REVIEW OF OPTOMETRY ■ The Optometrist and Obstructive Sleep Apnea, p. 30 VOL. 156 NO. 8 ■

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INDICATION IMPORTANT SAFETY INFORMATION cont’d VYZULTA® (latanoprostene bunod ophthalmic solution), 0.024% is • There have been reports of bacterial keratitis associated with the indicated for the reduction of intraocular pressure (IOP) in patients use of multiple-dose containers of topical ophthalmic products with open-angle glaucoma or ocular hypertension. that were inadvertently contaminated by patients • Contact lenses should be removed prior to the administration of IMPORTANT SAFETY INFORMATION VYZULTA and may be reinserted 15 minutes after administration • Increased pigmentation of the iris and periorbital tissue (eyelid) • Most common ocular adverse reactions with incidence *2% are can occur. Iris pigmentation is likely to be permanent conjunctival hyperemia (6%), eye irritation (4%), eye pain (3%), • Gradual changes to eyelashes, including increased length, and instillation site pain (2%) increased thickness, and number of eyelashes, may occur. These For more information, please see Brief Summary of Prescribing changes are usually reversible upon treatment discontinuation Information on next page. • Use with caution in patients with a history of intraocular References: 1. VYZULTA Prescribing Information. Bausch & Lomb Incorporated. infl ammation (iritis/uveitis). VYZULTA should generally not 2. Cavet ME. J Ocul Pharmacol Ther. 2018;34(1):52-60. DOI:10.1089/ be used in patients with active intraocular infl ammation jop.2016.0188. 3. Wareham LK. Nitric Oxide. 2018;77:75-87. DOI:10.1016/j. • Macular edema, including cystoid macular edema, has been niox.2018.04.010. 4. Stamer DW. Curr Opin Ophthalmol. 2012;23:135-143. reported during treatment with prostaglandin analogs. Use DOI:10.1097/ICU.0b013e32834ff 23e. 5. Cavet ME. Invest Ophthalmol Vis with caution in aphakic patients, in pseudophakic patients Sci. 2015;56(6):4108-4116. 6. Kaufman PL. Exp Eye Research. 2008;861:3-17. with a torn posterior lens capsule, or in patients with known DOI:10.1016/j.exer.2007.10.007. 7. Weinreb RN. J Glaucoma. 2018;27:7-15. 8. Weinreb RN. Ophthalmology. 2016;123(5):965-973. 9. Medeiros FA. Am J risk factors for macular edema Ophthalmol. 2016;168:250-259.

VYZULTA and the V design are trademarks of Bausch & Lomb Incorporated or its affi liates. ©2019 Bausch & Lomb Incorporated or its affi liates. All rights reserved. VYZ.0065.USA.19

RP0619_B & L Vyzulta.indd 1 5/15/19 9:37 AM BRIEF SUMMARY OF PRESCRIBING INFORMATION embryofetal lethality. Structural abnormalities observed in rabbit fetuses included anomalies of the great vessels and aortic arch vessels, domed head, sternebral This Brief Summary does not include all the information needed to use VYZULTA and vertebral skeletal anomalies, limb hyperextension and malrotation, abdominal safely and effectively. See full Prescribing Information for VYZULTA. distension and edema. Latanoprostene bunod was not teratogenic in the rat when ® VYZULTA (latanoprostene bunod ophthalmic solution), 0.024%, for administered IV at 150 mcg/kg/day (87 times the clinical dose) [see Data]. topical ophthalmic use. The background risk of major birth defects and miscarriage for the indicated Initial U.S. Approval: 2017 population is unknown. However, the background risk in the U.S. general population 1 INDICATIONS AND USAGE of major birth defects is 2 to 4%, and of miscarriage is 15 to 20%, of clinically recognized pregnancies. VYZULTA® (latanoprostene bunod ophthalmic solution) 0.024% is indicated for the reduction of intraocular pressure (IOP) in patients with open-angle glaucoma or Data ocular hypertension. Animal Data 4 CONTRAINDICATIONS Embryofetal studies were conducted in pregnant rabbits administered latanoprostene None bunod daily by intravenous injection on gestation days 7 through 19, to target the period of organogenesis. The doses administered ranged from 0.24 to 80 mcg/kg/day. Abortion 5 WARNINGS AND PRECAUTIONS occurred at doses ≥ 0.24 mcg/kg/day latanoprostene bunod (0.28 times the clinical dose, 5.1 Pigmentation on a body surface area basis, assuming 100% absorption). Embryofetal lethality (resorption) was increased in latanoprostene bunod treatment groups, as evidenced VYZULTA® (latanoprostene bunod ophthalmic solution), 0.024% may cause changes by increases in early resorptions at doses ≥ 0.24 mcg/kg/day and late resorptions to pigmented tissues. The most frequently reported changes with prostaglandin at doses ≥ 6 mcg/kg/day (approximately 7 times the clinical dose). No fetuses analogs have been increased pigmentation of the iris and periorbital tissue (eyelid). survived in any rabbit pregnancy at doses of 20 mcg/kg/day (23 times the clinical Pigmentation is expected to increase as long as latanoprostene bunod ophthalmic dose) or greater. Latanoprostene bunod produced structural abnormalities at solution is administered. The pigmentation change is due to increased melanin doses ≥ 0.24 mcg/kg/day (0.28 times the clinical dose). Malformations included content in the melanocytes rather than to an increase in the number of anomalies of sternum, coarctation of the aorta with pulmonary trunk dilation, melanocytes. After discontinuation of VYZULTA, pigmentation of the iris is likely retroesophageal subclavian artery with absent brachiocephalic artery, domed head, to be permanent, while pigmentation of the periorbital tissue and eyelash changes forepaw hyperextension and hindlimb malrotation, abdominal distention/edema, are likely to be reversible in most patients. Patients who receive prostaglandin and missing/fused caudal vertebrae. analogs, including VYZULTA, should be informed of the possibility of increased An embryofetal study was conducted in pregnant rats administered latanoprostene pigmentation, including permanent changes. The long-term effects of increased bunod daily by intravenous injection on gestation days 7 through 17, to target the pigmentation are not known. period of organogenesis. The doses administered ranged from 150 to 1500 mcg/ Iris color change may not be noticeable for several months to years. Typically, the brown kg/day. Maternal toxicity was produced at 1500 mcg/kg/day (870 times the clinical pigmentation around the pupil spreads concentrically towards the periphery of the iris dose, on a body surface area basis, assuming 100% absorption), as evidenced by and the entire iris or parts of the iris become more brownish. Neither nevi nor freckles of reduced maternal weight gain. Embryofetal lethality (resorption and fetal death) the iris appear to be affected by treatment. While treatment with VYZULTA® (latanoprostene and structural anomalies were produced at doses ≥ 300 mcg/kg/day (174 times bunod ophthalmic solution), 0.024% can be continued in patients who develop noticeably the clinical dose). Malformations included anomalies of the sternum, domed head, increased iris pigmentation, these patients should be examined regularly [see Patient forepaw hyperextension and hindlimb malrotation, vertebral anomalies and delayed Counseling Information (17) in full Prescribing Information]. ossification of distal limb bones. A no observed adverse effect level (NOAEL) was 5.2 Eyelash Changes established at 150 mcg/kg/day (87 times the clinical dose) in this study. VYZULTA may gradually change eyelashes and vellus hair in the treated eye. These 8.2 Lactation changes include increased length, thickness, and the number of lashes or hairs. Risk Summary Eyelash changes are usually reversible upon discontinuation of treatment. There are no data on the presence of VYZULTA in human milk, the effects on the 5.3 Intraocular Inflammation breastfed infant, or the effects on milk production. The developmental and health VYZULTA should be used with caution in patients with a history of intraocular benefits of breastfeeding should be considered, along with the mother’s clinical need inflammation (iritis/uveitis) and should generally not be used in patients with active for VYZULTA, and any potential adverse effects on the breastfed infant from VYZULTA. intraocular inflammation as it may exacerbate this condition. 8.4 Pediatric Use 5.4 Macular Edema Use in pediatric patients aged 16 years and younger is not recommended because of Macular edema, including cystoid macular edema, has been reported during potential safety concerns related to increased pigmentation following long-term chronic use. treatment with prostaglandin analogs. VYZULTA should be used with caution in 8.5 Geriatric Use aphakic patients, in pseudophakic patients with a torn posterior lens capsule, or in No overall clinical differences in safety or effectiveness have been observed between patients with known risk factors for macular edema. elderly and other adult patients. 5.5 Bacterial Keratitis 13 NONCLINICAL TOXICOLOGY There have been reports of bacterial keratitis associated with the use of 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility multiple-dose containers of topical ophthalmic products. These containers had been inadvertently contaminated by patients who, in most cases, had a Latanoprostene bunod was not mutagenic in bacteria and did not induce concurrent corneal disease or a disruption of the ocular epithelial surface. micronuclei formation in the in vivo rat bone marrow micronucleus assay. Chromosomal aberrations were observed in vitro with human lymphocytes 5.6 Use with Contact Lens in the absence of metabolic activation. Contact lenses should be removed prior to the administration of VYZULTA because Latanoprostene bunod has not been tested for carcinogenic activity in long-term this product contains benzalkonium chloride. Lenses may be reinserted 15 minutes animal studies. Latanoprost acid is a main metabolite of latanoprostene bunod. after administration. Exposure of rats and mice to latanoprost acid, resulting from oral dosing with 6 ADVERSE REACTIONS latanoprost in lifetime rodent bioassays, was not carcinogenic. The following adverse reactions are described in the Warnings and Precautions Fertility studies have not been conducted with latanoprostene bunod. The potential section: pigmentation (5.1), eyelash changes (5.2), intraocular inflammation (5.3), to impact fertility can be partially characterized by exposure to latanoprost acid, a macular edema (5.4), bacterial keratitis (5.5), use with contact lens (5.6). common metabolite of both latanoprostene bunod and latanoprost. Latanoprost acid 6.1 Clinical Trials Experience has not been found to have any effect on male or female fertility in animal studies. Because clinical trials are conducted under widely varying conditions, adverse reaction 13.2 Animal Toxicology and/or Pharmacology rates observed in the clinical trials of a drug cannot be directly compared to rates in the A 9-month toxicology study administered topical ocular doses of latanoprostene clinical trials of another drug and may not reflect the rates observed in practice. bunod to one eye of cynomolgus monkeys: control (vehicle only), one drop of 0.024% VYZULTA was evaluated in 811 patients in 2 controlled clinical trials of up to 12 bid, one drop of 0.04% bid and two drops of 0.04% per dose, bid. The systemic months duration. The most common ocular adverse reactions observed in patients exposures are equivalent to 4.2-fold, 7.9-fold, and 13.5-fold the clinical dose, treated with latanoprostene bunod were: conjunctival hyperemia (6%), eye irritation respectively, on a body surface area basis (assuming 100% absorption). Microscopic (4%), eye pain (3%), and instillation site pain (2%). Approximately 0.6% of patients evaluation of the lungs after 9 months observed pleural/subpleural chronic fibrosis/ discontinued therapy due to ocular adverse reactions including ocular hyperemia, inflammation in the 0.04% dose male groups, with increasing incidence and severity conjunctival irritation, eye irritation, eye pain, conjunctival edema, vision blurred, compared to controls. Lung toxicity was not observed at the 0.024% dose. punctate keratitis and foreign body sensation. U.S. Patent Numbers: 7,273,946; 7,629,345; 7,910,767; 8,058,467. 8 USE IN SPECIFIC POPULATIONS VYZULTA is a trademark of Bausch & Lomb Incorporated or its affiliates. 8.1 Pregnancy © 2019 Bausch & Lomb Incorporated or its affiliates. Risk Summary Distributed by: There are no available human data for the use of VYZULTA during pregnancy to inform Bausch + Lomb, a division of any drug associated risks. Valeant Pharmaceuticals North America LLC Latanoprostene bunod has caused miscarriages, abortion, and fetal harm in Bridgewater, NJ 08807 USA rabbits. Latanoprostene bunod was shown to be abortifacient and teratogenic when administered intravenously (IV) to pregnant rabbits at exposures ≥ 0.28 times the Based on 9612402 (Folded), 9612302 (Flat) 6/2018 clinical dose. Doses ≥ 20 μg/kg/day (23 times the clinical dose) produced 100% VYZ.0058.USA.19 Issued: 3/2019

RRP0619_BP0619_B & L VyzultaVyzulta PI.inddPI.indd 1 55/15/19/15/19 9:399:39 AMAM News Review

VOL. 156 NO. 8 ■ AUGUST 15, 2019

IN THE NEWS Trifocal IOL Beats EDOF

Heavy metals, toxic elements and oxidative stress may all play a role in in Near Work the development of early- and late- Both still scored high marks for distance and stage age-related macular degen- eration (AMD), researchers from India intermediate visual acuity. suggest. Their study found signifi cantly By Catherine Manthorp, Associate Editor increased levels of lead, cadmium, chromium, nickel and arsenic in the hen considering results at all near visual acuity choroid-retinal pigment epithelium and which of the newer- measurements. Still, the study retinas of donor patients’ eyes with early Wgeneration intraocular reported no differences in visual and late AMD. lenses (IOLs) may be best for your quality and symptoms between the Aberami S, Nikhalashree S, Bharathselvi M, et al. Elemental cataract patients, a study in Eye groups. concentrations in choroid-RPE and retina of human eyes with age-related macular degeneration. Exp Eye Res. July & Contact Lens reports both a While the trifocal had a clear 1, 2019. [Epub ahead of print]. diffractive trifocal lens and an advantage over the EDOF in near extended depth-of-focus (EDOF) visual acuity, both showed excel- Another study from India reviewed 229 lens performed well in distance lent performance in distance and patients who had penetrating kerato- and intermediate vision, but the intermediate visual acuity, investi- plasty (PK) for microbial keratitis and trifocal did better for near vision. gators noted. Both IOLs provided identifi ed several signifi cant risk fac- In the prospective, six-month high percentage of spectacle inde- tors for recurring infection, including study, researchers compared the pendence and patient satisfaction a fungal etiology, retro-iris exudates, visual results of both lenses. The with minimal level of disturbing coexisting endophthalmitis and investigation enrolled 160 eyes photic phenomena. grafts 10mm2 or larger. Despite these of 80 patients who had bilateral Investigators noted several limi- risks, the researchers still advocate cataract surgery and divided them tations of their study, including for PK as an effective treatment for into two groups. The patients the inclusion of just one trifocal severe cases of unresponsive microbial were then implanted with either lens design. Signifi cantly, patients keratitis. the trifocal or the EDOF lens in completed the questionnaire six Chatterjee S, Agrawal D. Recurrence of infection in both eyes. In addition to visual months after surgery—any photic corneal grafts after therapeutic penetrating keratoplasty for microbial keratitis. Cornea. June 26, 2019. [Epub acuity measurements, subjects also phenomena may have decreased ahead of print]. fi lled out a spectacle dependence by then, and patients may also questionnaire. have adjusted to new routines over Certain systemic drugs—ACE and The study found no statistically the time period. Also, the IOLs alpha-glucosidase inhibitors, fi brates signifi cant difference between the were targeted for emmetropia, and insulin—may increase the risk of groups in monocular and binocu- which may confound near and developing cortical cataracts, a study lar uncorrected distance visual intermediate vision results, and the reports. The investigation also found the acuity and corrected distance follow-up period of six months association was independent of hyper- visual acuity. Researchers noted was relatively short to assess the tension, hyperlipidemia and diabetes. monocular and binocular uncor- occurrence of posterior capsule “Consistently, the four medications were rected intermediate visual acuity opacifi cation, the researchers said. also associated with a greater severity and monocular distance-corrected Singh B, Sharma S, Dadia S, et al. Comparative level of cortical cataract,” the research- intermediate visual acuity were evaluation of visual outcomes after bilateral implan- ers wrote. tation of a diffractive trifocal intraocular lens and also comparable. an extended depth of focus intraocular lens. Eye Dai W, Tham YC, Chee ML, et al. Systemic medications and However, the trifocal had better Contact Lens. July 5, 2019. [Epub ahead of print]. cortical cataract: the Singapore Epidemiology of Eye Diseases Study. Br J Ophthalmol. July 4, 2019. [Epub ahead of print]. NEWS STORIES POST EVERY WEEKDAY MORNING AT www.reviewofoptometry.com/news

4 REVIEW OF OPTOMETRY AUGUST 15, 2019

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RO0819_Keeler Tono.indd 1 7/25/19 9:58 AM News Review For more, visit www.reviewofoptometry.com/news

2019 Income in Review

ike any other year, 2018 was in income, while 36% didn’t expect upon completing all of the ques- full of highs and lows for a change and only 8% were specu- tions in the survey, you’ll be en- Loptometry, income-wise. Has lating a decrease. Here’s our chance tered to win a $100 American Ex- this year been any better? We want to fi nd out if you were right! press Gift Card. It just takes a few to hear how you’ve been doing If you’re a practicing OD, please minutes, as there are only a handful fi nancially in 2019. take a few minutes to respond of questions. Thank you for your While earnings decreased among to our annual income survey participation—we wouldn’t know those with the most experience and share your fi nancial experi- where the fi eld stood fi nancially and the gap widened between self- ence over the last year with us. without you! employed and employed ODs last The results will be published year, average income increased, the anonymously in the December Take the Survey mid-career plateau disappeared and issue. All personal and fi nancial To participate in the the gender gap narrowed. information is confi dential and survey, visit www. Will 2019 continue the positive used for no other purpose than surveymonkey. trend? Last year, 56% of our sur- this survey. com/r/2019incomesurveyy vey respondents thought so, report- Just in case you need a little or scan the QR code. ing that they expected an increase extra push, here’s an incentive: Uveitic Glaucoma: a Combo for Concern Photo: Michael Trottini, OD, and Candice Tolud, OD laucoma patients with progressing eyes of both groups, uveitis have a much higher with the widest range (21mm Gage-corrected rate of rapid Hg) in the progressing uveitic visual fi eld loss than people with glaucoma group. Further analysis primary open-angle glaucoma indicated the uveitis group has a (POAG) alone, a large UK-based higher proportion of signifi cantly study reports. progressing eyes (21.2%) compared The investigation, using real- to the POAG group (18.5%). world data from fi ve glaucoma By identifying rapid progressors clinics in England, also reported early, clinicians can target interven- that eyes with glaucoma and uveitis tions to preserve vision. had nearly double (1.9x) the risk of Be on the lookout for glaucoma damage “While patients with a combina- disease progression compared with in uveitis patients. tion of uveitis and glaucoma lose those with POAG, yet the average visual function more rapidly than frequency of visual fi eld monitoring ed in uveitic glaucoma. Research- POAG, on average, they are moni- was the same for both diseases— ers also noted 11% of eyes with tored with visual fi elds at the same about 10 months. glaucoma and uveitis progressed intensity,” the researchers wrote. The study included 205 donor ≥ 1.5dB, while only 7% of POAG As such, clinicians managing eyes with uveitis and glaucoma and eyes progressed. patients with uveitis should remain 4,600 POAG-only eyes. Eyes with Secondary analysis of intraocular vigilant for glaucoma damage in uveitis presented with worse median pressure (IOP) parameters showed these high-risk patients, the study mean deviation than those with no difference in the mean IOP concludes. POAG (–3.8dB vs. –3.1dB), leading between the two groups. However, Liu X, Kelly SR, Montesano G, et al. Evaluating the impact of researchers to speculate that early the researchers noticed the IOP uveitis on visual fi eld progression using large scale real-world visual fi eld loss may be under-detect- range was wider in the fast- data. Am J Ophthalmol. June 25, 2019. [Epub ahead of print].

6 REVIEW OF OPTOMETRY AUGUST 15, 2019

004_ro0819_news.indd 6 8/7/19 6:57 PM THE HEAT IS ON!

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RO0819_Oculus.indd 1 7/25/19 9:49 AM News Review

Maryland Implements Screen Safety Guidelines Critic calls the effort to limit digital device use in schools “profoundly mediocre.”

ith the potential hazards environment and the screen. screens’ association with myopia of screen use gain- The state is also offering free or the impact of blue light on Wing more widespread resources to help educators ensure the retina, although it does awareness, Maryland’s Depart- proper posture, lighting and ap- provide information about blue ment of Education released a propriate distance from the screen. light’s effects on sleep as well as state-sanctioned best practices These documents are available computer vision syndrome and guide for digital device use in the online, along with video guides.2,3 its relationship to dry eye, eye classroom this month, in accor- In 2018, a Maryland bill re- strain and fatigue and headaches. dance with a bill aimed at protect- quested the state’s schools come However, it’s a start, she notes. ing students from the dangers of up with guidelines on how long “Parents now have a framework to excessive screen time. The result- students can be exposed to screens reference when working to protect ing guidelines offer health and and how laptops, tablet comput- their children at school,” she says. safety pointers, some of which ers and digital readers can impact 1. Spector C. Maryland mother pushes for screen time take digital eyestrain into ac- a child’s ocular health. The state’s regulations in schools. Star Democrat. www.stardem.com/ count.1 board of education, in partner- news/local_news/maryland-mother-pushes-for-screen-time- regulations-in-schools/article_29f329ca-7748-50e4-bfcb- With respect to eye care, the ship with its department of health, 1c298a70bf77.html. July 1, 2019. Accessed July 16, 2019. one-page guideline calls for educa- was tasked with working along- 2. Maryland Department of Education. Health and safety best tors in the state to limit students’ side physician groups to develop practices digital devices in the classroom. Maryland Public Schools. marylandpublicschools.org/programs/Pages/ITSLM/ time on devices to 10 to 20 preventative measures for digital HealthSafetyBestPractices.aspx. July 1, 2019. Accessed July minutes, with reminders to take device-associated eye diseases as 16, 2019. 3. Maryland Department of Health. Health and safety best eye and stretch breaks. Students well as other screen-related health practice guidelines: digital devices. Maryland Public Schools. should use devices at least 20 issues.4 marylandpublicschools.org/programs/Documents/ITSLM/ Health_and_Safety_Best_Practice_Guidelines_Digital_De- inches from their eyes while seated Cindy Eckard, an activist who vices.pdf. July 1, 2019. at a desk or table, and educators worked on the initial bill, called 4. Arentz D. Public schools – health and safety best prac- tices—digital devices. Maryland General Assembly. mgaleg. should keep the lighting condi- the state’s guidelines “profoundly maryland.gov/webmga/frmMain.aspx?id=hb1110&stab=0 tions even throughout the room mediocre,” and complained 1&pid=billpage&tab=subject3&ys=2018RS. Accessed July to minimize contrast between the that they don’t mention digital 16, 2019. Fasting Yields Better FA Results

esearchers recently found ages taken when patients were fl uorescein dye appearance) when that fasting oral fl uorescein fasting achieved better angiogra- patients had fasted compared with Rangiography (FA) yielded phy quality scores. They noted non-fasting (18.7±6.9 minutes vs. images of signifi cantly better qual- that non-fasting patients with 25.14±8.1 minutes). ity at a faster, more optimal rate higher body mass indexes had the “Oral FA could be a useful when compared with non-fasting worst scores. adjunctive examination to optical oral FA. The identifi cation of other coherence tomography (OCT) and This observational, case-cross- clinical parameters, such as drusen OCT angiography in patients who over study evaluated 160 eyes of staining, disciform scar stain- require FA studies but who have 80 patients undergoing routine ing and central and peripapillary diffi cult access or refuse an inva- oral FA for retinal disease and atrophy, were also signifi cantly sive procedure,” the study authors compared fasting and non-fasting better during the pre-fasting exam. concluded. ■ images of the same patient for dif- As for test speed, the researchers Amador-Patarroyo MJ, Lin T, Meshi A, et al. Identifying the ferent image quality parameters. obtained quality images ap- factors for improving quality of oral fl uorescein angiography. The researchers found the im- proximately 22% faster (time to Br J Ophthalmol. July 4, 2019. [Epub ahead of print].

8 REVIEW OF OPTOMETRY AUGUST 15, 2019

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RO0819_Reichert VRX.indd 1 7/30/19 10:00 AM Contents Review of Optometry August 15, 2019

43rd ANNUAL CONTACT LENS REPORT 30 The Optometrist and Obstructive Sleep Apnea Learn to keep your snoring patients’ increased risk of disease from keeping you up at night. By Susan Kovacich, OD

36 Top Causes of Double Visione Getting to the root of the problem is the key to treating Optometry in the and referring properly. Here’s a look at the common 52 Age of Disruption: etiologies of diplopia and how to tell them apart. By Rebecca Hepp, Managing Editor Doctors vs. Online Vendors These companies prioritize cost and convenience over quality eye care and the doctor-patient relationship. Here’s how to defuse the threat they pose. By Jeffrey Sonsino, OD

Provide Specialty Contact 56 Lenses and Thrive You can build doctor-patient loyalty and keep patients from shopping around by offering something your competitors don’t have. By Jane Cole, Contributing Editor

Don’t Miss Out on 42 Perfecting Prism 62 Multifocals Don’t back down from this life-changing treatment. Here’s where to start. By Erin C. Jenewein, OD These devices can be a practice builder, not a spirit breaker. Here’s how. By Mark De Leon, Associate Editor

Earn 2 CE Credit: 46 When Corneal Wounds The Dangers and the Won’t Heal 68 Diagnosis of CLMK Timely intervention can keep a bad situation from Despite many advances, the threat of contact lens-related spiraling out of control. microbial keratitis has not retreated. By Alison Bozung, OD, and Paul Hammond, OD By Jaya Sowjanya Siddireddy, PhD

REVIEW OF OPTOMETRY AUGUST 15, 2019 11

011_ro0819_toc.indd 11 8/7/19 7:12 PM Departments Review of Optometry August 15, 2019

4 News Review 16 Outlook Breaking Down Barriers JACK PERSICO BUSINESS OFFICES 18 Through My Eyes 11 CAMPUS BLVD., SUITE 100 Stay in the Fast Lane NEWTOWN SQUARE, PA 19073 PAUL M. KARPECKI, OD CEO, INFORMATION SERVICES GROUP MARC FERRARA 19 Chairside (212) 274-7062 • [email protected] More Lenses, More Problems PUBLISHER MONTGOMERY VICKERS, OD JAMES HENNE 20 (610) 492-1017 • [email protected] 20 Clinical Quandaries REGIONAL SALES MANAGER Red All Over MICHELE BARRETT PAUL C. AJAMIAN, OD (610) 492-1014 • [email protected]

REGIONAL SALES MANAGER 22 Focus on Refraction MICHAEL HOSTER How Much is Too Much (610) 492-1028 • [email protected]

MARC B. TAUB, OD, MS, AND VICE PRESIDENT, OPERATIONS PAUL HARRIS, OD CASEY FOSTER (610) 492-1007 • [email protected]

24 Retina Dilemmas VICE PRESIDENT, CLINICAL CONTENT Caution: Congestion Ahead? PAUL M. KARPECKI, OD, FAAO JAY M. HAYNIE, OD, [email protected]

DIANA SCHECHTMAN, OD, AND PRODUCTION MANAGER RASHID TAHER, MD SCOTT TOBIN (610) 492-1011 • [email protected] 28 Coding Connection 24 SENIOR CIRCULATION MANAGER Not Covered? No Problem HAMILTON MAHER JOHN RUMPAKIS, OD, MBA (212) 219-7870 • [email protected]

CLASSIFIED ADVERTISING 78 Ocular Surface Review (888) 498-1460 Disinfect the Natural Way SUBSCRIPTIONS PAUL M. KARPECKI, OD $56 A YEAR, $88 (US) IN CANADA, $209 (US) IN ALL OTHER COUNTRIES. 80 Retina Quiz SUBSCRIPTION INQUIRIES That’s Egg on Your Face (877) 529-1746 (US ONLY) MARK T. DUNBAR, OD OUTSIDE US CALL: (845) 267-3065

CIRCULATION 82 Glaucoma Grand Rounds PO BOX 81 When They Go Low, ODs Go Hight CONGERS, NY 10920 JAMES L. FANELLI, OD TEL: (TOLL FREE): (877) 529-1746 OUTSIDE US: (845) 267-3065 84 Surgical Minute 78 A Two-for-One Deal CHRISTINA TRAN, BS, LEONID SKORIN, JR., DO, OD, MS DEREK N. CUNNINGHAM, OD, AND CEO, INFORMATION SERVICES GROUP WALTER O. WHITLEY, OD, MBA MARC FERRARA SENIOR VICE PRESIDENT, OPERATIONS 85 Classifieds JEFF LEVITZ VICE PRESIDENT, HUMAN RESOURCES 88 Cornea + Contact Lens Q&A TAMMY GARCIA High Risk, Limited Options VICE PRESIDENT, CREATIVE SERVICES & PRODUCTION JOSEPH P. SHOVLIN, OD MONICA TETTAMANZI 89 Advertisers Index CORPORATE PRODUCTION DIRECTOR JOHN ANTHONY CAGGIANO

90 Diagnostic Quiz VICE PRESIDENT, CIRCULATION Painless But Suffering 90 EMELDA BAREA ANDREW S. GURWOOD, OD

12 REVIEW OF OPTOMETRY AUGUST 15, 2019

011_ro0819_toc.indd 12 8/7/19 7:11 PM THERE’S NO SWIITCHING THIS Xiidra is the only lymphocyte function-associated antigen-1 (LFA-1) antagonist treatment for Dry Eye Disease1,2

8ˆˆ`À>]Ì iwÀÃ̈˜>V>ÃÃœvƂ‡£>˜Ì>}œ˜ˆÃÌà Indication vœÀ ÀÞ Þi ˆÃi>Ãi]ˆÃ>«ÀiÃVÀˆ«Ìˆœ˜iÞi Xiidra® NKƂVGITCUVQRJVJCNOKEUQNWVKQP KUKPFKECVGFHQTVJG `Àœ« Ƃ‡>««ÀœÛi`̜ÌÀi>ÌLœÌ È}˜Ã VTGCVOGPVQHUKIPUCPFU[ORVQOUQHFT[G[GFKUGCUG &'&  >˜`Ãޓ«Ìœ“ÃœvÌ i`ˆÃi>Ãi°£]Î Important Safety Information :KKFTCKUEQPVTCKPFKECVGFKPRCVKGPVUYKVJMPQYP J[RGTUGPUKVKXKV[VQNKƂVGITCUVQTVQCP[QHVJGQVJGT KPITGFKGPVU 2,4 There’s no substitute. +PENKPKECNVTKCNUVJGOQUVEQOOQPCFXGTUGTGCEVKQPU Check out patient resources, TGRQTVGFKPQHRCVKGPVUYGTGKPUVKNNCVKQPUKVGKTTKVCVKQP F[UIGWUKCCPFTGFWEGFXKUWCNCEWKV[1VJGTCFXGTUG insurance coverage, and TGCEVKQPUTGRQTVGFKPVQQHVJGRCVKGPVUYGTGDNWTTGF XKUKQPEQPLWPEVKXCNJ[RGTGOKCG[GKTTKVCVKQPJGCFCEJG more at Xiidra-ECP.com KPETGCUGFNCETKOCVKQPG[GFKUEJCTIGG[GFKUEQOHQTVG[G RTWTKVWUCPFUKPWUKVKU 6QCXQKFVJGRQVGPVKCNHQTG[GKPLWT[QTEQPVCOKPCVKQPQHVJG References: UQNWVKQPRCVKGPVUUJQWNFPQVVQWEJVJGVKRQHVJGUKPINGWUG 1. :KKFTC=2TGUETKDKPI+PHQTOCVKQP?.GZKPIVQP/#5JKTG75 2.6(15&'95++4GUGCTEJ5WDEQOOKVVGG4GRQTVQHVJG4GUGCTEJ EQPVCKPGTVQVJGKTG[GQTVQCP[UWTHCEG 5WDEQOOKVVGGQHVJG6GCT(KNO1EWNCT5WTHCEG5QEKGV[&T['[G 9QTM5JQR++  Ocul Surf  3.(&#CRRTQXGU %QPVCEVNGPUGUUJQWNFDGTGOQXGFRTKQTVQVJG PGYOGFKECVKQPHQTFT[G[GFKUGCUG(&#0GYU4GNGCUG,WN[ CFOKPKUVTCVKQPQH:KKFTCCPFOC[DGTGKPUGTVGFOKPWVGU JVVRYYYHFCIQXPGYUGXGPVUPGYUTQQORTGUUCPPQWPEGOGPVU WEOJVO#EEGUUGF,WN[4.(QQFCPF&TWI HQNNQYKPICFOKPKUVTCVKQP #FOKPKUVTCVKQP'NGEVTQPKE1TCPIG$QQMJVVRYYYHFCIQX FQYPNQCFU&TWIU&GXGNQROGPV#RRTQXCN2TQEGUU7%/RFH 5CHGV[CPFGHƂECE[KPRGFKCVTKERCVKGPVUDGNQYVJGCIGQH #EEGUUGF,WPG [GCTUJCXGPQVDGGPGUVCDNKUJGF

For additional safety information, see accompanying Brief Summary of Safety Information on the adjacent page and Full Prescribing Information on Xiidra-ECP.com.

