the presbyopia-correcting intraocular lenses. Clin Ophthalmol. 2016;10:1965–70. post-operative course is expected perioperative care of the refractive 11. Walsh K, Jones L. The use of preservatives in dry eye to be temporary, take measures to surgery patient, cataract surgery drops. Clin Ophthalmol. 2019;13:1409-25. 12. Sutu C, Fukuoka H, Afshari N. Mechanisms and man- address the problem and counsel co-management and ocular surface agement of dry eye in cataract surgery patients. Curr Opin the patient. disease management. Ophthalmol. 2016;27:24-30. 13. Cho Y, Kim M. Dry eye after cataract surgery and 1. Trattler W, Majmudar P, Donnenfeld E, et al. The prospec- associated intraoperative risk factors. Korean J Ophthalmol. Since dry eye disease can have an tive health assessment of cataract patient (PHACO) study: the 2009;23:65-73. influence on ocular surgery before effect of dry eye. Clin Ophthalmol. 2017;11:1423-30. 14. Li X, Hu L, Hu J, Wang W. Investigation of dry eye disease 2. Roberts CW, Elie ER. Dry eye symptoms following cataract and analysis of the pathogenic factors in patients after cata- and after the procedure, providers surgery. Insight 2007;32(1):14-21. ract surgery. Cornea. 2007;26(9 Suppl 1):S16–S20. should recognize the condition and 3. Chuang J, Shih KC, Chan T, Wan KH, Jhanji V, Tong 15. Donnenfeld ED, Solomon K, Perry HD. The effect of hinge L. Preoperative optimization of ocular surface dis- position on corneal sensation and dry eye after LASIK. Oph- treat it appropriately. For some, ease before cataract surgery. J Cataract Refract Surg. thalmology. 2003 May; 110(5):1023-30. that treatment means delaying the 2017;43(12):1596-1607. 16. Dhungel D, Shrestha G. Visual symptoms associated 4. Shah S, Jani H. Prevalence and associated factors of dry with refractive errors among Thangka artists of Kathmandu procedure so the condition can be eye: our experience in patients above 40 years of age at a valley. BMC Ophthalmol. 2017;15:258.

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REVIEW OF OPTOMETRY MAY 15, 2020 47 Diet & Dry Eye

21st Annual Dry Eye Report Diet: Why Dry Eye Hangs in the Balance What we eat—and don’t eat—is impacting our ocular health. Here’s what you need to know. By Katherine Sanford, OD

he past 10,000 years have given rise to many changes in our nutritional environment, Twith enormous implications. A less varied diet and an increasingly sedentary lifestyle has led to an increased risk of chronic conditions such as atherosclerosis, hypertension, obesity, diabetes and many cancers.1 Today’s Western diet includes too many dietary grains and fatty foods and not enough fruits, vegetables and proteins. As a result, the number of omega-6 fatty acids in our diet are significantly higher while the amount of omega-3 fatty acids continues to decrease. The connections between omega- 3, omega-6 and inflammation are well documented in the medical This slit lamp photo demonstrates sodium fluorescein staining of a patient’s eye with literature, leaving some to speculate punctate keratitis. that this nutritional shift plays a role in the pathogenesis of dry eye than 50, which, at the upper range, read, drive and work on the com- disease (DED). makes it more prevalent in the US puter.5-7 Studies show that when population than diabetes, cancer direct costs such as office visits, tear DED in Modern Society and heart disease combined.2-4 therapies and supplements are com- Dry eye’s impact on society is sig- The irritation, blurred vision and bined with indirect costs (e.g., loss nificant. Based on the literature, the eye fatigue associated with dry eye of productivity), the yearly impact incidence of DED ranges between lead to a decrease in quality of life of DED on the US economy nears 5% and 30% in individuals older by impairing a patient’s ability to $55 million.5

48 REVIEW OF OPTOMETRY MAY 15, 2020 Practitioners have a variety of [downregulate inflammation Alpha linolenic acid treatments in their armamentarium and PG production] ALA 18:3n3 to combat this disease, including Omega 3 ophthalmic lubrication, lid and Stearidonic acid 18:4n3 PG = prostaglandins meibomian gland therapy, anti- TX = thromboxanes inflammatory eye drops and punc- LT = leukotrienes tal plugs.9 While these treatments Eicosatetraenoic acid can help to manage dry eye, clini- 20:4n3 cians continue to search for new 3 series PG [lower BP,prevent clots, block formation of 2 series PG] treatment options with a particular [numerous antiinflammatory, focus on those that address the anti proliferative, anti carcinogenic Eicosapentaenoic acid TX [reduces arrhythmia, fibrillation] underlying disease process.10 effects] EPA. 20:5n3 The search for dry eye answers has led researchers to question 5 series LT [inactive or antiinflammtory] Docosahexanoic acid whether nutrition, specifically the DHA 22:6n3 balance of omega-3 and omega-6 fatty acids and their role in inflam- These diagrams show the cascade of omega-3 (above) and omega-6 (below) mation, might hold the key. metabolism and eicosanoids. Adapted from Vasquez A.39

Linoleic acid Fatty Acid Basics [activate tumor promotor] LA 18:2n6 Dietary polyunsaturated fatty acids Omega 6 PG = prostaglandin (PUFAs) consist of two primary HP ETE = hydroperoxyeicosatetraenoic acid [favorably modulates adhesion HETE = hydroxyeicosatetraenoic acid categories: omega-6 and omega-3. Gamma linolenic acid molecules and hormone LT = leukotrienes GLA 18:3n6 Omega-3 and omega-6 PUFAs are receptors] derivatives of the essential fatty acids (EFAs) alpha-linolenic acid Di homogamma-linolenic acid 1 series PG [anti-inﬂammatory, vasodilation, (ALA) and linoleic acid (LA).11,12 DGLA 20:3n6 inhibits platelet aggregation] ALA is an omega-3 fatty acid found in flaxseed and chia that is con- 2 series PG [promotes Arachidonic acid cancer, promotes inﬂammation, verted by the body to the longer AA 20:4n6 chemotaxis, edema, increases chain PUFA eicosapentaenoic acid duration and intensity of pain] (EPA) then docosahexaenoic acid HPETE [promote tissue destruction] (DHA). Because this process is inef- ficient in humans, we must obtain HETE [procarcinogenic] EPA and DHA from food sources or 4 series LT [bronchoconstriction, edema, supplements.12-15 DHA and EPA are immunosuppression, procarcinogenic] found naturally in fish and krill oils, as the fish consume microalgae that linolenic acid (DGLA), which can inflammatory conditions such as produce them.12 then be converted to either AA or rheumatoid arthritis and improve LA is an omega-6 fatty acid to 1-series prostaglandins. Omega- symptoms in patients with dry eye found in vegetables oils, nuts, eggs 3, specifically EPA, competes with and Sjögren’s.17-19,21 and meat.20 Once ingested, it is the conversion of DGLA to inflam- Both omega-3 and omega-6 fatty desaturated and elongated to form matory AA, thus increasing the acids form eicosanoids, which are the longer chain PUFA gamma- production of anti-inflammatory signaling molecules within the body. linolenic acid (GLA) then arachi- 1-series prostaglandins. Eicosanoids from omega-3 are donic acid (AA).15,17 GLA, which is Biochemically, to get the full ben- key to the function of the cardio- found in black current seed oil and efits of increased GLA, you should vascular, pulmonary, immune and evening primrose oil, exhibits anti- ensure the patient also has adequate endocrine systems while omega-6 inflammatory properties while AA levels of EPA either through their eicosanoids are mediators of vaso- is pro-inflammatory. GLA increases diet or supplementation.19,20 GLA constriction and platelet aggregation the amount of dihomo-gamma- can provide relief from chronic which contribute to inflammation.12

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in livestock feed have led to a dramatic increase in the amount of omega-6 in our diet.1 The ratio of omega-6 to omega-3 in West- ern diets has now skyrocketed to approximately 15:1.25

The Roots of DED The Tear Film and Ocular Sur- This patient’s meibography reveals signs of severe dry eye in a patient with face Society’s Dry Eye Workshop meibomian gland dysfunction. II defined dry eye as a disease “in which tear film instability and Simply stated, omega-3 fatty revolution brought about primar- hyper-osmolarity, ocular surface acids are considered anti-inflam- ily three dietary changes for which inflammation and damage, and matory while omega-6 fatty acids there is no evolutionary precedent neuro-sensory abnormalities play are primarily pro-inflammatory.22,23 in our species.1 etiological roles.”5 While numerous Though some degree of inflamma- First, cereal grains entered the risk factors contribute to dry eye, tion is essential to the body’s ability human food supply, and quickly inflammation of the lacrimal gland, to prevent infection and recover become increasingly central to our ocular surface and meibomian from injury, excessive amounts diet; grains now provide the great- glands is a key contributor.5,19,25 can contribute to chronic disease est number of calories in the Ameri- When ocular surface inflamma- processes. Research shows that the can diet.1,16 Cereal grains are high in tion occurs, inflammatory mediators

decline in omega-3 in our tissues carbohydrates and omega-6 and are such as prostaglandin E2 and inflam- allows for its replacement with low in omega-3 and antioxidants.1 matory leukotrienes are synthe- increased amounts of omega-6.16 Second, poultry and soybean oil sized from eicosanoids and lead to Thus, a diet appropriately balanced consumption increased exponen- epithelial cell apoptosis, goblet cell in omega-3 and omega-6 fatty acids tially, and soybean oil’s contribution loss and corneal barrier disruption provides significant health benefits. to food calories increased 1,000- resulting in DED.14,19,25,26 Omega-3 There is a beneficial anti- fold while poultry’s contribution fatty acids competitively decrease inflammatory shift within the body increased four-fold. This resulted the production of inflammatory when the concentration of EPA and in a three-fold increase in essen- mediators and inhibit killer cell DHA is greater than that of AA tial omega-6 but only a two-fold activity.19 Cellular research shows due to competition in the synthesis increase in essential omega-3.16 that the efficacy of omega-3 in the of eicosanoids.12,14 An omega-6 to Lastly, farmers in the 1950s context of dry eye may be related to omega-3 ratio range from 1:1 to 4:1 began to use high-energy grain feed its influence on the composition of is consider optimal for the majority for cattle, which decreased days on lipids produced by meibomian gland of disease process.1 feed and improved marbling—or epithelial cells in addition to its anti- intramuscular fat—in the final inflammatory properties.14,27 Dietary Shifts product.11 While there is no signifi- Prior to the agricultural revolution, cant difference in omega-6 content Where Fatty Acids Fit In humans were primarily hunters and between the two feeding regimens, Studies in the 1970s found that gatherers. Lean meat, fish, leafy grass-fed beef has higher concentra- deaths due to coronary heart dis- green vegetables, fruits, berries and tions of omega-3 and has a more ease were particularly low in Inuit honey were readily available, and favorable omega-6 to omega-3 populations that have a diet high in the human diet had a vast degree of ratio. Gradually over time, consum- seafood.11 Researchers discovered variety.1 Wild game and plants con- ers have become accustomed to the that the omega-3 PUFAs in the sea- tributed an appreciable amount of flavor profile of grain-feed beef and food were responsible for the posi- omega-3 to the human diet, creating often prefer it to grass-fed beef.11 tive health effects.11 They also found a 1:1 ratio of omega-6 to omega-3 Together, the increased consump- that a diet high in omega-3 fatty fatty acids.1,16,24 tion of cereal grains, advent of the acids has wide-ranging health bene- The advent of the agricultural vegetable oil industry and changes fits such as lower serum triglyceride

52 REVIEW OF OPTOMETRY MAY 15, 2020 SLITLAMPS concentrations, improved cardiac subjective improvement in dry eye SLIT LAMPS function and lower C-reactive pro- symptoms as well as a decrease EXCEPTIONAL OPTICS tein and tumor necrosis factor.13,23,28 in corneal inflammatory mark- The importance of a balaned ers.19,21 Research shows omega-6 omega-6 to omega-3 ratio was supplements with combined LA first addressed in the 1990s when and GLA resulted in decreased researchers realized that large corneal inflammatory markers, an amounts of omega-6 in our diet increase in tear meniscus height and S4OPTIK’s causes the formation of more AA improved symptomatology.18,19 converging than EPA.29 The increased AA eico- Despite the growing body of binoculars sanoids lead to allergic and inflam- literature, none of it shows conclu- matory disorders and continued sive findings regarding omega fatty allow effortless proliferation of cancer cells.25 acids and dry eye. Comparisons maintenance of Although many studies have between trials are complicated fusion. found a correlation between by the fact that eligibility criteria, omega-3 fatty acids and DED, the supplement content/dosage, placebo Women’s Health Study in 2005 was content and outcome measures all the first systematic study to estab- vary considerably.9 lish the potential protective role of Even the American Academy of European omega-3 fatty acid supplementa- Ophthalmology remains cautious craftsmanship and tion in the treatment of DED.24 Of in its support of omega fatty acid engineering provide the approximate 32,000 women therapy in the treatment of dry included in the study, 4.7% gave eye due to lack of consensus. It’s reliable optics at self-reports of dry eye. Food fre- preferred practice patterns state all magnifications quency questionnaires showed a that “education regarding potential for confident 68% decrease in self-reported his- dietary modifications (including tory of dry eye in women who con- oral essential fatty acid supplemen- examinations. sumed greater than five servings of tation) should be included” within tuna per week. While the research- the initial treatment of dry eye and ers found no correlation between that “the use of essential fatty acid high omega-6 intake and dry eye, supplements for dry eye treatment they noted that subjects with a high has been reported to be potentially omega-6 to omega-3 ratio (15:1 or beneficial.” However, it also notes greater) were twice as likely to have the recent findings from the Dry Z-Series DED compared with subjects with Eye Assessment and Management H-Series a lower ratio.18,24 (DREAM) study and its failure to Since that study, numerous oth- support the benefit of oral fatty ers have evaluated these fatty acids acids over placebo.2 and DED. One of the first omega-3 dry eye clinical trials in 2011 found DREAM Raises Questions that the use of omega-3 supple- In 2018, the DREAM study ments resulted in improvements research group published findings in symptoms and tear produc- from a randomized controlled trial tion.30 Other investigations show conducted at 27 ophthalmologic that patients on omega-3 (EPA/ and optometric clinical centers in DHA) supplements experience sig- the US. In the study, dry eye patients Vertical and compact nificantly greater improvements in were assigned to either an active configurations available. symptoms and signs of dry eye than supplement containing 3,000mg patients receiving placebo.10,31-34 fish-derived omega-3 EPA/DHA or Even combinations of omega-3 a placebo of 1,000mg refined olive and the omega-6 GLA can provide oil.9,35 Patients were maintained on

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their assigned supplement for 12 Strike a Better Balance sources, primarily vegetable oils. months and their ocular health and The consumption of omega-6 fatty Avoiding corn, soybean, peanut and symptoms were monitored. The acids is at an all-time high, and sunflower oils and instead opting primary outcome was the mean nutritionists are recommending not for olive oil, coconut oil or butter change from baseline in the ocular only an increase in dietary omega-3 when cooking is beneficial. Finally, surface disease index (OSDI) score but also a decrease in omega-6 nutritionists recommend limiting with secondary outcomes of cor- intake to more efficiently balance the use of products that contain neal signs. It is frequently touted as the ratio. The Academy of Nutri- high amounts of vegetable oils and one of the most ‘real-world’ omega tion and Dietetics suggests consum- omega-6 such as salad dressing, supplement studies to date in that ing at least 500mg of EPA/DHA per mayonnaise and margarine.37 The patients with inflammatory condi- day (200mg more per day for preg- Institute of Medicine recommends tions such as rheumatoid arthritis nant or lactating females) and the that calories from omega-6 fats and Sjögren’s were included and American Heart Association recom- should comprise 5% to 10% of patients could continue certain dry mends 1,000mg per day for those your daily caloric intake. eye treatments.9 with coronary heart disease.36 Supplementation. Nutritional At the end of 12 months, both Dietary intake. The most effec- supplements are certainly beneficial DREAM study groups experienced tive way to increase omega-3 in increasing consumption of essen- a clinically significant decrease in through diet is by consuming non- tial fatty acids, and myriad options their OSDI scores compared with fried cold-water fatty fish such as are available to patients. However, baseline, and there was no signifi- salmon, mackerel, tuna or sardines dosages and fatty acid sources vary cant difference between the two two to four times per week. Marine significantly between products, and groups in signs of DED. The fact sources that contain EPA and DHA there is currently no FDA-approved that the change in OSDI scores did are preferred over flax, hemp and formulation.31,38 not differ significantly between chia due to the limited conversion Algal oil supplements are an the active and placebo supplement of ALA in the human body. Choos- excellent source of omega-3 for veg- groups confounded many in the dry ing grass-fed over grain-fed meat etarians who do not consume fish eye world.9 sources will also increase omega-3 products and prefer to avoid marine Researchers have proposed mul- intake.12,36 Numerous brands of sourced supplements.37 tiple explanations as to why the eggs, yogurt, juices and milk are DREAM study did not show the fortified with omega-3 and notably, Without a clear consensus on benefit of omega-3 over placebo in infant formulas have been fortified the use of omega fatty acids in the the treatment of dry eye, including with DHA since 2002.12 management of dry eye, finding the potential anti-inflammatory Minimal omega-6 is required the right management path can effects from the refined olive oil for normal metabolic function, seem daunting. Eye care providers placebo.35 The lack of GLA in and necessary amounts are easily can begin by discussing diet and the active supplement could also obtained by regular consumption nutrition with all of their patients, play a part in the similar efficacy of healthful sources such as olive particularly those suffering from results between the experimental oil, avocados and nuts (includ- dry eye. Provide information on and placebo groups.17 Finally, the ing nut butters). Efforts should be the recommended daily intakes real-world nature of the study is focused on decreasing unhealthful of omega-3 as well as the dietary

potentially a Photos: MIchelle Hessen, OD choices patients complicating can make to factor because increase omega-3 many patients and decrease were already omega-6 to skew using treatments the ratio in a such as artificial more health- tears and lower ful direction. dosage omega The impact of fatty acid supple- omega-3 and ments.35 Lissamine green staining on the conjunctiva reveals signs of dry eye. a balanced

54 REVIEW OF OPTOMETRY MAY 15, 2020 SLIT LAMPS omega-3/omega-6 ratio on systemic 16. Blasblag TL, Hibbeln JR, Ramsden CE. Changes in consumption of omega-3 and omega-6 fatty acids in the inflammatory and chronic condi- United States during the 20th century. Am J Clin Nutr. NEW LED 2011;93:950-62. tions is well supported by validated 17. Silva JR, Burger B, Kuhl CM, Candreva T. Wound heal- research, and the benefit of making ing and omega-6 fatty acids: from inflammation to repair. Illumination Mediators Inflamm. 2018;2503950. [Epub]. better nutritional choices is clear. 18. Kokke KH, Morris JA, Lawrenson JG. Oral omega-6 essential fatty acid treatment in contact lens associated dry More than 50,000 Inflammation plays a prominent eye. Cont Lens Ant Eye. 2008;31:141-46. role in DED, and it is rational to 19. Sheppard JD, Singh R, McClellan AJ. Long term supple- hours of clear, cool mentation with n-6 and n-3 pufas improves moderate to continue exploring the use of omega severe keratoconjunctivitis sicca: a randomized double blind illumination. fatty acids in its management. But clinical trial. Cornea. 2013;32(10):1297-1304. 20. Vasquez A. Reducing pain and inflammation naturally. more controlled large-scale studies Part II: new insights into fatty acid supplementation and its effect on eicosanoid production and genetic expression. with standardized outcomes are Nutritional Perspectives: J Counc Nutr Am Chiro Assoc. necessary to clarify exactly what 2005;28(1):5-16. 21. Brignole-Baudouin F, Fauduoin C, Aragona P. A multicen- role essential fatty acids and the tre, double-masked, randomized, controlled trial assessing omega-6/omega-3 ratio play in the the effect of oral supplementation of omega-3 and omega-6 fatty acids on a conjunctival inflammatory marker in dry eye treatment and prevention of dry patients. Acta ophthalmol. 2011;89:591-97. 22. Calder P. n-3 polyunsaturated fatty acids, inflam- eye. We as practitioners must stay mation, and inflammatory diseases. Am J Clin Nutrition. apprised to ensure we are practicing 2006;83(6):1505-19. 23. DiNicolantonio JJ, O’Keefe JH. Importance of maintain- good evidence-based medicine for ing a low omega-6/omega-3 ratio for reducing inflamma- ■ tion. Open Heart. 2018;e000946. our patients. 24. Miljanovic B, Trivedi KA, Dana MR. Relation between Dr. Sanford is an attending dietary n-3 and n-6 fatty acids and clinically diagnosed dry eye syndrome in women. Am J Clin Nutr. 2005;82:887-93. optometrist at the Memphis VA 25. Simopoulos AP. Evolutionary aspects of diet, the Medical Center. omeg-6/omega-3 ratio and genetic variation: nutritional implication for chronic diseases. Biomed Pharmacother. 2006;60:502-07. 1. Simopoulos AP. The importance of the ratio of omega-6/ 26. Russo GL. Dietary n-6 and n-3 polyunsaturated fatty omega-3 essential fatty acids. Biomed Pharmacother. acids: From biochemistry to clinical implications in cardio- 2002;56:365-79. vascular prevention. Biochem Pharmacol. 2009;77:937-46. 2. American Academy of Ophthalmology Cornea/External 27. Liu Y, Kam WR, Sullivan DA. Influence of omega 3 and Disease Panel. Preferred practice pattern guidelines: dry eye 6 fatty acids on human meibomian gland epithelial cells. syndrome. Academy of Ophthalmology. November 2018. Cornea. 2016; 35(8):1122-26. 3. Paulsen AJ, Cruickshanks KJ, Fisher ME. Dry eye in 28. Li K, Huang T, Zheng J. Effect of marine derived n-3 the beaver dam offspring study: prevalence, risk fac- polyunsaturated fatty acids on C-reactive protein, interleukin tors, and health-related quality of life. Am J Ophthalmol. 6 and tumor necrosis factor alpha: a meta- analysis. PLoS 2014;157(4):799-806. One 2014; 9:e88103. 4. Galor A, Feuer W, Lee D. Prevalence and risk factors of 29. Simopoulos AP. Omega 3 fatty acids in in health and dry eye syndrome in a United States Veterans Affairs popu- disease and in growth and development. Am J Clin Nutr. lation. Am J Ophthalmol. 2011;152: 377-84. 1991;54:438-63. 5. Craig TP, Nichols KK, Akpek EK. TFOS DEWS II definition 30. Wojtowicz JC, Butovich I, Uchiyama E. Pilot, prospective, and classification report. Ocular Surf. 2017;15(3):276-83. randomized, double masked, placebo controlled clini- 6. Stapleton F, Alves M, Bunya VY. TFOS DEWS II epidemiol- cal trial of an omega-3 supplement for dry eye. Cornea. ogy report. Ocular Surf. 2017;15(3):334-65. 2011;30(3):308-14. 7. Wei Y, Asbell P. The core mechanism of dry eye disease 31. Bhargava R, Kumar P. Oral omega-e fatty acid (DED) is inflammation. Eye Contact Lens. 2014;40(4):248- treatment for dry eye in contact lens wearers. Cornea. 56. 2015;34(4):413-20. 8. Yu J, Asche CV, Fairchild CJ. The economic burden of dry 32. Bhargava R, Kumar P, Kumar M. A randomized con- eye disease in the United States: a decision tree analysis. trolled trial of omega-3 fatty acids in dry eye syndrome. Int J Cornea. 2011;30(4):379-87. Ophthalmol. 2013;6(6):811-16. 9. Asbell PA, Maguire MG, Pistilli M. n-3 Fatty acid supple- 33. Deinema LA, Vingrys AJ, Wong CY. A randomized, double mentation for the treatment of dry eye disease. New Eng J masked, placebo-controlled clinical trial of two forms of Med. 2018;378:1681-90. omega-3 supplements for treating dry eye disease. Ophthal- 10. Kangari H, Eftekhari MH, Sardari S. Short-term con- mology. 2017;124:43-52. Easier observation of sumption of oral omega-3 and dry eye syndrome. Ophthal- 34. Epitropoulos AT, Donnenfield ED, Shah ZA. Effect of oral mology. 2013;120(11):2191-96. re-esterified omega-3 nutritional supplementation on dry minute details. 11. Daley CA, Abbott A, Doyle PS. A review of fatty acid pro- eyes. Cornea. 2016;35(9):1185-91. files and antioxidant content in grass-fed and grain-fed beef. 35. Asbell PA, Maguire MG. Why DREAM should make you Nutrition J. 2010;9:10. think twice about recommending omega-3 supplements. 12. National Institutes of Health. Omega-3 fatty acids fact Ocular Surf. 2019;17:617-18. Color temperature sheet for healthy professionals. https://ods.od.nih.gov/fact- 36. Vannice G, Rasmussen H. Position of the academy of sheets/Omega3FattyAcids-HealthProfessional. October 17, nutrition and dietetics: dietary fatty acids for healthy adults. maintained through the full 2019. Accessed march 24, 2020. J Acad Nutr Diet. 2014;114(1):136-53. 13. Chee KM, Gong JX, Rees DM. Fatty acid content of 37. Jacobs A. Balancing Act. Today’s Dietitian. range of illumination marine oil capsules. Lipids. 1990;25(9):523-28. 2013;15(4):38. 14. Giannaccare G, Pellegrini M, Sebastini S. Efficacy of 38. Rand AL, Asbell PA. Current opinion in ophthalmology adjustment. omega-3 fatty acid supplementation for treatment of dry nutritional supplements for dry eye syndrome. Curr Opin eye disease: a meta-analysis of randomized clinical trials. Ophthalmol. 2011;22(4):279-82. Cornea. 2019;38(5): 565-73. 39. Vasquez A. Reducing pain and inflammation naturally. 15. Hom MM, Asbell P, Barry B. Omegas and dry eye: more part 1: new insights into fatty acid biochemistry and the knowledge, more questions. Optom Vis Sci. 2015;92:948- influence of diet. Nutritional Perspectives. 2004;Oct:5,7- 56. 10,12,14.

