10 Tips for Improving Visual Fields, Page 62 REVIEW OF OPTOMETRY ■
VOL. 152 NO. 4 ■ April 15, 2015 www.reviewofoptometry.com
CORNEAL DISEASE
APRIL 15, 2015 ■ REPORT
EARN 2 CE CREDITS CORNEAL DISEASE REPORT ■ Corneal Harbingers OF SYSTEMIC DISEASE
VISUAL FIELD TESTING ■
A routine slit lamp exam may reveal telltale findings of health concerns elsewhere in the body. Here are the most common to look for. PAGE 53
» Firm Up Your Approach to Corneal Ectasia, PAGE 28 PRESCRIBING CHALLENGES
» Slit Lamp Essentials: Perform DBD with ASP for Stubborn RCE, PAGE 36
» Seeing Red: How Ocular Rosacea Impacts the Cornea, PAGE 46 » PLUS — Beat These Modern Day Prescribing Challenges, PAGE 70
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VOL. 152 NO. 4 ■ APRIL 15, 2015
IN THE NEWS Azithromycin Better
A thousand-year-old Anglo-Saxon remedy for eye infections, taken from Than Doxy for MGD a medieval medical “leech book,” has been found to kill the modern-day su- A new study says azithromycin better improves signs and perbug MRSA, according to microbiol- symptoms—at a lower price. By John Murphy, Executive Editor ogists at the University of Nottingham in the UK. The researchers demon- ral doxycycline has been a improvement of clinical signs and strated that “Bald’s eye salve” kills up mainstay for treating me- symptoms. But, the percentage of to 90% of MRSA bacteria in wound Obomian gland dysfunction clinical improvement was signifi- biopsies from in vivo mouse models. (MGD), but now a head-to-head cantly better in the azithromycin They believe the bactericidal effect of clinical trial has found that oral group, with particularly more the recipe is not due to a single ingre- azithromycin works better, faster, improvement in conjunctival red- dient but a combined effect, along with cheaper and with fewer side effects. ness and ocular surface staining.
the brewing methods and the container Photo: Paul Karpecki, OD In addition, patients in the doxy- material used. The researchers are cycline group had more gastrointes- continuing to investigate how and why tinal side effects (26%) than those in the ancient formula works. the azithromycin group (4%). Azithromycin is also much less The FDA decided not to approve expensive. “Since MGD is a chronic Avedro’s new drug application for its disease, multiple five-day pulse ribofl avin/KXL System for corneal treatment with azithromycin would crosslinking. This came as something be cheaper than long-term daily oral of a surprise because an FDA advisory doxycycline,” the authors wrote. panel had recommended the corneal When conservative treatment doesn’t Alan Kabat, OD, medical direc- crosslinking platform for approval in work, what’s the best medicine for MGD? tor for the TearWell Advanced Dry February. “We are disappointed with A new study finds it’s azithromycin. Eye Treatment Center in Memphis, the outcome of the review and the Tenn., says the study’s findings are implications this has for patients in The study, published in February’s welcome news. “I’d rather tell my the US suffering from keratoconus or British Journal of Ophthalmology, patients to do something once a corneal ectasia who remain in need of found that both oral azithromycin day for a week than twice a day for a therapeutic treatment for these sight- and doxycycline improved symp- a month, especially if the outcome threatening conditions,” said Avedro’s toms of MGD. However, patients will be the same,” he says. “Going CEO David Muller, PhD. on azithromycin had relatively bet- forward, I will certainly consider ter improvement in symptoms and using azithromycin one week per The FDA expanded the approved signs along with fewer side effects. month in my recalcitrant MGD use for Eylea intravitreal injection The researchers randomly patients.” (afl ibercept, Regeneron Pharmaceu- assigned 110 patients with MGD to He emphasizes that oral treat- ticals) to treat diabetic retinopathy in receive either a five-day course of ment is not the go-to therapy for patients with diabetic macular edema. oral azithromycin (500mg on day patients with MGD, but rather it’s Eylea is already approved to treat wet one, then 250mg/day) or one month for patients in whom conservative age-related macular degeneration, as of oral doxycycline (200mg/day). treatment proves insufficient or inef- well as diabetic macular edema and Patients continued eyelid warming/ fective. macular edema secondary to retinal cleaning and artificial tears. Kashkouli MB, Fazel AJ, Kiavash V, et al. Oral azithromycin vein occlusions. versus doxycycline in meibomian gland dysfunction: a After two months, both treat- randomised double-masked open-label clinical trial. Br J ment groups showed a significant Ophthalmol. 2015 Feb;99(2):199-204.
4 REVIEW OF OPTOMETRY APRIL 15, 2015
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Visual Fixation in Newborns Predicts Childhood Cognitive Development atching a baby’s eye is more soning at five years of age. than one of the joys of early According to the authors, their Cparenthood. It’s also a sign findings suggest that newborn VF is of brain development. A new study supported by brain-wide subcortical in The Journal of Neuroscience networks and represents an early found that early visual fixation pre- building block for the developmen- dicts neurocognitive development. tal cascades of cognition. Their “For many years, we have sus- study highlights the need to develop pected that such links exist,” says objective and quantitative measures Glen T. Steele, OD, FCOVD, pro- of newborn eye contact to help rec- fessor of Pediatric Optometry at A baby’s visual fixation holds clues to ognize developmental risks early on. Southern College of Optometry, and brain development as a child. To Dr. Steele, this is a very impor- chair of the InfantSee program and tant article that joins a growing Children’s Vision Committee of the In particular, the study sheds light body of work linking visual fixation American Optometric Association. on the scientific relevance of the eye ability to overall development, even contact of newborns. Researchers at including autism. He has lectured the University of Helsinki and Hel- on the development and importance Patient Takes ‘Contact Lens sinki University Central Hospital in of looking behavior, and he says the Adherence’ to a New Level Finland investigated the relationship article further emphasizes the need between newborn visual fixation for earlier identification and inter- (VF) and gaze behavior to perfor- vention in all aspects of visual fixa- mance in visuomotor and visual tion and function. “We can’t wait reasoning tasks in two cohorts with until they are three or five years old cognitive follow-up at two (n=57) to get involved, as much of their and five (n=1,410) years of age. future abilities are already deter- They determined that newborn mined in these early years,” he says. VF is significantly related to visual- Stjerna S, Sairanen V, Gröhn R, et al. Visual fi xation in human newborns correlates with extensive white matter networks motor performance at both two and and predicts long-term neurocognitive development. J Optometrist Monika Marczak, of McMur- five years, as well as to visual rea- Neurosci. 2015 Mar 25;35(12):4824-9. ray, Pa., found this contact lens that was “lost” under a patient’s lid for two and a half months. The patient hadn’t com- Scope Bill in New Mexico plained of any foreign body sensation, photophobia or decreased vision. But ptometrists in New In addition to prescribing powers, she did report mucus discharge the night Mexico may have reason the bill gives the board of optometry before and a slight swelling of the top lid. Oto celebrate soon, as a bill the “sole authority to determine “Once I stained the eye with a fl uores- expanding their scope of practice what constitutes the practice of cein sodium strip and inverted the top lid, passed in the state legislature with a optometry in accordance with the there was a thick layer of mucus deep unanimous vote on March 25. provisions of the Optometry Act” in the upper fornix,” Dr. Marczak says. Specifically, the bill allows ODs to and “sole jurisdiction to exercise “I removed the strand of mucus with prescribe hydrocodone and hydro- any other powers and duties under jeweler’s forceps, and only then was I codone-combination medications. It that act.” able to see there was a contact lens that also permits optometrists to admin- At press time, the bill was on was even deeper within the fornix.” ister epinephrine auto-injectors to the desk of Gov. Susanna Martinez counter anaphylaxis. awaiting her signature.
6 REVIEW OF OPTOMETRY APRIL 15, 2015
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RO0215_B & L Peroxiclear.indd 1 1/20/15 3:29 PM News Review
Highlights of SECO 2015 n treating glaucoma patients, ments” special session. Widefield don’t focus only on findings angiography, for instance, gives
such as high IOP. Also consider doctors a better view of the retina, BUSINESS OFFICES I 11 CAMPUS BLVD., SUITE 100 the impact that glaucoma has on allowing them to identify tears NEWTOWN SQUARE, PA 19073 quality of life, said David Friedman, along the periphery—possibly dis- CEO, INFORMATION SERVICES GROUP MD, during the “New Angles in pelling the “misconception that vit- MARC FERRARA Glaucoma” special session, which reous detachment only includes the (212) 274-7062 • [email protected]
he presented with Murray Fingeret, posterior pole,” Dr. Rafieetary said. PUBLISHER OD, at SECO 2015 in Atlanta in Ignoring changes in the periphery, JAMES HENNE (610) 492-1017 • [email protected] early March. he added, could lead to the develop- REGIONAL SALES MANAGER “The people across the chair are ment of horseshoe tears. MICHELE BARRETT not just people who need to be told The “Cutting Edge Cornea” (610) 492-1014 • [email protected]
that they have so many ganglion course offered a look at recent REGIONAL SALES MANAGER cells. That’s such a small part of advancements in corneal surgeries, MICHAEL HOSTER (610) 492-1028 • [email protected] what we’re doing in the clinic for including a sneak peek at corneal VICE PRESIDENT, OPERATIONS our patients,” said Dr. Friedman, inlays. According to speaker Terry CASEY FOSTER who is the director of the Dana Kim, MD, corneal surgeon and (610) 492-1007 • [email protected]
Center for Preventive Ophthalmol- professor at Duke University School VICE PRESIDENT, CLINICAL CONTENT ogy at Johns Hopkins University of Medicine, recent breakthroughs PAUL M. KARPECKI, OD, FAAO [email protected] School of Medicine. “We talk a lot in the safety and design of these PRODUCTION MANAGER about quality of life, but we do very devices could lead to their use for SCOTT TOBIN little about it.” presbyopia management. (610) 492-1011 • [email protected]
Focusing on quality of life helps SENIOR CIRCULATION MANAGER patients achieve the best outcomes And the Award Goes To… HAMILTON MAHER (212) 219-7870 • [email protected] possible, Dr. Friedman said. “Reha- In addition to continuing educa- CLASSIFIED ADVERTISING bilitation needs to be part of how tion, eye care professionals also (888) 498-1460 we care for patients.” came together to honor colleagues SUBSCRIPTIONS who have contributed significant $56 A YEAR, $88 (US) IN CANADA, advancements to the profession. $209 (US) IN ALL OTHER COUNTRIES. SECO’s highest honor, Optom- SUBSCRIPTION INQUIRIES (877) 529-1746 (US ONLY); etrist of the South, was awarded to OUTSIDE US, CALL (845) 267-3065 Richard Phillips, OD, of German- CIRCULATION town, Tenn., for his nearly three PO BOX 81 decades of practice and countless CONGERS, NY 10920-0081 OUTSIDE THE US, CALL 845-267-3065 leadership roles. Rob Pate, OD, of Hoover, Ala., was awarded Young Optometrist of
Outgoing SECO president Jim Herman, OD, the South for the significant impact CEO, INFORMATION SERVICES GROUP passed the gavel to incoming president he has made in less than 10 years of MARC FERRARA Stan Dickerson, OD. practice. SENIOR VICE PRESIDENT, OPERATIONS Last but certainly not least was JEFF LEVITZ Other Special Sessions the award for Paraoptometric of SENIOR VICE PRESIDENT, HUMAN RESOURCES LORRAINE ORLANDO Also at SECO 2015, speakers the South, presented to Caroline Eric Sigler, MD, and Mohammad Riggins, CPO, of Enoree, SC. As VICE PRESIDENT, CREATIVE SERVICES & PRODUCTION MONICA TETTAMANZI Rafieetary, OD, focused in part on president of the South Carolina VICE PRESIDENT, CIRCULATION the technologies that have made Paraoptometric Association from EMELDA BAREA sweeping changes in diagnostics in 2008 to 2011, she helped revitalize the “Spectrum of Retinal Detach- its lecture program. ■
8 REVIEW OF OPTOMETRY APRIL 15, 2015
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RO0215_Novabay.indd 1 1/28/15 11:01 AM Contents Review of Optometry April 2015 10 Tips For Improving Corneal 62 Visual Fields Disease Perimetry may seem like second nature, but these recommen- Report dations can help you obtain better results by refining your understanding of the technology. By Matt Horton, OD
Firm Up Your Approach to 28 Corneal Ectasia Optometrists must see these patients “through thick and thin.” By Karen Yeung, OD, and Sally Wu
Essential Procedures at the Slit Lamp: Perform DBD with ASP for Beat These Modern Day 36 Stubborn RCE 70 Prescribing Challenges If anterior stromal puncture doesn’t do the job for recalcitrant Today’s optometrists face difficult Rx decisions—from manag- recurrent corneal erosion, here’s a more aggressive option. ing pregnant patients to deciding whether a generic can be By Jason Ellen, OD, and Nathan Lighthizer, OD substituted for a brand. By Jane Cole, Contributing Editor
Seeing Red: How Ocular 46 Rosacea Impacts the Cornea Don’t forget that this condition can affect more than just the eyelids. Here’s what you need to know. By Sara Weidmayer, OD
Earn 2 CE Credits: Corneal Harbingers 53 of Systemic Disease A routine slitt llamp exam may reveall ttelltalellt l ffindingsi di of health concerns elsewhere in the body. Here are the most common to look for. By Andrew Bronner, OD
REVIEW OF OPTOMETRY APRIL 15, 2015 11
011_ro0415_toc.indd 11 4/6/15 11:52 AM Departments On The Web ›› Review of Optometry April 2015 and more 4 News Review Check out our multimedia and continuing education online at: 16 Outlook 20 www.reviewofoptometry.com The Societal Network JACK PERSICO Digital Edition 18 Chairside Left your copy of Friends and Family Discount Review of Optometry at MONTGOMERY VICKERS, OD the office? No problem! Access Review on your 20 Urgent Care computer or mobile device! Giant Cell Arteritis Warnings Go to www.reviewofoptometry. RICHARD MANGAN, OD com and click on the digimag link for the current issue. 24 Focus on Refraction As Flexible as an Oak Facebook and Twitter PAUL HARRIS, OD, AND For daily updates, “Like” MARC B. TAUB, OD, MS our page on Facebook or 26 Clinical Quandaries 24 “Follow” us on Twitter! Open Season on Closed Angles • www.facebook.com/revoptom PAUL C. AJAMIAN, OD • http://twitter.com/#!/revoptom 40 Coding Connection Coding for RCE and ASP JOHN RUMPAKIS, OD, MBA Look for augmented content and special offers from Review and 82 Cornea + Contact Lens Q+A our advertisers. Specified pages Navigating the Slippery Slope work in conjunction with your JOSEPH P. SHOVLIN, OD smartphone or other mobile device to enhance the experience. 84 Glaucoma Grand Rounds With Layar, interactive content Get Your Priorities in Order leaps off the page! JAMES L. FANELLI, OD 88 Retina Quiz 26 Vision Loss with Wet AMD MARK T. DUNBAR, OD Step1: Download the free Layar 92 Therapeutic Review app for iPhone or Android. Wearable Therapy for Dry Eye ALAN G. KABAT, OD AND JOSEPH W. SOWKA, OD 97 Surgical Minute Caution! Traumatic Cataracts Ahead Step 2: Look for pages with the DEREK N. CUNNINGHAM, OD, AND Layar Logo. WALTER O. WHITLEY, OD, MBA INTERACTIVE PRINT 99 Product Review 106 100 Meetings + Conferences Step 3: Open the Layar app, hold the phone above the page 101 Advertisers Index and tap to scan it. Hold the 102 phone above the page to view Classifieds the interactive content. 106 Diagnostic Quiz Head First Into the Exam Room The first 150 app downloads and completed ANDREW S. GURWOOD, OD forms will be entered into a drawing for a complimentary registration to one of Review’s 14-hour CE meetings, valued at $495. Stock Images: ©iStock.com/JobsonHealthcare
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RO0415_Zeiss.indd 1 3/19/15 3:09 PM CONTRIBUTING EDITORS JERRY CAVALLERANO, OD, PHD, BOSTON PAUL C. AJAMIAN, OD, ATLANTA WALTER L. CHOATE, OD, MADISON, TENN. AARON BRONNER, OD, KENNEWICK, WASH. BRIAN CHOU, OD, SAN DIEGO MILE BRUJIC, OD, BOWLING GREEN, OHIO A. PAUL CHOUS, MA, OD, TACOMA, WASH. DEREK N. CUNNINGHAM, OD, AUSTIN, TEXAS ROBERT M. COLE, III, OD, BRIDGETON, NJ MARK T. DUNBAR, OD, MIAMI GLENN S. CORBIN, OD, WYOMISSING, PA. ARTHUR B. EPSTEIN, OD, PHOENIX ANTHONY S. DIECIDUE, OD, STROUDSBURG, PA. JAMES L. FANELLI, OD, WILMINGTON, NC S. BARRY EIDEN, OD, DEERFIELD, ILL. FRANK FONTANA, OD, ST. LOUIS STEVEN FERRUCCI, OD, SEPULVEDA, CALIF. GARY S. GERBER, OD, HAWTHORNE, NJ MURRAY FINGERET, OD, HEWLETT, NY ANDREW S. GURWOOD, OD, PHILADELPHIA IAN BEN GADDIE, OD, LOUISVILLE, KY. ALAN G. KABAT, OD, MEMPHIS, TENN. MILTON HOM, OD, AZUSA, CALIF. DAVID KADING, OD, SEATTLE BLAIR B. LONSBERRY, MS, OD, MED, PORTLAND, ORE. PAUL M. KARPECKI, OD, LEXINGTON, KY. THOMAS L. LEWIS, OD, PHD, PHILADELPHIA JEROME A. LEGERTON, OD, MBA, SAN DIEGO DOMINICK MAINO, OD, MED, CHICAGO JASON R. MILLER, OD, MBA, POWELL, OHIO KELLY A. MALLOY, OD, PHILADELPHIA CHERYL G. MURPHY, OD, HOLBROOK, NY RICHARD B. MANGAN, OD, LEXINGTON, KY. CARLO J. PELINO, OD, JENKINTOWN, PA. RON MELTON, OD, CHARLOTTE, NC JOSEPH PIZZIMENTI, OD, FORT LAUDERDALE, FLA. PAMELA J. MILLER, OD, JD, HIGHLAND, CALIF. JOHN RUMPAKIS, OD, MBA, PORTLAND, ORE. BRUCE MUCHNICK, OD, COATESVILLE, PA. DIANA L. SHECHTMAN, OD, FORT LAUDERDALE, FLA. MARC MYERS, OD, COATESVILLE, PA. JEROME SHERMAN, OD, NEW YORK WILLIAM B. POTTER, OD, FREEHOLD, NJ JOSEPH P. SHOVLIN, OD, SCRANTON, PA. CHRISTOPHER J. QUINN, OD, ISELIN, NJ JOSEPH W. SOWKA, OD, FORT LAUDERDALE, FLA. JOHN L. SCHACHET, OD, ENGLEWOOD, COLO. MONTGOMERY VICKERS, OD, ST. ALBANS, W.VA. JACK SCHAEFFER, OD, BIRMINGHAM, ALA. WALTER O. WHITLEY, OD, MBA, VIRGINIA BEACH, VA. MICHAEL C. RADOIU, OD, STAUNTON, VA. KIMBERLY K. REED, OD, FORT LAUDERDALE, FLA. EDITORIAL REVIEW BOARD LEO P. SEMES, OD, BIRMINGHAM, ALA. JEFFREY R. ANSHEL, OD, CARLSBAD, CALIF. LEONID SKORIN, JR., OD, DO, ROCHESTER, MINN. JILL AUTRY, OD, RPH, HOUSTON BRAD M. SUTTON, OD, INDIANAPOLIS SHERRY J. BASS, OD, NEW YORK LORETTA B. SZCZOTKA, OD, PHD, CLEVELAND EDWARD S. BENNETT, OD, ST. LOUIS TAMMY P. THAN, MS, OD, BIRMINGHAM, ALA. MARC R. BLOOMENSTEIN, OD, SCOTTSDALE, ARIZ. RANDALL THOMAS, OD, CONCORD, NC CHRIS J. CAKANAC, OD, MURRYSVILLE, PA. KATHY C. WILLIAMS, OD, SEATTLE
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FOUNDING EDITOR FREDERICK BOGER The Societal Network 1891-1913
EDITORIAL OFFICES A new shared database lets ODs pool their clincial data, 11 CAMPUS BLVD., SUITE 100 NEWTOWN SQUARE, PA 19073 for the benefit of everyone. By Jack Persico, Editor-in-Chief EMAIL • [email protected] WEBSITE • WWW.REVOPTOM.COM magine every optometrist wide statistics and benchmarks. It’s SUBSCRIPTION INQUIRIES in the country being able optometry’s foray into the world of 1-877-529-1746 CONTINUING EDUCATION INQUIRIES “Ito collaborate on outcomes so-called “big data,” a trendy phrase 1-800-825-4696 for glaucoma management, amblyo- for the mining of massively large
EDITOR-IN-CHIEF • JACK PERSICO pia treatment, contact lens-induced databases to improve knowledge. (610) 492-1006 • [email protected] ulcers, myopia progression and It’ll also help you with the mun-
EXECUTIVE EDITOR • JOHN MURPHY more using evidence-based out- dane and often frustrating work (610) 492-1021 • [email protected] comes to improve our patient’s care of satisfying EHR meaningful use
SENIOR EDITOR • BILL KEKEVIAN instead of waiting years for clinical requirements and reporting to Medi- (610) 492-1003 • [email protected] trials,” said Jeff Michaels, OD, in care’s Physician Quality Reporting
ASSOCIATE EDITOR • ALIZA MARTIN an announcement about the AOA’s System. The AOA is working with (610) 492-1043 • [email protected] new clinical data registry. “As the EHR vendors to pull relevant data DIRECTOR ART/PRODUCTION • JOE MORRIS primary eye care profession, this is on patient care without compro- (610) 492-1027 • [email protected] a huge opportunity for optometry mising the privacy of patients or ART DIRECTOR • JARED ARAUJO and the millions of patients we serve doctors. The Academy of Ophthal- (610) 492-1032 • [email protected] every year.” mology has a similar registry, called DIRECTOR OF CE ADMINISTRATION • REGINA COMBS IRIS. Hopefully, there will come a (212) 274-7160 • [email protected] Treat Locally, Act Globally day when the two databases can be SPECIAL PROJECTS/E-PRODUCTS MANAGER • KAREN ROMAN That tantalizing prospect is how the merged or at least connected. (610) 492-1037 • [email protected] AOA describes the Measures and In the meantime, look for MORE EDITORIAL BOARD Outcomes Registry for Eyecare, or to launch at the AOA’s annual meet- CHIEF CLINICAL EDITOR • PAUL M. KARPECKI, OD ASSOCIATE CLINICAL EDITORS • JOSEPH P. SHOVLIN, OD; MORE for short. It’s a good pitch. ing in Seattle this June. ALAN G. KABAT, OD; CHRISTINE W. SINDT, OD Doctors by their very nature want DIRECTOR OPTOMETRIC PROGRAMS • ARTHUR EPSTEIN, OD to help people—so, here’s a chance A Registry on Your Wrist CLINICAL & EDUCATION CONFERENCE ADVISOR PAUL M. KARPECKI, OD to join in a project that helps all Patients are getting connected, CASE REPORTS COORDINATOR • ANDREW S. GURWOOD, OD patients, not just the one in your too. Apple’s new initiative called CLINICAL CODING EDITOR • JOHN RUMPAKIS, OD, MBA CONSULTING EDITOR • FRANK FONTANA, OD chair right now. Your patient base is ResearchKit puts software on then no longer just your own com- phones and, soon, watches that lets COLUMNISTS CHAIRSIDE • MONTGOMERY VICKERS, OD munity, it’s society at large. patients register for medical stud- CLINICAL QUANDARIES • PAUL C. AJAMIAN, OD It’s a logical extension of the ies and enter health information CORNEA & CONTACT LENS Q+A • JOSEPH P. SHOVLIN, OD DIAGNOSTIC QUIZ • ANDREW S. GURWOOD, OD increasingly interconnected way directly into a clinical trial database. GLAUCOMA GRAND ROUNDS • JAMES L. FANELLI, OD of things nowadays. With online When everyone is walking around OCULAR SURFACE REVIEW • PAUL M. KARPECKI, OD URGENT CARE • RICHARD B. MANGAN, OD access ubiquitous and social net- with, in effect, a Star Trek tricorder RETINA QUIZ • MARK T. DUNBAR, OD working a routine part of everyday in their hand or strapped to their REVIEW OF SYSTEMS • CARLO J. PELINO, OD; life, doctors are sharing information wrist, ambitious stuff becomes JOSEPH J. PIZZIMENTI, OD SURGICAL MINUTE • DEREK N. CUNNINGHAM, OD; and advice about patient care all possible. Of course, not everyone WALTER O. WHITLEY, OD, MBA the time. But discussions online can has these popular but inessential THERAPEUTIC REVIEW • JOSEPH W. SOWKA, OD; ALAN G. KABAT, OD get wild and woolly, and privacy is gadgets. Income and age disparities NEURO CLINIC • MICHAEL TROTTINI, OD; always a concern. Plus, there’s no could skew the results mightily if MICHAEL DELGIODICE, OD FOCUS ON REFRACTION • MARC TAUB, OD; systematic way to analyze the data. not controlled for in data analysis. PAUL HARRIS, OD Services like the MORE registry But connecting patients, doctors and
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Friends and Family Discount Where’s the worst place to find your loved ones? In poverty? In prison? In trouble? Nope, it’s in your exam chair. By Montgomery Vickers, OD othing on earth is more an exam this year.” Folks, you can but they’re still on the same sample important than family. have your eyes examined any damn bottle I gave them last summer may NI want my family to be time you want. Suppose your insur- disagree, smack me back, or, more happy, happy, happy all of the time! ance only pays every other year; likely, prosecute. Therefore, I avoid them whenever that just means you get 50% off A jury of my OD peers would possible. EVERY YEAR—but only if you never convict me. Just kidding. The fact that my show up every year. But if you don’t believe in spank- family spreads from Texas to And they ask, “Are your glasses ing, how about a “time out”? Next California to Ohio actually creates a cheap?” Yes, my glasses are free! time your patient’s cell phone goes buffer that allows me to spend qual- But your glasses, purchased right off during the exam, try stepping ity time on the phone or Facetime here, will NEVER be CHEAP. out of the room for a while. An with each and every one of them. I Inexpensive? I can do that. Worth hour or so should do it. always make sure that I tell each of it? I can do that, too. Cheap? No. Also, the next time a long-lost them something meaningful. “Can you tell Mom she can’t cousin comes up at the family bar- More often than not, I say this: drive any more?” How would I becue and asks you about his eyes, “Here’s your mother.” know? She never drove me any- just smile and “remind him” that That always cheers them up. where. But I can tell you whether you’re a dentist. And don’t forget to she does or does not meet the legal tell him you moved your office to It Isn’t Chair Time, visual requirement for driving in the Canada. It’s Quality Time state of West Virginia. So, tell you Treat the patients like family, But as lovely as family may be, what… If you’ll call my Mom and that’s all I’m saying. That means lis- family also may cause our most pal- tell her she can’t drive, I will call ten to them. Teach them and learn pable distress. yours. Deal? from them. Respect them. And, Nowhere is this more true than when you need to, send them out- in the office. Young optometrists, When You’re Here, side to cut their own switch. ■ please listen. Do not believe for one You’re Family minute that your family will be your It’s just family stuff—things we first and best patients. Oh, they’ll all face as sons and daughters and probably come to you for eye care spouses and parents and grand- and eyewear. After all, the price is parents. Now, for me, I still think right, right? But, they will not lead spanking can be a good teaching to a profitable practice. That’s not tool. However, my glaucoma their problem. It is yours and yours patients who alone. swear they take I’ve been in practice for 35 years. their meds That means my family includes every day people I would have never met if it wasn’t for the office. I love them. They (mostly) love or at least kindly tolerate me. It’s a family. Sure, we squabble. I fuss at them for saying asinine things like, “My insurance won’t let me come for
18 REVIEW OF OPTOMETRY APRIL 15, 2015
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Giant Cell Arteritis Warnings Don’t miss the subtle signs of this potentially sight-robbing condition. By Richard Mangan, OD
iant cell arteritis (GCA), ischemic optic neuropathy also known as temporal (AAION).6,7 A study esti- Garteritis, is the most com- mates that one out of five mon vasculitis in adults older than patients diagnosed with 50 years, with an incidence of GCA will develop mon- approximately 18 per 100,000 per ocular vision loss related to year.1 It affects women four times AAION, with more than more often than it affects men and one-third experiencing one has a prevalence that is highest in or more episodes of tran- caucasians, especially those of Scan- sient vision loss prior to dinavian or Northern European the event.6 Vision is often decent.2-4 count fingers or worse and The disease is a vasculitis affect- is accompanied by a pro- ing medium and large-sized vessels nounced afferent pupillary Fig. 1. Optic nerve and retinal ischemia consistent that commonly, although not exclu- defect. If left untreated, with AAION and GCA. sively, develop in the superficial approximately 50% will temporal artery and other extra- go on to lose vision in the While GCA most commonly affects cranial branches of the carotid fellow eye within days to weeks of patients older than 65 years, be on artery. This explains why a head- onset.8 AAION secondary to GCA the lookout for this condition in ache is the most common symptom is considered a true ocular emer- any patients older than 50 years associated with GCA.5 gency. who complain of antecedent or Often, GCA can develop into In the acute phase, the optic simultaneous temporal head pain, sudden vision loss and is considered nerve will appear swollen and pale scalp tenderness and jaw claudica- a true ocular emergency. This arti- (figure 1), often associated with tion (pain with chewing). Proximal cle reviews the sequelae, diagnosis flame-shaped hemorrhages. muscle and joint pain (polymyalgia and treatment of GCA. Later, as the swelling subsides, rheumatica), as well as constitu- optic atrophy sets in. Other signs tional symptoms such as fatigue, AAION that may be associated with sweating, fever and weight loss, A highly-feared sequelae of GCA AAION include cotton wool spots, should raise suspicion for GCA. It involves sudden, painless and pro- central retinal artery occlusion, is important to note, however, that found vision loss in one or both branch retinal artery occlusion and approximately one out of every five eyes secondary to arteritic anterior cranial nerve involvement (espe- patients who present with visual cially CN VI). The affected eye will loss secondary to AAION do so Table 1. Physical Examination often show an altitudinal visual without any systemic complaints. • Examination of the temporal artery to field defect, but arcuate and ceco- detect prominence, noularity, or tender- central scotoma’s have also been Diagnosis ness of a palpation of the artery and the surrounding skin. reported. How important is it to confirm the • Evaluate the strength of the temproal diagnosis through temporal artery artery pulse. Case History biopsy before starting treatment? • Perform ausculation of the carotid artery Perform a thorough and careful Initiation of oral or IV steroids for bruits. case history when confronted with can adversely affect the results of • Check blood pressure. an acute ischemic optic neuropathy. a temporal artery biopsy, the gold-
20 REVIEW OF OPTOMETRY APRIL 15, 2015
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standard diagnostic procedure in • New-onset head- confirming GCA.10 However, when ache. dealing with visual symptoms or • Positive temporal sudden severe vision loss in one artery biopsy. eye related to AAION, waiting for If three out of five a biopsy result is not an option. are considered posi- Given the potentially devastating tive, this carries a sen- consequences of delaying treatment, sitivity (93.5%) and order bloodwork (CBC, ESR, CRP, specificity (91.2%) FBS, FTA-ABS and ANA) and initi- that distinguishes ate treatment immediately, ideally GCA from other in cooperation with a specialist in forms of vasculitis.18 internal medicine or rheumatology. Therefore, even in Studies show that if aggressive cases where the ESR steroid treatment is initiated within and biopsy results are Fig. 2. Fluorescein angiography typically shows delayed the first 24 hours of the onset of inconclusive, patients choroidal and central retinal artery filling, with possible visual symptoms, the patient has a that present with an choroidal nonperfusion, especially in the peripapillary area. better than 50% chance of obtain- AAION and have the ing some improvement in vision. A other risk factors listed here should What is generally agreed upon is delay in treatment drops these odds be treated promptly. that patients with transient or per- to approximately 5%.11 sistent vision loss need immediate A temporal artery biopsy should IV vs. Oral Steroid Delivery treatment by either delivery meth- still be ordered and ideally per- Research has yet to clearly establish od, whichever will be most timely. formed within one week of starting the benefits of IV methylpredniso- In general, therapy with high-dose steroids. Evidence suggests that lone vs. oral steroids with respect oral steroids is necessary for several immediate treatment does not usu- to improved visual recovery. Some weeks and is then followed by a ally confound biopsy results within studies report improved visual slow taper and maintenance dosing this time frame and in some cases recovery with IV delivery while oth- to maintain a low ESR and CRP.21 for as long as three weeks out.12 ers report no difference.19-20 The case for IV administration of Prognosis False Negatives methylprednisolone instead of oral The main goal of treatment is to Note that not all patients with GCA administration of steroids is based prevent involvement of the fellow will have abnormal labs. Fifteen more on the importance of prompt eye and other systemic vascular percent to 30% of patients with initiation of treatment and control complications such as stroke or positive temporal artery biopsies of side-effects from treatment rather myocardial infarction. While some have a normal ESR.13-15 It is also than better outcomes. First, compli- anecdotal cases report significant important to note that biopsy of the ance is 100% when medication is visual improvement with prompt temporal artery carries a significant given intravenously. Also, drugs treatment, the prognosis for visual false negative rate (5% to 9%) due are typically more potent and act recovery from AAION is generally to skip lesions.16 faster when delivered intravenously. poor. In fact, 30% of patients will The American College of Rheu- Studies suggest that patients started continue to suffer visual decline matology (ACR) has developed a on a three-day induction dose of despite aggressive IV methylpred- five-point scoring system with equal IV methylprednisolone, 15mg/ nisolone treatment.22 weighting for each of the following kg/d (about 1g per day), followed Risk factors for progressive five parameters for GCA diagno- by oral prednisolone therapy (40 visual loss despite steroid therapy sis:17 to 60mg/d) are able to be weaned include an elevated CRP, older • Age more than 50 years. off oral steroids faster than when age, and significant optic disc • A Westergren ESR greater than placed on oral treatment alone.20 swelling.23 50. Patient tolerance of IV methylpred- Giant cell arteritis is a severe • Temporal artery tenderness or nisolone is similar to that found inflammatory condition that can abnormality on exam (table 1). with oral administration. lead to stroke, blindness, and heart
22 REVIEW OF OPTOMETRY APRIL 15, 2015
0020_ro0415_urgent.indd20_ro0415_urgent.indd 2222 44/1/15/1/15 11:1711:17 AMAM attack. Two thirds of patients with (temporal) arteritis? Ann Intern Med 1994;120:987–92. 13. Huston K, Hunder G, Lie J, et al. Temporal artertitis: a GCA offer a chief complaint of 25-year epidemiologic, clinical, and patholgic study. Ann Intern headache or temporal head pain. Med 1978;88:162-67. 14. Smetana G, Shmerling, R. Does this patient have temporal Knowing the other signs, symp- arteritis? JAMA 2002;287:92-101. toms, and risk factors for GCA 15. Hayreh S, Podhajsky, P, Raman, R, Zimmerman, B. Giant cell arteritis: validity and reliability of various diagnositic criteria. Am may allow you to act in time so as J Ophthalmol 1997;123:285-96. to avoid serious complications, like 16. Gonzalez EB. Arteritis associated with systemic disease. Coron Artery Dis 1995;6:207–12. blindness, from happening on your 17. Hunder G, Bloch D, Michel B, et al. The American College watch. ■ of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum 1990;33:1122–8. 18. Haist S. Stroke after temporal artery biopsy. Mayo Clin Proc 1. Unwin B, Williams C, Gilliland W. Polymyalgia rheumatica 1985;60:538. and giant cell arteritis. Am Fam Physician 2006;74:1547–54. 19. Chevalet P, Barrier J, Pottier P, et al. A randomized, 2. Eberhardt R, Dhadly M. Giant cell arteritis: diagnosis, Fig. 3. In the late phase of the angiogram, multicenter, controlled trial using intravenous pulses of methyl- management, and cardiovascular implications. Cardiol Rev leakage of dye is bound by the area of prednisolone in the initial treatment of simple forms of giant cell 2007;15:55–61. arteritis: a one-year follow-up study of 164 patients. J Rheumatol 3. Smith C, Fidler W, Pinals R. The epidemiology of giant cell optic disc swelling. 2000;27:1484–91. arteritis: report of a ten-year study in Shelby County, Tennessee. 20. Mazlumzadeh M, Hunder G, Easley K, et al. Treatment Arthritis Rheum 1983;26:1214–19. 8. Weyand C, Goronzy J. Giant-cell arteritis and polymyalgia of giant cell arteritis using induction therapy with high-dose 4. Wernick C, Duvey, M, Bonafede, P. Familial gianct cell rheumatica. Ann Intern Med 2003;139:505–15. corticosteroids: a double-blind, placebo-controlled, randomized arteritis: report of an HLA-typed sibling pair and review of the 9. Hayreh SS, Podhajsky PA, Zimmerman B. Occult giant cell prospective clinical trial. Arthritis Rheum 2006;54:3310–18. literature. Clin Exp Rheumatol 1994;12:63-6. arteritis: ocular manifestations. Am J Ophthalmol 1998;125:521– 21. Hayreh S, Zimmerman B. Management of giant cell arteritis. 5. Salvarani C, Cantini F, Bolardi L, Hunder G. Polymyalgia rheu- 26. Our 27-year clinical study: New light on old controversies. Oph- matica and giant-cell arteritis. N Engl J Med 2002;347:261–71. 10. Ray-Chaudhuri N, Kine D, Tijani SO, et al. Effect of prior thalmologica 2003; 217: 239–59. 6. Gonzales-Gay M, Blanco R, Rodriguez-Valverde V, et al. steroid treatment on temporal artery biopsy findings in giant cell 22. Danesh-Meyer H, Savino P, Gamble G. Poor prognosis of Permanent visual loss and cerebrovascular accidents in giant cell arteritis. Br J Ophthalmol 2002;86:530–2. visual outcome after visual loss from giant cell arteritis. Ophthal- arteritis: predictors and response to treatment. Arthritis Rheum 11. Fraser J, Weyand C, Newman N, Biousse V. The Treatment of mology 2005;112:1098–103. 1998;41:1497–504. Giant Cell Arteritis. Rev Neurol Dis. 2008;5(3):140–52. 23. Loddenkemper T, Sharma P, Katzan I, Plant GT. Risk factors 7. Liozon E, Ly K, Robert P. Ocular complications of giant cell 12. Achkar AA, Lie JT, Hunder GG, et al. How does previous for early visual deterioration in temporal arteritis. J Neurol Neuro- arteritis. Rev Med Interne. Jul 2013;34(7):421-30. corticosteroid treatment affect the biopsy findings in giant cell surg Psychiatry. Nov 2007;78(11):1255-9.