^Óä£n- ˆÀi1-˜V°]i݈˜}̜˜] ƂäÓ{Ó£°£‡nää‡nÓn‡Óänn°ƂÀˆ} ÌÃÀiÃiÀÛi`°-, >˜`Ì i- ˆÀiœ}œ>ÀiÌÀ>`i“>ÀŽÃœÀÀi}ˆÃÌiÀi`ÌÀ>`i“>ÀŽÃœv - ˆÀi* >À“>ViṎV>œ`ˆ˜}ÃÀi>˜`ˆ“ˆÌi`œÀˆÌÃ>vwˆ>Ìið >ÀŽÃ`iÈ}˜>Ìi`® >˜`Ò>ÀiœÜ˜i`LÞ- ˆÀiœÀ>˜>vwˆ>Ìi`Vœ“«>˜Þ°-{£Î{£äÇÉ£n

RRO0819_Shire.inddO0819_Shire.indd 1 77/25/19/25/19 10:3110:31 AMAM VGUVGFOIMIFC[ HQNFVJGJWOCPRNCUOCGZRQUWTGCV the recommended human ophthalmic dose [RHOD], based on VJGCTGCWPFGTVJGEWTXG=#7%?NGXGN 5KPEGJWOCPU[UVGOKE GZRQUWTGVQNKƂVGITCUVHQNNQYKPIQEWNCTCFOKPKUVTCVKQPQH:KKFTC Rx Only CVVJG4*1&KUNQYVJGCRRNKECDKNKV[QHCPKOCNƂPFKPIUVQVJG risk of Xiidra use in humans during pregnancy is unclear. Animal Data BRIEF SUMMARY: .KƂVGITCUVCFOKPKUVGTGFFCKN[D[KPVTCXGPQWU +8 KPLGEVKQP Consult the Full Prescribing Information for complete product VQTCVUHTQORTGOCVKPIVJTQWIJIGUVCVKQPFC[ECWUGF information. an increase in mean preimplantation loss and an increased INDICATIONS AND USAGE KPEKFGPEGQHUGXGTCNOKPQTUMGNGVCNCPQOCNKGUCVOIMI Xiidra® NKƂVGITCUVQRJVJCNOKEUQNWVKQP KUKPFKECVGFHQTVJG FC[TGRTGUGPVKPIHQNFVJGJWOCPRNCUOCGZRQUWTGCV VTGCVOGPVQHVJGUKIPUCPFU[ORVQOUQHFT[G[GFKUGCUG &'&  the RHOD of Xiidra, based on AUC. No teratogenicity was QDUGTXGFKPVJGTCVCVOIMIFC[ HQNFVJGJWOCP DOSAGE AND ADMINISTRATION RNCUOCGZRQUWTGCVVJG4*1&DCUGFQP#7% +PVJGTCDDKV Instill one drop of Xiidra twice daily (approximately 12 hours an increased incidence of omphalocele was observed at the CRCTV KPVQGCEJG[GWUKPICUKPINGWUGEQPVCKPGT&KUECTF NQYGUVFQUGVGUVGFOIMIFC[ HQNFVJGJWOCPRNCUOC VJGUKPINGWUGEQPVCKPGTKOOGFKCVGN[CHVGTWUKPIKPGCEJG[G GZRQUWTGCVVJG4*1&DCUGFQP#7% YJGPCFOKPKUVGTGFD[ Contact lenses should be removed prior to the administration +8KPLGEVKQPFCKN[HTQOIGUVCVKQPFC[UVJTQWIJ#HGVCN0Q QH:KKFTCCPFOC[DGTGKPUGTVGFOKPWVGUHQNNQYKPI 1DUGTXGF#FXGTUG'HHGEV.GXGN 01#'. YCUPQVKFGPVKƂGFKP administration. the rabbit. CONTRAINDICATIONS Lactation 6JGTGCTGPQFCVCQPVJGRTGUGPEGQHNKƂVGITCUVKPJWOCP Xiidra is contraindicated in patients with known hypersensitivity VQNKƂVGITCUVQTVQCP[QHVJGQVJGTKPITGFKGPVUKPVJG milk, the effects on the breastfed infant, or the effects on milk RTQFWEVKQP*QYGXGTU[UVGOKEGZRQUWTGVQNKƂVGITCUVHTQO formulation. ocular administration is low. The developmental and health ADVERSE REACTIONS DGPGƂVUQHDTGCUVHGGFKPIUJQWNFDGEQPUKFGTGFCNQPIYKVJ Clinical Trials Experience the mother’s clinical need for Xiidra and any potential adverse Because clinical studies are conducted under widely varying effects on the breastfed child from Xiidra. conditions, adverse reaction rates observed in clinical studies Pediatric Use of a drug cannot be directly compared to rates in the clinical 5CHGV[CPFGHƂECE[KPRGFKCVTKERCVKGPVUDGNQYVJGCIGQH VTKCNUQHCPQVJGTFTWICPFOC[PQVTGƃGEVVJGTCVGUQDUGTXGF years have not been established. KPRTCEVKEG+PƂXGENKPKECNUVWFKGUQHFT[G[GFKUGCUGEQPFWEVGF YKVJNKƂVGITCUVQRJVJCNOKEUQNWVKQPRCVKGPVUTGEGKXGFCV Geriatric Use NGCUVFQUGQHNKƂVGITCUV QHYJKEJTGEGKXGFNKƂVGITCUV  No overall differences in safety or effectiveness have been 6JGOCLQTKV[QHRCVKGPVU  JCFŰOQPVJUQHVTGCVOGPV observed between elderly and younger adult patients. GZRQUWTGRCVKGPVUYGTGGZRQUGFVQNKƂVGITCUVHQT NONCLINICAL TOXICOLOGY approximately 12 months. The majority of the treated patients Carcinogenesis, Mutagenesis, Impairment of Fertility YGTGHGOCNG  6JGOQUVEQOOQPCFXGTUGTGCEVKQPU Carcinogenesis: Animal studies have not been conducted TGRQTVGFKPQHRCVKGPVUYGTGKPUVKNNCVKQPUKVGKTTKVCVKQP VQFGVGTOKPGVJGECTEKPQIGPKERQVGPVKCNQHNKƂVGITCUV dysgeusia and reduced visual acuity. Other adverse reactions Mutagenesis: .KƂVGITCUVYCUPQVOWVCIGPKEKPVJGin vitro TGRQTVGFKPVQQHVJGRCVKGPVUYGTGDNWTTGFXKUKQP #OGUCUUC[.KƂVGITCUVYCUPQVENCUVQIGPKEKPVJGin vivo conjunctival hyperemia, eye irritation, headache, increased mouse micronucleus assay. In an in vitro chromosomal lacrimation, eye discharge, eye discomfort, eye pruritus and aberration assay using mammalian cells (Chinese sinusitis. JCOUVGTQXCT[EGNNU NKƂVGITCUVYCURQUKVKXGCVVJGJKIJGUV Postmarketing Experience concentration tested, without metabolic activation. 6JGHQNNQYKPICFXGTUGTGCEVKQPUJCXGDGGPKFGPVKƂGFFWTKPI Impairment of fertility: .KƂVGITCUVCFOKPKUVGTGFCV postapproval use of Xiidra. Because these reactions are KPVTCXGPQWU +8 FQUGUQHWRVQOIMIFC[ reported voluntarily from a population of uncertain size, it is not HQNFVJGJWOCPRNCUOCGZRQUWTGCVVJG always possible to reliably estimate their frequency or establish TGEQOOGPFGFJWOCPQRJVJCNOKEFQUG 4*1& QH a causal relationship to drug exposure. NKƂVGITCUVQRJVJCNOKEUQNWVKQP JCFPQGHHGEVQP Rare cases of hypersensitivity, including anaphylactic reaction, fertility and reproductive performance in male and bronchospasm, respiratory distress, pharyngeal edema, swollen female treated rats. tongue, and urticaria have been reported. Eye swelling and rash have been reported. USE IN SPECIFIC POPULATIONS Pregnancy /CPWHCEVWTGFHQT5JKTG75+PE5JKTG9C[.GZKPIVQP/# There are no available data on Xiidra use in pregnant women to (QTOQTGKPHQTOCVKQPIQVQYYY:KKFTCEQOQTECNN KPHQTOCP[FTWICUUQEKCVGFTKUMU+PVTCXGPQWU +8 CFOKPKUVTCVKQP Marks designated ®CPFvCTGQYPGFD[5JKTGQTCPCHƂNKCVGFEQORCP[ QHNKƂVGITCUVVQRTGIPCPVTCVUHTQORTGOCVKPIVJTQWIJ 5JKTG75+PE5*+4'CPFVJG5JKTG.QIQCTGVTCFGOCTMUQT IGUVCVKQPFC[FKFPQVRTQFWEGVGTCVQIGPKEKV[CVENKPKECNN[ TGIKUVGTGFVTCFGOCTMUQH5JKTG2JCTOCEGWVKECN*QNFKPIU+TGNCPF relevant systemic exposures. Intravenous administration of .KOKVGFQTKVUCHƂNKCVGU NKƂVGITCUVVQRTGIPCPVTCDDKVUFWTKPIQTICPQIGPGUKURTQFWEGF Patented: please see JVVRUYYYUJKTGEQONGICNPQVKEGRTQFWEVRCVGPVU an increased incidence of omphalocele at the lowest dose .CUV/QFKƂGF5

RRO0819_ShireO0819_Shire PI.inddPI.indd 1 77/25/19/25/19 10:3010:30 AMAM EarnEarn uupp to 1717 CCEE CreditsCredits* ANNUAL • EST. 1976

A REVIEW MEETING OF CLINICAL EXCELLENCECCELLENCEELLENCE

Register before Labor Day for a special summer THE LONGEST discount! RUNNING WINTER CE MEETING IN EYE CARE! $495 ($100 off ) FEBRUARYF 14-17, 20200 ASPEN, COLORADO Westin Snowmass Conference Centernter The meeting features relevant topics in glaucoma, dry eye, external disease and retina. www.SkiVision.com

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Review Education Group partners with Salus University for those ODs who are licensed in states that require university credit. See event website for complete details. Outlook By Jack Persico, Editor-in-Chief PRINTED IN USA

FOUNDING EDITOR, FREDERICK BOGER 1891-1913

EDITORIAL OFFICES Breaking Down Barriers 11 CAMPUS BLVD., SUITE 100 NEWTOWN SQUARE, PA 19073 There’s nothing special about multifocal and toric

SUBSCRIPTION INQUIRIES 1-877-529-1746 contact lenses. And that’s a good thing. CONTINUING EDUCATION INQUIRIES 1-800-825-4696 hen Henry Ford launched the technology. Standardization and

EDITOR-IN-CHIEF • JACK PERSICO the Model T in 1908, he decades of refinements by manufac- (610) 492-1006 • [email protected] joked that it comes in turers have made toric and multifocal MANAGING EDITOR • REBECCA HEPP W any color you want, “as long as you contact lenses closer to single vision (610) 492-1005 • [email protected] SENIOR EDITOR • BILL KEKEVIAN want black.” The Model T was the lenses in fitting ease. Granted, they (610) 492-1003 • [email protected] first mass-produced automobile, and do have limitations that require com- ASSOCIATE EDITOR • CATHERINE MANTHORP the only way Ford could build it at promise by the patient—just as Ford’s (610) 492-1043 • [email protected] ASSOCIATE EDITOR • MARK DE LEON high volume was to limit consumers’ Model T did—but that enables more (610) 492-1021 • [email protected] choices. Contact lenses had arrived 20 people to benefit from them. Yet they SPECIAL PROJECTS MANAGER • JILL HOFFMAN years prior, but wouldn’t be mass-pro- continue to get the ‘specialty’ tag. (610) 492-1037 • [email protected] ART DIRECTOR • JARED ARAUJO duced until the early 1970s. For more Doing so perpetuates the belief that (610) 492-1032 • [email protected] than 80 years, they were a highly cus- these are niche applications reserved DIRECTOR OF CE ADMINISTRATION • REGINA COMBS tomized product—what today might for those doctors so enamored of (212) 274-7160 • [email protected] be called artisanal or bespoke. They contact lens practice as to call them- EDITORIAL BOARD were also highly fragile and fraught selves specialists. CHIEF CLINICAL EDITOR • PAUL M. KARPECKI, OD with problems. Practitioners had to Enough already. There’s no good ASSOCIATE CLINICAL EDITORS • JOSEPH P. SHOVLIN, OD; ALAN G. KABAT, OD; CHRISTINE W. SINDT, OD be specialists to get it right. reason why these shouldn’t be mass- DIRECTOR OPTOMETRIC PROGRAMS • ARTHUR EPSTEIN, OD Standardization made contact market lenses. There are millions CLINICAL & EDUCATION CONFERENCE ADVISOR lenses accessible to millions. It also of astigmats, presbyopes and even PAUL M. KARPECKI, OD CASE REPORTS COORDINATOR • ANDREW S. GURWOOD, OD made this clinical service available astigmatic presbyopes out there. To CLINICAL CODING EDITOR • JOHN RUMPAKIS, OD, MBA to thousands of ODs who otherwise mentally cordon these people off as CONSULTING EDITOR • FRANK FONTANA, OD might not have had the background ‘specialty lens patients’, as so many

COLUMNISTS and motivation to offer it. still do, sets yourself up for failure CHAIRSIDE • MONTGOMERY VICKERS, OD Fast forward to today. Contact and missed opportunities. The bar- CLINICAL QUANDARIES • PAUL C. AJAMIAN, OD lens fitting is under siege by online rier to success here is an artificial CODING CONNECTION • JOHN RUMPAKIS, OD sellers who interrupt the doctor- one, more mental than practical. You CORNEA & CONTACT LENS Q+A • JOSEPH P. SHOVLIN, OD patient relationship so they can wouldn’t call a PAL or a single vision DIAGNOSTIC QUIZ • ANDREW S. GURWOOD, OD THE ESSENTIALS • BISANT A. LABIB, OD swoop in with cheap (perhaps knock- eyeglass lens with cyl ‘specialty oph- FOCUS ON REFRACTION • MARC TAUB, OD; off) products. Experts say it’s not thalmic lenses’, would you? PAUL HARRIS, OD that hard to push back if you play up Those who receive our publication GLAUCOMA GRAND ROUNDS • JAMES L. FANELLI, OD your skills as a contact lens specialist Review of Cornea & Contact Lenses NEURO CLINIC • MICHAEL TROTTINI, OD; MICHAEL DELGIODICE, OD and offer specialty contact lenses that will see that this month’s issue is our OCULAR SURFACE REVIEW • PAUL M. KARPECKI, OD can’t be easily substituted online. annual compendium of every contact RETINA DILEMMAS • DIANA L. SHECHTMAN, OD; This brings up two questions: lens product on the market. We’ve JAY M. HAYNIE, OD what is a contact lens specialist, and given it a clean and colorful new look RETINA QUIZ • MARK T. DUNBAR, OD REVIEW OF SYSTEMS • CARLO J. PELINO, OD; what is a specialty contact lens? It’s this year. We also grouped the lenses JOSEPH J. PIZZIMENTI, OD commonly accepted that a contact a little differently, breaking the soft SURGICAL MINUTE • DEREK N. CUNNINGHAM, OD; lens specialist is someone who can fit lens listings into two main categories: WALTER O. WHITLEY, OD, MBA THERAPEUTIC REVIEW • JOSEPH W. SOWKA, OD GPs, and lately sclerals, plus custom general use and special use. We inten- THROUGH MY EYES • PAUL M. KARPECKI, OD soft lenses—in addition to the mass- tionally put into the general-use cat- URGENT CARE • RICHARD B. MANGAN, OD market soft lenses. egory a few lens modalities that some More problematic is the definition might be surprised to see there: you JOBSON MEDICAL INFORMATION LLC of a specialty lens. It feels like the guessed it, torics and multifocals. Just terminology didn’t keep pace with go with it—Henry Ford would. ■

16 REVIEW OF OPTOMETRY AUGUST 15, 2019

016_ro0819_outlook.indd 16 8/7/19 7:15 PM EASY, CLEAN, PORTABLE.

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RRO0319_Menicon.inddO0319_Menicon.indd 1 22/25/19/25/19 11:5211:52 AMAM Through My Eyes

Stay in the Fast Lane Optometrists are in the driver’s seat. Take some new opportunities for a spin. By Paul M. Karpecki, OD, Chief Clinical Editor

ptometrists don’t see them- in-office, patient-pay procedures. Be a Co-pilot selves in a power position, Until insurance covers these, doc- Patients trust the provider they have Obut any profession that sees tors can set pricing to appeal to seen for the last two, or 20, years 88% of all comprehensive exams, in patients while also maintaining a more than someone they meet for 15 this case eye exams, wields consider- healthy margin. One essential in- minutes before a procedure. That’s able power. And with an election office treatment is BlephEx, because why ODs should be integral to the that will focus on healthcare, 2020 removing the biofilm from the IOL or MIGS selection process. will be a critical year for optometry. lashes and lid margins for patients By the end of the year, RxSight It’s time to embrace this position and with meibomian gland dysfunction will introduce the light-adjustable use it to serve our patients—and our (MGD)/blepharitis can significantly lens. I’ve seen the adjustment pro- practices—better. A significant part improvement signs and symptoms. cess first hand, and most patients of doing that is recognizing disrup- Many patients state that their eyes with an adjustable light lens had tors in the field and adapting to stay have not felt this good in decades. uncorrected distance vision of 20/12 ahead of the inevitable changes. Another important in-office proce- or better. We will be the doctors dure is thermal pulsation with Lipi- determining the optimal refraction Test Drive the New Model Flow (Johnson & Johnson Vision), post-surgery, whether that’s with Today, 120 million people are in iLux (Tear Film Innovations), monovision, full distance correction their 40s, 50s and 60s, and more TearCare (Sight Sciences) or, soon, in both eyes, astigmatism modifica- than 38% of them have significant Ocusoft’s eyelid warming device. tion or, one day, presbyopic cor- astigmatism. Those 32 million Intense pulsed light (IPL), with either rection designs. Our involvement patients need a multifocal contact the Eye-Light IPL (Lombart) or is key to alleviating the demand on lens with astigmatic correction, yet Lumenis’s IPL, is another in-office surgeons, considering that the need most of them believe they are not option for most ODs. I recently for cataract surgery will exceed the candidates for contact lenses because purchased an Eye-Light IPL system supply of surgeons within the next of presbyopia, astigmatism or both. and treated 50 patients with it in seven years. That means we need to Bausch + Lomb’s new Ultra the first six weeks. We’ve been very handle more of the care, including Multifocal for Astigmatism contact impressed with its ease of use, the comanagement and, when we can, lens now provides an easy in-office patient experience and the results. laser procedures. ODs can also look option. This lens provides a high Most patients require only two treat- into working with surgeons with DK/t (163), high water content ments and I can see a significant in-office surgical suites to offer more (46%) and a high modulus (70). improvement in telangiectatic vessels advanced procedures and help meet It has parameters from -6.00D to and overall inflammation in the eye. the growing needs of patients. +4.00D, around the clock in 10° Patients have noticeable improve- When you control the majority of steps, three cylinder powers and ments in symptoms. all comprehensive eye exams and are two add powers. In clinical trials, Many patients who have delayed more than 40,000 strong, you can 92% of patients said they could shift treatment of their MGD or dry eye be disruptive for the betterment of naturally from near to far through- will require a combination of all patients. There are many opportuni- out the day. three in-office procedures. When ties to choose from—make sure you combined with dry eye therapies and aren’t the one being disrupted. ■ Upgrade Your Tech Package at-home care, these procedures may Note: Dr. Karpecki consults for Another valuable addition for your solve the complex puzzle of dry eye companies with products and ser- patients—and your bottom line—is for many patients. vices relevant to this topic.

18 REVIEW OF OPTOMETRY AUGUST 15, 2019

018_ro0819_TME.indd 18 8/7/19 6:54 PM Chair Side

More Lenses, More Problems If only we could upgrade our patients the way we upgrade our contact lenses. By Montgomery Vickers, OD

s the technologies in chem- To absorb such an absurd cost A Taste of the Future istry and plastics explode, increase, I think the kids should Meanwhile, contact lens manufac- Acontact lenses are becom- pay for their own contact lenses by turers diligently march on. Lenses ing more comfortable, safer and skipping one can of soda per day continue to improve with higher more efficacious than ever before. (I know, I know, that’s really hard oxygen permeability, better optics Of course, it’s just our luck that for the poor little souls, and no one and even UV protection. We even our patients have simultaneously should have to sacrifice like that). have lenses that darken in the sun, devolved. In the older, more primi- For our older patients trying to making us all look like cats after tive lenses they were thrilled to see read the game score on the phone too much catnip. What’s next, they 20/40 and had no problem remov- hidden in their lap while pretending taste like bubble gum and you just ing them after six hours to allevi- to care about their boss’s quarterly eat them when you’re done to be ate dryness and pain. Now, in the performance presentation, bifocal environmentally friendly? amazing new lens designs, they are contact lenses have created a new While you’re at it, why not apoplectic because the lenses don’t era of psychological pathologies. design a lens that knows the make them 25 years old again and But they seem to work really well answers to a kid’s SATs so we can they missed one letter on the 20/15 for patients who are motivated and keep their movie star parents out of line in their left eye. understand they still beat wear- jail? I don’t want to pay more taxes Obviously, all of this is your ing glasses at work. If only we so they can have caviar in Riker’s. fault, and they aren’t afraid to tell could get them to stop driving to Somewhere, deep in the bowels you so. Louisiana at midnight in a hurri- of a laboratory, some mad scientist cane while wearing them. is working on the perfect contact Never Good Enough As I am now 66 years old, I can lens. You know… the one that will Thus, we still see contact lens drop- truly relate to the challenges of try- lead to world peace. I can’t wait to outs every day. I get it… it’s really ing to see distance and near with- see what it tastes like. ■ frustrating to have to put contact out glasses. I have been known to lenses in every day, even if they do change my multifocal contact lenses let you do cool things like see. It’s two or three times in one day at the also way too much work to remove office in search of the Holy Grail of and discard them every day. That lens wear. Of course, hiding my age takes time away from what’s impor- spots and dermatochalasis behind a tant like Googling, “How tall is cool pair of glasses may actually LeBron James?” make a lot more Plus, better technologies have sense for me. increased the (perceived) cost to our patients. When I started wearing contact lenses in high school, my mom paid $300 for two lenses, and I was grounded for a month after I accidentally dropped them down the sink drain the first night. Now, they are ridiculously expensive, something like $2.00 for two lenses.

REVIEW OF OPTOMETRY AUGUST 15, 2019 19

019_ro0819_Chairside.indd 19 8/6/19 1:59 PM Clinical Quandaries

Red All Over If certain glaucoma medications cause adverse effects, consider these options. Edited by Paul C. Ajamian, OD

I have a patient who was put duction are becoming increasingly Q on Rhopressa (netarsudil, attractive options for patients. Aerie Pharmaceuticals) after other “MIGS should be considered as medications did not work. Her adjunctive therapy, especially when pressure lowered significantly, but topical therapies have failed or are six weeks later her eyes turned very poorly tolerated,” Dr. Wroten says. red, and she’s now mortified to go In the hands of an experienced out in public. Lumify (brimonidine surgeon, they are quick and tartrate ophthalmic solution 0.025%, effective, with device instillation Bausch + Lomb) didn’t help quiet the occurring immediately after the eyes. Is this a common problem? intraocular lens is inserted in the “I’ve personally had a fair capsular bag. A amount of clinical success While netarsudil therapy may be effective, If this patient was not a candidate prescribing Rhopressa to treat glau- patients can experience conjunctival hyperemia. for cataract surgery, then selective coma; however, ocular hyperemia laser trabeculoplasty would be does occur at some level in roughly However, he has also had two another attractive option. This 50% of patients who begin netar- patients with uncontrolled IOP on procedure is well-tolerated and sudil 0.02% therapy,” says Chris maximum topical glaucoma therapy effective for about 80% of patients, Wroten, OD, of Bond-Wroten Eye who experienced a nearly 40% lowering IOP by 20% to 30% for Clinic in Louisiana. As many as one reduction in pressure when netarsudil about 24 months on average.2 It is in five patients experience conjunc- was added—atypical cases. also repeatable once the effect wears tival hemorrhage, and 5% to 10% “It will be interesting to see if off, with similar therapeutic effect manifest eyelid and/or instillation tachyphylaxis develops because expected. More invasive filtering and site erythema, so red eyes are not netarsudil was found to be most valve surgeries were probably not uncommon.1 effective when IOP was below warranted given her mild stage of “Although a number of patients 26mm Hg at initiation of therapy,” glaucoma. do experience side effects such as Dr. Wroten says.2 With our patient, Dr. Wroten had these, most are mild and tolerable, tried just about every medication, so so netarsudil is certainly a welcome A New Hope the laser and surgical options were addition to our glaucoma treatment Given the side effects, Dr. Wroten all that were left. He controlled her arsenal,” Dr. Wroten notes. had no choice but to stop the IOP at 12mm Hg after the iStent Two other side effects of note patient’s medication. A week later, Inject (Glaukos) was put in, and she are corneal verticillata, which can her eyes were dramatically quieter, is only on a beta blocker now. occur in up to 20% of patients and but it will take time for the corneal “Fortunately, with today’s diag- is usually after four or more weeks changes to resolve. Because the nostic technologies and treatment of therapy, and blurred vision, which patient also presented with cata- options, patients with glaucoma is reported in 5% to 10% of those racts, he determined that she would have a far better prognosis than ever 1 taking netarsudil. be a great candidate for minimally- before,” Dr. Wroten says. ■ Dr. Wroten has had three patients invasive glaucoma surgery (MIGS) 1. Rhopressa. Prescribing Information. rhopressa.com/ whose intraocular pressure (IOP) to manage her IOP in conjunction assets/pdf/RHOPRESSA-Prescribing-Information.pdf. responded well to the medication but with cataract surgery. Accessed July 3, 2019. 2. Khouri AS, Lari HB, Berezina TL, et al. Long term efficacy were forced to discontinue therapy MIGS devices and procedures that of repeat selective laser trabeculoplasty. J Ophthalmic Vis due to significantly blurred vision. shunt and/or reduce aqueous pro- Res. 2014;9(4):444-8.

20 REVIEW OF OPTOMETRY AUGUST 15, 2019

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RP0819_Akorn.indd 1 7/11/19 11:13 AM Focus on Refraction

How Much is Too Much? Many patients are over-plussed at near. With these simple strategies, you can learn how to avoid this. By Marc B. Taub, OD, MS, and Paul Harris, OD

question that often arises Ais how to determine bifocal power for patients. We all learned about the tables and charts that depict the loss of accommodation with age in optometry school. Presbyopia is in full force by the time most patients This patient is completing range testing with an iPad as his target. reach 40, and by the age of 70, everyone needs a +2.50 add at near, right? and do not like looking or having to look closely at Not so fast. Here, we will discuss how our method things to see them, they learn to inhibit accommo- of using ranges and showing them to our patients in dation or, put more blatantly, start to get lazy. The varying real-life conditions helps us tailor lenses to “zero-position,” or the dark focus point of the whole their specific needs. system, shifts outward, which, over time, can manifest as an increase in the hyperopia at distance. When left The Problem With Too Much Plus unchecked for long enough, this can cause patients to It turns out that, based on age alone, many patients become dependent on some plus for clarity and relax- get too much plus at near. Over time, these patients ation at distance. show an increase in hyperopia at distance well beyond the +0.50 or +0.75 they measured for many years. How to Avoid Too Much Plus The period between being prescribed full plus at near The development of many different near retinoscopy based on age and developing increasing hyperopia techniques—including book, bell, MEM, stress-point at distance varies from three to five years, and many and just-look retinoscopy—made it possible to steer patients go through it. clear of giving too much plus at near. The pioneers When looking at progressive myopia, many believe of our profession looked at different aspects of the the problem begins at near and spreads to distance. retinoscopic reflex in relation to the demands patients Sustained close work causes a type of form deprivation experience and the targets they look at. They discov- in the periphery, which, when combined with periph- ered that there is an optimum amount of plus and that eral defocus, seems to be the driving force behind axial too little or too much can cause short- and long-term length changes in the eye. The blur at distance is just a problems for patients. side effect of the close work. Without the close work Another test we all learned in optometry school is the causing peripheral defocus and form deprivation, the fused cross-cylinder (FCC) test. It’s problematic in that eye wouldn’t change the way it does or experience about 25% of patients don’t see a difference between myopia that progresses faster than normal. the vertical and horizontal lines when the test is done in Too much plus at near also sets up a situation where the traditional way. Some phoropters, however, can flip patients are not rewarded for supplying their own the Jackson cross cylinders used to administer the test accommodation. If they have too much plus at near to an alternate orientation, making it possible to obtain

22 REVIEW OF OPTOMETRY AUGUST 15, 2019

022_ro0819_FoR.indd 22 8/6/19 2:32 PM a clear endpoint for nearly all patients. But, modify- ing how we arrive at these endpoints still does not give us a foolproof way to come up with add powers that aren’t too high. FCC test results and negative relative accommodation and positive relative accom- modation findings only give us a framework within which we can come up with add powers for our patients. Stress-point retinoscopy was then developed to come up with the optimum plus lens for near. The technique is very difficult for many to master and requires the use of a spot retinoscope. Though a new spot retinoscope is now on the market, the technique still remains difficult to grasp. When used correctly, it yields an optimum amount of plus that the patient can use successfully immediately without risk of rejection. Often, the plus power a patient receives for near from the stress point retinoscopy method is less than the FCC test. If you don’t know how to do stress-point reti- noscopy or you don’t have a spot retinoscope, trial framing the plus to see if it is clear at a patient’s habitual or desired reading distance and to measure ranges for the lenses over which the patient can see clearly is another option. Give the patient a target, such as a computer or phone screen, that resembles something they normally look at. Have them bring it closer to them until it begins to blur, and then have them push it further from them until it begins to blur. This establishes the range over which the lenses will work and sets the stage for a discussion about the reduced depth of field of focus and the loss of accommodation amplitude that occur with age. Our patients want one lens to do it all and everything to be perfectly clear all time, regardless of where the demand is in their visual field. It’s up to us to help them achieve that, with whichever method we decide to use.

We have found that many people prefer sacrificing a bit of the very close range for big extensions in the back end of the range, which is less plus for near, and self-select this option when given the chance to see and understand their choices. It may be beneficial to determine the add power you would normally give with your current method of prescribing and then obtain the range measure- ments with the technique we suggested to give your patients two options and see what they prefer. You may find that less is best and stabilizes your patient’s distance refractions over time. ■

022_ro0819_FoR.indd 23 8/6/19 2:33 PM Retina Dilemmas

Caution: Congestion Ahead Use your diagnostic toolkit to navigate the crucial distinction between true and pseudopapilledema. By Jay M. Haynie OD, Diana Shechtman OD, and Rashid Taher, MD

hen a patient has an sured 20/20 OU, intraocular elevated optic nerve pressures (IOPs) measured Whead (ONH) with 15mm Hg OD and 14mm blurred disc margins, alarm bells Hg OS, pupil assessment was should go off. These could be normal without afferent pupil- harbingers of true papilledema lary defect (APD) and her body caused by an underlying sys- mass index (BMI) was 21.0. temic process or mass lesion in Her anterior segment examina- need of urgent treatment. Fig. 1. SD-OCT of a patient with papilledema shows tion was unremarkable, but her But these signs could also be the shadow or darkening of the deeper structures. dilated examination revealed a pseudopapilledema. Optic nerve congested ONH in each eye with head drusen (ONHD), the most differentiating pseudopapilledema blurred disc margins (Figure 2). We common etiology of pseudopapill- from true papilledema, as the latter then performed SD-OCT, FAF and edema, are found in approximately will show nerve fiber layer edema on B-scan ultrasonography (Figure 3), 1% of the population with bilateral SD-OCT imaging, which may cast which helped us diagnose her with distribution in 75% to 85%.1-3 a shadow on the structures below buried ONHD and advise annual Although patients with benign (Figure 1). ONHD, on the other follow-up. ONHD are often asymptomatic, hand, will be hyper-reflective on ONHD are generally seen well the drusen can cause elevation, con- SD-OCT. with FAF; however, in younger gestion and blurred margins of the patients, as in this case, the drusen optic nerve, simulating papilledema. Blurry Signs deposits are more posterior and may Patients with ONHD are often Cases by Dr. Haynie not been seen until later in life. asymptomatic, leading to a high Case 1. An 11-year-old Caucasian Case 2. A 37-year-old Hispanic rate of incidental discovery. Visual female with an elevated ONH was woman was referred by her neurolo- inspection of an elevated ONH is referred to rule out papilledema. She gist for an evaluation of optic nerve often insufficient to confirm pseu- had no visual complaints and denied edema. She was diagnosed with pap- dopapilledema and rule out a more headaches. Her visual acuities mea- illedema by a local ophthalmologist serious diagnosis. Thus, a multitude of tests—including radiologic neu- roimaging and a spinal tap—are warranted to rule out an intracranial mass or lesion and to assess for increased intracranial hypertension. Many other useful diagnostic tests are available in the optometric set- ting to assess ONHD, including spectral domain OCT (SD-OCT), fundus autofluoresence (FAF), intra- venous fluorescein angiography (IVFA), OCT angiography (OCT-A) and B-scan ultrasonography. Fig. 2. Color fundus images reveal crowded elevation of the ONH with indistinct SD-OCT can be quite helpful in margins in both eyes.

24 REVIEW OF OPTOMETRY AUGUST 15, 2019

024_ro0819_RD.indd 24 8/7/19 7:28 PM COMBO COMBINE WITH OUR margins. Her IVFA was UNIQUE STAND normal without late leakage as we would expect with papilledema. Her SD-OCT and FAF Eff ortless images confirmed the diagnosis of ONHD instrument (Figures 4 and 5). A Diagnostic positioning Roadmap Commentary by Dr. Shechtman and Dr. Taher Although no set pro- tocols exist for the assessment of pseudo- papilledema vs. true Fig. 3. SD-OCT, top, and ultrasonography, bottom, show papilledema, a compre- hyper-reflective lesions deep in the ONH consistent hensive eye examination with drusen. Findings were similar in both eyes. with a dilated fundus evaluation and the use who then referred her to neurology. of various diagnostic However, her radiologic neuroimag- modalities can be quite valuable ing and lumbar puncture were both when distinguishing between the normal, and the neurologist referred two (Table 1). her for a retinal consultation. Her We have found that IVFA is par- chief complaint was headaches, ticularly useful in distinguishing which were later attributed to prob- papilledema from pseudopapill- able migraine. Her past medical his- edema by revealing ONH leakage. tory was negative. Her visual acuity On ultrasonography, another helpful measured 20/20 OU, IOPs measured diagnostic tool, drusen appear as Advanced 20mm Hg OD and 21mm Hg OS, hyper-reflective calcified bodies in pupil assessment was normal with- the optic nerve and will continue ergonomics out APD and her BMI was 27.0. Her to show increasing brightness even anterior segment examination was at a low gain. Other ancillary test- unremarkable, but dilation revealed ing such as OCT, visual fields and congested ONHs with blurred disc FAF can also be helpful. SD-OCT of ONHD can reveal an elevated disc with a characteristic “lumpy-bumpy” appearance. A nerve with true papill- edema, however, may reveal a smooth internal contour of the ONH with a Fig. 4. SD-OCT of the left eye shows hyper-reflective lesions characteristic hypo- deep in the ONH consistent with drusen. The right eye reflective “V” pat- shows similar findings. tern in the subretinal

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Table 1. ONHD vs. True Papilledema Features ONHD True Papilledema Visual Transient vision +/- transient vision loss, double vision and visual symptoms loss and visual field field defects (typically an enlarged blind spot) defects can occur Headaches Not associated with If present, often described as worse upon ONHD awakening and/or with postural changes Neurological None Tinnitus, vertigo, nausea/vomiting, peripheral symptoms neuralgias Optic nerve Elevation confined Elevated swollen nerve, hyperemia, peripapillary appearance to disc vessel obscuration; +/- flame shaped hemorrhages, cotton wool spots, +/- Paton’s lines; SVP absent Vasculature Anomalous branching Microvascular dilation pattern

space adjacent to the ONH. ONHD can help prevent progressive Corneal Topography & More! Although these are distinct find- optic neuropathy and slow visual ings, SD-OCT alone should not be field loss, but ONHD are dynamic used to distinguish between the two and can cause shifts of the refractile conditions. Furthermore, because bodies at any time. the calcific properties of drusen have In any case where the diagnosis of inherent autofluorescent ability, pseudopapilledema is not confirmed, ONHD will show hyperfluorescence referral to a neuro-ophthalmologist on FAF. Drusen autofluorescence is is warranted. True papilledema inversely proportional to its depth, requires an immediate referral for meaning deeply buried drusen may radiological imaging, such as MRI Meibomian Gland be difficult to assess. Additionally, or CT MRA/MRV, followed by lum- Imaging & Analysis if the cause of pseudopapilledema is bar puncture. ■ not ONHD, FAF would show unre- markable findings. 1. Auw-Haedrich C, Staubach F, Witschel H. Optic disk drusen. Surv Ophthalmol. 2002:47(6):515-32. Although ONHD are often found 2. Erkkila H. Clinical appearance of optic disc drusen in in isolation, they may be associated childhood. Albrecht Von Graefes Arch Klin Exp Ophthalmol. with other ocular findings, such as 1975;193(1):1-18. 3. Mehrpour M, Torshizi F, Esmaeeli S, et al. Optic nerve sonog- angioid streaks, that correlate with raphy in the diagnostic evaluation of pseudopapilledema and underlying conditions. Additionally, raised intracranial pressure: A cross-sectional study. Neurology Non-Invasive Tear Film lowering IOP in patients with Research International. 2015:Article ID 146059. Break-up Analysis

Tear Meniscus Height

Fig. 5. FAF confirmed focal hyperautofluoresence of the ONH consistent with lipofuscin (ONHD) in both eyes.

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024_ro0819_RD.indd 27 8/7/19 7:29 PM Coding Connection

Not Covered? No Problem Financial waivers of liability are the key to getting paid in today’s world. By John Rumpakis, OD, MBA, Clinical Coding Editor

oday’s healthcare system is form, and you must use Medicare’s the patient always has financial a fickle beast, and the chal- specific form, found at www.cms. responsibility for the procedure or Tlenges of navigating the payor gov/medicare/medicare-general- test being conducted. system can be overwhelming. But information/bni/abn.html. Medicare Modifier GZ: Item or service you can always get paid for what Advantage Plans (Medicare Part C) expected to be denied as not reason- you do. If you ever write a charge have their own forms with distinct able and necessary. This reports that off to a zero balance, you are not and separate rules. For commercial an ABN was not issued. CMS will taking full advantage of the rules payors, the Medicare Part B ABN automatically deny these services that exist to get paid. Consult with form works if you remove the word and indicate the beneficiary is not your billing department and spot Medicare and substitute “your medi- responsible for payment. Without an check your EOBs to make sure they cal insurance carrier.” This allows ABN prior to performing the service, aren’t writing off patient balances. you to properly submit claims to you cannot bill the patient. This is where understanding the any commercial medical carrier and Modifier GY: Item or service rules that govern the financial waiv- preserve your payment rights. statutorily excluded or does not ers of liability is crucial. meet the definition of any Medicare Modifiers benefit. This reports when a service Paperwork Once the patient completes the is specifically excluded by Medicare A financial waiver of liability is an ABN, add it to the patient record. and an ABN was not issued. CMS informed consent document you Notify the carrier on a claim-by- will deny these claims and the ben- use when you expect a patient’s claim basis that you have a com- eficiary will be totally responsible insurance will not cover a proce- pleted ABN form by using modifiers for all financial liability. dure or durable medical equipment on the specific procedure or DME in Modifiers GA and GZ are often (DME) such as eyeglass frames and question. Four common modifiers used if a procedure doesn’t meet lenses. The document informs the can be appended to the CPT codes— medical necessity as determined by a patient prior to a procedure being either as a requirement by Medicare Medicare local or national coverage performed or materials ordered that or voluntarily: determination. Modifiers GX and they may be financially liable for Modifier GA: ABN issued as GY are for items or services statu- the costs should the carrier deny required by payer policy, individual torily excluded from the Medicare the claim. The patient must provide case. This is used to report that a program. Here, an ABN is optional, consent by signature and accept required ABN was issued and filed but provides proof the beneficiary financial responsibility for you to for a service. CMS will assign finan- understands he will be liable for pay- proceed. The carrier can then legally cial liability to the beneficiary should ment. When using either modifier, and properly transfer the financial the services be denied. the provider should bill the patient liability to the patient, so you don’t Modifier GX: Notice of liabil- for the services provided. have to write off a balance that you ity issued, voluntary under payer Today’s private practice faces had a right to collect. policy. This reports that a voluntary many challenges—getting paid The form you use is incredibly ABN was issued for a service that is shouldn’t be one of them. Follow the important, as failure to use the right statutorily excluded from Medicare rules and get paid 100% of the time one prevents you from collecting reimbursement. Medicare will reject for 100% of what you do. You’ve from the patient should a claim be non-covered services appended with earned it. ■ denied. Medicare Part B requires an GX and assign liability to the benefi- Send your coding questions to advanced beneficiary notice (ABN) ciary. Since this is a voluntary ABN, [email protected].