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21st Annual Dry Eye Report Don’t Overlook Aqueous-deficient Dry Eye Familiarize yourself with this subset so that you’re better able to detect and manage it if it does present. By Candice Tolud, OD

n recent years, diagnosis, manage- The two predominant etiologies, ment and treatment of dry eye ADDE and EDE, can present as disease (DED) have expanded single and separate processes or may Igreatly. Our understanding of overlap with each other. The signs what makes an eye “dry” has grown and symptoms of both affect the from simply stating that a patient entire ocular surface, including the has dry eye to understanding the tear film, cornea, conjunctiva, eyelids many factors that can contribute to and lacrimal and meibomian glands.2 its etiology. EDE is caused by MGD, and While emerging treatments largely ADDE results from reduced aque- focus on evaporative dry eye (EDE), ous secretion. EDE, and cases of aqueous deficiency can exist inde- DED that involve EDE and ADDE, pendently or even concurrently in accounts for over 80% of all dry eye Patients with punctate corneal patients who have meibomian gland cases. Only about 10% of DED is staining—a common finding in ADDE— dysfunction (MGD). Make sure you classified as strictly ADDE.3 can be asymptomatic or have severe pain don’t overlook this uncommon but and decreased vision. impactful condition while evaluating Aqueous Deficiency a patient for dry eye. The following ADDE can be divided into Sjögren’s autoantibodies, specifically anti-SSA article reviews aqueous-deficient dry syndrome (SS) and non-SS.4 and anti-SSB. Earlier stages of SS can eye (ADDE) and corresponding diag- Sjögren’s. This chronic autoim- be detected through biomarkers for nostic and management options. mune disorder is characterized anti-salivary protein-1, anti-carbonic by immune cell infiltration of the anhydrase and parotid-specific Dry Eye Subsets exocrine glands and systemic com- protein.5,6 You can order these The Tear Film and Ocular Surface plications due to autoantibody tests, along with other rheumato- Society (TFOS) defines DED as “a production.4 SS predominantly logic markers, such as anti-nuclear multifactorial disease of the ocular affects women and may be due to an antibodies, rheumatoid factor, surface characterized by a loss of abnormal immune response to envi- erythrocyte sedimentation rate and homeostasis of the tear film and ronmental or viral triggers in suscep- c-reactive protein.5 The gold stan- accompanied by ocular symptoms, in tible patients.4 It mainly targets the dard for SS diagnosis has long been which tear film instability and hyper- lacrimal and salivary glands and can salivary gland biopsy, but ultrasound osmolarity, ocular surface inflamma- cause gland destruction and signs and imaging is emerging as a potential tion and damage and neurosensory symptoms of dry eye and mouth.4 technique for earlier detection.5-7 abnormalities play etiological Serological testing for SS is geared Non-Sjögren’s. ADDE without roles.”1 toward detecting the presence of systemic autoimmune features of SS

56 REVIEW OF OPTOMETRY MAY 15, 2020 Image: TFOS DEWS II could involve congenital or acquired forms of DED.7 Causes of non-SS dry eye include lacrimal gland abla- tion, congenital alacrima, triple A syndrome and ocular surface aging. Systemic conditions, such as sar- coidosis and lymphoma, and viral DED is on a continuum of pathophysiology and is not a dichotomous disease. infections, such as hepatitis C and HIV/AIDS, are also potential causes.7 Tear hyperosmolarity. Out of of the lower eyelid shortly after a Direct damage to the lacrimal gland all the available clinical tests, this blink. The simplest way to grade it is due to radiation therapy of the head/ marker has the highest correlation to conduct meniscometry at the slit neck, chemical injury or cicatricial to DED severity. The DEWS II states lamp by judging the meniscus height changes resulting from graft-vs.-host that tear osmolarity is the single in comparison with the slit lamp disease, Stevens-Johnson syndrome, best metric to diagnose and clas- beam height, but this method has trachoma or ocular pemphigoid may sify DED.8 A positive result is any poor inter-visit repeatability.8 Digital lead to ADDE.7 Another contribut- reading greater than 308mOsm/L measurement techniques are emerging factor includes decreased corneal or a difference of more than eight ing and exhibit better reproducibility sensation, which can be triggered between eyes. Although the patho- but are not mainstay at this time.8 pharmacologically, after refractive physiology of patients with EDE or Perform Schirmer’s testing by surgery or secondary to disease.7 ADDE differs, the tear osmolarity inserting the paper strip at the Signs and symptoms are similar in and distribution do not.9 temporal one-third of the lower lid non-SS and SS.4 However, the onset Ocular surface staining. Con- margin and measuring the length of of dry eye is later in non-SS patients. junctival and lid margin damage is wetting after five minutes either with Non-SS patients also tend to be older best viewed with lissamine green or without anesthesia. A Schirmer’s and have less severe disease with a staining, and corneal damage is more test result >10mm is normal, smaller risk of blindness.4 visible with fluorescein dye.8 Rose between 5mm and 10mm is border- bengal concentrates on corneal and line and <5mm is indicative of aque- General Testing conjunctival cells that lack mucin ous deficiency.8 Conducting the test DED testing is the same for all cases. and can identify damaged epithelial without an anesthetic is best to con- There are three key diagnostic tests cells.9 Staining in either eye confirms firm severe ADDE, but its variability the DEWS II recommends in symp- a positive result that commonly indi- and invasiveness precludes its use as tomatic patients who have screened cates late-stage DED. Ocular surface a routine diagnostic test of tear vol- positive on patient questionnaires, staining is defined as more than five ume, especially in cases with concur- such as the Dry Eye Questionnaire 5 corneal or nine conjunctival spots or rent EDE where tear quality rather (score >6) or the Ocular Surface Dis- lid margin staining (lid wiper epithe- than quantity is predominantly ease Index (score >13) (OSDI). liopathy) greater than 2mm in length. affected.8 Under these circumstances, Tear breakup time. Noninvasive While DEWS II suggestions for testing can stimulate a reflex tearing tear breakup time (TBUT) is always initial DED testing do not include response on insertion of the testing recommended over traditional tear volume, this parameter plays strip and mask results.8 fluorescein TBUT to minimize the an important role in assessing ocu- dye’s impact on tear film stability. lar surface health and homeostasis, Treatment Options However, if fluorescein is used, the particularly in patients with aqueous Historically, ADDE was treated by test strip should be dry and applied deficiency.8 Decreased tear volume prescribing tear replacement prod- to the outer canthus to decrease any may be a key pathogenic mechanism ucts or by conserving tears via punc- irritation of the ocular surface, and and diagnostic sign of ADDE patients tal plugs.10 While these methods still measurements should be taken one who suffer independently from EDE.8 play a key role in treating ADDE, to three minutes after instillation.8 Tear volume can be indirectly recent treatments focus on better Noninvasive TBUT is measurable evaluated noninvasively via tear stimulating tear production.10 with a corneal topographer.8 A posi- meniscus assessment, which can help Managing dry eye often requires tive test result is a TBUT of less than with DED subclassification.8 The several simultaneous methods of 10 seconds after the patient blinks. meniscus is best viewed in the center care. Following a patient’s signs and

REVIEW OF OPTOMETRY MAY 15, 2020 57 Dry Eye

available in three preservative-free serum, and other blood-derived tear forms: Restasis (cyclosporine A substitutes, can promote corneal 0.05%, Allergan), Cequa (cyclospo- epithelial wound healing, inhibit the rine A 0.9%, Sun Pharmaceuticals) release of inflammatory cytokines, and Klarity-C (cyclosporine A 0.1%, increase the number of goblet cells Imprimis Rx). and encourage mucin expression.10 Xiidra (lifitegrast, Novartis) is a Specialized compounding pharma- small-molecule integrin antagonist cies formulate autologous serum, the that binds to cell surface proteins concentration of which depends on found on leukocytes and blocks the symptom severity, after the patient’s This patient has extensive punctate integrin lymphocyte function-asso- blood is drawn and screened for epithelial keratitis and decreased TBUT. ciated antigen-1 and cognate ligand HIV, hepatitis and other conditions.10 intercellular adhesion molecule-1 Typically kept frozen for up to symptoms to gauge the efficacy of interactions.13 In vitro studies have nine months at -20°C, a defrosted their current treatment regimen is shown that Xiidra may inhibit the vial is good for about 24 hours after key when deciding whether addi- recruitment of previously activated it thaws, as it is non-preserved.10 tional therapy is necessary. T-cells, the activation of newly A study found that treatment with Artificial tears. These over-the- recruited T-cells and the release of autologous serum can improve counter products do not address the pro-inflammatory cytokines, inter- patient symptoms in as soon as 10 pathophysiology of DED but can rupting the perpetual cycle of inflam- days in 60% of patients and two offer temporary relief.10 Products mation that promotes DED.13 months in 79%.10 While patient vary in osmolarity, viscosity and Often, low-dose topical steroids, symptoms, TBUT and corneal stain- pH. Higher viscosity agents, such as such as Lotemax SM (loteprednol ing improved, Schirmer’s scores carboxymethyl cellulose, hyaluronic etabonate ophthalmic gel 0.38% and remained the same, and ocular acid, HP-guar, polyvinyl alcohol 0.5%, Bausch + Lomb), are used as a surface disease recurred after discon- and propylene glycol, are typically pretreatment or concomitantly with tinuation of treatment.10 reserved for overnight use. Viscosity cyclosporine or lifitegrast earlier on Punctal occlusion. ADDE patients enhancers are beneficial to the ocular and tapered off after a few weeks. benefit from aqueous retention on surface, as they increase tear film Preservative-free steroids, such as the ocular surface, and, as such, thickness, shield against desiccation, dexamethasone 0.01%—which is temporary or permanent punctal promote tear retention at the ocular currently unavailable in the US— occlusion of one or both puncta at surface, protect the ocular surface, can improve symptoms of chronic the level of the punctal opening or maintain physiological corneal thick- ocular surface irritation that were deeper can be an appropriate treat- ness, improve goblet cell density and previously unresponsive to preserved ment.10 Commonly, punctal occlu- relieve dry eye symptoms. Osmopro- topical steroids, such as loteprednol sion is performed via punctal plugs. tectants, such as trehalose—which 0.2%, fluorometholone 0.1% and Absorbable, collagen-based plugs can be found in TheraTears Extra prednisolone 1%.10 (Akorn) and Refresh Optive Mega-3 Biological tear substitutes. In (Alcon)—can protect corneal cells more advanced cases of DED where from desiccation and high osmolarity topical pharmaceutical agents do by fortifying cell membranes.11,12 not provide adequate relief of severe Topical pharmaceutical agents. ocular surface disease, as is the case Cyclosporine A is an immunomodu- with many ADDE patients, autolo- latory drug with anti-inflammatory gous serum is an effective option. It properties that inhibits the IL-2 is derived from the biomarkers in activation of lymphocytes.10 Topical a patient’s own blood and contains cyclosporine was approved by the many biochemical characteristics FDA for moderate to severe DED similar to that of human tears, such The patient improved after four months and can improve inflammation, tear as pH level, nutrients, vitamins, albu- of treatment with topical lubrications, a osmolarity, conjunctival goblet cell min, fibronectin and epithelial and tapered course of topical steroids and density and tear production.10 It is nerve growth factors.10 Autologous lifitegrast twice daily.

58 REVIEW OF OPTOMETRY MAY 15, 2020 IN THE RACE AGAINST GLAUCOMA, DURABILITY WINS Glaucoma demands outcomes that endure. Results from the largest MIGS pivotal trial to date have shown that the Hydrus® Microstent delivers the greatest improvement compared to cataract surgery alone for IOP reduction and medication elimination at 24 months.1-4,*

And now, at 3 years the Hydrus Microstent is the only MIGS device with results from a pivotal trial showing a statistically significant reduction in risk of invasive secondary glaucoma surgeries.†

When durability matters, choose the MIGS option that endures—Hydrus Microstent.

Delivering a new confidence.

Diagnostic Criteria of SS 14 CAUTION: Federal law restricts this device These American-European Consensus Classification Criteria for SS were published in 2002: to sale by or on the order of a physician. INDICATIONS FOR USE: The Hydrus Microstent 1. Ocular symptoms (at least one of the following): dry eye symptoms for more than three is indicated for use in conjunction with cataract surgery for the reduction of intraocular pressure months, artificial tear use more than three times a day, foreign body sensation (IOP) in adult patients with mild to moderate primary open-angle glaucoma (POAG). 2. Ocular signs (at least one of the following): abnormal Schirmer’s test results (<5mm of CONTRAINDICATIONS: The Hydrus Microstent is contraindicated under the following wetting in five minutes without anesthesia), positive vital dye staining (>4) circumstances or conditions: (1) In eyes with 3. Oral symptoms (at least one of the following): dry mouth symptoms for more than three angle closure glaucoma; and (2) In eyes with traumatic, malignant, uveitic, or neovascular months, liquid use for comfort while swallowing, recurrent swollen salivary glands glaucoma or discernible congenital anomalies of the anterior chamber (AC) angle. WARNINGS: 4. Oral signs (at least one of the following): abnormal salivary scintigraphy, abnormal Clear media for adequate visualization is required. Conditions such as corneal haze, parotid sialography, unstimulated whole salivary flow (≤1.5mL in 15 minutes) corneal opacity or other conditions may inhibit gonioscopic view of the intended implant 5. Positive autoantibodies: anti-SSA or anti-SSB location. Gonioscopy should be performed prior 15 to surgery to exclude congenital anomalies In 2012, the American College of Rheumatology proposed simplified diagnostic criteria: of the angle, peripheral anterior synechiae (PAS), angle closure, rubeosis and any 1. Positive autoantibodies (anti-SSA or anti-SSB) or positive RF and ANA titer >1:320 other angle abnormalities that could lead to 2. Labial salivary gland biopsy exhibiting focal lymphocytic sialadenitis with a focus score improper placement of the stent and pose a 2 hazard. PRECAUTIONS: The surgeon should of one per 4mm monitor the patient postoperatively for proper maintenance of intraocular pressure. The safety 3. Keratoconjunctivitis sicca with an ocular staining score >3 (assuming the patient is not and effectiveness of the Hydrus Microstent has not been established as an alternative currently using daily drops for glaucoma and has not had corneal or cosmetic surgery in to the primary treatment of glaucoma with medications, in patients 21 years or younger, the last five years) eyes with significant prior trauma, eyes with abnormal anterior segment, eyes with chronic Any patient suspected of having SS should be referred to rheumatology for further sys- inflammation, eyes with glaucoma associated with vascular disorders, eyes with preexisting temic evaluation and treatment. pseudophakia, eyes with uveitic glaucoma, eyes with pseudoexfoliative or pigmentary glaucoma, eyes with other secondary open angle glaucoma, eyes that have undergone prior incisional glaucoma surgery or cilioablative with absorption rates that vary from purinergic P2Y2 receptor agonist procedures, eyes that have undergone argon laser trabeculoplasty (ALT), eyes with one week to six months are the most that stimulates water and mucin unmedicated IOP < 22 mm Hg or > 34 mm Hg, eyes with medicated IOP > 31 mm Hg, eyes commonly used. Non-absorbable, secretion from conjunctival epithelial requiring > 4 ocular hypotensive medications prior to surgery, in the setting of complicated or “permanent,” plugs are typically and goblet cells and improves tear cataract surgery with iatrogenic injury to the anterior or posterior segment and when 10 implantation is without concomitant cataract silicone-based. For advanced cases, film stability. It is only approved surgery with IOL implantation. The safety and effectiveness of use of more than a single permanent surgical closure of the overseas as of now. Studies have Hydrus Microstent has not been established. ADVERSE EVENTS: Common post-operative puncta via total or partial thermal shown topical diquafosol signifi- adverse events reported in the randomized pivotal trial included partial or complete device cauterization, occlusion with a con- cantly improves corneal and conjunc- obstruction (7.3%); worsening in visual field MD by > 2.5 dB compared with preoperative (4.3% junctival flap, punctal suturing or tival staining, TBUT and Schirmer’s vs 5.3% for cataract surgery alone); device malposition (1.4%); and BCVA loss of ≥ 2 ETDRS 10 lines ≥ 3 months (1.4% vs 1.6% for cataract total destruction of the canaliculus scores. Topical lacritin, a glyco- surgery alone). For additional adverse event information, please refer to the Instructions for can be performed. protein that stimulates pro-secretory Use. MRI INFORMATION: The Hydrus Microstent is MR-Conditional meaning that the device Punctal occlusion is most success- activity in the lacrimal gland, has is safe for use in a specified MR environment under specified conditions. Please see the ful when combined with other DED therapeutic potential in treating Instructions for Use for complete product 10 information. treatments. Occluding the puncta in ADDE in SS patients with reduced 10 References: 1. Samuelson TW, Chang DF, the presence of ocular surface inflam- lacritin levels. Marquis R, et al; HORIZON Investigators. A Schlemm canal microstent for intraocular mation is controversial, as there Oral secretagogues. Oral pilocar- pressure reduction in primary open-angle glaucoma and cataract: The HORIZON Study. Ophthalmology. 2019;126:29-37. 2. Vold S, is a concern that occlusion of tear pine and cevimeline, both cholinergic Ahmed II, Craven ER, et al; CyPass Study Group. Two-Year COMPASS Trial Results: Supraciliary outflow can prolong the presence of agonists, are commercially available Microstenting with Phacoemulsification in 10 Patients with Open-Angle Glaucoma and pro-inflammatory cytokines on the to treat SS. While Sjögren’s patients Cataracts. Ophthalmology. 2016;123(10):2103- 2112. 3. US Food and Drug Administration. ocular surface. As such, treating sur- who participated in a recent study Summary of Safety and Effectiveness Data (SSED): Glaukos iStent® Trabecular Micro- face inflammation is recommended noticed more improvement in oral Bypass Stent. US Food and Drug Administration website. https://www.accessdata.fda.gov/cdrh_ prior to occlusion. vs. ocular dryness with the secreta- docs/pdf8/P080030B.pdf. Published June 25, 2012. 4. US Food and Drug Administration. Summary of Safety and Effectiveness Data Moisture chamber glasses. These gogues, the drugs did improve ocular (SSED): iStent inject Trabecular Micro-Bypass System. US Food and Drug Administration are specially designed to slow tear surface staining, goblet cell density website. https://www.accessdata.fda.gov/ 10 cdrh_docs/pdf17/P170043b.pdf. Published evaporation by providing a humid and TBUT. Cevimeline had a better June 21, 2018. environment and minimizing airflow side effect profile than pilocarpine.10 *Comparison based on results from individual 10 pivotal trials and not head to head comparative over the ocular surface. They are a However, there was no observed studies. potential adjunct to prescribed treat- improvement in tear production with †Data on file - includes trabeculectomy and tube shunt. ment for increased symptom relief.10 either medication.10 Topical aqueous secretagogues. Neurostimulation. Intranasal tear Diquas (diquafosol tetrasodium 3% neurostimulation induces normal ophthalmic solution, Santen) is a tear production by stimulating the ©2020 Ivantis, Inc. Ivantis and Hydrus are registered trademarks of Ivantis, Inc. All rights reserved. IM-0008 Rev D nasolacrimal reflex.10 The naso- essential ions found in tears. Unfortu- Lacrimal gland regeneration is an lacrimal reflex up-regulates tear nately, once the neuropathic pain has emerging treatment option that is production following chemical or centralized, a bandage lens may be exploring several strategies for stem mechanical stimulation of the nasal insufficient for reducing symptoms.10 cell expansion and differentiation mucosa.10 The TrueTear Intranasal Amniotic membrane grafts. These into lacrimal tissue for organogenesis Tear Neurostimulator (Allergan) can successfully treat severe DED and engraftment techniques. This temporarily increases tear production with persistent epithelial defects or method is in its beginning phases.7 during neurostimulation in adults. corneal ulceration and scarring. They As our understanding of dry eye This device consists of a handheld consist of cryopreserved human continues to expand, so do diagnos- stimulator unit equipped with a dis- amniotic membranes, which con- tic and treatment options that allow posable two-pronged hydrogel tip tain a wide variety of neuropeptides us to better serve these patients. and an external charger.10 It allows and neurotransmitters.10 Grafts are While so much of the focus remains self-delivery of minute electrical cur- inserted similarly to a scleral lens and on EDE, make sure you have a suf- rents with variable waveform to the typically dissolve in about one week. ficient understanding of ADDE so anterior ethmoidal nerve, stimulating One study shows symptom improve- you’re better able to manage these 10 immediate natural tear production. ment for four months in dry eye cases in the chance they do present Preliminary testing shows increased patients treated with a Prokera Slim and work side-by-side with rheuma- 10 Schirmer’s scores and decreased (Bio-Tissue) for five days. tology for the best results. 10 patient symptoms. Surgical approaches. In the most Dr. Tolud completed a residency in severe cases of DED, surgical inter- ocular disease and practices at Van- Advanced Strategies vention may be necessary. Options tage Eye Care, South Jersey Eye Phy- For more advanced or temperamen- include tarsorrhaphy, mechanical sicians Division, in Columbus, NJ. tal cases, there are a few options dacryoreservoirs, gland transplanta- She also serves as president of the available at your disposal. tion and lacrimal gland regeneration. New Jersey chapter of the American Therapeutic contact lenses. Ban- Tarsorrhaphy is a temporary or Academy of Optometry. n dage lenses can improve ocular permanent surgical procedure that comfort, maintain corneal integrity partially or totally closes the eyelids 1. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II definition and classification report. Ocul Surf. 2017;15(3):276-83. and prolong ocular surface mois- to decrease ocular surface exposure 2. Craig JP, Nelson JD, Azar DT, et al. TFOS DEWS II report execu- turization by reducing the effects and tear evaporation in cases where tive summary. Ocul Surf. 2017;15(4):802-12. 3. Messmer EM. The pathophysiology, diagnosis, and treatment of of an adverse environment.10 The all other treatments have failed.10 dry eye disease. Dtsch Arztebl Int. 2015;112(5):71-81. 4. Bron AJ, de Paiva CS, Chauhan SK, et al. TFOS DEWS II patho- availability of silicone hydrogel In patients with ADDE and a physiology report. Ocul Surf. 2017;15(3):438-510. lenses, along with their high oxygen Schirmer’s score less than 2mm 5. Hauswirth S. Diagnosing and treating Sjögren’s syndrome. Optometry Times. August 14, 2016. [Epub ahead of print]. permeability, has helped promote who have difficulty maintaining 6. Abd-Allah NM, Hassan AA, Omar G, et al. Evaluation of patients with dry eye for the presence of primary or secondary Sjögren’s their use as a therapeutic device in frequent topical lubrication or who syndrome. Clin Ophthalmol. 2019:13:1787-97. the management of many ocular have not found relief from less inva- 7. Liu CY, Hirayama M, Ali M, et al. Strategies for regenerating the lacrimal gland. Curr Ophthalmol Rep. 2017;5(3):193-8. surface diseases, including DED.10 sive measures, mechanical devices 8. Wolffsohn JS, Arita R, Chalmers R, et al. TFOS DEWS II diagnostic methodology report. Ocul Surf. 2017;15(3):539-74. Soft lenses are typically used on an called dacryoreservoirs may be an 9. Beckman KA, Luchs J, Milner MS. Making the diagnosis of extended wear basis. A recent study option.10 They deliver lubricating or Sjögren’s syndrome in patients with dry eye. Clin Ophthalmol. 2016;10:43-53. shows that, in Sjögren’s patients, the pharmaceutical agents from a reser- 10. Jones L, Downie LE, Korb D, et al. TFOS DEWS II management and therapy report. Ocul Surf. 2017;15(3):575-628. use of silicone hydrogel lenses used voir through a silicone catheter that 11. McDonald MB, Fumuso PW. Trehalose: a novel as bandage contact lenses provided continuously lubricate the ocular treatment for dry eye. Healio. www.healio.com/ophthalmology/cornea-external-disease/news/print/ocular-surgery- significant improvement in visual surface.10 While they improve TBUT, news/%7B6d1f0d15-4321-487b-8aa8-56648bdec2d2%7D/ trehalose-a-novel-treatment-for-dry-eye?page=3. July 10, 2018. acuity for up to six weeks after dis- corneal staining and conjunctival Accessed April 20, 2020. continuing wear, OSDI scores, TBUT hyperemia, there is a risk of infection 12. Horton M, Horton M, Reinhard E. Master the maze of artificial tears. Rev Optom. 2018;155 (11):48-56. and corneal staining.10 in the reservoir and device that may 13. Karpecki P. Say hii to Xiidra. Rev Optom. August 15, 2016. 10 [Epub ahead of print]. Gas permeable scleral lenses are require its removal. 14. Vitali C, Bombardieri S, Jonsson R, et al. Classification criteria used in cases of moderate to severe Transplantation of functioning for Sjögren’s syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. Ann DED and aim to provide a repository exocrine tissue from one of the three Rheum Dis. 2002;61(6):554-8. 15. Shiboski SC, Shiboski CH, Criswell L, et al. American College of tears and effective protection to major salivary glands, typically the of Rheumatology classification criteria for Sjögren’s syndrome: a the ocular surface.10 A new solution submandibular gland, offers lubrica- data-driven, expert consensus approach in the Sjoögren’s Inter- national Collaborative Clinical Alliance cohort. Arthritis Care Res called Nutrifill (Contamac) contains tion in cases of severe ADDE.10 (Hoboken). 2012;64(4):475-87.