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020_ro0415_urgent.indd 23 4/1/15 11:16 AM Focus on Refraction As Flexible as an Oak A professional pilot’s ‘muscle-building glasses’ do nothing for his dangerous double vision problem. By Paul Harris, OD and Marc B. Taub, OD, MS
colleague recently asked me to take a look at a friend of A hers, a professional pilot for private jet services. One year prior, the pilot needed his glasses remade three times by yet another opto- metric colleague, and he was still unhappy. He had his first symptom of double vision in 1994 and recalled getting his first prism in 1996 after suffering a concussion as a fire- fighter. He was given what he was Our patient, a professional pilot, saw two runways while trying to land a plane. told were “muscle-building glasses.” We were immediately sworn tion between posture and movement revealing. He saw five dots, which to secrecy to not call up the FAA with vision and refractive condi- indicates that his eyes are out of because he had been flying a plane tions.1,2 With his restricted back alignment relative to the lights for 23 of the past 24 hours. Upon movement, we expected some inter- whenever he looked 20° or more final approach to the airport, he esting asymmetries in his visual sys- downward or 35° to his right or left. clearly saw two runways, one next tem—and we weren’t disappointed. This clearly showed that his binocu- the other, and wondered on which We have to admit that we don’t larity was fragile, to say the least. one should he land the plane. How neutralize a new patient’s glasses In the phoropter, with his new to pick? He closed one eye and said, until we’re done with the exam refraction, we performed vertical “That must be the one.” When he because we don’t want to be biased ranges with prism moving in front of opened his other eye, he looked by the prior data. And this patient the left eye with the right eye as the harder and harder to move the sec- had optometric data going back to reference eye and found: ond one over to the first one, and 2009 for comparison. • Left infra duction showed a then brought the plane down. break at 13.5Δ and a recovery of He knew that he had pushed Diagnostic Data 12.0Δ himself beyond his limits and never Visual acuity with his current glasses • Left supra duction showed a wanted to do that again. was quite good at 20/19 OD, 20/14 break at -10.0Δ and a recovery of OS and 20/13 OU. A cover test over -11.5Δ History his glasses, which he said had prism This means that he has a total In October 1999, he had sustained in them, revealed 10Δ exophoria, 3Δ vertical range of half a prism diop- another concussion in a motorcycle right hyper at distance and 4Δ exo- ter at distance and needed between accident. In February 2000, he phoria, 3Δ right hyper at near. 11.5Δ and 12.0Δ of vertical prism. had fusion of his C4-C6 vertebrae. His refraction was pretty straight- He also needed at least 3Δ more In 2010, he underwent fusion of forward: +2.75 OD and +3.00 -0.75 over his glasses. At near, he had the L4-L5-S1 vertebrae. x 180 OS. With his glasses, near same half a prism diopter of range, We laughed when he proudly point of convergence was 4”/6” OD but this range increased to 14.0Δ to stated that he was “as flexible as an out, and he reported diplopia spon- 14.5Δ of vertical prism. oak tree,” but this actually raised a taneously. Although patients with these ver- red flag because of the likely connec- The Worth 4-dot test was quite ticals can function with less prism
24 REVIEW OF OPTOMETRY APRIL 15, 2015
024_ro0415_FoR.indd 24 4/1/15 11:32 AM in their glasses, they’ll compensate Previous Data sight-based examination, you’ll find with a head tilt. In some cases, the Now it was time to see what was the source of the patient’s visual glasses themselves have gotten out in his glasses as determined by his issue, which will allow you to finally of adjustment. Induced vertical previous eye care providers. His address it. In this patient’s case, prism can occur when one lens is habitual glasses were: giving more and more prism, or giv- high and the other is low relative to • +3.00 -0.50 x 30 +2.50 add 3Δ ing the prism he had before simply the visual axes. This patient’s glasses base-down because he had it before without were slightly out of kilter and he • +3.00 -1.00 x 167 +2.50 add doing the requisite testing, was just had a small head tilt, but nothing 3Δ base-up not solving his problem. extraordinary. He had been prescribed only 6Δ Fortunately, he was no longer fly- What about his horizontal ranges, of vertical prism, yet his testing ing commercially, so we didn’t have you ask? At distance, his base-in showed he needed a minimum of to “ground” him. He will begin range was a respectable break at 9Δ 11.5Δ to not have to tilt his head or vision therapy soon after receiving with recovery at 6Δ, but his base-out “work” at it. his new glasses with a goal to reduce was non-existent. At -4Δ or 4Δ of Most concerning was that his the amount of the prism needed for base-in, he broke into seeing double binocular testing from the previ- fusion and to improve his control vision while moving toward base- ous optometric records was limited over his visual system.3,4 ■ Δ out. He had to go back to 5 of to a cover test and, in one or two 1. Harmon DB. Notes on a Dynamic Theory of Vision. Santa Ana, base-in to recover fusion again. So, instances, a phoria measure, which CA: Optometric Extension Program Foundation; 1958. based on the recoveries, his zone of is only a central tendency measure- 2. Kraskin RA. Lens Power in Action. Santa Ana, CA: Optometric Extension Program Foundation; 1982. comfortable binocular vision should ment. This is not sufficient, so be 3. Robertson KM, Kuhn L. Effect of visual training on the be a range of 1Δ horizontally and a sure to investigate vergence ranges. vertical vergence amplitude. Am J Optom Physiol Opt. 1985 Oct;62(10):659-68. half a prism diopter vertically. Yes 4. Cooper J. Orthoptic treatment of vertical deviations. J Am indeed, as flexible as an oak tree! By digging deeper than the basic Optom Assoc. 1988 Jun;59(6):463-8.
024_ro0415_FoR.indd 25 4/1/15 11:33 AM Clinical Quandaries
Open Season on Closed Angles Which comes first in a patient with narrow angles: peripheral iridotomy or cataract extraction? Edited by Paul C. Ajamian, OD A 68-year-old Asian tor for cataract over Q female came in for a time,” Dr. Friedman cataract evaluation, but her says. “When you do angles were so narrow by an iridotomy, the gonioscopy that I was afraid angle opens up in to dilate her. Do I send her about three-quarters out for a laser peripheral iri- of people. So it dotomy first, and then dilate definitely does alter her to assess the cataract? angle configuration “Ideal care involves in the majority of A a dilated peripheral patients in whom it’s exam before cataract done.” surgery,” says David Again, this is the Friedman, MD, PhD, case in which the professor of ophthalmol- When dilating a cataract patient with narrow angles, such as this one, patient does not ogy at the Wilmer Eye the risk of acute angle-closure attack is very low. have visual symp- Institute and director of toms. “I wouldn’t the Dana Center for Preventive cataract. “The likelihood that the insist that the lens should come out Ophthalmology at Johns Hopkins patient will have an acute angle-clo- just because there’s angle closure University School of Medicine. But, sure attack when dilated at the time or residual angle closure after an this patient’s case is not an ideal sit- of surgery is really low,” he says. iridotomy,” Dr. Friedman says. “I uation. “It’s a difficult problem and “I even know some surgeons who think that’s going a little too far, one that requires some judgment. will use dilation as a provocative because there certainly are risks And you’ll get a lot of different test to see if an iridotomy is needed. with cataract surgery—low risks, responses from different doctors,” I don’t personally do that but, but risks all the same.” Dr. Friedman says. because this is an area with limited In his opinion, “I think the risk evidence to support what we do, Does the consideration that the of an acute attack is very low, even it’s a fairly reasonable approach.” Q patient is Asian factor into the if the angles are closed.” Furthermore, “once the cataract decision of whether to dilate? The question boils down to is out, there’s pretty much no risk No, says Dr. Friedman, who whether the patient appears ripe for of an acute attack. It would be A has researched the epidemiol- cataract surgery. incredibly unlikely,” Dr. Friedman ogy of angle-closure glaucoma in • Cataract surgery is likely. says. Cataract surgery is essentially Asian populations. “If you think this is a visually- the cure for angle closure. “Taking “While Asians may have a significant cataract and surgery is out the lens will open the angle slightly higher rate of angle closure imminent, it’s reasonable to refer permanently in virtually anyone,” and angle-closure glaucoma, I still to your cataract surgeon. Be sure to he says. think the risk of acute attack with get a look at the nerve and macula • Cataract surgery is not likely. dilation is very, very small,” he through an undilated pupil before “If the patient doesn’t have a says. Make gonioscopy part of your you refer, to alleviate any fundus visually significant cataract, and routine on all patients with shallow concerns,” Dr. Friedman says. therefore surgery is unlikely in the chambers, Asian or otherwise, and The surgeon will dilate the eye at near future, then I would refer the document your results clearly and the time of surgery and take out the patient for an iridotomy and moni- carefully. ■
26 REVIEW OF OPTOMETRY APRIL 15, 2015
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RO0415_MS Technology.indd 1 3/23/15 2:56 PM Ectasia
Corneal Disease Report Firm Up Your Approach to Corneal Ectasia Optometrists must see these patients “through thick and thin.” By Karen Yeung, OD, and Sally Wu Image: William Trat orneal ectasia can severely impair vision, especially in the progressive form caused by the inherent structural C tler, MD instability of the cornea. The clinical signs can challenge your detection skills—corneas with subclinical keratoconus are clinically normal in appearance but have subtle irregu- larities on corneal topography. These cases are especially important to identify because they can easily develop into iatrogenic keratoconus Pentacam imaging of a 68-year-old male patient with keratoconus. post refractive surgery.1 Advanced corneal imaging sys- cause, treatments to improve the Causes of Ectasias tems are detecting earlier stages of vision of ectasias are similar. Ectasias are either genetically or genetically caused ectasias and also Although treatments are numer- iatrogenically caused. The most minimizing iatrogenic causes of ous, those within optometry’s pur- prevalent and most understood ectasias from LASIK and other cor- view are mostly limited to corrective genetically caused ectasia is kerato- neal surgery procedures.2 lenses; still, we are called upon conus. Affecting approximately 50 Ectasias can also present from to diagnose and comanage these to 230 per 100,000, keratoconus is contact lens-induced corneal warp- patients throughout the course of a non-inflammatory corneal disease age and, while distortion is some- the disease, which can span decades. with clinical signs of inferior corneal times permanent, usually these are For these reasons and more, all progressive stromal thinning, scis- temporary and return to normal optometrists should be well versed sor reflex upon retinoscopy, corneal once the CLs are removed. Vision in the causes and consequences of protrusion and irregular astigma- correction for ectasias has been corneal ectasia. This article will tism.3-5 Histopathologically, there improving through advanced gas review current technology for is iron deposition in the epithelial permeable/scleral CLs and medically detection, CL corrections for visual basal layer and breaks in Bowman’s through collagen crosslinking and symptoms and the range of medical layers.6 Though typically they pres- lamellar surgeries. Regardless of the and surgical treatments available. ent bilaterally asymmetrical, reports
28 REVIEW OF OPTOMETRY APRIL 15, 2015
028_ro0415_f1.indd 28 4/1/15 11:51 AM of unilateral keratoconus cases Table 1. Treatment Options for Keratectasia exist.7 The second eye of unilateral Ectasia Severity Early Moderate Advanced keratoconus is still considered a sus- CL Treatments Glasses Corneal GPs Corneal GPs pect for developing keratoconus and Soft CLs Piggyback CLs Scleral lenses is hence contraindicated for LASIK. Hybrid CLs Iatrogenic ectasias occur primar- Scleral lenses ily through post-corneal refractive Surgical Treatments CXL CXL Lamellar keratoplasty surgery. They are rare, but debilitat- Intracorneal rings Intracorneal rings PKP ing when they occur. Studies have reported incidence rates of 0.04% to risk factor.10 Studies have reported three-dimensional images of the 0.66%, with higher complications post-LASIK ectasia development cornea from two-dimensional cross post LASIK as compared to pho- from three to 57 months after the sections. The modality includes torefractive keratectomy (PRK).1,8-10 surgical procedure.10,13 slit scanning, Scheimpflug imag- Iatrogenic ectasias are generally ing, OCT and very high frequency found in refractive surgery patients Detection of Ectasia (VHF) ultrasound imaging. Each of that are younger, have high myopia, Whereas moderate and severe these devices, when used indepen- have thinner corneas or have had ectasias are easily diagnosed with dently, gathers different informa- multiple refractive surgery enhance- biomicroscopy, retinoscopy and tra- tion about the cornea. They each ments.1,11 Thicker flaps, which com- ditional placido disc-based corneal evaluate the anterior and posterior promise residual stromal thickness, topographies linked to programmed corneal elevations and their pachy- excessive tissue removal from high indices and algorithms specifically metric distribution, which is impor- refractive errors and/or undiagnosed designed for keratoconus detection tant for detecting any ectasia or forme-fruste keratoconus during and diagnosis, subclinical keratoco- predisposition to ectasia. When the LASIK, or both, ultimately causes nus is more difficult to detect.14-18 information from different devices is thinner corneas. The thinned cor- The popularity of LASIK and other used together, the accuracy of ecta- neal biomechanical strength wanes forms of corneal refractive surgery sia detection is even greater. while the intraocular pressure causes in the 1990s and the risk of iatro- • Slit scanning involves slits pro- forward corneal bowing, resulting in genic ectasia spurred the develop- jected on the cornea. The anterior ectasia.12 ment of corneal tomography, which and posterior edges of the slits are One study found that all patients has revolutionized the detection of analyzed and presented as three- who develop iatrogenic ectasia post subclinical keratoconus. dimensional topographic maps. LASIK had at least one predictable Corneal tomography produces Research shows this is more sensi-
Image: William Trat tive than earlier devices for detection of keratoconus since it takes images of the entire cornea.19-21 The latest slit scanning systems, including the
tler, MD Orbscan II, actually use both slit scanning and placido technology. • The rotating Scheimpflug imag- ing devices such as the Pentacam (Oculus) measures the anterior and posterior corneal surfaces, as well as corneal volume and spatial profiles from three-dimensional models. Researchers found that keratoconus has thinner corneas with less corneal volume.22 • Optical coherence tomography creates an optical cross sectional Pentacam imaging of a 38-year-old male with post-LASIK ectasia. The three images scan of the specific layers of the detail changes post epi-on crosslinking treatment. cornea. This could be important for
REVIEW OF OPTOMETRY APRIL 15, 2015 29
028_ro0415_f1.indd 29 4/1/15 11:52 AM Ectasia
detecting epithelial thickness irregu- tact lens correction for keratoconus minisclerals (15.0mm to 18.0mm) larities, which may be early indica- and has delayed the need for surgery and full scleral lenses (18.1mm tors of early keratoconus.23 in approximately 80% to 98.9% of to 24.0mm) rest entirely on the • VHF ultrasound measures the all fittings.3,26,27 conjunctiva and vault over the cor- thickness of individual corneal lay- Corneal GPs range in size from nea.28,31 Larger lenses are more com- ers by a series of scans in different 8mm to 10mm in diameter and are fortable especially for those with meridians in an arc that matches the ideal for small central cones or mild focally steep cones or those with curvature of the cornea. Research- keratoconic eyes.28 With increased sensitive corneal epithelium since ers used this to measure the mean ectasia severity, larger diameters vaulted lenses reduce friction with thickness of LASIK flaps and found improve lens centration. Intralimbal the cornea.28,32 Scleral lenses should that those with a mean thickness lenses are slightly larger at 10.5mm be fit with the highest Dk material of 163.6µm had greater risks of to 12mm in diameter. Though possible and without excessive cor- ectasia, especially in patients with corneal GPs provide crisper vision neal clearance, to minimize hypoxia greater ablation depth.24 than soft lenses, dropout occurs from the combination lens and tear from discomfort. Piggyback CLs film thickness.33 Treatment of Ectasias can improve comfort, but can be • Medical/surgical treatment. For The first-line treatment for visual inconvenient for patients because of ectatic patients who are intolerant disturbance due to corneal ectasia is their need to clean and care for both of CLs, medical and surgical treat- corrective lenses, but recent surgical soft and GP contact lenses. Hybrid ments are available. Traditional advances offer the promise of more CLs may also improve the comfort; treatments have been limited to permanent solutions. however, their variable clinical per- contact lenses and full-thickness • Contact lenses. In early stages formance, high giant papillary con- penetrating keratoplasty (PKP). of ectasia, spectacles, soft CLs and junctivitis rates and breakage at the Though graft survival rates usu- even custom aberration-correcting GP and soft lens junction may limit ally extend up to 20 years and soft CLs may be adequate to correct their use.29,30 The very recent surge sometimes beyond, reasons to defer for vision changes. But as the ectasia of scleral lens options and popular- doing PKPs for as long as possible progresses, the optically smooth ity has provided a more comfortable include the generally young age of surface from a rigid gas permeable option for ectatic eyes. keratoconic patients (and thus the (GP) lens is necessary to ameliorate Scleral lenses are generally challenge of achieving life-long graft the irregular corneal surface of reserved for moderate to advanced survival), graft rejection and failure, the ectatic eye to provide clearer stages of ectasia as well as those surgical complications and the risks vision. Corneal GPs, and now more who have failed in comfort from of developing secondary cataracts popularized scleral lenses, are the traditional GPs. Whereas corneo- and glaucoma from long-term ste- mainstay visual treatments for these sclerals (12.9mm to 14.9mm) rest roid use. Visual rehabilitation after eyes.25 GPs comprise 65% of con- on both the cornea and sclera, PKP is also difficult. • Intrastromal corneal ring seg-
Photo: Peter Hersh, MD, Hersh Vision Group, Teaneck, NJ. ment implantation. For mild to FDA Approval Pending for moderate ectasias with little to no US Launch of Crosslinking corneal scarring, intrastromal cor- for Keratoconus neal ring (Intacs) use is an option. Though its advisory panel recommended It involves the insertion of one or approval, the FDA recently requested two polymethylmethacrylate seg- additional information before giving the go- ments into the corneal stroma to ahead to Avedro’s drug/device combination flatten the irregular anterior corneal of Photrexa (riboflavin) and KXL System shape and hence improve uncor- (UVA light) for the treatment of progressive rected visual acuity.34 Segments of keratoconus and corneal ectasia following varying thickness can be implanted; refractive surgery. The company is work- the thicker the segment, the more ing to address the questions and move A keratoconic patient undergoing a significant the flattening effect. forward with FDA approval. collagen crosslinking procedure. They are generally inserted on the inferior cornea to flatten the steep
30 REVIEW OF OPTOMETRY APRIL 15, 2015
028_ro0415_f1.indd 30 4/1/15 12:01 PM areas of inferiorly located cones. Clinical Pearls that would most benefit early to Intrastromal corneal rings do not moderate ectasias. stop the progression of keratoconus • Consider using multiple corneal CXL involves the application and the residual refractive errors are imaging technologies along with of riboflavin on epithelialized or often more challenging to treat with clinical judgment to best identify early de-epithelialized central corneas, corneal GP contact lenses due to the ectasias. depending upon protocol treatment. sharp topography differences at the • For early and moderate ectasias, The cornea is then exposed to ultra- junction of the intrastromal corneal including the “normal” eye of a violet A light, which activates the ring segment.35 Complications many keratoconic patient, CXL is a viable riboflavin and creates new crosslinks include patient dissatisfaction with option to preserve and ideally prevent within the collagen and intrastromal visual outcomes, discomfort and progression. matrix of the stroma.40 CXL on de- ring segment extrusion.36 • For moderate to advanced ectasias, epithelialized corneas is more effec- • Collagen crosslinking (CXL). or patients who are intolerant of GP tive than on epithelized corneas, but Whereas the current treatments lenses, consider a scleral lens. Fit a there is a longer recovery time, more for ectasias revolve around visual high Dk material without excessive patient discomfort and increased rehabilitation, CXL is a promis- corneal clearance to prevent hypoxia. risk of infections.37,41 ing treatment to actually delay and • Expect to see more CXL procedures Accelerated CXL uses a higher potentially halt the progression of performed in tandem with other cor- intensity UV light for shorter peri- many ectasias, including keratoco- neal surgeries. ods of time. Studies are evaluating nus, pellucid marginal degeneration the effectiveness and safety profile and post-LASIK ectasias.37-40 It is ity by forming new chemical bonds of accelerated vs. non-accelerated a procedure that increases corneal between the collagen strands of the CXL. Evidence may show that the rigidity and biomechanical stabil- corneal stroma. This is a procedure accelerated CXL is as effective and
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028_ro0415_f1.indd 31 4/1/15 11:51 AM Ectasia
safe as conventional CXL, but more Photo: William Trat intrastromal corneal ring insertion research is needed.42 Though rare, improved the keratoconic outcomes risks of complications post CXL more than corneal crosslinking include corneal haze, keratitis, alone.44 But caution is warranted endothelial cell loss and CXL inef- tler, MD since keratoconus can still progress fectiveness.39,40 years after corneal crosslinking.45,46 Long-term studies are limited, • Lamellar keratoplasty. When but show promise in achieving the above treatments fail, severe ectasia stability in many patients. ectasias may require surgical inter- Researchers found the standard vention. Lamellar procedures such CXL method improved visual acu- as deep anterior lamellar kerato- ities and stabilized the progression Intacs in an eye with keratoconus. plasty (DALK) and crescentic lamel- of post-LASIK induced ectasias over lar keratoplasty are options. DALK 42 months.40 In a retrospective case Combining other interventions involves removing the corneal series, another study found that with CXL offers a new frontier in stroma down to Descemet’s mem- accelerated CXL was able to halt treatment that addresses both struc- brane and replacing it with donor the progression of keratoconus, in tural and refractive needs. While cornea with or without Descemet’s addition to improving their patients’ intrastromal corneal rings improve membrane. Compared to PKP, visual acuities, keratometry values the visual acuity, CXL performed DALK offers a lower risk of graft and corneal aberrations after 24 after intrastromal corneal ring rejection, early visual rehabilitation, months.39 Overall, CXL is a novel implantation stabilizes the cornea better wound strength and limited treatment to stabilize the progres- to slow down future progression.43 endothelial cell loss. It is a compli- sion of both keratoconus and post- One study showed the addition cated procedure, but one with the LASIK ectasia. of the corneal crosslinking after same rate of graft survival and final visual acuity outcomes as PKP.47 A Consensus on Keratoconus For ectasias that involve the far Thirty-six experts from around the world recently came to a consensus on defini- periphery of the cornea, such as tions and recommendations related to keratoconus and other ectatic diseases.1 A in pellucid marginal degeneration, few of the key items agreed upon include: large-diameter PKPs are discouraged • Abnormal posterior ectasia, abnormal corneal thickness distribution and clini- as their proximity to the limbus and cal noninflammatory corneal thinning are mandatory findings for a keratoconus its blood vessels make grafts more diagnosis. prone to rejections. • Ectatic disorders include keratoconus, pellucid marginal degeneration (PMD), Semilunar, crescentic and annular keratoglobus and postrefractive surgery progressive corneal ectasia. lamellar keratoplasty use donor • True unilateral keratoconus “does not exist.” grafts that spare the central cornea. • Keratoconus, PMD and keratoglobus are distinguished by the thinning location The central vision is minimally and pattern. affected even if the graft is rejected • The best and most widely used test to diagnose early keratoconus is corneal and becomes opaque. These grafts tomography (Scheimpflug imaging or anterior segment OCT). decrease the overall corneal astig- • Visual rehabilitation and halting disease progression are the two main goals of matism, but the results can be short- nonsurgical management of keratoconus. lived because thinning and ectasia • Contact lenses do not slow or halt disease progression, but are important for can recur.48,49 visual rehabilitation. Advancements in ectasia detec- • Patients should pursue surgical intervention only if they are not satisfied with tion, prevention and treatment are their vision with contact lenses or glasses. constantly emerging. Improved • Corneal crosslinking (CXL) is very important for patients with documented pro- technologies, especially in the form gression of keratoconus. of corneal tomography, can now To read more about the consensus report, visit www.reviewofoptometry.com identify genetically caused ectasias web_exclusives/. at early stages. The combination of
1. Gomes JA, Tan D, Rapuano CJ, et al. Global consensus on keratoconus and ectatic diseases. Cornea. 2015;34(4):359-69. the different tomography systems provides complementary views of
32 REVIEW OF OPTOMETRY APRIL 15, 2015
028_ro0415_f1.indd 32 4/1/15 12:02 PM LOTEMAX® GEL–UNIQUE FORMULATION DESIGNED TO CONTROL INFLAMMATION
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Indications and Usage ILOTEMAX® !7A/1=@B71=AB3@=727<271/B324=@B63B@3/B;3=AB=>3@/B7D3 I/1B3@7/:7<431B7= Please see brief summary of full prescribing information on adjacent page. References: 1.!$(", !%@3A1@707<5 <4=@;/B7=<'3>B3;03@ 2. =<5&!37B@7BH"'7=C"3@;3B&@0( !=B3>@32<=: 3B/0==AB=>3@/B7D3>/7</<27 K TM/@3B@/23;/@9A=4/CA16!=;0 <1=@>=@/B32=@7BA/4M:7/B3A L /CA16!=;0 <1=@>=@/B32 )' ! , - . DISCOVER THE POWER OF GEL RP1113_BL Lotemax.indd 1 10/17/13 11:24 AM USE IN SPECIFIC POPULATIONS Pregnancy Teratogenic Effects: Pregnancy Category C. Loteprednol etabonate has been shown to be embryotoxic (delayed ossification) and teratogenic (increased incidence of meningocele, abnormal left common carotid artery, and limb flexures) when administered orally to rabbits during organogenesis at a dose of 3 mg/kg/day (35 times the maximum daily clinical dose), a dose which caused no maternal toxicity. The no-observed-effect-level (NOEL) for these effects was 0.5 mg/kg/day Brief Summary: Based on full prescribing information. (6 times the maximum daily clinical dose). Oral treatment of rats during organogenesis resulted in teratogenicity (absent innominate artery at ≥5 mg/ To report SUSPECTED ADVERSE REACTIONS, contact Bausch & Lomb at kg/day doses, and cleft palate and umbilical hernia at ≥50 mg/kg/day) and 1-800-323-0000 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch embryotoxicity (increased post-implantation losses at 100 mg/kg/day and decreased fetal body weight and skeletal ossification with ≥50 mg/kg/day). INDICATIONS AND USAGE Treatment of rats with 0.5 mg/kg/day (6 times the maximum clinical dose) during organogenesis did not result in any reproductive toxicity. Loteprednol LOTEMAX is a corticosteroid indicated for the treatment of post-operative etabonate was maternally toxic (significantly reduced body weight gain during inflammation and pain following ocular surgery. treatment) when administered to pregnant rats during organogenesis at doses DOSAGE AND ADMINISTRATION of ≥5 mg/kg/day. Invert closed bottle and shake once to fill tip before instilling drops. Oral exposure of female rats to 50 mg/kg/day of loteprednol etabonate from Apply one to two drops of LOTEMAX into the conjunctival sac of the affected the start of the fetal period through the end of lactation, a maternally toxic eye four times daily beginning the day after surgery and continuing treatment regimen (significantly decreased body weight gain), gave rise to throughout the first 2 weeks of the post-operative period. decreased growth and survival, and retarded development in the offspring CONTRAINDICATIONS during lactation; the NOEL for these effects was 5 mg/kg/day. Loteprednol LOTEMAX, as with other ophthalmic corticosteroids, is contraindicated in etabonate had no effect on the duration of gestation or parturition when most viral diseases of the cornea and conjunctiva including epithelial herpes administered orally to pregnant rats at doses up to 50 mg/kg/day during the simplex keratitis (dendritic keratitis), vaccinia, and varicella, and also in fetal period. mycobacterial infection of the eye and fungal diseases of ocular structures. There are no adequate and well controlled studies in pregnant women. WARNINGS AND PRECAUTIONS LOTEMAX should be used during pregnancy only if the potential benefit Intraocular Pressure (IOP) Increase justifies the potential risk to the fetus. Prolonged use of corticosteroids may result in glaucoma with damage to the Nursing Mothers optic nerve, defects in visual acuity and fields of vision. Steroids should be It is not known whether topical ophthalmic administration of corticosteroids used with caution in the presence of glaucoma. If this product is used for 10 could result in sufficient systemic absorption to produce detectable quantities days or longer, intraocular pressure should be monitored. in human milk. Systemic steroids appear in human milk and could suppress Cataracts growth, interfere with endogenous corticosteroid production, or cause other untoward effects. Caution should be exercised when LOTEMAX is administered Use of corticosteroids may result in posterior subcapsular cataract formation. to a nursing woman. Delayed Healing Pediatric Use The use of steroids after cataract surgery may delay healing and increase the Safety and effectiveness in pediatric patients have not been established. incidence of bleb formation. In those diseases causing thinning of the cornea or sclera, perforations have been known to occur with the use of topical Geriatric Use steroids. The initial prescription and renewal of the medication order should No overall differences in safety and effectiveness have been observed be made by a physician only after examination of the patient with the aid between elderly and younger patients. of magnification such as slit lamp biomicroscopy and, where appropriate, NONCLINICAL TOXICOLOGY fluorescein staining. Carcinogenesis, Mutagenesis, Impairment Of Fertility Bacterial Infections Long-term animal studies have not been conducted to evaluate the Prolonged use of corticosteroids may suppress the host response and carcinogenic potential of loteprednol etabonate. Loteprednol etabonate was thus increase the hazard of secondary ocular infections. In acute purulent not genotoxic in vitro in the Ames test, the mouse lymphoma tk assay, or in conditions of the eye, steroids may mask infection or enhance existing a chromosome aberration test in human lymphocytes, or in vivo in the single infection. dose mouse micronucleus assay. Treatment of male and female rats with up to Viral Infections 50 mg/kg/day and 25 mg/kg/day of loteprednol etabonate, respectively, (600 Employment of a corticosteroid medication in the treatment of patients with and 300 times the maximum clinical dose, respectively) prior to and during a history of herpes simplex requires great caution. Use of ocular steroids may mating did not impair fertility in either gender. prolong the course and may exacerbate the severity of many viral infections PATIENT COUNSELING INFORMATION of the eye (including herpes simplex). Administration Fungal Infections Invert closed bottle and shake once to fill tip before instilling drops. Fungal infections of the cornea are particularly prone to develop coincidentally Risk of Contamination with long-term local steroid application. Fungus invasion must be considered Patients should be advised not to allow the dropper tip to touch any surface, in any persistent corneal ulceration where a steroid has been used or is in as this may contaminate the gel. use. Fungal cultures should be taken when appropriate. Contact Lens Wear Contact Lens Wear Patients should be advised not to wear contact lenses when using LOTEMAX. Patients should not wear contact lenses during their course of therapy with Risk of Secondary Infection LOTEMAX. If pain develops, redness, itching or inflammation becomes aggravated, the ADVERSE REACTIONS patient should be advised to consult a physician. Adverse reactions associated with ophthalmic steroids include elevated FOR MORE DETAILED INFORMATION, PLEASE READ THE PRESCRIBING intraocular pressure, which may be associated with infrequent optic nerve INFORMATION. damage, visual acuity and field defects, posterior subcapsular cataract formation, delayed wound healing and secondary ocular infection from Bausch & Lomb Incorporated pathogens including herpes simplex, and perforation of the globe where there Tampa, Florida 33637 USA is thinning of the cornea or sclera. US Patent No. 5,800,807 ©Bausch & Lomb Incorporated The most common adverse drug reactions reported were anterior chamber inflammation (5%), eye pain (2%), and foreign body sensation (2%). ®/™ are trademarks of Bausch & Lomb Incorporated or its affiliates. 