28 REVIEW OF OPTOMETRY AUGUST 15, 2019

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RRO0819_Eyevance.inddO0819_Eyevance.indd 1 77/25/19/25/19 9:569:56 AMAM Systemic Disease

The Optometrist and Obstructive Sleep Apnea Learn to keep your snoring patients’ increased risk of disease from keeping you up at night. By Susan Kovacich, OD

lthough several types of attention to its associated ocular sleep-disordered breath- diseases. ing exist, obstructive Asleep apnea (OSA) is Diagnosis certainly the most common and The main risk factor for OSA the most publicized.1 The condi- is obesity (which can double tion is caused by a complete or the risk), specifically a neck partial anatomical upper airway circumference greater than 17 collapse that temporally restricts inches.2,5,6 It is more prevalent or obstructs breathing, often in a in males, with females catching cyclical pattern. The reduction of up following menopause. Aging, breathing is hypopnea, the cessa- craniofacial deformities, smok- tion of breathing is apnea. This ing and alcohol use before bed respiratory disruption reduces Vogt’s striae, as seen here, can indicate are also associated with OSA.2 blood oxyhemoglobin saturation keratoconus, which is more common in patients Most patients with OSA have no and impacts blood pressure, heart with OSA than those without. problems breathing while awake, rate, sympathetic activity, meta- but during sleep, muscle tone bolic activity and sleep. It elevates the disordered sleep it causes can relaxes and soft tissue in the phar- an individual’s risk for hyperten- have a deleterious impact on liter- ynx collapses to obstruct the air- sion, coronary artery disease, myo- ally every part of the human body, way. It’s the obesity that increases cardial infarction, congestive heart and the eyes are no exception. In the soft tissue (adipose) around the failure and stroke. fact, OSA is associated with several pharynx combined with a decrease OSA patients may experience ocular conditions, from the anterior in muscle tone with age—OSA is cognitive dysfunction, depression to posterior segment and impacting two to three times more prevalent and the sleep disturbances may a wide range of structures from the in patients older than 65.2 While even trigger metabolic syndrome tear film to the optic nerve. a complex neurochemical feed- and lead to diabetes.2,3 Addition- Here, we review the risk fac- back mechanism exists to promote

ally, the risk for gout is increased tors for OSA, how to recognize breathing when blood CO2 rises, by two times in older patients and and diagnose an OSA patient and the stimuli is insufficient to over- OSA is a risk factor for dislipid- how the optometrist can coman- ride the soft tissue obstruction emas.3,4 As you can see, OSA and age these patients, with special when the airway is compromised.

30 REVIEW OF OPTOMETRY AUGUST 15, 2019

030_ro0819_F1_Kovachic.indd 30 8/7/19 5:36 PM The impaired feedback Photos: Victoria Roan, OD patients in this study mechanism will result was 31.2.9 in imprecise ventila- Another study tion undershoots focused on FES, a con- and overshoots with dition characterized by sudden neurological an elastic-like upper arousals to promote eyelid that is easily pli- breathing which dis- ant and everted during rupt the sleep cycle.7 sleep or manually with While questionnaires minimal lateral trac- can be helpful for tion. The study found screening, OSA is Patients with OSA may 16 out of 17 patients formally diagnosed experience a variety of lid with OSA had FES.8 with polysomnogra- and lash conditions such This high correlation phy, or a continuous as lash ptosis, at left, and suggests that every overnight sleep study, floppy eyelid syndrome, patient with OSA should where the patient’s which is characterized by have their lids everted breathing, heart rate, superior lids that are easily to check for FES related brain waves, blood everted with minimal lateral papillary conjunctivitis. oxygen levels and force, as shown above. Any patient diagnosed other parameters are with FES who has not monitored.2,6 been diagnosed with Sleeping with OSA is character- Ocular Associations OSA should be referred to their ized by loud snoring, periods of not OSA is associated with several eye primary care physician for a work- breathing, followed by gasps when conditions. In 2005, investiga- up, or a cardiologist, neurologist, breathing resumes.2 People who tors reported an association with or pulmonologist if the patient sleep alone may be unaware of their floppy eyelid syndrome (FES), is currently under their care. The breathing disorder, and may become primary open angle glaucoma rubbery tarsal plate in FES fails to habituated to the daytime sleepi- (POAG), normal-tension glaucoma support the eyelid platform prop- ness and fatigue that results from (NTG), optic neuropathy, nonar- erly, with the eyelashes pointing fragmented sleep. People in rela- teritic anterior ischemic optic neu- downwards over the visual axis, tionships are more likely to be diag- ropathy (NAION) and papilledema making the presence of lash ptosis nosed with OSA as they are more with raised intracranial pressure a red flag.12 Differential diagnosis likely to be informed of their sleep (ICP).8 Additional research shows includes other types of chronic breathing disorder (SBD).2 Even so, an association with keratoconus papillary conjunctivitis. FES approximately 78% to 80% of the and an increase in diabetic retinop- patients tend to be obese males OSA population who could benefit athy (DR), especially proliferative with OSA. from treatment go undiagnosed.2 diabetic retinopathy (PDR) as well For any acute corneal or con- Furthermore, as the American as central serous retinopathy.9-11 junctival insult, eye care providers population becomes more obese, Research shows OSA’s impact on may apply an ophthalmic oint- the rate of sleep disordered breath- an array of structures within the ment, such as erythromycin, and ing in the American population eye, including the lids, the cornea, switch to a lubricating ointment continues to rise. One study using the optic nerves, and the retina. when the lesions resolve. Protecting data from 2007 to 2010 estimates Anterior segment and lids. In a the eyes during sleep by taping the that the rate of SBD in American population of patients with kera- eyelids or using a tightly-fitting eye adults aged 30 to 70 is 14% in men toconus, 18% had previously been mask or shields may be indicated. and 5% in women with symptoms diagnosed with OSA with sleep For severe cases, surgical tighten- that meet the Medicare criteria for testing and an additional 47% of ing of the eyelids is an option.13 OSA, which is a significant increase patients at high risk for developing Optic nerves and glaucoma. compared with data collected from OSA, according to a 2012 study.9 Researchers believe OSA can dam- 1988 to 1994.6 Of note, the average BMI of the age the vascular and mechanical

REVIEW OF OPTOMETRY AUGUST 15, 2019 31

030_ro0819_F1_Kovachic.indd 31 8/7/19 5:36 PM Systemic Disease

Ocular Conditions Associated with OSA the addition of pulsatile tinnitus. Keratoconus (KC) Acetazolamide is often prescribed if there is no sulfa allergy, whether Floppy eyelid syndrome (FES) the patient is symptomatic or not.20 Nonarteritic anterior ischemic optic neuropathy (NAION) The Journal of Clinical Sleep Medi- Papilledema with raised intracranial pressure/ Idiopathic Intracranial Hypertension (IIH) cine reports on one patient treated with both acetazolamide and CPAP Primary open angle glaucoma (POAG)/Normal tension glaucoma (NTG) who showed resolution of papill- Retinal vascular disease (retinal vacular occlusion (RVO), diabetic retinopathy (DR)) edema.21 Another study suggested Central serous retinopathy (CSR) that using the Berlin questionnaire would be a practical tool to direct IIH patients at high risk for OSA Photo: Diana Shechtman OD structures within the second cra- for polysomnography.22 nial nerve. Among other factors, Retina and vasculature. Retinal the recurrent impaired nocturnal vascular occlusion (RVO) includes vascular perfusion caused by OSA sudden, painless vision loss that is may damage the optic nerve, while usually unilateral, with visual field raised nocturnal intracranial pres- defects. Retinal hemorrhages and sure and elastic fiber depletion can dilated, tortuous veins are often cause mechanical damage.14 seen.23 Symptoms of RVO usually NTG patients frequently have manifest upon waking similar to OSA issues, according to one study NAION, suggesting microvascu- showing that a large percentage of lar and hypercoagulable changes middle aged or older NTG patients during nocturnal apnea events. test positive for OSA with poly- Research shows that patients with somnography. Researchers hypoth- RVO often have OSA, and OSA is esize that impaired autoregulation This pediatric patient’s papilledema is now considered to be a risk factor of optic disc circulation results evident due to the microvascular dilation for RVO events.1 in nerve damage.15 NTG is more of the optic nerve, vessel obscuration Diabetic retinopathy (DR). The highly associated with and OSA and Paton’s line (red arrows). hyperglycemia caused by diabetes than with POAG. Papilledema is associated with OSA. leads to oxidative stress and dam- NAION patients with OSA expe- age to the vascular endothelium, rience nocturnal hypoxia, which mass, emergency cranial imaging is resulting in permeable blood may result in episodic hypotension. indicated.17 The nocturnal hypoxia vessels.24 Early nonproliferative Also, the nocturnal hypoxia may caused by OSA changes the cere- diabetic retinopathy (NPDR) is directly damage the optic nerve. bral vasculature which itself is asso- characterized by retinal hemor- Investigators point to an exception- ciated with elevated ICP.18 rhages and microaneurisms. The ally high association with NAION Idiopathic intracranial hyperten- leaky blood vessels allow the depo- and OSA, with 70% of NAION sion (IIH), also called pseudotumor sition of hard exudates (lipids) patients having OSA. When refer- cerebri, is a condition that primar- and fluid in the macula resulting ring NAOIN patients, be sure ily impacts females with obesity. in diabetic macular edema (DME) to mention the association with It is also associated with OSA and and vision loss. Progressive capil- OSA.16 disordered sleep.19 Signs include lary nonperfusion resulting in isch- Papilledemas can include pseu- increased ICP, normal brain imag- emia will promote the formation dopapilledema, papillitis, ischemic ing and increased opening pressure of PDR which is characterized by optic neuropathy and hypertensive on lumbar puncture with normal the proliferation of neovasculariza- optic neuropathy among others. All cerebral spinal fluid findings and tion on the surface of the retina involve optic disc swelling caused an enlarged blind spot. Symptoms or optic disc. PDR can result in by raised intracranial pressure for patients with IIH and elevated vitreous hemorrhages, fibrosis and (ICP). Since papilledema can some- ICP are similar to the symptoms tractional detachments.25 In a study times be caused by an intracranial of those with papilledema with of diabetic patients who already

32 REVIEW OF OPTOMETRY AUGUST 15, 2019

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RO0819_B&L Biotrue.indd 1 7/25/19 9:51 AM Systemic Disease

Systemic Conditions Associated with OSA these are not as effective as CPAP. Comorbid condition Prevalence of OSA Reconstructive surgery to the upper airway to improve airflow has also 1 Congestive heart failure 11% to 37% been performed, but the effective- Stroke and transient ischemic attack 43% to 72%1 ness of such procedures is not well 31 Development of hypertension 42%2 studied. CPAP usage needs to be long- 3 Gout 50% term which is impacted by poor 1. Young T, Skartrud J, Peppard P. Risk factors for obstructive sleep apnea in adults. JAMA. 2004;291(16):2013-6. adherence by users. The ben- 2. Peppard P, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and efits of extended usage cannot be hypertension. N Engl J Med. 2000;342(19):1378-84. 3. Zhang Y, Peloquin C, Dubreuil M, et al. Sleep apnea and the risk of incident gout. Arthritis and Rheumatology. A population- ignored—CPAP usage can reduce based, body mass index-matched cohort study. 2017;67(12):3298-302. snoring and nocturnal awakenings which improves sleeping.32 The had DR, PDR was much more surgically created hole with a tube associated reduction in daytime prevalent in patients with OSA.10 leading through the front of the sleepiness has also been associated Vascular endothelial growth factor neck and into trachea, created by with a decrease in motor vehicle (VEGF) is sensitive to hypoxia and a tracheotomy.2 This invasive pro- accidents attributed to OSA.32 responsible for new blood vessel cedure adversely affects the ability CPAP usage seems to have its production.26 Nocturnal desatura- to speak and impacts eating. The largest impact on cardiovascular tion and reoxygenation caused by patient is also burdened by the care outcomes and hypertension. Meta- OSA was thought to be directly of the “trach tube” to prevent clog- bolic syndrome and hyperlipid- related to the increased develop- ging and infection.29 emia is also improved.32 The sleep ment of PDR in these patients.10 All of this changed when the fragmentation in OSA seems to The management of diabetic continuous positive airway pressure primarily affect attention/vigilance retinopathy includes tight glyce- (CPAP) ventilator was developed, while hypoxia is linked to global mic control, panretinal and focal which is now considered standard cognitive function.33 A meta-review laser photocoagulation, anti-VEGF in OSA treatment.30 A machine of CPAP treatment on cognitive therapy and vitrectomy.25,27 provides constant airflow, and function showed medium to large Central serous retinopathy (CSR) the patient wears a mask over the improvements in five subcategories is an idiopathic serous retinopathy nose or mouth or both to direct of executive function.34 characterized by blurred vision, the flow through the airway dur- Due to the strong association metamorphopisia and a central ing sleep. This continuous pushing with obesity, lifestyle changes are blind spot. The patient presents of air through the trachea keeps encouraged for those patients with with a serous detachment of the the airway open and prevents the OSA who are obese—defined as neurosensory retina in the macula. airway collapse experienced in any body mass index (BMI) of The classic patient profile is a male OSA. Research shows that CPAP greater than 30. While diet and between the ages of 25 and 50 who usage reduces airway obstructions exercise leading to weight loss can is stressed, which is why an asso- and improves sleep in patients with help reduce the severity of OSA, it ciation with cortisol is suspected.28 OSA, reducing daytime sleepiness is thought that weight reduction The constant interruption of the and other systemic impacts.31 alone may be insufficient to reverse sleep cycle in OSA affects the sym- CPAP usage is not without its the condition.35 Cessation of smok- pathetic system and promotes an own issues, as some patients can- ing along with the reduction of increased production of circulating not tolerate wearing a mask during nighttime alcohol use are also norepinephrine and epinephrine sleep or develop a dry nose or other encouraged.31 which is thought to increase vascu- issues. CPAP usage can also have lar permeability leading to serous deleterious effects on the eyes, also, CPAP Impact fluid leakage.11 which will be discussed later. Other If the ocular impacts of OSA OSA treatments include mouth weren’t enough, CPAP usage also Systemic Treatment guards or splints which widen the can have a deleterious effect on the Before 1981, the only treatment airway by pushing the jaw forward eye. Air blown into the eyes from for OSA was a tracheostomy, a and advancing the tongue, but poor fitting CPAP masks has long

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0030_ro0819_F1_Kovachic.indd30_ro0819_F1_Kovachic.indd 3344 88/7/19/7/19 5:375:37 PMPM Photo: Paul Chous, OD coma is associated with sleep apnea syndrome. Ophthalmo- been known to cause ocular dry- logica. 2002;216(3):180-4. 16. Mojon D, Hedges T, Ehrenberg B, et al. Association between ness. Conjunctivitis resulting from sleep apnea syndrome and nonarteritic anterior ischemic optic CPAP use was reported as early neuropathy. Arch Ophthalmol. 2002;120(5):601-605. 36 17. Papilledema. In: The Wills Eye Manual: Office and Emer- as 1984. One paper identified gency Room Diagnosis and Treatment of Eye Disease. 7th ed. Bagheri N, ed. Philadelphia: Wolters Kluwer; 2017:259-60. anterior segment problems such as 18. Jennum P, Borgensen SE. Intracranial pressure and obstruc- dryness and recurrent corneal infec- tive sleep apnea. Chest. 1989;95(2):279-83. 19. Marcus D, Lynn J, Miller J, et al. Sleep disorders: a tions observed in contact lens wear- risk factor for pseudotumor cerebri? J Neuroophthalmol. 37 2001;21(2):121-3. ers being treated with CPAP. 20. Idiopathic Intracranial Hypertension/Pseuodtumor Cerebri. Improvements in CPAP mask fit- In: The Wills Eye Manual: Office and Emergency Room Diag- nosis and Treatment of Eye Disease. 7th ed, Bagheri N, ed. ting can reduce air leakage, and the Philadelphia: Wolters Kluwer;2017:261-2. importance of keeping the CPAP Patients with concurrent diabetes 21. Javaheri S, Golnik K. Resolution of papilledema associated with OSA treatment. J Clin Sleep Med. 2011;7(4):399-400. disinfected is better understood, and OSA who already have diabetic 22. Thurtell MJ, Bruce B, Rye D, et al. The Berlin questionnaire screens for obstructive sleep apnea in idiopathic hypertension. J but dryness can still result from air retinopathy are more likely to progress to Neuroophthalmol. 2011;31(4):316-9. being pushed up through the nose proliferative diabetic retinopathy, as seen 23. Central retinal vein occlusion. In: The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye into the nasal lacrimal canal, espe- here, than those without OSA. Disease. 7th ed, Bagheri N, ed. Philadelphia: Wolters Klu- wer;2017:289-91. cially with those who have nasal 24. Ceriello A. New insights on oxidative stress and diabetic lacrimal tubes.38,39 If improvement usage and be able to make a timely complications may lead to a “causal” antioxidant therapy. Dia- betic Care. 2003;26(5):1589-96. in dryness cannot be attained with referral to the patient’s primary 25. Mohamed Q, Gillies M, Wong T. Management of diabetic retinopathy: A systematic review. JAMA. 2007;298(8):902–16. changes in the mask fit, punctal care physician or appropriate man- 26. Schulz R, Hummel C, Heinemann S, et al. Serum levels of plugs may be used to help with aging specialist for diagnosis and vascular endothelial growth factor are elevated in patients with 40 obstructive sleep apnea and severe nighttime hypoxia. Am J air reflux. In addition, besides treatment. ■ Respir Crit Care Med. 2002;165(1):67-70. Dr. Kovacich is a clinical associate 27. Diabetic retinopathy. In: The Wills Eye Manual: Office and the aforementioned association of Emergency Room Diagnosis and Treatment of Eye Disease. 7th OSA with glaucoma, CPAP use is professor at the Indiana University ed, Bagheri N, ed. Philadelphia: Wolters Kluwer;2017:295-300. 28. Central Serous Chorioretinopathy. In: The Wills Eye Manual: also linked to elevated intracocular School of Optometry. Office and Emergency Room Diagnosis and Treatment of Eye pressure, making the monitoring Disease. 7th ed, Bagheri N, ed. Philadelphia: Wolters Kluwer; 1. Santos M, Hofmann J. Ocular manifestations of obstructive 2017:305-6. of OSA patients who are glauco- sleep apnea. J Clin Sleep Med. 2017;13(11):1345-8. 29. Mitchell R, Hussey H, Setzen G, et al. Clinical consensus 2. Young T, Skartrud J, Peppard P. Risk factors for obstructive statement: tracheostomy care. Otolarynol Head Neck Surg. matous or glaucoma suspects who sleep apnea in adults. JAMA. 2004;291(16):2013-6. 2013;148 (1):6-20. are treated with CPAP even more 3. Singh J, Cleveland J. Gout and the risk of incident obstructive 30. Weaver T, Grunstein R. Adherence to continuous positive air- sleep apnea in adults 65 years or older: an observational study. way pressure therapy. Proc Am Thorac Soc. 2008;5(2):173-8. critical.41 J Clin Sleep Med.2018;14(9):1521-7. 31. Giles T, Lasserson T, Smith B, et al. Continuous positive air- 4. Karkinski D, Georgievski O, Dzekova-Vidimliski P, et al. ways pressure for obstructive sleep apnoea in adults. Cochrane OSA is a prevalent condition that Obstructive sleep apnea and lipid abnormalities. Open Access Database of Sys Rev. 2006;25(1):CD001106. is often underdiagnosed and that Maced J Med Sci. 2017;5(1):19-22. 32. Donovan L, Boeder S, Malhotra A, Patel S. New develop- 5. Davies R. The relationship between neck circumfer- ments in the use of positive airway pressure for obstructive has serious health implications. Pay ence, radiographic pharyngeal anatomy, and the obstructive sleep apnea. J Thorac Dis. 2015;7(8):1323-42. sleep apneoa syndrome. European Respiratory Journal. 33. Bucks R, Olaithe M, Eastwood P. Neurocognitive func- special attention to patients who 1990;3(5):509-14. tion in obstructive sleep apnoea: A meta-review. Respirology. have keratoconus, FES, lash ptosis, 6. Peppard P, Young T, Barnet, et al. Increased prevalence 2013;18(1):61-70. of sleep-disordered breathing in adults. Am J Epidemiol. 34. Olaithe M, Bucks R. Executive dysfunction in OSA before papilledema and vascular issues. 2013;177(9):1006-14. and after treatment. A meta-analysis. Sleep. 2013;36(9):1297-305. 7. Dempsey JA, Veasey S, Morgan B, O’Donnell C. Pathophysi- 35. Araghi MH et al. Effectiveness of lifestyle interventions on Question those known to have OSA ology of sleep apnea. Physiol Rev. 2010;90(1):47-112. obstructive sleep apnea (OSA): systematic review and meta- about their treatment protocol, 8. McNab A. The eye and sleep. Clin Exp Ophthalmol. analysis. Sleep. 2013;36(10):1553-62. 2005;33(2):117-25. 36. Stauffer J, Fayter N, MacLurg B. Conjunctivitis from nasal especially if they’re using a CPAP. 9. Gupta P, Stinnett S, Carlson A. Prevalence of sleep apnea in CPAP apparatus. Chest. 1984;86(5):802. patients with keratoconus. Cornea. 2012;31(6):595-9. 37. Harrison W, Pence N, Kovacich S. Anterior segment com- Patients are not always forthcoming 10. Shiba T, Sato Y, Takahashi M. Relationship between diabetic plications secondary to continuous positive airway pressure about this and may not be aware of retinopathy and sleep-disordered breathing. Am J Ophthalmol. 2009;147(6):1017-21. machine treatment in patients with obstructive sleep apnea. its potential impact on their eyes. 11. Huon LK, Liu SY, Camacho M, Guilleminault C. The associa- Optometry. 2007:78(7);352-55. tion between ophthalmologic diseases and obstructive sleep 38. Singh N, Walker R, Cowan F, et al. Retrograde air escape via Ask them about any dry eye issues apnea: a systematic review and meta-analysis. Sleep Breath. the nasolacrimal system: a previously unrecognized complica- and consider testing them for ocular 2016;20(4):1145-54. tion of continuous positive airway pressure in the manage- 12. Schlötzer-Schrehardt U, Stojkovic M, Hofmann-Rummelt C, ment of obstructive sleep apnea. Ann Otol Rhinol Laryngol. dryness. Unusual or unexplained et al. The pathogenesis of floppy eyelid syndrome: involvement 2014;123(5):321-4. of matrix metalloproteinases in elastic fiber degradation. Oph- 39. Cannon P, Madge S, Selva D. Air regurgitation in patients on recurrent bacterial conjunctivitis thalmol. 2005;112(4):694-704. continuous positive airway pressure (CPAP) therapy following could also be a possible indicator of 13. Floppy Eyelid Syndrome. In: The Wills Eye Manual: Office dacrocystorhinostomy with or without Lester-Jones tube inser- and Emergency Room Diagnosis and Treatment of Eye Disease. tion. Br J Ophthalmol. 2010;94(7):891-3. CPAP complications. 7th ed, Bagheri N, ed. Philadelphia: Wolters Kluwer; 2017:136- 40. Goktas O, Haberman A, Thelen A, Schrom T. The punctum 7. plug as an option for treating retrograde airflow from the lacri- The optometrist is well posi- 14. Perez-Rico C, Gutierrez-Diaz E, Mencia-Gutierrez E, et al. mal sac. Laryngorhinootologie. 2007;86(10):732-5. tioned to be alert to both ocular Obstructive sleep apnea-hypopnea syndrome (OSAHS) and 41. Kiekens S, De Groot V, Coeckelbergh T, et al. Continuous glaucomatous optic neuropathy. Graefes Arch Clin Exp Ophthal- positive airway pressure therapy is associated with an increase and systemic conditions that may mol. 2014;252(9):1345-57. in intraocular pressure in obstructive sleep apnea. Invest Oph- be related both to OSA and CPAP 15. Mojon D, Hess C, Goldblum D, et al. Normal-tension glau- thalmol Vis Sci. 2008;49(3):934-40.

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Top Causes of Double Vision Getting to the root of the problem is the key to treating and referring properly. Here’s a look at the common etiologies of diplopia and how to tell them apart. By Christopher L. Suhr, OD, MPH, Luanne Chubb, OD, and Lisa Himmelein, OD

patient presenting with dip- lopia—whether horizontal, vertical or diagonal—is Aoften a clinical challenge.1 Constant diplopia with acute onset will have different differentials than intermittent diplopia, for example.2,3 While the cause can be benign, some cases, such as those accompanied by new headache, ocular pain, unilat- CN VI palsy, seen here in the right eye, accounts for 50% of all isolated CN palsies. eral pupil dilation, muscle weakness, ptosis, trauma or papilledema, raise if the diplopia is monocular or bin- lenticular changes, vitreal opacities red flags for immediate referral.4,5 ocular, as binocular diplopia may and macular disease are all possible Most etiologies will fall into one have a life-threatening cause.3,4 causes of monocular diplopia.4,7,8 of five categories: (1) refractive, (2) Medications (e.g., antidepressants, binocular vision disorder, (3) orbital Monocular Diplopia antihistamines, diuretics) may con- disease, (4) neuromuscular junction Diplopia that persists when one eye tribute to ocular surface dryness and dysfunction, or (5) injury to the cen- is covered falls into the category of induce a monocular diplopia.9 tral nervous system/cranial nerves monocular diplopia, or polyopia (CNs).6 A systematic approach to (greater than two images). Clinicians Binocular Diplopia the differentials is key to identifying should have the patient cover each Unlike monocular diplopia, binocu- and treating benign causes—and eye separately when testing for mon- lar diplopia, due to ocular misalign- promptly referring patients when it is ocular diplopia. This finding is rarely ment, will disappear when either eye vision or life threatening. due to cortex lesion and is generally is covered. The type of diplopia the attributable to causes within the eye patient complains of—horizontal, Patient History itself. Decreased vision due to uncor- vertical or diagonal; worse at dis- The first step on the path to proper rected astigmatism, dry eye and tear tance or near; increased or decreased identification is a thorough patient film deficiencies, corneal pathol- in a particular gaze position—helps history. The clinician must determine ogy or scarring, iris abnormalities, to identify which extraocular muscle

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A thorough systemic test versions, the patient fixates on a Diplopia that varies throughout the health history and step-by-step target that is slowly moving laterally day, improves with rest and may examination is key to localizing most while the clinician checks the medial have an associated ptosis is highly underlying etiologies.2,3,10 A systemic rectus of the adducting eye and the suggestive of MG as the underlying health history should include ques- lateral rectus of the abducting eye. cause.7 Other differentials to con- tions regarding trauma, diabetes, The target is then moved superiorly sider that present with a variable pat- hypertension, thyroid disease, cancer, to evaluate the superior/inferior tern of diplopia include thyroid eye infection and immunosuppression— rectus of the abducted eye and the disease, Guillain-Barré syndrome, all of which could cause CN palsies inferior/superior oblique of the Parinaud syndrome, Miller-Fisher and diplopia through vascular or adducting eye. The test is repeated syndrome, trauma, Parinaud (dorsal restrictive mechanisms.2,6,10 on the opposite side to test contra- midbrain) syndrome and Wernicke’s Although less frequently, certain lateral gaze.3,5,13 Forced duction test- encephalopathy.2,9,14 medications can cause binocular ing can identify muscle restriction Here some common underlying diplopia, such as anticonvulsants, such as in thyroid disease or muscle etiologies of binocular diplopia: selective serotonin reuptake inhibitor entrapment by a fracture following Refractive. Misalignment of the antidepressants, erectile dysfunction trauma.3,5,13 optical centers of prescription glasses medications, migraine therapies and Horizontal diplopia, when the or non-prescription reading glasses, other medications with anticholiner- images are truly side-by-side, is sug- poor fitting glasses and the edges gic properties. Many antidepressants gestive of a medial or lateral rectus of high prescription glasses may all may aggravate the symptoms of a under action or restriction.2,3,9,10 cause diplopia or worsen an exist- convergence insufficiency by affect- Horizontal diplopia present only ing heterophoria. Aniseikonia from ing accommodation.6,11 at near, and especially noted with refractive error results in differences Ocular motility and alignment prolonged near work, is more in image size and shape in the visual testing may include the cover/ likely attributable to a convergence cortex, causing diplopia when wear- uncover test, alternate cover test, insufficiency, which can occur in ing glasses. Contact lens use often Maddox rod and corneal light reflex. children and adults idiopathically. resolves the image difference in most Ocular misalignment may be caused Convergence insufficiency can occur cases of aniseikonia.1 by a tropia, and an obvious eye turn after trauma, in neurodegenerative Binocular vision disorder. A is noted. A phoria occurs when the diseases such as Parkinson’s disease patient with a history of childhood misalignment is not obvious, and and with medications that have an strabismus may develop diplopia diplopia occurs only when binocu- anti-cholinergic effect on accom- later in life due to a decompensation larity is disrupted. A key point in modation.7 Differential diagnosis of their misalignment.10 Decompen- alignment testing is the evaluation for horizontal diplopia at distance sating phorias and vergence prob- for comitancy, in which the size of includes unilateral or bilateral CN VI lems are the most common cause of an ocular deviation remains the same palsy, internuclear ophthalmoplegia diplopia at near only. Asthenopia in all directions of gaze. A comitant (INO), age-related decompensating occurs with extended near activities, deviation, such as a decompensat- esophoria or muscle restriction, most resulting in diplopia and headaches. ing heterophoria, presents with an commonly from thyroid disease, a Convergence insufficiency results in intermittent or gradual onset, shows space occupying lesion or myasthe- diplopia after prolonged near work full range of ocular movement in all nia gravis (MG).2,9,10 and may be associated with uncor- positions of gaze and may have a Vertical diplopia assessment rected refractive error, dry eye and history of childhood strabismus.12 In involves the four remaining muscles: Parkinson’s disease.1 contrast, CN palsies and extraocular the superior and inferior recti and Orbital disease. Thyroid eye muscle restrictions cause non-comi- the superior and inferior oblique. disease (TED), idiopathic orbital tant deviations with the greatest dip- CN III and IV palsies, skew devia- inflammation and orbital tumors are lopia noted in the direction of action tions (with or without INO), muscle the most common extraocular mus- of the weakened muscle.2,3,9,10 Clini- restrictions and decompensated pho- cle and orbital diseases that cause cians must examine each eye sepa- rias can all cause vertical diplopia.9 diplopia.2,3 Orbital inflammation rately (ductions) to catch a subtle Some diseases may cause variable is usually unilateral and may affect restriction that could be missed when patterns of horizontal, vertical and the orbital fat, extraocular muscles, evaluating both eyes together.3,5,13 To oblique diplopia throughout the day. lacrimal gland, sclera or optic nerve.

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Onset may be sudden and painful, emergent situation, as the sinus can resulting in a vertical diplopia.3,6,18 and the eye may appear proptotic. cause a negative pressure that pulls Giant cell arteritis. A patient This has been associated with rheu- on the inferior orbital wall, trapping with GCA can present with any matoid arthritis, sarcoidosis and, less the inferior rectus muscle, resulting CN palsy.10 GCA should be ruled frequently, giant cell arteritis (GCA). in an inability to elevate the affected out in all patients who present with Testing includes rheumatoid factor, eye and vertical diplopia.3,6 diplopia, especially those older than chest x-ray and ACE level for sar- The orbital floor in adolescents is age 60. Urgent blood work should coidosis and anti-nuclear antibody flexible and can quickly open and include complete blood count, for systemic lupus erythematosus. close, trapping the inferior rectus, c-reactive protein (CRP) and sedi- TED predominantly occurs in and may present with no other obvi- mentation rate (ESR). If the platelet hyper-thyroid states, although ous signs of trauma. Patients with a count, CRP and ESR are elevated or approximately 10% of patients can history of orbital trauma and a white GCA is suspected based on accom- present with hypo- and euthyroid eye (or lack of subconjunctival hem- panying scalp tenderness, headache, states, which may not correlate orrhage) will need emergent imaging fever and generalized malaise, clini- with the thyroid status.8 Lab testing to determine if there is entrapment of cians should refer the patient for includes thyroid function and thyroid the inferior rectus, especially in chil- urgent treatment.8,19 Studies indicate antibody tests, and risk factors are dren. In these cases, decompression that GCA is the underlying cause of higher in females, smokers and those surgery is urgently needed within 24 diplopia in anywhere from 3% to with family history of disease.3 Pain- to 48 hours to avoid ischemia of the 15% of presenting cases of diplopia less proptosis, muscle restriction, lid muscle.15 Conversely, if there is no with biopsy proven GCA, but the retraction and variable lymphocytic muscle entrapment, due to orbital risk of morbidity and mortality is too inflammatory infiltration are notable floor fracture, surgical intervention high to miss this disease.8,19 findings that occur in approximately may be considered in two weeks.16 Neuromuscular junction dysfunc- 50% of patients with Graves’ Dis- Neoplasms and sinus-related tion. MG is the classic neuromuscu- ease.3 The inferior and medial rectus issues should be considered in the lar junction disease that can become are the most affected, causing a presence of a correlating health his- life threatening when it affects the vertical diplopia due to restriction tory. Secondary orbital tumors, lym- muscles of respiration, causing in elevation and an esotropia due phomas and metastatic cancers are respiratory failure. Approximately to restricted abduction.2,3,5,8,9 Most the most common orbital neoplasms 50% to 60% of MG patients pres- patients have a mild form of TED, presenting with unilateral proptosis ent with a ptosis and diplopia, and but 3% to 7% will have vision- and resistance to retropulsion.3 All approximately 20% to 30% have threatening concerns from corneal patients with a new onset of diplopia localized ocular involvement.5,8 The disease or optic nerve compression.8 and a history of cancer should have most common age of onset is in the A CT scan of the orbit will assess the urgent imaging studies.17 Rarely, a third decade for women and the sev- extraocular muscles and optic nerve silent sinus syndrome will cause a enth decade for men.5 Weakness of and reveal muscle enlargement and downward displacement and enoph- the medial rectus is fairly common, risk of optic nerve impingement.8 thalmos of the eye. The obstruction but diplopia can vary between hori- Other, less common, orbital causes of the ostium of the maxillary causes zontal, vertical and oblique. Patients of diplopia include trauma and neo- a negative pressure that pulls down- report variable fatigue and ptosis plasms. A blow-out fracture is an ward on the inferior orbital wall, of one or both eyelids that worsens with prolonged activity or toward the end of the day. However, MG can cause a fluctuating diplopia at any time of the day, even on waking.9 A recent history of weakness and difficulty walking or swallowing are found in generalized MG but absent in the ocular form. As with TED, cli- nicians should remain suspicious of MG in all cases, as it can mimic CN As many as 60% of MG patients, such as this one, present with ptosis and diplopia. IV, VI and partial CN III palsies in

38 REVIEW OF OPTOMETRY AUGUST 15, 2019

036_ro0819_F2_Suhr.indd 38 8/6/19 2:43 PM addition to INO, although the pupil is never involved.2,3 Several in-office tests are available to help support the diagnosis of MG. During the Cogan lid twitch test, the patient looks down for a few seconds and the clinician then watches the lid reaction when they return to primary gaze. A 1mm to 2mm drop of eyelid elevation immediately after return- This patient has longstanding medial rectus palsy secondary to facial trauma. ing to primary gaze is a positive response. Application of ice packs for motility abnormality and is present cit. It is the most common isolated one to two minutes or a resting state in as many as 53% at some point in ocular motor palsy and accounts for for 10 minutes is an another easy their illness.8 Patients presenting with 50% of them.8 The patient reports in-office test, and an improvement in an INO should be urgently sent for horizontal diplopia that is worse at the ptotic eyelid is a positive response imaging and bloodwork. distance and worse when looking in in suspected cases of MG. Fatigue Cranial nerve palsies. CN III, IV the direction of the affected muscle. in prolonged upgaze for at least two and VI palsies share many of the Microangiopathic disease causes minutes with a resulting ptosis, wors- same underlying etiologies such as up to 36% of isolated, acute CN ened ptosis or inability to maintain microvascular CN palsies, intracra- VI palsies in patients older than age upgaze is considered a positive test.2 nial aneuryms and neoplasms.10,20 50 with vascular risk, and diplopia Approximately 15% of MG patients Trauma can impair the function of spontaneously resolves within two to will have thyroid changes and co- any nerve, but CN IV in particu- three months.2,8 Wernicke’s encepha- existing TED, while about 10% will lar is more susceptible to trauma. lopathy, MS and Duane’s retraction have thymoma present and will be Microvascular disease accounts for syndrome may be mistaken for a CN evaluated for surgery.5 many CN palsies in patients older VI palsy and should be considered Internuclear ophthalmoplegia. than 50, especially in those with in the differentials.2,5,7 In all other This is a lesion or injury of the known microvascular disease. Pain patients with an acute CN VI palsy, medial longitudinal fasciculus. Clini- and rapidity of onset provide less assessment for causes such as GCA, cally, the patient will not be able to definitive clues about cause, should tumors, intracranial hemorrhage adduct the affected eye (or look a cerebrovascular accident be sus- and trauma warrant referral to the nasally) and the non-affected eye will pected. Pain can be severe or absent emergency room for evaluation and show an abducting nystagmus (when in aneurysmal CN III palsies and imaging studies.8,17 If increased intra- looking temporally); convergence, ischemic events, though a significant cranial pressure is the underlying if present, will be spared.3 An INO headache and CN III palsy requires cause of a CN VI palsy, a thorough may occur unilaterally or bilaterally, careful pupil testing and referral to evaluation should include optic nerve and a review of 410 inpatients in 33 an emergency room. Research sug- head assessment for the presence of years shows the underlying cause can gests acute onset is associated with associated papilledema.8,17 be divided into three major catego- ischemic events while slow onset is A CN IV palsy affects the func- ries: (1) stroke, (2) multiple sclerosis associated with compressive cases.20 tion of the superior oblique muscle, (MS) and (3) other causes such as A CN VI palsy is the most common, resulting in a vertical oblique diplo- trauma, injury, infection, tentorial followed by CN IV and CN III.7 In pia more noticeable in downgaze.9 herniation, tumor and GCA.14 A all cases of nerve palsies, evaluation Trauma in the most common due to lesion in the pontine or para-pontine must carefully determine if single the long course of the nerve around area can cause a gaze palsy opposite or multiple nerves are involved, as the midbrain.5 In the absence of the INO, resulting in a “one-and- imaging is most often warranted, trauma, clinicians should test to rule a-half syndrome.” An INO that particularly when multiple cranial out TED and MG.7 As with CN VI presents bilaterally results in a large nerves are involved.21 palsies, microangiopathy is the major exotropia in both eyes causing a CN VI innervates only the lateral cause of a CN IV palsy in patients “wall-eyed effect.”9 In patients with rectus muscle, and paralysis causes older than 50.7,8 The pneumonic MS, an INO is the most common an estropia from an abduction defi- GOTS—gaze opposite, tilt same—