REVIEW OF OPTOMETRY MAY 15, 2020 61 Systemic Meds

Statins and the Eye: What You Might Not Know

These lipid-altering drugs are changing lives for the better, but the optometrist is responsible for monitoring their many impacts—good and bad—on ocular health. By Carrie Ho, OD, Angella Gentry, OD, and Richard Zimbalist, OD

tatins are a class of lipid- Although many studies into hypercholesterolemia and mixed altering drugs that revolu- statins and ocular conditions show hyperlipidemia. Through inhibition tionized hypercholesterolemia conflicting results or are of statis- and regression of coronary athero- Streatment and aid in primary tical insignificance, some results sclerosis, anti-inflammatory prop- and secondary cardiovascular suggest statins could potentially erties and atherosclerotic plaque disease (CVD) prevention. An mitigate various ocular conditions. stabilization, statins decrease rates estimated 38.6 million Americans Here, we explain how statins of CVD and mortality.1 were on a statin regimen in 2011 affect different patients’ eyes—for Available statins include lov- and 2012, a nearly 38% increase better or for worse, and how the astatin, pravastatin, simvastatin, from 24 million in 2003 and 2004.1 OD can oversee these patients and fluvastatin, atorvastatin, rosuvas- This rise in use makes statins the their ocular and visual health. tatin and pitavastatin.2,3 Statins’ most commonly prescribed class of beneficial effects result from their cholesterol-lowering drug. Due to Mechanism of Action capacity to reduce cholesterol this widespread use, it’s vital optom- Statins are a potent drug for lower- biosynthesis and modulate lipid etrists understand the possible effects ing low-density lipoprotein (LDL) metabolism from inhibition upon they can have on patients’ eyes. cholesterol in the treatment of 3-hydroxy-3-methylglutaryl- coenzyme A (HMG-CoA) reductase in the liver. HMG-CoA reductase is the enzyme that converts HMG-CoA into mevalonic acid, a cholesterol precursor.3 Statins are HMG-CoA inhibitors that alter the conformation of the enzyme when they bind to its active site, preventing HMG-CoA reductase from attaining a functional structure. The reduction of cholesterol in This 61-year-old patient’s left eye has an ischemic branch retinal vein occlusion with hepatocytes leads to the increase of evidence of frank neovascular edema. hepatic LDL receptors, ultimately

62 REVIEW OF OPTOMETRY MAY 15, 2020 reducing circulating LDLs and its eye disease. A recent report shows precursors. that oral statins may have the poten- Statins also impart a modest bene- tial to decrease the conversion of fit in concentrations of triglycerides, Graves’ disease to thyroid-associated high-density lipoproteins (HDL) orbitopathy by 40%.10,11 A 2018 and very low-density lipoproteins study of 30 patients shows that (VLDL).2 Moreover, statins exert statin users tend to have a reduced pleiotropic effects such as improve- number of orbital decompressions ment of endothelial function, and strabismus surgeries compared enhancing the stability of atheroscle- with non-statin users.11 rotic plaques, decreasing oxidative Ocular inflammation/uveitis. stress and inflammation, and inhib- Statins may be beneficial in ocular iting thrombogenic response.4 This fundus image shows retinal inflammatory diseases by stabilizing arteriosclerosis in a 45-year-old the blood-ocular and blood-retinal Adverse Effects patient with a total cholesterol of 304, barriers (BRB) as well as endothelial Statins are generally well tolerated, triglycerides of 1,290 and LDL of 129. cells.12 Research also shows statins and adverse reactions occur less can reduce levels of key inflamma- frequently than with other classes of Interestingly, a prospective pilot tory markers, such as interleukins 6 lipid-lowering agents.2,3 Liver and study with 10 dry eye and blephari- and 8, TNF-alpha, and C-reactive muscle toxicity are the most notable tis patients found that topical ator- protein.12,13 Research from 2015 adverse effects of statins.2,3 Although vastatin may be a potential therapy, found statin users were 48% less studies have reported conflicting as demonstrated by improved tear likely to develop uveitis than non- results, statins could have effects on film break up time, blepharitis score statin users.13 glucose metabolism in non-diabetic and bulbar conjunctival injection.6 Cataracts. Studies on statin use patients or affect glycemic control of While the mechanism is largely and cataract development have diabetic patients.2,3 unknown, it may be due to the anti- yielded inconsistent and conflicting Intensive statin therapy may inflammatory pleotropic effects; results. Some reports have found increase the risk of developing larger clinical studies are required an increased risk of cataracts from diabetes; however, the benefits of to establish the efficacy and statins on cardiovascular events safety of topical statin use. and mortality outweigh the risks. Orbit. Myopathies are a Patients with liver failure, renal rare adverse reaction to statin insufficiency, hypothyroidism, therapy. Retrospective case advanced age and serious infections reports suggest inflammation are more prone to experiencing such of the extraocular or levator adverse reactions.2,3 muscles as a possible etiology; however, other patient The Anterior Segment risk factors such as advanced Adverse effects here range from age, hypertension, diabetes exacerbation of dry eye to myopa- and other comorbid cardio- thy or possible accelerated cataract vascular conditions cannot be development, but positive associa- entirely ruled out. Of note, tions exist as well. cases of ptosis, blepharop- Ocular surface. The Blue Moun- tosis and external ophthal- tains Eye Study III survey found that moplegia associated with oral statins were associated with an statin usage have completely increase in moderate to severe dry resolved upon discontinua- This 64-year-old patient had a history of poorly eye symptoms, possibly due to the tion of statin use.7-9 controlled insulin-dependent diabetes with disruption of essential cholesterol The anti-inflammatory significant DME in the right eye. She underwent synthesis for meibum lipid homeo- effects of statins may be ben- two aflibercept injections previously. Some stasis in the meibomian glands.5 eficial in the area of thyroid research shows statins may also reduce VEGF.

REVIEW OF OPTOMETRY MAY 15, 2020 63 Systemic Meds

IOP.20,22 They also inhibit rho-kinase activity, which may increase aqueous outflow and reduce IOP.20,22 The improved retinal and choroidal perfusion may benefit the health of the optic nerve and the nerve fiber layer. There are also potential neu- roprotective effects that may protect retinal ganglion cells.20,22 Further studies are warranted to confirm This 55-year-old patient with diabetes developed significant bilateral DME over six statins’ potential benefit in OAG months. Some patients who take statins are less likely to develop DME. management. Diabetic retinopathy. Endothe- statin use, while others showed no Glaucoma/intraocular pressure. lial dysfunction and inflammatory association or even a protective The current treatment of open-angle processes lead to the development effect.14-16 One possible mechanism glaucoma (OAG) is aimed primar- of diabetic retinopathy (DR). Statins may be statins’ bidirectional effects ily towards intraocular pressure have vasoprotective actions and are on oxidation processes, includ- (IOP) reduction, although clinical able to penetrate the BRB, reducing a possible mitochondrial effect challenges often arise when OAG ing endothelial cell dysfunction and that may increase the risk of cata- progresses despite adequate IOP ultimately protecting against the racts.14 High cholesterol is required control. The search for other treat- sight threatening complications of to maintain transparency of the ments, such a statins, is a rising area DR.23-25 By reducing reactive oxy- crystalline lens; some researchers of interest amongst researchers. gen species, increasing nitric oxide hypothesize that the inhibition of Literature on statins and glauco- levels and increasing the number of cholesterol biosynthesis by statin ma are conflicting in nature. While endothelial progenitor cells, statins medications could prevent proper some studies do not support statins’ have the ability to improve vascular epithelial cell development within protective role against OAG, recent resistance, blood flow velocity and the crystalline lens, increasing the research endorses their protective retinal perfusion thereby sustaining risk of cataract development.14 role.17-22 A large observational study the stability of the BRB.26,27 In contrast, a meta-analysis of 136,782 participants reported In a study that looked at patients shows a clinically relevant protec- that higher serum cholesterol levels with Type 2 diabetes and dyslip- tive effect of statins in preventing were associated with a higher risk idemia, those taking statins had cataract formation, with a more of primary OAG; five or more years a significantly lower rate of DR, pronounced effect in younger of statin use was associated with nonproliferative DR, proliferative patients.16 a 21% lower risk, and use for 10 DR (PDR), vitreous hemorrhage, Although the exact mechanism is years or more had a 40% lower tractional retinal detachment and unknown, statins may help to pre- risk.20 Other studies have found that diabetic macular edema (DME) vent cataracts through its pleotropic long-term use of statins is associ- than the non-statin group.28 The effects and decreasing by LDLs. ated with a reduced risk of OAG study also indicted that statin users In 2017, investigators published (independent of the IOP); however, also had lower rates of ophthalmic research on more than 313,200 the results did not reach statistical interventions such as retinal laser cataract cases and concluded that significance.21 treatment, intravitreal injection no clear evidence shows that statin Researchers have proposed a few and vitrectomy.28 Moreover, these use increases the risk of cataract hypotheses to explain the mecha- researchers reported a decreased risk development.15 nism of how statins reduce the risk in DR progression with the use of of OAG. Statins increase aqueous higher doses and longer duration of Posterior Segment outflow through the upregula- statin therapy.28 Could statins be protective against tion of endothelial nitric oxide Two large clinical studies show glaucoma, diabetic retinopathy or synthase resulting in vasodilation fenofibrate has beneficial effects AMD? The jury is still out but some and increased retinal and choroidal against DR progression, indepen- studies are encouraging. blood flow, leading to a reduction in dent of its lipid-modifying action

64 REVIEW OF OPTOMETRY MAY 15, 2020 in Type 2 diabetics. Although Vitreoretinal surgery for rheg- fenofibrate is not classified as a matogenous retinal detachment. statin medication, it can reduce the Statin therapy may have a poten- frequency of PDR by 30% and the tially beneficial effect on vitreo- need for laser treatment for DME by retinal (VR) surgery outcomes. 31%.29 Additionally, one study also Statins exhibit anti-inflammatory, noted that the combination of feno- antioxidative, anti-fibroproliferative, fibrate with simvastatin synergisti- and microvasculoprotective effects cally reduced DR progression rate that contribute to photoreceptor by 40%, compared with simvastatin survival, the retinal wound healing treatment alone.29,30 process and inflammation related Diabetic macular edema. Hyper- to proliferative vitreoretinopathy cholesterolemia is regarded as a (PVR) formation in eyes after sur- strong risk factor for endothelial gery for rhegmatogenous retinal dysfunction, which contributes to These macular cube analysis images of detachment (RRD).43,44 Research the development of DME.31,32 In the same patient from the previous page shows statins can reduce intravitreal univariant analysis, the total cho- shows clinically significant macular levels of angiopoietin-2, vascular lesterol and LDL were significantly edema in both eyes. endothelial growth factor (VEGF) higher in patients with clinically and matrix metalloproteinase-2, significant macular edema and were tissue remodeling factors.30,38-41 which are factors associated with a risk factor for retinal hard exudate Similarly, a prospective observa- vascular permeability, inflammation, formation.33-36 tional study found that diabetic vit- and fibroproliferation.45 Results from a retrospective study rectomy patients with preoperative According to a Finnish popu- show a noteworthy relationship statin treatment (mainly receiving lation-based cohort study, the use between serum triglycerides and lipophilic simvastatin or atorvas- of simvastatin and atorvastatin DME, which corresponds to the tatin) had a better one-month best- was associated with a significantly findings of the Fenofibrate Interven- corrected visual acuity improvement lower risk of re-vitrectomy in tion and Event Lowering in Dia- and a lower frequency of postopera- patients whom previously under- betes study. Additionally, a recent tive complications than those with- went intervention for a RRD.46 Of meta-analysis found that statins out statin treatment.42 These studies note, rosuvastatin also lowered the protected against the development indicate that statins, particularly repeat procedure rate but to a lesser of DME and progression of DR in simvastatin, appear to contribute to degree than the aforementioned patients with Type 2 diabetes.31,36,37 a lower incidence of complications medications.46 Lipophilicity impacts Large and long-term randomized after diabetic vitrectomy. on the pleiotropic effects of statins controlled prospective studies are necessary to obtain a more complete assessment of the effects of statin therapy on DR and DME. Vitrectomy for proliferative diabetic retinopathy. PDR is characterized by retinal neovascularization, contractile scar tissue formation, vitreous hemorrhage, tractional retinal detachment, and neovascular glaucoma. In randomized clinical trials, the use of simvastatin deceler- ated DR progression and visual acuity loss which may be attributed to the medication’s ability to suppress expression and secretion of potent Here, the same 55-year old patient’s macular cube change analysis of right and left vasoactive, proinflammatory and eyes demonstrate the frank progression of DME over the course of six months.

REVIEW OF OPTOMETRY MAY 15, 2020 65 Systemic Meds

larger proportion of statin users developed a CNV (29.3%) compared to non-statin users (23.3%); these results remained true after adjusting for age, sex, race, and comorbidity status.64 Retinal vein occlusion. Athero- sclerosis, along with cardiovascular risk factors such as hyperlipidemia, diabetes and hypertension, contributes to the pathophysiology of retinal vein occlusion (RVO).65 Elevated cholesterol levels can change the plasma viscosity and alter platelet Here, raster images of the previous patient show center-involved macular edema of function, predisposing the blood the right eye and diffuse edema and retinal thickening of the left eye. to thrombosis and hemostasis.66 Research shows low-dose simv- such as cell function, coagulation report a protective effect in early astatin promotes vascular repair and inflammation. Although the AMD, while others show an asso- through upregulation of VEGF pleiotropic effects of statins have ciation between their use and AMD and NO levels, while higher doses been related to the outcomes of development at five years.53-61 inhibited reparative processes and re-vitrectomy rates after RDD, The heterogeneity of AMD sug- resulted in cell death due to deple- additional randomized clinical trials gests that the effects of statins may tion of intracellular cholesterol and are warranted to further determine vary by stage, reducing the develop- disruption of key structures within the effects of statins on VR surgery ment of drusen at the onset of AMD the cells, which increases ischemia- outcomes. and having further anti-inflamma- induced neovascularization.67 How- Age-related macular degenera- tory effect on late-disease.58 Studies ever, an additional study found no tion (AMD). Recent epidemiologic, also suggest the need for a genetic preventive or therapeutic benefit of genetic and pathological evidence analysis to understand whether the statins in high-risk patients.68 Very shows AMD and atherosclerosis genotype can influence a response few studies have explored the role of share several risk factors, leading to statins as a therapeutic option.62 statins in the management of RVO. to the hypothesis that statins may One factor impacting the conflicting provide protective effects in AMD. results is the lack of standardization Despite the dearth of randomized There have been several reported of statin dosages or individual lipo- trials focusing on statins and their mechanisms of how statins may aid philicity for each class of drug.63 effects on the eye, there is inconsis- in preventing AMD progression.47 Choroidal neovascular mem- tent evidence regarding their role in Researchers believe the cholesterol- brane. Elevated intraocular levels various eye conditions. At this time, lowering, antioxidant, anti-inflam- of VEGF play an important role the literature does not support the matory action, antiproliferative and in the development of CNV and recommendation that eye care phy- anti-endothelial dysfunction effect AMD. Research shows statins sicians change their practice patterns of statins reduce the incidence and reduce plasma levels of VEGF and or recommend statins solely for progression of AMD.48-51 Statins downregulate transcription factors improved ocular health. However, may also have the ability to preserve involved in VEGF expression, thus statins are medications ODs encoun- vascular supply to the outer retina potentially reducing the incidence ter every day. Optometrists need to and may inhibit secretion of MMP, and progression of CNV.51 be versed in the potential side effects which is involved in the develop- Implications of statins on CNV and work to comanage the patent ment of choroidal neovasculariza- development is not well understood with their primary care doctor, car- tion (CNV).47,52 with few relevant trials and obser- diologist or internist. It’s prudent Research on statins’ effect on vational studies.59 Interestingly, a to advise patients to discuss their AMD has yielded inconsistent and large cross-sectional study of 3,090 cholesterol levels with their primary conflicting results. Some studies patients with dry AMD found a care physician. n