9303400 RRP1113_BLP1113_BL LotemaxLotemax PI.inddPI.indd 1 110/16/130/16/13 9:529:52 AMAM Ectasia 25. Weed KH, MacEwen CJ, McGhee CN. The Dundee the cornea to hopefully provide a A New Organization University Scottish Keratoconus Study II: a prospective study better understanding of the pre- Focused on Keratoconus of optical and surgical correction. Ophthalmic Physiol Opt. 2007;27(6):561-7. dictors of iatrogenic ectasia and The International Keratoconus 26. Wagner H, Barr JT, Zadnik K. Collaborative Longitudinal ultimately eliminate that as well. Academy of Eye Care Professionals Evaluation of Keratoconus (CLEK) Study: methods and findings Ectasia patients are fortunate to (IKA) was recently established to promote to date. Cont Lens Anterior Eye. 2007;30(4):223-32. 27. Bilgin LK, Yilmaz S, Araz B, et al. 30 years of contact lens have growing visual rehabilitation ongoing education and scientific develop- prescribing for keratoconic patients in Turkey. Contact Lens Ant treatment options in the advancing ment in the area of keratoconus and other Eye. 2009;32:16-21. 28. Barnett M, Mannis J. Contact lens in the management of areas of contact lenses, collagen forms of corneal ectasia. It will also pro- keratoconus. Cornea. 2011;30(12):1510-6. crosslinking, intrastromal corneal mote the awareness and understanding of 29. Maguen E, Caroline P, Rosner IR, et al. The use of the treatment strategies. SoftPerm lens for the correction of irregular astigmatism. CLAO ring implantation and lamellar J. 1992;18(3):173-6. surgeries. Future combination treat- IKA will provide an array of educational 30. Abdalla YF, Elsahn AF, Hammersmith KM, et al. SynergEyes ments with CXL will hopefully one initiatives, including live events, web- lenses for keratoconus. Cornea. 2010;29(1):5-8. 31. Worp EVD, Bornman D, Ferreira DL, et al. Modern scleral day eliminate the need for corneal based education, social media activities contact lenses: A review. Contact Lens & Anterior Eye. transplantation. ■ and publications in the professional litera- 2014;37:240-50. 32. Schornack MM, Patel SV. Scleral lenses in the management Dr. Yeung is a diplomate in ture. It will cooperate with other organiza- of keratoconus. Eye & Contact Lens. 2010;36(1):39-44. the Cornea, Contact Lenses, tions—such as the National Keratoconus 33. Jaynes JM, Edrington TB, Weissman BA. Predicting scleral Foundation—to advance knowledge, GP lens entrapped tear layer oxygen tensions. CLAE. 2015;44-7. and Refractive Technologies sec- 34. Zare MA, Hashemi H, Salri MR. Intracorneal ring segment tion of the American Academy awareness and quality of care. implantation for the management of keratoconus: safety and of Optometry. She is the senior The founding executive board includes efficacy. J Cataract Refract Surg. 2007;33:1886-91. 35. Hladun L, Harris M. Contact lens fitting over intrastromal cor- optometrist at UCLA Arthur Barry Eiden, OD, Andrew Morgenstern, neal rings in a keratoconic patient. Optometry. 2004;75(1):48-54. Ashe Student Health and Wellness OD, Timothy McMahon, OD, Joseph 36. Pinero DP, Alio JL, Uceda-Montanes A, et al. Intracorneal ring segment implantation in corneas with post-laser in situ ker- and a clinical assistant professor Barr, OD, William Tullo, OD, Clark Chang, atomileusis keratectasia. Ophthalmol. 2009;116(9):1665-74. of Western University of Health OD, Eric Donnenfeld, MD, and Yaron 37. Lesniak SP, Hersh PS. Transepithelial corneal collagen Rabinowitz, MD. Professionals interested crosslinking for keratoconus: Six-month results. J Cataract Sciences College of Optometry. Refact Surg. 2014;40:1971-9. Sally Wu is a pre-optometry stu- in membership in IKA should email the 38. Moshirfar M, Edmonds JN, Behunin NL, et al. Current dent getting a BA in psychology at group: [email protected]. options in the management of pellucid marginal degeneration. Journal of Refractive Surgery. 2014;30(7):474-85. UCLA, class of 2015. 39. Ozgurhan EB, Kara N, Cankaya KI, et al. Accelerated corneal cross-linking in pediatric patients with keratoconus: 24-Month 14. Kalin NS, Maeda N, Klyce SD, et al. Automated topographic 1. Randleman JB, Woodward M, Lynn M, et al. Risk assess- Outcomes. Journal of Refractive Surgery. 2014;30(12):843-9. screening for keratoconus in refractive surgery candidates. CLAO ment for ectasia after corneal refractive surgery. Ophthalmol. 40. Yildirim A, Cakir H, Kara, et al. Corneal collagen crosslinking J. 1996;22:164-7. 2008;115:37-50. for ectasia after laser in situ keratomileusis: Long-term results. J 2. McMonnies CW. Screening for keratoconus suspects 15. Maeda N, Klyce SD, Smolek MK, et al. Automated keratoco- Cataract Refract Surg. 2014;40:1591-6. among candidates for refractive surgery. Clin & Exp Optom. nus screening with corneal topography analysis. Invest Ophthal- 41. Hashemiman H, Jabbarvand M, Khodaparast M, et al. Evalu- 2014;97:492-8. mol Vis Sci. 1994;35:2749-57. 3. Kennedy RH, Bourne WM, Dyer JA. A 48-year clinical 16. Maeda N, Klyce Sd, Smolek MK. Comparison of methods for ation of corneal changes after conventional versus accelerated and epidemiologic study of keratoconus. Am J Ophthalmol. detecting keratoconus using videokeratography. Arch Ophthal- corneal cross-linking: A randomized controlled trial. Journal of 1986;101:267-73. mol. 1995;113(7):870-4. Refractive Surgery. 2014;30(12):837-42. 4. Rabinowitz YS. Keratoconus: major review. Survey of Ophthal- 17. Rabinowitz YS, McDonnell PJ. Computer-assisted corneal 42. Konstantopoulos A, Mehta JS. Conventional versus acceler- mol. 1998;42(4):297-319. topography in keratoconus. Refract Corneal Surg. 1989;5:400-8. ated collagen cross-linking for keratoconus. Eye & Contact Lens. 5. Romero-Jimenez M, Santodomingo-Rubido J, Woffsohn JS. 18. Rabinowitz YS, Rasheed K. KISA% index: a quantitative 2014. (E-pub ahead of print). Keratoconus: a review. Cont Lens Anterior Eye. 2010;33:157-66. videokeratography algorithm embodying minimal topographic 43. Ferial MZ, Jawkhab AA, Al-Tuwairqi W, et al. Visual 6. Sherwin T, Brookes, NH. Morphological changes in kerato- criteria for diagnosing keratoconus. J Cataract Refract Surg. rehabilitation in low-moderate keratoconus: intracorneal ring conus: pathology or pathogenesis. Clin Experiment Ophthalmol. 1999;25(10):1327-35. segment implantation followed by same-day topography-guided 2004;32(2):211-7. 19. Lim L, Wei RH, Chan WK, et al. Evaluation of keratoconus in photorefractive keratectomy and collagen cross linking. Int J 7. Li X, Rabinowitz YS, Rasheed K, et al. Longitudinal study of Asians: role of Orbscan II and Tomey TMS-2 corneal topogra- Ophthalmol. 2014;7(5):800-6. the normal eyes in unilateral keratoconus patients. Ophthalmol- phy. Am J Ophthalmol. 2007;143(3):390-400. 44. Chan CC, Sharma M, Wachler BS. Effect of inferior-segment ogy. 2004;111(3):440-6. 20. Reddy JC, Rapuano CJ, Cater JR, et al. Comparative evalu- Intacs with and without C3-R on keratoconus. J Cataract Refract 8. Rad AS, Jabbarvand M, Saifi N. Progressive keratectasia after ation of dual Scheimpflug imaging parameters in keratoconus, Surg. 2007;33(1):75-80. laser in situ keratomileusis. J Refract Surg. 2004;20(5):S718-22. early keratoconus, and normal eyes. J Cataract Refract Surg. 45. Kymionis GD, Kontadakis GA, Kounis GA, et al. Simultane- 9. Pallikaris IG, Kymionis GD, Astyrakakis NI. Corneal ectasia 2014;40:582-92. ous topography-guided PRK followed by corneal collagen cross- 21. Sahin A, Yildirim N, Baskmak H. Two-year interval changes induced by laser in situ keratomileusis. J Cataract Refract Surg. linking for keratoconus. J Refract Surg. 2009;25(9):s807-11. 2001;27(11):1796-802. in Orbscan II topography in eyes with keratoconus. J Cataract 46. Kymionis GD, Karavitaki AE, Grentzelos MA, et al. Topogra- 10. Randleman JB, Russell B, Ward MA, et al. Risk factors Refract Surg. 2008;34(8):1295-9. phy based keratoconus progression after corneal cross-linking. and prognosis for corneal ectasia after LASIK. Ophthalmology. 22. Ambrosio R, Alonso RS, Luz A, et al. Corneal-thickness spa- 2003;110:267-75. tial profile and corneal-volume distribution: tomographic indices Cornea. 2014;33(4):419-21. 11. Holland SP, Srivannaboon S, Reinstein DZ. Avoiding serious to detect keratoconus. J Cataract Ref Surg. 2006;32:1851-9. 47. Keane M, Coster D, Ziaei M, et al. Deep anterior lamellar corneal complications of laser assisted in situ keratomileusis 23. Kanellopoulos AJ, Asimellis G. OCT corneal epithelial topo- keratoplasty versus penetrating keratoplasty for treating keratoco- and photorefractive keratectomy. Ophthalmol. 2000;107:640-52. graphic asymmetry as a sensitive diagnostic tool for early and nus. Cochrane Database Syst Rev. 2014;22(7):CD009700. 12. Ambrosio R Jr, Nogueira LP, Caldas DL, et al. Evaluation of advancing keratoconus. Clin Ophthalmol. 2014;18(8):2277-87. 48. Maccheron LJ, Daya SM. Wedge resection and lamel- corneal shape and biomechanics before LASIK. Int Ophthalmol 24. Reinstein DZ, Sutton HF, Srivannanboon S, et al. Evaluating lar dissection for pellucid marginal degeneration. Cornea. Clin. 2011;51:11-39. microkeratome efficacy by 3D corneal lamellar flap thickness 2012;31(6):708-15. 13. Said A, Hamade JH, Tabbara KF. Late onset corneal ectasia accuracy and reproducibility using Artemis VHF digital ultra- 49. Rasheed K, Rabinowitz YS. Surgical treatment of advanced after LASIK surgery. Saudi J Ophthalmol. 2011;25:225-30. sound Arc-Scanning. J Refract Surg. 2006;22:431-40. pellucid marginal degeneration. Ophthalmol. 2000;107:1836-40. REVIEW OF OPTOMETRY APRIL 15, 2015 35 0028_ro0415_f1.indd28_ro0415_f1.indd 3535 44/1/15/1/15 12:0212:02 PMPM DOWNLOAD LAYAR APP FOR INTERACTIVE EXPERIENCE Slit Lamp Essentials INTERACTIVE PRINT Essential Procedures at the Slit Lamp: Perform DBD with ASP for Stubborn RCE If anterior stromal puncture doesn’t do the job for recalcitrant recurrent corneal erosion, here’s a more aggressive option. By Jason Ellen, OD, and Nathan Lighthizer, OD oc, I’m afraid to open and recurrent symp- my eyes in the morn- toms—but difficult to ing.” It’s a complaint treat, especially when “Dthat’s both shocking it’s recalcitrant RCE. and severe in nature. But, it’s Previous articles have one that we’ve heard several discussed numerous times in our clinical experi- conservative treatment ence. modalities that are very These were extremely effective in managing frustrated patients who had most cases of RCE, a long history of recurrent including hypertonic corneal erosions. They had ointment, bandage soft already tried medical ther- contact lenses, oral dox- apy, including doxycycline, Top left: a patient with Salzmann’s nodular degeneration and ycycline, topical steroids Muro 128 (Bausch + Lomb), epithelial basement membrane dystrophy prior to debridement. and anterior stromal FreshKote (Focus Labs), Top right: post-treatment day one with amniotic membrane ring puncture (ASP).1 (See topical steroids and even in place. Bottom left: day one with fluorescein stain and filter. “Simple ASP at the Slit bandage contact lenses—all Bottom right: at one month out, the eye has almost fully healed. Lamp,” facing page.) without success. However, many of In these severe cases, is there In this article—the fourth in a the cases seen in our surgical refer- another surgical option that could six-part, print-and-video instruc- ral center are patients with more benefit such patients? How and tional series—we’ll show you how stubborn RCE who have failed when do you perfrom these more we do it. combinations of these nonsurgical aggressive procedures? therapeutic regimens. Difficult and DBD and ASP for Tough Cases recalcitrant cases seem to be a result To see a narrated video of Recurrent corneal erosion (RCE) of traumatic RCE coupled with a this procedure, visit www. not only can be difficult to diag- history of EBMD. (In our clinical reviewofoptometry.com, or scan this QR code. nose—due to its usual presentation experience of treating recalcitrant of few clinical signs yet debilitating cases that have failed conservative 36 REVIEW OF OPTOMETRY APRIL 15, 2015 036_ro0415_f2.indd 36 4/2/15 5:02 PM therapy, many seem to have concur- Simple ASP at the Slit Lamp rent EBMD that may involve the If a patient has simple recurrent erosion from previous trauma (such as a fingernail to the entire cornea, which likely contrib- cornea) and no underlying sign of epithelial basement membrane dystrophy (EBMD), ante- utes to the poorer adhesion of the rior stromal puncture at the slit lamp can provide adequate adherence of the epithelium to epithelium in the area of previous the stroma. (This is assuming all other complicating factors of dry eye disease and poste- trauma.) So, the therapeutic goal rior blepharitis are currently being treated and controlled as well.) is to not only treat the current area The idea behind ASP is that the punctures—no more than 250µm of penetration into of erosion, but also to help prevent the corneal surface—facilitate a slight inflammatory event that leads to minor scarring and future complications/erosions in essentially serves as a “spot weld” to better anchor the epithelium to the stroma. other areas due to the underlying The procedure is best performed using an anterior stromal puncture needle rather than EBMD. a bent syringe. An ASP needle comes pre-packaged and pre-bent at the tip to prevent the If the patient with EMBD has point from going too deep into the stroma, penetrating no more than 0.1mm. This takes the failed aggressive topical and oral guesswork out of bending your own needle, which you could bend too much or too little. therapy for RCE, consider surgical Here’s how ASP is performed: treatment with or without ASP. Sur- • Apply one drop topical anesthetic (proparacaine 0.5%). gical treatments include diamond • Apply one drop of topical fluoroquinolone each minute for three minutes. burr debridement (DBD) and pho- • Test the surrounding area for poor adhesion with a Weck-Cel sponge to determine the totherapeutic keratectomy (PTK). area of treatment. Areas affected by EBMD • DBD. Studies have shown that or prior trauma—in which the epithelium removal of the affected area of epi- is loosely adherent to the underlying base- thelium combined with polishing ment membrane and stroma—will feel Bowman’s layer using a diamond loose and will more easily separate from burr decreases the recurrence rate healthy cornea with light pressure and (6%) when compared with debride- force from the Weck-Cel. ment alone (18% recurrence).2 • Using the ASP needle, apply punctures • PTK. This is also an excellent 0.25mm to 0.5mm apart to the area of option to smooth the corneal sur- loose epithelium, as well as a 0.5mm ring face after epithelial debridement; into the area of adherent epithelium. The however, the cost to the patient is punctures should be deep enough to pen- usually higher because reimburse- etrate into the anterior stroma. Scarring in ment for use of the laser is rarely the visual axis has the potential to reduce covered under insurance. Further- best-corrected visual acuity, so stay clear Use a Weck-Cel sponge to find and more, research has shown that PTK of the central visual axis when performing dislodge areas of loose epithelium. has a slightly higher incidence of anterior stromal puncture. postsurgical haze and recurrence • Next, apply a bandage soft contact when compared with DBD.3 lens for comfort and to facilitate healing. Accordingly, here’s a step-by-step Patients may experience mild to moderate method for DBD with ASP. pain in the first one to two days after the procedure, even with the bandage lens in 1. Discuss the Procedure place, due to the dozens of small punc- In most cases, these patients have tures from the ASP procedure. Proper edu- reached the point where they’re cation usually helps alleviate the patient’s ready for a treatment that is more immediate concerns, and most patients aggressive because conservative feel much better one or two days later. therapy has failed and they’re mis- ASP may not cure the underlying prob- erable. lem, so patients may still need to continue Discuss the risks and benefits topical therapy to help control symptoms. of the procedure, and have the Yet, it should significantly reduce the epi- With the ASP needle, puncture both patient sign a consent form. (The sodes of recurrent erosion and severe pain loose and adherent epithelium, risks include mild scarring of the upon waking. penetrating the anterior stroma. cornea in the treated area, possible REVIEW OF OPTOMETRY APRIL 15, 2015 37 036_ro0415_f2.indd 37 4/2/15 5:02 PM Slit Lamp Essentials decreased vision if the affected area is within the visual axis, infection, pain and discomfort during healing, and recurrence—all of which are complications of not treat- ing. Benefits include reduction or elimination of recur- rence of erosions, and possibly decreasing the burden of current topical/oral treatment.) Explain that the first couple of nights after the pro- cedure may be more uncomfortable than the episodes of erosion, and that the patient may need oral narcotics for a couple of days. Visual ability will be significantly reduced for a period of a week or more depending on rate of heal- ing area and size of treatment, and whether a bandage Prepare your instrument tray ahead of time. Treat this procedure soft contact lens or an amniotic membrane graft (e.g., as a sterile surgery. Prokera, Bio-Tissue) will be used. Tell patients they can expect their vision to return to pre-surgical levels within two to three weeks. 2. Prep the Patient Having a surgical microscope and surgical chair makes the procedure much easier because the stability of the eye is much greater and sterility is easier to maintain during the procedure. However, it can certainly be per- formed at the slit lamp. Stock your surgical tray for the procedure before- hand: Weck-Cels; golf club spud; lid speculum; ASP needle; and Alger brush with diamond burr tip. Treat this as a sterile surgery—clean the entire ocular adnexa with a swab of Betadine 5% (povidone-iodine sterile ophthalmic prep solution, Alcon), and let the patient sit for three minutes. During this time, instill a topical fluroquinolone and proparacaine—one drop of First, apply mild pressure with a Weck-Cel sponge to remove each every minute for three minutes. areas of loose epithelium. Slide them off the corneal surface. Cover the non-sterile areas of the patient’s forehead, nose and cheek with a sterile drape to allow you to rest your hands during the procedure. Insert a lid speculum to keep the eyelids and lashes away from the surgical field. Also, wear gloves and a mask to maintain sterility. 3. Debride the Epithelium To test for the areas of debridement, use a Weck-Cel sponge to dislodge and remove the areas of loose epi- thelium. Mild pressure will cause the affected epithe- lium to slide easily and freely from the corneal surface (and usually in a much larger area than the area of erosion). Also, you may need a spud to remove small islands of adherent tissue or to dissect the edge of the affected epithelium in order to leave 1mm of epithelium For areas that don’t come loose as easily, use a golf club spud. adhered to the limbus. Removal of the epithelium up to Leave at least 1mm of epithelium adhered to the limbus. or beyond the limbus can slow the re-epithelialization 38 REVIEW OF OPTOMETRY APRIL 15, 2015 036_ro0415_f2.indd 38 4/2/15 5:02 PM LET’S KEEP SOMETHING STRAIGHT ABOUT AREDS2 Only PreserVision® AREDS 2 Formula contains the exact ingredient dosages recommended by the National Eye Institute† based on the evidence from the AREDS2 study.1,2* Get patient samples and education materials at 1-844-BL-VITES. † For patients with moderate to advanced age-related macular degeneration. *This statement has not been evaluated by the Food and Drug Administration. PreserVision. Exactly. This product is not intended to diagnose, treat, cure, or prevent any disease. References: 1. Yong JJ, Scott IU, and Greenberg PB. Ocular nutritional supplements. Ophthalmology. 2014:1-5. 2. Chew EY, Clemens TE, SanGiovanni JP, et al. Lutein and zeaxanthin and omega-3 fatty acids for age-related macular degeneration. JAMA. 2013;309(19):1-11. PreserVision is a trademark of Bausch & Lomb Incorporated or its affi liates. AREDS2 is a registered trademark of the United States Department of Health and Human Services (HHS). ©2015 Bausch & Lomb Incorporated. PREV-56994 US/PV2/15/0006 SEE BETTER. LIVE BETTER. RP0415_BL Preservision.indd 1 3/17/15 1:58 PM Slit Lamp Essentials Coding Connection By John Rumpakis, OD, MBA, Clinical Coding Editor Coding for RCE and ASP A major procedure can be reported separately from the office visit, but a minor procedure cannot. s surgical procedures become more common in optometry has taken a particular interest in the improper and fraudulent use of practices, medical coding and record compliance can become modifier -25. Aareas of concern and exposure. From a medical record stand- Also consider the NCCI rules when performing multiple proce- point, major and minor surgical procedures require a separate nar- dures on the same day. All of these procedures are allowed on the rative, often referred to as a surgical report. This report describes same day without conflict, with the exception of 92071 (fitting of a several key items: the surgical procedure; preparation of the surgi- contact lens for ocular surface disease) and performing debridement cal field; instruments and approach used by the surgeon; and a (65435) on the same day as placement of the amniotic membrane statement of patient status at the end of the procedure. (65778).2,3 (While federal rules allow you to perform certain combi- Coding a surgical procedure first involves recognizing whether it nations of procedures together, check with your specific local carrier is designated as minor (a global period of 0 or 10 days) or major (a if its rules vary from the federal standards.) global period of 90 days). Perhaps the most common mistake ODs The coding for these two RCE situations may look something like make is to bill for an office visit on the same day as a minor surgi- this based upon these procedures: cal procedure. By definition, a minor surgical procedure already Clinical Situation Codes Performed Codes Allowed includes an office visit, so it should not be billed in conjunction with Office visit 992XX–57 992XX–57 an office visit on the same date, unless it had nothing to do with the Anterior stromal puncture 65600–RT/LT 65600–RT/LT decision to perform the minor surgery. In managing a patient with recurrent corneal erosion (RCE), both Fitting of a bandage 92071 types of procedures are performed: major surgery (65600–multiple contact lens punctures of anterior cornea, 90 days), as well as minor surgery Office visit 992XX–57 992XX–57 (65435–removal of corneal epithelium with or without chemocau- Anterior stromal puncture 65600–RT/LT terization, 0 days; and 65778–placement of amniotic membrane on the ocular surface; without sutures, 10 days). This distinction is Debridement of the cornea 65435–51–RT/LT 65600–51–RT/LT important to know because of the medical coding convention that Fitting of a bandage 92071–RT/LT must be followed for each type of procedure. contact lens The National Correct Coding Initiative (NCCI) Policy Manual for Placement of amniotic 65778–RT/LT 65778–RT/LT 1 Medicare Services clearly defines this. For a major surgical pro- membrane cedure, you can separately report the office visit performed on the same date of service as the procedure using modifier -57.1 A minor Providing these surgical services at the slit lamp highlights just procedure, though, cannot be reported separately from the office how far optometry has come in providing state-of-the-art care. But visit. The same holds true for a visit with a new patient—the fact with increased privileges comes increased responsibility for under- that the patient is “new” to the provider doesn’t justify reporting an standing the rules and regulations for medical coding and medical office visit on the same date of service as a minor procedure. record compliance of these surgical procedures. ■ However, a significant and separately identifiable E&M service Send questions and comments to ROcodingconnection@gmail. unrelated to the minor surgical procedure is separately reportable com. with modifier -25. The E&M service and minor surgical procedure 1. Centers for Medicare & Medicaid Services. The National Correct Coding Initiative Policy do not require different diagnoses. Manual for Medicare Services. Jan 2015:I-17. The problem arises when ODs improperly use these modifiers to 2. CCIPlus Module. www.CodeSAFEPLUS.com. 3. Centers for Medicare & Medicaid Services. The National Correct Coding Initiative Policy get reimbursed for the office visit. The Office of Inspector General Manual for Medicare Services. Jan 2015:XI-12. 40 REVIEW OF OPTOMETRY APRIL 15, 2015 036_ro0415_f2.indd 40 4/2/15 5:03 PM Imaging With Depth-of-fi eld. Just Dandy. What if none of your slit images or video had blurry edges? You would have a Haag-Streit, of course. Invest in one and submerge yourself into our extreme world of depth of fi eld. Visit haag-streit-usa.com to learn about our entire range of slit lamps and imaging systems. 80O.787.5426 haag-streit-usa.com © 2015 Haag-Streit USA. All Rights Reserved. RO0415_Haag Dandy.indd 1 3/26/15 10:52 AM Slit Lamp Essentials Two Other Indications for DBD with ASP: Preoperative Corneal Irregularity and Salzmann’s Nodular Degeneration Our referral center performs a large number of cataract surgeries and occasionally patients’ EBMD and/or Salzmann’s is significant enough that preoperative corneal measurements are too distorted to allow for proper IOL selection, especially in patients who elect toric or premium IOLs. If you notice Salzmann’s nodules, use the spud to lift the leading edge. While grabbing and lifting the leading edge of the nodule with small-toothed forceps, use the spud to dissect the nodule from the Here, forceps were needed to isolate the nodule, allowing use of the spud to dissect the nodule from corneal stroma. corneal stroma back to the limbus. The nodule should “peel” off with the consistency of removing Velcro. In cases where concurrent EBMD is present, consider performing DBD with or without ASP to allow a better adhesion of the epithe- lium after debridement. Once the eye is healed, better preoperative keratometry and regular topography are achievable. In some cases, Using the golf club spud, roll and lift the leading edge of the the procedure actually improves the patient’s vision to a point that Salzmann’s nodule. Try to leave the limbal edge intact. cataract surgery isn’t necessary. process. (See “Two Other Indica- tions for DBD with ASP: Preop- erative Corneal Irregularity and Salzmann’s Nodular Degenera- tion,” above.) 4. DBD and Polishing Next, use an Alger brush with a diamond burr tip to gently smooth the exposed corneal surface and remove the uneven basement mem- brane. Be sure to hold the handle of the Alger brush so that the burr always spins toward the center of the cornea. This also allows you to smooth the edges of the remaining limbal epithelium. Only mild pres- sure, using smooth broad strokes, needs to be applied. Remove any residual epithelial cells with a moistened Weck-Cel sponge. Instill a drop of topical Use the diamond burr (with rotation toward the center of the cornea) to smooth the antibiotic and a drop of NSAID on exposed cornea. Take care to preserve the limbal cells. Roll the edge of the epithelium the exposed surface. toward the pupil, but don’t overdo the pressure or you risk scarring in the visual axis. 42 REVIEW OF OPTOMETRY APRIL 15, 2015 036_ro0415_f2.indd 42 4/2/15 5:03 PM RELIEF AT THE MAIN SOURCE of dry eye symptoms Target Lipid Layer Defi ciency: Soothe® XP With Restoryl® Mineral Oils Recommend Soothe XP as your fi rst choice for dry eye patients. To request samples, please call 1-800-778-0980. Now available at major retailers nationwide. Distributed by Bausch + Lomb, a Division of Valeant Pharmaceuticals North America LLC, Bridgewater, N.J. © 2015 Bausch & Lomb Incorporated. Soothe and Restoryl are trademarks of Bausch & Lomb Incorporated or its affi liates. All other brand/product names are trademarks of their respective owners. PNS07412 US/SXP/14/0006 RO0315_BL Soothe.indd 1 2/24/15 10:35 AM Slit Lamp Essentials 5. Add ASP Keep in mind that because epi- then again every one to two days Although not conventional, per- thelium is now removed, the punc- until complete re-epithelialization forming ASP at this stage can maxi- tures will be slightly deeper than occurs. Use of sodium fluorescein mize adherence of the epithelium to ASP performed with the epithelium stain will diffuse through the amni- the stroma in severe cases of RCE, intact. Use caution in patients who otic membrane graft and allow you in our experience. may have severe corneal thinning to monitor the healing of the defect. So, once you’ve completely due to keratoconus or post-op Once the epithelium has healed removed the loose epithelium and LASIK. Preoperative pachymetry completely, remove the Prokera any nodules, use the ASP needle may be needed in these cases, as ring or BSCL and discontinue the to treat the entire exposed surface. the ASP needle could theoretically antibiotics and NSAID. If the cen- Make a grid of punctures about penetrate a cornea that is 250µm or tral visual axis was treated with 1mm apart, but stay clear of the thinner. diamond burr polishing, then con- central visual axis. Apply enough tinue the steroid (or add one if an pressure to deform the corneal sur- 6. Place the BSCL or AMG amniotic membrane was used) for face in order to penetrate the ante- At this point, place either a bandage an additional two weeks to help rior stroma. soft contact lens or amniotic mem- reduce formation of central corneal brane graft on the surface to allow haze. (Corneal haze is less signifi- for re-epithelialization and comfort cant when using an amniotic mem- during the healing process. brane, in our experience.) We prefer to use a Prokera in our clinic if insurance allows—this pro- With a small investment in time vides anti-inflammatory coverage and surgical equipment, you can during this healing process without employ these techniques to expand using a topical steroid, which can the corneal treatment options for slow re-epithelialization. We’ve patients with RCE, EBMD and Sal- also noted that the Prokera seems zmann’s degeneration. Your patient to inhibit corneal postoperative who was afraid to open her eyes in haze formation better than use of a the morning will truly have an “eye BSCL. opening” experience from all that However, in instances when an you can do for them, and you’ll To enhance patient comfort and promote amniotic membrane cannot be used gain a patient for life. ■ re-epithelialization, apply a bandage due to cost or insurance coverage, a Dr. Ellen is the clinical direc- contact lens soaked in fluoroquinolone. bandage contact lens is appropriate. tor of BVA Advanced Eye Care in Tulsa, Okla., where he specializes 7. Post-op Regimen in the diagnosis and treatment of Prescribe a topical fluoroquinolone ocular disease. TID or QID to prevent infection Dr. Lighthizer is the assistant during healing, and an NSAID QD dean for clinical care services, or BID to aid patient comfort until director of continuing education, the defect is healed. If the patient and chief of both the specialty care received a bandage soft contact clinic and the electrodiagnostics lens, add a topical steroid TID to clinic at the Oklahoma College of QID to the regimen as well. Also, Optometry. Norco (hydrocodone/acetamino- phen 5mg/325mg or 10mg/325mg, 1. Bronner A. Peeling back the layers of RCE. Rev Optom. 2013 Jan;150(1):42-9. Watso Pharmaceuticals) will help 2. Wong VW, Chi SC, Lam DS. Diamond burr polishing for the patient through the first couple recurrent corneal erosions: results from a prospective ran- domized controlled trial. Cornea. 2009 Feb;28(2):152-6 of nights of discomfort. 3. Sridhar MS, Rapuano CJ, Cosar CB, et al. Phototherapeu- If possible, use an amniotic membrane Schedule the patient to return on tic keratectomy versus diamond burr polishing of Bowman’s ring, which can be a better option than a day one to check for amniotic ring membrane in the treatment of recurrent corneal erosions associated with anterior basement membrane dystrophy. bandage contact lens. or BSCL position and healing, and Ophthalmology. 2002 Apr;109(4):674-9. 