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036_ro0819_F2_Suhr.indd 39 8/6/19 2:43 PM Diplopia

indicates there is a greater vertical cover testing to catch a subtle signs. dition for any clinician to address. deviation when the patient looks Patients with palsies with ischemic The key to following the right course to the opposite side of the affected causes are usually older with risk of action is determining the underly- muscle or tilts their head to the same factors such as diabetes, hyperten- ing etiology. Primary care optom- side. For example, a right superior sion, hyperlipidemia and tobacco etrists often have patients complain oblique impairment will have a right use. Pupil evaluation may help nar- of diplopia, and with the right tools hypertropia: greater diplopia with a row the differential, as the pupillary and skills, every OD can properly right head tilt and when looking to fibers reside on the dorsomedial treat, coordinate a proper referral the left. The patient will have a left aspect of the oculomotor nerve and and often reassure the patient with a head tilt to minimize their diplopia.5,7 are affected in 90% of compressive benign presentation. ■ A decompensated congenital CN pathologies, causing a fixed, dilated Dr. Suhr is chief of the Optometry IV can be distinguished from an pupil. In contrast, microvascular Section at the Philadelphia Corporal acute CN palsy by evaluating verti- ischemia causes an infarct in the Michael J. Crescenz VA Medical cal fusional amplitudes with prism center of the nerve, which spares the Center. bars or the amount of ocular rota- pupil in 70% of ischemic cases. Up Drs. Chubb and Himmelein are tion between the eyes along with the to 30% of ischemic palsies will have staff optometrists at the Philadelphia size of the vertical deviation.10 The an anisocoria of 1mm to 2mm. Isch- Corporal Michael J. Crescenz VA prism bar test is performed by mea- emic palsies usually improve within Medical Center. suring the range of prism that will three months, and never demonstrate 1. Mashige KP, Munsamy AJ. Diplopia. South African Family Prac- eliminate the diplopia. Normal verti- aberrant regeneration. The pupil tice. 2015;58(sup1):S12-17. cal fusional amplitudes range from rule cannot be applied to rule out a 2. Rucker JC, Tomsak RL. Binocular diplopia. The Neurologist. 2005;11(2):98-110. one to four prism diopters, whereas compression lesion when the palsy in 3. Dinkin M. Diagnostic approach to diplopia. Continuum (Min- patients with congenital strabismus incomplete.2,5,9,20 neap Minn). 2014;20:942-65. 4. Low L, Shah W, MacEwen CJ. Double vision. BMJ. may demonstrate up to six prism In addition, all patients with a 2015;351:h15385. diopters of vertical fusion ampli- new onset diplopia and a history of 5. Aminoff MJ, Josephson SA, eds. Neuro-Ophthalmology in 10,20 Medicine, 5th ed. Philadelphia: Elsevier Science; 2014:487-99. tude. A review of old photos may cancer require urgent imaging studies 6. Alves M, Miranda A, Narciso MR, et al. Diplopia: a diagnostic also help to identify those patients to rule out a metastatic lesion.17 challenge with common and rare etiologies. Am J Case Reports. 2015;16:220-23. with longstanding congenital palsies. Researchers have debated the use 7. Iliescu DA, Timaru CM, Alexe N, et al. Management of diplopia. CN III innervates the inferior of imaging in all CN palsies for some Romanian J Ophthalmol, 2017; 61(3):166-170. 8. Margolin E, Lam CTY. Approach to a patient with diplopia in the oblique and the superior, inferior time, and most agree those with emergency department. J Emerg Med. 218;54(6):799-806. and medial recti muscles. A complete an acute isolated CN III palsy need 9. Friedman D. Pearls: diplopia. Sem Neurol, 2010;30(1):54-65. 10. Peragallo J, Newman N. Diplopia—an update. Sem Neurol, oculomotor palsy results in complete urgent imaging to rule out a com- 2016;36(4):357-61. ptosis, a mid-dilated pupil and an pressive aneurysm or suspected cav- 11. Alao A, Lewkowicz C. Seeing double: sertraline and diplopia: a case report. Internat J Psychiatry in Med. 2015;49(1):107-10. eye that appears “down and out.” ernous sinus thrombosis. Imaging of 12. O’Colmain U, Gilmour C, MacEwen CJ. Acute-onset diplopia. Patients report an oblique diplopia the brain and orbits is appropriate in Acta Ophthalmologica. 2013;92(4):382-86. 13. Pelak VS. Evaluation of diplopia: an anatomic and systematic when the eyelid is lifted. Any CN suspected retro-bulbar mass, TED or approach. Hospital Physician. 2004;40(3):16-25. III palsy needs immediate imaging, orbital trauma. In patients older than 14. Keane JR. Internuclear ophthalmoplegia. Arch Neurol. 2005;62(5):714. including CTA or MRA, as compres- 60, referral for urgent bloodwork is 15. Hammond D, Grew N, Khan Z. The white-eyed blowout sion from an aneurysm of the pos- indicated to rule out GCA.8 fracture in the child: beware of distractions. J Surg Case Rep. 2013;(7):rjt054. terior communicating artery is the However, a literature review 16. Grob S, Yonkers M, Tao J. Orbital fracture repair. Seminars in most common etiology of a complete shows that, for CN VI palsies, no Plastic Surg. 2017;31(1):31-39. 17. Kirsch CFE, Black K. Diplopia: what to double check in palsy with pupil involvement and is definitive answer for imaging exists, radiographic imaging of double vision. Radiologic Clinics of North life threatening. Ischemic or micro- as both prospective and retrospective America. 2017;55(1):69-81. 18. Saffra N, Rakhamimov A, Saint-Louis LA, Wolintz RJ. Acute vascular causes are more common, cohorts had valid arguments for their diplopia as the presenting sign of silent sinus syndrome. Ophthal- and the diplopia often improves dur- conclusions of imaging all patients mic Plast Reconstr Surg. 2013;29(5):e130-1. 19. Gupta PK, Bhatti MT, Rucker JC. A sweet case of bilateral ing the recovery from the event. The with isolated CN VI palsies. Thus, sixth nerve palsies. Surv Ophthalmol. 2009;54(2):305-10. presence of pain may occur in both clinicians should always consider 20. Cornblath WT. Diplopia due to ocular motor cranial neuropa- thies. Continuum (Minneap Minn)., 2014;20(4 Neuro):966-80. scenarios but does not help to differ- imaging CN palsies, especially when 21. Murchison AP. Neuroimaging and acute ocular motor mono- entiate between them. presenting with other neurological neuropathies. Arch Ophthalmol. 2011;129(3):301-5. 21 22. Elder C, Hainline C, Galetta SL, et al. Isolated abducens nerve However, most CN III palsies are signs and symptoms. palsy: update on evaluation and diagnosis. Curr Neurol Neurosci not complete, and clinicians must use Diplopia can be a concerning con- Rep. 2016;16(8):69.

40 REVIEW OF OPTOMETRY AUGUST 15, 2019

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RO0819_Visioneering.indd 1 7/25/19 10:00 AM Vision Care Perfecting Prism Don’t back down from this life-changing treatment. Here’s where to start. By Erin C. Jenewein, OD

rism can be a power- phoria. Divergence insufficiency ful treatment for many is associated with systemic and conditions and for many neurological disorders, so we must Ppatients, specifically for rule out any underlying condi- those who suffer from asthenopia tions that may be causing it. Any or diplopia. Although successfully patient presenting with divergence prescribing it can sometimes seem insufficiency and neurological like a time-consuming and daunt- symptoms should undergo a full ing task, the following tips can neurological evaluation and imag- help you smoothly incorporate the ing.2 use of prism for binocular vision Vision therapy aims to decrease conditions into your practice for symptoms of vergence anomalies the best outcomes. by increasing the compensating fusional vergence range (base-in Identifying Prism Candidates for esophoria and base-out for One of the most important aspects Use Wesson cards to measure fixation disparity exophoria). The normal amount of successfully prescribing prism and the associated phoria. of fusional divergence ability at is choosing patients who will distance is lower than that of benefit the most from it. The first binocular vision disorders—such as fusional convergence ability, mak- hurdle is ensuring your patient is divergence insufficiency, basic eso- ing it challenging to sufficiently comfortable with wearing spectacles. phoria and vertical heterophoria— increase ranges to compensate for Although small amounts of vertical can often benefit from treatment esophoria or esotropia at distance. prism can be prescribed in contact with prism, particularly relieving This combined with the success of lenses, patients who need prism usu- prism, while others—including prism treatment in patients with ally have to wear it on a spectacle those with convergence excess, con- divergence insufficiency makes pre- lens. Although this seems like a very vergence insufficiency, divergence scribing prism the ideal initial treat- basic requirement for prism use, it excess or basic exophoria—are bet- ment for this condition. One study can present an obstacle if not done ter managed with other treatment successfully treated 87 patients with appropriately or at all. Patients who modalities, such as vision therapy or divergence insufficiency between wear contact lenses the majority of lenses.1 An option for prism patients two and 18 prism diopters (PDs) the time or who have undergone is prescribing prism to relieve diplo- with prism with none of the patients refractive, cataract or strabismus pia and asthenopia and concurrently in the study requiring additional surgery may not be happy with having the patient do vision therapy treatment or surgery.3 Another study the idea of moving or going back to attempt to decrease or eliminate found that 100% of patients with to spectacle wear even if it relieves the amount of prism needed. divergence insufficiency (30 patients) asthenopia or diplopia. Educating Divergence Insufficiency. Diver- had success with prism.4 patients on the benefits of prism gence insufficiency patients are Basic Esophoria and Exophoria. wear is key in helping get them on often symptomatic for diplopia and Prism can be used alone or in com- board in these cases. asthenopia at distance and may pres- bination with vision therapy to treat Patients with non-strabismic ent with a decompensated distance basic esophoria and exophoria.

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042_ro0819_F3_Jenewein.indd 42 8/6/19 2:51 PM deviation is condition, adult presbyopic patients primary or with convergence insufficiency may secondary. benefit from prism treatment.10,11 A primary Strabismus. While patients with vertical strabismus often benefit from prism deviation is wear, it is important to first deter- the same in mine whether a strabismic patient presence and is fit for treatment with prism by size whether evaluating their potential for sensory This patient is wearing a Fresnel membrane prism on their glasses. the patient is fusion and whether the addition of strabismic or prism will improve their sensory Vertical Heterophoria. Another aligned. A secondary vertical devia- fusion status. Prism is prescribed to condition commonly treated with tion, on the other hand, presents these patients to partially or com- prism is vertical heterophoria, or when the patient’s eyes are strabis- pletely eliminate the motor demand vertical strabismus. Vertical devia- mic but disappears when the patient so they are able to fuse. If a patient tions often cause patients to expe- aligns their eyes to the ortho posi- does not have good potential for rience significant symptoms even tion.7 Secondary vertical deviations sensory fusion, then the assistance when the deviation is small. Our are common in strabismic patients, that prism gives to the motor system normal supraduction and infraduc- particularly in those with intermit- won’t allow for normal fusion, and tion abilities are limited, so improv- tent exotropia. If an intermittent it doesn’t make sense to prescribe it. ing these ranges to compensate for a horizontal strabismus patient has a Sensory Anomalies. Patients with vertical deviation can be challenging. primary vertical deviation, vertical sensory anomalies, such as suppres- The difficulty of training vertical prism may help improve their ability sion or anomalous correspondence, vergence ranges along with the suc- to fuse the horizontal deviation. In cannot be treated with prism until cess in treating vertical deviations patients with a secondary vertical they have been eliminated. Testing with prism make prism the most deviation, however, vertical prism for suppression and anomalous cor- appropriate initial management tool is not an appropriate treatment. respondence can be easily done with in these patients. Retrospective case Rather, treatment for a secondary the Worth Dot test. The test can reviews of patients with an acquired vertical deviation should aim to identify and characterize suppression hyper deviation secondary to a supe- improve horizontal sensory and based on the room’s illumination rior oblique palsy found that 76% motor fusion through vision therapy and the distance of the test from to 92% of participants were success- so the patient is not in the strabismic the patient. If a patient sees four fully treated with prism alone.5,6 position as often, thus eliminating dots in free space or gives a diplopia These patients often present with the vertical deviation. response but is able to fuse with horizontal and vertical deviations. Convergence Insufficiency. prism, perform a unilateral cover In many of these cases, the initial Prisms aren’t as successful in treat- test. If no movement is seen on the management strategy is prescribing ing convergence insufficiency and unilateral cover test, the patient vertical prism.1 Often, if the vertical are used less frequently than other has normal correspondence. If the deviation is decreased or eliminated, treatment modalities. The most patient gives a fusion response with the patient may be able to comfort- effective treatment for this condition or without prism but movement ably fuse the horizontal deviation. is office-based vision therapy, but on the unilateral cover test is seen, If the patient is still symptomatic, prism can be considered in patients then anomalous correspondence is combining prism and vision therapy who are unable to undergo this suspected and relieving or corrective may help improve convergence and treatment modality.1,8 A study did prism is not an appropriate manage- divergence ranges. When consider- not find a significant difference in ment option. The most successful ing whether it is appropriate to the signs or symptoms of children prism cases are often patients who prescribe vertical prism for a patient with convergence insufficiency who have intermittent strabismus and with combined horizontal and ver- wore base-in prism compared with good potential for normal fusion or tical deviations, particularly for a children who wore placebo lenses.9 patients with strabismus who have patient with intermittent strabismus, Although prism has not been shown not developed any sensory anoma- first identify whether the vertical to be beneficial in children with this lies. They tend to be older pediatric

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vectographic slide is commonly used done by using Sheard’s or Percival’s to determine the associated phoria. criteria or determining the associated Electronic charts are now routinely phoria as with heterophoric patients. used in practice, and many of them Another method used for prescrib- have an available distance target for ing for patients with intermittent determining fixation disparity and strabismus, particularly for those the associated phoria. who have difficulty with fusion in The preferred method for pre- free space, is Caloroso’s Residual scribing prism for vertical hetero- Vergence Demand (RVD).7 RVD phoria is determining the vertical criteria look at the direction and size Use the Fresnel prism trial set for associated phoria.12 This can be of the deviation and determine how patients with larger amounts of prism. done at near using the Wesson card much residual vergence demand the or at distance. patient should have after prescrib- or adult patients with new-onset or ing relieving prism. RVD states that decompensated strabismus. After Case #1 esotropic patients of magnitude 6 these patients are evaluated for any A 25-year-old female presented com- to 20 PDs should be left with 4 to underlying systemic or neurological plaining of double vision and head- 6 PDs of residual vergence demand. disease, which must always be ruled aches that worsened with prolonged Patients with 20 to 30 PDs of exo- out in any case of new-onset strabis- near work. Her medical history was tropia should be left with 10 to 15 mus, they are often good candidates unremarkable, and her ocular his- PDs of residual vergence demand, for a prism prescription. tory was remarkable only for low and patients with a vertical stra- myopia, for which she wore glasses. bismus of 3 to 10 PDs should be Prescribing Prism Upon examination, she had a left with 2 to 4 PDs of residual ver- After identifying a patient who small exophoria and a 3 PD right gence demand.7 RVD is best used in stands to benefit from a prism pre- hyperphoria at distance and near. patients who have vergence ranges scription, the next step is deciding Her vertical associated phoria, which that have been maximally trained how much prism to prescribe. There I determined using the Wesson card, through vision therapy but still need are many different ways to do this, was 2 PD right hyperphoria. I trialed prism to maintain binocular vision but the best method to use depends 2 PDs of base-down prism using a in free space.12 on the type of binocular vision disor- Fresnel prism over the right eye and Determining how much prism der for which you are prescribing. dispensed at the initial visit. During a is required for improved fusion, or Prescribing relieving prism for follow-up examination three months “fusion prism,” is another method horizontal, non-strabismic, binocu- later, the patient noted increased for prescribing prism for your stra- lar vision disorders can be done by comfort and resolved diplopia and bismic patients. Fusion prism is the calculating Sheard’s or Percival’s headaches while wearing the Fresnel minimum amount of prism needed criteria by using clinical data or prism. A new prescription for prism to see a change from diplopia or analyzing fixation disparity and lenses was dispensed to the patient suppression to normal binocular determining the associated phoria.1 at the follow-up examination. vision.12 To determine prism using At near, fixation disparity and the Patients with constant strabismus this method, use the Worth Dot test associated phoria can be found may need corrective prism, or an to find a preliminary prism amount. with a Wesson card. While viewing amount of prism that completely While viewing the Worth Dot test, the card, the patient reports what neutralizes their strabismus, in order prism is gradually increased until the color line the black arrow is aligned to obtain good levels of fusion. patient reports fusion. You can also with. The patient is also instructed Relieving prism is often prescribed use Random Dot Stereo (RDS) test- to keep the words around the lines for patients with intermittent strabis- ing to determine fusion prism. Prism clear to control accommodation. mus and sometimes for those with is gradually increased until a patient To determine the associated phoria, constant strabismus. This decreases is able to appreciate the forms on add prism in the appropriate direc- the motor fusion demand, allowing the RDS test. After a preliminary tion until the patient reports that the the patient to fuse more comfort- prescription of fusion prism is deter- arrow is aligned with the center line. ably. Prescribing for some patients mined, it is recommended that you At distance, the American Optical with intermittent strabismus can be trial frame the patient and have them

44 REVIEW OF OPTOMETRY AUGUST 15, 2019

042_ro0819_F3_Jenewein.indd 44 8/6/19 2:52 PM look around to see if they experience reported no diplopia in her glasses, your patients on proper frame and any diplopia when viewing objects and, eventually, she was able to see lens selection will help them choose in the room. If your patient is still 250 seconds of arc RDS stereoacu- a frame and lens combination for experiencing diplopia, additional ity. This patient continued with the best cosmetic outcome. When prism may be needed to help them vision therapy to help improve her prescribing ground-in prism, high achieve fusion. sensory and motor fusion with the index lenses, plastic frames and hope of eventually titrating down frames that are smaller in size help Case #2 the amount of prism she wears. improve the weight and cosmesis of A 5-year-old female initially the lenses. Antireflective coating is presented for a strabismus and Considering Options also beneficial for patients wearing amblyopia evaluation. She had been Before settling on a final prism pre- prism lenses. previously diagnosed with esotropia scription, it is often helpful to trial and amblyopia but was not cur- frame the amount of prism you are Prism is a powerful tool that can rently wearing any correction. about to prescribe to ensure that it be used to successfully treat a variety On initial presentation, her best- will help you achieve your goals. of binocular vision conditions. Prism corrected visual acuities were 20/40 Most trial lens sets come with prism prescriptions often greatly improve OD and 20/25 OS. Her cover test lenses, but for larger angles of stra- the quality of life of your patients by revealed a 25 PD constant right bismus, it may be helpful to use a reducing asthenopia and diplopia. esotropia with a 2 PD constant Fresnel prism trial set. Although Although prescribing it can seem right hypotropia. Her cycloplegic younger patients may not be able intimidating at first, with practice retinoscopy was +3.00sph OD and to give good, subjective feedback, and a bit of trial and error, you can +2.25sph OS. I prescribed glasses older children and adult patients perfect your ability to prescribe (+3.00 sph OD, +2.25 sph OS) for should wear the trial prism set while prism for your patients in no time. ■ the patient, and she returned for engaging in an activity that normally Dr. Jenewein is an assistant pro- follow-up care, eventually patching causes them to experience diplopia fessor at Salus University, Salus Uni- and undergoing vision therapy for or asthenopia (reading or distance versity’s Principal Site Investigator her amblyopia. viewing) to see if it eliminates diplo- for the Pediatric Eye Disease Investi- Through her full plus spectacles, pia and improves comfort. gator Group, a Fellow of the Ameri- she still had a 14 PD constant right Fresnel membrane prisms can can Academy of Optometry and a esotropia and a 2 PD constant right be very useful for many aspects of Diplomate of the Binocular Vision, hypotropia. Beginning treatment, prescribing prism. They are low in Perception and Pediatric Optom- the patient suppressed on Worth Dot cost and can be easily applied to etry Section of the Academy. Her testing and had no RDS stereoacu- a pair of spectacle lenses in-office research interests include strabismus ity, even with corrective prism in to try out on a patient for several and binocular vision disorders. place. As her vision improved with days or weeks, and refining the 1. Scheiman M, Wick B. Clinical management of binocular vision: hetero- amblyopia treatment, I continued to prism prescription is inexpensive phoric, accommodative, and eye movement disorders. 1994, Philadelphia, PA: Lippincott Williams & Wilkins. 632. 2. Jacobson DM. Divergence insufficiency revisited: natural history monitor her sensory fusion. and simple. Fresnel prism, however, of idiopathic cases and neurologic associations. Arch Ophthalmol. 2000;118(9):1237-41. At the follow-up examination degrades visual acuity and contrast 3. Godts D, Mathysen DG. Distance esotropia in the elderly. Br J Ophthal- mol. 2013;97(11):1415-9. after nine weeks of patching and sensitivity, and some patients may 4. Tamhankar MA, Ying GS, Volpe NJ. Effectiveness of prisms in the 12 management of diplopia in patients due to diverse etiologies. J Pediatr vision therapy for amblyopia, her not find it cosmetically appealing. Ophthalmol Strabismus. 2012;49(4):222-8. 5. Tamhankar MA, Ying GS, Volpe NJ. Success of prisms in the man- visual acuities were equal in both A significant decrease in visual acu- agement of diplopia due to fourth nerve palsy. J Neuroophthalmol. 2011;31(3):206-9. eyes, and all testing showed normal ity through the Fresnel lens can be 6. Neena R, Giridhar A. Effectiveness of prisms in relieving diplopia in supe- rior oblique palsies. Kerala J Ophthalmol. 2016;28(1):38-42. correspondence. She was able to seen at larger prism powers, particu- 7. Caloroso E, Rouse MW. Clinical management of strabismus. 1993, Oxford, UK: Butterworth Heinemann Books. fuse on the Worth Dot test with 12 larly at those greater than 12 PDs.13 8. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol. 2008;126(10):1336-49. PDs base-out and 3 PDs base-up When trialing Fresnel prism, it is 9. Scheiman M, Cotter S, Rouse M, et al. Randomised clinical trial of the effectiveness of base-in prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. Br J Oph- OD. With a trial frame, she was not advisable to only place the Fresnel thalmol. 2005;89(10):1318-23. 10. Teitelbaum B, Pang Y, Krall J. Effectiveness of base in prism for presby- able to appreciate RDS stereoacuity over one eye so that the patient opes with convergence insufficiency. Optom Vis Sci. 2009;86(2):153-6. 11. Pang Y, Teitelbaum B, Krall J. Factors associated with base-in prism in-office. I prescribed 12 PDs base- retains good binocular visual acuity treatment outcomes for convergence insufficiency in symptomatic presby- opes. Clin Exp Optom. 2012;95(2):192-7. out and 3 PDs vertical prism, split with the prism in place. 12. Cotter SA. Clinical uses of prism: a spectrum of applications. Mosby’s Optometric Problem Solving Series, ed. R. London. 1995, St. Louis, Mis- between her eyes. Although cosmesis can be an souri: Mosby. 13. Véronneau-Troutman S. Fresnel prisms and their effects on visual acu- At the follow-up examination, she issue with prism glasses, educating ity and binocularity. Trans Am Ophthalmol Soc. 1978;76:610-53.

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0042_ro0819_F3_Jenewein.indd42_ro0819_F3_Jenewein.indd 4455 88/6/19/6/19 2:522:52 PMPM Ocular Surface When Corneal Wounds Won’t Heal Timely intervention can keep a bad situation from spiraling out of control. By Alison Bozung, OD, and Paul Hammond, OD

orneal epithelial regeneration is constantly taking place. The limbus houses the palisades of Vogt—a spe- Ccialized niche for maintenance and development of corneal stem cells that dif- ferentiate to form the basal cells of the epi- thelium. From this region, the cells migrate centrally then move anteriorly, transforming into wing cells and then superficial squamous cells. The superficial cells desquamate and are taken away by the tear film. Wound Healing Up Close A corneal insult triggers a cascade of healing mechanisms. Epithelial injury stops basal cell mitosis and causes the release of cytokines This patient displays an inferior corneal epithelial defect seen in and growth factors. Basal cells develop filo- neurotrophic keratopathy. podia, which enable them to migrate across the wound. Adhesion molecules expressed by the basal cells allow for adherence to the underlying Impaired Corneal Healing basement membrane. Once the defect is covered with The procedure described above, while elegant, is falli- a single basal cell layer, mitosis resumes and cells pro- ble. Several conditions can lead to the corneal healing liferate to re-establish regular epithelial stratification. process failing, forming persistent epithelial defects Basal hemidesmosomes slowly re-form to replace the (PED) and possibly underlying ulceration. weaker adhesion molecule connections. Neurotrophic keratitis (NK), for example, com- In cases of deeper stromal trauma, additional mol- promises corneal healing by reducing nerve function.4 ecules are released, including prostaglandins, platelet- Diabetes, herpetic keratitis, corneal surgery, topical activating factors, cytokines and various growth drug toxicity and trigeminal nerve damage are all factors.1 These substances potentiate transformation among the leading causes of neurotrophic PEDs.4 of keratocytes into myofibroblasts—contractile cells Limbal stem cell deficiency (LSCD) is defined by capable of migrating and filling the wound. The myofi- inhibited proliferation of epithelial basal cells lead- broblasts arrange into a network, secrete extracellular ing to conjunctivalization of the limbus and adjacent matrix, then apoptose.2 Unfortunately, residual haze is cornea. LSCD may result from chemical or thermal common as a result of increased collagen fibril diam- burns, topical drug toxicity, a history of ocular sur- eter and less precise organization.3 gery, Stevens-Johnson syndrome or ocular cicatricial

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046_ro0819_F4_Bozung.indd 46 8/7/19 7:34 PM pemphigoid. Additionally, severe autoimmune-related This Sjögren’s dry eye or cicatricial exposure of the ocular surface syndrome can result in poor epithelial health.4 patient’s associated Clinical Evaluation dry eye was A comprehensive approach that includes both history treated with and slit lamp exam is integral to determine a PED’s Prokera, an etiology. Accurate history can aid in determining risk overlay that factors for poor corneal healing. Conditions such as protects the diabetes, history of ocular or neurologic surgeries, surface and contact lens wear or use of topical ophthalmic medica- releases tions should all raise red flags.4 nutrients On clinical examination, perform a thorough and growth inspection of the ocular adnexa, tarsal and bulbar con- factors while junctiva, cornea and anterior chamber. In the ocular absorbing adnexa, don’t overlook eyelid malposition, as this can inflammatory be a component of poor ocular surface health. Poor lid debris as the closure, entropion, ectropion and poor blink through epithelium lateral canthal tendon disinsertion may lead to expo- grows in sure keratopathy. Examination should include the lid underneath margin for signs of keratinization, meibomian gland it. The above dysfunction or trichiasis. photo shows Next, turn your attention to the conjunctiva for the patient signs of subepithelial tarsal fibrosis, symblepharon, before bulbar conjunctival scarring or forniceal shortening. Prokera These may provide insight into a history of prior ocu- placement, lar surface inflammation/infections or prior ocular the lower surgeries. Careful observation at the limbus can pro- one is after vide clues about LSCD, such as pannus or abnormal placement. peripheral corneal epithelium. On corneal examination, infectious etiologies In the event that an epithelial defect will not heal such as a bacterial corneal ulcer or herpetic kerati- with basic treatment strategies, more aggressive thera- tis must be ruled out by noting pertinent negatives, pies are indicated. Though scleral lenses may be con- which include absence of a stromal infiltrate, anterior sidered at any stage of impaired ocular surface, severe chamber reaction or keratic precipitates. Consider or recalcitrant PEDs often require their use to protect the appearance of the corneal epithelial defect; neu- the ocular surface. Patients with deep-set eyes, small rotrophic corneal defects typically present as inferior lid apertures or poor dexterity may not be able to suc- ovoid epithelial defects with rolled edges. Photo docu- cessfully use a scleral lens. Amniotic membrane tissue mentation is quite helpful in many cases. You should or autologous serum eye drops may be used when assess decreased corneal sensation before making an more conservative measures fail. In these cases, mov- NK diagnosis. This can be done quantitatively with ing toward early tarsorrhaphy may be the best option. Cochet-Bonnet esthesiometry or qualitatively with the “cotton wisp” test. Custom-fit Sclerals For patients who are able to tolerate daily contact A Graduated Approach lens wear, scleral lenses can provide significant benefit Corneal healing can often be aided by the placing an in corneal healing.5 These devices serve as a physical oxygen-permeable bandage contact lens with frequent barrier, decrease evaporation from the ocular surface, preservative-free artificial tears and prophylactic anti- increase tear-cornea contact and provide a smoother biotic drops. In cases where inflammation is not a refractive surface. In chronic NK or LSCD, they are a major factor, consider early placement of punctal plugs great first-line treatment strategy. to augment natural tear retention. In the event that a cornea or sclera is quite irregular,

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046_ro0819_F4_Bozung.indd 47 8/7/19 7:34 PM consider fitting or referring for a more customizable device. Unlike most other scleral lens devices, the PROSE (Prosthetic Replacement of the Ocular Sur- face Ecosystem, BostonSight) employs a computer- aided design system to allow for more precise fitting. The EyePrintPro (Eyeprint Prosthetics) uses 3D scan- ning of a patient’s ocular surface impression to create a device that is precisely contoured to the individual eye. The Serum Solution ASEDs, also known as autologous serum tears, are becoming increasingly popular amongst eye care pro- fessionals. ASEDs contain numerous growth factors, immunoglobulins, fibronectin and vitamin A, which promote cell proliferation and migration. The first step in producing ASEDs is a blood draw. After blood is harvested from an individual, it is then centrifuged and the serum portion is retained. Depending on the compounding pharmacy’s regula- tions or the doctor’s specifications, the percent of autologous serum may vary. Many pharmacies start at 20% serum, but this may be modified based on response to treatment. Traditionally, we have relied on local or hospital compounding pharmacies to produce ASEDs for our patients. More recently, com- panies such as Vital Tears, which provides a mobile phlebotomy service, allow for a convenient option for both the physician and patient. Additional autologous hemoderived products include plasma rich in growth factors (PRGF) and platelet-rich plasma (PRP). Both of these products are obtained in a similar fashion, and the difference in production occurs with the speed and duration of centrifugation. PRP and PRGF have proven advan- tages over ASEDs, due to their increased concentra- tion of growth factors, anti-inflammatory cytokines and other platelet derivatives since they are not lost in the centrifugation process.4 Both PRGF and PRP have been successful in treating dry eye disease, post-LASIK ocular surface syndrome, and PRP specifically has also been used for glaucoma- associated ocular surface disease and recurrent cor- neal erosions.6-10 Experimental research may support reduced inflammation and likelihood of stromal scar- ring with PRP vs. ASEDs, though no prospective ran- domized clinical trials have compared the efficacy of these three hemoderived ophthalmic treatments.11 Allogeneic, as opposed to autologous, platelet- derived eye drops are also being evaluated in clinical studies. One such therapy, Elate Ocular (Cambium

066_ro0619_F4.indd046_ro0819_F4_Bozung.indd 68 48 6/5/198/7/19 12:38 7:35 PM PM Medical) is seeking FDA approval for ocular graft vs. host-disease. FDA-approval could allow insurance cov- erage for this therapy in the future. These drops would alleviate the need for patient blood draws, as the plate- lets are sourced from healthy donors. Typically, autologous eye drops are started four to six times daily in the affected eye, with the percent and dosage titrated upward according to clinical response. Each of the aforementioned autologous drops must be kept in the freezer until ready to be used, then stored in a fridge or on ice if the patient is traveling. This, along with the lack of insurance coverage, must be discussed with the patient prior to starting treatment. Unfortu- nately, these factors may sometimes be a deterrent for those who need this therapy. Amniotic Options Ocular surface grafting via amniotic membrane (AM) application has been reported in ophthalmic litera- ture as far back as 1940, but has gained significant popularity in the last 20 years as cryopreserved and dehydrated products have become widely available for in-office use.12 The donor graft material is har- vested from placental tissue obtained during elective Caesarean sections, screened for transmissible dis- eases and preserved. Prokera (Biotissue), a cryo-pre- served product, is held in position by a polycarbonate ring. Two dehydrated options, AmbioDisk (Katena) and BioDOptix (Integra LifeSciences), are placed under a bandage contact lens. AM provides many proven beneficial properties to accelerate ocular surface healing beyond acting as a physical barrier and reducing frictional microtrauma from the eyelids. These include anti-inflammatory, anti-scarring, antimicrobial and anti-angiogenic effects, as well as inherent limited immunogenicity.13 AM use can promote corneal nerve regeneration and increase corneal sensitivity, which supports corneal re-epithelialization.14,15 The most common conditions treated with AM include NK, ulcerative keratitis, filamentary keratitis, recurrent corneal erosions, refractory dry eye disease, acute chemical/thermal burns and LSCD.16 Cases of infectious keratitis have also been treated with AM, but only after appropriate antimicrobial treatment has had time to sufficiently sterilize the ulcer.17 The purpose of AM in these cases is to decrease inflam- mation, pain and scarring and promote epithelializa- tion. Starting to use amniotic membranes may seem daunting, but company representatives will help

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surface has stimulated interest in amniotic-derived eye drops for similar indications, including Regener-Eyes (RNI Solutions) and Genesis (Ocular Science).19 These drops have many of the same cytokines, growth factors and nutrients as amniotic membrane grafts, and select case reports and retrospective series show they can improve corneal epithelial healing and limbal stem cell proliferation.20,21 Currently, the lack of standardized clinical trials leaves much to be learned about nuances and efficacy, but amniotic drops hold promise as topi- cal biologic treatments for ocular surface disease while avoiding the blood draw process necessary for ASED/ PRP/PRGF. Oral Medications Tetracyclines exhibit anti-collagenase activity by reduc- ing levels of matrix metalloproteinases and pro-inflam- matory interleukins. For this reason, research shows they are beneficial in epithelial basal cell migration and stromal healing, and are commonly used in cases of stromal ulceration or severe chemical burns. Typically, This patient with neurotrophic keratitis underwent penetrat- doxycycline is dosed at 100mg twice daily. Though not ing keratoplasty. Here, they’re seen before (above) and after a stand-alone therapy, tetracyclines may confer addi- (below) plasma rich in growth factor eye drop application. tional benefit in recalcitrant PEDs. Oral antivirals are also an important consideration clinicians prepare the materials and instructions for when a PED is not improving as expected. Underlying your first patient. Our experiences have left us with herpetic keratitis is a common culprit in these cases, two primary strategies for applying AM: as a bandage and starting oral acyclovir or valacyclovir is a safe to protect the ocular surface while it regenerates or as adjunctive medication to prescribe that may easily scaffolding for the new growth itself. Prokera works resolve the problem. well as an overlay, protecting the surface, releasing nutrients and growth factors, and absorbing inflamma- Lid Closure tory debris as the epithelium grows in underneath it. One of our mentors once said, “a closed eye is a happy Conversely, AmbioDisk adheres directly to the corneal eye.” He was referring to how ambient air can desic- surface and can serve either as an overlay bandage or cate the ocular surface in cases of severe dry eye, but can be trimmed to inlay healthy basement membrane it’s a mantra we can apply even with our neurotrophic scaffolding for epithelial cells to adhere to and migrate patients. However, closure of the lids by surgical across.18 The AM will ultimately integrate into the host means can impact an individual’s psychosocial health tissue when used as an inlay, or slough off as an over- due to altered cosmesis. That being said, it remains a lay when epithelial healing is complete. viable option for PEDs that prove recalcitrant to other, The primary complication for Prokera is patient more accepted means. discomfort due to the polycarbonate ring, but in our Tarsorrhaphies can be temporary or permanent. A experience, this is less common with the Prokera Slim great in-office option is a ‘tape tarsorrhaphy’—a very and improves after the first 24 hours. The dehydrated short-term approach that will allow for near total lid AM products tend to have issues with adherence and closure. This can be done by trimming a 1x1” square may slip out from under the bandage lens. We’ve of plastic surgical tape, having the patient close their found this issue can be avoided by using a temporary eyes, pulling their brow upwards to smooth any lid hydrogel adhesive like ReSure Sealant (Ocular Thera- creases, then applying the tape with the inferior edge peutix) around the periphery of the graft before plac- juxtaposing the eyelashes. It will likely need to be re- ing the bandage contact lens. applied daily by the patient at home, and over the long The recent success of AM in treating the ocular term may cause a skin reaction underlying the tape.