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Age-related December 2, 2019. ment for diabetic retinopathy (FIELD study): a randomized 3. Stancu C, Anca S. Statins: mechanism of action and effects. controlled trial. Lancet. 2007;370:1687-97. macular degeneration and protective effect of HMG Co-A J Cell Mol Med. 2001;5(4):378-87. 30. Chew E, Ambrosius W, Davis M, et al; ACCORD Study reductase inhibitors (statins): results from the National 4. Liao J, Laufs U. Pleiotropic effects of statins. Annu Rev Phar- Group; ACCORD Eye Study Group. Effects of medical therapies Health and Nutrition Examination Survey 2005-2008. Eye. macol Toxicol. 2005;45:89-118. on retinopathy progression in Type 2 diabetes. N Engl J Med. 2014;28:472-80. 5. Ooi K, Lee M, Burlutsky G, et al. Association of dyslipidaemia 2010;363:233-44. 54. Guymer RH, Baird PN, Varsamidis M, et al. Proof of concept, and oral statin use, and dry eye disease symptoms in the Blue 31. Rangaswamy S, Penn M, Saidel G, Chisolm G. Exogenous randomized, placebo-controlled study of the effect of simvas- Mountains Eye Study. Clin Exp Ophthalmol. 2018;47(2):187-92. oxidized low-density lipoprotein injuries and alters the barrier 6. Ooi K, Wakefield D, Billson F, Watson S. Efficacy and safety of tatin on the course of age-related macular degeneration. PloS function of endothelium in rats in vivo. Circ Res. 1997;80:37-44. ONE. 2013;8:e83759. topical atorvastatin for the treatment of dry eye associated with 32. Ding J, Wong TY. Current epidemiology of diabetic reti- blepharitis: A pilot study. Ophthalmic Research. 2015;54(1):26-33. nopathy and diabetic macular edema. Curr Diabetes Rep. 55. Tan JS, Mitchell P, Rochtchina E, Wang JJ. Statins and the 7. Ertas F, Ertas N, Gulec S, et al. Unrecognized side effect of 2012;12:346-54. long-term risk of incident age-related macular degeneration: the statin treatment: unilateral blepharoptosis. Ophthalmic Plastic & 33. Jew O, Peyman M, Chen T, Visvaraja S. Risk factors for clini- Blue Mountains Eye Study. Am J Ophthalmol. 2007;143:685-7. Reconstructive Surgery. 2006;22(3):222-4. cally significant macular edema in a multi-ethnics population 56. Klein R, Klein BE, Tomany SC, et al. Relation of statin use to 8. Negveskey G, Kolsky M, Laureno R, Yau T. Reversible with Type 2 diabetes. Int J Ophthalmol. 2012;5:499-504. the 5-year incidence and progression of age-related maculopa- atorvastatin-associated external ophthalmoplegia, antiace- 34. Chew E, Klein M, Ferris F, et al. Association of elevated thy. Arch Ophthalmol. 2003;121:1151-5. tylcholine receptor antibodies, and ataxia. Arch Ophthalmol. serum lipid levels with retinal hard exudate in diabetic retinopa- 2000;118(3):427-8. 57. van Leeuwen R, Tomany SC, Wang JJ, et al. Is medica- thy. Early Treatment Diabetic Retinopathy Study (ETDRS) Report tion use associated with the incidence of early age-related 9. Finsterer J, Zuntner G. Rhabdomyolysis from simvastatin 22. Arch Ophthalmol. 1996;114:1079-84. triggered by infection and muscle exertion. South Med J., 35. Klein B, Moss S, Klein R, Surawicz T. The Wisconsin epi- maculopathy? Pooled findings from 3 continents. Ophthalmol. 2005;98(8):827-9. demiologic study of diabetic retinopathy. XIII. Relationship of 2004;111:1169-75. 10. Stein J, Childers D, Gupta S, et al. Risk factors for develop- serum cholesterol to retinopathy and hard exudate. Ophtahlmol. 58. Vavvas DG, Daniels AB, Kapsala ZG, et al. Regression of ing thyroid-associated ophthalmopathy among individuals with 1991;98:1261-5. some high-risk features of age-related macular degeneration graves disease. JAMA Ophthalmol. 2015;133(3):290. 36. Chung Y, Park S, Choi S, et al. Association of statin use and (AMD) in patients receiving intensive statin treatment. EBioMedi- 11. Reynolds A, Del Monte M, Archer S. The effect of oral statin hypertriglyceridemia with diabetic macular edema in patients cine. 2016;5:198-203. therapy on strabismus in patients with thyroid eye disease. J with type 2 diabetes and diabetic retinopathy. Cardiovasc Dia- AAPOS. 2018;22(5):340-3. 59. Ma L, Wang Y, Du J, et al. The association between statin betol. 2017;16(1):4. use and risk of age-related macular degeneration. Sci Rep. 12. Yunker J, McGwin G, Read R. Statin use and ocular inflam- 37. Knickelbein J, Abbott A, Chew F. Fenofibrate and diabetic matory disease risk. J Ophthalmic Inflamm Infect. 2013;3(1):8. retinopathy. Curr Diab Rep. 2016;16(10):90. 2015;5:18280. 13. Borkar D, Tham V, Shen E, et al. Association between statin 38. Sen K, Misra A, Kumar A, Pandey R. Simvastatin retards 60. Maguire MG, Ying GS, McCannel CA, et al. Statin use and use and uveitis: results from the pacific ocular inflammation progression of retinopathy in diabetic patients with hypercholes- the incidence of advanced age-related macular degeneration in study.” Am J Ophthalmol. 2015;159(4):707-13. terolemia. Diabetes Res Clin Pract. 2002;56:1-11. the complications of age-related macular degeneration preven- 14. Leuschen J, Mortensen E, Frei C, et al. Association of statin 39. Lee S, Kim J, Lee H, et al. Simvastatin suppresses expres- tion trial. Ophthalmol. 2009;116:2381-2385. use with cataracts: a propensity score-matched analysis. JAMA sion of angiogenic factors in the retinas of rats with strepto- 61. Gehlbach P, Li T, Hatef E. Statins for age-related macular Ophthalmol. 2013;131(11):1427-34. zotocin-induced diabetes. Graefes Arch Clin Exp Ophthalmol. degeneration. Cochrane Database Syst Rev. 2016;Cd006927. 15. Yu S, Chu Y, Li G, et al. Statin use and the risk of cataracts: 2011;249:389-97. 62. Roizenblatt M, Naranjit N, Maia M, Gehlbach PL. The ques- a systematic review and meta-analysis. J Am Heart Assoc. 40. Miyahara S, Kiryu J, Yamashiro K, et al. Simvastatin inhibits 2017;6(3):e004180. leukocyte accumulation and vascular permeability in the retinas tion of a role for statins in age-related macular degeneration. Int 16. Kostis J, Dobrzynski J. Prevention of cataracts by statins: a of rats with streptozotocin-induced diabetes. Am J Pathol. J Mol Sci. 2018;19:3688 meta-analysis. J Cardiovasc Pharmacol Ther. 2014;19(2):191- 2004;164:1697-706. 63. Miller JW, Bagheri S, Vavvas DG. Advances in age-related 200. 41. Tuuminen R, Sahanne S, Loukovaara S. Low intravitreal macular degeneration understanding and therapy. US Ophthal- 17. Owen C, Care I, Shah S, et al. Hypotensive medication, angiopoietin-2 and VEGF levels in vitrectomized diabetic patients mic Rev. 2017;10:119-130. statins, and the risk of glaucoma. Invest Ophthalmol Vis Sci. with simvastatin treatment. Acta Ophthalmol. 2014;92:675-81. 64. Rajeshuni N, Ludwig CA, Moshfeghi DM. The effect of statin 2010;51(7):3524-30. 42. Tuuminen R, Sahanne S, Haukka J, Loukovaara S. Improved exposure on choroidal neovascularization in nonexudative age- 18. Iskedjian M, Walker J, Desjardins O, et al. Effect of selected outcome after primary vitrectomy in diabetic patients treated related macular degeneration patients. Eye. 2019;33:163-165. antihypertensives, antidiabetics, statins and diuretics on adjunc- with statins. Eur J Ophthalmol. 2016:26(2):174-181. tive medical treatment of glaucoma: a population-based study. 43. Koh K. Effects of statins on vascular wall: vasomotor 65. Rehak M, Wiedemann P. Retinal vein thrombosis: pathogen- Curr Med Res Opin. 2009;25(8):1879-88. function, inflammation, and plaque stability. Cardiovasc Res. esis and management. J Thromb Haemost. 2010;8:1886-94. 19. Leung D, Li F, Kwong Y, et al. Simvastatin and disease stabi- 2000;47(4):648-657. 66. Dodson PM, Galton DJ, Hamilton AM, Blach RK. Retinal vein lization in normal tension glaucoma: a cohort study. Ophthalmol. 44. Takemoto M, Liao JK (2001) Pleiotropic effects of occlusion and the prevalence of lipoprotein abnormalities. Br J 2010;117(3):471-6. 3-hydroxy-3-methylglutaryl coenzyme a reductase inhibitors. Ophthalmol. 1982;66:161-4. 20. Kang J, Boumenna T, Stein J, et al. Association of statin Arterioscler Thromb Vasc Biol 21(11):1712-1719. 67. Medina RJ, O’Neill CL, Devine AB, et al. The pleiotropic use and high serum cholesterol levels with risk of primary open 45. Tuuminen R, Haukka J, Loukovaara. Statins in rhegmatog- effects of simvastatin on retinal microvascular endothelium has angle glaucoma. JAMA Ophthalmol. 2019;137(7):756-65. enous retinal detachment are associated with low intravitreal important implications for ischaemic retinopathies. PloS ONE. 21. Marcus M, Muskens R, Ramdas W, et al. Cholesterol-low- angiopoietin-2, VEGF and MMP-2 levels, and improved visual ering drugs and incident open-angle glaucoma: a population- acuity gain in vitrectomized patients. Graefes Arch Clin Exp 2008;3:e2584. based cohort study. PLoS ONE. 2012;7(1): e29724. Ophthalmol. 2014;253:1685-1693. 68. Matei VM, Xia JY, Nguyen C. Poor outcomes despite aspirin 22. Stein J, Newman-Casey P, Talwar N, et al. The relationship 46. Loukovaara S, Sahanne S, Takala A, Haukka J. Statin use or statin use in high-risk patients with retinal vein occlusion. between statin use and open-angle glaucoma. Ophthalmol. and vitreoretinal surgery: Findings from a Finnish population- Graefe’s Arch Clin Exp Ophthalmol. 2017;255:761-6.

REVIEW OF OPTOMETRY MAY 15, 2020 67 Referrals

Five Cases You Shouldn’t Refer Don’t be afraid to keep these patients in your practice; you have the skillset and scope of practice to help them. By Laine S. Higa, OD

ngoing technological separation from the macula advances, new drug for- and optic nerve.1 mulations and increased Pathophysiology. VMA Oscope of practice have is described as a perifoveal all collided to allow optom- vitreous detachment in the etrists the opportunity to man- presence of persistent foveal age difficult cases that were attachment observed on ocu- once previously referred to our lar coherence tomography ophthalmology counterparts. (OCT).1 VMA is a variant of These five disease presenta- normal given the physiologi- tions—vitreomacular adhesion cal presence of vitreoretinal (VMA) and traction (VMT), adhesion. The observance of post-op cystoid macular edema Case 1. This is the horizontal OCT B-scan of the left VMA with OCT represents (CME), neurotrophic keratitis eye of an 85-year-old black male patient with VMT a single stage of impending (NK), traumatic brain injury who is being monitored. BCVA is 20/50- OS. He reports vitreous separation from the (TBI) and glaucoma/ocular metamorphopsia on the Amsler grid but denies scotoma. retina without underlying hypertension (OHTN)—are We discussed monitoring vs. surgical consultation, and abnormalities (i.e., intrareti- commonly evaluated in the the patient prefers to self-monitor with Amsler grid. nal cysts).1 The International optometric setting and can be He is being followed every three months with serial Vitreomacular Traction Study managed successfully, in most macular OCT and dilated fundus exam. Group has subclassified VMA cases, without referral. Case into two types: focal and examples help illustrate how body, optic nerve and internal limit- broad.1 Focal VMA occurs optometrists can independently treat ing membrane (ILM) of the retina. when there is less than or equal to and manage each condition. As we age, gel liquefaction occurs 1,500µm of vitreous adhesion over- within the vitreous body, causing a lying the ILM, while broad VMA VMA and VMT weakening of the vitreoretinal adhe- occurs when the adhesion is greater In adults, the average volume of the sions posteriorly.1,2 This biochemi- than 1,500µm.1 Patients with VMA vitreous body is 4mL.1 The vitreous cal change manifests clinically as a typically do not report visual symp- is contained in the posterior cham- posterior vitreous detachment (PVD) toms and have the potential for the ber of the eye in a cortex that abuts and can be ongoing for decades. A condition to spontaneously resolve the posterior lens capsule, ciliary PVD occurs when there is vitreous without retinal sequelae.

68 REVIEW OF OPTOMETRY MAY 15, 2020 VMT is the attachment of the tion and macular OCT. vitreous cortex to the ILM in the Management of VMT area of the macula, resulting in ana- mirrors that of VMA in tomic abnormality of the area. Like cases where the patient is VMA, there are two types: focal and asymptomatic for metamor- broad.1 The condition is focal when phopsia and scotoma and the size of the vitreous-ILM adhe- VA is 20/60 or better in the sion is less than or equal to 1,500µm affected eye. Case 2. Here is a macular OCT of a 64-year-old and broad when the adhesion is Interestingly, a systematic black female with focal VMA in the right eye. greater than 1,500µm.1 review and meta-analysis BCVA is 20/20 OD. The patient is asymptomatic VMT occurs when there is an of the safety and efficacy of for metamorphopsia or scotoma and is being imbalance between vitreous lique- pars plana vitrectomy (PPV) monitored yearly. faction and the separation of the for VMT found a mean vitreous cortex from the retina.3,4 improvement in VA to 20/53 cal exam of the fundus, FA, macu- The result of this mismatch is an postoperatively.8 lar OCT or a combination of all anomalous PVD—an attachment of Additionally, a retrospective case three. With macular OCT imaging, the vitreous to the ILM in the macu- series that reviewed the prognostic intra-retinal spaces are observed in lar region. The area of the anoma- factors of postoperative intraretinal the area of and around the foveal lous PVD has subsequent tractional cystoid spaces (ICS) after primary umbo. Patients with IGS will report deformation given the continued PPV for VMT found that preop- decreased VA and contrast sensi- vitreous attachment anteriorly.1 erative ICS was a major risk factor tivity and metamorphopsia in the VMT is more likely to affect for persistent ICS post-op.2 Thus, affected eye(s). Advancements in females than males and has the high- patients with VMT with or without cataract removal have dramatically est incidence in the sixth decade intraretinal cysts with a VA of 20/60 reduced the prevalence of post-op of life.5 The estimated prevalence or better can be appropriately man- complications, and the prevalence of of VMT is 22.5 cases per 100,000 aged in the optometric practice. A IGS in those without risk factors is persons.6 Unlike VMA, patients with macular OCT should be done with a 1% to 2%.12 VMT often have visual complaints dilated fundus exam at three- to six- Pathophysiology. Surgically such as decreased visual acuity (VA), month intervals to assess for changes induced inflammation is the root metamorphopsia, blurred vision, in VMT, VA and symptoms. etiology of IGS. During surgery, 2,7 micropsia and photopsia. Prior to the patient leaving, per- activation of phospholipase A2

Management. Most, if not all, form an in-office Amsler grid to (PLA2) propagates the inflammatory cases of VMA can be monitored demonstrate how to use the grid pathway by up-regulating arachi- conservatively. Given that VMA and to note any pre-existing meta- donic acid (AA) production. AA may be a transient aging change and morphopsia or scotoma. Should production results in eicosanoid (i.e., the vitreous may likely separate from either be present, make note of this prostaglandin) and leukotriene syn- the ILM without issue, referral to and educate the patient that they thesis via the cyclooxygenase (COX) a retina specialist is not warranted. are to return should they notice any and lipoxygenase (LOX) pathways, Patients with VMA have no underly- changes from the current findings respectively.13 These inflammatory ing changes to the foveal umbo so (Cases 1 and 2). mediators, produced in the anterior VA is preserved, except in the setting chamber during cataract surgery, of other macular and retinal condi- Post-op CME have the potential to migrate pos- tions. Conservatively, patients can In 1953, Irvine-Gass syndrome (IGS) teriorly to the retina.14 When this be given a home Amsler grid to test was first reported for CME follow- occurs, the inflammatory mediators monocularly on a frequent basis. ing cataract surgery, followed by the cause vasodilation, vascular perme- Patients should be instructed to call first fluorescein angiography (FA) ability and disruption of the blood- the office immediately should they diagnosis in 1969.9,10 IGS typically retinal barrier.15 notice changes such as metamor- occurs within 12 weeks with a peak Management. IGS can effec- phopsia and scotoma. Follow-up for incidence between weeks four and tively be treated with a combina- VMA would be six months to a year six after cataract surgery.11 tion of topical corticosteroids and with a full dilated fundus examina- The diagnosis is made with clini- non-steroidal anti-inflammatory

REVIEW OF OPTOMETRY MAY 15, 2020 69 Referrals

drugs (NSAIDs). Corticosteroids of the ocular surface by mediating that may result in corneal perfora- 21,22 inhibit PLA2, down-regulating the the production of trophic factors tion or melting. NK can result production of AA and subsequent that support and maintain the cor- from past ocular infections (herpes substrates for both COX and LOX neal epithelium and corneal nerves.19 being the most common), chemi- enzymes.16 Corticosteroids also have NK is an uncommon corneal dis- cal corneal burns, ocular surgeries, the ability to inhibit vasodilation, ease in which the sensory-mediated topical medications, cranial nerve V decrease vascular permeability and reflexes are reduced. The estimated palsy and select systemic diseases.22,23 stabilize intracellular and extracel- prevalence of NK is 1.6 to 4.2 cases Diagnosis of NK is confirmed lular membranes.17 NSAIDs work per 10,000 persons.19,20 quantitatively or qualitatively with downstream of the inflammatory Currently, the disease is classified in-office corneal sensitivity testing. cascade by inhibiting the COX into three stages. Stage one manifests Pathophysiology. Corneal epithe- enzymes, thereby decreasing eico- with punctate epithelial keratitis, epi- lial turnover and transparency is due sanoid formation. thelial hyperplasia, stromal scarring to the highly innervated network of Often, patients with IGS will and corneal neovascularization.21,22 corneal nerves.24 The human cornea already have these drugs in their Stage two is a persistent epithelial is the most innervated structure in arsenal for both pre- and post-oper- defect.21 The most severe, stage the body—40 times more innervated ative use. Each drug’s formulation three, is corneal stromal ulceration than tooth pulp and 400 times more will dictate the specific dos- innervated than human ing of both the corticosteroid skin.25 Corneal stem cell pro- and NSAID. For generic liferation and differentiation prednisolone and ketorolac, is mediated by the secretion QID dosing of both medica- of neurotrophins released tions is warranted. by the trigeminal nerve.24 Clinicians can schedule fol- In cases of NK, decreased low-up with VA, intraocular amounts of nerve growth pressure (IOP), fundus exam- factor (NGF), substance ination and macular OCT in P, calcitonin gene-related two- to four-week intervals peptide, neuropeptide Y until complete resolution is and acetylcholine are signifi- noted. If IGS is persistent cantly reduced.24 The reduc- past 12 weeks of topical tion of neurotrophins results treatment, consider increas- in both morphological and ing the topical prednisolone metabolic epithelial disrup- to Q1H while awake. tions leading to ocular sur- In one clinical trial, there face defects and non-healing was a statistically significant corneal wounds.20 Addi- difference in best-corrected tionally, the ocular surface visual acuity (BCVA) and suffers further desiccative macular thickness 12 weeks stress from poor tear re- after changing the dosing establishment due to reduced frequency of prednisolone blink rates. to Q1H while awake.18 It is Management. Treat- important to slowly taper ment and management of both the corticosteroid and NK is dependent on the NSAID to prevent the recur- stage with more aggressive rence of intraocular inflam- and surgical interventions mation (Case 3). Case 3. Above is the initial macular OCT scan of a 64-year- usually reserved for stage old black female who developed IGS nine weeks post-op in three. Therapy for stage Neurotrophic Keratitis the right eye. BCVA was 20/40. Below is her macular OCT one includes use of artificial Corneal sensation is impor- scan after 11 weeks of difluprednate 0.05% and ketorolac tears, most often preserva- tant to maintain homeostasis 0.5% therapy in the right eye. Her BCVA resolved to 20/20. tive-free if the drop is used

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Photo: Patrick McMannamon, OD to manage the resulting visual impairments for patients with mild TBI (mTBI), a closed head injury with loss of consciousness <30 minutes, a Glasgow Coma Score of 13 or greater, post-traumatic amnesia <24 hours, altered level of awareness <24 hours and normal neural imaging studies.29 Visual symptoms of mTBI are exacerbated at near with complaints of visual acuity fluctuations, headaches and pho- tophobia with near work.30 This is not surprising given binocular vision diagnoses of accommodative dysfunction, convergence insufficiency Case 4. A 78-year-old white male with stage two NK in the left eye was successfully (CI) and saccadic dysfunction have treated with Oxervate over a 56-day treatment course. The patient had a history of been reported most frequently in the herpes zoster with persistent epithelial defects for which he underwent a partial literature.30,31 lateral tarrsorhaphy OS. Post-Oxervate therapy, there was full epithelialization, and Management. Researchers suggest the tarrsorphaphy was removed 90 days later due to continued corneal health and a four-tiered conceptual model for patient interest. Special thanks to Patrick McMannamon, OD, for the case. the management of mTBI to address the visual, psychological and neuro- frequently throughout the day to The complete healing of the cor- logical sequelae: decrease preservative-induced ocular neal epithelium is paramount in the • Tier 1 is the basic optometric surface toxicity. management of NK to prevent risk visual examination where the Stage two NK requires the use of ulceration and perforation. Man- patient’s refractive, binocular of corneal or scleral therapeutic agement and follow up will depend visual system and ocular health contact lenses, amniotic membrane on the stage of the condition and the are evaluated.32 transplantation, topical autologous modality of treatment instituted. For • Tier 2 is the detection of serum drops and topical recombi- more severe cases of NK, daily fol- oculomotor-based vision prob- nant human NGF.20,24,26 One study low up may be warranted—at least lems via version, vergence and found both amniotic membrane initially—until complete epithelial accommodative evaluation.32 treatment and conventional treat- healing has occurred (Case 4). The abnormalities found dic- ment (tarrsorhaphy and a bandage tate whether lenses for distance contact lens) were both effective Traumatic Brain Injury and near, vision therapy and/or options for refractory neurotrophic With the increased awareness of the prism are indicated. corneal ulcers.27 visual sequela after a TBI, optom- • Tier 3 is non-oculomotor based Stage three NK often requires etrists play a key role in the inter- vision problems.32 In this tier, surgical intervention to prevent professional management team. the patient’s spatial localization, corneal perforation. In 2018, Oxer- Approximately 2.8 million people in motion sensitivity, photosensi- vate (cenegermin-bkbj 0.002%, the United States sustained a TBI in tivity, vestibular function, visual Dompé), a topical human NGF, was 2013, most commonly as a result of fields and visual information FDA approved for the treatment a fall, being struck by or against an processing are evaluated.32 of NK. In a multicenter, random- object or a motor vehicle accident.28 Treatments for the non-ocu- ized, vehicle-controlled pivotal trial, Additionally, with US troops arriv- lomotor vision problems may researchers found that Oxervate had ing back from the Middle East, an include prism, yoked prism, statistically higher rates of corneal increased prevalence of TBI can be tints, binasal occlusion, vision/ healing compared with the vehicle expected from returning active duty vestibular therapy and visual when dosed six times a day over a service members. information processing and per- 56-day period.26 Optometrists are well positioned ceptual therapy.32

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• Tier 4 addresses non-vision effective in delaying or preventing decreasing aqueous production and based problems.32 The patient is onset of POAG in 50% of patients lowering the episcleral venous pres- screened for depression, fatigue, with elevated IOP when IOP was sure.36,37 In two phase three clinical cognitive impairment and decreased by 20%.34 trials, Rhopressa QD significantly behavioral, postural, attention Management. With the plethora lowered IOP from baseline and was and neurological problems.32 of drug classes available, optom- found to be non-inferior to timolol.38 Based on pertinent concomitant etrists can individualize therapy Additionally, in states where issues, the patient may need based on drug allergies, systemic laser procedures are included in the evaluation and treatment by medications and ocular diseases. optometric scope of practice, selec- psychiatry, psychology, counsel- Topical drugs can be classified into tive laser trabeculoplasty (SLT) is ing and neurology.32 three categories based on how they an effective first-line therapy when The overall success of the patient lower IOP: by increasing aqueous compared with conventional topical may require multiple assessments of outflow via the trabecular meshwork medication intervention.39 In one the different aspects of the visual sys- or the uveoscleral meshwork and by study, first-line SLT treatment pro- tem, vision information processing decreasing aqueous production. vided drop-free IOP control for at system and inter-collaborative care Within the past two years, two least three years and was deemed the with other professionals (Case 5).32 new drugs have come to the market most cost-effective first-line therapy as possible first-line or adjunctive for POAG and OHTN.39 Glaucoma and agents for the treatment of glaucoma Once a patient is diagnosed with Ocular Hypertension and OHTN. Vyzulta (latanoprostene treatable glaucomatous disease, Numerous randomized clinical tri- bunod 0.024%, Bausch + Lomb) is a clinicians should initiate a topical als have concluded that lower IOP dual-mechanism drug that increases medication that is most appropriate delays or prevents progression of pri- uveoscleral outflow of aqueous and for the patient and/or discuss SLT mary open-angle glaucoma (POAG). increases both trabecular meshwork treatment. Follow-up is usually six The Collaborative Normal Tension and Schlemm’s canal outflow via a to eight weeks later to determine Glaucoma Study found slower nitric oxide metabolite.35 In a con- medication/SLT efficacy (looking for progression in visual field defects trolled comparison study of Vyzulta a 20% to 30% decrease in IOP from when IOP was lowered by 30% and latanoprost 0.05%, researchers highest recorded untreated IOP). or more.33 A faster rate of progres- found a statistically significant dif- At follow up, clinicians should sion was noted in women, patients ference in IOP lowering with Vyzulta ensure compliance, as prescribed, with migraines and those with disc at days seven, 14 and 28 compared and any noted side effects that may hemorrhages. Notably, the untreated with latanoprost.35 Vyzulta is dosed alter use and compliance. If the group was highly variable with some one drop at bedtime. efficacy is unsatisfactory, follow patients not progressing in a five- Rhopressa (netarsudil 0.02%, up again six to eight weeks later to year period.33 Aerie), another new drug, is a rho confirm poor response to the treat- In the Ocular Hypertension Treat- kinase inhibitor with three mecha- ment regimen. Yearly structural and ment Study, researchers found topi- nisms to lower IOP: by increasing functional testing (visual fields and cal ocular hypotensive agents were trabecular meshwork outflow, OCT), gonioscopy and optic nerve head photography are important Case 5. Treat TBI With Lenses and augment topical treatment with A 45-year-old Hispanic male, a social worker, presented to the TBI clinic for evaluation of noted progression. With myriad eye strain, eye pain, sensation of increased eye pressure and headaches after hitting his topical drug classes, combinations head on a wooden table while trying to plug in his computer. He reported limited ability in and laser treatment options, clini- reading for a sustained period of time, although his job requires extended computer and cians can delay or adjust topical near activities. treatments to meet target IOP while Exam findings were remarkable for CI and accommodative dysfunction in both eyes. managing practical drop schedules The patient was successfully treated with separate distance and near glasses and with the patient (Case 6). reported increased comfort and duration with near tasks. This case demonstrates a Tier 2 management of mTBI with successful visual comfort If you feel that any presentation is with the use of lenses. Special thanks to Siva Meiyeppen, OD, for the case. beyond your level of comfort, don’t forget about your colleagues who