44 REVIEW OF OPTOMETRY APRIL 15, 2015 036_ro0415_f2.indd 44 4/2/15 5:03 PM BIOFINITY MULTIFOCAL LENSES easy An for you and your presbyopic fit patients. CooperVision Biofinity® multifocal lenses Biofinity® combine a high-performing 3rd generation multifocal material with a streamlined fitting process. Now even your most challenging presbyopic patients can enjoy the freedom of all-distance clarity and lasting comfort. Balanced Progressive™ Technologygy enhancesenhances vision nearnear, ffarar aandnd intermeintermediate.diate It also allows for an individualized fitting for each wearer and each eye. Dominant eye lens Non-Dominant eye lens Distance vision Near vision Spherical central zone Spherical central zone Intermediate vision Intermediate vision Progressive zone Progressive zone Near vision Distance vision Spherical zone Spherical zone Lens edge Lens edge Biofinity & Biofinity XR Biofinity toric Biofinity multifocal Download your Biofinity multifocal 3-step fitting guide at coopervision.com/fitting-guide ©2014 CooperVision, Inc. RO0215_Coopervision Biofinity.indd 1 1/20/15 3:42 PM Ocular Rosacea Corneal Disease Report SEEING RED: How Ocular Rosacea Impacts the Cornea Don’t forget that this condition can affect more than just the eyelids. Here’s what you need to know. By Sara Weidmayer, OD he ruddy cheeks and While our thoughts of ocular prominent facial vessels that rosacea often end with the eyelids, characterize rosacea are as corneal disease is often concomi- Tobvious as they are distinc- tant. It’s rare that ocular rosacea tive. From W.C. Fields to Prince leads to marked or blinding corneal William to Bill Clinton, these damage, but corneal involvement patients are easy to identify. Less has been noted in up to 33% of obvious, though, are the ocular patients with rosacea, and severe signs—especially those that signal sequelae are possible.1,5 Be sure to corneal involvement. look critically at the cornea and Rosacea is a relatively common conjunctiva in these patients. disorder, affecting up to 10% of This article provides an overview the adult population; it’s most fre- of rosacea and how it affects the quently seen in those with fair skin ocular surface. and tends to manifest around facial folds.1-4 Middle-aged adults are An Uncertain Pathogenesis most commonly affected, though Researchers have proposed many children can also have this disor- Ocular rosacea patient with typical eyelid theories regarding the pathogenesis der.3,5 As many as 58% to 72% findings, but also note the irregular of rosacea, though none have been of rosacea patients have ocular corneal light reflex due to marked confirmed. The prevailing wisdom involvement, and 45% to 85% inferior corneal dryness. points to a mix of vascular and have ocular complaints.1,3,4,6 The immunologic dysfunction.3,5 An most frequently reported ocular keratopathy, corneal vasculariza- increase in bacterial eyelid flora signs are blepharitis and meibomian tion and infiltrates with corneal appears to have a strong contribu- gland dysfunction, followed by con- scarring and opacity.1,5 Ocular tory effect on ocular manifestations. junctival hyperemia—particularly manifestations of rosacea may pre- Bacteria produce several lipolytic interpalpebrally—eyelid margin cede dermatologic signs in 20% of exoenzymes—including cholesteryl telangiectasias, punctate epithelial patients.1,3,6,7 esterase, triglyceride lipase and 46 REVIEW OF OPTOMETRY APRIL 15, 2015 046_ro0415_f3.indd 46 4/1/15 12:26 PM fatty wax esterase—that act on the lipid-based meibum by hydrolyz- ing its sterol esters and wax, thus increasing glycerides and free fatty acids.5,8 The latter are irritating and toxic to the ocular surface and adnexa.9,10 This process also alters the meibum’s solubility, causing it to thicken.9 Inadequate and solidi- fied meibum destabilizes the lipid layer of the tear film, allowing the aqueous to evaporate more quickly, increasing tear osmolarity and stim- ulating the inflammatory cascade.4,5 Chronic inflammation causes atrophy of the meibomian glands themselves, decreasing meibum pro- duction.5,8,9 Symptoms associated with this process include burning or stinging, conjunctival and eyelid Typical facial presentation with cutaneous rosacea; note rhinophyma, facial margin redness, foreign body sen- telangiectasias and eyelid findings. sation and often watery eyes from reflexive aqueous production. patient comfort. Peripheral stromal a pro-inflammatory cytokine, and Ocular rosacea patients also infiltrates are commonly seen with matrix metalloproteinase 9 (MMP- characteristically have an increased ocular rosacea; recurrent corneal 9), a collagen matrix-degrading eyelid margin density of Demo- erosions, ulcers, edema, stromal enzyme secreted by devitalized epi- dex.11 An immune response to keratitis, opacification or scar- thelial cells.5,14-17 Tear volume drops Demodex infestation on eyelash ring, neovascularization, pannus or as IL-1α increases, and dry eye follicles and within meibomian phlyctenules may also occur.2,3,5,6 symptoms can worsen in the pres- glands also appears to contribute to Limbal stem cell deficiency due to ence of elevated MMP-9 levels.14-16 chronic eyelid and meibomian gland chronic inflammation may occur, InflammaDry (RPS), an in-office inflammation and dysfunction.5,9 resulting in inadequate corneal epi- test that samples tears for elevated Demodex mites carry bacteria that thelial regeneration. Inflammation levels of MMP-9, could be a good produce proteins which stimulate causes corneal epithelial cells to confirmatory tool to help with early an increased expression of matrix produce fibroblast growth factors diagnosis and treatment. MMP-9 metalloproteinase (MMP) activity.9 and pro-angiogenic factors such as also overpowers inhibitory metallo- Ocular rosacea is readily associ- vascular endothelial growth factor proteinase proteins found naturally ated with blepharitis, eyelid margin (VEGF).12 In response, conjuncti- in the eye, leading to MMP-9’s telangiectasias, meibomian gland val endothelial cells produce more degrading activity on the cornea, its dysfunction and symptoms asso- MMPs, and the limbal epithelial epithelial basement membrane and ciated with dryness. Along with cells, which are capable of produc- stromal extracellular matrix, result- eyelid disease, researchers have also ing neovascularization and opacifi- ing in stromal thinning.14,15 reported associations with conjunc- cation, migrate beyond their normal In ocular rosacea, the inferior and tivitis, chalazia, episcleritis, iritis, limbal location onto the cornea.11,13 intrapalpebral regions of the cornea scleritis and scleral perforation.1 Additional immunologic cells are are more susceptible to damage, recruited, and this all contributes to particularly the 3- and 9- o’clock Corneal Complications triggering angiogenesis and corneal positions, due to the position of the Up to 40% of patients with ocular neovascularization.12 tear meniscus inferiorly at rest and rosacea may also display punctate Ocular rosacea patients can have during a blink.5 Progressive corneal epithelial erosions.5 This alone can significantly increased tear concen- thinning and loss of stromal tissue cause a notable decline in vision and trations of interleukin-1α (IL-1α), can precipitate the formation of REVIEW OF OPTOMETRY APRIL 15, 2015 47 046_ro0415_f3.indd 47 4/1/15 12:26 PM Ocular Rosacea More severe manifestations can be treated with autologous serum drops, which are rich in vitamin A, epidermal growth factor and fibronectin, which promote healthy development, proliferation, migra- tion and differentiation of conjunc- tival and corneal epithelium; the serum contains bacteriostatic fac- tors including lysozymes, comple- ment and IgG.18,19 They are derived by centrifuging the patient’s whole blood (making them naturally non- allergenic) after it clots, reaping the plasma serum, filtering it and com- pounding it with preservative-free Another ocular rosacea patient with severe corneal involvement. Note the irregular saline into the desired concentra- corneal surface and corneal scarring. tion; it’s packaged into single-use vials to be used liberally.18,19 descemetocele; this herniation of tions. Management of ocular sur- Routine eyelid hygiene, massage Descemet’s membrane increases the face symptoms will include topical and warm compresses are a main- risk of perforation.2,5 Rare corneal therapy, beginning with liberal stay. Devices for the expression of presentations such as dendritic lubrication with artificial tears. meibum are also available, which keratopathy or features similar to Inadequate lubrication can lead to warm and massage the meibomian keratoconus have been reported due abnormal corneal epithelial slough- glands, improving meibum fluid- to chronic ocular rosacea.2,14 ing and corneal damage. ity and flow onto the tear film.5 Furthermore, the avascular cor- Thorough reviews of treatment for Managing Ocular Rosacea nea needs many components of the blepharitis, meibomian gland dys- Your role in helping patients live tears for normal wound healing and function and Demodex infestations with this chronic disease is aimed reduced tear quality and quantity are readily available elsewhere in at reducing pro-inflammatory con- adds further insult.15 Lipid-based the literature. Note that consistency tributors to the disease, controlling artificial tears make sense given the with these lid considerations and symptoms and reducing exacerba- meibomian gland involvement. liberal lubrication are founda- The Many Faces of Rosacea ing of the skin; this is most frequently seen as rhinophyma, but Rosacea is a chronic inflammatory dermatologic condition that can also affect the cheeks, chin, forehead and even the ears. This affects the central face: most commonly the cheeks, forehead, subtype is generally uncommon, but is usually seen along with the chin and nose.1-3 Other than ocular rosacea, three subtypes and other subtypes; it is more predominant in males.2,3 one variant exist2,3: The variant granulomatous rosacea can be diagnosed even Erythematotelangiectatic rosacea involves persistent flushing in the absence of other rosacea signs. It presents with non- of the mid-face, which can occur with or without visible telangiec- inflammatory, hard cutaneous papules or nodules which can vary tatic vessels. The central facial skin may be scaly or rough, mildly in color from yellow to brown to red; interestingly, they tend to edematous and can often burn or sting.2 It is four times more appear over relatively normal, non-inflamed skin, but can lead to common than the next most prevalent subtype, papulopustular.3 scarring.2,3 Sun exposure appears to significantly correlate with both its pre- 4 1. Kharod-Dholakia B, Loft ES, Song CD, et al. Ocular Rosacea. eMedicine. 18 Aug 2014. cipitation and severity. Available at http://emedicine.medscape.com/article/1197341-overview. Papulopustular presents with papules or pustules or both 2. Wilin J, Dahl M, Detmar M, et al. Standard classification of rosacea: Report of the overlying erythematous skin on the central face or around the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol. 2002;46:584-7. nose, eyes or mouth. The papules and pustules may wax and 3. Tan J, Berg M. Rosacea: Current state of epidemiology. J Am Acad Dermatol. wane, resembling acne vulgaris. It often occurs concomitantly with 2013;69(6):S27-S35. 2,3 4. Bae YI, Yun SJ, Lee JB, et al. Clinical evaluation of 168 Korean patients with rosacea: the erythematotelangiectatic presentation. the sun exposure coorelates with the erythematotelangiectatic subtype. Ann Dermatol. Phymatous acne rosacea involves enlargement and thicken- 2009;21(3):243-9. 48 REVIEW OF OPTOMETRY APRIL 15, 2015 046_ro0415_f3.indd 48 4/1/15 12:26 PM tional and cannot be overstated evidence of effective improvement neal thinning or melting in an eye for preventing and managing both in clinical signs and symptoms that is already at higher risk due to generalized rosacea and corneal of the disease typically require ocular rosacea-associated thinning manifestations of the disease. around two months of treatment.5 and inflammation. Corticosteroids Oral tetracyclines (doxycycline, Doxycycline is generally preferred reduce the production of MMP-9 tetracycline, minocycline) are the over tetracycline due to its longer and other inflammatory products, most effective treatment for der- half-life, and therefore less frequent so steroid use is a balance that matologic rosacea, and are also dosing.6 Doxycycline for ocular needs to be monitored clinically; clinically useful in ocular rosacea.6 rosacea is typically dosed at 50mg lower potency steroids are generally Interestingly, the antibiotic proper- to 100mg daily, though off-label preferred when possible.6,15 ties of the medication aren’t the and lower dosages—such as Oracea Cyclosporine ophthalmic emul- main desired effect, but rather their (Galderma Laboratories), a 40mg sion 0.05% (Restasis, Allergan) anti-inflammatory actions. Tetra- doxycycline tablet, 10mg of which may be helpful as well. Similar cyclines, even at sub-antimicrobial is delayed-release, and Periostat to corticosteroids, cyclosporine levels, inhibit neutrophil chemotac- (CollaGenex Pharmaceuticals), reduces the production of inflam- tic factors from bacterial flora, sup- a 20mg formulation dosed twice matory markers, including MMP- press pro-inflammatory cytokines daily—have been shown effective 9.15,17 A clinical trial of topical and inhibit bacterial protein synthe- and are gaining popularity.3,6,7,21 cyclosporine in patients with ocular sis, therefore decreasing bacterial Off-label use of topical ophthal- rosacea found that three months lipase and esterase.5-8,10,20 They also mic antibiotics (such as erythromy- of use produced both symptomatic inhibit keratinization, and these cin ointment) and antibiotic-steroid improvement and improvement effects are useful for the meibomian combinations are helpful in reduc- in clinical signs, including tear gland dysfunction associated with ing eyelid bacterial proliferation, production and degree of corneal ocular rosacea.9 Tetracyclines also eyelid margin disease and meibo- staining.5,17 Other trials found a inhibit collagenase, an inflamma- mian gland dysfunction associated reduction in inflammatory markers tory product that degrades collagen, with ocular rosacea. Topical oph- after six months of cyclosporine use and suppress MMP-9 produc- thalmic corticosteroids can be used in patients with keratitis sicca and tion.5,15 Thus, tetracyclines protect in pulses for exacerbations. Chronic dry eye.15 This may be a very viable the cornea from the inflammation use is generally discouraged due to option for many ocular rosacea seen in ocular rosacea.6 concern over steroid-induced cor- patients. Lastly, antiangiogenic effects, which can prevent corneal neovas- cularization, are achieved due to the inhibition of smooth-muscle cell migration and of vascular endothe- lial growth factor.7 In patients where tetracyclines are contraindicated (children, preg- nant women, patients with hepatic dysfunction, or those who are aller- gic or intolerant), macrolides may be used; however, little clinical data supports their efficacy and tetracy- clines are preferred.5 Oral antibiotics can be discon- tinued when symptomatic control is achieved or can be maintained chronically at low doses, with pulses as needed for exacerba- tions. Sub-antimicrobial dosages Typical eyelid findings with ocular rosacea; note eyelid margin keratinization and are typically for chronic use, and telangiectasias. REVIEW OF OPTOMETRY APRIL 15, 2015 49 046_ro0415_f3.indd 49 4/1/15 12:26 PM Ocular Rosacea Don’t Forget Contact Lenses in Ocular Rosacea Ideal soft lenses have low water content, high oxygen perme- By Amy Lagina, OD ability and a non-ionic surface. Soft HEMA (hydroxyethyl meth- Ocular rosacea has long been deemed a contraindication to acrylate) lenses will have decreased oxygen permeability as the contact lens wear. But we can often return these patients to safe lens dehydrates. Conversely, silicone hydrogel lenses will have contact lens wear by: (1) confirming the diagnosis, (2) working to increased oxygen permeability with lens dehydration. Silicone treat the underlying disease, (3) addressing the eyelid and ocular hydrogels also have high oxygen permeability, which significantly surface factors and (4) carefully educating the patient on the do’s reduces the corneal hypoxia that can lead to contact lens discom- and don’ts. fort.2 The iconicity is important to consider, as non-ionic lenses Mainstays of CL use in these patients are to protect the cornea will have less protein accumulation and deposition. Lens modulus and promote healing, or to alleviate symptoms. Specific goals can relates to the stiffness of the lens, with higher modulus lenses include vision correction, pain management, exposure and lid pro- being stiffer, which generally creates more lens awareness. Most tection, and assistance with corneal reepithelialization. silicone hydrogel lenses have lower water content and a higher Contact lenses used for therapeutic purposes can be either modulus, except Biofinity (comfilcon A 48%, CooperVision). bandage soft contact lenses or scleral gas permeable lenses. Daily, two-week and monthly replacement lenses are becoming Continuous use of the approved lenses may vary from one to four increasingly available. Daily lenses are ideal because they can be weeks, depending on the ocular surface condition. worn on an as-needed basis and discarded after each use. Finally, Scleral lenses are common for the management of ocular sur- vigilant lens hygiene is important to prevent additional exacerba- face diseases because they provide constant surface protection tions with ocular rosacea. Reminding patients to rub their lenses and enable more continuous lubrication. Scleral lenses are filled nightly, use fresh solution daily, or switching to a hydrogen perox- with a sterile saline prior to insertion and are fit to vault over the ide solution can greatly improve lens disinfection, compliance and entire cornea, eliminating any interaction between the cornea and overall success. the lens.1 Lens materials with high oxygen transmissibility are Dr. Lagina practices at both the VA Ann Arbor Healthcare recommended to prevent corneal hypoxia since scleral lenses are System and the Kellogg Eye Center in Ann Arbor, MI. She is a substantially thicker than standard gas permeable lenses. clinical instructor with the University of Michigan Department of If the ocular surface presentation is mild and is properly man- Ophthalmology and Visual Sciences. aged, patients can continue to wear regular lenses. Important characteristics to consider when prescribing are: water content, 1. Schornack MM, Pyle J, Patel SV. Scleral lenses in the management of ocular surface disease. Ophthalmology. 2014;121:1398-1405. oxygen permeability, iconicity, lens modulus, replacement sched- 2. Stapleton F, Papas E, et al. Silicone hydrogel contact lenses and the ocular surface. ule and maintenance. Ocul Surf. 2006;4(1):24-43. Other emerging treatments for which have made a profound differ- or the use of a keratoprosthesis.12 severe corneal involvement include ence in eye care, have been shown Because of chronic inflamma- topical hormonal therapy such as to reduce corneal neovasculariza- tion with ocular rosacea, post- dehydroepiandrosterone (DHEA) tion when applied via subcon- keratoplasty patients may have an and medroxyprogesterone acetate junctival injection or with topical increased risk of graft neovascu- (MPA). DHEA, an androgen, sup- administration; however, long-term larization.5 The use of therapeu- ports meibomian gland function.18 data is not available, route of deliv- tic amniotic membranes, which MPA, a synthetic progestin, inhibits ery and dosing have not been stan- inherently have anti-inflammatory MMP expression and interleukin- dardized, and this is an off-label use properties and promote healing and induced corneal collagen degrada- of these drugs.12,23,24 Neovascular- corneal epithelialization, may also tion by corneal fibroblasts.22 Their ization could also be targeted with be helpful in severe cases of ocular use is off-label, and there is limited Nd:YAG or argon laser ablation, rosacea with corneal involvement.6 evidence to date as to their efficacy. photodynamic therapy (PDT) or While the eyelids are more often Corneal neovascularization can fine needle thermal cautery.12 involved in ocular rosacea, don’t be addressed in several different Severe corneal involvement in forget the cornea! It’s involvement ways. Oral tetracyclines, as men- ocular rosacea may require surgical is potentially sight-threatening, so tioned above, can play a preventa- intervention. Corneal perforations appropriate management is key. ■ tive role, and topical corticosteroids require urgent ophthalmologic Dr. Weidmayer practices at the or non-steroidal anti-inflammatory treatment, ranging from cyano- VA Ann Arbor Healthcare System drugs can reduce the immunologic acrylate tissue glue to partial- or in Ann Arbor, MI. She is also a factors that trigger corneal neovas- full-thickness keratoplasty.6 Severe clinical instructor for the University cularization.12 Anti-VEGF agents neovascularization could also be a of Michigan Department of Oph- bevacizumab and ranibizumab, cause for corneal transplantation thalmology and Visual Sciences. 50 REVIEW OF OPTOMETRY APRIL 15, 2015 0046_ro0415_f3.indd46_ro0415_f3.indd 5050 44/1/15/1/15 12:2712:27 PMPM Rely on something that 1. Ghanem VC, Mehra N, Wong S, Mannis M. The prevalence of ocular signs in acne rosacea. Cornea. 2003;22(3):230-3. STAYS PUT 2. Lee WB, Darlington JK, Mannis MJ, Schwab IR. Dendritic keratopathy in ocular rosacea. Cornea. 2005;24(5):632-3. 3. Donaldson KE, Karp CL, Dunbar MT. Evaluation and treatment of children with ocular rosacea. Cornea. 2007;26(1):42-6. 4. Onaran Z, Karabulut AA, Usta G, Örnek K. Central corneal thickness in patients with mild to moderate rosacea. Can J Ophthalmol. 2012;47(6):504-8. 5. Bron A. Ocular rosacea. Up To Date. 11 Dec 2013. Avail- able at http://uptodate.com/contents/ocular-rosacea. 6. Kharod-Dholakia B, Loft ES, Song CD, et al. Ocular Rosa- cea. eMedicine. 18 Aug 2014. Available at http://emedicine. medscape.com/article/1197341-overview. 7. Sobolewska B, Doycheva D, Deuter C, et al. Treatment of ocular rosacea with once-daily low-dose doxycycline. Cor- nea. 2014;33(3):257-60. 8. Ta CN, Shine WE, McCulley JP, et al. Effects of mino- cycline on the ocular flora of patients with acne rosacea or seborrheic blepharitis. Cornea. 2003;22(6):545-8. 9. Mastrota K. Ocular surface disease. Optometric Manage- ment. 1 May 2009. Available at www.optometricmanagement. com/printarticle.aspx?articleID=102974. 10. Dougherty JM, McCulley JP. Bacterial Lipases and Chronic Blepharitis. Invest Ophthalmol Vis Sci. 1986;27(4):486-91. 11. O’Reilly N, Gallagher C, Katikireddy KR, et al. Demodex- associated bacillus proteins induce an aberrant wound healing response in a corneal epithelial cell line: possible implications for corneal ulcer formation in ocular rosacea. Invest Ophthalmol Vis Sci. 2012;53(6):3250-9. 12. Chiang HH, Hemmati HD. Treatment of Corneal Neovas- cularization. Eye Net Clinical Pearls. 2013;35-6. 13. Kim BY, Rias KM, Bakhtiari P, et al. Medically reversible limbal stem cell disease. Ophthalmol. 2014;121(10):2053-8. 14. Dursun D, Piniella AM, Pflugfelder SC. Pseudokeratoco- nus caused by rosacea. Cornea. 2001;29(6):668-9. 15. Kaufman HE. The practical detection of MMP-9 diagno- ses ocular surface disease and may help prevent its compli- cations. Cornea. 2013;32(2):211-6. 16. Kaufman HE. MMP-9 and its role in dry eyes. Advanced Parasol® Ocular Care. 2011;40-2. 17. Schechter BA, Katz RS, Lriedman LS. Efficacy of topical cyclosporine for the treatment of ocular rosacea. Adv Ther. 2009;26(6):651-9. * We’ve taken the worry out of plug retention, 18. Reed K. Dry eye treatment: the unusual suspects. 92% Review of Cornea and Contact Lenses. March 2013. RETENTION so you can concentrate on patient retention. Available at www.reviewofcontactlenses.com/content/d/ dry_eye/c/39490/. The Parasol® Punctal Occluder trumps the 19. Mangan R, Lehman S. How (and why) to make autolo- gous serum. Review of Optometry. March 2012. Available at competition with an unprecented 92% retention rate. www.reviewofoptometry.com/content/d/dry_eye/c/33139/. Use the Parasol® Punctal Occluder, designed for easy 20. Stone DU, Chodosh J. Oral tetracyclines for ocular rosacea: an evidence-based review of the literature. Cornea. insertion and guaranteed to stay put. 2004;23(1):106-9. 21. Shovlin JP. Which antibiotic for rosacea? Review of Optometry. March 2007. Available at www.reviewofoptom- TO ORDER: 866-906-8080 etry.com/content/d/cornea/c/15521/. [email protected] 22. Zhou H, Kimura K, Orita T, et al. Inhibition by medroxy- progesterone acetate of interleukin-1 -induced collagen odysseymed.com or beaver-visitec.com degradation by corneal fibroblasts. Invest Ophthalmol & Vis Sci. 2012;53(7):4213-9. 23. Chang J-H, Garg NK, Lunde E, et al. Corneal neovascu- larization: an anti-VEGF therapy review. Surv Ophthalmol. 2012;57(5): 415-29. 24. Stephenson M. Anti-VEGF for CNV: questions remain. Review of Ophthalmology. Sept. 2011. Available at www. reviewofophthalmology.com/content/i/1628/c/29956/. * “Plugs Reduce Dry Eye Symptoms, Improve Vision”, Craig McCabe, M.D., Review of Ophthalmology, 2009. BVI, BVI Logo and all other trademarks (unless noted otherwise) are property of a Beaver-Visitec International (“BVI”) company © 2015 BVI 046_ro0415_f3.indd 51 4/1/15 12:27 PM PREFERRED 13TO 1 THIS IS WHY more patients prefer our lenses. 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Based on an ongoing survey in Europe of 24 ECPs fi tting 280 customers in DAILIES TOTAL1® contact lenses. Alcon data on fi le, 2012. 3. Angelini TE , Nixon RM, Dunn AC, et al. Viscoelasticity and mesh-size at the surface of hydrogels characterized with microrheology. ARVO 2013; E-abstract 1614872. See product instructions for complete wear, care and safety information. © 2013 Novartis 7/13 DAL13315JAD RO0215_Alcon Dailies Total.indd 1 1/20/15 3:19 PM OPTOMETRIC STUDY CENTER 2 CE Credits (COPE approval pending) Corneal Disease Report Corneal Harbingers of Systemic Disease A routine slit lamp exam may reveal telltale findings of health concerns elsewhere in the body. Here are the most common to look for. By Andrew Bronner, OD hough retinal vasculature ated with its myriad autoimmune thy, it should come as no surprise disorders or iritis come to diseases—will ensure you are pre- that the cornea, which is the most mind first when we think pared to see even the most unusual densely innervated tissue in the Tabout systemic disease corneal issues stemming from sys- body, may also be impacted by and the eye, the cornea—with temic disease. diabetes. its unique clarity and dual zones Diabetic keratopathy is thought of immune function—provides Diabetes Mellitus to manifest as a result of changes in a unique window into a wide One of the most important sys- the density of corneal innervation, variety of systemic diseases that temic diseases monitored by particularly within the sub-basal otherwise would require labora- optometrists for its ocular effects nerve plexus. Based on the results tory or imaging-based evaluation. is diabetes. We are all aware of the of at least one study group assess- Systemic manifestations in the retinopathy and neovasculariza- ing Type I diabetes, these changes cornea range from the mundane, as tion of the iris and/or the angle result in reduced corneal sensation, with arcus senilis, to the unusual with potential for subsequent glau- increasing corneal thickness and and life-threatening, as with mul- coma, as well as the severe extra- cellular polymorphism of both tiple myeloma or vasculopathic ocular effects of diabetes; namely, the corneal epithelium and endo- disease. Reviewing many of these nephropathy and neuropathy. thelium. What’s more, the level manifestations—ignoring the well- Given that the eye is such a promi- of diabetic keratopathy correlates described or general associations, nent site for diabetic involvement well with the levels of retinopa- such as hypercholesterolemia with and in light of the potential for the thy, systemic polyneuropathy and arcus and keratitis sicca associ- disease to manifest as neuropa- nephropathy.1,2 Release Date: April 2015 Faculty/Editorial Board: Andrew Bronner, OD Expiration Date: April 1, 2018 Credit Statement: COPE approval for 2 hours of CE credit is pending Goal Statement: Although ocular manifestations of systemic dis- for this course. Check with your local state licensing board to see if this eases most often present with retinal involvement, several systemic counts toward your CE requirement for relicensure. conditions—such as diabetes, autoimmune disorders and infectious Joint-Sponsorship Statement: This continuing education course is diseases—can be diagnosed via corneal presentation. This article joint-sponsored by the Pennsylvania College of Optometry. educates optometrists on how to recognize the corneal signs of sys- Disclosure Statement: Dr. Bronner has no relevant financial relation- temic diseases and understand their role in disease management. ships to disclose. REVIEW OF OPTOMETRY APRIL 15, 2015 53 053_ro0415_f4_osc.indd 53 4/1/15 12:28 PM OPTOMETRIC STUDY CENTER Corneal Lines Comparison Waite-Beetham lines in a 73-year-old Vogt’s striae in a 31-year-old keratoconic Corneal stromal edema. Edematous lines diabetic. patient. Note how much finer, more tightly are much broader and less organized organized and more vertically arranged than Waite-Beetham lines. the Vogt’s striae are compared to Waite- Beetham lines. While these changes can be Vogt’s striae as seen in kerato- The cornea can be roughly assessed to some degree with for- conus, and tend to be somewhat thought of as having two distinct mal esthesiometry and pachymetry, wavy, though generally are immune zones: diabetic corneal neuropathy can arranged vertically or, less com- • The central cornea, characterized only be objectively defined by monly, obliquely (unlike edematous by its avascularity and lack of confocal microscopy and so falls pleats, which may be arranged in lymphatics, is relatively remote outside the optometrist’s ability to any direction). from the immune response and quantify. It is useful to know, how- These disturbances do not seem therefore sheltered to a certain ever, that as the disease progresses, to create pathology of the cor- degree, from destructive systemic patients with diabetes may become nea, nor do they appear to be the infectious as well as autoimmune more neurotrophic and develop harbinger of worsening systemic processes. thicker corneas. In the study ref- disease. In fact, while Descemet’s • The peripheral cornea, however, erenced, patients without diabetes wrinkles are more common in dia- with its proximity to the vascu- had an average corneal thickness betes (27% to 38% prevalence), lature, lymphatic channels and of 526µm, patients with mild neu- they occur in unaffected patients secondary lymph tissue of the ropathy had 558µm and patients as well (8% to 10.5%).3,4 They conjunctiva, sclera and episclera, with severe neuropathy had corneal become more common with age in is in a prime location to manifest thickness of 625µm.1 both populations, and occur earlier immune processes associated A frequently encountered but in patients with diabetes.3 Their with systemic infectious and infrequently recognized ocular man- presence—particularly in a patient autoimmune disease. ifestation of diabetes is the presence for whom you may already suspect Peripheral ulcerative keratitis of pleats in either the deep stroma diabetes—may be a warning sign (PUK) is a significant ocular mani- or Descemet’s membrane of the that a patient has developed the festation of systemic vasculitides, non-ectatic eye—sometimes simply condition. connective tissue diseases and referred to as Descemet’s wrinkles infectious disease of the juxtalim- and formally known as Waite- Peripheral Ulcerative Keratitis bal cornea. Beetham lines. They are more prom- Isolated corneal effects of iritis, While there are a number of inent, though arranged with less scleritis and episcleritis—often other corneal manifestations of density and precision, than Vogt’s associated with autoimmune dis- autoimmune disease more com- striae seen in keratoectasias. They ease—are also possible, and given mon than PUK, it remains a very are also not as thick and irregular as their significant relationship with important pathology to be aware pleats seen in edematous corneas. ocular morbidity and overall mor- of because of its potential for Descemet’s wrinkles may be tality, it is important for doctors to being the presenting manifesta- single or multiple, are longer than be aware of them. tion of autoimmune disease; one 54 REVIEW OF OPTOMETRY APRIL 15, 2015 053_ro0415_f4_osc.indd 54 4/1/15 12:28 PM study showed it preceded systemic gray to golden whorled deposits in diagnosis in 28% of cases.5-8 Addi- Systemic Etiologies of PUK the interpalpebral region of cornea tionally, among some forms of the • Rheumatoid arthritis occur almost universally in patients disease it is associated with a mor- on this drug and generally dissipate • Wegener’s granulomatosis tality rate as high as 50% over five upon cessation of the medication.10 years if systemic immunomodula- • Polyarteritis nodosa The rate of appearance upon ini- tory agents are not implemented.5-8 • Relapsing polychondritis tiation of the medication (days to Though many autoimmune or • Systemic lupus erythematosus months) and the disappearance systemic infectious diseases may • Sjögren’s syndrome upon cessation (months to years) result in PUK, the underlying varies widely from individual to • Churg-Strauss syndrome mechanism of a perilimbal vasculi- individual.10 tis seems to be relatively uniform. • Syphilis While quite prominent with bio- Characterized by a crescentic infil- • Lyme disease microscopy, verticillata generally trate with an overlying epithelial • Herpes zoster have no effect on vision beyond defect along the peripheral cornea, occasional reports of glare and PUK lesions will progressively thin ease can lead to the patient’s death. halos. Amiodarone is the most in the absence of appropriate treat- In addition to difficult treatment common source of verticillata, but ment and may lead to perforation of their ocular disease, which may there are other sources as well, of the cornea. generally be managed with oral including chloroquinine, hydroxy- Though it’s most typically associ- cortocosteroids, these patients need chloroquine—where, in the setting ated with adjacent areas of scleritis, to be placed on potent cytotoxic or of corneal deposits, there is also a PUK may occur as a primary mani- immunomodulatory agents to con- higher rate of retinopathy—tamox- festation as well; when isolated to trol their underlying condition.7 ifen, phenothiazine, suramin and the cornea without any systemic indomethacin, among others.10,11 etiology it is known as a Mooren’s Corneal Deposits While it may seem confusing ulcer, though some argue that Perhaps no corneal manifestation for this widely varied group of Mooren’s ulcer is actually associ- of systemic disease is as recogniz- medications to share the potential ated with hepatitis.5,9 able as the verticillata seen with for creating verticillata, it is not As topical corticosteroids are the use of the anti-arrhythmic their respective mechanisms that contraindicated due to their possi- medication amiodarone. These result in the manifestation, but the ble promotion of collagenase activ- ity (thereby enhancing keratolysis), topical treatment is limited primar- ily to aggressive lubrication. Surgi- cal and parasurical procedures such as application of a bandage contact lens, tissue glue, conjunctival resec- tion and keratoplasty may tempo- rize any risk of perforation or even act to stunt the ulcerative process, but ultimately systemic treatment is needed to abate the attack and reduce risk of recurrence.6 Though matrix metalloproteinases are implicated in the disease process, adjunctive use of tetracyclines is often ineffective. In the treatment of autoimmune- associated PUK, it is imperative to recognize the condition’s role as a herald of worsening systemic dis- Active peripheral ulcerative keratitis in a 35-year-old with thinning, vascularization ease; widespread vasculopathic dis- and lipid deposit. REVIEW OF OPTOMETRY APRIL 15, 2015 55 053_ro0415_f4_osc.indd 55 4/1/15 12:28 PM OPTOMETRIC STUDY CENTER tially fatal systemic conditions. Beyond localized crystalline cor- neal dystrophies such as Schny- der’s and Bietti’s corneo-retinal dystrophy, metabolic disease, neo- plastic and pre-neoplastic disor- ders are other sources of corneal crystals. Cystinosis is an X-linked reces- sive metabolic disease of the amino acid cystine, which becomes trapped in lysosomes, potentially affecting tissue function systemi- cally. There are three types of cystinosis, classified based on the time of development: infantile, intermediate and adult-onset, with infantile being the most severe Corneal crystals in a 56-year-old man with multiple myeloma. While they appear and possible fatal. The corneal granular in this direct illumination photo, the crystals scintillated with movement of crystals that develop regardless light across their surface. of subtype are generally fine and, given sufficient time, are diffusely biochemical behavior of the mol- deep epithelium.10,13 distributed throughout the anterior ecules. They all share ampiphi- While the link between Fabry’s cornea. Though they may be very lic properties, which allows the and corneal deposits is very strong, prominent, a patient’s visual acuity molecules to penetrate and create the chances of diagnosing the is generally not affected, barring lipid-based complexes within condition based on ocular exam photophobia.15 lysosomes.10 This eventually leads is quite low due to the limited Corneal crystals that develop to the whorl keratopathy. symptomology associated with its in middle age may be caused by These lysosome-born deposits ocular manifestations. In fact, in either local dystrophy or systemic are generally held in the basal epi- a study that looked at the utility metabolic disease. This group of thelium. Confocal microscopy has of community ocular screening patients must also have plasma also identified abnormalities within for Fabry’s disease, only one case cell dyscrasias on the differential the anterior stroma. The deposits was discovered in over eight mil- diagnosis. Plasma cell dyscrasias— and other abnormalities appear to lion patients—a fact that led the which include multiple myeloma, develop as medication precipitates authors to question the utility of monoclonal gammopathy of unde- through the tear film, a reason why community eye screen- Photo: Genzyme Corp. concomitant contact lens use may ings for this disease. The result in more dramatic whorls.10,12 authors, however, then Beyond pharmaceuticals, Fabry’s go on to point out how disease—an X-linked recessive dis- important it is to seize order of lipid metabolism and one these rare opportunities of many metabolic diseases that to recognize the findings results in corneal deposits—has a of verticillata when they near-universal link to verticillata as could potentially yield a well.13 Though the verticillata seen diagnosis of Fabry’s.14 with Fabry’s tend to display more Though much less well-formed vortices (whereas common than verticillate drug-induced variants have more of corneal deposits, corneal a “cat’s whisker appearance”), the crystals are important to Fabry’s associated corneal verticillata. Note how much underlying deposit, again, is lipid be aware of given their more well formed the pattern is than with typical complexes within lysosomes of the association with poten- medication-associated vortices. 