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046_ro0819_F4_Bozung.indd 50 8/7/19 7:35 PM Chemical tarsorrhaphy, performed by injecting botu- linum toxin into the levator muscle, is an alternative that lasts approximately three months. Alternatively, a suture tarsorrhaphy may be done by select placement of sutures and bolsters through the upper and lower eyelids and may quickly be removed following resolu- tion of the corneal defect. Permanent tarsorrhaphies employ excision of the lid margin epithelium prior to suturing, to allow the upper and lower eyelids to “stick” together once they heal, providing a longer term option for those with chronic disease. Based on the severity of ocular surface disease, a permanent tarsorrhaphy may be performed and is typi- cally closed up to the lateral limbus as a starting point. Platelet-rich plasma can help repair New Drugs and Future Directions recurrent corneal It’s an exciting time in the eye care field, as new thera- erosions. Here it is pies are being developed to help us treat our patients. after centrifugation Oxervate (cenegermin-bkbj, Dompé Pharmaceuticals) (top left), mixing is the only FDA-approved topical therapeutic drop with normal saline indicated for NK. It contains cenergermin-bkbj, a (top right) and, recombinant form of human nerve growth factor that finally, bottled.

supports differentiation and maintenance of corneal 2. Myrna KE, Pot SA, Murphy CJ. Meet the corneal myofibroblast: the role of myofibroblast trans- nerves. Nexagon (Eyevance Pharmaceuticals)—the formation in corneal wound healing and pathology. Vet Ophthalmol. 2009;12 Suppl 1:25-7. 3. Remingto, L. Cornea and Sclera. In:Clinical Anatomy of the Visual System. 3rd ed. St. Louis, Mo: active ingredient is CODA001—is a topical drug Elsevier, 2012. that inhibits cell membrane hemichannel formation, 4. Alio J, Rodriguez A, Ferreira-oliveira R, et al. Treatment of dry eye disease with autologous platelet-rich plasma: a prospective, interventional, non-randomized study. Ophthalmol Ther. decreasing proinflammatory cytokine release and tis- 2017;6(2):285-93. sue ischemia. Its primary indication is the treatment of 5. Alio JL, Rodriguez AE, Abdelghany AA, Oliveira RF. Autologous platelet-rich plasma eye drops for the treatment of post-LASIK chronic ocular surface syndrome. J Ophthalmol. PEDs, and clinical trials are underway as of this year. 2017;2017:2457620. Surgical treatment for NK has also gained popular- 6. Anitua E, Muruzabal F, De la fuente M, et al. plasma rich in growth factors for the treatment of ocular surface diseases. Curr Eye Res. 2016;41(7):875-82. ity recently through a procedure called corneal neuro- 7. Sánchez-avila RM, Merayo-lloves J, Fernández ML, et al. Plasma rich in growth factors eye tization, which involves adjoining a healthy sensory drops to treat secondary ocular surface disorders in patients with glaucoma. Int Med Case Rep J. 2018;11:97-103. nerve graft from the contralateral supraorbital or 8. Lee JH, Kim MJ, Ha SW, Kim HK. Autologous platelet-rich plasma eye drops in the treatment of supratrochlear nerve, and placing it into the peripheral recurrent corneal rrosions. Korean J Ophthalmol. 2016;30(2):101-7. 22 9. Anitua E, De la fuente M, Muruzabal F, et al. Plasma rich in growth factors (PRGF) eye drops cornea. stimulates scarless regeneration compared to autologous serum in the ocular surface stromal fibroblasts. Exp Eye Res. 2015;135:118-26. 10. de Rotth A. Plastic repair of conjunctival defects with fetal membranes. JAMA Ophthalmol. Corneal healing is a complex process, and we need 1990;83(3):522-25. to be ready to step in when the body’s own mecha- 11. Nakamura T, Yoshitani M, Rigby H, et al. Sterilized, freeze-dried amniotic membrane: a useful substrate for ocular surface reconstruction. Investig Ophthalmol Vis Sci. 2004;45(1):93-9. nisms aren’t adequate. From treatment of simple epi- 12. John T, Tighe S, Sheha H, et al. Corneal nerve regeneration after self-retained cryopreserved thelial abrasions to managing neurotrophic corneal amniotic membrane in dry eye disease. J Ophthalmol. 2017;2017:6404918. 13. Morkin MI, Hamrah P. Efficacy of self-retained cryopreserved amniotic membrane for treatment disease, each of us will face cases when our clinical of neuropathic corneal pain. Ocul Surf. 2018;16(1):132-8. expertise will be called upon. With new advances in 14. Cheng A, Zhao D, Chen R, et al. Accelerated restoration of ocular surface health in dry eye disease by self-retained cryopreserved amniotic membrane. Ocul Surf. 2016;14(1):56-63. both medications and surgical options, we can rise to 15. Sheha H, Liang L, Li J, Tseng S. Sutureless amniotic membrane transplantation for severe meet the challenge. ■ bacterial keratitis. Cornea. 2009; 28(10):1118–23. Dr. Bozung practices at Bascom Palmer Eye Institute 16. Malhotra C, Jain AK. Human amniotic membrane transplantation: Different modalities of its use in ophthalmology.World J Transplant. 2014;24;4(2):111-21. in Miami. 17. Murri M, Moshirfar M, Birdsong O, et al. Amniotic membrane extract and eye drops: A review Dr. Hammond is a consultative optometrist at North of literature and clinical application. Clin Ophthalmol. 2018;12:1105-12. 18. Asl NS, Nejat F, Mohammadi P, et al. Amniotic membrane extract eye drop promotes limbal Suburban Eye Specialists in Minneapolis. stem cell proliferation and corneal epithelium healing. Cell J. 2019;20(4):459-68. 19. Gupta PK. Clinical outcomes of amniotic cytokine extract in the treatment of dry eye disease. 1. Jester J, Ho-Chang J. Modulation of cultured corneal keratocyte phenotype by growth fac- Presented at the 2017 American Academy of Ophthalmology Annual Meeting. tors/cytokines control in vitro contractility and extracellular matrix contraction. Exp Eye Res. 20. Terzis JK, Dryer MM, Bodner BI. Corneal neurotization: a novel solution to neurotrophic kera- 2003;77(5):581-92. topathy. Plast Reconstr Surg. 2009;123(1):112-20.

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Optometry in the Age of Disruption: Doctors vs. Online Vendors These companies prioritize cost and convenience over quality eye care and the doctor- patient relationship. Here’s how to defuse the threat they pose. By Jeffrey Sonsino, OD

here has never been a bet- vulnerable to safety issues. ter time in America for In the health care sector, entrepreneurs to create a growing tide of websites Tstart up companies. Online and apps allows the public to platforms, such as Shopify, Square diagnose and treat themselves and Amazon Web Services, make without doctor oversight. Some it easy to interact with the compa- areas of medicine are push- nies they are associated with, and ing back, citing the dangers of funding mechanisms, including unmonitored self care as reasons Kickstarter and IndeGoGo, make for their resistance. The FDA it easy to raise money to fund is telling the public not to use business endeavors.1 Start ups untested and unapproved apps are everywhere you look. Conse- to diagnose concussions without quently, our culture has evolved to assistance from a doctor.2 Mid- prioritize convenience over value. wives are cautioning expectant mothers to stay away from baby A Threat to Patients This is an example of a Facebook advertisement heart monitor apps.3 Physicians Overnight, three scooter compa- used by 1-800 Contacts to promote the company’s are warning patients to steer nies recently dumped thousands online contact lens prescription renewal platform. clear of direct-to-consumer web- of scooters onto the streets of my sites supplying drugs without hometown, Nashville. Initially, over car hoods, hitting pedestrians requiring a prescription.4 people loved the convenience, low on sidewalks and blowing through In the contact lens field specifi- cost and accessibility of this mode red lights into cross traffic. The local cally, there is no shortage of compa- of transportation. Over time, how- academic medical center started nies not abiding by or adhering to ever, it became clear that the scooter reporting astronomical increases in the law. For years, optometrists have companies were not working with rates of head injuries due to scooter complained that 1-800 Contacts local leadership to enforce the safety accidents. Only after a well-publi- uses loopholes in passive verification of scooter riders. Their half-hearted cized death from a scooter accident methods to accommodate expired attempts to ensure riders used hel- did the city start to consider banning prescriptions and provide lens mets, drove safely and followed the scooters. This problem is character- quantities in excess of prescription rules of the road fell on deaf ears. istic of similar concerns occurring durations. With more severe conse- Every night on the news, I watched in health care, specifically in optom- quences than ever before, the online videos of drunk scooter riders flying etry, that are leaving patients equally vendor is now actively marketing the

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052_ro0819_F5_Sonsino.indd 52 8/7/19 5:15 PM ability to skip in-office eye assess- fication information directly to ments by encouraging consumers office staff, likely because the to renew their contact lens prescrip- company knows its requests tions online.5 will be denied. Making it possible to renew contact lens prescriptions online, Advocacy Efforts 1-800 Contacts partnered with Vis- Many organizations are fight- ibly.5,6 Visibly operates by obtain- ing to counter the backwards ing a patient’s prescription, giving narrative online contact lens them a do-it-yourself sight test and sellers are feeding to consum- renewing their prescription. Oph- ers that convenience and cost thalmologists work with the com- should supersede eye care and This patient suffered a corneal perforation due pany to issue these renewals. Most the doctor-patient relationship. to a Pseudomonas ulcer from ordering contact ophthalmologists and consultants The American Optometric lenses online without doctor oversight. who understand why contact lenses Association (AOA) is leading are class II and III medical devices the fight on behalf of optometrists cally and the contact lens manufac- would agree that this is not a good and our patients. Joining the AOA’s turing industry in general as well idea. But there are those who tend unparalleled advocacy efforts helps as a vision insurance plan and a to value convenience and cost over ODs protect patients from insurance technology start up. The organiza- annual exams and eye care.7 companies, corporations and even tion is supporting two bills in 2019 These direct-to-consumer contact themselves. The AOA encourages designed to shift the focus of contact lens companies exploit loopholes in those with questions about contact lens sales back to being patient- the passive verification process as lens violations to submit them to centric. The APS is also working to part of their business strategy, essen- [email protected] and those educate lawmakers on the hazards tially working around lens prescrip- with complaints to report them to of lax oversight of contact lenses. tions altogether. Many optometrists the FTC or FTA at www.accessdata. criticize Hubble as the main culprit fda.gov/scripts/medwatch or www. Fighting Back and are unwilling to prescribe the accessdata.fda.gov/scripts/email/oc/ Every optometrist can make several company’s lenses due to the poor buyonline/english.cfm.10 changes in their practice to ensure quality of their material, methafil- The Health Care Alliance for they are providing the best care to con A.8,9 Third-party Vision Path Patient Safety (APS) is a newer advo- their patients: offer convenience, “verifies” Hubble’s prescriptions but cacy organization that promotes provide patient education and differ- prefers leaving one-way voicemails the doctor-patient relationship and entiate their services and products. and not providing prescription veri- consists of AOA members specifi- Online sellers may have an edge when it comes to convenience, but it is time to close the gap. We can no ODs Take Charge longer continue to do business the In an effort to equip optometrists with tools to compete from a business perspective, I same way we have done it for the teamed up with a business strategist/entrepreneur to launch Eyeris. The company’s aim is past 20 years. If your staff is com- to help optometrists go head-to-head against disruptors by offering services that seek to municating with patients by calling neutralize their advantages. Patients want quick access to eye care, so we created soft- them, then it may be time to mod- ware that matches people seeking same- or next-day appointments with practitioners who ernize your practice. Text messages have openings due to cancellations or no-shows. This safer alternative to online vision tests outrank phone calls as the dominant provides patients with quality care, but on their schedules. Patients also want affordable form of communication with mil- lenses they can order online, so, later this year, Eyeris will debut a daily disposable that will lennials.11 If patients are unable to only be available with doctor oversight and cannot be substituted for another lens. Patients order contact lenses through your can order it online from Eyeris, but the doctor maintains control over the process—and website, it may be time to look into the margins, just as if they sold it in their office. We also believe our pricing advantage will adding this service. keep patients from looking to other online outlets. Only time will tell, but we feel Eyeris can These additions, plus allowing shift the way optometrists do business and help them compete with the tide of disruption. patients to conveniently schedule their appointments online, making

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some patients do not care for the doctor-patient relationship about or understand the and the highest standard of clini- information we have to cal eye care. The OD is at a turning offer. point in the evolution of eye care. However, how you Instead of succumbing to a future communicate with them narrative dictated by companies that makes a huge difference— do not have patients’ best interests if it is not effective or in mind, we should adapt the way clear, you are right back we practice to stay ahead. As long to square one. Sometimes as what we have to offer is valu- patients need to hear the able and unique to patients, we will consequences of skipping remain a central part of the equa- a test or exam, turning tion. ■ down treatment or misus- Dr. Sonsino is a partner in a ing a service or product specialty contact lens and anterior for the importance of segment practice in Nashville, Tenn. annual eye care to truly He is a diplomat of the Cornea and sink in. Make every visit Contact Lens section of the Ameri- meaningful for patients so can Academy of Optometry and the Read this transcript of an interaction between a patient that they have something past chairman of the Cornea and and direct-to-consumer contact lens company Aveo. to take away and are Contact Lens section of the Ameri- that much more likely to can Optometric Association. He co- sure you are not running behind and return next time. founded Eyeris, which launched at maximizing chair time, will hope- Not every patient is an optimal the 2019 AOA conference. fully sway patients away from taking candidate for off-the-shelf contact 1. Reeves J. Why it’s easier than ever to be an entrepreneur. Business the online vendor route. Implement- lenses. Patients with high ametropia Insider. www.businessinsider.com/why-now-is-the-best-time-to-start- ing these strategies into your practice or high astigmatism may be bet- a-company-2014-10. October 22, 2014. Accessed June 25, 2019. 2. Wicklund E. FDA targets DIY mHealth devices aimed at concus- is easy with optometry-friendly com- ter suited for hybrid lens wear, for sions, head injuries. mHealth Intelligence. mhealthintelligence.com/ news/amp/fda-targets-diy-mhealth-devices-aimed-at-concussions- panies that can help you advertise example, due to their higher Dk, head-injuries. April 11, 2019. Accessed June 25, 2019. these features on your website and in customizable base curve, centration 3. Coates L. Senior midwife begs pregnant women not to use ‘extremely dangerous’ baby heart monitor apps. Eastern Daily your practice. abilities and lack of a need for rota- Press. www.edp24.co.uk/news/health/jpuh-midwife-warning-over- Optometrists used to perform a tional stability. Patients with specific extremely-dangerous-app-1-5962093. March 27, 2019. Accessed June 25, 2019. battery of tests without explaining ocular problems require specific 4. Yarbrough JL. The dangerous side effect of digital wellness. Fash- ionista. fashionista.com/2019/03/digital-health-wellness-companies- what they were or why they were solutions that online vendors cannot government-regulations. March 20, 2019. Accessed June 25, 2019. doing them. Those days are long fulfill. If you offer a service or prod- 5. 1-800 contacts launches online eye exam powered by Opternative. Vision Monday. www.visionmonday.com/latest-news/article/1800- gone. Now, patients have options, uct that can not be or is not easily contact-launches-online-eye-exam-powered-by-opternative-1/. August 1, 2016. Accessed June 25, 2019. and if they are not getting what they replaced or replicated, patients will 6. Opternative changes name to ‘Visibly’ to better reflect a move need or want from you, they will go seek you out when they are in need. toward partnerships. Vision Monday. www.visionmonday.com/ latest-news/article/opternative-changes-name-to-visibly-to-better- elsewhere to find it. Patients must Set yourself apart from others and reflect-a-move-toward-partnerships. December 11, 2018. Accessed be armed with extensive, compre- give patients a reason to go to you June 25, 2019. 7. Federal Trade Commission. The contact lens rule and the evolving hensive eye care knowledge so that first, every time. contact lens marketplace. www.ftc.gov/system/files/documents/ public_events/1285493/panel_ii_contact_lens_health_and_safety_ when 1-800 Contacts calls for them Many companies have priorities issues.pdf. Accessed June 25, 2019. to “skip the air puff test,” they know that compromise consumer safety, 8. American Optometric Association. Concerns validated, AOA stands ground amid Hubble row. www.aoa.org/news/advocacy/hubble- what the test is and why it is impor- as was the case with the scooters in update. Accessed June 25, 2019. 9. American Optometric Association. A Letter to the Honorable tant and can make an educated deci- Nashville. Many organizations do Chairman Joseph Simons. www.aoa.org/Documents/CLCS/Hubble- sion for themselves. It may seem like not understand or respect quality April-2019(0).pdf. April 23, 2019. Accessed June 25, 2019. 10. American Optometric Association. Reporting contact lens viola- eye care; but, tions to the FDA and FTC. www.aoa.org/advocacy/federal-advocacy/ To listen to a call between a Hubble employee and the good news regulatory-issues/fclca/report-cls-violation/report-to-fda-and-ftc. Accessed June 25, 2019. a member of my staff, read this article online at is that many 11. Howe N. Why millennials are texting more and talking less. Forbes. www.forbes.com/sites/neilhowe/2015/07/15/why-millen- www.reviewofoptometry.com or scan the QR code. organizations nials-are-texting-more-and-talking-less/#2c2b300d5975. July 15, also advocate 2015. Accessed June 25, 2019.

54 REVIEW OF OPTOMETRY AUGUST 15, 2019

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RO0819_Lombart.indd 1 7/18/19 9:07 AM 43rd Annual Contact Lens Report Specialty Lenses

43rd Annual Contact Lens Report Provide Specialty Contact Lenses and Thrive You can build doctor-patient loyalty and keep patients from shopping around by offering something your competitors don’t have. By Jane Cole, Contributing Editor Photo: Robert Ensley, OD oday, patients have an investing the time to achieve a ever-increasing list of successful fit with a multifocal inexpensive options or toric lens can pay off many Tto choose from when times over.” buying their contact lenses— Specialty lens wearers, from online behemoth 1-800 especially multifocal-wearing Contacts to the recently presbyopes, are often long- launched Hubble that prom- term patients, and they are a ises the first box of daily “fantastic referral source” as disposable lenses will be free. well, Dr. Fischer explains. And most optometrists agree Still, specialty lenses remain that trying to compete with an untapped opportunity these bargain venues on price for many. A 2015 Gallup alone is a losing battle. A specialty lens, such as this mini-scleral, may be a good study of the US multifocal Instead, experts say you option for your patient with high corneal astigmatism— contact lens market found should focus on what these and it’s one only you can prescribe. 42% of patients between retailers can’t provide: qual- the ages of 40 and 54—and ity care. For contact lens fitters, this “In the last decade, there has 38% of those aged 55 to 64—have includes providing specialty contact been an incredible increase in lens expressed some interest in multifocal lenses that require more time and parameters that are available for our contact lenses.1 Despite this growing attention to fit, such as torics, mul- patients, but I often hear optom- need, just slightly more than half of tifocals, toric multifocals, sclerals, etrists mention they are hesitant to eye care professionals start a con- gas permeables (GPs) and hybrids. start the fitting process with these versation about innovative contact If you build a thriving practice of lens types because they are viewed lenses, and 91% of practitioners patients wearing these lens types, as more difficult or more time con- fit less than 20% of soft multifocal those patients will feel more loyal to suming,” says Andrew Fischer, OD, lenses.1,2 Even during a multifocal you and will be less inclined to shop of Specialty Eyecare Group in Kirk- lens conversation, only 15% of clini- around for the best deal. land, WA. “This may be true, but cians reported they present the lenses

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056_ro0819_F6_Cole .indd 56 8/7/19 5:42 PM enthusiastically to their patients, Stand Out With a Specialty Lens Practice while 48% said they offer warnings After selling his practice to a private equity affiliate more than two years ago and buying about the lenses’ downsides before an existing practice in central San Diego, Dr. Chou decided to shift his focus to specialty the patients have even tried them.2,3 contact lens prescribing. Since then, he’s grown to love Walmart, Costco, LensCrafters and Here, your colleagues offer insight other retail competitors he previously faced at his former group optometric practice. on how specialty lenses can help Because Dr. Chou’s new office caters to specialty lens patients, with an emphasis on your practice gain a leg up on the scleral lens prescribing and keratoconus and irregular cornea patients, the big box stores competition, in addition to some and retail chains refer him their hard-to-manage contact lens patients, and the relationship “do’s and don’ts” on how to best get is paying off in dividends. your patients into a specialty lens. He still does general eye exams, but most of his patients are wearing specialty lenses. Dr. Chou treats any and all corneal complications, including keratoconus and corneal trans- Play the Loyalty Card plant patients, and he fits scleral and prosthetic contact lenses in addition to impression Patients in specialty lenses are more scleral cover shells with EyePrint Pro (EyePrint Prosthetics) and corneal refractive therapy. apt to purchase lenses from their Although he doesn’t think there are enough patients with irregular corneas to support doctor, says Jason Miller, OD, of a thriving specialty contact lens practice for every OD, Dr. Chou still encourages others to EyeCare Professionals of Powell, delve into a specialty, such as myopia control or dry eye, to diversify their practice from Ohio. The fact that the doctor has mercantile optometry taken more time to find the best fit- “I am pleased with the outcome. Most optometrists will admit there are a lot of com- ting lens or the right combination petitive threats ranging from online refraction to Hubble. Now my practice coexists in this likely weighs into a patient’s decision ecosystem where all these other entities are too,” Dr. Chou says. on whether or not to search for a better price, he adds. A Caveat “I don’t really like to consider Specialty fits may help differentiate your practice, but this scenario may not always equate I’m competing with companies like to a large volume of patients, some experts warn. 1-800 just in price, because I can “While a specialty practice is ideal, it is impossible for the average OD to have one,” beat them with in-person service,” says Justin Bazan, OD, of Park Slope Eye in Brooklyn, NY. “You add specialty fits to your he explains. “By offering great ser- existing contact lens services, but there simply aren’t enough specialty patients to sustain vice and advanced technologies like a practice that only does specialty fits. You will have to compete with online retailers, not specialty lenses at a good price, it necessarily on price, but you will have to compete for the sale of soft contact lenses.” certainly helps swing that competi- Still, expertise in this area can give you a competitive edge over other practices, as tive edge toward the practice.” many patients, even those with general needs, may feel like they are in better hands when Specialty lenses—such as sclerals, seeing a “specialist.”

GPs, custom torics and hybrids— Photos: Brian Chou, OD require a greater emphasis on the relationship between the patient and the doctor, not the product, says Brian Chou, OD, owner of a spe- cialty contact lens practice, ReVision Optometry, in San Diego. “The commodity world of dis- posable contacts is inhabited by a very strong brand-centric emphasis on the product, where the patients Providing custom medical contact lenses, such as EyePrint Pro, has led to OD and develop a loyalty to the brand and MD referrals, including from big box and retail stores, Dr. Chou says. the product, not the services or the doctor,” Dr. Chou says. If patients see their contact lenses as a com- Dr. Chou gives the example of a posable lenses, the patient will often modity, online marketers are likely patient who wears a popular single- say it’s the brand, and in this case, it to amplify the perception that the vision daily disposable. “If you ask doesn’t matter who prescribes it. The doctor is not a necessary part of the the patient the reason behind their patient will just go to the lowest cost puzzle, he adds. wearing success in many of these dis- provider.”

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056_ro0819_F6_Cole .indd 57 8/7/19 5:41 PM 43rd Annual Contact Lens Report Specialty Lenses Photo: Vivian Shibayama, OD Photo: Irene Frantzis, OD sacrifice quality,” he says. “As a business model, fast and cheap can be successful; however, as a medical provider dealing with something as vital as my patients’ eyes and vision, quality eye care is not something I am will- ing to sacrifice.” This patient’s larger-than-average horizontal Remember that some- visible iris diameter led to contact lens one else will always be Patients with a high amount of astigmatism intolerance with traditional soft lenses. Her faster and cheaper than may not know they can achieve better vision OD took the time to design a toric lens with an you, says Stephanie Woo, with a well-fitting GP until you educate them. increased diameter, which did the trick. OD, of Havasu Eye Cen- ter in Arizona. Addition- In this scenario, patients see the fect fit in more complicated lenses, ally, you will lose if you’re trying to doctor as a third wheel interfering which often helps with loyalty. Cus- compete for patients who are look- with their access, because the focus tom soft lenses, sclerals, corneal GP ing to get the cheapest price. Instead, is on cost and convenience, not the lenses and orthokeratology designs be known for your high level of cus- care, Dr. Chou says. often need two or more lens orders tomer service and instrumentation, Specialty contact lenses, however, and evaluations on the eye before and patients will find great value in often require tremendous expertise, finalizing a lens prescription, he that, she says. beginning with the identification of explains. Dr. Miller agrees that it’s a mis- good candidates. take to chase online outlets. “That’s “Patients won’t come into the The Price Isn’t Always Right a bad race to the bottom, and office asking for a front-surface toric If practitioners are tempted to com- patient service has to be sacrificed in prism ballasted scleral contact lens,” pete on price with online entities and order to chase that lower price.” Dr. Chou explains. big box stores, they should know When price really is an issue, Instead, they usually say they it may be an unwinnable fight, the patients are more inclined to try want a certain brand of soft lenses. experts warn. specialty lenses if they can get help It’s up to you to notice they might Optometrists can address three from their insurance, so Dr. Fischer do well in another, more specialized, key features when structuring their suggests becoming familiar with the lens and offer that option. contact lens practice, according to rules of individual insurance plans. Dr. Fischer finds patients will Dr. Fischer: fast, cheap and quality. acknowledge and appreciate the “The catch is, we can only choose Find Your Followers extra time it takes to achieve a per- two. If we choose fast and cheap, we One of the simplest ways to open your patients’ eyes to specialty lenses Think Like Amazon is just by mentioning the option Savvy doctors should expand their thinking on ways to compete with 1-800 Contacts other when they are in the chair. Once you than price, Dr. Gerber says. have their interest, you have to dem- Instead of focusing on the lenses, the practice management expert suggests paying onstrate that you are well versed on attention to the event, experience and everything else that surrounds the delivery of the the latest lens technologies. contact lenses. “Talk about the lenses and always “Think about how online retailers compete with each other. Amazon isn’t always the low- do what’s best for the patient, est price provider, but they make it so easy to order and reorder and return things, that it’s regardless of your perception of the tempting to not even bother shopping for a better price,” Dr. Gerber says. Doctors should patient’s ability or willingness to pay make their patients’ contact lens experience—both online and in the office— “Amazonian” for them, which is often a barrier to to mitigate price pressure from competitors. doctors having the discussion in the “This goes for everything in their offices, not just specialty lenses,” he says. first place,” says practice manage- ment expert Gary Gerber, OD, of

58 REVIEW OF OPTOMETRY AUGUST 15, 2019

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Review 8-19 Reno-THP.indd 1 7/25/2019 12:35:55 PM RRO0819_ArtO0819_Art Optical.inddOptical.indd 1 77/26/19/26/19 8:398:39 AMAM 43rd Annual Contact Lens Report Specialty Lenses Photo: Suzanne Sherman, OD Many doctors try to same approach. “These patients are use their experience in our chair with near complaints, and make adjustments and fitting them into distance con- that could lead them tacts does not solve that problem. in the wrong direction, Multifocals provide an option to he says. Easy steps doc- correct for both distance and near. tors can take to better Additionally, I find transitioning a ensure their success patient into multifocals as an emerg- with specialty lenses is ing presbyope is much easier than being up-to-date with waiting until they have no accom- the newest technologies, modation left. For me, the earlier, not masking astigma- the better.” tism and being a strong Early presbyopes are some of the A smart OD resolved this patient’s daily rigid GP lens advocate of the newest easiest patients to fit with multi- awareness by piggy-backing a GP lens on top of a lens options, he says. focals, with the exception of those silicone hydrogel lens. “Additionally, many patients who are in “presbyopic doctors remember that denial,” Dr. Gerber adds. The Power Practice. one patient who was a challenging When fitting multifocals, for multifocal fit instead of remember- As 1-800 Contacts and other example, Dr. Woo will ask patients ing the many other patients who discount lens entities continue to if they would be willing to try a lens loved the technology.” infiltrate the marketplace, ODs have that allows them to see distance and Also, be crystal clear on who an opportunity to differentiate them- near without reading glasses, and would be a good candidate. Poor selves by focusing on what they do she finds most of the time, patients candidates, Dr. Woo says, include best: providing quality, specialized are excited to try them. patients who want pristine vision at eye care. Given today’s contact lens Mentioning specialty lens options all distances; have unrealistic expec- advancements, that includes offering in the exam room is part of the tations such as demanding 20/15 access to a variety of specialty lens routine for Dr. Fischer. “Specialty vision at far and near but never want modalities to meet the visual needs lenses do not require ‘special’ eyes. to wear glasses again; have failed in of each and every patient. ■ Specialty lenses are great for normal soft contacts due to dryness; or have 1. Multi-sponsor Surveys, Inc. 2015 Gallup Study of the U.S. corneas and those wanting higher ocular surface disease or other ocu- Multi-Focal Contact Lens Market. October 2015; Princeton, NJ. quality vision. Patients with moder- lar pathologies. 2. Bausch & Lomb’s Innovation Index, 2015. ate to high astigmatism and higher 3. Jobson Optical Research 2015.

prescriptions make great specialty Jump into Multifocals Photo: Robert Ensley, OD lens candidates.” For early presbyopes who He also encourages optometrists haven’t worn contacts, to get outside of their comfort zone optometrists may be more and take the plunge into specialty inclined to first introduce lenses. “Being able to fit contact them to a single vision lens lenses well comes with experience, before graduating them into and the more specialty lenses they a multifocal. But experts fit, the more comfortable they say this may be a misguided become. There are many tools, webi- approach that could hamper nars, resources and conferences that contact lens success. provide fantastic guidance on how “I jump right into mul- to succeed with specialty lenses. tifocal lenses,” Dr. Miller says. “It is easier to intro- This competitive athlete was not happy with his Troubleshooting duce multifocal contact fluctuating vision in standard soft toric lenses. A The number one fitting mistake lenses when patients first hybrid lens that provided GP optics without lens is not following the proper fitting start noticing symptoms.” rotation or dislodgement gave him comfortable guides, according to Dr. Miller. Dr. Fischer follows the 20/15 vision in each eye.

60 REVIEW OF OPTOMETRY AUGUST 15, 2019

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RO0219_Focus.indd 1 1/29/19 12:53 PM 43rd Annual Contact Lens Report Multifocals

Don’t Miss Out On Multifocals These devices can be a practice builder, not a spirit breaker. Here’s how. By Mark De Leon, Associate Editor

recent study estimates than 65, 77% said they had 1.8 billion people no limitations on the kind of globally have pres- work they can do.5 Abyopia, 826 million “Today’s presbyopes of whom have near vision are active folks who lead impairment because they demanding schedules filled have inadequate vision cor- with travel, fitness and fun,” rection—or none at all.1 This Pamela Lowe, OD, of Profes- staggering number is on the sional Eye Care Center in rise, the study authors note.1 Illinois, says. “They are and Many attribute the global want to look and feel more high prevalence of unmanaged youthful.” presbyopia to a lack of aware- These presbyopes make ness and access to affordable the best multifocal lens can- treatment in the developing Discussing presbyopia’s impact on your patient’s vision didates because “those who world, but research identifies early will reap many benefits. work in a dynamic environ- the same unmet need in devel- ment with various working oped countries, too.2 for optometry. distances will appreciate Multifocal contact lenses can— Here is a look at how optom- the freedom from reading glasses,” and should—be the answer to many etrists are overcoming the multifocal according to Robert Ensley, OD, of presbyopes’ vision concerns, yet one prescribing hurdles to provide their Gaddie Eye Centers in Kentucky. study found contact lens prescribing presbyopic patients the best vision Patients with an active lifestyle who to patients 45 years and older was correction options available. don’t have an unrealistic demand only 37%.3 In addition, about 42% for their vision will make excellent of spectacle wearers are presbyopes, Know Your Audience patients, he adds. compared with just 24% of contact Although presbyopes are still According to Shalu Pal, OD, who lens wearers. Still, spectacle-wearing patients in their 40s and older, they practices in Yorkville, Toronto, presbyopes prefer contact lenses aren’t the same patients they once ideal patients include those who are as often as non-presbyopes and were. Retirement-age Americans frustrated with reading glasses or demonstrate an interest in contact are feeling healthier than ever, with progressives and active patients who lens wear.4 This disparity between more than 75% aged 65 or older need hands free and head-tilting free patient interest in contact lens wear, reporting being in good, very good vision—patients who want easy, the number of multifocal prescrip- or excellent health—a demographic functional vision at all ranges and tions and the growing number of that has grown steadily over the all angles. presbyopes is a critical opportunity past 35 years.5 Of workers older “I like to recommend multifocals

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062_ro0819_F7_DeLeon.indd 62 8/7/19 5:22 PM to anyone who does outdoor It should become an important activities, so they don’t have to example of how you can correct The Outliers constantly wear glasses,” says your patient’s distance and near There will always be presbyopic patients Stephanie Woo, OD, of Havasu visual needs, she says. who won’t do well in multifocal lenses Eye Center in Arizona. Many Dr. Geffen discusses all three or have unrealistic vision correction presbyopic patients in Dr. Woo’s vision correction options—glasses, expectations. While everyone wants be practice who wear multifocals use contacts or surgery—so the patient independent of eyeglasses, some might them part-time, only using them knows he is the source for all of still need it as a supplement. when they are at the gym, hiking, their vision-related questions and “Emmetropes or very low hypertropes boating or playing sports. concerns. desperately want to be free from readers, “Many times patients feel if you Others such as Dr. Pal help pro- but typically want to compare the dis- wear contact lenses, it is a full-time vide a long-term plan at the end of tance vision with multifocals to what they commitment,” Dr. Lowe adds. “Let their assessment if they see presby- are used to unaided,” Dr. Ensley notes. patients know they can be a week- opia becoming a problem. “I offer Patients with occupations that require end warrior or occasional social them their multifocal options that extensive distance demands, such as wearer, especially with the single-use best match their prescription regard- pilots, engineers and truck drivers, might lenses now available.” less if they have asked for contact not be the best fit for full-time multifocal “Sometimes these patients slip lenses or not,” she says. lens wear. through the cracks because they have never expressed interest in con- Temper Expectations multifocal advances so they know tact lens wear before or have never Presbyopia reduces vision-related what’s available to fulfill patient been asked,” Dr. Ensley points out. quality-of-life, and although vari- needs and expectations,” Dr. Lowe When considering a patient’s ous vision correction options can says. To choose the right lens, clini- vision correction options, optom- improve it, nothing can restore cians first need to know about the etrists should not assume that pres- vision to its pre-presbyopic state.6 patient’s visual environment. byopic status, wear time, refractive “We give proper expectations to “Teasing out when they would error, or gender are factors that pre- our patients and try to under prom- like to wear lenses, what visual clude a patient from being interested ise and over deliver,” David Geffen, activities they perform and what in multifocal contact lens wear.4 OD, of Gordon Schanzlin New their visual environment entail are Vision Institute in San Diego, says. key,” she explains. Educate Early Dr. Woo suggests a handout out- “We first go through a series When a presbyopic patient is in lining what to expect could help of questions about lifestyle and your chair, you have their undivided patients be fully aware of what then decide on which distances are attention and a prime opportunity vision outcomes to expect. most important for the patient,” to talk to them about the condition. “Once a patient understands the Dr. Geffen explains. He focuses Having a conversation early about advantages and limitations they will first on providing the patient with presbyopia’s impact on their vision experience with lenses, they become excellent distance vision and tells will reap many benefits and can an engaged partner with the doc- them they can modify the near at help to assuage their fears. tor in achieving the best outcome,” the next visit, if necessary. “I like “Ask about near work demand, explains Dr. Lowe. this approach because if the patient eye fatigue and trouble focusing,” is unhappy with the distance they Dr. Ensley suggests. “Even if the Choose the Right Lens may not even wear the lenses to give patient isn’t struggling at the time, Multifocal contact lens materials, them the chance to adapt,” he adds. I might mention that when those designs and replacement schedules Dr. Ensley emphasizes the impor- issues arrive we have plenty of have come a long way from the time tance of a lens’s replacement sched- options for them to remain success- Dr. Lowe started fitting contacts ule. “New contact lens wearers ful with contact lenses.” more than 30 years ago. The optics almost always get daily disposable Dr. Lowe suggests getting into and comfort have improved consid- lenses to start them off on the path the habit of mentioning multifocal erably, and there are lens choices to of better compliance,” he says. contact lenses as a viable option for fit every lifestyle, she says. “Doctors Once they move to a multifocal, every potential presbyopic patient. need to stay educated on the latest daily disposable lenses give patients

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Partially supported by Administered by: unrestricted educational grants from: Sun Pharmaceuticals *Approval pending Bausch & Lomb Carl Zeiss Meditec Review Education Group partners with Salus University for those ODs who are licensed in states that require Alcon university credit. See www.reviewsce.com/events for any meeting schedule changes or updates. 43rd Annual Contact Lens Report Multifocals

the flexibility to choose part-time However, if a presbyopic patient and maintenance of the lenses they wear if they want and still remain in interested in multifocals is already wear. “A well-trained contact lens an ideal modality. wearing GP lenses, offer them an technician can educate and train the However, if the patient is already option in that type, Dr. Geffen says. patient efficiently and effectively,” in a monthly lens and comfortable “Most of my patients do not want she adds. with the material, Dr. Ensley will to go with GPs if they have never start with that brand’s multifocal. If worn lenses, so most start with Common Apprehensions that brand is unsuccessful, he will soft,” he notes. “If I cannot satisfy Despite better lens materials and switch to another brand with a dif- their visual need then we try GPs.” designs, many patients still struggle ferent optical design. Dr. Geffen also finds that the older with multifocal lens wear. One Soft vs. GP. A key decision patients have somewhat reduced study found 15% of presbyopic involves whether to use soft or gas corneal sensitivity, and often do well patients permanently discontinued permeable (GP) multifocal lenses. with GP multifocals. contact lens wear, reporting poor Each modality brings benefits to the Fitting. The entire multifocal vision (38%), discomfort (34%), table, the experts say. process requires a higher level of convenience (20%) and cost Soft lenses offer good initial com- commitment from both the patient (6%) as the primary reasons for fort, and the daily disposable lenses and optometrist. Before she begins a discontinuation.7 are a excellent option for the occa- new fit, Dr. Pal provides her patient Patients lost to contact lens wear sional or social wearer, according to with all of the details of the process: had a worse overall opinion of their Dr. Lowe. the time commitment, the length of distance, intermediate and near However, “rigid multifocal lens the visits, vision expectations and vision compared with subjects still options are great for more custom- costs. If, for any reason, the patient wearing their contact lenses.7 If ized designs to give the patient does not want to proceed because you address these three issues, you better clarity, especially by having one or more of the topics do not can ease your patients’ concerns options in translating designs vs. the resonate with them, her team knows and boost your multifocal fitting simultaneous vision of soft lenses,” prior to starting the fit. success: she adds. “If you properly prepare your Comfort. Presbyopes are a unique A patient’s prescription will patients with more information, group of contact lens wearers with ultimately determine whether they they are more likely to be on board distinct visual demands compared qualify for a standard soft multifo- with your directions and comply with non-presbyopic patients. But cal lens or a custom GP multifocal because they made an informed good vision must be paired with lens, Dr. Woo says. “Soft lenses decision to proceed,” Dr. Pal says. comfort, too. One study found that are easier to fit, easier to stock in “At the initial exam we find a presbyopes of all refractive errors office and require less chair time, so pair of lenses that are comfort- prefer contact lens correction when patients can leave wearing them, but able and perform well visually in they can achieve both good vision they can offer less precise vision and the office, Dr. Ensley says. “Then and comfort.4 more limited parameters,” she notes. we send the patient out in the real “Patients might ask about cost, A more customizable GP lens can world to try the lenses.” help patients with higher prescrip- Dr. Ensley then follows up tions but requires more chair time one to three weeks later to and a delay for ordering. “GPs are troubleshoot, if needed. also associated with higher fitting Staff, especially fees and cost,” Dr. Woo adds. contact lens technicians, Dr. Ensley finds that patients well educated in fitting pursuing a GP lens option need to multifocals and aware of understand comfort requires an the options can contribute adaptation period, but motivated to a successful fit, patients will do quite well. “GP according to Dr. Lowe. lenses also correct astigmatism of She believes that another 0.75D or more much better than key factor is having the Consider GP multifocal lens options for more soft multifocals,” he explains. patient know proper care customized designs that give better clarity.