74 REVIEW OF OPTOMETRY MAY 15, 2020 23. Vaidyanathan U, Hopping GC, Liu practice in the various HY, et al. Persistent corneal epithelial optometric subspe- defects: a review article. Med Hypothesis Discov Innov Ophthal- cialties who can man- mol. 2019;8(3):163. age those cases with 24. Di Zazzo A, Coassin M, Varacalli G, et al. Neurotrophic keratopathy: pros and you. Now more than cons of current treatments. Ocular Surf. 2019;17(4):619-23. ever, we are able to 25. Bonini S, Rama P, Olzi D, Lam- provide care to almost biase A. Neurotrophic keratitis. Eye. 2003;17(8):989-95. all of our patients by 26. Pflugfelder SC, Massaro-Giordano implementing the lat- M, Perez VL, et al. Topical recombinant human nerve growth factor (ceneg- est technologies and ermin) for neurotrophic keratopathy: pharmaceuticals to a multicenter randomized vehicle- controlled pivotal trial. Ophthalmology. help increase patients’ 2020;127(1):14-26. quality of life through 27. Khokhar S, Natung T, Sony P, et al. Amniotic membrane transplantation in vision. n refractory neurotrophic corneal ulcers: Dr. Higa is an a randomized, controlled clinical trial. Cornea. 2005;24(6):654-60. assistant professor at 28. Taylor CA, Bell JM, Breiding MJ, Xu PCO-Salus, where he L. Traumatic brain injury–related emergency department visits, hospitalizations, works with interns and deaths—United States, 2007 and and residents. He has 2013. MMWR Surveillance Summaries. 2017;66(9):1. a special interest in 29. Pinchefsky E, Dubrovsky AS, Fried- ocular surface disease man D, Shevell M. Part I—evaluation of pediatric post-traumatic headaches. Ped and anterior segment Neurol. 2015;52(3):263-9. 30. Singman E, Quaid P. Vision Disorders inflammation. in Mild Traumatic Brain Injury. In: Hof- Case 6. This is the guided progression analysis (optic nerve head OCT) fer M, Balaban C, eds. Neurosensory 1. Duker JS, Kaiser PK, Binder S, et Disorders in Mild Traumatic Brain al. The International Vitreomacular with visual fields (right eye only) of a 43-year-old black male who has Injury. Philadelphia: Academic Press; Traction Study Group classification been treated with Vyzulta for 25 months in both eyes. IOP has decreased 2019:223-244. Academic Press. of vitreomacular adhesion, traction, 31. Merezhinskaya N, Mallia RK, Park and macular hole. Ophthalmology. 40% and has been consistent at follow ups since initiating the drug. His D, et al. Visual deficits and dysfunctions 2013;120(12):2611-9. OCT and visual fields show no change over the 25-month period, indicating associated with traumatic brain injury: 2. Coussa RG, Antaki F, Zaguia F, et A systematic review and meta-analysis. al. Prognostic factors of postopera- successful treatment. Optom Vis Sci. 2019;96(8):542-55. tive intraretinal cystoid spaces after 32. Ciuffreda KJ, Ludlam DP. Conceptual incidence of macular edema after cataract surgery: a database primary pars plana vitrectomy for vitreomacular traction. J Curr model of optometric vision care in mild traumatic brain injury. J study of 81984 eyes. Ophthalmology. 2016;123(2):316-23. Ophthalmol. 2019;31(4):399-405. Behav Optom. 2011;22(1):10-3. 13. Ricciotti E, FitzGerald GA. Prostaglandins and inflam- 3. Johnson MW. Posterior vitreous detachment: evolution 33. Group CN. Comparison of glaucomatous progression mation. Arteriosclerosis, thrombosis, and Vascular Biology. and complications of its early stages. Am J Ophthalmol. between untreated patients with normal-tension glaucoma and 2011;31(5):986-1000. 2010;149(3):371-82. patients with therapeutically reduced intraocular pressures. Am 14. Ersoy L, Caramoy A, Ristau T, et al. Aqueous flare is 4. Sebag J. Anomalous posterior vitreous detachment: a unify- J Ophthalmol. 1998;126(4):487-97. ing concept in vitreo-retinal disease. Graefe’s Arch Clin Exp increased in patients with clinically significant cystoid 34. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Ophthalmol. 2004;242(8):690-8. macular oedema after cataract surgery. Br J Ophthalmol. Hypertension Treatment Study: a randomized trial determines 5. Steel DH, Lotery AJ. Idiopathic vitreomacular traction and 2013;97(7):862-5. that topical ocular hypotensive medication delays or prevents macular hole: a comprehensive review of pathophysiology, 15. Wielders L, Schouten JSAG, Nuijts RMMA. Prevention and the onset of primary open-angle glaucoma. Arch Ophthalmol. diagnosis, and treatment. Eye. 2013;27(1):S1-21. treatment of cystoid macular edema after cataract surgery. Curr 2002;120(6):701-13. 6. Jackson TL, Nicod E, Simpson A, et al. Symptomatic vitreo- Opin Ophthalmol. 2018;29(1):48-53. 35. Weinreb RN, Ong T, Sforzolini BS, et al. A randomised, macular adhesion. Retina. 2013;33(8):1503-11. 16. Comstock TL, DeCory HH. Advances in corticosteroid controlled comparison of latanoprostene bunod and latano- 7. Tadayoni R, Holz FG, Zech C, et al. Assessment of anatomical therapy for ocular inflammation: loteprednol etabonate. Internat prost 0.005% in the treatment of ocular hypertension and and functional outcomes with ocriplasmin treatment in patients J Inflamm. 2012;2012. open angle glaucoma: the VOYAGER study. Br J Ophthalmol. with vitreomacular traction with or without macular holes: 17. Sheppard JD, Comstock TL, Cavet ME. Impact of the topical 2015;99(6):738-45. results of OVIID-1 Trial. Retina. 2019;39(12):2341-52. ophthalmic corticosteroid loteprednol etabonate on intraocular 36. Wang RF, Williamson JE, Kopczynski C, Serle JB. Effect of 8. Jackson TL, Nicod E, Angelis A, et al. Pars plana vitrectomy pressure. Advances in Therapy. 2016;33(4):532-52. 0.04% AR-13324, a ROCK, and norepinephrine transporter for vitreomacular traction syndrome: a systematic review and 18. Campochiaro PA, Han YS, Mir TA, et al. Increased frequency inhibitor, on aqueous humor dynamics in normotensive monkey metaanalysis of safety and efficacy. Retina. 2013;33(10):2012- of topical steroids provides benefit in patients with recalcitrant eyes. J Glaucoma. 2015;24(1):51-4. 7. postsurgical macular edema. Am J Ophthalmol. 2017;178:163- 37. Kiel JW, Kopczynski CC. Effect of AR-13324 on episcleral 9. Irvine SR. A newly defined vitreous syndrome following cata- 75. venous pressure in Dutch belted rabbits. J Ocul Pharmacol ract surgery*: interpreted according to recent concepts of the 19. Mastropasqua L, Massaro‐Giordano G, Nubile M, Sacchetti Ther. 2015;31(3):146-51. structure of the vitreous, The Seventh Francis I. Proctor Lecture. M. Understanding the pathogenesis of neurotrophic keratitis: 38. Serle JB, Katz LJ, McLaurin E, et al. Two phase 3 clinical tri- Am J Ophthalmol. 1953;36(5):601-19. the role of corneal nerves. J Cell Physiol. 2017;232(4):717-24. als comparing the safety and efficacy of netarsudil to timolol in 10. Gass JD, Norton EW. Follow-up study of cystoid macular 20. Sacchetti M, Lambiase A. Diagnosis and management of patients with elevated intraocular pressure: rho kinase elevated edema following cataract extraction. Trans Am Acad Ophthalmol neurotrophic keratitis. Clin Ophthalmol. 2014;8:571. IOP treatment trial 1 and 2 (ROCKET-1 and ROCKET-2). Am J Otolaryngol. 1969;73(4):665. 21. Mackie IA. Neuroparalytic (neurotrophic) keratitis. Presented Ophthalmol. 2018;186:116-27. 11. Shoss BL, Tsai LM. Postoperative care in cataract surgery. at the Symposium on Contact Lenses: Transactions of the New 39. Gazzard G, Konstantakopoulou E, Garway-Heath D, et Curr Opin Ophthalmol. 2013;24(1):66-73. Orleans Academy of Ophthalmology. St Louis: Mosby; 1973. al. Selective laser trabeculoplasty versus drops for newly 12. Chu CJ, Johnston RL, Buscombe C, et al; United Kingdom 22. Semeraro F, Forbice E, Romano V, et al. Neurotrophic kerati- diagnosed ocular hypertension and glaucoma: the LiGHT RCT. Pseudophakic Macular Edema Study Group. Risk factors and tis. Ophthalmologica. 2014;231(4):191-7. Health Technol Assess. 2019;23(31):1-102.

REVIEW OF OPTOMETRY MAY 15, 2020 75 2 CE Credits (COPE approved)

MAXIMIZING OCT IN THE DIAGNOSIS AND MANAGEMENT OF GLAUCOMA This technology has become an integral part of glaucoma care, and optometrists must understand how to accurately use it. By Danica Marrelli, OD

laucoma can be defined Over the past two decades, objec- can be imaged that provide impor- as a chronic, progressive tive imaging with optical coherence tant information: the ONH, RNFL loss of retinal ganglion tomography (OCT) has become and macula. Gcells (RGCs) that results in increasingly important in the diag- Optic nerve head and retinal characteristic structural—optic nerve nosis of glaucoma. The diagnostic nerve fiber layer. The ONH/RNFL head (ONH) and retinal nerve fiber accuracy of all commercially avail- scan is presently the most popular layer (RNFL)—damage and cor- able spectral-domain OCT instru- scan protocol used in glaucoma responding functional (visual field) ments is similar and improves with diagnostics. The scan provides infor- loss. Historically, clinicians relied increasing severity of the disease.4-8 mation about the ONH, including on clinical assessment (ophthalmos- This activity discusses the technology disc size/area, rim area and cup- copy and fundus photography) of and provides a practical approach to to-disc ratio. The neuroretinal rim the ONH and RNFL to identify the analyzing the printouts. thickness profile is also displayed. structural changes. However, detect- The RNFL data typically includes ing glaucomatous changes in optic OCT Scan Protocols a thickness map, deviation map, nerves can be a difficult task and one Although differences in scan proto- RNFL thickness profile and average/ in which there is poor interobserver cols exist between manufacturers, global, quadrant and sector/clock agreement.1-3 there are three anatomic regions that hour thicknesses.

Release Date: May 15, 2020 Institute for Medicine is jointly accredited by the Accreditation Council Expiration Date: May 15, 2023 for Continuing Medical Education, the Accreditation Council for Estimated Time to Complete Activity: 2 hours Pharmacy Education, and the American Nurses Credentialing Center, to provide continuing education for the healthcare team. Postgraduate Jointly provided by Postgraduate Institute for Institute for Medicine is accredited by COPE to provide continuing edu- Medicine (PIM) and Review Education Group cation to optometrists. Educational Objectives: After completing this activity, the participant Faculty/Editorial Board: Danica Marrelli, OD, University of Houston College of Optometry. should be better able to: Credit Statement: This course is COPE approved for 2 hours of CE • Discuss OCT findings and common concerns with the technology. credit. Course ID is 67936-GL. Check with your local state licensing • Use OCT to confirm a diagnosis of glaucoma. board to see if this counts toward your CE requirement for relicensure. • Follow glaucoma patients with serial macular and RNFL scans. Disclosure Statements: • Avoid common concerns related to OCT technology. Dr. Marrelli has received consulting fees from Aerie, Allergan, Bausch & Target Audience: This activity is intended for optometrists engaged in Lomb, Carl Zeiss Meditec and fees for non-CE/CME services from Aerie, the care of patients with glaucoma. Bausch & Lomb, Carl Zeiss Meditec. Accreditation Statement: In support of improving patient care, this Managers and Editorial Staff: The PIM planners and managers have activity has been planned and implemented by the Postgraduate nothing to disclose. The Review Education Group planners, managers Institute for Medicine and Review Education Group. Postgraduate and editorial staff have nothing to disclose.

76 REVIEW OF OPTOMETRY MAY 15, 2020 OPTOMETRIC STUDY CENTER

After ensuring that the patient demographic information is correct, the first step when interpreting an ONH/RNFL scan is to ensure that it is high quality without obvious artifacts or acquisition errors. The optic disc should be well-centered within the fixed measuring circle, well illuminated and relatively free of motion artifacts (indicated by discontinuous blood vessel path or irregularly shaped optic nerve). The signal-to-noise ratio (i.e., signal strength) should be high. Since the RNFL thickness is derived from within the defined measuring circle, based on the specific machine used, Fig. 1. This Optovue OCT scan shows thinning of the inferior RNFL (absence of it is critical that there are no black “warmer” greens/yellows, and more “cool” blue inferior to the disc) and the inferior areas (indicating missing data) with- ganglion cell complex (presence of red areas below the horizontal) in the right eye. in the circle that will affect the aver- On the lower right portion of the printout, the RNFL is plotted against the normative/ age, quadrant or sector thickness reference database, where the inferior RNFL of the right eye dips well into the measurement. After ensuring good abnormal “red” range. Below that, the symmetry plot color-codes areas of significant scan quality, the clinician can move asymmetry between the right and left eye. on to choosing the scan analysis and interpreting the findings. base. Yellow pixels are considered These provide a visual representation A color-coded RNFL thickness “borderline” and represent the thin- of the optic nerve neuroretinal rim map allows a rapid “first glimpse.” nest 5% of the reference database and RNFL thickness in a “TSNIT” In this thickness map, warm colors (only 5% of normals fall within this pattern: starting with the temporal (reds and oranges) represent areas of range) and red pixels are considered thickness, moving to superior, nasal, thick RNFL and cooler blues repre- “abnormal” and represent the thin- inferior and back to temporal for sent thinner areas. The normal thick- nest 1% of the normative database. both rim and RNFL thickness. ness map will show a symmetrical While examining the deviation Another profile map gaining pop- hourglass or butterfly shape of thick map, the clinician should look for ularity is the NSTIN curve, which RNFL superiorly and inferiorly cor- loss in areas consistent with glau- splits the RNFL in the nasal hemi- relating with the anatomical location coma (superior/superotemporal field rather than temporal to allow of RNFL bundles. and inferior/inferotemporal). RNFL for better viewing of the susceptible Looking for symmetry is extreme- thickness measurements obtained temporal area of loss common in ly important in all OCT scans in from the measuring circle are pre- the macula. The neuroretinal rim glaucoma, as asymmetry is a hall- sented on the report as global/aver- profile may identify diffuse or focal mark of early disease (Figure 1). age, quadrant and sector/clock hour rim thinning, which should correlate A first look at symmetry can take measurements, with the color-coded with the clinical examination of the place with the thickness map, look- indicators of green, yellow and red optic nerve. A normal neuroretinal ing to see if the thickness appears for the 95%, 5% and 1% thickness rim profile will usually demonstrate symmetric between superior and percentiles of the reference database, thicker rims inferiorly and superior- inferior thickness within each eye respectively. These color codes are ly, correlating with the “ISNT Rule” and between the right and left eye. helpful in identifying potential prob- of clinical ONH assessment. Diffuse and focal (slit/wedge) RNFL lem areas, but the clinician should The TSNIT curve of the RNFL loss may be identifiable as cooler avoid diagnosing patients based should show peaks superiorly and colors on the thickness map. The strictly on the color maps. inferiorly; often the superior RNFL deviation map will identify areas Arguably the most important will show a “double hump” related that are outside normal limits based areas to examine on the ONH/ to blood vessel positioning. The on the instrument’s reference data- RNFL scan are the profile curves. neuroretinal rim and RNFL profile

REVIEW OF OPTOMETRY MAY 15, 2020 77 OPTOMETRIC STUDY CENTER

curves are overlaid on the reference the retina contains approximately The ganglion cell analysis is a database color coding. Dips into the 50% of the RGCs.10,11 Since glau- segmentation that includes only the yellow/red zones should arouse sus- coma is a disease of RGCs, it makes ganglion cell and inner plexiform picion but, again, are not diagnostic sense to look in the area of highest layers (GCIPL). Scans are centered of disease. When the profile curves ganglion cell population. on the fovea and the thickness may of the right and left eye are super- Second, unlike the optic nerve and be reported as sector, average and imposed, it is easy to identify areas peripapillary region, where a wide minimum. In addition, the Heidel- of asymmetry. Depending on the variation of normal exists, the mac- berg Spectralis instrument performs instrument, other parameters such ula is more uniform among patients, a detailed macular thickness sym- as disc size, rim area and cup-to-disc and the measurements can be more metry analysis, comparing superior ratio may also be presented on the repeatable. In healthy individuals, to inferior within an eye as well as ONH/RNFL scan. there is greater superior/inferior thickness of right eye compared with Macula. The newest area of symmetry of the macular thickness the left eye. interest in imaging for glaucoma than that of the peripapillary RNFL, A macula of normal thickness diagnosis is the macula. It’s long and in all individuals there is less has a uniform oval appearance on been known that glaucomatous impact of large blood vessels in the the thickness map. A hallmark of damage can occur there.9 However, macular area compared with the glaucomatous damage to the macula these subtle changes cannot be seen RNFL. In terms of diagnostic capa- appears as a distinct loss temporal on clinical exam. OCT has revolu- bility, research shows the macular to the fovea along the horizontal tionized our ability to evaluate and scans that use inner retina segmen- raphe, which is easily visible on quantify macular thickness. There tation are comparable with RNFL the thickness map (Figure 2). This are several reasons to consider the scans.4 appearance has been given several macula in early glaucoma. Much of our understanding of the nicknames, including the “squeegee First, the macula is the region of macula in glaucoma comes from the sign” (because it looks as if part of the retina with the highest density of work of Donald Hood, PhD. In an the inferior macula has been wiped RGCs, the cells impacted by glauco- extensive body of work, his team of away) and the “nautilus” (for its matous damage. The central 16° of researchers has identified the most similarity to a nautilus shell). likely area of early Macular OCT scans have limited ganglion cell loss in usefulness for glaucoma diagnostics the macula. This area, in the presence of macular disease, termed the “macular particularly disease that involves vulnerability zone,” is the inner retina. Macular edema, located just inferotem- epiretinal membranes and age- poral to the fovea and related macular degeneration all is commonly the site alter the thickness of the macula of early glaucomatous and the capability of the instrument damage.12 to segment the various layers. In Macular scan pro- patients with concomitant macular tocols for glaucoma disease, macular scans are unlikely vary in terms of what to be helpful in the diagnosis of is measured (the entire glaucoma.13 retinal thickness or Our new understanding of the only a segment of the importance of macular damage in inner retina), and if early glaucoma has necessitated a segmented, which lay- change in the way we think about ers are included. For perimetry. Conventional visual example, the ganglion field testing using either the 24-2 or cell complex is a seg- 30-2 testing strategy may miss or Fig. 2. This macular ganglion cell analysis scan shows the mentation of the inner underestimate the functional loss of characteristic wedge-shaped loss in the inferior temporal retina including the damage to the macular area. In these macular vulnerability zone. Note the squeegee sign more ganglion cell, inner test patterns, stimulus spacing of six pronounced in the right eye. plexiform and RNFL. degrees does not allow for adequate

78 REVIEW OF OPTOMETRY MAY 15, 2020 Fig. 3. This OCT scan represents a case of green disease. The RNFL deviation map appears clear, and the ONH/RNFL summary table and RNFL quadrant and clock hour analyses are all in the green. However, on careful evaluation of both the thickness maps and the RNFL TSNIT profile, it is clear that the superior RNFL is thinner than the inferior RNFL in the right eye. This asymmetry is characteristic of early glaucoma. This example also shows why correlating the OCT findings with the clinical exam is important. On exam, the patient had a slightly thin superior neuroretinal rim in the right eye, and a small optic disc hemorrhage on the superior rim. In addition, there was a corresponding inferior nasal step visual field defect. Intraocular pressure, while in the statistically normal range, was consistently 3mm Hg to 4mmHg higher in the right eye on each visit. sampling in the central area with the The Pitfalls of OCT normal; white represents the very highest population of retinal gan- While OCT technology has greatly thickest of the normative database glion cells.14-16 improved our ability to evaluate and may be normal or may represent By using a test strategy that the structural loss in glaucoma, it is abnormally thick RNFL (such as in includes closer stimulus spacing (for imperative that clinicians understand optic disc swelling). Yellow is con- example, the two-degree spacing of its potential pitfalls. sidered borderline, representing the the 10-2 or the central points of new Normative database. Each instru- thinnest 5% of the database, and red 24-2C test pattern), clinicians may ment compares scans against a refer- is considered abnormal, representing be able to improve their ability to ence database of patients without the thinnest 1% of the database. detect early functional loss related to ocular or systemic disease. OCT These databases are limited in size the macular damage.9 instruments provide color-coded and with regard to age, ethnicity, Currently, it’s not entirely clear reports to alert the clinician that a optic disc size and refractive error. which patients may benefit from numeric value falls within or outside Because of the limitations of the central 10° visual field testing. In of the normal range relative to the databases, some patients without cases with glaucomatous ganglion reference database. Typically, green disease will fall outside of the normal cell loss and a normal 24-2 test, the represents the top 95% thickness of range. These patients’ reports will 10° testing may be beneficial. the reference base and is considered flag them as red on the printouts.