56 REVIEW OF OPTOMETRY APRIL 15, 2015 053_ro0415_f4_osc.indd 56 4/1/15 12:29 PM termined significance (MGUS) and important diagnosis. In the absence Waldenstrom’s macroglobunemia, of other diagnostic clues, it may Local and Systemic Causes of among others—are characterized justify a hematology referral. Corneal Phlyctenules by an atypical population of plas- • Staphylococcus ma or B cells, which redundantly Band Keratopathy • Mycobacterium tuberculosis produce a single, monoclonal form A frequently encountered sequela • Chlamydia of immunoglobulin (IG) or an IG of chronic ocular inflammation, • Coccidiodes fragment, which then may become band keratopathy is characterized • Fungal infections deposited in tissue. by a sub-Bowman’s layer opacifi- • Protozoan infection The distribution and exact cation via deposition of calcium • Parasitic disease appearance of the corneal crystals phosphate. In addition to being • Rosacea seen in patients with these condi- caused by various ocular patholo- tions vary widely: from diffuse fine gies, systemic diseases that cause by a vascular tuft to the limbus. through-and-through crystals, to hypercalcemia may also lead to Their nodules may be smooth or very localized needle-like changes, band keratopathy.19 ulcerated depending on their staging, to lattice and granular-like deposits In hyperparathyroidism, which and when isolated to the limbus they and even those with verticillate results in systemic hypercalcemia, leave no clear zone between limbus appearance.11,16-18 They generally band keratopathy may be among and cornea. share the common feature of being the presenting signs. Interestingly, as The lesions represent a delayed- crystalline and iridescent upon opposed to ocular band keratopathy, onset hypersensitivity reaction to close examination.16 Despite the this keratopathy may spontaneously a wide variety of microbial and clear cornea being an ideal location regress when the underlying etiology viral antigens, the most common to see systemically-derived protein has been treated. Other systemic eti- being blepharitis associated with deposits, crystals are not common ologies of band keratopathy are sar- Staphylococcus.20 When associated findings, with one study reporting coidosis, gout, chronic renal failure, with tuberculosis, these will occur only a 1% incidence in patients multiple myeloma and metastatic almost exclusivity at a young age, with MGUS.16 disease.19 as the body eventually becomes Though an uncommon mani- In general, band keratopathy desensitized to the causative anti- festation of uncommon systemic in an otherwise unremarkable eye gen as it ages.20 diseases, corneal crystals in this should generate an appropriate Though the precise etiology will setting have diagnostic value, as level of clinical suspicion that sys- dictate treatment, all phlyctenules symptoms of these diseases are temic hypercalcemia may be play- will respond locally to topical relatively non-specific, and the ing a role. These patients should corticosteroids. As phlyctenules presence of corneal crystals can be asked about symptoms of bone are a hypersensitivity reaction, the help steer the clinician toward an pain or frequent urination, and be topical use of corticosteroids is safe sent for urinalysis and blood tests. and in no way contraindicated by Metabolic Dysfunction the underlying infectious etiology, and the Cornea Infection though of course when a systemic There are close to 40 recognized lyso- Although corneal manifestations of etiology is suspected concurrent somal storage diseases that may result in endogenous infectious disease are systemic treatment is necessary.20,21 ocular findings, many of which will gener- rare, given the significance of their A second mycobacterial infec- ate cornea-specific findings. All of these underlying etiologies it’s important tion, Mycobacterium leprae, is disorders share the common mechanism for clinicians to be aware of them. actually reported to have the high- of metabolic products becoming trapped Perhaps the most well-described est rate of ocular involvement in an in lysosomes due to lack of a variety of form is phlyctenular keratocon- infected individual of any systemic metabolic enzymes. For more on metabolic junctivitis and its association with infectious disease, with estimates of diseases affecting the cornea, Holland’s systemic Mycobacterium tuberculo- ocular involvement being as high Cornea (specifically, chapter 64 by Kenyon, sis infection. as 100% in an untreated popula- 22,23 Navon and Haritoglou) covers this broad Corneal phlyctenules are nodular tion. Though the worldwide group of disorders and their wide range of lesions made up of lymphoid tissue; burden has been significantly possible effects on the cornea.15 they may either be limbal or, when reduced with effective multidrug on the clear cornea, remain attached therapy (MDT) and the disease REVIEW OF OPTOMETRY APRIL 15, 2015 57 0053_ro0415_f4_osc.indd53_ro0415_f4_osc.indd 5577 44/1/15/1/15 12:3012:30 PMPM OPTOMETRIC STUDY CENTER sharing a similar appearance with Syphillis the perineuritis seen in Acantham- Interstitial keratitis associated with oeba keratitis.23 They manifest as syphilis is among the most widely focal chalky-white, pinhead-sized recognized corneal effects of infec- subepithelial opacities within an tious systemic disease. Syphilitic area of avascular pannus, and keratitis, in and of itself, is an atyp- unlike similar lesions seen with ical manifestation of an increasing- Acanthamoeba, which usually ly uncommon disease, accounting begin centrally, those seen with for only 5% of all cases of syphi- leprosy most often begin in the litic eye disease, with most of these superior cornea.25,26 These lesions cases being caused by the congeni- Leprosy keratitis in a patient with represent accumulations of active tal form of the disease.15 Though previously undiagnosed leprosy who bacillus within “foam cell” mono- the rate of acquired syphilis is presented to clinic in the US for cataract cytes; however, given the down- increasing again, the congenital dis- evaluation. regulation of the immune response ease remains uncommon, affecting to M. leprae over time, they display only one in one million.15,28 Bilat- is currently most associated with little to no local infiltration of eral presentation is most frequently developing countries, leprosy does white cells.27 Further, as no cuture associated with the congenital dis- still constitute a significant world- media exists for M. leprae, they ease, as is the tendency to develop wide source of ocular morbidity. cannot be effectively processed for ghost vessels upon resolution. In the United States, a country of microbiologic studies. Though the term “congenital immigrants, it is something with Treatment regimens for ocular syphilis” may lead the practitioner which the eye care provider should disease resulting from leprosy is to view this disease as one of gesta- at least have passing familiarity. similar to that of tuberculosis: local tion and infancy, syphilitic intersti- As the organism has a predilec- corticosteroids are fine when indi- tial keratitis is a late manifestation tion for cooler temperatures, the cated, but refer to infectious disease of congenital disease that common- anterior segment and adnexa, for confirmation of diagnosis (in ly develops between the ages of five which are 4° to 6° C cooler than this case with skin biopsy) and ini- and 20. Likewise, with the acquired the deep orbit, are the affected tiation of multidrug therapy. disease, keratitis is most typically a tissues. Nearly all other forms of ocular disease associated with systemic infection generally show predilection for the posterior seg- ment; however, whether leprosy affects the posterior segment at all is a matter of debate.24 The sight-threatening impact of leprosy generally has to do with lagoph- thalmos resulting in corneal opaci- fication or chronic plastic iritis resulting in gradual destruction of the ciliary body; however, direct involvement of the cornea is not uncommon. While most corneal findings in leprosy are general—punctate epi- thelial erosions, prominence of cor- neal nerves (with greater specificity if beading of nerves occurs) and varying degrees of neurotrophy— the subepithelial infiltrate seen with Deep interstitial ghost vessels in a patient with contact lens induced keratitis leprosy is nearly pathognomonic, mimicking syphilitic keratitis. 58 REVIEW OF OPTOMETRY APRIL 15, 2015 053_ro0415_f4_osc.indd 58 4/1/15 12:30 PM Photo: Jeff Urness, OD late manifestation, occurring years after the original infection. In both congenital and acquired disease, the keratitis initially cre- ates a deep focal inflammation of the stroma, typically starting in the periphery with a slight predilection for the superior cornea. In con- genital cases, this will sequentially develop within months in the fel- low eye. Vascularization typically follows the initial inflammation and perpetuates it, before ultimate- ly burning out and regressing. In acquired syphilis, the initial keratitis resembles congenital dis- ease, though tends to remain less severe, unilateral and avascular.15 Though uncommon—and in the acquired form limited primarily Peripheral thinning in a patient previously treated for syphilitic peripheral ulcerative to those who practice risky sexual keratitis. behaviors or intravenous drug use—syphilis should be suspected in the corneal periphery as seen 3. Henkind P, Wise GN. Descemet’s wrinkles in diabetes. Am J Oph- thalmol. 1961;52:371-4. in any case of bilateral stromal with Wilson’s disease being omit- 4. Mocan MC, Irkc M, Orhan M. Evidence of Waite-Beetham lines keratitis or deep stromal keratitis ted—hopefully it serves as a useful in the corneas of diabetic patients as detected by in vivo confocal microscopy. Eye. 2006;20:1488-90. without a previous episode of more review and reminder of the spec- 5. Ladas JG, Mondion BJ. Systemic disorders associated with superficial disease (i.e., if it’s not trum and possible seriousness of peripheral corneal ulceration. Current Opinion in Ophthalmology. 2000;11:468-71. herpetic). these manifestations both locally 6. Messmer EM, Foster CS. Vasculitic Peripheral Ulcerative Keratitis. Unfortunately, patients without to the cornea itself and systemi- Survey of Ophthalmology. 1999;43:379-96. a previous diagnosis do not tell cally. It’s important to periodically 7. Foster CS, Forstot SL, Wilson LA. Mortality rate in rheumatoid arthritis patients developing necrotizing scleritis or peripherial ulcer- you they have congenital syphilis be reminded that although our ative keratitis: Effects of systemic immune suppression. Ophthalmol- and I’ve yet to have a patient write focus and attention is on the organ ogy. 1984;91:1253-63. 8. Tauber J, et al. An Analysis of therapeutic decision making regard- “risky sexual behavior” or volun- of the eye, the overall health of ing immunosuppressive chemotherapy for peripheral ulcerative tarily document “intravenous drug the patient is ultimately the most keratitis. Cornea.1990;9:66-73. 9. Wilson SE, et al. Mooren’s ulcers and hepatitis C virus Infection. N user” on their initial health intake important consideration for us as Engl J Med. 1993;329:62. form. Because of this lack of trans- optometrists. Where ocular and 10. Hollander DA, Aldave AJ. Drug-induced corneal complications. Current Opinion in Ophthalmology. 2004;15:541-8. parency, serologic testing for syphi- systemic diseases converge, it is our 11. Sharma P, et al. Cloudy corneas as an initial presentation of mul- lis should be ordered in cases where responsibility as the nation’s pri- tiple myeloma. Clinical Ophthalmology. 214;8:813-7. 12. Falke K, et al. The microstructure of cornea verticillata in Fabry clinical suspicion puts syphilis on mary eye care provider to be astute disease and amiodarone-induced keratophaty: a confocal laser a differential.15,28 But keep in mind in our observation and conscien- scanning microscopy study. Grafes Arch Clin Exp Opthalmol. 2009;247:523-34. that there are a number of non- tious in our assessments so we can 13. Sodi A, Ioannidis A, Pitz S. Ophthalmological manifestations syphilitic causes of interstitial kera- refer patients in an appropriate and of Fabry disease. In: Mehta A, Beck M, Sunder-Plassmann G, eds. Fabry Disease: Perspectives from 5 Years of FOS. Oxford: Oxford titis and corneal ghost vessels, with timely manner. You might just be PharmaGenesis; 2006. Available from: http://www.ncbi.nlm.nih.gov/ some being as simple as contact saving someone’s life! ■ books/NBK11599/. 14. Hauser AC, et al. Results of an ophthalmologic screening lens use. Within the United States, Dr. Bronner is a staff optometrist programme for identification of cases with Anderson-Fabry disease. herpetic disease is twice as likely as at the Pacific Cataract and Laser Ophthalmiogica. 2004;218:207-9. 15. Kenyon KR, Navon SE, Haritoglou C. Corneal manifestations of any other pathology to cause the Institute of Kennewick, Wash. metabolic disease. In: Krachmer JH, Mannis MJ, Holland EJ, eds. presentation.29 Cornea. 2nd ed. St. Louis: Mosby;2004:749-76. 16. Spiegel P, et al. Unusual presentation of paraproteinemic corneal 1. Rosenberg M, et al. Corneal structure and sensitivity in type 1 Infiltrates. Cornea. 1990;9:81-5. diabetes mellitus. Invest Ophthalmol Vis Sci. 2000;41:2915-21. While this review is far from 17. Lisch W, et al. Chameleon-like appearance of immunotactoid complete—with important mani- 2. Petropoulos IN, et al. Rapid automated diagnosis of peripheral keratopathy. Cornea. 2012;31:55-58. neuropathy with in vivo corneal confocal microscopy. Invest Ophthal- 18. Chou JL, Sink ML. Corneal crystals: a precursor to cancer. festations such as copper deposits mol Vis Sci. 2014;55:2071-8. Optometry and Vision Science. 2011;88:E543-7. REVIEW OF OPTOMETRY APRIL 15, 2015 59 053_ro0415_f4_osc.indd 59 4/1/15 12:30 PM OPTOMETRIC STUDY CENTER 19. Mora ML, Smith RE. Corneal and systemic diseases. In: Tasman W, 23. Choyce DP. Ocular leprosy, with reference to certain cases shown. 27. Myrvang B, et al. Immune responsiveness to mycobacterium Jaeger EA eds. Duane’s Ophthalmology. Lipincott Williams Wilkins; 2006. Proceedings of the Royal Society of Medicine. 1955;48(2):108-12. leprae and other mycobacterial antigens throughout the clinical and 20. Mondino BJ. Inflammatory diseases of the peripheral cornea. 24. Ffytche TJ. Role of iris changes as a cause of blindness in histopathological spectrum of leprosy. Clinical Expir. Immunology. Ophthalmology. 19988;95:463-72. lepro matous leprosy. British Journal of Ophthalmology. 1973;14:541-53. 21. Rapuano C, Luchs JI, Kim T. Corneal infections, inflammations, 1981;65:231-9. 28. Wilhemus KR. Syphilitic interstitial keratitis. In: Krachmer JH, and surface disorders. In: Anterior Segment; The Requisites in Oph- thalmology. Mosby; 2000:115-8. 25. Choyce DP. Diagnosis and management of ocular leprosy. British Mannis MJ, Holland EJ, eds. Cornea. 2nd ed. St. Louis: Mosby; 22. Dethlefs R. Prevalence of ocular manifestations of leprosy in Journal Ophthalmology. 1969;53:217-23. 2004:1133-59. Port Moresby, Papua New Guinea. British Journal of Ophthalmology. 26. Krachmer JH, Palay D. Corneal Atlas. 2nd 466 Edition. Mosby 29. Schwartz GS, Harrison AR, Holland EJ. Etiology of immune stro- 1981;65:223-5. Elsevier; 2006. mal (interstitial) keratitis. Cornea. 1998;17(3):278-81. OSC QUIZ ou can obtain transcript-quality con- quantified with: b. Is an X-linked disorder of carbohydrate tinuing education credit through the a. Confocal microscopy. metabolism. YOptometric Study Center. Com plete b. Esthesiometry. c. Typically generates less prominent whorls the test form (page 61), and return it with c. Pachymetry. than those seen with medically-induced the $35 fee to: Optometric CE, P.O. Box 488, d. Careful slit lamp examination. verticillata. Canal Street Station, New York, NY 10013. d. Is often initially suspected based on corneal To be eligible, please return the card within 5. Due to its association with worsening sys- findings. one year of publication. temic vasculitis, peripheral ulcerative keratitis You can also access the test form and is associated with a mortality rate as high as: 10. Which of the following should NOT be con- submit your answers and payment via credit a. 10% if systemic immune modulatory treat- sidering in a differential diagnosis of a patient card at Review of Optometry online, www. ment is not initiated. with corneal crystals? reviewofoptometry.com. b. 25% if systemic immune modulatory treat- a. Metabolic disease. You must achieve a score of 70 or higher ment is not initiated. b. Multiple myeloma. to receive credit. Allow eight to 10 weeks c. 50% if systemic immune modulatory treat- c. Chronic myelogenous leukemia. for processing. For each Optomet ric Study ment is not initiated. d. Bietti’s corneo-retinal dstrophy. Center course you pass, you earn 2 hours of d. 75% if systemic immune modulatory treat- transcript-quality credit from Pennsyl vania ment is not initiated. 11. The plasma cell dyscrasias are a family of College of Optometry and double credit hematologic conditions that result in: toward the AOA Optom et ric Recog nition 6. Which of the following is not a cause of a. Excess production of immunoglobin. Award—Cate gory 1. peripheral ulcerative keratitis? b. Proliferation of lymphatic tissue. Please check with your state licensing a. Wegener’s granulomatosis. c. Too much hemoglobin within the blood. board to see if this approval counts toward b. Vitamin A deficiency. d. Accumulation of carbohydrate within lyso- your CE requirement for relicensure. c. Rheumatoid arthritis. zymes. d. Herpes zoster. 1. Which is NOT a manifestation of diabetic 12. Which is true regarding cystinosis? keratopathy? 7. Which treatment(s) is/are contraindicated a. It is the only metabolic disease that may a. Mild corneal edema. in management of peripheral ulcerative cause corneal findings. b. Reduced nerve density of the sub-basal keratitis? b. The infantile form may cause death. plexus. a. Oral corticosteroids. c. The adult onset form is the most severe. c. Epithelial polymorphism. b. Topical corticosteroids. d. Only the infantile form may result in corneal d. Endothelial polymorphism. c. Sub-Tenon’s corticosteroids. crystals. d. Both b and c. 2. Diabetic keratopathy: 13. Band keratopathy is NOT associated with a. Is associated with thinning of the cornea. 8. Which of the following is NOT true regard- this systemic condition: b. Is associated with hypersensitivity of cor- ing corneal verticillata? a. Hyperparathyroidism. neal nerves. a. They occur nearly universally in patients on b. Hyperthyroidism. c. Can be roughly correlated with level of amiodarone. c. Sarcoidosis. retinopathy. b. They are associated with a higher risk of d. Gout. d. Cannot be roughly correlated with systemic retinopathy when seen in association with polyneuropathy. hydroxychloroquine. 14. Which is true regarding corneal phlycte- c. They are caused by carbohydrate deposits nules? 3. Waite-Beetham lines: within lysozymes. a. They represent a Type III hypersensitivity a. Are only found in diabetics. d. They may be more prominent in contact response. b. Tend to indicate worsening systemic disease. lens wearers who use causative medications. b. There will always be a lucid zone between c. Manifest as very fine, densely distributed and the lesion and the limbus. vertically oriented lines in the deep cornea. 9. Fabry’s disease: c. Though they are related to systemic dis- d. Were first described in the 1930s. a. Results in corneal whorls that are biochem- ease, they represent an active local ocular ically similar to those seen in drug-induced infection. 4. Diabetic corneal neuropathy can be verticillata. d. They are most associated with tuberculosis 60 REVIEW OF OPTOMETRY APRIL 15, 2015 0053_ro0415_f4_osc.indd53_ro0415_f4_osc.indd 6600 44/1/15/1/15 12:3012:30 PMPM OSC QUIZ Examination Answer Sheet Valid for credit through April 1, 2018 when seen in children. This exam can be taken online at www.revoptom.com/continuing_education. Upon passing the exam, you can view your results immediately and download a real-time CE certificate. You can also view your 15. Which is NOT a possible causes of phlyc- test history at any time from the website. tenules? Corneal Harbingers of Systemic Disease a. Mycobacterium tuberculosis. b. Mycobacterium leprae. Directions: Select one answer for each question in the exam and completely darken the c. Staphylococcus. appropriate circle. A minimum score of 70% is required to earn credit. d. Rosacea. Mail to: Jobson - Optometric CE, PO Box 488, Canal Street Station, New York, NY 10013 Payment: Remit $35 with this exam. Make check payable to Jobson Medical Information LLC. 16. Which systemic infection has the highest rate of ocular involvement? COPE approval for 2 hours of CE credit is pending for this course. a. Herpes simplex. This course is joint-sponsored by the Pennsylvania College of Optometry b. Herpes zoster. c. Syphilis. There is an eight-to-ten week processing time for this exam. d. Leprosy. 1. A B C D 1 = Excellent 2 = Very Good 3 = Good 4 = Fair 5 = Poor 2. A B C D Rate the effectiveness of how well the activity: 17. Which is true regarding leprosy? 3. A B C D a. The most common ocular manifestation is 4. A B C D 21. Met the goal statement: 1 2 3 4 5 posterior uveitis. 5. A B C D 22. Related to your practice needs: 1 2 3 4 5 b. The keratitis associated with the disease 6. A B C D 23. Will help you improve patient care: 1 2 3 4 5 may be cultured to aid in the diagnosis. 7. A B C D 24. Avoided commercial bias/influence: 1 2 3 4 5 c. Culture material is Lowenstein-Jensen 8. A B C D 25. How would you rate the overall 9. A B C D quality of the material presented? 1 2 3 4 5 medium. 10. A B C D 26. Your knowledge of the subject was increased: d. The diagnosis can only be achieved by a 11. A B C D Greatly Somewhat Little skin biopsy. 12. A B C D 27. The difficulty of the course was: 13. A B C D Complex Appropriate Basic 18. The keratitis associated with leprosy: 14. A B C D How long did it take to complete this course? a. Is associated with vascularization. 15. A B C D b. Generally begins in the inferior cornea. 16. A B C D Comments on this course: c. Manifests as discrete, chalky, subepithelial 17. A B C D opacities. 18. A B C D d. Is associated with significant corneal 19. A B C D Suggested topics for future CE articles: 20. A B C D inflammation. 19. Which is the most common cause of interstitial keratitis in the US? Please retain a copy for your records. Please print clearly. a. Lyme disease. First Name b. Herpetic eye disease. Last Name c. Cogan’s syndrome. d. Syphilis. E-Mail The following is your: Home Address Business Address 20. Which is true regarding syphilitic intersti- tial keratitis? Business Name a. It’s most commonly a manifestation of early congenital disease. Address b. It’s most commonly a manifestation of late City State acquired disease. c. Vascularization and ghost vessels are ZIP most associated with congenital disease. Telephone # - - Fax # - - 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 by any fraudulent or improper means. Signature Date TAKE THE TEST ONLINE TODAY! www.reviewofoptometry.com/ Lesson 111213 RO-OSC-0415 continuing_education/ REVIEW OF OPTOMETRY APRIL 15, 2015 61 0053_ro0415_f4_osc.indd53_ro0415_f4_osc.indd 6611 44/1/15/1/15 12:3012:30 PMPM Visual Fields 10 Tips For Improving Visual Fields Perimetry may seem like second nature, but these recommendations can help you obtain better results by refining your understanding of the technology. By Matt Horton, OD isual field testing is an advantages over the older standard Swedish Interactive Threshold- essential part of eye care, of manual kinetic perimetry.1-2 ing Algorithm (SITA) Standard in necessary for diagnosis and SAP test patterns can be catego- 24-2 pattern with stimulus size III Vmanagement of multiple rized as threshold or screening. is generally the preferable test for conditions we see on a daily basis. Common threshold patterns are most routine glaucoma and neu- Perimetry is subjective in nature, 10-2, 24-2, 30-2 and 60-4. Field rological testing.4 Clinicians often and it is necessary to take care in analysis in glaucoma relies primar- have the misconception that SITA both the acquisition and analysis ily on the 24-2 and 30-2 patterns, Fast strategy is an easier test for of the testing data. Many barriers as the majority of ganglion cells patients who have difficulty taking to successful visual field testing lie within the central 30 degrees of a SITA Standard or full threshold exist, but much of the frustration fixation.3 Use of 24-2 has become strategy test. SITA Fast does take encountered can be avoided by fol- increasingly prevalent as the test of 2-5 minutes per eye to perform lowing some basic guidelines and choice in glaucoma due to its faster (compared with 3-7 minutes per using all the technological features testing time and reduced trial lens eye for SITA Standard). However, today’s devices offer. and lid artifact errors. A 24-2 has the algorithm it uses presents 54 test points and is identical to points requiring more discretion 1. Pick the right test the 72-point 30-2 testing protocol from the patient, and it is best used Most visual field testing is “stan- except for the removal of most in experienced test takers or young dard automated perimetry” (SAP). outer ring test points (24-2 retains patients.5 SAP is a computerized, threshold the two outermost nasal points static perimetry that tests the from the 30-2 pattern). 2. Know when to modify the central visual field with a white Both of these patterns have test testing strategy stimulus on a white background. points spaced six degrees apart. Stimulus size III is standard for Threshold testing has been the Points straddle the mid-line, allow- most situations and should be used standard for glaucoma care since ing for better identification of in patients with 20/200 or better. the mid 1980s, offering many glaucomatous defects. Increase size to V in patients with 62 REVIEW OF OPTOMETRY APRIL 15, 2015 062_ro0415_f5.indd 62 4/1/15 1:56 PM poorer vision (this may be indicated in some patients with advanced glaucoma). When altering the stimu- lus, keep in mind that the normative database, SITA test strategy, and pro- gression analysis will no longer be available. When severe field loss in advanced glaucoma is present, change Fig. 1. A 10-2 visual field can be a valuable addition to a 10-2 pattern to to standard 24-2 and 30-2 testing. Alternating these allow for more accu- tests will allow for better detecting of defects that rate assessment of threaten fixation. This 58-year-old black male has the remaining visual early normal-tension glaucoma associated with field. In cases where extensive macular ganglion cell loss and a visual vision is reduced due field defect that surrounds fixation. BCVA was 20/20 to macular disease OD and 20/25 OS. or central scotoma, use a diamond fixation target—this temporal quadrant of the optic displays four LEDs, allowing the nerve which is often preserved patient to center their gaze between in early glaucomatous disease).7 the targets.6 If there is even a single cen- tral point defect with a 24-2 3. Don’t overlook the central or 30-2 pattern, consider field in early glaucoma adding a 10-2 test to your The macula is +/-8 degrees from assessment (figure 1). This fixation and represents only a will allow proper detection of small portion of the retinal area, early macular damage. The but contains about 30% of the inferior temporal quadrant retinal ganglion cells.3 A 24-2 test of the circumpapillary RNFL only includes four points within is particularly susceptible to this highly sensitive region. The this damage and will correlate 24-2 test protocol was designed to with a small arcuate defect in detect nasal and arcuate glaucoma- superior central visual field. This tudes about the value of perimetry tous defects. These defects origi- 35-degree region of the RNFL has to encourage the patient to provide nate from damage to the arcuate been termed the “macular vulner- optimal results during testing.8 nerve fiber bundles—often visible ability zone.”7 Although the physician should on funduscopy with retinal nerve Also, be aware that macular not administer the test personally, fiber layer (RNFL) wedge defects damage can present diffusely rather they should take time during the or neuroretinal rim notching. than sectorally. exam to stress to the patient the Research shows significant sec- importance of perimetry in the tions of the inferior macula are 4. Understand the roles of management of their ocular dis- associated with the inferior arcuate the technician and physician ease. Physicians should continue bundle (the majority of macular It’s important that the staff and to encourage patients when subse- ganglion cells associated with the physician maintain positive atti- quent testing is ordered or reviewed. REVIEW OF OPTOMETRY APRIL 15, 2015 63 062_ro0415_f5.indd 63 4/1/15 1:56 PM Visual Fields Technicians should periodically get a refresher on the importance of perimetry. Those perform- ing perimetry should take the test themselves, so they can more effectively explain it to patients. Technicians should always be pres- ent during the testing period so they may provide re-education, as necessary, and feedback regard- ing testing reliability. A technician who does not properly respond to patients’ perimetry complaints pro- motes poor test taking. Fig. 2. Optic disc drusen may produce visual field defects similar to those seen 5. Recognize, reduce in glaucoma. This 58-year-old white male artifacts was found to have an inferior visual field Peripheral points, particularly defect correlating to superior disc drusen in a 30-2 test, are susceptible to (evident in the fundus photo). variability and artifact. Trial lens artifacts usually produce sharp tion losses greater than 20% can depressed visual fields. A false depressions at peripheral points, indicate poor reliability, but negative value of 10% to 15% or often in a ring pattern. These arti- improper mapping of the blind more is suggestive of inattention in facts are more common in mod- spot can cause false elevation of a patient without a significant field erate-high hyperopic corrections this index. Gaze tracking allows defect. If significant glaucomatous and when two trial lenses are used. for more accurate interpreta- loss is present, false negatives Make certain the lens is placed as tion of patient fixation stability. should not deem a test unreliable if close to the eye as possible; also, Gaze tracking measures up to it otherwise appears reliable.9 using spherical equivalent up to one degree, whereas traditional Age matters—the Humphrey 2.00D of refractive cylinder will fixation monitoring is sensitive for database uses norms grouped by help reduce some of these errors. three degrees (half the size of the age in 10-year intervals. Keep in Pupil size smaller than 2mm physiologic blind spot). mind that a patient’s results may or larger than 6mm can induce False positives are a key reliabil- appear to improve due to this artifacts. If you decide to dilate a ity index. “Trigger happy” patients grouping effect. For instance, if patient due to miosis, make certain will push the response button in testing was performed at age 59 to remain consistent on subsequent the absence of a stimulus. False and, on subsequent examinations, testing. If ptosis or dermatochalasis positives are primarily important age 60, the second test would be produce obstruction of the superior in tests that have defects—they compared with a different database field, then the eyelids may be taped are not a reason to invalidate an than the first test. for testing (again, this should be otherwise unremarkable or clear Know if you are detecting or noted on the field report to main- visual field test. If this index is monitoring a defect. Your inter- tain consistency on all testing). higher than 15%, the test needs to pretation strategy should differ in be invalidated or repeated (even patients being evaluated for the 6. Interpreting results 5% to 10% should be scrutinized). presence of a glaucomatous defect systematically Tests with high false positives and patients who have established Don’t take shortcuts in reviewing are automatically removed from visual field loss. data from visual fields—the profes- a Humphrey Guided Progression In patients who are glaucoma sional component of testing is the Analysis (GPA). suspects, rely on the Glaucoma interpretation, and each analysis False negatives represent vari- Hemifield Test (GHT) and the pat- report contains a wealth of data. ability in patient responses and tern deviation probability map. Know if a test is reliable; fixa- are seen at increasing levels in GHT was designed to have high 64 REVIEW OF OPTOMETRY APRIL 15, 2015 062_ro0415_f5.indd 64 4/1/15 1:58 PM ADDITIONAL OFFERS FROM VEATCH YOUR EXAM… Exam Lane Packages ONLY BETTER! 