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but if they are happy with com- Pushing Forward fort and vision, I seldom have Multifocal lens designs are patients go back to single vision improving by the day, but they on the basis of cost alone,”says aren’t perfect. Optometrists look Dr. Ensley. forward to new soft lenses that “We connect comfort with improve upon the visual quality of compliance,” Dr. Geffen says. today’s options. To make sure his patients are as “Decentered optics and variable comfortable as possible in their zone sizes can certainly improve lenses, he focuses on the impor- the visual quality of a multifocal tance of hygiene and follow-up lens,” Dr. Ensley says. “Currently care in the initial fitting visits. these can only be adjusted in cus- Discomfort remains the main tom lenses.” factor contributing to contact lens A presbyopic patient may not take on lens wear Dr. Pal also believes that discontinuation in all age groups, as easily as a patient who started wearing more customization could be but if you address it at the outset, lenses in adolescence. cost effective, especially when the hope of improved vision can designing a multifocal lens for motivate a contact lens dropout to charge for lenses until the evaluation patients who are unsuccessful with try multifocals again.4 period is finalized. They offer a test traditional methods. Anxiety. Some patients stop drive in contacts for a few minutes Despite the disconnect between wearing contact lenses because of in the office to give patients the presbyopes’ interest in contact lens an unsatisfactory previous experi- chance to experience how good the wear and multifocal contact lens ence, and the thought of trying them lenses have become. prescribing, many optometrists again can be daunting. “A past Awareness. Some patients are not who work with these lenses are failed experience can take all the aware contact lenses are an option optimistic regarding the modality’s motivation out of going down a fit- for them. “Some do not realize these future. ting path again,” Dr. Lowe says. lenses even exist, and others were “As the products continue to For others, wearing contact lenses told by prior doctors these lenses improve and the optics become is a new experience and they are do not work,” Dr. Geffen says. “I more crisp, I’m excited about being resistant because they don’t under- let them know my vast experience able to help more of our patients,” stand or are nervous about them, in using these lenses and my high Dr. Pal says. according to Dr. Pal. “Fear of put- success rate.” “We are seeing a great deal of ting lenses in and taking them out is It’s the OD’s job to educate research in the area of multifo- the primary reason,” she says. patients on their many vision correc- cals,” Dr. Geffen says. “I truly “Some new wearers really strug- tion options, and leaving multifocal believe that multifocal lenses are gle with contact lens handling and contact lenses off the list isn’t an best for most of our patients, and are not as patient as kids and young option, according to Dr. Pal. this positive attitude pervades our adults,” Dr. Ensley adds. “If a practitioner doesn’t fit mul- entire office.” ■ Perhaps the best way to quell a tifocal lenses, they should still edu- 1. Fricke TR, Tahhan N, Resnikoff S, et al. Global prevalence patient’s anxiety—whether new to cate patients on multifocals being of presbyopia and vision impairment from uncorrected pres- contact lenses or returning to the a source of vision correction, and byopia. Ophthalmology. 2018;125(10):1492-9. 2. Wolffsohn JS, Davies LN. Presbyopia: effectiveness of cor- modality—is to take the pressure then refer them to an optometrist rection strategies. Prog Retin Eye Res. 2019;68(1):124-43. off of contact lens wear being a full- who does multifocal lens fittings,” 3. Morgan PB, Efron N, Woods CA. An international survey of contact lens prescribing for presbyopia. Clin Exp Optom. time commitment at that moment. Dr. Woo advises. 2011;94(1):87-92. “Worst-case scenario, they don’t “If I were a patient and my 4. Rueff EM, Bailey MD. Presbyopic and non-presbyopic contact lens opinions and vision correction preferences. Cont work for you, and you are just back doctor did not educate me on all Lens Anterior Eye. 2017;40(5):323-8. to what you are doing now,”says of my options, and I found out 5. Plews L. Older americans in the workforce. United Income. unitedincome.com/documents/papers/United_Income_ Dr. Woo. there were other options, I would Older_Americans_in_the_Workforce.pdf. Accessed July 8, Dr. Geffen tells his patients that be upset and possibly not trust that 2019. 6. McDonnell PJ, Lee P, Spritzer K, et al. Associations of pres- there is no risk in trying the lenses, doctor in having my best interest,” byopia with vision-targeted health-related quality of life. Arch as his practice’s policy is to not she adds. Ophthalmol. 2003;121:1577-81.

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062_ro0819_F7_DeLeon.indd 66 8/7/19 5:22 PM Earn up to 12 CE 11th Annual Credits* OPTOMETRIC GLAUCOMA SYMPOSIUM Join our faculty of renowned ODs and MDs for a highly interactive meeting covering the most up-to-date information in glaucoma care. Earn up to 12 CE credits* for only $275. PROGRAM CO-CHAIRS

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43rd Annual Contact Lens Report

THE DANGERS AND THE DIAGNOSIS OF CLMK Despite many advances, the threat of contact lens-related microbial keratitis has not retreated. By Jaya Sowjanya Siddireddy, PhD

icrobial keratitis (MK) wear over the last decade has caused wearers worldwide, the morbid- is a rare and acute a dramatic rise in the prevalence of ity due to corneal ulcer has public corneal disease that contact lens-related microbial kera- health consequences.11 can lead to severe titis (CLMK).2-7 Prognosis of this Mvisual disability.1 The severity of the infectious disease is usually poor if Epidemiology infection depends on the underly- aggressive and appropriate therapy is The incidence of CLMK is two to ing condition of the cornea and not initiated promptly.2,8,9 four per 10,000 contact lens wearers the pathogenicity of the microbe. Contact lens wear has been per year for daily soft contact lens Although it used to occur mostly identified as one of the major risk wearers and 20 per 10,000 for over- with predisposing factors such as factors for MK, affecting almost night soft contact lens wearers.11-15 ocular trauma and ocular surface five in 10,000 wearers.10 Because of Despite the advent of silicone diseases, an increase in contact lens the massive number of contact lens hydrogel lenses that reduce the

Release Date: August 15, 2019 Institute for Medicine and Review Education Group. Postgraduate Expiration Date: August 15, 2022 Institute for Medicine is jointly accredited by the Accreditation Council Estimated Time to Complete Activity: 2 hours for Continuing Medical Education, the Accreditation Council for Jointly provided by Postgraduate Institute for Pharmacy Education, and the American Nurses Credentialing Center, Medicine (PIM) and Review Education Group to provide continuing education for the healthcare team. Postgraduate Institute for Medicine is accredited by COPE to provide continuing Educational Objectives: After completing this activity, the participant should be better able to: education to optometrists. • Discuss the incidence and types of MK, including bacterial, fungal Faculty/Editorial Board: Jaya Sowjanya Siddireddy, PhD, School of and Acanthamoeba infections. Optometry and Vision Science, University of New South Wales • Identify the many modifiable and non-modifiable risk factors Credit Statement: This course is COPE approved for 2 hours of CE associated with CLMK. credit. Course ID is 63763-CL. Check with your local state licens- • Provide prompt and correct diagnosis of MK, followed by effective ing board to see if this counts toward your CE requirement for pharmaceutical therapy or corneal procedure. relicensure. • Educate patients about proper contact lens wear, lens replace- Disclosure Statements: ment, and cleaning and disinfecting lenses and cases. Target Audience: This activity is intended for optometrists engaged Dr. Siddireddy has nothing to disclose. in the care of patients with contact lens-related microbial keratitis. Managers and Editorial Staff: The PIM planners and managers have Accreditation Statement: In support of improving patient care, this nothing to disclose. The Review Education Group planners, managers activity has been planned and implemented by the Postgraduate and editorial staff have nothing to disclose.

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068_ro0819_F8_Siddireddy_CE.indd 68 8/7/19 5:47 PM OPTOMETRIC STUDY CENTER Photo: Christine W. Sindt, OD hypoxic stress to the cornea, espe- infiltrates to severe MK.37 cially during overnight wear, the Sterile keratitis is 200 times risk for CLMK has not decreased.16 more prevalent than MK.38 Although daily disposable contact The most prominent lenses reduce the risk of corneal infil- contact lens-related risk trative events and severe MK, epide- factor for corneal infiltra- miological studies have not shown a tive events is extended or reduced incidence of MK with daily overnight lens wear.13,39-42 disposable contact lenses.11,17-19 Of all Research reports an nnnual the lens types, use of gas permeable incidence for severe kerati- lenses on a daily wear schedule have tis for overnight lens wear the lowest incidence of MK. at 96.4 per 10,000 wear- Bacteria, especially Pseudomo- ers compared with 6.4 per Serratia marcescens (as well as P. aeruginosa and S. nas species, are the most common 10,000 daily lens wearers.42 aureus) can form biofilms on contact lenses that are pathogens involved in MK, while far This suggests an 8.4-fold resistant to contact lens disinfecting solutions. fewer—but more severe—infections increase in risk for develop- are caused by Acanthamoeba and ing corneal keratitis due to overnight of pathogenic levels of bacteria to fungi.20-23 lens wear. initiate MK.47 In contact lens wear, The incidence of contact lens-relat- Evidence also suggests a higher hypoxic conditions may increase ed Acanthamoeba keratitis is one to rate of contact lens contamination bacterial binding, compromising five per one million soft contact lens with corresponding increases risk corneal integrity and impairing wearers in Europe and the United for corneal infiltrative events in lens wound healing.11,45,48 Ocular bio- States.24 Epidemiological studies wearers with two or more years of chemistry changes underneath the have confirmed the use of non-sterile experience compared with neophytes contact lens can also predispose water to clean or store contact lenses or those with less than two years of the lens wearer to infection.44 Inter- and showering or swimming while lens wear experience.11,18,19,41,43 action with the contact lens can wearing contact lenses as risk factors Showering with contact lenses or override the cornea’s defense mecha- for contact lens-related Acantham- rinsing contact lenses with tap water nisms and increase the rate at which oeba keratitis.25-29 Acanthamoeba is associated with an increased risk the microbes adhere to the ocular keratitis has also been linked to both of contact lens-related corneal infil- surface, leading to MK.44,48,49 The domestic and surface water contami- trative events.40 Most contact lens rate of progression of MK depends nation.25,30,31 disease-causing pathogens are water- on the virulence of the offending Fungal keratitis is rare in contact borne, so water exposure during lens pathogen and host factors.50 lens wearers, typically accounting for wear is a serious concern. Formation of biofilm on lenses about 5% of all CLMK.20 Fusarium and storage cases. Contact lenses are is a filamentous fungus mainly found Pathophysiology a fertile surface for bacterial adhe- in soil and plants.32 Outbreaks of Research to understand the mecha- sion and biofilm formation.44,48,49 contact lens-related Fusarium kera- nisms of ulceration is ongoing.44 As such, adhesion of bacteria—par- titis were reported between 2006 Several factors play a crucial role in ticularly Staphylococcus epidermis and 2007, primarily associated with contact lens-related keratitis: and P. aeruginosa—to contact lenses a specific contact lens disinfection Bacterial adherence to the lens is a major risk factor.44,49 Contact solution (ReNu with MoistureLoc, surface and reduced resistance of lens cases are associated with more Bausch + Lomb).33,34 Researchers the cornea to infection. In bacte- contamination than lenses or lens reported that 60% (10/15) of those rial keratitis, bacteria gain access care solutions.48,51 Notably, the same with the disease used water to clean to the corneal stroma through an strains found in corneal ulcers have contact lens storage cases.35 Follow- abnormality or defect in the corneal been isolated from contact lens ing the withdrawal of this disinfec- surface causing an inflammatory cases.51 The level of contamination tion solution from the market, the response, which results in loss of rate is associated with the age of the rates of disease returned to pre-out- transparency.45,46 First, penetration lens case.11 The upper rim of the lens break levels.36 of corneal epithelium (more severe case is ideal to harbor gram-negative Corneal infiltrative events range than punctate fluorescein staining) bacteria due to its air-liquid interface, from mild asymptomatic corneal needs to take place in the presence increasing the likelihood of biofilm

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formation.51 Contact with this area corneal surface may initiate inflam- contact lens case, care solutions and during lens handling can severely mation.57-61 Also, tear exchange the patient’s hands are contaminated contaminate the lens.51 is drastically reduced in soft con- with these pathogens, the risk of Resistance of microorganisms to tact lens wear.44,45,62 Although the developing MK increases. disinfecting systems. Not perform- impact of tear exchange is not Modifiable risk factors. Several ing the “rub and rinse” cleaning completely understood, the mean modifiable risk factors for MK and technique curtails the removal of tear elimination rate is 50% less corneal inflammatory events are microbes and creates a carryover in eyes wearing conventional con- associated with poor compliance. effect from lens case to lenses, lead- tact lenses compared with eyes of Modifiable risk factors are those that ing to an increase in microbial viru- non-lens wearers.44,48 Incidentally, a lens wearer has some control over, lence and survival rate.44,48,51 silicone hydrogels provide better tear as opposed to non-modifiable factors Stagnation of tear film behind exchange than conventional lenses.62 such as age and sex. contact lenses. The presence of Ocular surfaces of contact lens The major modifiable risk factors debris, toxins and antigens trapped wearers, compared with non-lens identified in epidemiological studies between the contact lens and cor- wearers, harbor greater numbers of of CLMK are overnight wear and neal surface, and their prolonged gram-negative bacteria and fewer poor hygiene, including omission of exposure, can increase the risk of numbers of gram-positive bacte- or infrequent lens disinfection, omit- infection.52 This could be the reason ria.63,64 Clinicians should consider ted or infrequent lens case cleaning, for lower CLMK risk with rigid this evidence and provide adequate omission of handwashing before gas permeable lenses, due to higher prophylactic antibiotic treatment handling lenses and smoking.11,13,75-78 post-lens tear exchange, compared against gram-negative organisms, Research estimates that overnight with soft contact lenses.14,53-56 In especially P. aeruginosa, which is the wear and poor hygiene account for addition, epithelial cell proliferation most prevalent gram-negative patho- about 43% and 33% of attributable and migration are slower in con- gen in CLMK.63,64 risk for developing CLMK.79 tact lens wearers, so epithelial cells Gram-positive bacteria are the Sleeping in contact lenses is anoth- that reside for a longer time on the most common organisms in CLMK, er commonly reported contact lens

Photo: Danielle M. Robertson, OD, PhD especially in temperate climates.10,65 risk behavior and one with a high These organisms include coagulase- relative risk for corneal infection.53,80 negative Staphylococcus (including S. Research shows sleeping in lenses is a epidermidis), S. aureus and Strepto- risk factor regardless of lens material coccus pneumoniae. Coagulase-neg- and frequency, with even occasional ative Staphylococcus is found on the overnight use conferring risk.77 lid margins and is considered normal In severe keratitis, contact lens flora, but it can become infectious in case hygiene (cleaning and replace- some instances.66 ment) accounts for 63% of the P. aeruginosa, S. aureus, and Ser- population-attributable risk. In addi- ratia marcescens can form biofilms tion, swimming is a risk factor for on contact lenses that are resistant to Acanthamoeba keratitis, and travel environmental challenges and con- is a risk for severe infection, thought tact lens solutions.67-69 P. aeruginosa to be related to disruption of rou- and S. epidermidis are also found to tine.25,65,81,82 adhere and replicate on contact lens- The risk of infection in extended es in vitro, on both silicone hydrogel wear is higher with increased wear- and regular hydrogel materials.70 ing time and less experience.11,53,55,83 The microbes that are isolated Wearers considering extended wear from contact lenses originate from should be motivated and aware of Staining of a contact lens storage case the lid margins, conjunctiva, hands, this increased risk; however, it is shows the correlation between age and lens cases, care solutions and the important to balance the risk with the level of microbial contamination. water supply.71-74 Pathogenic organ- other lifestyle risks. Some individu- Staining was evident as early as six isms are associated with MK, so it als, such as shift workers and those months and showed a dramatic increase is reasonable to assume that if the with busy lifestyles, may feel the con- in intensity beyond nine months. lid margins, conjunctiva, tear film, venience of extended wear outweighs

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068_ro0819_F8_Siddireddy_CE.indd 70 8/7/19 5:47 PM the increased risk. Water and Contact Lenses Don’t Mix neal melting and perforation.92 Despite a higher unadjusted Water exposure during contact lens wear is associated Hallmark signs are corneal incidence rate for daily use with multiple complications ranging from sterile corneal edema, a ring abscess (defined of silicone hydrogel contact infiltrates to more severe sight-threatening infections. Clear, as a circular infiltrate with a lenses compared with hydrogel unequivocal guidelines/recommendations to avoid all water less dense center) associated contact lens use, multivariate exposure—including handling contact lenses with wet with larger lesions and presence analyses have not identified hands, rinsing/storing contact lenses or storage cases in tap of hypopyon.93 lens material as an indepen- water, and showering with contact lenses—are needed.133 Acanthamoeba keratitis. dent risk factor.11,53 Swimming with contact lenses should be done with protective Subtle corneal signs with or Non-modifiable risk fac- goggles or using daily disposable contact lenses, which can without symptoms of pain can tors. Non-modifiable risk fac- be discarded immediately after swimming. Active dissemi- be found in early infection.94 tors include younger age, male nation of these guidelines to contact lens wearers through The early signs include an epi- gender and socioeconomic all stakeholders—including contact lens manufacturers, theliopathy with or without a class.53,56,78 Systemic risk fac- professional organizations, and contact lens practitioners—is dendritic appearance. Infiltrates tors include self-reported poor recommended.133 running along the nerves from general health, diabetes and the periphery (perineural infil- thyroid disease.83,84 trates) are virtually pathologic More recently, an increased expo- aware of the risks or understanding for Acanthamoeba keratitis, occur- sure (number of days of wear per the consequences of non-compliance ring in around 60% of cases.94,95 In week) in daily wear, hypermetropia, are likely to be key factors among later stages of infection, the involve- obtaining lenses via the internet or some lens wearers. ment of central stromal infiltration mail order and the early period of occurs in around 20% of cases.94 lens wear have been identified as Diagnosis Scleritis occurs in 15% to 20% of additional risk factors with contem- Bacterial keratitis. A substan- cases.94 If scleritis develops, patients porary lens types.11,53 Males tend to tial inflammatory response along often report severe, persistent pain.94 be more prone to complications in with replicating necrotic cells and Early diagnosis and prompt, appro- contact lenses, which may be due to microbes form infiltrates that are priate medical attention improves increased non-compliance and also a mostly irregular and focal, sur- the prognosis of disease. A delay in reluctance to seek care.85,86 rounded by diffuse inflammation and effective therapy for more than three Genetic differences in contact lens edema of the cornea.22,91 It is unusual weeks will likely worsen the progno- wearers can affect the susceptibil- to find a bacterial keratitis with no sis.96,97 ity and severity of keratitis. Small apparent focal epithelial defect.22,91 Fungal keratitis. Fungi are oppor- mutations (single nucleotide poly- In some cases, a focal infiltrate can tunistic organisms that do not infect morphisms) of interleukins, inflam- be absent and an epithelial defect a healthy cornea. However, after matory mediators and defensin (an or melting stromal keratitis may be trauma and inoculation, fungi can antimicrobial peptide) have been iso- the only signs of infection.22,91 Due proliferate, leading to tissue damage lated as contributory.87-89 This may to inflammation of the surrounding and the disruption of host defenses.98 mean some people have a degree of cornea, causing scattering of light Fungi secrete toxins, such as prote- innate protection against infection and photophobia, vision can be ases, that aid tissue destruction and and inflammation when wearing affected even if the lesion is not cen- allow the fungi to penetrate deep contact lenses, but this protection tral. Other signs such as lid swelling, into the cornea. The fungal hyphae is much lower than the risk of poor conjunctival chemosis and anterior and pseudohyphae both form large hygiene and overnight wear. chamber reaction are common in structures that cannot be fully ingest- While research shows that bacterial keratitis.91 ed by polymorphonuclear leukocytes risk-taking personality styles are P. aeruginosa is difficult to neu- and macrophages. Activation of resi- associated with non-compliance tralize due to its virulent structure, dent corneal cells and host inflamma- in contact lens wearers, no studies adaptability and high rate of survival tory cells that attempt to neutralize indicate whether risk taking is associ- under various conditions.44,45 Along the invading organisms adds to the ated with a susceptibility to corneal with intense immune response, P. tissue destruction.98 inflammation and infections.90 aeruginosa also produces enzymes The fungal species that cause kera- There are likely to be many drivers such as protease and elastase, which titis are the yeast, Candida sp., and for non-compliance, and not being digest collagen, contributing to cor- filamentary fungi such as Aspergillus

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0068_ro0819_F8_Siddireddy_CE.indd68_ro0819_F8_Siddireddy_CE.indd 7171 88/7/19/7/19 5:485:48 PMPM OPTOMETRIC STUDY CENTER Photo: Aaron Bronner, OD and overlying defects, but isms. These samples are then taken unlike most bacterial infec- for culture or molecular testing using tions, the onset of yeast-like polymerase chain reaction.66 Culture infections tends to be slow.102 results are available usually within The common features of fungal two to seven days.66 Fungi typically keratitis cases are serrated ulcer take longer than bacteria to grow. margins with raised slough and Drug sensitivity testing is per- a dry textured infiltrate that formed from the cultured organisms, is usually white or gray (not which is important to guide therapy yellow) and satellite lesions.103 in nonresponsive cases.66 If antibiot- Immune rings (ring infiltrates/ ics have been started in nonrespon- Wesley rings) are not pathog- sive cases, the treatment is stopped Differentiating the clinical signs of fungal nomonic for fungal keratitis for 24 hours to maximize the chance keratitis (seen here) from more common and can occur in other forms of organism recovery.22 bacterial ulcers can be difficult, especially with of keratitis, including those Corneal biopsy can be useful for yeast fungi such as Candida. caused by Acanthamoeba and recalcitrant cases.22 The biopsy is bacteria.94,103 deeper than a corneal scrape and sp. and Fusarium sp. Contact lens Other corneal inflammatory can be done freehand or with a tre- use and trauma are mainly associated events, such as infiltrative keratitis phine. This is particularly useful in with the filamentary fungi, while driven by microbial products and fungal keratitis as filamentary fungi ocular surface disease is commonly presumed hypersensitivity reactions, may proliferate in the deeper corneal caused by Candida sp.99 typically present with a non-specific layers, so surface scrapes may not Research recently shows micro- inflammatory response that can be capture the organism. Typically for sporidia is a parasitic fungus causes local or general.37 Sometimes these a biopsy, half the material is sent for keratoconjunctivitis. It has been can mimic the immune corneal microbial culture while the other half found in contact lens wearers, but response seen later in the course of is sent to histology for tissue process- is usually associated with soil/mud adenoviral keratoconjunctivitis.104 ing.22 Culture tends to be positive and occurs in immunocompromised Careful history of the redness and in around 50% of cases of clinically patients.100 symptoms, as well as the swelling of presumed bacterial keratitis and Differential diagnosis. Distin- the lymph glands and the more dif- slightly higher for Acanthamoeba.22 guishing between Acanthamoeba fuse, fluffy pattern of the infiltrates keratitis and herpes simplex virus that are seen in viral conditions, will Management (HSV) stromal keratitis can be dif- aid diagnosis.100 The goal of treatment is to rapidly ficult in the early stages, and around In localized sterile inflammation of eradicate the pathogen, so clinicians 50% of Acanthamoeba keratitis the cornea, such as marginal keratitis should assume CLMK is bacterial cases are misdiagnosed as HSV and contact lens-related peripheral unless proven otherwise.106-108 The keratitis.101 Epitheliopathy, pseudo- ulcer, the redness is usually sectorial gold standard treatment for corneal dendrites and stromal inflammation corresponding to the corneal lesion ulceration is fortified antibiotics, in Acanthamoeba keratitis are often and associated with lower pain, a such as cefazolin 5% and tobramy- confused with HSV stromal keratitis. staining diameter greater than the cin 1.3%, or fourth-generation fluo- These cases are then treated using infiltrate diameter (generally <1mm), roquinolones (either ciprofloxacin or corticosteroids. However, use of cor- and possibly a mild anterior chamber ofloxacin) as monotherapy.109,110 ticosteroids before the initiation of reaction. However, a case of infec- Research has observed an alarm- anti-amoebic drugs is independently tion shows diffuse and more intense ing trend of increased resistance associated with a four-fold increased redness. In moderate/severe infection, to antibiotics over the past two risk of poorer outcomes.101 the redness is deeper and the lid as decades.111-113 Pathogenic strains Differential diagnosis of the well as anterior chamber are likely to such as methicillin-resistant S. aureus clinical signs of fungal keratitis from be involved.105 (MRSA) and methicillin-resistant S. more common bacterial ulcers can be Diagnostic techniques. In cases of epidermidis (MRSE) are becoming difficult, especially with yeast fungi suspected MK, corneal scraping is more prevalent, and many strains such as Candida. Yeast infections usually the first step to collect sam- show multidrug resistance, including tend to present as discrete infiltrates ples containing the causative organ- resistance to both earlier and current

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068_ro0819_F8_Siddireddy_CE.indd 72 8/7/19 5:48 PM generation fluoroquinolones. pharmacy. The combination is often for use in the United States but case The most recent addition to a cephalosporin for gram positive series have shown good evidence that topical ocular fluoroquinolones is coverage, such as cephazolin, and an they are effective in vivo.118 Besivance (besifloxacin 0.6% oph- aminoglycoside for gram negative Fungal keratitis. This is often thalmic suspension, Bausch + Lomb), activity, either tobramycin or gen- highly invasive, and antifungal agents which decreases resistance due to its tamicin. A randomized clinical trial tend to be fungistatic, leading to unique molecular structure with an conducted in Australia revealed that prolonged treatment and often surgi- increased antibacterial potency.114 monotherapy with ofloxacin 0.3% cal intervention.119 Natamycin 5% Bacterial keratitis. Use of topical and moxifloxacin 1% had similar is usually the initial agent of choice. antibiotics is the standard treatment efficacy and safety compared with The Mycotic Ulcer Treatment Trial for most CLMK. For mild to moder- fortified tobramycin 1.33% and cep- Phase 1 (MUTT I) found natamycin ate cases, empirical therapy using a hazolin 5% antibiotics.116 to be more effective than voricon- broad spectrum fluoroquinolone is In many cases, topical steroids are azole for filamentary fungus, such generally employed.22 Ciprofloxa- used in the management of bacte- as Fusarium and Aspergillus.119,120 cin and ofloxacin are the mainstay rial keratitis in an attempt to limit Also, MUTT II demonstrated that fluoroquinolone antibiotics. The scarring as a lot of the damage in the addition of oral voriconazole to therapeutic regimen for bacterial keratitis occurs due to the inflam- topical natamycin does not improve keratitis includes use of a cycloplegic matory response. Topical steroids outcomes.121 Oral voriconazole can agent and frequent use of ciprofloxa- also decrease pain and may improve also be prescribed for deep fungal cin 0.3% antibiotic drops every 15 quality of life. A typical regimen ulcers and scleritis, although patients minutes for four hours, followed by introduces steroids once the ulcer commonly suffer from visual dis- every 30 minutes for four hours, and begins to re-epithelialize, which is an turbances and will also require liver then every hour around the clock for indication that the antibiotic therapy function tests.122 at least 24 hours. Depending on the is effective. Anti-fungals are less effective in severity of the ulcer and the clinical Tapering steroids is essential to deeper layers of the cornea. In early response, ciprofloxacin ointment avoid a rebound effect. The schedule phases, rapid progression of fungal can be substituted for the drops at of steroids, concurrent with antibi- keratitis is due to factors relating to a lower frequency during the night otics, might be QID for one week, organisms such as large fungal inocu- after one to two days of therapy. In BID for one week, QD for one week, lum. In later stages, the combination a severe ulcer, one to two weeks of and then cease. The main concerns of agent and host factors lead to therapy may be required for a com- for using topical corticosteroids in resistance to anti-fungals.99 plete therapeutic response.115 bacterial keratitis are delayed re epi- Chlorhexidine, an antiseptic for The first period is the sterilization thelialization, recurrent infection and treating Acanthamoeba keratitis, phase where the organism is neutral- increased risk of perforation.8 can be used as an alternative to ized, followed by the healing phase.22 Acanthamoeba keratitis. There natamycin.121,123 For yeast infections, The sterilization phase usually takes are no currently Photos: Aaron Bronner, OD three to five days. Often a dilating approved medications agent is used to relax the ciliary body for treating Acantham- and prevent ciliary spasm, stabilize oeba keratitis. However, the blood aqueous barrier and to biguanides (polyhexa- help prevent posterior synechiae. methylene biguanide Review is recommended within 24 0.02% to 0.06% and hours with daily follow-up until chlorhexidine 0.02% improvement is clearly established. to 0.2%) and diami- In a few days, the eye may be more dines (propamidine inflamed due to an inflammatory isethionate 0.1% and response to dead organisms, but it hexamidine 0.1%) is important that there is not a dra- are the most effective matic deterioration in status.22 cysticidal agents for Some centers tend to treat severe cases of Acanthamoeba A staphylococcal ulcer typically appears as a discrete cases with fortified antibiotics that keratitis.117 None of the infiltrate with well-defined borders and often are compounded by an accredited treatments are licensed surrounding edema.