REVIEW OF OPTOMETRY MAY 15, 2020 79 OPTOMETRIC STUDY CENTER

Non-glaucomatous Conditions termed “green disease,” may Glaucoma is not the only condition that can cause RNFL loss. Non-glaucomatous optic neu- result in underdiagnosis and a ropathies—including anterior ischemic optic neuropathy (AION) and optic neuritis—and optic delay in treatment of patients with disc drusen may produce RNFL loss that is similar to that of glaucoma. The clinical examina- glaucoma.21 tion of the optic nerve is paramount in differentiating such conditions. In a busy practice, it is easy to For example, in AION, clinicians would expect optic disc pallor rather than the cupping seen become overly reliant on the red/ in glaucoma. In some optic neuropathies, including toxic/nutritional and ethambutol-induced yellow/green color scheme to make optic neuropathy and dominant optic atrophy, temporal RNFL thinning is a feature that can a diagnosis of glaucoma. There are help differentiate the condition from glaucoma.32,33 two key steps in avoiding red and Retinal conditions that affect one hemifield, such as retinal detachment and branch retinal green disease misdiagnosis. artery and vein occlusions, may also produce superior/inferior asymmetric RNFL loss that The first is to correlate the OCT mimics that of glaucoma. Again, the clinical examination should provide information to arrive findings with other clinical exam at the appropriate diagnosis, although in the case of a chronic/resolved branch retinal artery findings (Figure 3). The OCT should occlusion, the clinical examination of the retina may appear quite normal. In this situation, augment, not replace, the doctor’s an important OCT feature is atrophy and thinning of the inner retinal layers in the area of the clinical examination of the optic occlusion, which may be seen on raster/line scans through the retina.34 nerve and RNFL. The second is to examine the The term “red disease” describes Likewise, some patients with scan for findings consistent with these patients who, despite being glaucoma will have scans in which glaucoma: superior/inferior loss of healthy, are flagged as abnormal on all numeric values fall within the neuroretinal rim and RNFL; sharply the OCT printout.17 Red disease is a normal range of the reference demarcated inferotemporal or supe- false positive, and without carefully database. These false negatives, rotemporal ganglion cell loss in the evaluating the individ- macula; and asymmetry ual components of the between the right and left scan and considering eyes (often seen easily on the scan in the context the superimposed TSNIT of the entire clinical curves). picture, these patients Artifacts. These occur may be incorrectly diag- in a surprising number of nosed and unnecessarily RNFL and macular scans. treated for glaucoma. Researchers found that In a study of 104 15.2% to 36.1% of RNFL normal eyes, researchers and macular scans in one found a false positive glaucoma clinic population glaucoma classifica- had artifacts, most of which tion in 40.4% of eyes were evident on the clinical based on ganglion cell printout.22 Other authors analysis and in 30.8% report up to 90% of scans of eyes based on RNFL have artifacts, although maps.18 They found not all artifacts will have that false positive clas- clinically significant impli- sification was associ- cations, and many are not ated with increased reproducible on repeat axial length and small scans.13,23-25 Recognizing optic disc size, a find- artifacts is critical to accu- ing supported by other rately interpreting the data. investigators.19,20 They Fig. 4. In this scan, large vitreous floaters in both eyes obscured Artifacts can be classi- recommend clinicians the signal and created black areas within the measuring fied into three categories: carefully evaluate the circle, which influenced the RNFL thickness measurements. In those related to acquisition/ location and pattern of addition, note the irregular shape of the optic nerve OS and the technician errors, ocular loss in eyes with abnor- discontinuous blood vessels in the deviation map of the left eye, pathology and software mal OCT maps. indicating a motion artifact. (segmentation) errors.

80 REVIEW OF OPTOMETRY MAY 15, 2020 Pearls & Pitfalls of OCT Interpretation Pearls: Pitfalls: • Ensure the image being interpreted is high-quality, with • Do not rely solely on the red/yellow/green color scheme to interpret a well-illuminated scan and an optic nerve or fovea cen- the OCT. Not every patient will fit within the reference database tered within the three-dimensional acquisition window. parameters. Watch for false positives and false negatives (i.e., red • Pay careful attention to profile plots and look for asym- and green disease) that may occur. metry that characterizes early glaucoma. • Watch for artifacts. Acquisition errors and segmentation errors are • Correlate OCT findings with clinical examination and common and can significantly impact the results of OCT. Remember other results. Don’t let the clinical exam become that concurrent macular disease may render the macular scans irrelevant. unusable for glaucoma. • Remember that glaucomatous damage to the macula • Remember that there are other conditions that can cause RNFL and may occur early. Use both RNFL and macular scans ganglion cell loss. High myopia, non-glaucomatous optic neuropa- to support a diagnosis of glaucoma. Consider a 10-2 thies and retinal disease such as vascular occlusions can mimic or other central visual field test if there is significant glaucoma on an OCT. Again, use OCT to enhance, not replace, the macular damage on OCT. clinical exam.

Technician errors may include may cause an artifact in a glaucoma diminish the instrument’s ability to truncation of the image, such that scan protocol (Figure 4). The most properly segment the retinal layers. not all of the image is included in common ocular pathology to cause High myopia causes thinning of the acquisition window. These errors artifacts is epiretinal membrane. both the RNFL and ganglion cell will result in areas with near zero Vitreoretinal interface disorders and layers, and highly myopic eyes may thickness and are easily recognized. epiretinal membrane may alter the also have anatomic features (includ- Remember that the RNFL and thickness of the retina, as well as ing ONH tilting, peripapillary atro- GCIPL floor is approximate- phy, myopic staphyloma ly 45µm, representing resid- and temporal RNFL bundle ual glial and vascular tissue. shifting) that may impact Improper circle placement structural assessment of the on ONH/RNFL scans is ONH and RNFL.13,23 another potential acquisition Software-related arti- error, although many instru- facts are primarily related ments now have algorithms to improper segmentation that make this less likely. of the retinal layers. Poor Poor signal-to-noise ratio signal strength related to may be due to media prob- media opacities and ocular lems such as cataract or dry surface disease may hinder eye.26 Pupil dilation and the proper segmentation slight movement in the x- and impact thickness mea- (right/left) and y- (superior/ surements. Vitreous float- inferior) axes may allow the ers may focally obscure scan to work around central the signal from the retina, lens opacities. The use of resulting in the inability an artificial tear immedi- to segment portions of the ately prior to acquisition scan. Asking the patient to may minimize the impact move their eye just prior of ocular surface dryness. Fig. 5. Here, event analysis shows significant change from to acquiring the scan may Train technicians to recog- baseline indicated by yellow and red pixels in the deviation reposition the floaters long nize these acquisition errors from baseline maps (green boxes) and on the TSNIT profile. enough to work around and to re-scan the patient There is also visible thinning over time on the thickness maps, them. In addition, high to minimize their impact on as the average RNFL thickness drops from 80µm to 68µm. myopia is a frequent cause interpretation. Trend analysis shows a significant rate of change in average, of improper segmenta- Any ocular pathology superior and inferior RNFL as well as an increase in the cup- tion in RNFL and macular that alters retinal thickness to-disc ratio. scans.

REVIEW OF OPTOMETRY MAY 15, 2020 81 OPTOMETRIC STUDY CENTER

Some instruments allow this way. Color indicators for manual re-segmentation note when rates of change of improperly segmented reach statistical significance. scans. Recognition and, When analyzing an OCT when possible, correction for progression, clinicians of segmentation errors is should remember that cur- important for accurate inter- rent OCT progression analy- pretation of the scan. sis software does not account Artifacts may be a source for the normal age-related of red/green disease. Poor thinning of RNFL and signal strength, acquisition macula. A number of studies errors, vitreous floaters and have investigated the rate of myopic RNFL thinning RNFL loss in both healthy may result in a false positive and glaucomatous eyes. One (red or abnormal) findings. study showed that the aver- Vitreoretinal interface disor- age RNFL in healthy subjects ders, myelinated nerve fiber changed at a rate of -0.48m/ layer and optic disc edema year, while the RNFL of may result in false negative glaucoma patients changed (green) findings. at a rate of -0.98m/year.28 In this study, rates of RNFL Detecting Progression Fig. 6. The patient in Figure 5 was lost to follow-up and was change were more rapid Once a patient is diagnosed not using his glaucoma medication. When he returned for than that of GCIPL change. with glaucoma, or a glauco- care and drop therapy was re-initiated, the baseline was Other researchers found that ma suspect has entered into reset to the first two scans following his return. The results accounting for age-related a surveillance program for of both event and trend analyses show that he has remained loss significantly impacted observation, the focus shifts relatively stable since re-initiation of therapy. the percentage of patients from diagnosis to detecting determined to be progress- progression. Structural progres- In general, more emphasis is ing.29 Research also shows that fail- sion may be detected as progressive placed on event analysis when there ure to consider age-related thinning RNFL thinning, ONH changes such are fewer follow-up examinations resulted in significant false positive as rim thinning, progressive inner (Figure 6). Interestingly, the most identification of progression.30 macular thinning or a combination common location for progressive In addition to age-related loss, cli- of all three. Two main strategies exist RNFL thinning is outside of the nicians should consider the severity for detecting progression using OCT: standard 3.4mm measuring circle. of the disease. The ability of OCT to event analysis and trend analysis. This means that some RNFL thin- detect RNFL thinning diminishes in In event analysis, progression is ning may be identified on the thick- more advanced disease, as the RNFL detected when the difference between ness change map but not on the measurement reaches the floor effect. a baseline and follow-up scan serial analysis of the circumpapillary Inner macular thickness, however, exceeds a predetermined amount, RNFL thickness measurements, is often more useful for progres- usually the instrument’s test-retest necessitating analysis of the entire sion detection in advanced disease, variability (Figure 5). Clinicians can scan, not one particular parameter.27 as more GCIPL is likely to remain think of this as a snapshot in time Trend analysis provides regression above the measurement floor for a that answers the question, “Has the analysis between a given parameter longer period of time.29 patient changed significantly from and time. Progression is defined as Finally, a positive correlation baseline?” Typically, the first time a significant negative slope of the exists between signal-to-noise ratio a scan shows progression, it will be parameter in question. This slope can and RNFL thickness, so consider the flagged in yellow (“possible progres- be considered a surrogate for the rate scan quality (particularly compared sion”), and if the same progression of change of the disease. Average and with baseline) when evaluating for is verified on a subsequent exam, the hemifield RNFL thickness measure- possible progression. progressing area will be flagged in ments, cup-to-disc ratio and inner Always confirm suspected pro- red (“likely progression”). macula thickness can all be analyzed gression with repeat testing. If

82 REVIEW OF OPTOMETRY MAY 15, 2020 damage in glaucoma as revealed by averaging optical coherence progression is confirmed, clinicians assess the optic nerve, RNFL and tomography data. Trans Vis Sci Tech. 2012;1(1):3. 15. Traynis I, De Moraes CG, Raza AS, et al. Prevalence and nature still have several decisions to make. macular changes that occur in glau- of early glaucomatous defects in the central 10° of the visual field. First, they must decide if any statisti- coma. It has become indispensable JAMA Ophthalmol. 2014;132(3):291-7. 16. Grillo LM, Wang DL, Ramachandran R, et al. The 24-2 visual cally significant change is clinically in our decision-making in glaucoma field test misses central macular damage confirmed by the 10-2 visual field test and optical coherence tomography. Trans Vis Sci relevant. Life expectancy and disease and other diseases. By understand- Tech. 2016;5(2):15. severity may play a role. For exam- ing the technology, its abilities and 17. Chong GT, Lee RK. Glaucoma versus red disease: imaging and glaucoma diagnosis. Curr Opin Ophthalmol. 2012;23(2):79-88. ple, a change (or rate of change) that potential pitfalls, optometrists can be 18. Kim KE, Jeoung JW, Park KH, et al. Diagnostic classification of macular ganglion cell and retinal nerve fiber layer analysis is alarming in a younger patient with well prepared to use this tool in the differentiation of false positives from glaucoma. Ophthalmology. moderate disease might be less clini- diagnosis and management of glau- 2015;122(3):502-10. 19. Seo S, Lee CE, Jeong JH, et al. Ganglion cell-inner plexiform cally meaningful in an older patient coma. n layer and retinal nerve fiber layer thickness according to myopia and optic disc area: a quantitative and three-dimensional analysis. BMC with mild disease. Dr. Marrelli is a clinical professor Ophthalmol. 2017;17(1):22. 20. Yamashita T, Sakamoto T, Yoshihara N, et al. Correlations In addition to the clinical rel- and assistant dean of Clinical Educa- between retinal nerve fiber layer thickness and axial length, peripapil- evance of a change, the optometrist tion of the Ocular Diagnostic and lary retinal tilt, optic disc size, and retinal artery position in healthy eyes. J Glaucoma. 2017;26(1):34-40. should consider whether the change Medical Eye Service at the University 21. Sayed MS, Margolis M, Lee RK. Green disease in optical coherence tomography diagnosis of glaucoma. Curr Opin Ophthlamol. is consistent with glaucoma or if of Houston College of Optometry. 2017;28(2):139-53. there is another explanation for the 22. Asrani S, Essaid L, Alder BD, et al. Artifacts in spectral-domain 1. Breusegem C, Fieuws S, Stalmans I, et al. Agreement and accu- optical coherence tomography measurements in glaucoma. JAMA change, such as cataract formation. racy of non-expert ophthalmologists in assessing glaucomatous Ophthalmol. 2014;132(4):396-402. If the change is deemed glaucoma- changes in serial stereo optic disc photographs. Ophthalmology. 23. Awadalla MS, Fitzgerald J, Andrew NH, et al. Prevalence and 2011;118(4):742-6. type of artefact with spectral domain optical coherence tomography tous, other considerations include 2. Azuara-Blanco A, Katz LJ, Spaeth GL, et al. Clinical agreement macular ganglion cell imaging in glaucoma surveillance. PLoS One. among glaucoma experts in the detection of glaucomatous changes 2018;13(12):e0206684. the time it took to reach that change of the optic disk using simultaneous stereoscopic photographs. Am J 24. Hwang YH, Kim MK, Kim DW. Segmentation errors in macular Ophthalmol. 2003;136(5):949-50. ganglion cell analysis as determined by optical coherence tomogra- (rate of progression), what the 3. Varma R, Steinmann WC, Scott IU. Expert agreement in evaluating phy. Ophthalmology. 2016;123(5):950-8. intraocular pressure and medica- the optic disc for glaucoma. Ophthalmology. 1992;99(2):215-21. 25. Liu Y, Simavli H, Que CJ, et al. Patient characteristics associated 4. Kansal V, Armstrong JJ, Pintwala R, et al. Optical coherence with artifacts in Spectralis optical coherence tomography imag- tion adherence was during that time tomography for glaucoma diagnosis: An evidence based meta- ing of the retinal nerve fiber layer in glaucoma. Am J Ophthalmol. analysis. PLoS One. 2018;13(1):e0190621. 2015;159(3):565-76. period and the impact of the next 5. Mwanza JC, Durbin MK, Budenz DL, et al. Glaucoma Diagnostic 26. Hardin JS, Taibbi G, Nelson SC, et al. Factors affecting Cirrus- intervention (additional medication, accuracy of ganglion cell-inner plexiform layer thickness: compari- HD OCT optic disc scan quality: a review with case examples. J son with nerve fiber layer and optic nerve head. Ophthalmology. Ophthalmol. 2015;746150. laser or incisional surgery) on the 2012;119(6):1151-8. 27. Leung CK. Diagnosing glaucoma progression with optical coher- 6. Fallon M, Valero O, Pazos, M, et al. Diagnostic accuracy of ence tomography. Curr Opin Ophthalmol. 2014;25(2):104-11. patient’s quality of life. imaging devices in glaucoma: a meta-analysis. Surv Ophthalmol. 28. Hammel N, Belghith A, Weinreb RN, et al. Comparing the rates 2017;62(4):446-61. of retinal nerve fiber layer and ganglion cell-inner plexiform layer 7. Oddone F, Lucenteforte E, Michelessi M, et al. Macular versus reti- loss in healthy eyes and in glaucoma eyes. Am J Ophthalmol. OCT helps detect progression, nal nerve fiber layer parameters for diagnosing manifest glaucoma: 2017;178:38-50. a systematic review of diagnostic accuracy studies. Ophthalmology. 29. Leung CKS, Ye C, Weinreb RN, et al. Impact of age-related but clinicians must carefully decide 2016;123(5):939-49. change of retinal nerve fiber layer and macular thickness on evalua- 8. Sullivan-Mee M, Ruegg CC, Pensyl D, et al. Diagnostic preci- tion of glaucoma progression. Ophthalmology. 2013;120(12):2485- what to do with all the informa- sion of retinal nerve fiber layer and macular thickness asymmetry 92. tion at their disposal.31 Finally, if a parameters for identifying early primary open-angle glaucoma. Am J 30. Wu Z, Saunders LJ, Zangwill LM, et al. Impact of normal aging Ophthalmol. 2013;156(3):567-77. and progression definitions on the specificity of detecting retinal therapeutic change is warranted due 9. Hood DC, Raza AS, de Moraes CG, et al. Glaucomatous damage of nerve fiber layer thinning. Am J Ophthalmol. 2017;181:106-13. the macula. Prog Retin Eye Res. 2013;32:1-21. 31. Weinreb RN, Garway-Heath DF, Leung C, et al, eds. World Glau- to progression, the clinician must 10. Curcio CA, Allen KA. Topography of ganglion cells in human coma Association Consensus Series 8: Progression of Glaucoma. reset the baseline of both structural retina. J Comp Neurol. 1990;300(1):5-25. Kugler Publications; 2011. 11. De Moraes CG, Song C, Liebmann JM, et al. Defining 10-2 32. Rosdahl JA, Asrani S. Glaucoma masqueraders: diagnosis by and functional testing to follow for visual field progression. Ophthalmology. 2014;121(3):741-9. spectral domain optical coherence tomography. Saudi J Ophthalmol. 12. Hood DC. Improving our understanding, and detection, of 2012;26(4):433-40. progression from the point of the glaucomatous damage: An approach based upon optical coherence 33. Pasol J. Neuro-ophthalmic disease and optical coherence tomography (OCT). Prog Retin Eye Res. 2017;57:46-75. tomography: glaucoma look-alikes. Curr Opin Ophthalmol. therapeutic intervention. 13. Wong JJ, Chen TC, Shen LQ, et al. Macular imaging for glauco- 2011;22(2):124-32. OCT has revolutionized our abil- ma using spectral-domain optical coherence tomography: a review. 34. Rodrigues IA. Acute and chronic spectral domain optical coher- Semin Ophthalmol. 2012;27(5-6):160-6. ence tomography features of branch retinal artery occlusion. BMJ ity to qualitatively and quantitatively 14. Hood DC, Raza AS, de Moraes CG, et al. The nature of macular Case Rep. 2013;2013:bcr2013009007.

OSC QUIZ

ou can obtain continuing education credit card at Review Education Group online, 1. Which of these is not typical of credit through the Optometric Study revieweducationgroup.com. You must achieve glaucoma? YCenter. Com plete the test form a score of 70 or higher to receive credit. Allow a. Uniform damage 360° around the optic and return it with the $35 fee to: Jobson four weeks for processing. For each Optomet nerve. Healthcare Information, LLC, Attn.: CE ric Study Center course you pass, you earn 2 b. Asymmetric damage between superior Processing, 395 Hudson Street, 3rd Floor hours of credit from Pennsyl vania College of and inferior poles of the optic nerve. New York, New York 10014. To be eligible, Optometry. c. Asymmetric damage between right and please return the card within three years of Please check with your state licensing left eyes. publication. You can also access the test form board to see if this approval counts toward d. Visual field defects that correlate to optic and submit your answers and payment via your CE requirement for relicensure. nerve damage.

REVIEW OF OPTOMETRY MAY 15, 2020 83 OPTOMETRIC STUDYSTUDY CENTER

OSC QUIZ

2. A large optic nerve (large vertical disc test and alerts when there has been a allow for manual re-segmentation of a diameter) is more likely to have: significant change. segmentation error. a. An average cup-to-disc ratio. b. It detects significant change that is d. Artifacts may be a source of red disease. b. A large cup-to-disc ratio. greater than the test-retest variability of c. A small cup-to-disc ratio. the instrument. 15. The most common pathology to cause d. It is impossible to predict. c. It calculates a slope (rate of change). a retinal artifact on an SD-OCT scan is: d. It can be used earlier in disease follow- a. Epiretinal membrane. 3. The thickest portion of the optic nerve up than trend analysis. b. Choroidal nevus. neuroretinal rim in a healthy/normal c. Large optic disc. individual is usually: 9. Which type of analysis determines a rate d. Small optic disc. a. Temporal. of change? b. Nasal. a. Event analysis. 16. When should a baseline be reset? c. Superior. b. Trend analysis. a. When a patient has suspected d. Inferior. c. Both event analysis and trend analysis. progression on an OCT. d. Neither event analysis nor trend b. When therapy is amplified due to 4. In a typical commercial SD-OCT, the analysis. confirmed progression. green shading of a particular parameter c. Every two years irrespective of means: 10. If structural change is suspected on an progression. a. The patient must be normal. SD-OCT scan, what is the next step? d. When the clinician is not happy with the b. The patient is within the top 90% a. Immediately increase therapy. rate of change. to 95% compared with the normative b. Repeat the scan to confirm or refute the reference database of the machine. suspected change. 17. When deciding whether or not to c. The patient definitely does not have c. Confirm the structural change with a amplify therapy after confirming structural glaucoma. functional (visual field) test. progression, which of the following should d. None of the above. d. None of the above. be considered? a. The time it took for the change to 5. Red disease refers to: 11. The RNFL is thickest and shows the occur in correlation with the patient’s a. False positive (identification of a normal brightest reflectivity on SD-OCT in which demographics. patient as abnormal). sectors? b. The intraocular pressure during the time b. False negative (identification of a a. Inferior/superior. of progression. glaucomatous patient as normal). b. Nasal/temporal. c. The impact of the next intervention. c. It depends on the instrument. c. Inferior/nasal. d. All of the above. d. None of the above. d. Superior/temporal. 18. False positive glaucoma classification 6. Which of the following represents a 12. In patients who show areas of macular with SD-OCT has been associated with: disease that can impact the interpretation ganglion cell loss but don’t show RNFL a. Increased axial length. of the retinal nerve fiber layer on an loss, which visual field test may be better b. Large optic disc. SD-OCT? able to detect visual field loss? c. Hyperopia. a. Optic disc drusen. a. 30-2. d. All of the above. b. Branch retinal vein occlusion. b. 24-2. c. Ischemic optic neuropathy. c. 10-2. 19. Which of the following is an SD-OCT d. All of the above. d. 120-point screening. finding consistent with the diagnosis of glaucoma? 7. Which of the following are advantages 13. The area of the macula most likely to a. Asymmetry of RNFL or ganglion cell of macular SD-OCT in the diagnosis of show ganglion cell loss in glaucoma has thickness between right and left eye. glaucoma over the peripapillary RNFL? been termed “the macular vulnerability b. Asymmetry between superior and a. Less impact from other anatomic zone,” which is located: inferior RNFL within an eye. components such as blood vessels. a. Inferior temporal to fovea. c. A sharply demarcated inferotemporal or b. More uniform anatomy in the macula b. Inferior nasal to fovea. superotemporal ganglion cell loss. compared with the peripapillary RNFL. c. Superior temporal to fovea. d. All of the above. c. Better superior/inferior symmetry d. Superior nasal to fovea. and right/left symmetry of the macula 20. Which of the following is true compared with the RNFL. 14. Which statement is true regarding regarding progression detection in d. All of the above. artifacts on an SD-OCT? SD-OCT? a. All artifacts have clinically significant a. The OCT instruments factor in age- 8. All of these are true about event analysis impact on the interpretation. related loss in their progression software. in looking for progression, except: b. Technician error is always unavoidable. b. RNFL thinning is more difficult to detect a. It compares each test with the baseline c. All commercially available instruments in more advanced disease.

84 REVIEW OF OPTOMETRY MAY 15, 2020 Mail to: Jobson Healthcare Information, LLC, Attn.: CE Processing, 395 Examination Answer Sheet Hudson Street, 3rd Floor New York, New York 10014 Maximizing OCT in the Diagnosis and Management of Glaucoma Payment: Remit $35 with this exam. Make check payable to Jobson Healthcare Information, LLC. Valid for credit through May 15, 2023 Credit: This course is COPE approved for 2 hours of CE credit. Course ID is Online: This exam can be taken online at revieweducationgroup.com. Upon pass- 67936-GL. ing the exam, you can view your results immediately and download a real-time CE Jointly provided by Postgraduate Institute for Medicine and Review Education certificate. You can also view your test history at any time from the website. Group. Directions: Select one answer for each question in the exam and completely Salus University has sponsored the review and approval of this activity. darken the appropriate circle. A minimum score of 70% is required to earn credit. Processing: There is a four-week processing time for this exam. Answers to CE exam: Post-activity evaluation questions: 1. A B C D Rate how well the activity supported your achievement of these learning objectives: 2. A B C D 1=Poor, 2=Fair, 3=Neutral, 4=Good, 5=Excellent 3. A B C D

4. A B C D 21. Discuss OCT findings and common concerns with the technology. 1 2 3 4 5 A B C D 5. 22. Use OCT to confirm a diagnosis of glaucoma. 1 2 3 4 5 6. A B C D 23. Follow glaucoma patients with serial macular and RNFL scans. 1 2 3 4 5 7. A B C D 24. Avoid common concerns related to OCT technology. 1 2 3 4 5 8. A B C D 9. A B C D 25. Based upon your participation in this activity, do you intend to change your practice behavior? 10. A B C D (choose only one of the following options)

11. A B C D A I do plan to implement changes in my practice based on the information presented. B 12. A B C D My current practice has been reinforced by the information presented. C 13. A B C D I need more information before I will change my practice.