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This finding has decrease at the two-year and five- been show to have 94% specific- year marks once a progression rate ity.11 GHT borderline is displayed is reliably established. when the p value is between 1% Also, keep in mind that an and 3%. Generalized depression artifactual reduction in sensitivity indicates that the most sensitive may be seen on the first perimet- test points are less than 50% of ric test in approximately 10% of normal. Abnormally high sensitiv- patients.15 ity is a red flag and indicates low These patients may require two reliability (usually associated with or three tests to produce an accu- a high rate of positives). rate and reliable baseline result. If a field shows scattered non- specific depressions, keep in mind Fig. 3. The GPA summary report will show 8. Be on the look out for that a diagnostic early glaucoma- two baseline fields: a Glaucoma Change masquerading retinal and tous defect is generally recognized Probability Map (an event analysis) of the optic nerve conditions as a repeatable cluster of three or most current test and a VFI graph (trend Concomitant retinal or neuro- more points on the same side of the analysis) for all available fields. This is logical disease can confound inter- horizontal meridian all reaching a patient with advanced glaucoma and pretation of visual field defects statistical significance (with one or progressing cataract. No progression is in many patients. Altitudinal or more points having p<1% signifi- detected adjacent to the dense arcuate arcuate field defects may be seen cance)—the test points adjacent to scotoma, which itself is too depressed to in anterior ischemic optic neu- the blind spot may be ignored. allow for progression analysis. ropathy, vascular occlusion, optic If a patient with visual field disc drusen (figure 2) or sectoral loss is being monitored with serial overall field sensitivity (worsening retinal photocoagulation treat- examination, use the mean devia- cataract may also decrease PSD). ment. Peripheral field constriction tion (MD), pattern standard devia- VFI is a metric that was created may be present in optic neuritis, tion (PSD) and visual field index to help with staging and progres- nonglaucomatous optic atrophy, (VFI) to track progression. sion of glaucoma. It is intended to advanced retinitis pigmentosa or MD is sensitive to media opac- reflect ganglion cell loss and func- acute zonal occult ocular retinopa- ity, uncorrected refractive error, tion. VFI is displayed in a percent- thy (AZOOR). Nonproliferative and miosis. MD will be less sensi- age from 0 to 100. It is weighted diabetic retinopathy can also cause tive in early-stage glaucoma and preferentially to central points and scattered visual field deviations, other cases with localized field loss. more resistance to cataract.12 even in mild stages.16 Moderate The GHT can better aid in iden- and severe diabetic retinopathy tifying early, localized defects, and 7. Test, test, repeat will more likely have a dense and PSD can be useful for tracking The real utility of visual fields lies repeatable visual field defect. these milder defects. In the pres- in tracking progression of glau- ence of other suspicious findings, a comatous defects. The European 9. Use progression PSD of p <5% is a strong indicator Glaucoma Society (EGS) recom- analysis tools of glaucomatous loss. PSD, how- mends visual field testing several We expect progression in the ever, will spike in early disease and times yearly for the first two years majority of glaucoma patients. In peak in the early part of advanced after diagnosis.13 This will help fact, the Early Manifest Glaucoma disease; however, it will then establish a rate of progression Treatment Trial showed that 59% however decrease due to reduced and identify the roughly one in of glaucoma patients will progress 66 REVIEW OF OPTOMETRY APRIL 15, 2015 062_ro0415_f5.indd 66 4/1/15 1:59 PM Discover Biotrue ® ONEday Lenses Made from HyperGel™, a bio-inspired material designed to work like the eye Meets Matches Mimics oxygen level the water content of lipid layer of the open eye needs1 the cornea — 78%2 tear film3 Now Available Biotrue® ONEday for Presbyopia Recommend comfortable vision throughout the day with Biotrue ONEday and Biotrue ONEday for Presbyopia. ForFor momorere iinformation,nformation ccallall 1-800-828-9030,1-800-828-9030 contact your Sales Representative or visit biotrue.com Distributed by Bausch + Lomb, a Division of Valeant Pharmaceuticals, North America LLC, Bridgewater, N.J. © 2014 Bausch & Lomb Incorporated. ®/™ are trademarks of Bausch & Lomb Incorporated or its affiliates. PNS07134 US/BPR/14/0013 REFERENCES: 1. Brennan NA. A Model of Oxygen Flux Through Contact Lenses, Cornea 20(1):104-108, 2001. 2. Bergmanson J. Clinical Ocular Anatomy and Physiology. 14th ed. Houston, Texas: Texas Eye Research and Technology Center; 2007. 3. Twenty-two subjects participated in a randomized, double-masked, contralateral eye study to evaluate water loss of Biotrue® ONEday, 1-Day ACUVUE MOIST, and 1-Day ACUVUE TruEye. After 4, 8, 12, and 16 hours of wear, lenses were removed and immediately weighed (wet weight). The lenses were then completely dried and reweighed (dry weight). The percent water loss was then calculated for each lens from the wet and dry weights. RO0215_BL Biotrue.indd 1 1/21/15 3:21 PM Visual Fields in eight years, even if treated and gression often takes two or more to repeated visual field defects as well controlled.17 Determining if years. EMGT had a mean of 33 well as patients progressing on the rate of progression will affect months to progression in 30-2 pro- their fields without detectable visual function and quality of life tocols and 37 months for 24-2.5 progression of RNFL or ganglion is important when making the Trend-based progression will cell loss. Clinicians should none- decision to proceed with escalating display linear regression analysis theless seek to find correlation therapy that carries increased risk of VFI. If the tests span two or of structure and function to help of side effect. Even in light of 21st more years, the software will plot strengthen diagnosis and bring century technology, serial visual a future prediction of progres- attention to specific areas in com- field testing remains the most sion. Prior to VFI, MD was used plementary testing components. accurate means of determining for progression analysis, but VFI Understand that early glauco- progression in glaucoma. Mod- provides a more accurate determi- matous defects may have variable ern perimeters are equipped with nation in the presence of cataract depth and location (although they powerful software tools that allow and cataract surgery.21 will be in the same area). The practitioners to accurately track If a patient experiences non- defect will deepen into a repeatable these metrics. glaucomatous loss due to vascular defect with time. The nasal and The best tools for progression occlusion, ischemic optic neuropa- superior fields are more likely to analysis on HFA units are GPA thy or panretinal laser, it is neces- show early glaucomatous defects. Change Probability, VFI trend, sary to establish a new baseline for Extensive RNFL loss (~30%) is and MD trend, and linear regres- visual field testing as well as change necessary to produce a visual field sion and cluster regression analysis the tests used in progression analy- defect.22,23 An individual (especially on Octopus units. GPA requires a sis. Make certain to check the two a patient with a large optic nerve) minimum of five tests to fully uti- baseline tests in GPA for accuracy. may have as much as one third of lize its features. Two tests will be Any tests are usable unless false her or his RNFL deteriorate while selected automatically for baseline, positives are higher than 15%. still maintaining “green” norma- but these tests may be manually Avoid using fields that are further tive levels on OCT analysis (this selected. From this baseline, GPA than 6-12 months apart for base- is often referred to as “green dis- is able to provide both event- and line. Update to new baselines if ease”).24 A recent study reported trend-based progression analysis on there is a significant change in ther- the highest correlation between future tests (figure 3). apy (such as filtration procedure). progression on OCT and visual Event-based progression deter- Also note that GPA is not available field to occur at a 10µm RNFL mines whether or not progression when MD is over 20dB. loss on SD-OCT.25 For many has occurred on a point-by-point Using progression analysis for patients, advanced glaucoma- basis. Trend-based progression will nonglaucomatous field loss should tous optic atrophy will result in a determine the rate of progression. be limited to VFI linear regression/ severely depressed RNFL that does Event-based progression analysis trend analysis (the GPA change not allow for proper detection of has been used in several landmark probability was designed for use in progression. For these patients in glaucoma clinical trials (such as glaucoma). Some conditions, such particular, visual field testing will EMGT, AGIS and CIGTS).18-20 as optic neuritis, may have such a best provide information about the The GPA Change Probability Map high inherent variability that quan- progression of their disease. displays a point-by-point analysis titative progression analysis is not Having an idea of the patient’s and indentifies progression if at possible. For neurological field loss, independent risk factors for glau- least three points have worsened the overview report is preferred. coma, aside from structural and (marked as “possible progression” functional testing, can allow clini- if repeated in two tests and “likely 10. Make the correlation cians to either raise or lower their progression” if repeated in three between structure, function threshold for diagnosis. If a patient tests). These criteria for progression Conventional wisdom holds that is high risk given IOP and age, were established by the EMGT.18 structural change precedes func- then a structure and function cor- Using this method has 96% sen- tional loss in glaucoma. However, relation is certainly not necessary sitivity in 30-2 and 91% in 24-2. we often see patients who demon- to establish good certainty of a Keep in mind that detecting pro- strate significant RNFL loss prior diagnosis. Conversely, you would 68 REVIEW OF OPTOMETRY APRIL 15, 2015 0062_ro0415_f5.indd62_ro0415_f5.indd 6868 44/1/15/1/15 1:591:59 PMPM hold testing on a healthy 40-year-old patient to a high degree of specificity—the condition is much less commonly seen in that population and the diagnosis carries with it the potential of signifi- cant burden due to the long life expectancy. ■ Dr. Horton is a staff optometrist at the Cincin- Are you prepared for National nati VA Medical Center. He is also an adjunct faculty member at Ohio State University College Sunglasses Day? of Optometry. The Vision Council is working to educate consumers on 1. Heijl A. Automatic perimetry in glaucoma visual field screening. A Clinic Study. Albrecht Von Graefes Arch Klin. Exp Ophthalmol. 1976;200(1):21-37. the negative health effects of UV rays, and steer them 2. Herbolzheimer W. Computer program controlled perimetry, its advantages and KPVQ[QWTUVQTGUCPFQHƂEGUVQƂPFVJG78RTQVGEVKXG disadvantages. Klin Monbl Augenheilkd. 1986;189(4):270-7. 3. Hebel R, Hollander H. Size and distribution of ganglion cells in the human retina. eyewear that they need. Anatomy and Embryology. 1983;168(1):125-136. 4. Khoury J, Donahue S, Lavin P, Tsai J. Comparison of 24-2 and 30-2 perimetry in glaucomatous and nonglaucomatous optic neuropathies. J Neuroophthalmol. Increase your sales of sunglasses! Join us in spreading 1999;19(2):100-8. 5. Heijl A, Bengtsson B, Chauhan B, et al. A comparison of visual field progression the message of UV protection. criteria of 3 major glaucoma trials in early manifest glaucoma trial patients. Ophthal- mology. 2008;115(9):1557-65. 6. Humphrey Field Analyzer User Manual. Dublin, CA: Carl Zeiss Meditec, Inc.; 2010. thevisioncouncil.brandmuscle.net 7. Hood D, Raza A, de Moraes C, et al. Glaucomatous damage of the macula. Prog Retin Eye Res. 2013; 32: 1-21. doi: 10.1016/j.preteyeres.2012.08.003. Epub 2012 Sep 17. 8. Kutzko K, Brito C, Wall M. Effect of instructions on conventional automated perim- etry. Invest Ophthalmol Vis Sci. 2000;41(7):2006-13. 9. Bengtsson B, Heijl A. False-negative responses in glaucoma perimetry: indicators of patient performance or test reliability? Invest Ophthalmol Vis Sci. 2000;41(8):2201-4. 10. Katz J, Sommer A, Gaasterland D, Anderson D. Comparison of ana- lytical algorithms for detecting glaucomatous visual field loss. Arch Ophthalmol. 1991;109(12):1684-9. 11. Asman P, Heijl A. Glaucoma Hemifield Test. Automated visual field evaluation. Arch Ophthalmol. 1992;110(6):812-9. 12. Bengtsson B, Heijl A. A visual field index for calculation of glaucoma rate of pro- gression. Am J Ophthalmol. 2008;145(2):343-53. 13. European Glaucoma Society. Terminology and Guidelines for Glaucoma. 3rd ed. Savona: Editrice Dogma S.r.l.; 2008. 14. Chauhan BC, Garway-Heath DF, Goñi FJ, et al. Practical recommendations for measuring rates of visual field change in glaucoma. The British Journal of Ophthal- CELEBRATE YOUR SHADES! mology. 2008;92(4):569-73. 15. Heijl A, Bengtsson B. The effect of perimetric experience in patients with glaucoma. Arch Ophthalmol. 1996;114(1):19-22. 16. Trick G, Trick L, Kilo C. Visual field defects in patients with insulin-dependent and noninsulin-dependent diabetes. Ophthalmology. 1990;97(4):475-82. 17. Leske M, Heijl A, Hyman L, et al. EMGT Group. Predictors of long-term progres- sion in the early manifest glaucoma trial. Ophthalmology. 2007;114(11):1965-72. 18. Leske M, Heijl A, Hyman L, Bengtsson B. Early Manifest Glaucoma Trial: design Keep your eyes healthy by wearing UV-protective sunwear and baseline data. Ophthalmology. 1999;106(11):2144-53. 19. Advanced Glaucoma Intervention Study 2 Visual field test scoring and reliability. #NationalSunglassesDay Ophthalmology. 1994;101(8):1445-55. 20. Musch D, Lichter P, Guire K, Standardi C. The Collaborative Initial Glaucoma Treatment Study: study design, methods, and baseline characteristics of enrolled 2TQOQVKQPCNKVGOUCTGPQYCXCKNCDNGQPNKPGVQJGNR patients. Ophthalmology. 1999;106(4):653-62. 21. Rao H, Jonnadula G, Addepalli U, et al. Effect of cataract extraction on Visual Field GPICIGEQPUWOGTUCPFRCVKGPVUKPFKUEWUUKQPUCDQWV Index in glaucoma. J Glaucoma. 2013;22(2):164-8. 22. Kerrigan-Baumrind L, Quigley H, Pease M et al. Number of ganglion cells in UWPUCHGDGJCXKQTUKPHQTOVJGOQHVJG78RTQVGEVKXG glaucoma eyes compared with threshold visual field tests in the same persons. Invest G[GYGCTQRVKQPUCXCKNCDNGCPFTCKUGCYCTGPGUUQH0CVKQPCN Ophthalmol Vis Sci. 2000;41(3):741-8. 23. Reis A, Vidal K, Kreuz A, et al. Nerve fiber layer in glaucomatous hemifield loss: a Sunglasses Day, June 27, 2015. case-control study with time-and spectral-domain optical coherence tomography. Arq Bras Oftalmol. 2012;75(1):53-8. 24. Jampel H, Vitale S, Ding Y, et al. Test-retest variability in structural and functional +VGOUECPDGFQYPNQCFGFCUKUQTEWUVQOK\GFYKVJ[QWT parameters of glaucoma damage in the glaucoma imaging longitudinal study. J Glau- coma. 2006;15(2):152-7. DTCPFKPICPFECPDGRTKPVGFFKTGEVN[QTXKCRTKPVQP 25. Kaushik S, Mulkutkar S, Pandav S, et al. Comparison of event-based analysis of demand services. glaucoma progression assessed subjectively on visual fields and retinal nerve fibre layer attenuation measured by optical coherence tomography. Int Ophthalmol. 2014 Dec 13. [Epub ahead of print] 062_ro0415_f5.indd 69 4/1/15 1:59 PM Clinical Care Beat These Modern Day Prescribing Challenges Today’s optometrists face difficult Rx decisions—from managing pregnant patients to deciding whether a generic can be substituted for a brand. By Jane Cole, Contributing Editor he maiden battle to gain the patient fails on it, then we have tives, which can alter characteristics prescription rights was first to prescribe multiple drugs in that of the medication and change the won by optometrists in West category or in multiple categories efficacy and side effects of the drug. TVirginia in 1976. Other just to cover the original drug “As a general rule, the doctor states have all followed suit, but we prescribed. And when we can should always prescribe the most with these privileges often come actually get a drug that is covered, appropriate medication for each challenges. sometimes it’s financially out of patient’s condition,” says optome- From insurance coverage stran- reach for the patient.” trist Jimmy Bartlett of Birmingham, gleholds to deciding whether a This article looks at some typi- Ala. patient with financial constraints cal and not-so-typical modern day In practice, however, managed will do as well on a more afford- prescribing challenges, and how to care, insurance and economic issues able generic (instead of the brand tackle them. must be considered, and these often name you’d prefer), optometrists supersede the theoretical optimum, often face difficult prescribing deci- Challenge #1: Brand name Dr. Bartlett adds. sions even before they pick up their or generic? “We always want to use what is Rx pad. The idea that a generic drug is an in the best interest of each patient, “The fact that many of the adequate Plan B for a brand-name and therapeutic care may entail branded prescriptions we typically drug is still hotly debated. using a somewhat less desirable write are becoming more and more The FDA requires that generic generic substitute, particularly if the difficult to obtain for a patient drug manufacturers demonstrate alternative is no therapeutic care at because of medical insurance and bioequivalence to the branded all,” he says. “Unfortunately, in this pharmacy plans is a major prob- drug, so the generic must contain age of managed care, we are forced lem,” says optometrist Ben Gaddie the same concentration of active to have these discussions with of Louisville, Ky. “We’re often ingredients as the branded drug’s the patient as a matter of routine, advised to use a drug perhaps two formulation. But other variations whereas in years past these issues or three generations old that just are permitted in the generic, such as required only an occasional discus- doesn’t get the job done. And when inactive ingredients and preserva- sion in problematic situations.” 70 REVIEW OF OPTOMETRY APRIL 15, 2015 070_ro0415_f6.indd 70 4/1/15 2:08 PM Photo: Paul M. Karpecki, OD Here are some considerations to keep in mind when deciding whether to prescribe a brand-name drug or a generic: • Generics are not necessarily cheaper. In some cases, generic alternatives are not a lower-cost option. In fact, Freehold, NJ, optometrist William Potter says some generic prices are “through the ceiling.” “To some degree, it’s an upside- down world,” Dr. Potter says. Dr. Potter says he writes a fair amount of prescriptions for Tobra- dex ST (tobramycin 0.3%/dexa- methasone 0.05%, Alcon) and gives his patients coupons to help offset the price, so the final cost of the brand-name medication is approxi- mately $40 to $50. For a serious condition such as uveitis, many doctors will insist on a brand-name “We wrote for Tobradex generi- medication—no generic substition allowed. cally a few months ago,” Dr. Potter says. “The patient called from the severe pathology,” she says. “In generics aren’t nearly as efficacious pharmacy and said, ‘I can’t do this. those cases, I write for branded as the branded drug,” Dr. Gaddie This generic drug costs $100.’ Now Pred Forte, but I also tell the patient says. remember, this is a drug that’s been that I’m writing for brand name This has much to do with the on the market for 25 years, and it’s only and they should not allow the particle size of the steroid molecule. been generic for three years. We pharmacist to substitute.” Because the steroid is a suspension, called the pharmacist who told us, Dr. Autry reinforces to patients the patient has to shake the bottle ‘If it wasn’t for the patient’s insur- that the brand name should be vis- in order to get the concentration of ance, generic Tobradex would have ible on the side of the bottle, and the drug correct. But many patients cost $250.’ And that’s for a little, she stresses they should not leave just don’t shake medications, he ‘white bottle’ legacy drug. This is the pharmacy unless they have the adds. the kind of thing we’re up against.” right medication. “I don’t really get Additionally, the size of the • Assess the clinical need. Look- any pushback because of the way I actual steroid particle can make ing at the patient’s clinical condi- present it to the patient, and phar- an impact on the solubility of the tion, when should an OD write for macies in the Houston area often drug and therefore affect how well brand name only? carry the brand.” it treats the inflammation, he adds. “Some brands trump gener- When considering a brand name “If I’m treating someone with just ics, but not necessarily in every or generic, Dr. Gaddie first looks a mild ocular surface problem, a patient,” says Jill Autry, OD, RPh, at the urgency or degree of the generic steroid may be fine. But if of Houston. patient’s condition. If a patient I’m treating someone with a seri- For example, Dr. Autry gener- has a very aggressive uveitis, for ous inflammatory condition, then ally prescribes brand-name Pred instance, he prescribes a brand- I really feel like the branded drugs Forte (prednisolone acetate 1%, name steroid and not a generic. work better and are quicker and Allergan) rather than the generic “We know in the steroid class safer than the generic drugs.” equivalent. “It is fairly well estab- of medication, the gold standard Similarly, if a patient has a low- lished that the Pred Forte brand has always been Pred Forte. There risk bacterial conjunctivitis, Dr. has better suspension qualities than are many generic drug manufactur- Gaddie will consider a generic anti- the generic, especially with a more ers, and we know from studies the biotic because most of the bacterial REVIEW OF OPTOMETRY APRIL 15, 2015 71 070_ro0415_f6.indd 71 4/1/15 2:08 PM Clinical Care Photo: Aaron Bronner, OD Prescribing With Hands Tied What’s it like to practice in a state that still has restrictive prescribing privileges? For optometrist Dawn Chivers, who prac- tices in New York—one of the few states that allows ODs to treat patients only with topical or OTC meds—the current pre- scribing limitations impact her patients and her practice, especially when a patient is sitting in her chair on weekends or in the evening when most primary care physicians and ophthalmologists don’t have office hours. If a patient has an acute condition, needs an oral medication and it’s a Saturday, chances are they’ll have to go If the patient’s insurance won’t cover the medication you prescribe for this corneal to the emergency room. This scenario ulcer, or if the drug is in short supply, have a second option in mind. can often lead to delayed treatment, increased cost to the patient and even strains that cause conjunctivitis are • Fight pharmacy substitution. incorrect treatment, she adds. fairly responsive to most generic Optometrist Melvin Friedman Dr. Chivers, who is the vice presi- topical antibiotics, he says. of Memphis, Tenn., requires his dent of the New York State Optometric Looking at glaucoma drugs, patients to sign an Rx waiver citing Association (NYSOA), recently sent a Xalatan (latanoprost, Pfizer) now they have been told the difference patient to the ER on a Friday afternoon has a generic equivalent that is pro- between generic vs. brand-name for herpes keratitis with a note with the duced by numerous manufacturers drugs. correct diagnosis and recommended in various countries. Thus, a patient He also trains his staff to handle course of treatment for oral acyclovir. The may not be given the same generic calls from pharmacists who want patient came back to Dr. Chivers’ office version when refilling the Rx. Dr. to substitute with a generic. For first thing Monday morning with extreme Gaddie says that some patients do example, Dr. Friedman recently discomfort and declining vision. The ER well on the generic, but other times, wrote a prescription for Besivance doctor had prescribed topical Vigamox when a patient obtains a different (besifloxacin, Bausch + Lomb) and (moxifloxacin, Alcon) instead of Dr. generic version of latanoprost, it the pharmacist called the practice Chivers’ recommendation. doesn’t work as well, he says. to see if generic ciprofloxacin could The patient had a $50 co-pay at the “If I had a choice, I would want be used as a substitute, but the staff emergency room, waited four hours and every patient to be on branded refused. Dr. Friedman called the was given a prescription for a drop that glaucoma drugs,” Dr. Gaddie says. pharmacist directly and told him cost about $100, all to have her condition “If a generic doesn’t work as well, ciprofloxacin and Besivance are not worsen. “The patient now has a central then we have to add a second medi- equivalent. The pharmacist blamed scar on her cornea and reduced vision in cation or maybe a third medica- the insurance company for the that eye,” Dr. Chivers adds. tion just to get the pressure down switch, he says. Since 1998, New York ODs have been to where it needs to be than if we “I told the pharmacist if he ever fighting to expand their oral prescribing used a branded prostaglandin to put my patient at risk again, I privileges. On the upside, Dr. Chivers start with. It costs the system more would report him and his staff to says the NYSOA has made significant money, there are potentially more the pharmacy board,” Dr. Fried- strides over the past year in building side effects for the patient, and man says. “Not enough physicians support in the state legislature regarding what you have is a more complex are willing to take a stand, and oral prescriptive authority. “We believe treatment regimen because it takes that’s a problem.” 2015 could be the year we are finally two to three drugs to have the • Find a solution. But what hap- able to see this common sense legislation efficacy of one of the branded glau- pens if the patient can’t afford the enacted into law,” she says. coma prostaglandins.” brand-name drug you prescribe? 72 REVIEW OF OPTOMETRY APRIL 15, 2015 070_ro0415_f6.indd 72 4/1/15 2:08 PM COST OF GOODS SAVINGS CAN ONLY HELP YOU GROW SO MUCH IN THE NEW ERA OF POPULATION HEALTH MANAGEMENT, WHAT’S YOUR PLAN TO WIN: More Patients More Profi ts More Time All of the Above Go To VisionSourcePlan.com and We’ll Give You Ours © Vision Source L.P. 2015. All Rights Reserved. RO0115_Vision Source.indd 1 1/2/15 10:50 AM Clinical Care Photo: Christine Sindt, OD In the event of drug shortage or if a pharmacy doesn’t immediately have the drug you want, always have a work-around, the experts say. For example, if a certain fixed- combination antibiotic/steroid is not available, prescribe a combina- tion using a desirable topical anti- biotic along with a separate topical steroid, Dr. Bartlett says. When AzaSite (azithromycin, Akorn) was in limited supply to treat blepharitis off-label, Dr. Autry instead prescribed oral doxycycline or oral azithromycin. She says these drugs have worked well as a substitute, and they are generally cheaper. Also in the case of blephari- If a needed medication isn’t available topically—such as fortified ceftazidime for tis, Dr. Potter has three alternate gram-negative coverage against Pseudomonas—consider special ordering it from a options ahead of time—erythromy- compounding pharmacy. cin ointment, oral doxycycline or azithromycin—if his preferred drug Dr. Autry always tells the patient Challenge #2: How do you is unavailable. what she thinks is the best treat- deal with state restrictions or “Really, for any medicine you ment option available. limited supply? prescribe, you have to be ready to “If it’s not doable, then certainly While a few states don’t allow ODs have a work-around,” says optom- we need to talk and see if there is a to prescribe oral meds (see “Pre- etrist Jeffry Gerson of Kansas City, combination or a different medica- scribing With Hands Tied,” page Kan. “Although you always have a tion that will work,” she says. “I 72), optometrists from these states best choice in mind, you also need tell this to the patient on the front should already have established to have a second choice—whether end because $250 a month can be working relationships with primary there’s a shortage and lack of avail- a big difference from $50 a month care physicians or ophthalmologists ability, or because the patient has a For some people $50 is a lot, so who can assist with prescribing financial issue, or if the patient lives you have to make a judgment call. needs, Dr. Bartlett says. ODs who in a rural area and the pharmacy In these cases, I’ll say, ‘There is work in the same office with oph- doesn’t have what you want and another medication I can try, and thalmologists should have estab- the pharmacist can’t get the medica- we’ll see how it goes.’ And the lished “standing orders” whereby tion for a few days.” patient will often say, ‘Well, $50 I prescriptions can be written, e-pre- For example, if a patient has a can do.’” scribed or called in to the pharmacy corneal ulcer, Dr. Gerson’s first If the brand-name drug is the on behalf of the patient but under option is Zymaxid (gatifloxacin best treatment option, optometrists the order (and thus shared legal 0.5%, Allergan). If the pharmacy can often help lessen the burden of responsibility) of the MD. doesn’t have that in stock, he’s the cost by offering manufacturers’ “It is much more cumbersome to ready with his second choices, coupons or advising about patient establish relationships with physi- Moxeza (moxifloxacin 0.5%, assistance programs they may be cians in other offices, but this was Alcon) or Besivance. If neither eligible for. “I can’t tell you how routinely done in most states prior of those is available, Dr. Gerson many times patients don’t know to the enabling of statutory privi- would ask what is in stock in the these options are available,” Dr. leges to allow independent prescrib- same drug class, followed by con- Friedman says. “If the patient can’t ing by optometrists,” Dr. Bartlett sidering a generic that would be a afford it, we can help.” says. close equivalent. 74 REVIEW OF OPTOMETRY APRIL 15, 2015 070_ro0415_f6.indd 74 4/1/15 2:08 PM RP0315_Lombart.indd 1 2/23/15 9:52 AM Clinical Care tions for systemic diseases, he adds. The ‘Non-Prescribing’ and Rx Switch Challenge For example, topical beta-blockers What do you do when a patient assumes he or she needs a prescription and expects you to are staple glaucoma drugs, but the get out your Rx pad before leaving the office? patient may also be taking oral beta- This non-prescribing challenge is a common one, Dr. Gerson says. “If someone comes blockers for their blood pressure. in with a watery, red eye that looks viral, it’s a challenge to satisfy the patient without an Studies have found the concomitant antibiotic fix.” use of topical and oral beta-blocker In this case, explain that the condition is viral like the flu. And, in the same way an oral drugs reduces the efficacy of both.1 antibiotic is ineffective against the flu, an antibiotic eye drop won’t help either, Dr. Gerson Other patients have systemic says. medical conditions such as asthma, Another Rx conundrum is when an ER or primary care doctor refers a patient to you, and COPD, heart failure and arrhyth- the patient has already purchased a drug the referring doctor has prescribed that you don’t mias, so the optometrist needs to think will work. “It’s even more of a challenge if you want to prescribe them a brand drug, aware of the patient’s health history but the prescription they got from the emergency room cost $4 and the drug you want and not put the patient at cardiac them to buy instead is $60,” Dr. Gerson says. or pulmonary risk when using a If the patient has already started the other medication and has had no improvement by beta-blocker or alpha agonists, for the time he or she comes to see you, the discussion is easier. However, it’s more difficult if example, Dr. Gaddie says. the patient has been on the other drug for only a day or two. “You really need to stay on top “It’s a delicate situation,” Dr. Gerson says. “You don’t want to discredit the other physi- of the literature to recognize the cian who saw them. You need to tell the patient, ‘I know the other doctor gave you a pre- trade names of certain drugs,” he scription for an antibiotic, but I would really like you to try this because I think it is going to says. “There are newer drugs that work much better.’ It’s important to explain and be up front with the patient.” maybe we weren’t exposed to when we were in optometry school, but it’s still our responsibility to stay Challenge #3: How do you allergy problem was for the most up-to-date and make sure there are effectively manage patients part mitigated, he says. no contraindications to any topical who have allergies, are However, that original 0.2% medications.” taking other medications for concentration was used in the devel- • Prescribing for pregnant/nurs- concomitant disease, or are opment of Combigan (brimonidine ing patients. Another challenge you nursing/pregnant? 0.2%/timolol 0.5%, Allergan) and face is managing pregnant or nurs- Know the issues that may arise from Simbrinza (brinzolamide 1%/ bri- ing patients. “Prescribing during the patient’s medical history, such monidine 0.2%, Alcon). pregnancy is always a risk-benefit as: “The problem is the development consideration,” Dr. Bartlett says. • Managing medication aller- of this combo agent started before Although the general rule is to gies. A careful medication history the newer concentration of brimo- avoid medications during preg- almost always reveals the class of nidine was available, so these two nancy, this is often not practical, medications to which the patient combination medicines contain the especially for chronic conditions may be allergic or sensitive, says higher percentage formulation of such as allergies, glaucoma or ocu- Dr. Bartlett. It is usually possible to brimonidine and its higher rate of lar hypertension, he adds. Doctors select an alternate drug class that allergy,” Dr. Gaddie says. “So for may be able to select a drug in the can be safely prescribed, he adds. patients who are allergic, it knocks comparatively safer FDA pregnancy Dr. Gaddie finds many of his glau- out two or three glaucoma medica- category B, Dr. Bartlett says. When coma patients can become allergic to tions.” drugs in the more risky category C brimonidine. The drug, developed In such cases, Dr. Gaddie tries (such as topical steroids) are needed, in the late 1990s, was originally a different class of medications or the patient can be instructed on the formulated at 0.2%.“There was a even considers laser trabeculoplasty technique of nasolacrimal occlusion 15% to 20% allergy rate for glau- as an option. for one to two minutes after each coma patients taking this drug,” Dr. • Cautious concomitant prescrib- drop instillation. Gaddie says. Allergan subsequently ing. Doctors often treat patients Dr. Gaddie is currently managing lowered the concentration but main- for ophthalmic conditions who are a pregnant 32-year-old patient diag- tained the drug’s efficacy, and the also on other concomitant medica- nosed with glaucoma. The patient is 76 REVIEW OF OPTOMETRY APRIL 15, 2015 0070_ro0415_f6.indd70_ro0415_f6.indd 7676 44/1/15/1/15 2:092:09 PMPM THE SHIELD INSTITUTE AND PURE VISION ARTS CELEBRATE AN EXTRAORDINARY FAMILY SAVE THE DATE MAY 6, 2015 METROPOLITAN WEST 635 West 46 Street, NYC SPECIAL GUEST AMY POEHLER CO-CHAIRS Chris & Marianne Leone Cooper Kevin Genirs Lori & John Reinsberg To celebrate with us, go to www.shield.org Or call 212 243-7300 RO0415_Shield.indd 1 3/24/15 10:33 AM Clinical Care Photo: Leonard J. Press, OD topically. For example, because medications have a wide range of vancomycin is not available in a safety,” he says. topical form for Staph. coverage in Dr. Autry also suggests working severe corneal ulcers, compounding up a pediatric dosing chart to have is an option. Another example is on-hand in the office. This resource fortified, compounded ceftazidime could include the proper dosing of a for gram-negative coverage against typical drug you’d prescribe, such as Pseudomonas. amoxicillin or azithromycin, based Additionally, if a patient with on the child’s age and weight. ocular surface disease needs more She provides this example: than Restasis (cyclosporine, Aller- gan), a compounding pharmacist Volume of can create cyclosporine ophthalmic Augmentin ES-600 ointment, autologous serum drops, Body Powder for Oral tacrolimus solution or ointment, or Weight (kg) Suspension albumin drops, she says. providing 90mg/ Prescribing a drug for children, such Your pharmacist down the street kg/day as amoxicillin for a case of preseptal is not necessarily going to be able to 8 3.0mL twice daily cellulitis, requires specific dosing based compound ocular preparations from on the child’s age and weight. scratch, so find a good compound- 12 4.5mL twice daily ing pharmacist ahead of time before 16 6.0mL twice daily three months pregnant and planning a patient walks through the door, to breastfeed. “All glaucoma medi- Dr. Autry suggests. (To find one, 20 7.5mL twice daily cations are really contraindicated visit: www.pccarx.com/contact-us/ 24 9.0mL twice daily during pregnancy and breastfeeding, find-a-compounder.) so I have to consider whether this One caveat about compounding 28 10.5mL twice daily patient is going to have significant medications is whether insurance 32 12.0mL twice daily vision loss or potentially go blind will pay for it. “Once you get into in a year-and-a-half and weigh that these homebrews, insurance is going 36 13.5mL twice daily against the risk to the developing to be a question,” Dr. Potter says. baby if the mother takes the medica- “It’s never going to be a question One of the key challenges Dr. tion.” on a corneal ulcer, but if I say, ‘I Gaddie sees: optometrists not gain- In this case, Dr. Gaddie is work- think the Restasis should be twice ing confidence in prescribing while ing closely with the patient’s as strong and I think the insurance being exposed to more ophthalmic obstetrician to determine the best should pay for it,’ the answer is diseases. treatment decision. often no.” “Optometrists may have all the clinical knowledge in the world, Challenge #4: When should Challenge #5: How do you but they still can be hesitant to you consider compounding prescribe for pediatric prescribe,” he says. “I encourage medications for off-label use? patients? doctors to start prescribing with Compounding ophthalmic medica- “Many practitioners are uncomfort- low-risk conditions as a stepping tions may be a necessity if you need able with using systemic medica- stone to managing more compli- a different strength, dosage, formu- tions in children, but this is simply cated ocular diseases. Once optom- lation or ingredients. a matter of gaining clinical experi- etrists start treating conditions such Dr. Autry frequently prescribes ence,” Dr. Bartlett says. Get started as allergy and dry eye, it gives them compounded drugs, most com- by prescribing broad-spectrum the confidence to tackle conditions monly to increase the concentra- antibiotics for internal hordeolum such as glaucoma.” ■ tion of medications to treat corneal and preseptal cellulitis in children, ulcers. he suggests. 