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such as Candida, which is more hand washing, and internet purchase tact lenses, lens care products, dry common in patients with a history of lenses.49,51,130,131 Non-compliance eye and microbiology at the School of ocular surface disease and in with manufacturers’ recommended of Optometry and Vision Science, immunosuppressed patients, topical frequency of replacement of contact University of New South Wales. amphotericin B is recommended.119 lenses is found to be highest among 1. McLeod SD, LaBree LD, Tayyanipour R, et al. The importance of initial Echinocandins (such as caspofungin teenagers and wearers of non-silicone management in the treatment of severe infectious corneal ulcers. Oph- 119 130 thalmology. 1995;102(12):1943-8. and micafungin) can be added. hydrogel lenses. 2. McLeod SD, Kolahdouz-Isfahani A, Rostamian K, et al. The role of Some evidence suggests that fluoro- Contact lens wearers using hydro- smears, cultures, and antibiotic sensitivity testing in the management of suspected infectious keratitis. Ophthalmology. 1996;103(1):23-8. quinolones may be synergistic with gen peroxide solution may be more 3. Benson WH, Lanier JD. Current diagnosis and treatment of corneal 124 ulcers. Curr Opin Ophthalmol. 1998;9(4):45-9. amphotericin. Often multiple compliant with their lens replace- 4. Musch DC, Sugar A, Meyer RF. Demographic and predisposing factors agents are used to offer maximum ment schedule due to the complex in corneal ulceration. Arch Ophthalmol. 1983;101(10):1545-8. 5. Dart JK. Predisposing factors in microbial keratitis: the significance of coverage.119 and demanding care regimen.130 contact lens wear. Br J Ophthalmol. 1988;72(12):926-30. 6. Liesegang TJ. Contact lens-related microbial keratitis: Part I: Epidemi- Topical steroids should not be Daily disposable lenses were associ- ology. Cornea. 1997;16(2):125-31. 7. Schaefer F, Bruttin O, Zografos L, Guex-Crosier Y. Bacterial keratitis: used during the treatment of a ated with lowest rate of complica- a prospective clinical and microbiological study. Br J Ophthalmol. fungal infection. Corticosteroids tions in general.130 Better storage lens 2001;85(7):842-7. 8. Miedziak AI, Miller MR, Rapuano CJ, et al. Risk factors in micro- induce fungal growth by suppress- case designs, frequent replacement of bial keratitis leading to penetrating keratoplasty. Ophthalmology. 125 1999;106(6):1166-70; discussion 1171. ing ocular immune mechanisms. the lens case (at least once in three to 9. Vajpayee RB, Dada T, Saxena R, et al. Study of the first contact man- Topical cyclosporine A, however, six months) and improved hygiene of agement profile of cases of infectious keratitis: a hospital-based study. Cornea. 2000;19(1):52-6. may be synergistic to fungal therapy lens cases may decrease the incidence 10. Bourcier T, Thomas F, Borderie V, et al. Bacterial keratitis: predis- 51 posing factors, clinical and microbiological review of 300 cases. Br J because it inhibits filamentary fungal of corneal ulceration. Ophthalmol. 2003;87(7):834-8. 126,127 11. Stapleton F, Keay L, Edwards K, et al. The incidence of con- growth. Timely diagnosis and treatment tact lens-related microbial keratitis in Australia. Ophthalmology. Therapeutic penetrating kera- are of paramount importance as 2008;115(10):1655-62. 12. Poggio EC, Glynn RJ, Schein OD, et al. The incidence of ulcerative toplasty. In severe cases of corneal early treatment can limit the scar- keratitis among users of daily-wear and extended-wear soft contact lenses. N Engl J Med. 1989;321(12):779-83. infection, therapeutic penetrating ring and vision loss caused by 13. Lam DS, Houang E, Fan DS, et al. Incidence and risk factors for keratoplasty can be considered to CLMK.46,106,109,132 Treatment delayed microbial keratitis in Hong Kong: comparison with Europe and North America. Eye (Lond). 2002;16(5):608-18. prevent the spread of the pathogen by more than 12 hours increases the 14. Cheng KH, Leung SL, Hoekman HW, et al. Incidence of contact- 48 lens-associated microbial keratitis and its related morbidity. Lancet. to other parts of the eye, especially in risk for vision loss. 1999;354(9174):181-5. 15. Seal DV, Kirkness CM, Bennett HG, et al. Population-based cohort filamentary fungal cases. However, study of microbial keratitis in Scotland: incidence and features. Cont this involves the risk of pathogens Post-marketing surveillance of Lens Anterior Eye. 1999;22(2):49-57. 16. Papas EB, Vajdic CM, Austen R, Holden BA. High-oxygen-transmis- entering the anterior chamber during drugs and devices is important to sibility soft contact lenses do not induce limbal hyperaemia. Curr Eye 128 Res. 1997;16(9):942-8. surgery. Furthermore, corticoste- the health and safety of the general 17. Chalmers RL, Hickson-Curran SB, Keay L, et al. Rates of adverse roids used to limit graft rejection public. Because contact lenses and events with hydrogel and silicone hydrogel daily disposable lenses in a large postmarket surveillance registry: the TEMPO Registry. Invest may exacerbate the growth of fungus accompanying lens care solutions Ophthalmol Vis Sci. 2015;56(1):654-63. 18. Radford CF, Minassian D, Dart JK, et al. Risk factors for nonulcerative that may remain in the eye following are regulated as medical devices by contact lens complications in an ophthalmic accident and emergency 128 department: a case-control study. Ophthalmology. 2009;116(3):385-92. surgery. In Acanthamoeba kerati- the Food and Drug Administration 19. Steele KR, Szczotka-Flynn L. 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Por YM, Mehta JS, Chua JL, et al., Acanthamoeba keratitis associated 70% of contact lens wearers are non- improvements can be made to con- with contact lens wear in Singapore. Am J Ophthalmol. 2009;148(1):7-12. 130 28. Kilvington S, Gray T, Dart J, et al. Acanthamoeba keratitis: the role of compliant. Higher rates of com- tact lenses, care products, manufac- domestic tap water contamination in the United Kingdom. Invest Oph- plications have been associated with turer guidelines, and labelling. ■ thalmol Vis Sci. 2004;45(1):165-9. 29. Butler TK, Males JJ, Robinson LP, et al. Six-year review of Acan- men, teens/young adults, smokers, Dr. Siddireddy is a postdoctoral thamoeba keratitis in New South Wales, Australia: 1997-2002. Clin Exp Ophthalmol. 2005;33(1):41-6. longer periods of lens wear, lack of research fellow specializing in con- 30. Ji WT, Hsu BM, Chang TY, et al. Surveillance and evaluation of the

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Effect of oral voriconazole on fungal keratitis in the mycotic thelial basal cells toward the corneal surface during use of extended-wear 90. Carnt N, Keay L, Willcox M, et al. Higher risk taking propensity of ulcer treatment trial II (MUTT II): a randomized clinical trial. JAMA Oph- contact lenses. Invest Ophthalmol Vis Sci. 2003;44(3):1056-63. contact lens wearers is associated with less compliance. Cont Lens thalmol. 2016;134(12):1365-72. 59. O’Leary DJ, Madgewick R, Wallace J, Ang J. Size and number of Anterior Eye. 2011;34(5):202-6. 122. Zrenner E, Tomaszewski K, Hamlin J, et al. Effects of multiple doses epithelial cells washed from the cornea after contact lens wear. Optom Vis 91. Carnt N, Samarawickrama C, White A, Stapleton F. The diagnosis and of voriconazole on the vision of healthy volunteers: a double-blind, Sci. 1998;75(9):692-6. management of contact lens-related microbial keratitis. Clin Exp Optom. placebo-controlled study. Ophthalmic Res. 2014;52(1):43-52. 60. Ren DH, Petroll WM, Jester JV, et al. The relationship between con- 2017;100(5):482-93. 123. Rahman MR, Minassian DC, Srinivasan M, et al. Trial of tact lens oxygen permeability and binding of Pseudomonas aeruginosa to 92. Willcox MD. Pseudomonas aeruginosa infection and inflammation chlorhexidine gluconate for fungal corneal ulcers. Ophthalmic Epidemiol. human corneal epithelial cells after overnight and extended wear. CLAO during contact lens wear: a review. Optom Vis Sci. 2007;84(4):273-8. 1997;4(3):141-9. J. 1999;25(2):80-100. 93. Oka N, Suzuki T, Ishikawa E, et al. Relationship of virulence factors 124. Stergiopoulou T, Meletiadis J, Sein T, et al. Isobolographic analysis 61. Ladage PM, Yamamoto K, Ren DH, et al. Effects of rigid and soft and clinical features in keratitis caused by Pseudomonas aeruginosa. of pharmacodynamic interactions between antifungal agents and cipro- contact lens daily wear on corneal epithelium, tear lactate dehydrogenase, Invest Ophthalmol Vis Sci. 2015;56(11):6892-8. floxacin against Candida albicans and Aspergillus fumigatus. Antimicrob and bacterial binding to exfoliated epithelial cells. Ophthalmology. 94. Dart JK, Saw VP, Kilvington S. Acanthamoeba keratitis: diagnosis and Agents Chemother. 2008;52(6):2196-204. 2001;108(7):1279-88. treatment update 2009. Am J Ophthalmol. 2009;148(4):487-499.e2. 125. Stern GA, Buttross M. Use of corticosteroids in combination with 62. Paugh JR, Stapleton F, Keay L, Ho A. Tear exchange under hydrogel 95. Robbie SJ, Vega FA, Tint NL, et al. Perineural infiltrates in Pseudo- antimicrobial drugs in the treatment of infectious corneal disease. Oph- contact lenses: methodological considerations. Invest Ophthalmol Vis monas keratitis. J Cataract Refract Surg. 2013;39(11):1764-7. thalmology. 1991;98(6):847-53. Sci. 2001;42(12):2813-20. 96. Claerhout I, Goegebuer A, Van Den Broecke C, Kestelyn P. Delay in 126. Cardenas ME, Cruz MC, Del Poeta M, et al. Antifungal activities of

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antineoplastic agents: Saccharomyces cerevisiae as a model system to 129. Robaei D, Carnt N, Minassian DC, Dart JK. Therapeutic and 2010;81(11):598-607. study drug action. Clin Microbiol Rev. 1999;12(4):583-611. optical keratoplasty in the management of Acanthamoeba keratitis: 131. Chalmers RL, Keay L, Long B, et al. Risk factors for contact lens com- 127. Perry HD, Doshi SJ, Donnenfeld ED, Bai GS. Topical cyclosporin risk factors, outcomes, and summary of the literature. Ophthalmology. plications in US clinical practices. Optom Vis Sci. 2010;87(10):725-35. A in the management of therapeutic keratoplasty for mycotic keratitis. 2015;122(1):17-24. 132. Huerva V, Sanchez MC. Refractive outcome after severe Pseudomo- Cornea. 2002;21(2):161-3. 130. Yeung KK, Forister JF, Forister EF, et al. Compliance with soft nas aeruginosa keratitis. Optom Vis Sci. 2011;88(4):E548-52. 128. Ansari Z, Miller D, Galor A. Current thoughts in fungal keratitis: contact lens replacement schedules and associated contact lens-related 133. Arshad M, Carnt N, Tan J, et al. Water exposure and the risk of diagnosis and treatment. Curr Fungal Infect Rep. 2013;7(3):209-218. ocular complications: The UCLA Contact Lens Study. Optometry. contact lens-related disease. Cornea. 2019;38(6):791-797.

OSC QUIZ

ou can obtain continuing education d. Temperate climatic conditions. a. Epitheliopathy, no dendritic appearance. credit through the Optometric Study b. Hyphae. YCenter. Com plete the test form 6. Contact lens disease-causing pathogens c. Perineural infiltrates. and return it with the $35 fee to: Jobson are: d. Ring abscess. Healthcare Information, LLC, Attn.: CE a. Airborne. Processing, 395 Hudson Street, 3rd Floor b. Waterborne. 14. About 50% of Acanthamoeba keratitis New York, New York 10014. To be eligible, c. Both a and b. cases are misdiagnosed as keratitis due to: please return the card within three years of d. None of the above. a. Propionibacterium. publication. You can also access the test b. Streptococcus. form and submit your answers and pay- 7. Corneal ulceration begins with: c. Pseudomonas. ment via credit card at Review Education a. Loss of corneal transparency. d. Herpes simplex virus. Group online, www.reviewsce.com. b. Slower epithelial cell proliferation and You must achieve a score of 70 or higher migration causing inflammatory response. 15. All of the following are conventional to receive credit. Allow four weeks for pro- c. Pathogenic level of bacteria gaining access diagnostic techniques to identify causative cessing. For each Optomet ric Study Center to the corneal stroma. organisms in MK, except: course you pass, you earn 2 hours of credit d. Penetration of corneal epithelium more a. Corneal biopsy. from Pennsyl vania College of Optometry. severe than punctate staining. b. Histopathological analysis. Please check with your state licensing c. Filter paper technique. board to see if this approval counts toward 8. All of the following are population-attribut- d. Drug sensitivity testing. your CE requirement for relicensure. able risks for CLMK, except: a. Smoking. 16. All of the following are gold standard 1. The incidence of CLMK in daily soft contact b. Poor hand hygiene. treatments for corneal ulceration, except: lens wearers is: c. Omission or infrequent lens disinfection. a. Cefazoline. a. 2 to 4 per 1,000. d. Diabetes. b. Ciprofloxacin. b. 2 to 4 per 10,000. c. Tobramycin. c. 20 to 40 per 10,000. 9. Which of these pathogens is highly difficult d. Amphotericin. d. 20 to 40 per 100,000. to neutralize? a. Propionibacterium. 17. Which of these is a concern for using 2. Which of these lenses have the lowest b. Acanthamoeba. topical corticosteroids in bacterial keratitis? incidence of MK? c. Pseudomonas. a. Re-epithelialization. a. Daily disposables. d. Herpes simplex virus. b. Increased risk of perforation. b. Silicone hydrogels. c. Recurrent infection. c. Gas permeable lenses. 10. Which microbe produces protease and d. All of the above. d. Cosmetic contact lenses. elastase that digests collagen, contributing to corneal melting and perforation? 18. Which reason for contact lens complica- 3. Which of these is a risk factor for MK? a. Propionibacterium. tions is highest among teenagers? a. Washing lens cases with contact lens b. Acanthamoeba. a. Smoking. solutions. c. Pseudomonas. b. Longer periods of lens wear. b. Use of non-sterile tap water to store con- d. Herpes simplex virus. c. Internet purchase of lenses. tact lenses. d. Non-compliance with manufacturers’ rec- c. Swimming while wearing contact lenses. 11. Which of these is a hallmark sign of ommended frequency of lens replacement. d. Both b and c. Pseudomonas aeruginosa keratitis? a. Ring abscess. 19. Active dissemination of clear unequivocal 4. Which MK type is more rare than others? b. Epitheliopathy with dendritic appearance. guidelines to lens wearers should be through: a. Bacterial. c. Perineural infiltrates. a. Contact lens manufactures. b. Fungal. d. Pseudohyphae. b. Contact lens practitioners. c. Acanthamoeba. c. Professional organizations. d. Both b and c. 12. Which of the following is a hallmark sign d. All of the above. of Acanthamoeba keratitis? 5. A 2006-2007 outbreak of contact lens- a. Hypopyon. 20. Contact lenses and accompanying lens related Fusarium keratitis was primarily b. Ring abscess. care solutions are regulated by the FDA as: associated with: c. Perineural infiltrates. a. Medical devices. a. Water exposure. d. Pseudohyphae. b. Drugs. b. Disinfecting solution. c. Cosmetics. c. Non-compliance. 13. Which is a hallmark of fungal keratitis? d. Biologics.

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0068_ro0819_F8_Siddireddy_CE.indd68_ro0819_F8_Siddireddy_CE.indd 7676 88/7/19/7/19 5:495:49 PMPM Mail to: Jobson Healthcare Information, LLC, Attn.: CE Processing, 395 Examination Answer Sheet Hudson Street, 3rd Floor New York, New York 10014 The Dangers and The Diagnosis of CLMK Payment: Remit $35 with this exam. Make check payable to Jobson Healthcare Information, LLC. Valid for credit through August 15, 2022 Credit: This course is COPE approved for 2 hours of CE credit. Course ID is Online: This exam can be taken online at www.reviewsce.com. Upon passing the 63763-CL. exam, you can view your results immediately and download a real-time CE certifi- Jointly provided by Postgraduate Institute for Medicine and Review Education cate. 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 1 2 3 4 5 4. A B C D 21. Discuss the incidence and types of MK, including bacterial, fungal and Acanthamoeba infections.

5. A B C D 22. Identify the many modifiable and non-modifiable risk factors associated with contact lens-related 1 2 3 4 5 6. A B C D microbial keratitis.

7. A B C D 23. Provide prompt and correct diagnosis of MK, followed by effective pharmaceutical therapy or corneal 1 2 3 4 5 8. A B C D procedure.

9. A B C D 24. Educate patients about proper contact lens wear, lens replacement, and cleaning and disinfecting lenses 1 2 3 4 5 10. A B C D and cases. 11. A B C D 25. Based upon your participation in this activity, do you intend to change your practice behavior? 12. A B C D (choose only one of the following options) 13. A B C D A I do plan to implement changes in my practice based on the information presented. 14. A B C D B My current practice has been reinforced by the information presented. C 15. A B C D I need more information before I will change my practice.

16. A B C D

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

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

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 118583 RO-OSC-0819

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0068_ro0819_F8_Siddireddy_CE.indd68_ro0819_F8_Siddireddy_CE.indd 7777 88/7/19/7/19 6:136:13 PMPM Ocular Surface Review

Disinfect the Natural Way New hypochlorous acid options are making this a viable antimicrobial solution. Here’s how to choose—and use—it correctly. By Paul M. Karpecki, OD

ypochlorous acid (HOCl) ing a short course of a topical has a multitude of uses antibiotic-corticosteroid to keep Hin wound care, dermatol- the bacterial levels at bay.8,9 ogy, dentistry and eye care. It is the most common disinfectant in medi- Protect the Microbiome, cal, industrial and domestic use, Prevent Resistance and has the same active ingredient Our bodies are home to a diverse of household bleach but with a dif- microbiome, and eyes are no ferent chemical structure.1 Bleach, exception. Some bacteria, fungi or sodium hydroxide, is typically and viruses may protect against found in concentrations that range harmful pathogens, and full eradi- from 1% to 5%, which would Hypochlorous acid is a natural, gentle way to cation is rarely beneficial.10 Thus, result in chemical burns to the eye eradicate bacteria on and around the eyelids. we often aim to simply reduce the upon contact. HOCl, however, is overall bacterial load. found in much lower concentrations In eye care, HOCl can provide Studies show that blepharitis and has no such risks. effective relief from dry eyes and hor- patients, for example, harbor a bacte- HOCl is an appealing disinfectant deola. It’s a treatment option for red, rial load more than 14 times greater because it is an all-natural antimicro- itchy eyelids associated with condi- than controls, and a HOCl solution bial agent. Pure HOCl is produced tions such as blepharitis and meibo- may help reduce the number without as an element of the human immune mian gland dysfunction (MGD). Lid strengthening harmful strains.2,11 response.2,3 During the oxidative hygiene products containing HOCl Researchers also discovered that burst, small, highly reactive molecules are an excellent addition to a patient’s HOCl decreased the bacterial load by such as HOCl are generated as white daily wellness routine to decrease the more than 90% without significantly blood cells respond to pathogens in microbial load on the lids and lashes.7 altering the diversity of the bacte- the body.2,4 HOCl is released by neu- Surfactant cleaners are often a nec- rial species.2 In addition, products trophils to kill microorganisms and essary long-term therapy, but HOCl containing HOCl generally are not neutralize toxins released from patho- is also a safe daily use option, as it is antibiotics and do not contribute to gens and inflammatory mediators.5 unlikely to cause skin irritation asso- the ever-growing issue of antibiotic Because it is neutralized quickly, ciated with other cleaners and scrubs resistance.7,12,13 HA is nontoxic to the ocular surface.5 containing preservatives or other additives. HOCl is also an excellent Pick the Right Product Gentle But Effective choice following in-office blepharoex- Four factors are important when dif- Although HOCl is natural, it’s sur- foliation because it can prolong well- ferentiating HOCl solutions: purity, prisingly potent. It has broad-spec- ness after bacterial load de-bulking. preservation, pH and prescription. trum antimicrobial activity and can For patients with MGD, HOCl is Purity. Many HOCl products kill microorganisms rapidly (Table well paired with warm moist com- contain ingredients, such as bleach 1).6 HOCl is highly effective in vitro press therapy to provide the dual byproducts and other chemicals, you against a wide range of microorgan- effect of reducing the bacterial burden may not want patients encountering isms, helping to fight infection, reduce and promoting secretions. on a daily basis. For long-term use, inflammation, control the body’s We can also use HOCl as preopera- look for solution free of additives, response to injury and enhance its tive antisepsis, to clean instruments fragrance, chemicals or other byprod- natural ability to heal. such as tonometry tips, and follow- ucts. All HOCl formulations are safe

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078_ro0819_OSR.indd 78 8/6/19 2:57 PM Surfactants and HOCl: A One-Two Punch and dry eye, more clinicians are turn- While HOCl may be beneficial in severe conditions, many patients still need to use surfactant ing to HOCl—particularly now that cleaners. The root cause of anterior blepharitis is the overproduction of oils, which harbor bac- so many choices are available OTC or teria that cause eyelid inflammation. The key to reducing this bacteria flora is to first remove in doctors’ offices.2 ■ the excessive oils from the eyelids and then follow up with antimicrobials. Mild surfactants in Note: Dr. Karpecki consults for several eyelid cleansers act to dissolve and remove oil, debris and desquamated skin. HOCl companies with products and services formulas do not contain these surfactants and are largely ineffective in debriding the oil, scales relevant to this topic. and debris often associated with eyelid irritation. Accordingly, in the most severe cases where 1. Gray MJ, Wholey WY, Jakob U. Bacterial responses to reactive HOCl might be most beneficial, clinicians should recommend a combination therapy including chlorine species. Annu Rev Microbiol. 2013;67:141-60. both a surfactant cleanser and HOCl to achieve the best outcomes for the patient. 2. Stroman DW, Mintun K, Epstein AB, et al. Reduction in bacterial load using hypochlorous acid hygiene solution on ocular skin. Clin Ophthalmol. 2017;11:707-14. 3. Hurst JK. What really happens in the neutrophil phagosome? Free regardless of the purity level. Without a product. OTC HOCl solutions can Radic Biol Med. 2012;53(3):508-20. the sodium hypochlorite (NaOCl) have the same concentration of active 4. Kumar V, Abbas AK, Fausto N. Acute and chronic inflammation. In: Robbins and Cotran Pathologic Basis of Disease. 7th ed. Philadelphia: balance, the equilibrium shifts and the ingredient, but marketing statements Elsevier; 2005:29-73. 5. Sindt C. Wash away your old hygiene strategy. Rev Cornea Contact pure products are unstable. are typically more general. Several Lens. 2014;151(4):7. Preservation. The stability of formulations are now available and 6. Wang L, Bassiri M, Najafi R, et al. Hypochlorous acid as a potential wound care agent: part I. Stabilized hypochlorous acid: a component HOCl solutions is generally quite marketing in eye care, including: of the inorganic armamentarium of innate immunity. J Burns Wounds. limited. Although HOCl may have • Avenova (NovaBay). This pre- 2007;6:e5. 7. Harsch AG, Stout N, Lighthizer N. Beat the blepharitis blues. Rev a shelf life of years, once a bottle scription spray contains pure HOCl Cornea Contact Lens. 2016;153(7):12-15. 8. Dang V. Sizing up anti-inflammatories in dry eye disease. Rev is opened, the product begins to and is designed to remove microor- Optom. 2018;155(4):62-65. degrade. If your patient uses the solu- ganisms and debris on and around 9. Romanowski E, Stella N, Yates K, et al. In vitro evaluation of a hypo- chlorous acid hygiene solution on established biofilms. Eye Contact tion only occasionally, a brand with a the eyelid margins. Lens. 2018 Nov;44(Suppl 2):S187-S191. 10. Lina G, Boutite F, Tristan A, et al. Bacterial competition for human longer shelf life may be important to • HypoChlor (OcuSoft). This nasal cavity colonization: role of Staphylococcal agr alleles. Appl maximize efficacy and avoid waste. 0.02% concentration of HOCl, avail- Environ Microbiol. 2003;69(1):18-23. 11. Bezza Benkaouha I, Le Brun C, Pisella PJ, et al. Bacterial flora in pH. The properties of HOCl in able without a prescription in both blepharitis. J Fr Ophtalmol. 2015;38(8):723-28. 12. Ono T, Yamashita K, Murayama T, Sato T. Microbicidal effect of solution depend strongly on the solu- spray and gel formulations, is stable weak acid hypochlorous solution on various microorganisms. Bio- tion’s pH.14 For patients with pru- opened or unopened for 18 months. control Science. 2012;17(3):129-33. 13. Debabov D, Noorbakhsh C, Wang L, et al. Avenova with Neutrox ritis, for example, HOCl can either • Bruder Hygienic Eyelid Solu- (pure 0.01% HOCl) compared with OTC product (0.02% HA). Nova- decrease or promote the condition, tion. This 0.02% pure HOCl solu- Bay Pharmaceuticals:1-5. 14. Pelgrift RY, Friedman AJ. Topical hypochlorous acid (HOCl) as a depending on the product’s pH.14 tion is available OTC and may be a potential treatment of pruritus. Curr Derm Rep. 2013;2:181. Research shows that a pH of 3.5 to beneficial addition to a daily eye care 5 is necessary to maintain a stable regimen for patients with mild or Table 1. Broad Spectrum Activity HOCl solution, maximize its antimi- moderate conditions. HOCl solution can be bactericidal against crobial activities and minimize unde- • Sterilid Antimicrobial (Akorn). the following pathogens:6 sirable degrading products.6 This OTC spray is 0.01% HOCl with Aspergillus niger When pH is less than 3.5, the solu- a 24-hour shelf life open or unopened. Candida albicans 6 Corynebacterium amycolatum tion exists as a mixture of chlorine. • HyClear (Contamac). Stable for Enterobacter aerogenes When pH is higher than 5.5, NaOCl up to 18 months after opening, this Escherichia coli starts to form and becomes the pre- product contains 0.01% HOCl and Haemophilus influenzae dominant species in the alkaline pH.6 is available only through ophthalmol- Klebsiella pneumoniae Prescription. While in the past ogy or optometry practices. Methicillin-resistant staphylococcus aureus Micrococcus luteus optometrists needed to write a pre- • Zenoptiq Hypochlorous Acid Proteus mirabilis scription for most HOCl solutions Solution (Focus Laboratories). Avail- Pseudomonas aeruginosa marketed for ocular use, several able without a prescription, this spray Serratia marcescens over-the-counter (OTC) options exist maintains stability for 18 months Staphylococcus aureus today. This is not due to an FDA after opening. Ingredients include Staphylococcus epidermidis Staphylococcus haemolyticus decision to reclassify HOCl. Instead, 99.94% electrolyzed oxygenated Staphylococcus hominis the prescription-only availability of water, 0.048% sodium chloride, Staphylococcus saprophyticus specific HOCl solutions is a manu- 0.01% HOCl and 0.002% NaOCl. Streptococcus pyogenes facturer prerogative that generally Because reducing the bacterial load Vancomycin-resistant enterococcus allows for more specific claims about is a useful tool for blepharitis, MGD faecium

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0078_ro0819_OSR.indd78_ro0819_OSR.indd 7799 88/6/19/6/19 2:572:57 PMPM Retina Quiz

That’s Egg on Your Face When a patient presents with a combination of progressive vision blur and a particular retinal appearance, all signs point to one diagnosis. By Mark T. Dunbar, OD

50-year-old male presented with slowly progressive Ablurred vision in his left eye, which he said he’d experienced over the past few years. He reported his right eye has been “bad” for at least 10 years and that he was diagnosed with a retinal condition when he was 27 years old. That primarily affected his right eye, but he believed the left was becoming significantly affected. On exam, his best-corrected visual acuity was 20/400 OD eccentrically Fig 1 . Our patient’s fundus photos reveal changes in both maculae. viewing and 20/60 OS. Confronta- tion visual fields were full-to-careful finger counting OU. His ocular motility testing was normal, and the pupils were equally round and reactive to light without an afferent pupillary defect. The anterior seg- ment was unremarkable. His ten- sions measured 16mm Hg OU. On dilated fundus exam, the vitre- ous was clear, optic nerves appeared heathy with small cups and good rim coloration and perfusion. Obvi- ous retinal changes were seen in the macula of each eye (Figure 1). Opti- cal coherence tomography (OCT) Fig. 2. OCT images of the right and left macula. What are the striking features? was also performed (Figure 2). a. Neurosensory retinal detachment lings would have it. Take the Retina Quiz and loss ellipsoid zone. c. 50% chance. 1. What is the most likely diagnosis? b. Retinal pigment epithelial detach- d. Greater than 90% chance. a. Central serous chorioretinopathy. ment. b. Best’s vitelliform macular dystro- c. Choroidal neovascularization. 4. What is the prognosis? phy. d. Macular schisis. a. Stability with no effect on visual c. Adult-vitelliform macular dystro- 3. What is the likelihood that any function. phy. siblings he has might have the same b. Slow, steady progression and loss d. Cone dystrophy. condition? of central vision in his left eye. a. Almost no chance. It’s not heredi- c. Return to normal vision following 2. What are the essential findings on tary. treatment. the OCT? b. About a one in 10 chance his sib- d. Complete blindness.

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080_ro0819_RQ.indd 80 8/7/19 5:57 PM Diagnosis Best’s Vitelliform Macular Dystrophy Staging The macular appearance in both • Stage I (Previtelliform): may appear normal or have only minimal retinal changes. eyes was quite striking, especially the • Stage II (Vitelliform): classic “egg-yolk” lesion. right eye where central retinal pig- • Stage III (Pseudohypopyon): layering of lipofuscin. ment epithelial (RPE) depigmenta- • Stage IV (Vitelleruptive): breakup/clumping of the material gives “scrambled” egg appearance. tion and atrophy were clearly visible. • Stage V (Atrophic): Central RPE and retinal atrophy. Surrounding the macula we noted a circumferential ring that had a bull’s left eye is in stage III, as the pseudo- is deposited in the outer retinal eye pattern. The left eye also had phyopyon is clearly apparent with layers. This is thought to be the central RPE atrophic changes, but layering of the lipofuscin material. It accumulation of the photoreceptor clearly not to the extent of the right is likely that his left eye will experi- outer segments containing lipo- eye. The patient appeared to have a ence a slow progression. About 20% fuscin.4 As the disease progresses neurosensory detachment that was of patients will develop choroidal and atrophy develops, loss of the visible on both the clinical exam neovascularization (CNV) following ellipsoid junction will occur in the and OCT. Inferior to the macula the the atrophic stage which can further macula; outside the macula, the almost hypopyon-like appearance have an effect on central acuity.1,2 hyper-reflected band can still be helped make the diagnosis. Research links BVMD to a present as we see in our patient. The family history also provided genetic mutation on the BEST1 The hyper-reflective area in the a clue to the diagnosis—his sister gene, which is located on chromo- right eye represents the white band reportedly has the same condi- some 11 (11q12.3).3 It encodes for that we described as a bull’s eye in tion, and his mother is a carrier. a transmembrane protein besto- appearance. Our patient was diagnosed when phin 1 which is believed to affect It is unknown if the serous he was 28 years old. So what does the conductance of chloride which detachment seen in both eyes truly this all add up to? Our patient has negatively affects the transport of represents a detachment of the Best’s vitelliform macular dystrophy fluid across the RPE. This in turn sensory retina from the RPE, or (BVMD), an autosomal dominant results in the accumulation of debris more likely a separation of the RPE hereditary retinal dystrophy that between the RPE/photoreceptor from its underlying attachment to affects the retinal pigment epithe- complex and Bruch’s membrane. Bruch’s membrane leaving a central lium. Vision is usually not affected The diagnosis can usually be subfoveal hypolucent space. until childhood or early adulthood made based on clinical presentation. No genetic treatments available and generally has a good prognosis When in doubt, an electrooculogram yet for BVMD. Our patient was for maintaining good central vision is diagnostic and will be positive able to maintain good central acu- in at least one eye. even in the previtelliform stage when ity in the left eye for many years. The classic description for BVMD the retina appears unaffected and the Five years earlier, at 45 years old, is the bilateral yellow egg-yolk vision is normal. his acuity was still 20/25 and he appearance of the macula. At one was able to drive and was func- point our patient had that appear- Monitoring tioning without difficulty. Over the ance, but as the disease evolves the Mutimodal imaging, including fun- following five years, he has expe- appearance can change. BVMD is dus photography, OCT and fundus rienced a slow decline in acuity classified by five stages. (see BVMD autofluoresence (FAF), may be that affected his quality of life. We staging). helpful in characterizing BVMD. referred him to low vision services Our patient’s right eye has pro- OCT can show classic structural and issued him stronger reading gressed from Stage IV to Stage V changes within the retina. Even in glasses over his contact lenses. ■

because of the atrophic changes the previtelliform stage, thickening 1. Ryan S. Retina, 4th ed. In: Schachat AP, ed. Volume II; Medical Retinal. Philadelphia. Elsevier;2006. in the fovea, but you can still see and hyper-reflectivity of the RPE/ 2. Gass J. Stereoscopic atlas of macular diseases. Diagnosis remnants of the tale tell sign of ellipsoid zone (IS/OS junction) can and Treatment. 4th ed, Mosby, St. Louis;1997:304-11. 3. Stone E, Nichols B, Streb L, et al. Genetic linkage of vitel- Stage IV BVMD, which is more be seen. In the vitelliform stage, liform macular degeneration (Best’s disease) to chromosome 11q13. Nat Genet. 1992;1(4):246-50. like a “scrambled egg” appearance a homogenous hyper-reflective 4. Battaglia Parodi M, Iacono P, Romano F, Bandello F. around the macular than Stage II, band will be present, which repre- Spectral domain optical coherence tomography features in different stages of Best vitelliform macular dystrophy. Retina. which resembles an “egg yolk.” His sents the vitelliform material that 2018;38(5):1041-6.

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0080_ro0819_RQ.indd80_ro0819_RQ.indd 8181 88/7/19/7/19 5:575:57 PMPM Glaucoma Grand Rounds

When They Go Low, ODs Go High Bad-mouthing other doctors doesn’t serve your patients. By James L. Fanelli, OD

64-year-old Peripapillary atrophy Caucasian female was evident in both presented as a new eyes. patient after her pre- Her macular evalu- Avious eye care provider retired. ations were essentially She complained of long-stand- unremarkable. Her ing blurred vision, relatively vascular appearance equal between the two eyes. was consistent with She also reported chronic mild arteriolarsclerotic blepharitis and dry eye diag- retinopathy in both noses, with blepharitis flare- eyes, and her peripheral ups on the rise. She had been Fig. 1. Bruch’s membrane opening display of the patient’s retinal evaluations were given a long term prescription left eye demonstrating erosion of the left inferotemporal remarkable for 360 for neo-poly-dex drops to use neuroretinal rim. Note at the marked area the neuroretinal rim degrees of cystoid and when the blepharitis flared is only 95µm thick at that point. scattered areas of pav- and has been using them about ingstone degeneration. once a month, for approximately a clear post LASIK flaps, with no evi- During the fundus examination, it week, twice a day. She had under- dence of striae, epithelial ingrowth was clear that her optic nerves were gone LASIK surgery approximately or other physical aberration to both not healthy, and with the erosion of 18 years prior. She was also taking corneas. The anterior chamber the neuroretinal rims to the extent simvastatin 80mg QD, multivita- angles were open and the anterior they were, my initial impression was mins, calcium glucosamine and chambers were quiet. Applanation that she most likely had visual field magnesium daily. She reported that tensions were 12mm Hg OD and loss involving fixation. Given her her son had been diagnosed with OS at 2:42pm. Through dilated relatively low IOP, the differential glaucoma a few years earlier. pupils her crystalline lenses were of normal tension glaucoma arises, Her last visit to her previous pro- characterized by incipient nuclear which has connotations of possible vider was a year earlier, at which sclerosis, but not to the level to neuro-ophthalmic etiologies. This time she was told the blurry vision account for the 20/30-2 BCVA. instigated a closer re-evaluation of was related to her dry eyes as well Pupils were ERRLA with no affer- the optic nerves, which, on second as, apparently, some ‘changes’ to ent pupillary defect. view, demonstrated normal size her corneas following the LASIK Stereoscopic examination of her optic nerves, no evidence of edema surgery. optic nerves demonstrated eroded or elevation, and in particular no At the initial visit, best-corrected neuroretinal rims in both eyes, evidence of pallor. visual acuities (BCVA) were 20/25-2 with the right showing more thin- The previous LASIK is also OD and 20/30-2 OS. Confrontation ning than the left. The remaining, playing a role in the low IOP read- fields were slightly restricted supe- thinned neuroretinal rims were ings, as contrasted to the optic riorly, which I initially attributed to plush and perfused. The cup-to-disc nerve appearance. Pachymetry her dermatochalasis. ratios were 0.70 x 0.85 OD with measurements were obtained, and an exceedingly thin neuroretinal the central corneal readings were Evaluation rim from 6 o’clock to 9 o’clock, 487µm OD and 470µm OS. When A slit lamp examination of her ante- and 0.60 x 0.75 OS with an eroded asked, she reported that she was rior segments was remarkable for rim from 3 o’clock to 6 o’clock. fairly myopic prior to the LASIK,

82 REVIEW OF OPTOMETRY AUGUST 15, 2019

082_ro0819_GGR.indd 82 8/7/19 6:11 PM and when pressed for an is difficult to diagnose. It’s estimate of her contact probable your condition lens powers, she reported was not manifest when that they were in the -9.00 you last saw them.” For range OU. others, where I may find it hard to be complimentary, Diagnosis I may reply similarly to At this point, the case this: “Well, I’m not sure seems to be pretty straight- Fig. 2. Total macular thickness of the left eye, demonstrating exactly what Dr. X was forward of undiagnosed thinning of global retinal indices inferotemporally. Note the seeing at that time, but glaucoma. Exceedingly evident difference on the asymmetry map between the superior this is what you have now straightforward in fact. and inferior macular hemispheres. and this is how I’m going A high myope undergoes to care for you.” LASIK surgery OU, with resul- handle this any differently than Did I throw the previous doctor tant thin corneas and resultant any other case where we suspect under the bus? No, I redirected, low IOP readings by applanation someone dropped the ball? Do we took control of the discussion and tonometry. The extent of her optic undermine the other doctor’s repu- told the patient what I would do nerve damage indicated that the tation? No. Though it’s tempting to for them. It’s actually quite an damage did not occur in the last react, it serves no purpose, especially effective tactic, especially when a six to 12 months. Even though the to the patient. Treat this patient like new-to-you patient has been see- patient was using a drop contain- any other. Explain your findings, ing a different provider and you’re ing dexamethasone off and on for make no excuses for the disease and delivering news they have not an extended period of time, IOP explain your management plan. heard previously. readings at the initial visit were not In this case, I asked the patient to Remember, our duty is to the indicative of a significant steroid return to clinic in a couple of weeks patient and the profession. Treat response. for threshold fields, optical coher- each patient as you would want to Could IOPs have been sig- ence tomography and Heidelberg be treated. Is it in a patient’s best nificantly high for a long enough retina tomograph optic nerve imag- interest to be seen by a provider period of time to cause the neu- ing, as well as gonioscopy. who is very anti-optometry? No, roretinal rim damage? While it’s When the patient asks why their but neither is it in their interest to possible, she only used the steroid previous doctor didn’t catch the hear you grouse about organized infrequently. Even though one can disease, I would encourage you medicine. argue that a corrected IOP would not to trash the other provider, as The provider in this patient’s be higher than that seen in clinic, that may only serve the purpose of earlier care was someone who did the evidence is clear that the neuro- making the new-to-you patient feel not respect optometry, did not work retinal damage occurred over time. uncomfortable with your bedside with optometry and who at every And certainly it would have been manner. For those providers whom occasion took the opportunity to present at the time of her last visit I respect, and for whom I under- disparage optometry. When the to her previous eye care provider. stand will occasionally have a case shoe is on the other foot, don’t be head south, I usually reply some- like them! We can work around Managing the Mismanaged thing like: “Well, Dr. X is a com- providers like that and still care for We have all been in a scenario petent doctor and your condition the patient. ■ where a patient appears to have been mismanaged. While we often Fig. 3. This macular we give another provider the ben- image demonstrates efit of the doubt, in this case the significant thinning of prior provider was a militant anti- the ganglion cell layer optometry crusader who, as a result, contiguous with the received few OD referrals over their eroded inferotemporal career and, partly as a result, their neuroretinal rim as seen surgical outcomes suffered. Do you in Figure 1.