14. A B C D 26. Thinking about how your participation in this activity will influence your patient care, how many of your

15. A B C D patients are likely to benefit? (please use a number):

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D 27. If you plan to change your practice behavior, what type of changes do you plan to implement? (check all 29. Which of the following do you anticipate will that apply) be the primary barrier to implementing these changes? a Apply latest guidelines b Change in pharmaceutical therapy c Choice of treatment/management approach a Formulary restrictions d Change in current practice for referral e Change in non-pharmaceutical therapy f Change in differential b Time constraints diagnosis g Change in diagnostic testing h Other, please specify: ______c System constraints ______d Insurance/financial issues

e Lack of interprofessional team support 28. How confident are you that you will be able to make your intended changes? f Treatment related adverse events a Very confident b Somewhat confident c Unsure d Not confident g Patient adherence/compliance

h Other, please specify: Please retain a copy for your records. Please print clearly.

First Name 30. Additional comments on this course: Last Name ______E-Mail ______The following is your: Home Address Business Address ______Business Name

Address Rate the quality of the material provided: City State 1=Strongly disagree, 2=Somewhat disagree, 3=Neutral, 4=Somewhat agree, 5=Strongly agree ZIP 31. The content was evidence-based. Telephone # - - 1 2 3 4 5 Fax # - - 32. The content was balanced and free of bias.

1 2 3 4 5 By submitting this answer sheet, I certify that I have read the lesson in its entirety and completed the self- assessment exam personally based on the material presented. I have not obtained the answers to this exam 33. The presentation was clear and effective. by any fraudulent or improper means. 1 2 3 4 5 Signature Date

Lesson 119701 RO-OSC-0520

REVIEW OF OPTOMETRY MAY 15, 2020 85 Cornea+Contact Lens Q+A

Patient, Heal Thyself When contact lens wear leads to limbal stem cell deficiency, you may be able to turn to autologous serum tears for help. Edited by Joseph P. Shovlin, OD

My patient has had a partial lim- dosed four to six times daily. If signs Q bal stem cell deficiency (LSCD) and/or symptoms don’t improve following soft contact lens (CL) wear or the initial presentation is more for several decades. I have treated severe, she advises prescribing a her with a few options with minimal higher concentration. improvement. Should I consider autolo- Long-term use of concentrations gous serum tears? above 50% may slow epithelial LSCD occurs when there is growth and increase scarring and A loss of or damage to LSCs or inflammation due to serum pro- the microenvironment that promotes Superior epitheliopathy extends inflammatory factors.3 Dr. Lucas their survival, according to Katelyn centripetally in a whorl pattern in LSCD notes that lower concentrations may Lucas, OD, of Price Vision Group in secondary to chemical burn. be used for years if the patient con- Indianapolis. She notes that LSCs are tinues to improve. If LSCD resolves, required for corneal epithelialization majority being soft CL users.2 Dr. she recommends discontinuing to maintain surface integrity and cor- Lucas recommends conducting a serum tear use and continuing with neal transparency. thorough slit lamp exam, as punctate conservative therapy to promote a staining may be the only early sign. healthy environment for LSCs. The Breakdown Many CL-induced LSCD cases After the patient has blood drawn, Dr. Lucas notes that partial/sectoral can be reversed with the cessation of Dr. Lucas says they can then take LSCD occurs when a section of the CL use, says Dr. Lucas, adding that their vials to a compounding phar- limbus is involved, typically the supe- dry eye therapy can help improve the macy or a company that partners rior limbus, and can be managed by ocular surface. When conservative with local labs. To prevent contami- improving the ocular surface to pro- therapy is not enough, she suggests nation and degradation, serum tears vide a livable environment for LSCs. considering topical vitamin A, punc- need to be refrigerated or kept frozen Total/diffuse LSCD typically results tal plugs, topical anti-inflammatory until needed. In diabetes patients, in surgery, as no LSCs are present to meds or autologous serum tears. She finger-prick autologous blood is a repopulate the corneal epithelium. warns that severe CL-induced LSCD low-cost, accessible alternative. Primary causes of LSCD result from may require surgical management CL-induced LSCD can be difficult congenital or genetic disorders, while with autologous or allograft LSC to diagnose due to its subclinical, secondary causes are due to ocular transplantation. asymmetric presentation. Clinicians surface disorders or external factors, must carefully examine their CL including CL wear.1 The Process patients, as early intervention can The cause of CL-induced LSCD is Autologous serum tears contain a help restore LSC health. When met likely multifactorial, with potential variety of factors that help epithelial with challenges in the LSCD man- factors including hypoxia, disinfect- cells with proliferation, differen- agement, autologous serum tears are ing solution, mechanical trauma tiation and maturation.3 Dr. Lucas a great tool to treat refractory ocular and dry eye.2 These cases are easily notes that concentrations range from surface disease. n overlooked, says Dr. Lucas, as they 20% to 100%, and dosages can 1. Le Q, Xu J, Deng SX. Review: the diagnosis of limbal stem cell are typically mild and patients are be anywhere from BID to hourly deficiency. Ocul Surf. 2018;16(1):58-69. 2. Rossen J, Amram A, Milani B, et al. Contact lens-induced limbal usually asymptomatic. It is esti- depending on severity. When initially stem cell deficiency. Ocul Surf. 2016;14(4):419-34. mated that up to 5% of CL wearers prescribing serum tears, she typically 3. Yeh SI, Chu TW, Cheng HC, et al. The use of autologous serum to reverse severe contact lens-induced limbal stem cell deficiency. develop signs of LSCD, with the starts with a 20% concentration Cornea. January 24, 2020. [Epub ahead of print].

86 REVIEW OF OPTOMETRY MAY 15, 2020 Earn up to

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Track the Hill of Vision The visual field mean deviation is key when assessing glaucomatous changes. By Bisant A. Labib, OD

laucoma is a progressive optic Gneuropathy characterized by retinal nerve fiber layer loss with or without subsequent visual field (VF) damage. Both the diagnosis and management of glaucoma is largely dependent on the patient’s VF tests.1,2 Deciding when to initiate or change treatment is determined by a number of different factors, one of the most important being the interpretation of various aspects of the patient’s VF testing. However, interpreting a VF printout At left, the 24-2 VF shows one centrally depressed point, which manifests as a larger defect on can be daunting, with sev- the 10-2 VF, at right, due to higher resolution and more central field. The MDs are similar but eral elements to evaluate slightly worse on the 10-2 VF due to larger defect detected with higher resolution. and consider. An easy and important index to keep track of is Field Analyzer. The most common lar glaucoma, a 10-2 may replace the mean deviation (MD). VF test employed for glaucoma or supplement the 24-2 test. In patients and glaucoma suspects is contrast to the 24-2, the 10-2 test VF Basics the 24-2 test. This measures the measures the central 10 degrees Automated VF perimetry is a stan- central 24 degrees of field, consist- of fixation with higher resolution, dard test that clinicians can use to ing of a total of 54 test points, each consisting of a total of 68 test evaluate the presence and progres- separated by six degrees. points separated by two degrees. sion of glaucomatous defects, most In the setting of severe visual Assessing the central 10 degrees of commonly using the Humphrey loss, or even in cases of early macu- fixation in standard 24-2 testing would be of little value, as it is only Visual Field Index represented by 12 overall points.2 A similar measurement that is often used in correlation with the MD is the visual field index Before performing any VF inter- (VFI). The VFI was developed to better establish changes in glaucoma patients and address pretation, clinicians must first eval- the drawbacks of the MD. While the MD is measured as a decibel value, the VFI is a percent- uate the test for accuracy. The three age relative to the sensitivity of a reference group of healthy observers. indices that determine reliability are For example, a healthy patient with no vision loss and a full field would have a VFI of 100%. fixation losses, false positives and Unlike the MD, the VFI disregards general reductions in sensitivity associated with cataracts or false negatives. Generally speak- refractive errors, unless they are associated with patter deviations outside the normal range.8 ing, the arbitrary cutoff values are set at 33% for false negatives and

88 REVIEW OF OPTOMETRY MAY 15, 2020 false positives and 20% for fixation MD Beyond Glaucoma loss.3 Once clinicians determine that The MD, an easily identified value on a standard VF printout, can provide a significant the test is valid, they can use the VF amount of information to aid in the management and treatment of glaucoma patients. readout for clinical management. It can also help clinicians measure possible progression in other ocular disorders. For example, research shows MD can help clinicians determine visual outcome in patients Mean Deviation with papilledema secondary to idiopathic intracranial hypertension—patients with low MD While there are several useful values at initial presentation had a more favorable visual outcome.9 aspects of a VF printout, the MD Additionally, comparison of MD values between the two eyes can be an excellent pre- is one of the most important. The dictor of the presence of an afferent pupillary defect (APD).10 The greater the difference in MD is the average, point-wise dif- MD values, the larger grade the APD when observed clinically. In the same manner, glau- ference between a given test result coma patients who present clinically with an APD will have more asymmetric VF loss.11 and the normal, age-matched reference value.1 This value is derived from the total deviation plot and visual outcome.1 MD is also a mea- to monitor the MD in 10-2 VFs for indicates the overall depression sure used in clinical trials to deter- severe defects.2 or elevation of a patient’s hill of mine drug efficacy. For example, vision. For example, a patient with one study comparing timolol and Mean deviation is a simple a positive MD value will have a brimonidine treatments concluded measure that can help clinicians better than normal hill of vision that they were both similarly effica- efficiently identify visual changes (which could occur simply because cious by comparing study partici- in a number of ocular conditions, the patient’s VF is better than pants’ MD slopes in their VFs over the most notable being glaucoma. the normative database, or in a time as an outcome measure.6 It should be an integral part of a patient with excessively high false Reliability of a VF test can also clinician’s assessment when caring positives), whereas a patient with a affect the MD value. The greater for patients with the potential for very low MD will have a decreased the percentage of false negatives— visual field loss. n hill of vision, indicating pathology.4 which may be increased in glau- Identifying if a patient’s visual coma patients—the lower the MD. 1. Chauhan BC, Garway-Heath DF, Goñi FJ, et al. Practical recommendations for measuring rates of visual field change field is truly progressing is a mul- Similarly, a trigger-happy patient in glaucoma. Br J Ophthalmol. 2008;92(4):569-73. tifactorial process that can be with high false positives will yield a 2. Rao HL, Begum VU, Khadka D, et al. Comparing glaucoma 3 progression on 24-2 and 10-2 visual field examinations. challenging. Many patients may higher MD. Age is also something PLoS One. 2015;10(5):e0127233. exhibit progressive VF loss in the worth considering, as research 3. Tan NYQ, Tham YC, Koh V, et al. The effect of testing reliability on visual field sensitivity in normal eyes: the Singapore absence of clear, structural optic shows an association with increas- Chinese eye study. Ophthalmology. 2018;125(1):15-21. nerve changes.5 In addition, VF ing age and lower MD values, sug- 4. Thomas R, George R. Interpreting automated perimetry. Indian J Ophthalmol. 2001;49(2):125-40. results can be inconsistent, making gesting more aggressive treatments 5. Anderson AJ. significant glaucomatous visual field pro- it difficult to discern a clinically sig- in elderly patients with VF second- gression in the first two years: what does it mean? Transl Vis 7 Sci Technol. 2016;5(6):1. Erratum in: Transl Vis Sci Technol. nificant progression compared with ary to glaucoma. 2017;6(1):10. regular test variability. Mean deviation values are pres- 6. Yokoyama Y, Kawasaki R, Takahashi H, et al. Effects of brimonidine and timolol on the progression of visual field To help improve visual field test- ent on both the 24-2 and 10-2 defects in open-angle glaucoma: a single-center randomized ing consistency, clinicians should analyses. Rates of MD changes in trial. J Glaucoma. 2019;28(7):575-83. 7. Bommakanti N, De Moraes CG, Boland MV, et al. Baseline perform at least six VF tests in the glaucomatous eyes with VF defects age and mean deviation affect the rate of glaucomatous vision first two years after a patient is on both types of tests are similar loss. J Glaucoma. 2020;29(1):31-38. 8. Mansuri G, Chawala A, Gandhi S, et al. Relationship of a diagnosed with glaucoma to estab- in mild to moderate loss. However, new visual field index, the VFI, with Mean deviation (MD) in lish baseline reliability and rule out the changes in MD in severe glau- 30-2 and 24-2 threshold tests examined by Humphrey field analyzer in POAG patients. Gujarat Med J. 2014;69(1):93-95. rapid progression. coma with advanced VF loss are 9. Mikkilineni S, Trobe JD, Cornblath WT, De Lott L. Visual Using MD values can be an more significant in the 10-2. This is field mean deviation at diagnosis of idiopathic intracranial hypertension predicts visual outcome. J Neuroophthalmol. important tool in these cases. A likely due to the peripheral points 2019;39(2):186-90. rapid rate of progression based of the 24-2 reaching their “floor.” 10. Bobak SP, Goodwin JA, Guevara RA, et al. Predictors of visual acuity and the relative afferent pupillary defect in optic only on the MD is established at Having the inability to detect neuropathy. Doc Ophthalmol. 1998;97(1):81-95. more than -2dB per year. The less peripheral worsening will mask the 11. Bruckmann A, Gäßler C, Dietzsch J, et al. High correlation between relative afferent pupillary defect (RAPD) and visual decrease in the MD over time, the severity of changes occurring cen- field loss in patients with glaucomatous optic neuropathy. better the chance of maintaining trally. As such, it is more important Invest Ophthalmol Vis Sci. 2011;52(14):5513.

REVIEW OF OPTOMETRY MAY 15, 2020 89 Therapeutic Review

Managing Neovascular Glaucoma Following a step-wise approach affords the best outcome. By Joseph W. Sowka, OD

n 82-year-old man pre- microhyphema may be seen gonio- sented with a moderately scopically. Funduscopically, there painful left eye for the will often be evidence of retinal ves- A previous two weeks. He sel occlusion (either artery or vein), was diabetic and hypertensive and DR, ocular ischemic syndrome or had been diagnosed with open-angle another condition stimulating retinal glaucoma in both eyes nearly two ischemia. years earlier. His right eye was in the Retinal hypoxia induces vascular advanced stage and he had moderate endothelial growth factor (VEGF) nonproliferative diabetic retinopathy This patient had pain with vision loss to act upon healthy endothelial cells (DR) in each eye. He was prescribed and profound pathological findings such of viable capillaries to stimulate the a prostaglandin analog for glaucoma as hyphema, microcystic edema and formation of a fragile new plexus of and reappointed for ongoing care, peripupillary iris neovascularization. vessels (neovascularization).11-16 In but was lost to follow-up until now. cases of extreme retinal hypoxia— At this visit, he was 20/25 OD Discussion such as ischemic central retinal vein and bare light perception OS. He Patients with NVG typically pres- occlusion—very few retinal capil- was bilaterally pseudophakic with ent with a chronically red, painful laries are viable. In that instance, posterior chamber intraocular lenses eye, which often has significant researchers theorize that VEGF can in each eye. He reported still using vision loss. The majority of patients’ diffuse forward to the nearest area latanoprost. He had moderate glau- presenting acuity will be below of viable capillaries, namely the pos- comatous optic nerve damage in the 20/200.1-3 They often have signifi- terior iris. Neovascularization buds right eye with a small amount of cant concurrent vascular disease, off of the capillaries of the posterior neovascularization of the disc and such as diabetes, hypertension or iris, grows along the posterior iris, DR elsewhere. His intraocular pres- giant cell arteritis (GCA)— diabetes through the pupil, along the anterior sures (IOP) were 23mm Hg OD and is the most common precipitating surface of the iris and then into the 62mm Hg OS. His left eye mani- cause of NVG.3-8 Patients are also angle. Once in the angle, the neovas- fested central microcystic corneal likely to have an antecedent his- cularization, along with attendant edema, florid iris neovascularization tory of a retinal vessel occlusion, fibrovascular support membrane, and hyphema. Gonioscopically, carotid artery disease, chronic retinal acts to both physically block the his right angle was open to at least detachment or advanced DR.5,8 angle as well as bridge the angle and scleral spur while his left angle was These patients will have visible physically pull the iris and cornea closed with peripheral anterior syn- neovascularization of the iris and into apposition. This blocks the tra- echiae (PAS) for 180˚, with hyphema angle. The patient will typically have becular meshwork with progressive and angle neovascularization for the significant corneal edema, anterior PAS.17 remaining part of the angle. Due to segment inflammation, anterior corneal edema, circulating red blood chamber cell and flare reaction. Management cells in the anterior chamber and a They’ll usually have elevated IOP, Neovascular glaucoma requires poor dilation, we could not see the often exceeding 60mm Hg.1,9,10 prompt and aggressive therapy that left fundus. Gonioscopically, there will be total involves IOP and inflammation Clearly, this was an acutely urgent or near-total angle closure with mas- control as well as management of case of neovascular glaucoma sive areas of PAS and neovascular- retinal ischemia and any precipitat- (NVG). ization of the angle. In early cases, ing conditions. Upon first presenta-

90 REVIEW OF OPTOMETRY MAY 15, 2020 mented trabeculectomy for neovascular glaucoma. A preliminary tion, prescribe a strong cycloplegic ing antiangiogenic injection if the report. Indian J Ophthalmol. 2002;50(4):287-93. 6. Hamanaka T, Akabane N, Yajima T, et al. Retinal ischemia and such as atropine 1% BID as well as a causative factor is unaddressed. For angle neovascularization in proliferative diabetic retinopathy. Am topical steroid such as prednisolone that reason, antiangiogenic therapy J Ophthalmol. 2001;132(5):648-58. 7. Chen KJ, Chen SN, Kao LY, et al. Ocular ischemic syndrome. acetate 1% or difluprednate 0.05% should only be considered a valuable Chang Gung Med J. 2001;24(8):483-91. 10 8. Detry-Morel M. Neovascular glaucoma in the diabetic patient. QID. The fact that the angle may adjunct along with laser photoabla- Bull Soc Belge Ophtalmol. 1995;256:133-41. 29,30 9. Shazly TA, Latina MA. Neovascular glaucoma: etiology, diag- be closed with PAS does not pre- tion in the management of NVG. nosis and prognosis. Semin Ophthalmol. 2009;24(2):113-21. clude pharmacologic mydriasis from Medical therapy following PRP is 10. Löffler KU. Neovascular glaucoma: aetiology, pathogenesis and treatment. Ophthalmologe. 2006;103(12):1057-63 atropine. Neither does the elevated common, though frequently insuf- 11. Kozawa T, Sone H, Okuda Y, et al. Vascular endothelial growth factor levels in the aqueous and serum in diabetic reti- IOP disqualify steroid use. This ficient to manage the glaucoma. nopathy with or without neovascular glaucoma. Nippon Ganka will greatly add to patient comfort. Often, IOP lowering surgical meth- Gakkai Zasshi. 1998;102(11):731-8. 12. Pe’er J, Folberg R, Itin A, et al. Vascular endothelial growth Aqueous suppressants in the form of ods are required. Trabeculectomy factor upregulation in human central retinal vein occlusion. Ophthalmology. 1998;105(3):412-6. beta blockers, carbonic anhydrase with antimetabolite adjuncts have 13. Tripathi RC, Li J, Tripathi BJ, et al. Increased level of vascular inhibitors and alpha adrenergic effectively managed the elevated IOP endothelial growth factor in aqueous humor of patients with neovascular glaucoma. Ophthalmology. 1998;105(2):232-7. agonists may be used to temporar- in NVG.5 Often, the use of drain- 14. Tolentino MJ, Miller JW, Gragoudas ES, et al. Vascular 10 endothelial growth factor is sufficient to produce iris neovascu- ily reduce IOP. However, chronic age devices are necessary to optimize larization and neovascular glaucoma in a nonhuman primate. medical therapy is not indicated for 31, 32 Arch Ophthalmol. 1996;114(8):964-70. surgical outcomes. 15. Hu DN, Ritch R, Liebmann J, et al. Vascular endothelial neovascular glaucoma. Aqueous growth factor is increased in aqueous humor of glaucomatous eyes. J Glaucoma. 2002;11(5):406-10. suppressants will temporize IOP and This patient’s NVG clearly result- 16. Scholl S, Kirchhof J, Augustin AJ. Antivascular endothelial growth factors in anterior segment diseases. Dev Ophthalmol. lead to a false sense of security, as ed from ischemic retinal disease. 2010;46:133-9. the neovascular process will continue He was prescribed atropine 1% 17. Hamard P, Baudouin C. Consensus on neovascular glau- 18 coma. J Fr Ophtalmol. 2000;23(3):289-94. with further angle closure. BID, prednisolone acetate 1% QID, 18. Sivak-Callcott JA, O’Day DM, Gass JD, et al. Evidence-based recommendations for the diagnosis and treatment of neovascular Management of anterior seg- brinzolamide/brimonidine fixed glaucoma. Ophthalmology. 2001;108(10):1767-76. ment neovascularization and NVG 19. Brooks AM, Gillies WE.The development and management of combination TID in the left eye and neovascular glaucoma. Aust N Z J Ophthalmol. 1990;18(2):179-85. involves eradication of the vessels. latanoprost QHS OU and scheduled 20. Cashwell LF, Marks WP. Panretinal photocoagulation in the management of neovascular glaucoma. South Med J. This is best accomplished with pan- for definitive treatment with a retinal 1988;81(11):1364-8. retinal photocoagulation (PRP) to 21. Stefaniotou M, Paschides CA, Psilas K. Panretinal cryopexy specialist. Upon meeting with the for the management of neovascularization of the iris. Ophthalmo- destroy ischemic retina, minimize retina specialist approximately two logica. 1995;209(3):141-4. 22. Lee SC, Kim GO, Kim DH, et al. Endoscopic laser photoco- oxygen demand of the eye, and weeks later, his eye pain had disap- agulation for management of neovascular glaucoma. Yonsei Med reduce the amount of VEGF being J. 2000;41(4):445-9. peared, his IOP lowered to 24mm 23. Lee SJ, Lee JJ, Kim SY, Kim SD. Intravitreal bevacizumab 19-22 released. PRP tends to effectively Hg OS and his cornea had cleared (Avastin) treatment of neovascular glaucoma in ocular ischemic cause regression and involution of syndrome. Korean J Ophthalmol. 2009;23(2):132-4. enough to allow fundus examina- 24. Yazdani S, Hendi K, Pakravan M, et al. Intravitreal bevaci- anterior segment neovascularization tion. He still had an iris neovascu- zumab for neovascular glaucoma: a randomized controlled trial. 17 J Glaucoma. 2009;18(8):632-7. in approximately 60% of cases. larization, but the hyphema had 25. Beutel J, Peters S, Lüke M, et al. Bevacizumab as adjuvant This may also reduce IOP as well as cleared. Fundus examination of the for neovascular glaucoma. Acta Ophthalmol. 2010;88(1):103-9. 26. Batioğlu F, Astam N, Ozmert E. Rapid improvement of retinal induce vessel regression. right eye revealed end stage glauco- and iris neovascularization after a single intravitreal bevacizumab While PRP is the most definitive matous atrophy and extensive retinal injection in a patient with central retinal vein occlusion and neovascular glaucoma. Int Ophthalmol. 2008;28(1):59-61. treatment for the neovascularization hemorrhaging. Fluorescein angiog- 27. Katsanos A, Gorgoli K, Mikropoulos DG, et al Assessing the causing NVG, the advent and use of raphy demonstrated poor flow into role of ranibizumab in improving the outcome of glaucoma filter- ing surgery and neovascular glaucoma. Expert Opin Biol Ther. antiangiogenic drugs has proven a the left eye and a combined central 2018;18(6):719-24. valuable adjunct. Intravitreal inject- retinal artery and vein occlusion. He 28. Andrés-Guerrero V, Perucho-González L, García-Feijoo J, et al. Current perspectives on the use of anti-VEGF drugs as adju- able agents such as bevacizumab, received an anti-VEGF injection and vant therapy in glaucoma. Adv Ther. 2017;34(2):378-95. ranibizumab and aflibercept have was scheduled for PRP. n 29. Hasanreisoglu M, Weinberger D, Mimouni K, et al. Intra- been demonstrated through numer- vitreal bevacizumab as an adjunct treatment for neovascular 1. Kuang TM, Liu CJ, Chou CK, et al. Clinical experience in glaucoma. Eur J Ophthalmol. 2009;19(4):607-12. ous reports, both controlled studies the management of neovascular glaucoma. J Chin Med Assoc. 30. Ciftci S, Sakalar YB, Unlu K, et al. Intravitreal bevacizumab 2004;67(3):131-5. combined with panretinal photocoagulation in the treatment and case series, to cause prompt and 2. Nabili S, Kirkness CM. Trans-scleral diode laser cyclophoto- of open angle neovascular glaucoma. Eur J Ophthalmol. thorough regression of anterior seg- coagulation in the treatment of diabetic neovascular glaucoma. 2009;19(6):1028-33. Eye. 2004;18(4):352-6. 23- 31. Alkawas AA, Shahien EA, Hussein AM. Management of neo- ment neovascularization in NVG. 3. Al-Shamsi HN, Dueker DK, Nowilaty SR, Al-Shahwan SA. vascular glaucoma with panretinal photocoagulation, intravitreal 28 Neovascular glaucoma at king khaled eye specialist hospi- bevacizumab, and subsequent trabeculectomy with mitomycin C. Regression can be significant and tal - etiologic considerations. Middle East Afr J Ophthalmol. 2009;16(1):15-9. J Glaucoma. 2010 Feb 22. [Epub ahead of print] occur within a period as short as 4. Lawrence PF, Oderich GS. Ophthalmologic findings as 32. Eid TM, Radwan A, el-Manawy W, el-Hawary I. Intra- one day following injection.26 Neo- predictors of carotid artery disease. Vasc Endovascular Surg. vitreal bevacizumab and aqueous shunting surgery for 2002;36(6):415-24. neovascular glaucoma: safety and efficacy. Can J Ophthalmol. vascularization can recur follow- 5. Mandal AK, Majji AB, Mandal SP, et al. Mitomycin-C-aug- 2009;44(4):451-6.