1. Schuman JS. Effects of systemic beta-blocker therapy on the efficacy and safety of topical brimonidine and timo- She also turns to compound- “Dosage calculations are typically lol. Brimonidine Study Groups 1 and 2. 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Paul Karpecki, OD Doug Devries, OD Andrew Gurwood, OD Nathan Lighthizer, OD Marc Myers, OD Jack Schaeffer, OD [Program Chair] 3 WAYS TO REGISTER ONLINE: WWW.REVOPTOM.COM/CHARLESTON2015 EMAIL LOIS DIDOMENICO: [email protected] PHONE: 866-658-1772 Stock Image: ©iStock.com/JobsonHealthcare Up to Administered By 17 CE Review of Optometry® Credits Approval Pending (COPE approval pending) 2015_charleston_spread.indd 1 4/2/15 3:34 PM Up to 17 CE Credits (COPE approval pending) FRANCIS MARION HOTEL 387 KING STREET-CHARLESTON, SC 29403 Discounted Room Rate: Standard Room $239/night Deluxe Room $269/night Discounted Room Rate Limited For reservations, call 877-756-2121 and identify yourself as a participant of “Review of Optometry” for group rate. www.revoptom.com/Charleston2015 Stock Images: ©iStock.com/JobsonHealthcare Registration Information Name NPI # (NPI numbers will only be used for HCP reporting purposes) Practice Affiliation Mailing Address City State Zip Code Telephone Fax Email Name Badge Information (please print clearly) My Name My Guest Additional Guests Payment Information Rate per person No. in party Subtotal OD Registration - $495 $495 x ______= $______(includes 15 hours of CE, breakfasts, reception) Call for daily and student rates. 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Approval Pending Review of Optometry® 2015_charleston_spread.indd 2 4/2/15 3:34 PM Cornea+Contact Lens Q+A Navigating the Slippery Slope Is it ever okay for a patient with corneal ectasia to wear a scleral contact lens with corneal touch? Edited by Joseph P. Shovlin, OD Photo: Greg DeNaeyer, OD I have recently started to fit are studies that sug- Q scleral lenses. One of my gest flat-fitting con- first cases is an extremely steep, tact lenses are asso- peripherally thinned grafted cornea ciated with corneal that now has ectasia. Regardless of incident scarring.1 what diameter lens and design I’ve Other research tried, I can’t get the lens to clear the suggests that oxida- steep portion of the corneal ectasia. tive stress, includ- There’s about 0.5mm touch below ing mechanical the center of the cornea. Are there trauma, contributes any frank contraindications to allow- to keratoconus.2 ing a patient who finds the lens com- In the case of this fortable to wear this lens? particular patient, Generally, every attempt however, “the A flat-fitting scleral contact lens on a keratoconus patient. A should be made to clear the lens is probably apical region; however, depending acceptable as long as the patient to be fit with a reverse geometry on the patient, some corneal touch is comfortable and the epithelium design, meaning the secondary may be okay. is healthy,” he says.“ Monitor the curve is steeper than the base “The standard definition for a patient at least every six months curve,” Dr. Sindt says. “You may well-fit scleral lens is that it com- and advise them to return imme- need to steepen and lengthen the pletely vaults over the corneal diately if they experience discom- secondary curve more or increase surface,” says Greg DeNaeyer, fort.” the optic zone size if the lens still OD, clinical director for Arena If the patient does in fact dem- touches the graft.” Eye Surgeons in Columbus, Ohio. onstrate epithelial disruption, Dr. Regardless, before even fitting “However, a complete vault is DeNaeyer suggests piggybacking the lens, Dr. Sindt recommends not always achieved for patients a scleral lens on a silicone hydro- getting an endothelial cell count to with severe corneal irregularity or gel daily disposable. “The soft make sure the cornea can support for a scleral lens that significantly lens will act as a cushion to help scleral lens wear. “It is common decenters.” protect the epithelium,” he says. to experience corneal edema with Dr. DeNaeyer points out there “Silicone hydrogel lenses maxi- endothelial cell counts under 800 2 Photo: Christine W. Sindt, OD mize transmissibility, and daily cells/mm ,” she says. If the cornea disposables help to reduce care is deemed healthy enough, Dr. complexity and deposit-related Sindt suggests fitting a full scleral complications.” lens, rather than a mini scleral Christine W. Sindt, OD, lens, since full sclerals have larger clinical associate professor at the landing zones, making it easier University of Iowa, notes that this to manipulate the intermediate issue, referred to as a tilted graft curves. ■ or recurrence of keratoconus, is 1. Barr JT, Wilson BS, Gordon MO, et al. Estimation of the common. Typically seen in older incidence and factors predictive of corneal scarring in the A theoretical lens on the eye with the grafts, it occurs when the host tis- Collaborative Longitudinal Evaluation of Keratoconus (CLEK) secondary curve zone steeper than the study. Cornea. 2006 Jan;25(1):16-25. sue thins and stretches, she adds. 2. Kenney MC, Brown DJ. The cascade hypothesis of kerato- base curve. In some cases, “these grafts need conus. Cont Lens Anterior Eye. 2003 Sep:26(3):139-46. 82 REVIEW OF OPTOMETRY APRIL 15, 2015 082_ro0415_clqa.indd 82 4/1/15 2:56 PM Exceptional all-day lens wear, every day, for every eye UNSURPASSED COMFORT Clinically unsurpassed in overall comfort and rated superior to Dailies® AquaComfort Plus® in beginning to end-of-day comfort EXCELLENT SAFETY PROFILE1 ¶ Confi rmed in an unprecedented, year-long, observational study of 570 wearers— no other lens has published this kind of safety data, including Dailies® AquaComfort Plus® UV PROTECTION† Blocks approximately 97% UVB and 82% UVA rays.‡ Dailies® AquaComfort Plus® does not meet ANSI/ISO standards for UV blocking ANSI=American National Standards Institute; ISO=International Organization for Standardization. ACUVUE ® Brand Contact Lenses are indicated for vision correction. As with any contact lens, eye problems, including corneal ulcers, can develop. Some wearers may experience mild irritation, itching or discomfort. Lenses should not be prescribed if patients have any eye infection, or experience eye discomfort, excessive tearing, vision changes, redness or other eye problems. Consult the package insert for complete information. Complete information is also available from VISTAKON® Division of Johnson & Johnson Vision Care, Inc., by calling 1-800-843-2020 or by visiting acuvueprofessional.com. †Helps protect against transmission of harmful UV radiation to the cornea and into the eye. WARNING: UV-absorbing contact lenses are NOT substitutes for protective UV-absorbing eyewear such as UV-absorbing goggles or sunglasses, because they do not completely cover the eye and surrounding area. You should continue to use UV-absorbing eyewear as directed. NOTE: Long-term exposure to UV radiation is one of the risk factors associated with cataracts. Exposure is based on a number of factors such as environmental conditions (altitude, geography, cloud cover) and personal factors (extent and nature of outdoor activities). UV-blocking contact lenses help provide protection against harmful UV radiation. However, clinical studies have not been done to demonstrate that wearing UV-blocking contact lenses reduces the risk of developing cataracts or other eye disorders. Consult your eye care practitioner for more information. ‡UV-blocking percentages are based on an average across the wavelength spectrum. ¶ This observational/surveillance registry relied on patient reports of symptomatic adverse events that led them to seek clinical care. These results should be considered in conjunction with other clinical results on the safety and effi cacy of daily disposable etafi lcon A contact lenses, which also generally show low rates of such events. Although no symptomatic infi ltrative events were reported in this study, such events can occur with daily disposable lenses, including 1-DAY ACUVUE® MOIST, as noted in the product labeling. 1. Chalmers RL, Hickson-Curran SB, Keay LJ, Gleason W. Safety of hydrogel and silicone hydrogel daily disposables in a large post-market surveillance registry—the TEMPO registry. Presented at: ARVO 2014 Annual Meeting: May 4-8, 2014; Orlando, FL. The third party trademarks used herein are trademarks of their respective owners. ACUVUE ®, 1-DAY ACUVUE® MOIST, and VISTAKON® are trademarks of Johnson & Johnson Vision Care, Inc. © Johnson & Johnson Vision Care, Inc. 2015 ACU-A44516-C March 2015 RO0415_Vistakon Moist.indd 1 3/30/15 11:44 AM Glaucoma Grand Rounds Get Your Priorities in Order Decck?A patient By presentsJames L. Fanelli, with eye O.D. pain, elevated IOP, cataracts and vein occlusion. To get all your ducks in a row, which problem do you address first? By James L. Fanelli, OD n February 2015, an 86-year- posterior subcapsular old white female presented on haze in both eyes. The I an urgent basis referred from a posterior cortical cata- local urgent care center due to the ract in the right eye was possibility of zoster, with a note of on the visual axis; that “blisters” on the eyelid. She had of the left eye was off the been to the urgent care center the visual axis. previous day with complaints of Her cup-to-disc ratios blurred vision in the right eye as were 0.35 x 0.35 OD well as periocular pain on the right and 0.20 x 0.20 OS. Disc side. Gonioscopy could not confirm neovascularization in margins were distinct, The patient was in no acute dis- the angle, although OCT shows that it is open. The although the right was tress. She complained of intermit- question remains whether a vascularization is present. somewhat hyperemic, tent pain and redness in and around and fine details were dif- the right eye for the past couple of Slit lamp examination of the ficult to ascertain due to the media weeks. She mentioned that she had anterior segment was remarkable opacities in that eye. received the shingles vaccine about for several items. Of minimal sig- Both maculae were character- two years earlier. She denied any nificance was mild blepharitis and ized by retinal pigment epithelial photopsia. dermatochalasis in both eyes. The granulation and drusen, consistent The last time I saw her in my cornea in the right eye was mildly with mild nonangiogenic age-related office was in 2012, and she was lost hazy, with moderate striate kera- macular degeneration. But the to follow up until this presentation. topathy and guttatae. The cornea of significant finding in the right eye What initially brought her into the the left was clear, except for a sym- was a central retinal vein occlusion urgent care center was the discom- metric presentation of the guttatae. (CRVO) with what appeared to be fort in her right eye, which she Examination of the anterior cham- resorbing intraretinal hemorrhages described as a dull, non-stabbing bers—specifically looking for cells in all quadrants. The retinal vascu- pain that had worsened in the past and flare—was difficult in the right lature was characterized by moder- three days. eye because of the corneal haze, so ate arteriolar sclerotic retinopathy Current medications included no cells were appreciated; the left in both eyes, clearly discernable omeprazole QD, metoprolol QD anterior chamber was unremark- in the left eye. The retinal venules and an unknown Rx sleep aid HS. able. Iris details were also somewhat were moderately tortuous OD>OS. She had no allergies to medications. obscured in the right eye, and were Peripheral retinal evaluation was normal in the left. The right eye also unremarkable OU. Diagnostic Data showed moderate episcleral injec- Upon gonioscopic examination, Her visual acuity was hand motions tion. details of the angle anatomy in the at three feet in her right eye, 20/40 Intraocular pressure measured right eye were obscured by the hazy in her left, neither improving with 42mm Hg OD and 26mm Hg OS cornea. In the left eye, the angle was pinhole. She displayed an equivo- at 2:15 PM. Angles appeared to be normal and open. Anterior segment cal afferent pupillary defect in the open by Van Herick estimation. OCT imaging confirmed the pres- right eye, with both pupils slug- Upon dilation, her crystalline ence of open angles in both eyes. gishly reacting to light. Extraocular lenses were characterized by 2+ OCT evaluation of the macula motilities were full in all positions anterior and posterior cortical cata- was unremarkable in the left eye, of gaze. racts, 3+ nuclear cataracts and mild but the right was consistent with 84 REVIEW OF OPTOMETRY APRIL 15, 2015 084_ro0415_ggr.indd 84 4/1/15 2:27 PM DOWNLOAD LAYAR APP FOR INTERACTIVE EXPERIENCE First 150 app downloads & completed forms will be entered into a drawing for REGISTRATION OPEN! FREE MEETING & REGISTRATION VALUED AT $495 INTERACTIVE PRINT ies a log nd o T r n e h a c t e m REVIEW OF OPTOMETRY T N T EDUCATIONAL MEETINGS OF CLINICAL EXCELLENCE e n w t e s N & T IN VISION CARE MAUI, HAWAII 2015 JULY 23-26 WAILEA BEACH MARRIOTT RESORT & SPA 3700 WAILEA ALANUI DRIVE, MAUI, HI 96753 $100 OFF BY CE COURSE TOPICS: MAY 23RD New Advances in the Management of Lid Margin Disease Clinical Management of Ocular Surface Disease Technological Innovations in Eye Care Cancer and the Eye: Ocular Tumors, Malignancies and Neoplasms Expert Panel on Glaucoma Diagnosis and Treatment What the Primary Care Optometrist Should Never Miss Don’t Let Swollen Optic Nerves Make You Nervous Conquering Therapeutic Dilemmas INTERACTIVE PRINT Watch video with meeting FACULTY chair, Paul Karpecki for more reasons to attend! Paul Karpecki, OD Ron Melton, OD Brad Sutton, OD Randall Thomas, OD Program Chair 3 WAYS TO REGISTER ONLINE: WWW.REVOPTOM.COM/MAUI2015 EMAIL LOIS DIDOMENICO: [email protected] PHONE: 866-658-1772 Up to Administered By 14 CE Review of Optometry® Credits Stock Image: ©iStock.com/JobsonHealthcare Approval pending (COPE approval pending) 2015_maui.indd 1 4/2/15 3:32 PM 20TH ANNUAL OPHTHALMIC PRODUCT GUIDE Innovative products to enhance your practice The future is in your hands. One tap, many possibilities. Experience the digital edition on your handheld device. Use your smart device to scan the code below or visit: www.reviewofoptometry.com/supplements/ Download a QR scanner app. Launch app and hold your mobile device over the code to view http://www.reviewofoptometry.com/supplements 2015_opg_ad_fullpge.indd 1 1/30/15 3:09 PM Glaucoma Grand Rounds Photo: Greg Black, OD, and Julie Tyler, OD macular edema associated with In light of the FA findings, and the CRVO. Lastly, I took fundus given that the IOP-lowering agents photos to document the state of the had no effect, we can safely assume CRVO at this initial presentation. that we are dealing with neovas- cular glaucoma. To answer the Diagnosis original question—which came The patient’s right eye certainly first?— the vein occlusion was prob- has a CRVO of unknown dura- ably the precipitating factor that led tion, associated macular edema to the patient’s current constellation and significantly elevated IOP, While difficult to see by gonioscopy, our of problems. OD>OS. The elevated IOP was very patient had neovascularization of the But there are a few other items likely the source of her intermittent angle, as seen in this similar patient. that were put on the back burner pain in the right eye. She had no until the clinical picture became evidence of an active outbreak of macular edema associated with the clearer, and now need to be dealt herpes zoster. VO, a retinal consult is in order, with. One is her rather dense cata- but not necessarily specifically for racts. The other is establishing the Management and Discussion the reduction of the macular edema. etiology of the VO in the first place Elevated IOP can induce a CRVO. On the contrary, a retinal consult as these are often associated with Also, one of the sequelae of long- was ordered primarily to obtain a elevated blood pressure, elevated standing CRVO is the develop- fluorescein angiogram (FA) to help cholesterol and diabetes. This of ment of neovascularization of the determine whether an occult retinal course is managed by the patient’s posterior and anterior segments, neovascularization was present. The primary health care provider, and and subsequently, due to neovas- presence of neovascularization of I’ve contacted him for consultation. cularization of the iris and anterior the retina can be a good indicator The retinal specialist, whose chamber angle, neovascular glau- that the underlying etiology of the view in the right eye was likewise coma. Because the media were not elevated IOP is, in fact, sequelae limited, felt that the cataract in that clear, neovascularization of neither from the neovascularization due to eye should be removed prior to per- the posterior segment nor anterior retinal hypoxia. forming panretinal photocoagula- segment were visible. The quandary At the completion of the initial tion (PRP). My opinion was that the at this visit pertained to the presence visit, we scheduled the patient for patient would be best served if the of two distinct clinical entities, each a fluorescein angiogram, and I cataract surgery was performed by of which can induce the other. prescribed Lumigan (bimatoprost a glaucoma surgeon comfortable in So which came first? Did the VO 0.01%, Allergan) HS OD as well lens extractions. induce neovascularization and sub- as Alphagan P (brimonidine 0.1%, Ultimately, after consultation sequent neovascular glaucoma? Or, Allergan) BID OD. with a glaucoma surgeon, the cur- did elevated IOP (of non-neovascu- When the patient returned for rent plan is to proceed with lens lar origin) induce the VO? follow up, she was still in as much extraction with IOL in the right eye, In preparing a management plan pain, but her IOP now measured with the combination of Ahmed for this patient, multiple problems 44mm Hg OD and 25mm Hg OS. valve implantation at the same time need to be sorted out; so, it’s the Obviously, the IOP-lowering agents (to facilitate quicker IOP reduction optometrist’s duty to direct the were having little effect, so the like- and better long-term IOP stability), patient’s care with the help of other lihood that her ocular hypertension followed shortly by PRP. subspecialties. It’s important to also was neovascular in origin seemed For now, the patient is continuing include evaluations that may in fact more plausible. The patient’s FA with follow-up visits here. In such help shed light on the ultimate cause was scheduled the following day, so cases, the optometrist must main- of these two problems. Obviously, I did not make any changes in her tain visits with these patients during IOP needs to be lowered, not only medications pending the results. surgical interventions. After all, the to reduce the likelihood of neuro- Sure enough, the FA revealed patient will return to the OD for retinal rim damage, but also to occult neovascularization of the ret- long-term care, so it’s critical that mitigate the role that IOP may have ina, and possible anterior segment the optometrist be involved with all had in inducing the VO. Given the late fluorescein staining was noted. aspects of the perioperative care. ■ REVIEW OF OPTOMETRY APRIL 15, 2015 87 084_ro0415_ggr.indd 87 4/1/15 2:27 PM Retina Quiz Vision Loss With Wet AMD A new outlook on an easily misinterpreted finding. By Mark T. Dunbar, OD n 86-year-old Hispanic lens with a patent periph- male with a history of wet eral iridotomy and superior Aage-related macular degen- corneal sutures intact. The eration in both eyes presented with anterior chamber of his left a chief complaint of painless, pro- eye revealed 1+ cell. Fundus gressive vision loss in both eyes. He findings of the left eye are received multiple intravitreal Avas- represented in figure 1. Hei- tin injections, most recently three delberg SD-OCT images of months prior in the left eye. his left eye are available for His past ocular history was sig- review in figures 2 and 3. nificant for a recent intraocular lens exchange and anterior vitrectomy in Take The Retina Quiz the left eye. 1. What is the likely Fig. 1. This fundus photo shows the left eye of an His ocular medications included cause for vision loss in this 86-year-old presenting with painless, progressive prednisolone acetate in the left eye patient’s left eye? vision loss. Can you identify the cause? four times a day, as well as Timolol a. High IOP causing twice a day in the left eye due to a glaucomatous damage from figures 2 and 3? history of ocular hypertension from chronic steroid response. a. Anti-VEGF injection. steroid response. He admitted to b. Inflammation from recent IOL b. Focal laser photocoagulation. very poor compliance with both of exchange. c. Combination of topical NSAID his topical ophthalmic medications. c. Fibrosis and geographic atro- and steroid. His medical history was signifi- phy from age-related macular d. Observation. cant for multiple systemic patholo- degeneration. gies, including benign prostatic d. All of the above. For answers, turn to page 106. hyperplasia, arthritis, hypertension, osteoporosis and a pacemaker. His 2. What finding is represented by Diagnosis systemic medication list was exten- the arrows in figure 2 and 3? The structures denoted with arrows sive, although none with known a. Irvine-Gass macular edema. on the SD-OCT (figures 2 and 3) significant ocular side effects. b. Outer retinal tubulation. represent outer retinal tubules. Upon examination, his distance c. Cystoid macular edema. Thanks to the precision of SD- BCVA was 20/60+ in the right eye d. Subretinal fluid. OCT, investigators in 2009 detect- and counting fingers at one foot in ed a “peculiar” change in the outer the left eye. His intraocular pres- 3. What other diagnostic test retina in their study of 63 patients sure was 18mm Hg in the right would be helpful in determining the with advanced retinal disease.1 eye and 31mm Hg in the left eye. etiology of the findings in figures 2 They described round or ovoid The slit lamp examination of his and 3? spaces with a hyporeflective center right eye revealed a posterior cham- a. B-scan echography. and hyperreflective border within ber intraocular lens, geographic b. Fundus autofluorescence. the outer nuclear layer that simulat- atrophy without obvious fluid or c. Fluorescein angiography. ed the appearance of cystoid macu- heme in the macula, and old laser d. Time-domain ocular coherence lar edema or subretinal fluid on scars around a horseshoe tear in tomography. isolated scans. The study also made the peripheral retina. The slit lamp use of SD-OCT C-scans to allow en examination of his left eye revealed 4. What is the appropriate treat- face visualization of the outer reti- an anterior chamber intraocular ment for the findings highlighted in na, which showed that these spaces 88 REVIEW OF OPTOMETRY APRIL 15, 2015 088_ro0415_rq.indd 88 4/1/15 2:29 PM THIS IS WHY patients can enjoy refreshing comfort with every blink—no matter what the day may bring. 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See product instructions for complete wear, care, and safety information. © 2014 Novartis 12/14 DAF15001JAD RO0415_Alcon Dailies.indd 1 3/30/15 2:15 PM Up to 12 CE Credits REGISTRATION OPEN: (COPE approval pending) DECEMBER 4-5, 2015 ANAHEIM, CA THE OPTOMETRIC RETINA SOCIETY AND REVIEW OF OPTOMETRY PRESENT: RETINA UPDATE2015 Featured Faculty Hajir Dadgostar, MD, PhD Brad Sutton, OD Stuart Richer, OD Blair Lonsberry, OD Jeffry Gerson, OD Steve Ferrucci, OD ORS Mission Statement Sheraton Park Hotel “The mission of the Optometric Retina Society (ORS) is to At the Anaheim Resort promote the advancement of vitreoretinal knowledge for clinicians, ophthalmic educators, residents, and students. 1855 S. Harbor Boulevard The ORS is dedicated to posterior segment disease prevention, Anaheim, CA 92802 diagnosis, management and co-management.” For hotel reservations call: 866-837-4197 Standard Room Rate: $149/night 3 Ways to Register Course Topics • Nutrition and Genetics in Retinal Wellness Online: www.revoptom.com/ORSRETUPDATE2015 • New Paradigms in Retinal Vascular Disease Email Lois DiDomenico: • Vitreoretinal Grand Rounds [email protected] • Medical and Surgical Retina Update Phone: • Macular Holes and Epiretinal Membranes 877-451-6510 • What’s New in Retinal Imaging Stock Image: ©iStock.com/JobsonHealthcare Administered By ® Review of Optometry Approval pending 2015ORS_savethedateSECO_new.indd 1 4/2/15 3:32 PM Retina Quiz often continued linearly throughout the outer nuclear layer in branching tubular structures. They determined these changes represented “outer retinal tubulation.” Outer retinal tubules are com- monly seen in advanced AMD patients. In the CATT study, outer retinal tubules were present in 10.1% of AMD patients at 56 Figs. 2. and 3. Can you identify what the red arrows are pointing to in this patient’s weeks after initial treatment with Heidelberg SD-OCT images? anti-VEGF and 17.4% at 104 weeks after treatment.2 retinal tubule specimens, allowing relatively refractory to treatment In patients with geographic atro- researchers to definitively cor- and the mere presence suggests the phy, outer retinal tubules may be respond OCT appearance to ana- disease is end-stage and relatively present in 21% to 26% of patients.3 tomical composition.5 That team quiescent and therefore this finding Outer retinal tubules can also be determined the defining features alone shouldn’t prompt intervention. found in other advanced retinal of outer retinal tubulation on Our patient was treated with an diseases such as associated CNVM histology as a circular or ovoid intravitreal Avastin injection in the and subretinal fibrosis, pattern dys- external limiting membrane bor- left eye solely due to his preference trophy, AZOOR, multifocal choroi- der made by Müller cell processes for a treat-and-extends approach, as ditis, pseudoxanthoma elasticum, with radially oriented photorecep- his fundus exam and SD-OCT did Stargardt disease, gyrate atrophy, tors in four phases of degenera- not reveal any intra-retinal fluid. He choroideremia, chronic central tion, ranging from both outer and was also counseled extensively on serous chorioretinopathy, retinitis inner segments to minimal or no the importance of compliance with pigmentosa, cone dystrophy and photoreceptor segments. his topical ocular medications, and Bietti crystalline dystrophy. Beyond the clinical appearance, was told to resume Prednisolone Interestingly, Christine Curcio they also determined the location Acetate in the left eye with a weekly and colleagues first described outer of the outer retinal tubulation to taper, and well as Timolol twice a retinal tubules in a histopatho- be in the outer nuclear layer with day in the left eye. logic study of AMD in 1996.4 They a hyperreflective band in either a The presence of outer retinal found that surviving photoreceptors closed or open configuration, with tubulation on the SD-OCT images in advanced AMD had an apparent often overlying dysmorphic or of this patient’s left eye likely indi- reorganization into interconnecting absent retinal pigment epithelium. cates quiescent and end-stage age- tubes over areas of scarring. How- These defining features help dif- related macular degeneration. ■ ever, it was not until the advent and ferentiate these lesions from cystoid This case was written and provid- common clinical use of SD-OCT macular edema, which is more com- ed by Savannah Brunt, OD, ocular that a clearer understanding of monly found in the outer plexiform disease resident at Bascom Palmer outer retinal tubules was realized. and inner nuclear layer and does Eye Institute. Initial studies postulated the pro- not have a hyperreflective border on 1. Zweifel S, Engelbert M, Laud K, et al. Outer retinal cess of outer retinal tubulation like- SD-OCT. tubulation. Arch Ophthalmol. 2009;127(12):1596-602. ly begins with sublethal injury of It is easy to confuse the clinical 2. Lee J, Folgar F, Maguire M, et al. Outer retinal tubulation photoreceptors leading to invagina- appearance of outer retinal tubules in comparison of age-related macular degeneration treatment trials (CATT). Ophthalmology. 2014;121:2423-31. tion of the photoreceptor layer until and cystoid macular edema. It is 3. Hariri A, Nittala M, Sadda S, et al. Outer retinal tubulation opposing ends establish connections clinically important to make the as a predictor of the enlargement amount of geographic atrophy in age-related macular degeneration. Ophthalmology. and form tubular structures. distinction because improper diag- 2015;122:407-13. Another study compared the nosis may prompt physicians to 4. Curcio C, Medeiros N, Millican C. Photoreceptor loss in age-related macular degeneration. Invest Ophthalmol Vis Sci. appearance of outer retinal tubu- unnecessarily treat with anti-VEGF 1996;37(7):1236-49 lation in patients with advanced injections or focal laser photocoag- 5. Schaal K, Freund K, Litts K, et al. Outer retinal tubulation in advanced age-related macular degeneration: Optical Coher- AMD on SD-OCT to their ulation when no actual fluid is pres- ence Tomographic Findings Correspond to Histology. Retina. actual histology in post-mortem ent. In fact, outer retinal tubules are 2015 Jan. [Epub ahead of print]. Accessed: March 17, 2015. REVIEW OF OPTOMETRY APRIL 15, 2015 91 088_ro0415_rq.indd 91 4/1/15 2:29 PM Therapeutic Review Wearable Therapy for Dry Eye Can this decidedly old-school measure hold its own in a more sophisticated era? By Alan G. Kabat, OD and Joseph W. Sowka, OD sk the average person what periocular humidity an optometrist does, and for alleviating the signs chances are the response and symptoms of dry A 4-6 will include the term “glasses.” eye. A meta-analysis As sophisticated as our profes- of seven prior studies sion becomes, and as much as we even found that the use continue to expand our scope of of moisture chambers practice, spectacle frames and cor- or goggles provided rective lenses will always reside at more effective corneal the heart and soul of optometry. protection than lubri- Even today, eyewear plays a cating drops in critical major role in how we make a liv- care patients with the ing. According to a report pub- potential for exposure Severe dry eye can result in corneal epithelial disruption. lished by the Academy for Eye keratopathy.7 In one study, half the subjects ranked their symptoms as severe, but after one-month one month of using moisture Care Excellence, private practice Two of the more retention eyewear, only 3% did so. optometrists derive about 44% of highly regarded and their gross income from the sale of comprehensive publications in Such a statement, however, is prescription eyeglasses; this exceeds recent history regarding dry eye akin to suggesting that, since arti- even the revenue earned from pro- disease—the Delphi Panel report ficial tear preparations are merely fessional examination fees, which and the DEWS report—both palliative in nature, they should amounts to only 38%.1 recommend moisture-conserving be used only as a last resort. Of But can we gain something spectacles as part of their treat- course, we all know that these more with the use of these devices? ment algorithms.8,9 However, this topical agents actually represent Could this workhorse of optomet- therapeutic modality seems to have first-line therapy for virtually all ric practice pull double-duty and always been perceived as a last patients with dry eye complaints. help to address a growing health resort treatment; in fact, the Delphi Could moisture-retention devices problem in eye care; namely, ocular panel placed moisture goggles in be similarly placed in the front line? surface disease? Recent develop- the same category (DTS Level 4 ments suggest it may be possible. Severity) with punctal cautery, oral Research cyclosporine therapy and surgical Despite the apparent stigma, recent Moisture-Retention Eyewear tarsorrhaphy. research has evaluated a new The concept of moisture-retention Why would this be the case? generation of moisture-retention eyewear is not new. Publications We speculate that the cumbersome eyewear and the results are most detailing the design of moist-cham- nature of these devices and poor compelling. In an independent ber spectacles date back nearly 70 cosmesis noted with the most com- study, researchers evaluated 11 years and explicit instruction on mon options, such as swim goggles patients with evaporative dry eye how to fabricate moisture cham- or acrylic side-shields, has preclud- over three months.10 ber eyeglasses is available in the ed their widespread acceptance by Inclusion criteria consisted of optometric literature from 20 years patients. Additionally, these devices symptomatic dry eye complaints, a ago.2,3 Highly respected clinician- possess no curative effect and do tear breakup time (TBUT) less than scientists have consistently touted not address the root cause of ocu- five seconds, Schirmer score greater the potential benefits of increased lar surface disorders. than 8mm and corneal fluorescein 92 REVIEW OF OPTOMETRY APRIL 15, 2015 092_ro0415_tr.indd 92 4/1/15 2:59 PM The Rick Bay Foundation for Excellence in Eyecare Education www.rickbayfoundation.org Support the Education of Future Healthcare & Eyecare Professionals About Rick Scholarships are awarded to advance the education Rick Bay served as the publisher of students in both Optometry and Ophthalmology, of The Review Group since 1991. and are chosen by their school based on qualities that To those who worked for him, embody Rick’s commitment to the profession, including he was a leader whose essence was based integrity, compassion, partnership and dedication to the in a fi erce and boundless loyalty. greater good. To those in the Interested in being a partner with us? industry and the professions he served, he will be remembered Visit www.rickbayfoundation.org for his unique array of skills (Contributions are tax-deductible in accordance with section 170 of the Internal Revenue Code.) and for his dedication to exceeding the expectations of his customers, making many of them fast friends. (The Rick Bay Foundation for Excellence in Eyecare Education is a nonprofi t, tax-exempt organization under section 501(c)(3) of the Internal Revenue Code.) 2015_rickbay_housead.indd 1 3/27/15 10:07 AM CONTINUE YOUR EDUCATION WITH REVIEW OUR FLAGSHIP TITLE, REVIEW OF OPTOMETRY, IS THE MARKET’S LEADING RESOURCE FOR ALL OF YOUR OPTOMETRY NEEDS. The Review Group is dedicated to Review of Optometry is your primary source for ground-breaking the constant growth and education clinical information as well as timely news, market trend information and continuing education programs. of the profession. Review offers Review of Cornea & Contact Lenses serves as a valuable resource for many different publications and all practitioners and features detailed articles focusing on various fitting methods, solutions and corneal cases. Also available is the Review of services to help enhance your Cornea & Contact Lenses “Annual Contact Lenses & Lens Care” Guide, a yearly publication detailing the newest lenses and lens care products. practice and patient care. The Review Group’s Ophthalmic Product Guide brings you the newest and most innovative products on the market. Published every February and July, the guide provides concise information about new literature, drugs and equipment designed to help your practice thrive. The Review Group also offers valuable continuing education sessions in both print and online formats, allowing a convenient way for you to earn CE credits. In addition, Review also offers an impressive fleet of free e-newsletters, such as Optometric Physician, the Optometric Retina Society quarterly e-newsletter and the Optometric Glaucoma Society E-Journal, so you can keep up to date on breaking news and the latest research online. On top of these products, the Review Group also spearheads meetings and conferences, bringing together experts in the field and providing a forum for practitioners to earn CE credits and learn from others in the profession. www.reviewofoptometry.com Jobson Medical Information LLC The Review Group 2015_ro_tsrad.indd 90 4/2/15 12:26 PM Therapeutic Review staining present in at least one retention eyewear, is relegated to quadrant of one eye. such an obscure and limited sta- Individuals with punctal plugs or tus. If the studies are correct, this punctal cautery and those wearing treatment modality can alleviate contact lenses were excluded from symptomatic irritation in dry eye the study. All subjects were pre- patients by 50% or more. scribed 7eye (formerly Panoptyx) Given our profession’s historical moisture-retention eyewear and expertise with the fabrication, han- were able to select from a variety dling and dispensing of corrective of sizes, styles and tints to allow eyewear, this approach to dry eye for an optimal fit while maximiz- seems like a natural fit. ing both appearance and function. In a three-month study, patients using Perhaps the time has come to Subjects were instructed to use the moisture retention glasses (7eye) were reexamine the benefits of moisture- eyewear in addition to their usual able to cut their dry eye severity by more retention eyewear for the adjunc- treatment and were evaluated than half. tive therapy of dry eye disease. before and after the three months Sometimes, an old-school approach for dry eye severity using the is the best way to tackle a new-age Symptom Assessment in Dry Eye problem. ■ (SANDE) index and corneal fluo- Dr. Kabat is Clinical Care Con- rescein staining.11 sultant at TearWell Advanced Dry At the conclusion of the study, Eye Treatment Center in Memphis, subjects reported an overall accept- Tenn. Neither he nor Dr. Sowka ability rate of 72% (Likert score has any direct financial interest 6.48 out of 9) for the eyewear in In the past, swim goggles were used as in the products mentioned in this terms of tolerability and symptom moisture chambers for dry eye. article. relief. The SANDE score dimin- 1. Profile of Independent Practice Optometry. Academy for Eye ished by an impressive 55% and eyewear in nine specific complaints Care Excellence. Accessed: February 13, 2015. Available at: www. myalcon.com/docs/Profile_Private_Practice_Optometry.pdf both a clinically and statistically including burning, redness, itching, 2. Hallett JW, Pittler S. Individually made acrylic moist- significant reduction in mean cor- diminished vision, light sensitiv- chamber spectacles and pinhole glasses. Am J Ophthalmol. 