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082_ro0819_GGR.indd 83 8/7/19 6:11 PM Surgical Minute Edited By Derek N. Cunningham, OD, and Walter O. Whitley, OD, MBA A Two-for-one Deal Here’s when to consider referring your patient for phaco-ECP, which addresses cataracts and glaucoma in one operation. By Christina Tran, BS, and Leonid Skorin, Jr., DO, OD, MS

ombining cataract phaco- identical to those after cataract emulsification with endo- surgery. The patient should avoid Cscopic cyclophotocoagulation rubbing their eyes for one week and (ECP) of the ciliary processes can will need to wear a plastic eye shield help lower a patient’s intraocular at bedtime. The patient is prescribed pressure (IOP) by decreasing the topical moxifloxacin and ketorolac production of aqueous humor. QID. After phaco-ECP, patients will Studies show the combination pro- have more postoperative iritis and cedure can achieve an average IOP will need to use topical predniso- decrease between 2.6mm Hg and Using a video monitor, the surgeon lone every two hours for one week, 3.3mm Hg.1,2 Several studies found locates and treats the ciliary processes, which will then be tapered over the the average number of post-op glau- which become white and shrunken. next month. The patient should coma therapies decreased by one continue using their glaucoma medication two years post-op.2-4 gling with medication compliance medications, as it may take four to The endoscope is inserted through and want to reduce their dependence six weeks for the procedure to take the phacoemulsification incision, on multiple topical medications. maximal effect.7,8 Glaucoma medica- and the second procedure only adds tions may be tapered off accordingly a few minutes to the operating time. Step-by-step as IOPs begin to drop. ■ The IOP-lowering effect is equiva- After phacoemulsification of the Ms. Tran is a fourth-year student lent to procedures such as trabecu- cataract and insertion of the intra- at Pacific University College of lectomy and insertion of drainage ocular lens (IOL), the surgeon Optometry. devices but comes with fewer injects non-preserved lidocaine Dr. Skorin is a consultant in the complications of hypotony or phthi- intracamerally for additional anes- Department of Surgery, Community sis.5 Other advantages over MIGS thesia. Viscoelastic injected over the Division of Ophthalmology in include no need to implant a device capsular bag and under the iris cre- the Mayo Clinic Health System in in the eye and decreasing IOP (aque- ates more space for the endoscope, Albert Lea, MN. ous) production versus working on reduces the risk of damaging the iris 1. Roberts SJ, Mulvahill M, SooHoo JR, et al. Efficacy of com- IOP outflow. or the IOL and allows for a clear bined cataract extraction and endoscopic cyclophotocoagulation view of the ciliary processes.7 The for the reduction of intraocular pressure and medication burden. Int J Ophthalmol. 2016;9(5):693-98. Ideal Candidates surgeon inserts endoscope through 2. Siegel MJ, Boling WS, Faridi OS, et al. Combined endo- scopic cyclophotocoagulation and phacoemulsification versus Patients need to qualify for both cat- the incision and applies treatment phacoemulsification alone in the treatment of mild to moderate aract surgery and ECP to qualify for to at least 270 degrees of the ciliary glaucoma. Clin Exp Ophthalmol. 2015;43(6):531-39. 3. Francis BA, Berke SJ, Dustin L, Noecker R. Endoscopic cyclo- the combined procedure. Most types processes with 0.25 watts on a con- photocoagulation combined with phacoemulsification versus of glaucoma can be treated with tinuous mode.7,8 Ciliary processes phacoemulsification alone in medically controlled glaucoma. J Cataract Refract Surg. 2014;40(8):1313-21. ECP with the exception of active become white and shrunken after 4. Clement CI, Kampougeris G, Ahmed F, et al. Combining phacoemulsification with endoscopic cyclophotocoagula- uveitic glaucoma and patients with a few seconds of treatment. After tion to manage cataract and glaucoma. Clin Exp Ophthalmol. IOPs greater than 40mm Hg.6 ECP treatment, the endoscope is removed 2013;41(6):546-51. 5. Sun W, Yu CY, Tong JP. A review of combined phacoemul- is a viable option for patients strug- and viscoelastic is aspirated. sification and endoscopic cyclophotocoagulation: efficacy and safety. Int J Ophthalmol. 2018;11(8):1396-1402. 6. Kahook MY, Noecker RJ. Endoscopic cyclophotocoagulation. To see a video of this Post-op Considerations Glaucoma Today. 2006;4(6):24-9. procedure, visit www. 7. Berke SJ. Endophotocoagulation. In: Glaucoma. 2nd ed. The patient is seen at one day, one Philadelphia: Elsevier; 2015:1160-66. reviewofoptometry.com, or week and one month after the pro- 8. Fallano KA, Conner IP, Noecker RJ, Schuman JS. scan the QR code. Cyclodestructive procedures in glaucoma. In: Ophthalmology. cedure. Their instructions are almost 5th ed. Philadelphia: Elsevier; 2019:1131-34.

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ASSISTANT PROFESSOR POSITIONS: PRIMARY CARE/OCULAR DISEASE & OPHTHALMIC OPTICS &ƵůůͲƟŵĞŶŽŶͲƚĞŶƵƌĞƚƌĂĐŬĨĂĐƵůƚLJƉŽƐŝƟŽŶƐĨŽƌƚŚĞŚŝĐĂŐŽŽůůĞŐĞŽĨKƉƚŽŵĞƚƌLJ ZĞƐƉŽŶƐŝďŝůŝƟĞƐ͗ĂŶĚŝĚĂƚĞƐĂƌĞĞdžƉĞĐƚĞĚƚŽďĞŚŝŐŚůLJŬŶŽǁůĞĚŐĞĂďůĞŝŶƚŚĞĮĞůĚŽĨƉƌŝŵĂƌLJĐĂƌĞĂŶĚŽĐƵůĂƌĚŝƐĞĂƐĞĂŶĚĚĞǀĞůŽƉ ĂŶĚƚĞĂĐŚĐŽƵƌƐĞƐĂŶĚͬŽƌůĂďŽƌĂƚŽƌŝĞƐŝŶƚŚĞƐƵďũĞĐƚĂƌĞĂ͘dŚĞƉƌŝŵĂƌLJĐĂƌĞĐĂŶĚŝĚĂƚĞŵƵƐƚĂůƐŽďĞĂďůĞƚŽƉƌŽǀŝĚĞĚŝƌĞĐƚƉĂƟĞŶƚ ĐĂƌĞĂŶĚĐůŝŶŝĐĂůŝŶƐƚƌƵĐƟŽŶƚŽƉƌŽĨĞƐƐŝŽŶĂůƐƚƵĚĞŶƚƐĂƐǁĞůůĂƐƌĞƐŝĚĞŶƚƐ͕ĂŶĚďĞŝŶǀŽůǀĞĚŝŶŝŶƚĞƌĚŝƐĐŝƉůŝŶĂƌLJƉƌĂĐƟĐĞǁŝƚŚŽƚŚĞƌ ĞĚƵĐĂƟŽŶĂůƉƌŽĨĞƐƐŝŽŶĂůƐ͘ ĂŶĚŝĚĂƚĞƐŵƵƐƚďĞǁŝůůŝŶŐƚŽĂĐƟǀĞůLJƉĂƌƟĐŝƉĂƚĞŝŶĐƵƌƌŝĐƵůĂƌĂƐƐĞƐƐŵĞŶƚ͕ƉƌŽĨĞƐƐŝŽŶĂůĚĞǀĞůŽƉŵĞŶƚ͕ƐƚƵĚĞŶƚĐŽƵŶƐĞůŝŶŐĂŶĚƐĞƌǀŝĐĞĂĐƟǀŝƟĞƐǁŝƚŚŝŶƚŚĞ ĐŽůůĞŐĞ͕ƵŶŝǀĞƌƐŝƚLJĂŶĚƚŚĞƐĐŝĞŶƟĮĐĐŽŵŵƵŶŝƚLJ͘^ƵĐĐĞƐƐĨƵůĐĂŶĚŝĚĂƚĞƐĂƌĞĂůƐŽĞdžƉĞĐƚĞĚƚŽďĞŝŶǀŽůǀĞĚŝŶƌĞƐĞĂƌĐŚĂŶĚƐĐŚŽůĂƌůLJĂĐƟǀŝƟĞƐ͕ĂŶĚŚĂǀĞĂƐŝŶĐĞƌĞ ĐŽŵŵŝƚŵĞŶƚƚŽŽƉƚŽŵĞƚƌŝĐĞĚƵĐĂƟŽŶ͕ĐŽŵŵƵŶŝƚLJƐĞƌǀŝĐĞĂŶĚƉĂƟĞŶƚĐĂƌĞ͘WƌŝŵĂƌLJĚƵƟĞƐŝŶĐůƵĚĞ͕ďƵƚĂƌĞŶŽƚůŝŵŝƚĞĚƚŽ͗

ĂͿdĞĂĐŚŝŶŐ ďͿ^ĞƌǀŝĐĞ ĐͿ^ĐŚŽůĂƌůLJĂĐƟǀŝƚLJ ͻĞǀĞůŽƉŝŶŐĂŶĚĚĞůŝǀĞƌŝŶŐůĞĐƚƵƌĞƐĂŶĚͬŽƌ ͻ,ĞůƉŝŶŐƚŽŵĂŝŶƚĂŝŶĂŶĚŐƌŽǁƚŚĞƐƚĂƚĞŽĨƚŚĞ ŶŐĂŐŝŶŐŝŶƌĞƐĞĂƌĐŚĂŶĚƐĐŚŽůĂƌůLJĂĐƟǀŝƚLJ͕ŝŶĐůƵĚͲ ůĂďŽƌĂƚŽƌŝĞƐĨŽƌƌĞůĂƚĞĚĂƌĞĂƐ͕ĂƐĂƐƐŝŐŶĞĚ͖ ĂƌƚŽƉƚŽŵĞƚƌLJƉƌŽŐƌĂŵǁŝƚŚĂƐƚƌŽŶŐŝŶƚĞƌĚŝƐĐ ŝŶŐƉƌĞƐĞŶƚĂƟŽŶƐĂƚƐĐŝĞŶƟĮĐŵĞĞƟŶŐƐ͕ƌĞƐĞĂƌĐŚ͕ ͻŵďƌĂĐŝŶŐĂŶĚĞŶŚĂŶĐŝŶŐƚŚĞĚŝĚĂĐƟĐ ƉůŝŶĂƌLJĨŽĐƵƐƚŚĂƚŵĞĞƚƐƚŚĞŶĞĞĚƐŽĨƉĂƟĞŶƚƐŝŶ ĂŶĚƉƵďůŝĐĂƟŽŶŝŶƉĞĞƌƌĞǀŝĞǁĞĚũŽƵƌŶĂůƐƐƵĸĐŝĞŶƚ ƉŚŝůŽƐŽƉŚŝĞƐŝŶƚŚĞK͘͘ƉƌŽŐƌĂŵ͖ ƚŚĞƐƵƌƌŽƵŶĚŝŶŐĐŽŵŵƵŶŝƚLJ͖ŝƐĞĸĐŝĞŶƚ͕ƉĂƟĞŶƚ ƚŽƋƵĂůŝĨLJĨŽƌĂĐĂĚĞŵŝĐĂĚǀĂŶĐĞŵĞŶƚŝŶĂŶŽŶͲ ͻDĂŝŶƚĂŝŶŝŶŐĂŶĚĞdžƉĂŶĚŝŶŐƚŚĞŚŝŐŚƋƵĂůŝƚLJ ĨƌŝĞŶĚůLJ͕ĂŶĚĐŽƐƚͲĞīĞĐƟǀĞ͖ ƚĞŶƵƌĞŽƌƚĞŶƵƌĞƚƌĂĐŬƉŽƐŝƟŽŶ͘ ĐůŝŶŝĐĂůƉƌĂĐƟĐĞĞŶǀŝƌŽŶŵĞŶƚĨŽƌŽƉƚŽŵĞƚƌLJ ͻtŽƌŬŝŶŐĐůŽƐĞůLJƚŽŐĞƚŚĞƌǁŝƚŚĂůůŽƉƚŽŵĞƚƌLJ ƐƚƵĚĞŶƚƐŽŶƌŽƚĂƟŽŶ͖ ĂŶĚŽƉŚƚŚĂůŵŽůŽŐLJĨĂĐƵůƚLJƚŽƉƌŽǀŝĚĞĂ ͻWƌĞĐĞƉƟŶŐƐƚƵĚĞŶƚƐŽŶĐůŝŶŝĐĂůƌŽƚĂƟŽŶĂƚ ĐŽŵƉůĞƚĞƌĂŶŐĞŽĨĞLJĞĂŶĚǀŝƐŝŽŶĐĂƌĞƐĞƌǀŝĐĞƐ͖ ƚŚĞDŝĚǁĞƐƚĞƌŶhŶŝǀĞƌƐŝƚLJLJĞ/ŶƐƟƚƵƚĞǁŚĞƌ ͻWĂƌƟĐŝƉĂƟŶŐŝŶůĞĂĚĞƌƐŚŝƉƌŽůĞƐŝŶƐƚĂƚĞ͕ ĂƉƉůŝĐĂďůĞ͖ ƌĞŐŝŽŶĂů͕ĂŶĚŶĂƟŽŶĂůŽƉƚŽŵĞƚƌLJ ŽƌŐĂŶŝnjĂƟŽŶƐ͖ YƵĂůŝĮĐĂƟŽŶƐ: ĂŶĚŝĚĂƚĞƐŵƵƐƚƉŽƐƐĞƐƐĂŽĐƚŽƌŽĨKƉƚŽŵĞƚƌLJĚĞŐƌĞĞĨƌŽŵĂŶKͲĂĐĐƌĞĚŝƚĞĚŝŶƐƟƚƵƟŽŶ͕ŵƵƐƚŚĂǀĞĐŽŵƉůĞƚĞĚĂŶKͲĂĐĐƌĞĚŝƚĞĚ ƌĞƐŝĚĞŶĐLJ͕ĂŶĚŵƵƐƚďĞĞůŝŐŝďůĞĨŽƌĂŶŝůůŝŶŽŝƐŽƉƚŽŵĞƚƌŝĐƐƚĂƚĞůŝĐĞŶƐĞ͘WƌŝŵĂƌLJĞLJĞĐĂƌĞĐůŝŶŝĐĂůĞdžƉĞƌƟƐĞŝƐĂůƐŽƌĞƋƵŝƌĞĚ͘ ^ĂůĂƌLJǁŝůůďĞĐŽŵŵĞŶƐƵƌĂƚĞǁŝƚŚƋƵĂůŝĮĐĂƟŽŶƐĂŶĚĞdžƉĞƌŝĞŶĐĞ ZĞǀŝĞǁŽĨĂƉƉůŝĐĂƟŽŶƐǁŝůůďĞŐŝŶŝŵŵĞĚŝĂƚĞůLJĂŶĚĐŽŶƟŶƵĞƵŶƟůƚŚĞƉŽƐŝƟŽŶŝƐĮůůĞĚ ŽŶƚĂĐƚŝŶĨŽƌŵĂƟŽŶ͗/ŶƚĞƌĞƐƚĞĚĂƉƉůŝĐĂŶƚƐƐŚŽƵůĚĂƉƉůLJŽŶůŝŶĞĂƚǁǁǁ͘ŵŝĚǁĞƐƚĞƌŶ͘ĞĚƵĂŶĚŝŶĐůƵĚĞĐƵƌƌŝĐƵůƵŵǀŝƚĂĞĂŶĚůĞƩĞƌŽĨŝŶƚĞƌĞƐƚ ƐƉĞĐŝĨLJŝŶŐƚŚĞƉŽƐŝƟŽŶĂŶĚĐŽůůĞŐĞƚŚĂƚŚĞͬƐŚĞǁŝƐŚĞƐƚŽďĞĐŽŶƐŝĚĞƌĞĚĨŽƌ͘ƉƉůŝĐĂƟŽŶƉĂĐŬĞƚƐŚŽƵůĚŝŶĐůƵĚĞĐƵƌƌŝĐƵůƵŵǀŝƚĂĞĂŶĚůĞƩĞƌŽĨ ŝŶƚĞƌĞƐƚ͘/ŶƋƵŝƌŝĞƐŵĂLJďĞĚŝƌĞĐƚĞĚƚŽƌ͘DĞůŝƐƐĂ^ƵĐŬŽǁ͕ĞĂŶ͖DŝĚǁĞƐƚĞƌŶhŶŝǀĞƌƐŝƚLJ͗ŵƐƵĐŬŽΛŵŝĚǁĞƐƚĞƌŶ͘ĞĚƵ͘ DŝĚǁĞƐƚĞƌŶhŶŝǀĞƌƐŝƚLJŝƐĂŶƋƵĂůKƉƉŽƌƚƵŶŝƚLJͬĸƌŵĂƟǀĞĐƟŽŶĞŵƉůŽLJĞƌƚŚĂƚĚŽĞƐŶŽƚĚŝƐĐƌŝŵŝŶĂƚĞĂŐĂŝŶƐƚĂŶĞŵƉůŽLJĞĞŽƌĂƉƉůŝĐĂŶƚďĂƐĞĚƵƉŽŶƌĂĐĞ͕ ĐŽůŽƌ͕ƌĞůŝŐŝŽŶ͕ŐĞŶĚĞƌ͕ŶĂƟŽŶĂůŽƌŝŐŝŶ͕ĚŝƐĂďŝůŝƚLJ͕ŽƌǀĞƚĞƌĂŶƐƐƚĂƚƵƐ͕ŝŶĂĐĐŽƌĚǁŝƚŚϰϭ͘&͘Z͘ϲϬͲϭ͘ϰ;ĂͿ͕ϮϱϬ͘ϱ;ĂͿ͕ϯϬϬ͘ϱ;ĂͿĂŶĚϳϰϭ͘ϱ;ĂͿ͘

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Career Opportunities Practice For Sale Staff Optometrist Wanted FOR SALE Bard Optical is a family owned full-service retail optometric practice with 22 offices (and growing) throughout Central Illinois. Bard Optical prides itself on having a progressive CALIFORNIA - CONTRA COSTA optometric staff whose foundation is based on dƵƌŶŬĞLJƉƌĂĐƟĐĞŐƌŽƐƐŝŶŐΨϳϴϬ͕ϬϬϬ one-on-one patient service. We are currently accepting CV/resumes for Optometrists to join ŝŶϮϬϭϴ͕ŶĞƫŶŐΨϮϮϬ͕ϬϬϬǁŚŝůĞ Practice Sales •
Appraisals •
Consulting our medical model optometric practice that ŽǁŶĞƌǁŽƌŬŝŶŐŽŶůLJϰĚĂLJƐƉĞƌ www.PracticeConsultants.com includes extended testing. The practice ǁĞĞŬ͘dŚĞϮϭϬϬƐƋ͘Ō͘ĐůĂƐƐŽĸĐĞ includes but is not limited to general optometry, PRACTICES
FOR
SALE
contact lenses and geriatric care. Salaried, ŚĂƐϮĞdžĂŵƌŽŽŵƐĨƵůůLJĞƋƵŝƉƉĞĚ full-time positions are available with excellent ǁŝƚŚĂĚǀĂŶĐĞĚĚŝĂŐŶŽƐƟĐĞƋƵŝƉ- NATIONWIDE base compensation and incentive programs ŵĞŶƚ͕ĂŶĚĞĚŐŝŶŐůĂď͘ Visit us on the Web or call us to learn
and benefits. Some part-time opportunities may also be available. more about our company and the NEW YORK – MID-HUDSON VALLEY practices we have available. Current positions are available in >ŝǀĞĂŶĚƉƌĂĐƟĐĞŝŶĂďĞĂƵƟĨƵů͕ [email protected] Bloomington/Normal, Decatur/Forsyth, ǀŝďƌĂŶƚĐŽŵŵƵŶŝƚLJŽŶůLJϭЪŚŽƵƌ Peoria, Sterling and Canton as we continue to grow with new and established offices. ĚƌŝǀĞĨƌŽŵDĂŶŚĂƩĂŶ͘'ƌŽƐƐŝŶŐ ΨϳϬϬ͕ϬϬϬŝŶϮϬϭϴǁŝƚŚΨϮϭϬ͕ϬϬϬŝŶ  Please email your information to ŽǁŶĞƌ͛ƐŶĞƚ͘^ƚĂƚĞͲŽĨͲƚŚĞͲĂƌƚĞƋƵŝƉ- [email protected] or call Mick at 309-693-9540 ext 225. ŵĞŶƚŝŶĐůƵĚĞƐKƉƚŽǀƵĞKd͕ĐŽƌŶĞĂů www.PracticeConsultants.com Mailing address if more convenient is: ƚŽƉŽŐƌĂƉŚĞƌĂŶĚƌĞƟŶĂůĐĂŵĞƌĂ͘ Bard Optical Attn: Mick Hall, Vice President 8309 N Knoxville Avenue 100% Financing Available Peoria, IL 61615 ĂůůĨŽƌĂ&ƌĞĞWƌĂĐƟĐĞǀĂůƵĂƟŽŶ Bard Optical is a proud PRACTICE FOR SALE Associate Member of the 800-416-2055 Illinois Optometric Association. ǁǁǁ͘dƌĂŶƐŝƟŽŶŽŶƐƵůƚĂŶƚƐ͘ĐŽŵ Rare opportunity www.bardoptical.com to assume ownership of ĂϭϰͲLJĞĂƌƉƌŝǀĂƚĞƉƌĂĐƟĐĞ͘ OPTOMETRIST ϭ͘ϯDŝůůŝŽŶŐƌŽƐƐĞĚŝŶϮϬϭϴ͘ ϯϬйŐƌŽǁƚŚŽǀĞƌϮϬϭϳ͘ Optometrist wanted ĨŽƌϮϱLJĞĂƌƉƌĂĐƟĐĞ͘ dŚŝƐŽŶĐĞͲŝŶͲĂͲůŝĨĞƟŵĞŽƉƉŽƌƚƵŶŝƚLJ ƵƌƌĞŶƚKƌĞƟƌŝŶŐ͘ ďƌŝŶŐƐLJŽƵƚŽWĞŶŶƐLJůǀĂŶŝĂ͘ Do you have ϵϬDŝůĞƐƚŽWŚŝůĂĚĞůƉŚŝĂĂŶĚϭϬϬ All equipment in place DŝůĞƐƚŽEz͘ ĂŶĚƉĂƟĞŶƚƐĂƌĞ CE Programs? ϭϲKŚŽƵƌƐǁĞĞŬůLJ͘ ^ŝŐŶŝĮĐĂŶƚŐƌŽǁƚŚƉŽƚĞŶƟĂů͘ ƌĞĂĚLJĨŽƌLJŽƵ͘ CONTACT US TODAY dŚŝƐƵƉƐĐĂůĞKƉƟĐĂůŽƵƟƋƵĞĂŶĚ FOR CLASSIFIED ADVERTISING Contact Bill Palmer KƉƚŽŵĞƚƌŝĐWƌĂĐƟĐĞŽĐĐƵƉŝĞƐ 772-468-0008 Toll free: 888-498-1460 ĂƉƉƌŽdžŝŵĂƚĞůLJϮϳϬϬƐƋƵĂƌĞĨĞĞƚǁŝƚŚ E-mail: [email protected] ƚǁŽŶĞǁĨƵůůLJĞƋƵŝƉƉĞĚĞdžĂŵůĂŶĞƐ͘ dĂLJůŽƌƌĞĞŬKƉƟĐĂů ǀĞƌLJƚŚŝŶŐŝƐŶĞǁ͘ Fort Pierce, Florida ĚǀĂŶĐĞĚĚŝĂŐŶŽƐƟĐĞƋƵŝƉŵĞŶƚ͘ EĞǁŽƉƟĐĂůĮŶŝƐŚŝŶŐůĂď͘ EŽǁĞĞŬĞŶĚƐŽƌůĂƚĞĞǀĞŶŝŶŐƐ͘ YƵĂůŝĮĞĚďƵLJĞƌƐŽŶůLJ͘ Contact: [email protected] Targeting Optometrists? CLASSIFIED ADVERTISING WORKS

• JOB OPENINGS • CME PROGRAMS Do you have Products • PRODUCTS & SERVICES • AND MORE... and Services for sale?

Contact us today for classified advertising: CONTACT US TODAY Toll free: 888-498-1460 FOR CLASSIFIED ADVERTISING E-mail: [email protected] Toll free: 888-498-1460 E-mail: [email protected]

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Faculty

Full-time Faculty Positions Available Non-Tenure Track Assistant, Associate, or Clinical Professor (Various Emphasis Areas) optometry.umsl.edu

The College of Optometry at the University of 4XDOLÀFDWLRQV - All positions require: St. Louis region and the 3rd largest in Missouri Missouri-Saint Louis invites applications for full-time • Ability to contribute to the development, evaluation, with 131 degree and associate programs. non-tenure track positions with an opportunity to join and enhancement of optometric education For additional information about UMSL see: a dynamic and progressive academic community. • Ability to contribute to the mission and strategic umsl.edu Successful applicants will receive a nine-month priorities of the College of Optometry appointment. Initial rank for the full-time clinical • Open to development and use of innovative The College of Optometry includes a 4-year appointments will be commensurate with prior experi- instructional strategies and technology professional degree (O.D.) program and post- HQFHTXDOL¿FDWLRQVDQGLQGLYLGXDOLQWHUHVWV7KHUHLV • Commitment to effective dissemination of evidence professional residency programs. the possibility for a summer instructional assignment based practice and translating research into For additional information about the College see: if mutually agreeable. clinical care and education. optometry.umsl.edu • Demonstrated knowledge in area of emphasis and Applications are encouraged from a variety contemporary issues in optometry and healthcare. Those who wish to be considered a candidate of areas including: for a position must provide an application that The positions require a Doctor of Optometry (OD) includes a letter of interest, curriculum vitae and • Eye and Vision Research degree, license to practice optometry in Missouri, a a list of four professional references. Formal • Sports Vision and Performance commitment to work with diverse student and patient submissions via the University website: • External Disease and Dry Eye populations, and alternative teaching styles such www.umsl.jobs. Applications will be accepted • Ocular and Systemic Disease including as learner-centered and case-based approaches. A and reviewed immediately. The positions will diagnostic and therapeutic procedures license to practice in Illinois is desirable. Candidates UHPDLQRSHQXQWLO¿OOHG • Primary Eye Care with a Masters or Doctoral Degree with a record of scholarship or who have completed an ACOE- Questions may be directed to: accredited residency are preferred. Julie DeKinder, OD Responsibilities - Successful candidates for clinical Director, Academic Programs ranks are expected to provide instruction in the The University of Missouri-St. Louis is a public, [email protected] professional program and serve as a mentor for metropolitan land-grant institution committed to basic student research. The primary areas of emphasis and applied research, teaching and service with The University of Missouri-Saint Louis is an equal opportunity/ GHSHQGXSRQSULRUDFFRPSOLVKPHQWVTXDOL¿FDWLRQV 17,000 students and 1,325 full and part-time DI¿UPDWLYHDFWLRQHPSOR\HUFRPPLWWHGWRH[FHOOHQFHWKURXJK and candidate interests. faculty members. UMSL is the largest university in the diversity.

Continuing Education

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REVIEW OF OPTOMETRY AUGUST 15, 2019 87

ROPT0819.indd 87 7/25/19 10:48 PM Cornea+Contact Lens Q+A

High Risk, Limited Options Treatment for limbal stem cell deficient eyes can take one of two routes, neither of which guarantees a successful outcome. Edited by Joseph P. Shovlin, OD Photo: David Hardten, MD I have a patient with severe limbal stem cell deficiency Q (LSCD) who was told by her cornea specialist that she is at high risk for corneal transplantation and her only option is a keratoprosthesis. What is her prognosis with this proce- dure? What are the risks associated with it? Does she have any other options? “There are multiple facets to this question,” A according to Scott G. Hauswirth, OD, who prac- tices and teaches in Colorado, “but it is important to understand the basic premise behind this dilemma.” He says a high-risk transplant is usually defined as one that has a vascularized cornea or a history of multiple grafts. Immunologic rejection can occur in up to 70% of these grafts, even with aggressive, local immunosup- pressive therapy.1 This patient is undergoing limbal stem cell transplantation. Limbal Territory The limbus is the border between the cornea and the worth noting that the limbal stem cell transplantation sclera and is typically 1mm to 2mm wide. It contains option typically only works well if the patient does not a variety of cells with various functions, including the have severe dry eye.3 limbal stem cell niche, which is home to the progenitor Multiple studies show good results for keratopros- cells that eventually differentiate and migrate across the thesis in eyes with LSCD.5-7 One large literature review cornea to form the layers of the corneal epithelium. Dr. noted that 64.1% of eyes reached visual acuities better Hauswirth notes that insult to this area decreases its abil- than 20/200 with a device retention rate of 88.9% over ity to regenerate a healthy corneal epithelium and dis- an average follow-up period of 25 months.8 Similarly, a rupts the barrier function of the limbus, without which study comparing the results of Boston Type I keratopros- the cornea would become repopulated by conjunctiva, thesis implantation in patients with or without LSCD leading to stromal haze, vascularization, opacification revealed a device retention rate of 75% and visual acu- and scarring. ities of at least 20/200 in 77% of patients in the LSCD Unfortunately, corneal transplantation in patients with cohort.5 Outcomes of patients who underwent limbal LSCD is often destined to fail and represents a signifi- stem cell transplantation and penetrating keratoplasty cant challenge to practitioners and surgeons.2-4 were demonstrated in a study of 48 eyes with LSCD— 90% of which were considered high-risk—that achieved Choose Wisely a three-year graft survival rate of 62.5%.4 According to Dr. Hauswirth, there are two methods to Dr. Hauswirth says keratoprosthesis has evolved to address this challenging case—keratoprosthesis or lim- solve the problems presented by multiple graft failures, bal stem cell transplantation, followed by penetrating high-risk grafts and LSCD. He notes, however, that cre- keratoplasty. While both are viable choices, he says the ating a device with biologically inert material that can be decision to choose one over the other depends on the incorporated into the ocular tissues to replace the cornea number of previous corneal transplantation attempts is a novel approach that has taken many different revi- and the degree of scarring and loss of viable limbus. Sur- sions to even come close to perfecting. Dr. Hauswirth geon comfort and experience also play roles, he adds. It’s adds that while Boston type I keratoprosthesis is the

88 REVIEW OF OPTOMETRY AUGUST 15, 2019

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most common in the United States, other methods, such Akorn Pharmaceuticals ...... 21 Phone ...... (800) 932-5676 as tibial bone keratoprosthesis and osteo-odonto-kera- ...... www.akorn.com toprosthesis, have performed well in clinical trials, and Alcon Laboratories ...... 92 some, including AlphaCor keratoprosthesis, are available Phone ...... (800) 451-3937 but have had a less robust uptake in the United States.9 Fax ...... (817) 551-4352 ...... According to Dr. Hauswirth, limbal stem cell trans- Art Optical Contact Lens, Inc...... 59 plantation techniques differ based on the origin of the Phone ...... (800) 253-9364 transplanted tissues and their placement location on the ...... www.artoptical.com

eye but usually involve the use of systemic immunomod- Bausch + Lomb ...... 2, 3, 18 A-B 33 ulatory medications that all have their own set of risks.10 Phone ...... (800) 323-0000 Fax ...... (813) 975-7762 He notes that these stronger local and systemic immuno- ...... modulators keep the host immune system from attacking Bruder Ophthalmic Products ...... 23 the new limbal cells, ensuring corneal graft survival. Phone ...... (888) 827-8337 Dr. Hauswirth says the limbal cells can be harvested ...... [email protected] through autologous cultivation (from a presumably CooperVision ...... 91 healthy second eye), living donor cultivation or allogenic Phone ...... (800) 341-2020 donor cultivation. In the case of allogenic harvesting, Eyevance Pharmaceuticals ...... 29 ABO/HLA tissue matching is preferred.11 He notes that Phone ...... (817) 677-6120 while the cells can also be harvested from a cadaver with ...... eyevance.com or without ABO/HLA matching, these patients would Focus Laboratories, Inc...... 61 Phone ...... (866) 752-6006 likely then be on long-term immunosuppression. After Fax ...... (501) 753-6021 harvesting a 1mm to 2mm section of the limbus, Dr...... www.focuslaboratories.com Hauswirth says the cells are then cultivated on organic Katena ...... 9 media until they reach a size where they can be directly Phone ...... (800) 225-1195 ...... www.katena.com transplanted to the host. On the horizon are methods that involve transplant- Keeler Instruments ...... 5 Phone ...... (800) 523-5620 ing stem cells derived from other areas, such as the oral Fax ...... (610) 353-7814 mucosa, and ex vivo methods of stem cell cultivation, ...... 12,13 including mesenchymal stem cell harvesting. How- Lombart Instruments ...... 55 ever, these methods are rather new and do not have a Phone ...... (800) 446-8092 Fax ...... (757) 855-1232 long track record of success like the two discussed earlier, both of which are worth looking into. ■ Menicon ...... 17 Phone ...... (800) MENICON ...... [email protected] 1. Jabbehdari S, Baradaran Rafii A, Yazdanpanah G, et al. Update on the management of high-risk ...... www.meniconamerica.com penetrating keratoplasty. Curr Ophthalmol Rep. 2017;5(1):38-48. 2. Dua HS, Saini JS, Azuara-Blanco A, et al. Limbal stem cell deficiency: concept, aetiology, clinical OcuSoft ...... 7 presentation, diagnosis and management. Indian J Ophthalmol. 2000;48(2):83-92. Phone ...... (800) 233-5469 3. Sacchetti M, Rama P, Bruscolini A, et al. Limbal stem cell transplantation: clinical results, limits Fax ...... (281) 232-6015 and perspectives. Stem Cells Int. 2018...... 4. Borderie VM, Levy O, Georgeon C, et al. Simultaneous penetrating keratoplasty and amniotic membrane transplantation in eyes with a history of limbal stem cell deficiency. J Fr Ophthalmol. 2018;41(7):583-91. Reichert Technologies ...... 10 5. Aravena C, Bozkurt TK, Yu F, et al. Long-term outcomes of the Boston type I keratoprosthesis in the Phone ...... (888) 849-8955 management of corneal limbal stem cell deficiency. Cornea. 2016;35(9):1156-64. Fax ...... (716) 686-4545 6. Basu S, Taneja M, Narayanan R, et al. Short-term outcome of Boston type 1 keratoprosthesis for ...... www.reichert.com bilateral limbal stem cell deficiency. Indian J Ophthalmol. 2012;60(2):151-3. 7. Sejpal K, Yu F, Aldave AJ. The Boston keratoprosthesis in the management of corneal limbal stem S4OPTIK ...... 25, 27 cell deficiency. Cornea. 2011;30(11):1187-94. Phone ...... (888) 224-6012 8. Shanbhag SS, Saeed HN, Paschalis EI, et al. Boston keratoprosthesis type 1 for limbal stem cell deficiency after severe chemical injury: a systematic review. Ocul Surf. 2018;16(3):272-81. Shire Ophthalmics ...... 13, 14 9. De la Paz MF, Salvador-Culla B, Charoenrook V, et al. Osteo-odonto-, Tibial bone and Boston Phone ...... (877) 266-1144 keratoprosthesis in clinically comparable causes of chemical injury and autoimmune disease. Ocul ...... www.shire.com Surf. April 12, 2019. (Epub ahead of print). 10. Ballios BG, Weisbrod M, Chan CC, et al. Systemic immunosuppression in limbal stem cell trans- Veatch ...... 48, 49 plantation: best practices and future challenges. Can J Ophthalmol. 2018;53(4):314-23. Phone ...... (800) 447-7511 11. Cheung AY, Sarnicola E, Kurji KH, et al. Cincinnati protocol for preoperative screening and donor Fax ...... (602) 838-4934 selection for ocular surface stem cell transplantation. Cornea. 2018;37(9):1192-7. 12. Choe HR, Yoon CH, Kim MK. Ocular surface reconstruction using circumferentially-trephined autologous oral mucosal graft transplantation in limbal stem cell deficiency. Korean J Ophthalmol. Visioneering Technologies, Inc...... 41 2019;33(1):16-25. Phone ...... (844) 884-5367 13. Yazdanpanah G, Jabbehdari S, Djalilian AR. Emerging approaches for ocular surface regeneration...... www.vtivision.com Curr Ophthalmol Rep. 2019;7(1):1-10. This advertiser index is published as a convenience and not as part of the advertising contract. Every care will be taken to index correctly. No allowance will be made for errors due to spelling, incorrect page number or failure to insert.

0088_ro0819_CLQA.indd88_ro0819_CLQA.indd 8899 88/6/19/6/19 4:314:31 PMPM Diagnostic Quiz

Painless But Suffering By Andrew S. Gurwood, OD

History A 77-year-old Caucasian male presented to the office with a chief complaint of poor vision in his left eye for five days. He explained that, upon waking, he noticed his vision was bad. He recounted having been treated by a retinal specialist the last time this happened, that time to his right eye. He reported no pain. His history included medically controlled diabetes and hypertension. He denied allergies This 77-year-old patient has had poor vision in his left eye for nearly a week. Can the of any kind. details of his exam and these fundus images explain the cause of his disturbance?

Diagnostic Data anterior segment was normal in you take to manage this patient? His best-corrected entering visual the right eye, but found suspended Based on the information provided, acuities were 20/20 OD and red cells in the anterior chamber what would be your diagnosis? 20/200 OS at distance and near. of the left. Goldmann applanation What is the patient’s most likely His external examination uncov- tonometry measured 15mm Hg prognosis? To find out, please visit ered a central scotoma in the left OU. www.reviewofoptometry.com. ■ eye upon facial Amsler testing. All other external findings were Your Diagnosis normal, and there was no evidence Does the case presented require Retina Quiz Answers of afferent pupillary defect. Bio- any additional tests, history or (from page 80): 1) b; 2) a; 3) c; 4) b. microscopic examination of the information? What steps would

Next Month in the Mag • Learning to Live with Blue Light Exposure Coming in September, Review of Optometry will present its • Tools and Tech for Low Vision and Visual Rehabilitation Annual Technology Issue. Topics include:

Also in this issue: • Retinal Imaging Technologies: In With the New and With the Old • Getting to the Bottom of Corneal Infiltrates (Earn 2 CE Credits) • How to Get More Out of Your OCT • How to Prescribe Pain Medications Responsibly

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90 REVIEW OF OPTOMETRY AUGUST 15, 2019

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