REVIEW OF OPTOMETRY MAY 15, 2020 91 Review of Systems

A Common Denominator Polycystic ovary syndrome is a hormonal disorder that can have ocular implications. By Carlo J. Pelino, OD, and Joseph J. Pizzimenti, OD

olycystic ovary syndrome diovascular risk by evaluating their (PCOS) is a complex condition body-mass index (BMI), fasting lipid characterized by menstrual and lipoprotein levels and metabolic P 2,3,11 irregularities, androgen excess and syndrome risk. ovarian cysts.1 It is defined as the Women with PCOS have a higher presence of any two of the following: rate of infertility and are at increased polycystic ovaries, anovulation or oli- risk of pregnancy loss and complica- goovulation and hyperandrogenism.2 tions, including gestational diabetes.1,3 They also have an increased A Triad of Signs prevalence of coronary artery calcifi- A woman has polycystic ovaries if 20 cation and thickened carotid intima or more follicles—functional units of media, which may be responsible ovaries that secrete hormones—are for subclinical atherosclerosis.1,3 present in at least one ovary. Ultra- Fig. 1. The HPG axis runs a feedback loop Approximately 10% of women with sonography can detect polycystic that could cause PCOS if interrupted. PCOS have type 2 diabetes, and ovaries, which typically involve 10 30% to 40% have impaired glucose to 12 small follicles spaced close lion women of childbearing age in tolerance by the age of 40.11 Perform together in a bilateral formation on the US alone.3 Researchers believe glucose tolerance and glycosylated the peripheral edge of the ovaries.2,3 PCOS is caused by a disordered feed- hemoglobin testing, regardless of a Anovulation occurs when the back loop between the ovaries and patient’s weight. ovaries do not release an oocyte dur- the hypothalamic-pituitary-gonadal ing the menstrual cycle, precluding (HPG) axis (Figure 1). This leads to Ocular Comorbidities ovulation; however, a woman may deficits in the release of luteinizing Estrogen, progesterone and andro- still menstruate. If ovulation is pres- hormone in the presence of follicle- gen receptors have been found in the ent but irregular, it’s called oligoovu- stimulating hormone.1,2 cornea, lens, iris, ciliary body, retina, lation (fewer than nine menstrual The inappropriate gonadotropin lacrimal glands, meibomian glands cycles per year).1,4 secretion seen in PCOS is most likely and conjunctiva. It is thus incumbent Hyperandrogenism—defined a result of, rather than a cause of, on ODs to identify potential signs of by hirsutism, excess of blood tes- ovarian dysfunction. Another consis- PCOS and its ocular comorbidities.12 tosterone (T) levels or both—is an tent biochemical feature of PCOS is These may include ocular dryness endocrine disorder that affects 5% a raised plasma T level.8 This causes and/or itching, diabetic retinopathy, to 10% of women of reproductive concomitant insulin resistance and floppy lid syndrome, central serous age.5 Clinical manifestations include compensatory hyperinsulinemia, chorioretinopathy, keratoconus and hirsutism, acne, androgenic alopecia increasing glucose intolerance. These anterior ischemic optic neuropathy. and virilization.1,4 Many of these patients tend to be overweight; Idiopathic intracranial hypertension patients also tend to have PCOS. nearly half of all women with PCOS (IIH), or pseudotumor cerebri, may are clinically obese.9 Many have be another. PCOS Essentials obstructive sleep apnea (OSA), IIH initially presents as bilateral At least 7% of all adult women have which adds to the risk of cardiovas- optic disc edema of unknown cause PCOS, with one study estimating cular disease.10 Clinicians should ask (Figure 2). It predominantly affects this number to be as high as 21%.6,7 OSA patients about excessive day- women of childbearing age who are It impacts approximately five mil- time somnolence and assess their car- obese. The condition causes chroni-

92 REVIEW OF OPTOMETRY MAY 15, 2020 Photo: Leonard V. Messner, OD cally elevated intracranial pressure should not be used together.15 Met- and papilledema, which may lead formin use can be continued into to progressive optic atrophy and pregnancy and may decrease miscar- reduced visual function.13 riage rates. Given that obesity is commonly Medications could include:1-3 associated with IIH and PCOS, there • Hypoglycemic agents may be an association between the • Selective estrogen receptor two. A study of 38 women with modulators IIH found 15 also had PCOS and • Topical hair-removal agents 24 were obese.13 The researchers • Oral contraceptive agents proposed PCOS-driven obesity facili- • Anti-androgens tates IIH after learning that increased • Topical acne agents intra-abdominal and cardiac filling Surgical management of PCOS pressures associated with obesity aims to restore ovulation. There may result in a retrograde increase are two types: laparoscopic ovarian in cerebrospinal fluid pressure.13 drilling and ovarian wedge resection. Another study reported that out of Fig. 2. Bilateral optic disc edema is Laparoscopic drilling uses electro- 58 women with IIH, nine had PCOS, visible in a patient with IIH, OD on top. cautery or a laser to destroy parts concluding that the prevalence of of the ovary and trigger ovulation. PCOS is higher in IIH patients.14 Ovarian biopsy may histologically Wedge resection removes a section of Beyond obesity, PCOS may be confirm PCOS; however, ultraso- ovary to help regulate menstruation associated with IIH through an nography generally supersedes histo- and promote normal ovulation.1-3 increased risk of thrombosis. High pathologic analysis. An endometrial PCOS is a common, lifelong estrogen levels, common in PCOS biopsy can evaluate for endometrial health condition in women. These and severe obesity, are thrombophilic disease, such as malignancy.2,3 patients can develop serious health and may play a role in the develop- problems, especially if they are ment of IIH, particularly in patients Treatment overweight, and must be managed with coagulation disorders.13,14 Lifestyle changes combined with accordingly. Even ODs have a part metformin can help with weight loss, to play, as ocular comorbidities Diagnosis which is recommended to reduce could be present. n When PCOS is suspected, first cardiovascular risks and complica- 1. Carmina E, Lobo RA. Polycystic ovary syndrome (PCOS): arguably the 2,3 most common endocrinopathy is associated with significant morbidity in exclude all other disorders that could tions associated with diabetes. women. J Clin Endocrinol Metab. 1999;84(6):1897-9. 2. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. result in menstrual irregularity and Pharmacologic treatments are Revised 2003 consensus on diagnostic criteria and long-term health risks hyperandrogenism, including adrenal reserved for metabolic derangements, related to polycystic ovary syndrome. Fertil Steril. 2004;81(1):19-25. 3. Ndefo UA, Eaton A, Green MR. Polycystic ovary syndrome: a review or ovarian tumors, thyroid dysfunc- such as anovulation, hirsutism and of treatment options with a focus on pharmacological approaches. P T. 2013;38(6):336-55. tion, congenital adrenal hyperplasia, menstrual irregularities. First-line 4. Vause TDR, Cheung AP, Sierra S, et al. Ovulation induction in polycystic ovary syndrome. J Obstet Gynaecol Can. 2010;32(5):495-502. hyperprolactinemia, acromegaly and medical therapy usually consists of 5. Yildiz BO. Diagnosis of hyperandrogenism: clinical criteria. Best Pract Res 2,3 Clin Endocrinol Metab. 2006;20(2):167-76. Cushing syndrome. an oral contraceptive to regulate 6. Copp T, Jansen J, Doust J, et al. Are expanding disease definitions 3,4 unnecessarily labelling women with polycystic ovary syndrome? BMJ. Baseline screening includes: menstruation and decrease the risk 2017;358:j3694. 7. Aubuchon M, Legro RS. Polycystic ovary syndrome: current infertility • Thyroid function tests of endometrial cancer, which is management. Clin Obstet Gynecol. 2011;54(4):675-84. • Serum prolactin level associated with obesity and chronic 8. Barber TM, Franks S. Genetics of polycystic ovary syndrome. Front Horm Res. 2013;40:28-39. • Total and free T levels anovulation (but not necessarily 9. Rosenfield RL, Ehrmann DA. The pathogenesis of polycystic ovary syndrome (PCOS): the hypothesis of PCOS as functional ovarian hyperan- • Free androgen index PCOS).2,3 drogenism revisited. Endocr Rev. 2016;37(5):467-520. 10. Tasali E, Van Cauter E, Ehrmann DA. Polycystic ovary syndrome and • 17-hydroxyprogesterone level If symptoms are not sufficiently obstructive sleep apnea. Sleep Med Clin. 2008;3(1):37-46. 11. Ehrmann DA, Barnes RB, Rosenfield RL, et al. Prevalence of impaired • Urinary free cortisol and creati- alleviated, an androgen-blocking glucose tolerance and diabetes in women with polycystic ovary syndrome. Diabetes Care. 1999;22(1):141-6. nine levels agent may be added. First-line treat- 12. Adıyeke SK, Karaca I, Yıldırım S, et al. Anterior segment findings in women with polycystic ovary syndrome. Turk J Ophthalm. 2017;47(1):24-7. • Low-dose dexamethasone sup- ments for ovulation induction when 13. Glueck CJ, Iyengar S, Goldenberg N, et al. Idiopathic intracranial hypertension: associations with coagulation disorders and polycystic-ovary pression test fertility is desired are letrozole and syndrome. J Lab Clin Med. 2003;142(1):35-45. • Insulin-like growth factor 1 level clomiphene citrate.2,3 Clomiphene 14. Avisar I, Gaton DD, Dania H, et al. The prevalence of polycystic ovary syndrome in women with idiopathic intracranial hypertension. Scientifica. • Human chorionic gonadotropin and metformin can induce ovula- July 30, 2012. [Epub ahead of print]. 15. Wellberry C. Diagnosis and treatment of polycystic ovary syndrome. Am level tion in patients seeking fertility but Fam Physician. 2007;76(6):865-76.

REVIEW OF OPTOMETRY MAY 15, 2020 93 Retina Quiz

Repairing a Misdiagnosis A patient averts a crisis related to his worsening cloudy vision. By Rami Aboumourad, OD, and Mark T. Dunbar, OD

19-year-old Jamaican male 4. What is most likely diagnosis presented with “cloudy consistent with the patient’s clini- Avision” in the left eye for cal presentation? nearly two months. He was diag- a. Eales’ disease. nosed with toxoplasma chorio- b. Familial exudative vitreoreti- retinitis in his home country and nopathy. treated with Bactrim DS (sulfa- c. Proliferative diabetic retinopa- methoxazole-trimethoprim, Roche thy. Pharmaceuticals), but his symp- d. Proliferative sickle cell retinopa- toms did not improve. Lab tests thy. for toxoplasmosis came back negative, and the patient was referred 5. Based on the Goldberg classifi- for a second opinion given the lack cation, the patient’s left eye would of improvement. be categorized as: On examination, his unaided a. Stage II. visual acuity was 20/20 OD and b. Stage III. 20/800 OS with no improvement c. Stage IV. with pinhole. A relative afferent d. Stage V. pupillary defect was detected in the left eye. His extraocular motilities Fig. 1. These ultra-widefield fundus For answers, see page 98. were full in both eyes and his left photos show our young patient’s right eye had a mild peripheral constric- (at top) and left eyes. What do you notice Diagnosis tion on confrontation visual fields. that can explain his blurry vision? It was evident that our patient has The intraocular pressures (IOP) a large macula-off retinal detach- measured 14mm Hg OD and 7mm peripheral retinal changes in the ment in the left eye. We were able Hg OS. The anterior segments left eye? to see multiple retinal tears, one were unremarkable. Fundus pho- a. Rhegamtogenous retinal detach- of which can be seen in the fundus tos and corresponding fluorescein ment. photograph at 4:00. But that’s not angiograms (FA)—early and late b. Retinal neovascularization. all. Superior to the retinal tear, he phase—reflect the posterior seg- c. Retinal capillary angiomas. also had an area of active neovas- ments findings (Figures 1 to 3). d. Both a and b. cularization in the shape of a sea- fan. The neovasculation was not Take the Retina Quiz 3. Which of the following best just in the left eye but also in the 1. How would you characterize the describes the FA findings? peripheral retina of the right eye. peripheral retinal changes in the a. Early hyperfluorescence with The widefield FA in the left eye right eye? late staining. highlights where we can see hyper- a. Multiple retinal tears. b. Early hyperfluorescence with fluorescense in the early phase and b. Choroidal neovascularization. late leakage. leakage (via increased hyperfluo- c. Retinal neovascularization. c. Early phase is normal with late rescence with blurring of margins) d. Retinal capillary angiomas. pooling. in the late phase (Figure 2). The FA d. Hyperfluorescence associated in the right eye also shows large 2. How would you characterize the with window defect. areas of capillary nonperfusion

94 REVIEW OF OPTOMETRY MAY 15, 2020 Goldberg Stages of Sickle Cell Retinopathy1-6 I. Peripheral arterial occlusions – Can have multiple simultaneous peripheral vascular occlusions and silver-wiring of arterioles. II. Peripheral arteriovenous anas- tomoses (hairpin loops) – Vascular Fig. 2. The ultra-widefield FA shows our patient’s right eye in mid phase, at left, and remodeling at the junction of perfused and left eye in the early phase. nonperfused retina that strives to shunt blood from occluded arterioles to adjacent anterior to the areas of neovascu- blood vessels and cause chronic venules. These lesions do not leak FA. larization (Figure 2). low-grade peripheral ischemia, III. Neovascular and fibrous prolifera- Given these findings, we con- while Hb SS disease causes larger tions – Defined by sea-fan lesions that cluded our patient had a traction thrombi that are more likely to are typically found in the peripheral retina. retinal detachment secondary to affect large blood vessels and These lesions do leak on FA. proliferative sickle cell retinopa- cause systemic crises.1,4,5 IV. Vitreous hemorrhage – Defined by the thy that evolved into a combined Diagnosis is largely clinical and presence of vitreous hemorrhage. Typically tractional-rhegmatogenous retinal graded using a universal classi- secondary to vitreous traction and can be detachment (TRD/RRD). fication system (See, “Goldberg focal overlying sea-fan lesions or diffuse. Stages of Sickle Cell Retinopa- Chronic vitreous hemorrhage can lead to Discussion thy”). According to the Goldberg fibroglial membranes and vitreous strands Sickle cell disease comprises a classification, our patient is in that can induce traction. group of hemoglobinopathies Stage III OD and Stage V OS. The V. Retinal detachment – Defined by the characterized by intravascular hallmark defining feature of Stage presence of a TRD, usually secondary to hemolysis that ultimately results III disease is sea-fan neovascular chronic non-clearing vitreous hemorrhage. in defective oxygen transporta- fronds, and the defining feature of Can also develop combined TRD/RRD. tion.1,2 Sickle cell disease is the Stage V disease is traction retinal most common inherited blood dis- detachment. Ultra-widefield FA can provide order and affects nearly 100,000 Proliferative sickle cell reti- great insight as to whether sea- Americans.2,3 Approximately one nopathy is unique from other fan lesions are active or inactive, in 12 black individuals carry the proliferative vitreoretinal diseases which can help guide the decision sickle cell trait and sickle cell disin that the neovascular sea-fan to treat versus observe. Spectral ease affects ~1/365-500 African- lesions can autoinfarct in up to domain OCT and OCT angiog- American births and ~1/16,300 60% of cases, therefore becom- raphy can provide information Hispanic-American births.1-3 ing inactive and no longer pose a regarding the foveal architecture The patient had a known diag- threat to vision.1-7 For that reason, and presence of ischemia.1,2,4 nosis of hemoglobin (Hb) SC dis- patients with proliferative sickle ease with no prior systemic crises cell retinopathy are treated on a After a discussion about the of note. Hemoglobin SC disease is case-by-case basis and treatment risks, benefits and alternatives, the second most common form of may not be uniformly indicated. If the patient was taken into surgery. sickle cell disease, but is the most intervention is indicated, options Panretinal photocoagulation was likely to cause sickle cell retinopa- include laser, anti-vascular endo- applied anterior to the sea-fan thy.1-6 Hemoglobin SS disease is thelial growth factor intravitreal lesions nasally and temporally in the most common form of sickle injections and surgery (for non- his right eye. The combined TRD/ cell disease, but is associated with clearing vitreous hemorrhage or RRD in the left was repaired with a higher rate of mortality.2,6,7 retinal detachment). The ultimate the placement of a scleral buckle, Hemoglobin SC results in goal of treatment is to prevent pars plana vitrectomy, endoscopic hypercoagulability of blood and is progression from Stage III to photocoagulation and insertion more likely to compromise smaller Stages IV or V when possible. of silicone oil. The patient had a

REVIEW OF OPTOMETRY MAY 15, 2020 95 Retina Quiz

SC Retinopathy Findings1-6 Nonproliferative • Salmon patch hemorrhages – Pinkish- orange hemorrhages between the retina and internal limiting membrane, typically found in the equatorial retina. • Iridescent spots – Small schisis cavi- ties post-salmon patch hemorrhage or post-arteriolar occlusions that appear with multiple glistening, refractile iridescent Fig. 3. These ultra-widefield FA images depict the late phase in both eyes. spots. • Black sunbursts – Flat areas of hyper- good surgical result with reattach- 2. Akhter M, Latting M, Scott Al. Management of proliferative pigmentation thought to be secondary to sickle cell retinopathy. Eyenet magazine. www.aao.org/eyenet/ ment of the retina and excellent intraretinal hemorrhages tracking into the article/proliferative-sickle-cell-retinopathy. October 2018. regression of the sea-fan lesion in Accessed April 17, 2020. subretinal space or representative of focal both eye. He continues to be fol- 3. Centers for Disease Control and Prevention. Data & statis- underlying choroidal ischemia or neovas- tics on sickle cell disease. www.cdc.gov/ncbddd/sicklecell/ lowed closely. n data.html. October 21, 2019. Accessed April 17, 2020. cular membrane formation. 4. Yanoff M, Duker JS, eds. Ophthalmology. 5th ed. Philadel- Dr. Aboumourad practices at phia: Elsevier; 2019. Proliferative the Bascom Palmer Eye Institute 5. Menaa F, Khan B, Uzair B, Menaa A. Sickle cell retinopa- • Sea-fan lesions – Neovascular fronds thy: improving care with a multidisciplinary approach. J in Miami. This case came courtesy Multidiscip Healthc. 2017;10:335-46. that typically form in the periphery at arte- of Jayanth Sridhar, MD, also of the 6. Gass J, Agarwal A. Gass’ Atlas of Macular Diseases, 5th riovenous crossings secondary to periph- Bascom Palmer Eye Institute. ed. Philadelphia: Elsevier Saunders; 2012. 7. Platt O, Brambilla D, Rosse W, et al. Mortality in sickle cell eral arteriolar occlusions. 1. Ryan SJ ed. Retina. 5th ed. Philadelphia: Elsevier Saun- disease. Life expectancy and risk factors for early death. N ders; 2013. Engl J Med. 1994;330(23):1639-44.

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96 REVIEW OF OPTOMETRY MAY 15, 2020 Review Classiﬁ eds

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REVIEW OF OPTOMETRY MAY 15, 2020 Diagnostic Quiz

A Bumpy Ride A patient is concerned about a progressive growth. By Andrew S. Gurwood, OD

History revealing A 52-year-old black male reported symmetric to the office with a chief complaint cup-to-disc of a lump in the left eyelid. He ratios measur- explained that the lump had been ing 0.3/0.3 progressively worsening over the OD and last four months. His systemic and 0.3/0.35 OS, ocular histories were unremarkable respectively, and he denied exposure to chemi- with normal cals or allergies of any kind. peripheries.

Diagnostic Data Your Diag- His best-corrected entering visual nosis acuities were 20/20 in each eye at Does the case distance and near. His external presented examination was normal with no require any evidence of afferent pupil defect. additional The pertinent anterior segment tests, history Can this image of our 52-year-old patient’s presenation help you findings are demonstrated in the or informa- identify his diagnosis? photograph. Goldmann applana- tion? Based tion tonometry measured 15mm on the information provided, what To find the answers, please visit Hg OU. Dilated funduscopy was would be your diagnosis? What is Review of Optometry online at within normal limits, both eyes, the patient’s most likely prognosis? www.reviewofoptometry.com. n

Retina Quiz Answers (from page 94): 1) c; 2) d; 3) b; 4) d; 5) d.

Next Month in the Mag • Is Your Approach to Diabetic Retinopathy Working? Coming in June, Review of Optometry will present its annual • Improve Your Macular Exam retina report. • Recognizing Retinitis Pigmentosa

Topics include: Also in this issue:

• Sizing Up Geographic Atrophy • Caring for the Pregnant Patient (Earn 2 CE Credits)

• Setting Patient Expectations for Anti-VEGF Therapy • The Tools to ID Brain Injury

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