1946 Jun;29:725-8. neal staining was seen in all corneal ity, discomfort in air conditioning, 3. Hart DE, Simko M, Harris E. How to produce moisture chamber quadrants. Frequency of artificial grittiness, dryness and excessive eyeglasses for the dry eye patient. J Am Optom Assoc. 1994 Jul;65(7):517-22. tear instillation also decreased from tearing, with a mean overall reduc- 4. Tsubota K. The effect of wearing spectacles on the humidity of a mean of eight times per day to tion of 57%. Initially, half of the the eye. Am J Ophthalmol. 1989 Jul 15;108(1):92-3. 5.Korb DR, Greiner JV, Glonek T, et al. Effect of periocular humid- just four and a half times per day, subjects ranked their symptoms as ity on the tear film lipid layer. Cornea. 1996 Mar;15(2):129-34. or 44%. Tear break-up time was severe, but at the one-month visit 6. Korb DR, Blackie CA. Using goggles to increase periocular humidity and reduce dry eye symptoms. Eye Contact Lens. 2013 the only factor not impacted. only 3% did so. Jul;39(4):273-6. 7. Zhou Y, Liu J, Cui Y, et al. Moisture chamber versus lubrication The authors concluded that Thirty percent of subjects for corneal protection in critically ill patients: a meta-analysis. moisture retention eyewear might reported their overall symptoms Cornea. 2014 Nov;33(11):1179-85. 8. Dysfunctional tear syndrome study group. Dysfunctional tear be a valuable adjunct in the man- were eliminated when wearing the syndrome: a Delphi approach to treatment recommendations. agement of evaporative dry eye and moisture-retaining eyewear.12 Cornea. 2006 Sep;25(8):900-7. 9. Management and therapy of dry eye disease: report of the Man- that the low profile design of the agement and Therapy Subcommittee of the International Dry Eye 7eye product line provided better An Old-School Approach WorkShop (2007). Ocul Surf. 2007 Apr;5(2):163-78. 10. Waduthantri S, Tan CH, Fong YW, Tong L. Specialized cosmesis, increasing compliance. The most recent studies of dry Moisture Retention Eyewear for Evaporative Dry Eye. Curr Eye Res. That study echoes an earlier, eye in the United States suggest a 2014 Jun 30:1-6. [Epub ahead of print] 11. Schaumberg DA, Gulati A, Mathers WD, et al. Development 13 unpublished multicenter study that prevalence rate of nearly 15%. and validation of a short global dry eye symptom index. Ocul Surf. followed 110 patients suffering Given the disease’s pervasive 2007 Jan;5(1):50-7. 12. Research Digest: Panoptx Eye Wear Shown to Relieve Dry- from transient or chronic dry eye nature—growing ever more com- Eye Symptoms. Ophthalmology Management, May 1, 2004. Accessed: February 13, 2015. Available at: www.ophthalmolo- symptoms for a month. Surveys mon with the aging of our popula- gymanagement.com/articleviewer.aspx?articleid=86091 conducted before and after this tion—it seems inappropriate that a 13. Paulsen AJ, Cruickshanks KJ, Fischer ME, et al. Dry eye in the beaver dam offspring study: prevalence, risk factors, trial show a distinct improvement noninvasive, potentially beneficial and health-related quality of life. Am J Ophthalmol. 2014 after wearing moisture-retaining treatment option, such as moisture- Apr;157(4):799-806. REVIEW OF OPTOMETRY APRIL 15, 2015 95 092_ro0415_tr.indd 95 4/1/15 2:59 PM Left your Review of Optometry magazine at the offi ce? No problem! Read Review on the go from any mobile device! Just simply go to www.reviewofoptometry.com and click on the digimag link to get your current issue. 2015 Digimag house ad_RO.indd 1 4/2/15 12:18 PM Surgical Minute By Derek N. Cunningham, OD, and Walter O. Whitley, OD, MBA Caution! Traumatic Cataracts Ahead What to expect when you’re expecting the unexpected during cataract surgery. s well-defined, predictable The surgeon will not know and refined as routine cata- what they are truly dealing Aract surgery has become, with until entering the eye there is one situation in which the and assessing the structural surgeon must always plan on sur- support of the lens. In almost prises and have multiple alternate all circumstances, the sur- techniques at the ready: traumatic geon will attempt an extra- cataracts. These pose a unique set capsular cataract extraction of problems for surgeons, and even (leaving the capsular bag the most thorough slit lamp exam intact) and place a new lens can’t fully prepare surgeons for in the bag, if possible. When what they’ll experience in the oper- zonules are compromised ating room. or missing, the surgeon can use capsular tension rings Hope for the Best, to maintain the size and cir- Surgeons must approach traumatic cataract cases Prepare for the Worst cumference of the capsule to differently than a typical senile cataract—with Any amount of injury that causes allow insertion and centra- numerous contingency plans ready, given the a traumatic cataract to form will tion of a new lens. potential for intraoperative surprises. also likely affect collateral tissues. If the eye is stable, the most common Intraoperative Concerns Each of these scenarios requires associated structural defects would A significant concern with these unique lenses, apart from aphakics, include: iris synechiae, angle reces- cases is the risk of intraoperative that would have to be on hand and sion, iridodialysis, weakened or lost vitreous prolapse. When the eye is preselected based on the patient’s zonular support and lens capsule fully dilated and the lens capsule is biometry data. defects. Careful slit lamp examina- manipulated, vitreous may escape tion will allow you to see much, anteriorly around the capsule or Knowing is Half the Battle but not all, of the extent of these newly placed IOL, leading to fur- Because of the unknown variables defects. ther complications or the need for a and extensive contingency planning During pre-op evaluation, the vitrectomy. Dispersive viscoelastics, necessary, it is critical to identify surgeon will pay extra attention to often used to maintain anterior these patients before they enter the any areas that show angle recession chamber volume, can both keep the operating room. A thorough history or iridodialysis, as this will sug- capsular bag inflated and tampon- of all cataract patients should be gest localized lens zonule defects. ade any incipient vitreous prolapse. performed—including always ask- The one thing we can’t always see If the capsular bag is not suit- ing about a history of eye trauma. well, or ever confidently guess, is able for lens insertion, alternative This is especially important for the amount and extent of zonular options include: placing the lens in patients of routine cataract age compromise or posterior capsule the sulcus (in front of the capsular where natural senile lens changes integrity. For this reason, any trau- bag but behind the iris) if there is can be hastily assumed. If any his- matic cataract is approached with enough anatomy remaining; sutur- tory of eye trauma is reported, it a worst-case scenario mindset, and ing a posterior chamber lens to the should be relayed to the surgeon alternative options are planned iris; placing an anterior chamber as early as possible to allow for based on intraoperative findings. lens; or leaving the patient aphakic. adequate preparation. ■ REVIEW OF OPTOMETRY APRIL 15, 2015 97 097_ro0415_surgical.indd 97 4/1/15 4:13 PM DOWNLOAD LAYAR APP FOR INTERACTIVE EXPERIENCE First 150 app downloads and completed forms will be entered into a drawing for FREE MEETING AND REGISTRATION VALUED AT $495 INTERACTIVE PRINT es and T gi re o a l t o m REVIEW OF OPTOMETRY n e EDUCATIONAL MEETINGS OF CLINICAL EXCELLENCE h T n c t e N s T w T e & N E ON CAR IN VISION2015 CARE PAUL KARPECKI, OD PROGRAM CHAIR REGISTRATION OPEN PHILADELPHIA, PA NOVEMBER 6-8 MAUI, HI* NEW Includes hands-on workshops JULY 23-26 CHARLESTON, SC JUNE 12-14 Up to For more information visit www.reviewofoptometry.como et y.co Administered By 17 CE Review of Optometry® Approval pending Credits Stock Images: ©iStock.com/JobsonHealthcare (COPE approval pending) * Workshops not available - See website for information about snorkeling catamaran activity 2015meetings_V5.indd 1 4/6/15 11:42 AM Product Review Practice Management Additional high-add powers through the same range Website Personalization Service are expected later this year, B+L says. Let patients hear your unique take on what makes your Visit www.bausch.com. practice special—in your own voice. A new service offered by Clompus Consulting analyzes the strategic Plus Powers for Air Optix Colors advantages of your office and creates a personalized Hyperopic patients interested in color-enhancing contact script for you. Record a message at home or at the office lenses now can consider Air Optix Colors from Alcon, as using headphones provided by the company and the the company has just added plus powers to its monthly service will edit it into a broadcast-quality audio file that replacement SiHy product line. The full power range you can embed on your website. is now +6.00D to -6.00D in quarter-diopter steps and Digital audio services offer a better way to make an -6.50D to -8.00D in half-diopter steps. All nine colors emotional connection with patients on your website, are available at all powers, Alcon says. according to the company. You can also change the Visit www.alcon.com. audio message several times a year to highlight new ser- vices and products. Simplifying Lens Care Visit www.clompusconsulting.com. A new contact lens case can help make the lens cleaning and disinfecting process simpler for patients by color- Diagnostic Equipment coding the storage chambers, accord- New Field Analyzer ing to manufacturer Alcon. The new A new visual field analyzer is designed to improve the case that comes with Clear Care solu- speed and accuracy of perimetry tests, according to man- tion has blue and white lens baskets to ufacturer Zeiss. The Humphrey Field help patients more easily differentiate Analyzer 3 (HFA3) automates trial between left and right lenses before lens correction based on the patient’s and after cleaning. Also, lens baskets refractive data, to reduce setup time. It in the new case now have tabs to also captures images of eye position at enable easier opening. each stimulus point, allowing you to Alcon says Clear Care patients are check for false negatives due to ptosis more compliant with lens care regi- or misalignment. Zeiss also says the mens, and is encouraging doctors to gaze tracker on the HFA3 provides see the product as a “problem preventer” rather than a faster initialization and works on a problem solver and offer it more routinely to patients. wider spectrum of patients compared Visit www.alcon.com. with earlier HFA models, and that the touch screen inter- face for technicians is faster and more intuitive. Dry Eye Care HFA3 test results are equal to and interchangeable Preservative-Free Eye Drops with results from prior generations of the HFA, accord- Patients who experience dry eye symptoms and routinely ing to the manufacturer. need an artificial tear can now use a preservative-free Visit www.meditec.zeiss.com. product in a multi-use bottle. Oasis Tears PF Preservative- Contact Lenses Free lubricant eye drops are Expanded Power Range for Multifocal CLs packaged in a 10mL bottle that Now, more presbyopes who previously could not wear prevents contamination with a contact lenses have a new option to consider. Biotrue specially designed closing tip, OneDay for Presbyopia (nesofilcon A) contact lenses valve and air venting system that are now available in an expanded power range for those prevents microbial entry into the with low-add needs, according to Bausch + Lomb. bottle, according to Oasis Medi- Launched last summer with low-add correction cal. Replacing the usual unit-dose through the powers of +3.00D to -6.00D, the range vials, this system keeps the drops has been expanded to +6.00D to -9.00D (0.25D steps), sterile for up to 90 days after increasing multifocal options for more patients. opening, the company says. ■ REVIEW OF OPTOMETRY APRIL 15, 2015 99 099_ro0415_products.indd 99 4/1/15 3:37 PM Meetings + Conferences April 2015 Optometry Alumni Association. CE Hours: 5. Key Faculty: Mark ■ 17-19. NOA Spring Conference-CE Event. Embassy Suites, Dunbar, Michael Springer. To register, go to www.neco.edu/ Lincoln, NE. Hosted by: Nebraska Optometric Association. To academics/continuing-education/sunday-series, call Margery register, email [email protected]. Warren at (617) 587-5687 or email [email protected]. ■ 17-22. ASCRS-ASOA Symposium and Congress 2015. San ■ 3-5. CE in Italy. Hotel Silla, Florence, Italy. Hosted by: James Diego Convention Center, San Diego, CA. Hosted by: ASCRS/ Fanelli. CE Hours: 12. Key Faculty: James Fanelli, Carlo Pelino. ASOA. To register, go to: http://annualmeeting.ascrs.org. To register, email James Fanelli at [email protected] or ■ 18-19. Miami Nice Educational Symposium 2015. Westin go to www.CEinItaly.com. Colonnade, Coral Gables, FL. Hosted by: Miami-Dade ■ 3-7. ARVO 2015. Colorado Convention Center, Denver. Optometric Physicians Association. CE Hours: 17 COPE- Hosted by: The Association for Research in Vision and approved, 12 transcript quality. Key Faculty: Ken Lebow, John Ophthalmology. To register, go to www.arvo.org/Annual_ McGreal, Carl Spear, Al Morier, John McClane, Albert Woods. Meeting. To register, go to www.miamieyes.org or email Steve Morris at ■ 7-9. CE in Italy. Palazzo Al Valabro, Rome, Italy. Hosted by [email protected]. James Fanelli. CE Hours: 12. Key Faculty: James Fanelli, Carlo ■ 22-26. 13th Annual Educational Conference. Hilton Embassy Pelino, Joseph Pizzimenti. To register, email James Fanelli at Suites at Kingston Plantation, Myrtle Beach, SC. Hosted by: [email protected] or go to www.CEinItaly.com. American Academy of Optometry New Jersey Chapter. CE ■ 15-17. Arizona Optometric Association 2015 Spring Hours: 16. Key Faculty: Mark Friedberg, Alan Kabat. To register, Congress. Hilton Tucson El Conquistador Golf & Tennis Resort, call Dennis Lyons at (732) 920-0110 or email [email protected]. Tucson, AZ. Hosted by: Arizona Optometric Association. To reg- ■ 23-25. Mountain West Council of Optometrists (MWCO) ister, go to: http://arizona.aoa.org. Annual Congress. Bally’s, Las Vegas, NV. Hosted by: Mountain West Council of Optometrists. CE Hours: 24. To June 2015 register, go to www.mwco.org or call (888) 376-6926. ■ 5-7. June “Summer” Conference. Harborside Hotel & Marina, ■ 23-26. 2015 Annual Spring Convention. Marriott Hotel & Little Bar Harbor, ME. Hosted by: Maine Optometric Association. To Rock Convention Center, Little Rock, AR. Hosted by: Arkansas register, call (207) 288-5033 or toll-free (800) 328-5033. Optometric Association. To register, email Vicki Farmer at vicki@ ■ 12-14. 2015 Annual Meeting. Myrtle Beach, SC. Hosted arkansasoptometric.org. by: North Carolina State Optometric Society. To register, email ■ 29-May 7. Annual Educational Conference and Exposition. Adrianne Drollette at [email protected]. Red Lion Colonial Hotel, Helena, MT. Hosted by: Montana ■ 19-21. 2015 VOA Annual Conference. Hilton, McLean, VA. Optometric Association. To register, call (406) 443-1160 or Hosted by: Virginia Optometric Association. To register, call Bo email [email protected]. Keeney at (804) 643-0309. ■ 30-May 1. Spring 2015 Convention. Pierre Ramkota, Pierre, ■ 24-28. Optometry’s Meeting 2015. Washington State SD. Hosted by: South Dakota Optometric Society. To register, Convention Center, Seattle, WA. Hosted by: American email Deb Mortenson at [email protected] or go to Optometric Association and American Optometric Student southdakota.aoa.org. Association. To register, go to http://optometrysmeeting.org. ■ 26-July 5. A Comprehensive Update on Contemporary May 2015 Eye Care. Northern European Capitals Cruise, departs ■ 2-3. 8th Annual Evidence Based Care in Optometry Copenhagen, Denmark. Hosted by: Dr. Travel Seminars/The Conference. Turf Valley Conference Center and Resort, New Jersey Society of Optometric Physicians. Key Faculty: Ellicott City, MD. Hosted by: Maryland Optometric Randall Thomas. CE Hours: 12. To register, email Robert Association & Johns Hopkins-Wilmer Eye Institute. To regis- Pascal at [email protected] or visit DrTravel.com. ter, email Annie Phan at [email protected]. ■ 3. OptoWest Regional Conference. Anaheim Marriott Suites, July 2015 Anaheim, CA. Hosted by: California Optometric Association. ■ 4-11. Tropical CE Puerto Rico. El Conquistador—Waldorf CE Hours: 6. Key Faculty: Steven Ferrucci, Bruce Onofrey, Mary Astoria, Puerto Rico. Hosted by: Tropical CE. Key Faculty: Schmidt. To register, go to www.optowest.com, call Sarah Harbin Jimmy Bartlett, Kim Reed. CE Hours: 20. To register, call at (916) 266-5022 or email [email protected]. Stuart Autry at (281) 808-5763, email [email protected] ■ 3. NECO Sunday Seminar Series CE. New England College or go to www.tropicalce.com. of Optometry, Boston, MA. Hosted by: New England College of ■ 10-12. 21st Conference on Clinical Vision Care. Southern 100 REVIEW OF OPTOMETRY ARPIL 15, 2015 1100_ro0415_m&c.indd00_ro0415_m&c.indd 100100 44/2/15/2/15 1:431:43 PMPM Advertisers Index For advertising opportunities contact: Michele Barrett (215) 519-1414 or [email protected] College of Optometry, Memphis, TN. Hosted by: OEP James Henne (610) 492-1017 or [email protected] Foundation. CE Hours: 17. To register, email Theresa Krejci at [email protected] or go to www.oepf.org. Michael Hoster (610) 492-1028 or [email protected] ■ 16-19. 2015 Victoria Conference. Inn at Laurel Point, Victoria, British Columbia, Canada. Hosted by: Pacific Akorn Consumer Health ...... 17 MediNiche ...... 79 University. Key Faculty: Terry Burris, Danica Marelli, Curtis Phone ...... (800) 579-8327 Phone ...... (888) 325-2395 ...... www.akorn.com ...... [email protected] Baxstrom, Tad Buckingham. CE Hours: 20. To register, email ...... www.mediniche.com Jeanne Oliver at [email protected] or go to www.paci- Alcon Laboratories ...52, 89, 108 ficu.edu. Phone ...... (800) 451-3937 NovaBay ■ 16-19. Florida Optometric Association Annual Fax ...... (817) 551-4352 Pharmaceuticals, Inc...... 10 Convention. The Breakers, Palm Beach, FL. Hosted by: Phone ...... (800) 890-0329 Florida Optometric Association. Key Faculty: William Alden Optical ...... 31 ...... [email protected] Marcolini, Ian Gaddie, Mark Dunbar, Christian Guier, Paul Phone ...... (800) 253-3669 ...... www.avenova.com ...... [email protected] Palmber, April Jasper. CE Hours: 30 Total, 22 per OD. To ...... www.aldenoptical.com Odyssey Medical (now part of register, call Jessica Brewton at (805) 877-4697, email Beaver-Visitec International, [email protected] or go to www.floridaeyes.org. Allergan, Inc...... 9 Inc.) ...... 51 ■ 17-18. OOPA Summer CE Event. The Resort at the Phone ...... (800) 347-4500 Phone ...... (866) 906-8080 Mountain, Welches, OR. Hosted by: Oregon Optometric ...... www.odysseymed.com Physicians Association. Key Faculty: Gordon Johns, Beth Bausch + Lomb ...... 39 Kinoshita, Lorne Yudcovitch, Rebecca Uhlig, Robert Egan, Stan Phone ...... (866) 246-8245 Regeneron Pharmaceuticals, ...... www.bausch.com Inc...... 19, 20 Teplick. CE Hours: 13. To register, email Lynne Olson at lynne@ Phone ...... (914) 847-7000 oregonoptometry.org or go to www.oregonoptometry.org. Bausch + Lomb ...... 7, 33, 34 ...... www.regeneron.com ■ 22-25. Northern Rockies Optometric Conference. Snow ...... 43, 67, 107 King Hotel, Jackson, WY. Host: Northern Rockies Optometric Phone ...... (800) 323-0000 SynergEyes, Inc...... 21 Conference. Key Faculty: Ben Gaddie, Mark Dunbar, Fax ...... (813) 975-7762 Phone ...... (877) 733-2012 Rebecca Wartman. CE Hours: 16. To register, email Kari ...... [email protected] Cline at [email protected], or visit www.nrocmeet- Carl Zeiss Meditec Inc...... 13 ...... www.SynergEyes.com Phone ...... (877) 486-7473 ing.com. Fax ...... (925) 557-4101 The Shield ...... 77 ■ 23-26. New Technologies and Treatments in Vision Phone ...... (212) 243-7300 Care. Wailea Beach Marriott Resort & Spa, Wailea, HI. Host: CooperVision ...... 15, 45 ...... www.shield.org Review of Optometry. Key Faculty: Paul Karpecki, Brad Phone ...... (800) 341-2020 Sutton, Randall Thomas, Ron Melton. CE Hours: 14. To regis- Veatch ...... 65 ter, email Lois DiDomenico at [email protected], Haag-Streit ...... 41 Phone ...... (800) 447-7511 call (866) 658-1772 or visit www.reviewofoptometry.com. Phone ...... (800) 627-6286 Fax ...... (602) 838-4934 Fax ...... (603) 742-7217 ■ 23-26. CE in the Rockies. Rocky Mountain Park Inn, Estes Vision Source ...... 73 Park, CO. Host: University of Houston College of Optometry. Keeler Instruments ...... 5 Phone ...... (281) 312-1111 Key Faculty: Danica Marrelli. CE Hours: 21. To register, email Phone ...... (800) 523-5620 Fax ...... (281) 312-1153 [email protected], call (713) 743-1900 or visit ce.opt.uh.edu/. Fax ...... (610) 353-7814 ...... www.visionsource.com ■ 31-Aug. 2. Southwest Florida Educational Retreat. South Seas Island Resort, Ft. Myers, FL. Host: Southwest Florida Lombart Instruments ...... 75 Vistakon ...... 2-3, 83 Optometric Association. Key Faculty: Jimmy Bartlett, Tammy Phone ...... (800) 446-8092 Phone ...... (800) 874-5278 Fax ...... (757) 855-1232 Fax ...... (904) 443-1252 Than, Ron Foreman. CE Hours: 18. To register, email Brad Middaugh at [email protected] or visit www.swfoa.com. M&S Technologies ...... 27 Phone ...... (877) 225-6101 To list your meeting, please send the details to: Fax ...... (847) 763-9170 Rebecca Hepp, Senior Associate Editor Email: [email protected] This advertiser index is published as a convenience and not as part of the advertising contract. Every care Phone: (610) 492-1005 will be taken to index correctly. No allowance will be made for errors due to spelling, incorrect page number, or failure to insert. 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OD practices • 14 Day Free Demo Trial Become Board Certified by the • Email/Text Communications AMERICAN BOARD www.quikeyes.com OF OPTOMETRY Exam held each January & July PACKAGE DEAL Register at americanboardofoptometry.org East Central Florida, 7KH$PHULFDQ%RDUGRI2SWRPHWU\%RDUG&HUWL¿FDWLRQSURJUDPLVFHUWL¿HGE\WKH 1DWLRQDO&RPPLVVLRQIRU&HUWLI\LQJ$JHQFLHVDQGLWV0DLQWHQDQFHRI&HUWL¿FDWLRQ long established optometric SURFHVVLVDSSURYHGE\WKH&HQWHUVIRU0HGLFDUHDQG0HGLFDLG6HUYLFHV practice located in 100 year old historic building. Practice gross 276k. Building worth about 150k. Will sell both for 189k or practice alone for 79k. I’m retiring and motivated. For more info email [email protected]. OPTOMETRIC PRACTICE FOR SALE PRACTICE SALES NORTHEASTERN PA & APPRAISAL Very Successful ongoing optometric prac- Expert Services for: Practice Sales • Appraisals • Consulting ƟĐĞĨŽƌƐĂůĞŝŶEŽƌƚŚĞĂƐƚĞƌŶW͘dŚĞƉƌĂĐ- www.PracticeConsultants.com Buying or Selling a Practice ƟĐĞŝƐŐƌŽƐƐŝŶŐϲϬϬ<ͬLJƌ͘dŚŝƐƉƌĂĐƟĐĞŝƐ PRACTICES FOR SALE ŽŶĞŽĨĂŬŝŶĚǁŝƚŚĂǀĞƌLJůĂƌŐĞĂŶĚďƌŽĂĚ Practice Appraisal ƉĂƟĞŶƚďĂƐĞĂŶĚůĂƌŐĞĐŽŶƚĂĐƚůĞŶƐďĂƐĞ͘ Practice Financing NATIONWIDE dŚĞ ƉƌĂĐƟĐĞ ƐĞƌǀŝĐĞƐ ŵĂŶLJ ǀŝƐŝŽŶ ĐĂƌĞ Partner Buy-in or Buy-out Visit us on the Web or call us to learn ƉƌŽŐƌĂŵƐƚŚĂƚůĞŶĚƐƚŽŝƚƐƐƵĐĐĞƐƐ͕ĂůŽŶŐ more about our company and the ǁŝƚŚ Ă ĨƵůů ĐŽŵƉůĞŵĞŶƚ ŽĨ ĚŝƌĞĐƚ ƉĂLJŝŶŐ Call for a Free Consultation practices we have available. (800) 416-2055 ƉĂƟĞŶƚƐ͘/ǁŝůůďĞǁŝůůŝŶŐƚŽǁŽƌŬŝŶƚŚĞ [email protected] ƉƌĂĐƟĐĞ͘ www.TransitionConsultants.com Serious replies only. 800-576-6935 Email: [email protected] ó®ã«ÊÃÖ½ãÄÃÄÊÄãã®Ä¥Ê www.PracticeConsultants.com 104 REVIEW OF OPTOMETRY APRIL 15, 2015 ROPT0415.indd 104 3/25/15 7:34 AM Review Classifi eds Continuing Education EYE-SIGHT 20/20, Inc. Presents Spring 2015 Saturday/Sunday, June 6-7, 2015 16 hours of Advanced COPE Approved CE for Optometrists Our Respected Presenters: JEROME SHERMAN, OD, FAAO SHERRY BASS, OD, FAAO JIMMY BARTLETT, OD, FAAO ANTHONY LITWAK, OD, FAAO Join US. "Where Doctors Gather to Share Knowledge & Experience" FOXWOODS CASINO- Ledyard, CT Contact: Dr. Antoinette D. Parvis 508-987-9679 or visit the website for all details: www.eyesightce.com Upcoming Events All 8 hours in Natick, Mass April 19th Sept 27th Oct 18th and Nov 15th Career Opportunities OCULAR SYMPOSIUM STAFF OPTOMETRIST Lectures in Ocular Diagnosis and Treatment Bard Optical is a leading Midwest vision care organization in business for over 70 years and Formal Lectures for Optometrists we are still growing. The company is based in by Noted Subspecialists in Ophthalmology Peoria, IL with 20 retail offices throughout the central Illinois area, as far north as Sterling and as far south as Jacksonville. Once again Friday, Saturday, Sunday, June 5-7, 2015 this year we were named to the Top 50 Optical 24 hours CE credits (8 hours each day) Retailers in the United States by Vision Monday – currently ranking 37th. A progres- SAN FRANCISCO, CALIFORNIA sive optometric staff is vital to the continued growth of our organization whose foundation TOPICS TO INCLUDE is based on one-on-one patient service. We are currently accepting CV/resumes for Refractive Surgery Glaucoma Cataract Surgery optometrists focused on full scope primary Oculoplastics Ocular Trauma Ocular Oncology medical patient care. The candidate must have Neuro-Ophthalmology Retina, OCT Ocular Pediatrics an Illinois license with therapeutics. The prac- tice includes (but is not limited to) general For information call or write: optometry, contact lenses, and geriatric care. Salaried, full-time positions are available with 0DVMBS4ZNQPTJVNt10#PYt4BO'SBODJTDPt$"t excellent growth programs and benefits. t'"9 Some part-time opportunities may be avail- FNBJMPDVMBSTZNQ!BPMDPN able also. Please email your information to [email protected] or fax to 309-693-9754. Mailing address if more convenient is Bard Optical, Attn: HR, 8309 N Knoxville Avenue, Peoria, IL 61615. Ask about opportunities within Bard Optical. We have openings in several existing and new offices opening soon in central Illinois. Do you have Equipment Bard Optical is a proud and Supplies for Sale? Associate Member of the Illinois Optometric Association. Contact us today for classified advertising: www.bardoptical.com Toll free: 888-498-1460 • E-mail: [email protected] REVIEW OF OPTOMETRY APRIL 15, 2015 105 ROPT0415.indd 105 3/25/15 7:34 AM Diagnostic Quiz Head First Into the Exam Room By Andrew S. Gurwood, OD History A 33-year-old white female pre- sented with a chief complaint of blurry vision in both eyes, more so in the left than the right, for the previous three months. She was able to pinpoint that the constant blur developed just after she was in an auto accident. She reported hitting the left side of her head on the back of the passenger seat, in a slow moving vehicle accident while not wearing a seat belt. Her previ- ous ocular and systemic histories Slit lamp images of a 33-year-old white female who presented with a chief complaint were unremarkable and she denied of blurry vision in both eyes, but more so in the left eye. any known allergies to medications or other substances. Hg in the right eye and 18mm Hg formed, with improved visual acu- in the left eye using Goldmann ity measuring 20/25. Diagnostic Data applanation tonometry. Dilated Her best corrected entering Snel- fundus examination revealed Your Diagnosis len visual acuity was 20/20 in the no significant posterior pole or What is your diagnosis and pre- right eye and 20/30 in the left eye peripheral retinal findings. The sumed cause of the condition? at distance and near. Refraction nerves were distinct, with cup-to- How would you approach this revealed hyperopia of +0.75D in disc ratios of 0.3/0.35 in both eyes. case? What is the likely prognosis? the right eye and +1.50D in the left An optical coherence tomog- To find out, please visit Review eye, with no improvement in vision raphy scan was performed and of Optometry online at www. for either eye. The pertinent biomi- revealed no sign of macular edema, reviewofoptometry.com. Click on croscopic findings are illustrated in hole, sustained vitreomacular trac- the cover icon for this month’s the photographs. Her intraocular tion or retinal detachment in either issue and select “Diagnostic Quiz” pressure was measured as 15mm eye. Laser interferometry was per- from the table of contents. ■ Retina Quiz Answers (from page 88): 1) c; 2) b; 3) c; 4) d. Next Month in the Mag • Rx Dry Eye Drugs in the Pipeline May is Review of Optometry’s annual dry eye report • Slit Lamp Essentials: Meibomian Gland Expression Topics include: • Plus —Women’s Eye Health: Gender Distinctions and Treatment • Subjective vs. Objective Mismatch in Dry Eye: What To Do? Decisions (earn 2 CE credits) REVIEW OF OPTOMETRY (ISSN 0147-7633) IS PUBLISHED MONTHLY, 12 TIMES A YEAR BY JOBSON MEDICAL INFORMATION LLC, 100 AVENUE OF THE AMERICAS, NEW YORK, NY 10013-1678. PERIODICALS POSTAGE PAID AT NEW YORK, NY AND ADDITIONAL MAILING OFFICES. POSTMASTER: SEND ADDRESS CHANGES TO REVIEW OF OPTOMETRY, PO BOX 81, CONGERS, NY 10920-0081. SUBSCRIPTION PRICES: US: ONE YEAR $56; TWO YEARS $97, CANADA: ONE YEAR $88, TWO YEARS $160, INT’L: ONE YEAR $209, TWO YEARS $299. FOR SUBSCRIPTION INFORMATION CALL TOLL-FREE (877) 529-1746 (USA); OUTSIDE USA, CALL (845) 267-3065. OR EMAIL US AT [email protected]. PUBLICATIONS MAIL AGREEMENT NO: 40612608. CANADA RETURNS TO BE SENT TO BLEUCHIP INTERNATIONAL, P.O. BOX 25542, LONDON, ON N6C 6B2. 106 REVIEW OF OPTOMETRY APRIL 15, 2015 106_0415_dq.indd 106 4/1/15 3:38 PM Best-in-class properties for best-in-class performance1 Bausch + Lomb ULTRA® contact lenses with MoistureSeal® technology combine best-in-class physical properties for a revolutionary silicone hydrogel lens.1 Dk/t MODULUS ASPHERIC THIN EDGE OPTICS DESIGN Patient preferred for end-of-day Bausch + Lomb ULTRA® contact lenses 163 70 comfort over the leading silicone hydrogel lenses2 2 to 1 ACUVUE OASYS 147 73 vs. ACUVUE OASYS 3 to 1 AIR OPTIX AQUA 138 102 vs. AIR OPTIX AQUA 4 to 1 Biofi nity 160 82 vs. Biofi nity Retains moisture for a full 16 hours.1 Go to www.blultra.com or contact a Bausch + Lomb sales representative today REFERENCES: 1. Data on fi le. Bausch & Lomb Incorporated. Rochester NY; 2013. 2. Results from a 22-investigator, multi-site study of Bausch + Lomb Ultra contact lenses with MoistureSeal technology, on 327 current silicone hydrogel lens wearers. After 7 days of wear, subjects completed an online survey. Subjects rated performance across a range of attributes. Preference comparisons represent only those subjects expressing a preference. Ratio is based on the average across the silicone hydrogel lenses represented in the study. ®/™ are trademarks of Bausch & Lomb Incorporated or its affi liates. All other product/brand names are trademarks of their respective owners. ©2014 Bausch & Lomb Incorporated. US/ZUS/14/0149 RO0315_BL Ultra.indd 1 2/19/15 3:46 PM NOW APPROVED ANTICIPATED RETAIL AVAILABILITY MARCH 10 From Alcon, committed to providing new treatment options for patients. Olopatadine is licensed from Kyowa Hakko Kirin Co., Ltd. Japan ©2015 Novartis 01/15 PAZ15017JAD RP0315_Alcon Pazeo.indd 1 2/17/15 2:23 PM