Glaucoma Report

Optometry’s Role in the Diabetes Epidemic, p. 32

July 15, 2020 www.reviewofoptometry.com

26th Annual Glaucoma Report

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WITH NEARLY 100% WATER at the outermost surface, all that touches the eye is WAYSa cushion of moisture.1-3 Give your GLAUCOMApatients a contact lens that feels like nothing CARE. IS CHANGING For more information7 about theBetter lens drugs,that safer surgeries, smarter diagnostics and new approaches feels like nothing, visit DAILIESTOTAL1.com. are easing the burden on patients—and their ODs, p. 54

References:Glaucoma: 1. Angelini TE, NixonThe RM, Perils Dunn AC,of etProgression al. Viscoelasticity and, p. mesh-size38 • EARN at the surface2 CE CREDITS of hydrogels — characterizedA Practical with microrheology. Approach Invest to Ophthalmol Angle-closure Vis Sci. , p. 60 2013;54:E-abstract 500. 2. Thekveli S, Qui Y, Kapoor Y, et al. Structure-property relationship of dele lcon A lenses. Cont Lens Anterior Eye. 2012;35(suppl 1):e14. 3. Based on laboratory measurement of unworn lenses; Alcon data on le, 2011. ALSO: FindingALSO: Systemic Satisfying Diseases the in the Complicated Anterior Segment, PresbyopeP. 78 • New, p. 24series— • What’sTake Charge Your of DiscGlaucoma, Diagnosis?P. 88 , p. 46 See product instructions for complete wear, care and safety information. © 2019 Alcon Inc. 09/19 US-DT1-1900022

Optometry’s Role in the Diabetes Epidemic, p. 32

July 15, 2020 www.reviewofoptometry.com

26th Annual Glaucoma Report

WAYS GLAUCOMA CARE IS CHANGING 7Better drugs, safer surgeries, smarter diagnostics and new approaches are easing the burden on patients—and their ODs, p. 54

Glaucoma: The Perils of Progression, p. 38 • EARN 2 CE CREDITS — A Practical Approach to Angle-closure, p. 60

ALSO: FindingALSO: Systemic Satisfying Diseases the in the Complicated Anterior Segment, PresbyopeP. 78 • New, p. 24series— • What’sTake Charge Your of DiscGlaucoma, Diagnosis?P. 88 , p. 46 SHE MAY NEED MORE THAN ARTIFICIAL TEARS TO DISRUPT INFLAMMATION IN DRY EYE DISEASE1,2

Her eyes deserve a change.

Choose twice-daily Xiidra for lasting relief that can start as early as 2 weeks.3*†

*In some patients with continued daily use. One drop in each eye, twice daily (approximately 12 hours apart). † X iidra is an LFA-1 antagonist for the treatment of dry eye disease. Pivotal trial data: The safety and efficacy of Xiidra were assessed in four 12-week, randomized, multicenter, double-masked, vehicle-controlled studies (N=2133). Patients were dosed twice daily. Use of artificial tears was not allowed during the studies. The study endpoints included assessment of signs (based on Inferior fluorescein Corneal Staining Score [ICSS] on a scale of 0 to 4) and symptoms (based on patient-reported Eye Dryness Score [EDS] on a visual analogue scale of 0 to 100).3 A larger reduction in EDS favoring Xiidra was observed in all studies at day 42 and day 84. Xiidra reduced symptoms of eye dryness at 2 weeks (based on EDS) compared to vehicle in 2 out of 4 clinical trials. Effects on signs of dry eye disease ICSS (on a scale from 0-4; 0=no staining; 4=coalescent) was recorded at each study visit. At day 84, a larger reduction in inferior corneal staining favoring Xiidra was observed in 3 of the 4 studies.3

Indication Xiidra® (lifitegrast ophthalmic solution) 5% is indicated for the treatment of signs and symptoms of dry eye disease (DED). Important Safety Information • X iidra is contraindicated in patients with known hypersensitivity to lifitegrast or to any of the other ingredients. • In clinical trials, the most common adverse reactions reported in 5-25% of patients were instillation site irritation, dysgeusia and reduced visual acuity. Other adverse reactions reported in 1% to 5% of the patients were blurred vision, conjunctival hyperemia, eye irritation, headache, increased lacrimation, eye discharge, eye discomfort, eye pruritus and sinusitis. • To avoid the potential for eye injury or contamination of the solution, patients should not touch the tip of the single-use container to their eye or to any surface. • Contact lenses should be removed prior to the administration of Xiidra and may be reinserted 15 minutes following administration. • Safety and efficacy in pediatric patients below the age of 17 years have not been established.

Please see Brief Summary of Prescribing Information on adjacent page.

References: 1. U.S. Food and Drug Administration. Code of Federal Regulations, Title 21, Volume 5 (21CFR349). https://www.accessdata.fda.gov/ scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?CFRPart=349&showFR=1. Accessed April 17, 2020. 2. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017;15(3):575-628. 3. Xiidra [prescribing information]. East Hanover, NJ: Novartis Pharmaceuticals Corp; November 2019.

Novartis Pharmaceuticals Corporation One Health Plaza East Hanover, New Jersey 07936-1080 © 2020 Novartis 5/20 XIA-1388813 XIIDRA® (lifitegrast ophthalmic solution), for topical ophthalmic use teratogenicity at clinically rele vant systemic exposures. Intravenous Initial U.S. Approval: 2016 administration of lifitegrast to pregnant rabbits during organogenesis pro- BRIEF SUMMARY: Please see package insert for full prescribing information. duced an increased incidence of omphalocele at the lowest dose tested, 3 mg/kg/day (400-fold the human plasma exposure at the recommended 1 INDICATIONS AND USAGE human ophthalmic dose [RHOD], based on the area under the curve ® Xiidra (lifitegrast ophthalmic solution) 5% is indicated for the treatment [AUC] level). Since human systemic exposure to lifitegrast following ocu- of the signs and symptoms of dry eye disease (DED). lar administration of Xiidra at the RHOD is low, the applicability of animal 4 CONTRAINDICATIONS findings to the risk of Xiidra use in humans during pregnancy is unclear Xiidra is contraindicated in patients with known hypersensitivity to [see Clinical Pharmacology (12.3) in the full prescribing information]. lifitegrast or to any of the other ingredients in the formulation [see Data Adverse Reactions (6.2)]. Animal Data 6 ADVERSE REACTIONS Lifitegrast administered daily by IV injection to rats, from pre-mating The following serious adverse reactions are described elsewhere in the through gestation Day 17, caused an increase in mean pre-implantation labeling: loss and an increased incidence of several minor skeletal anomalies at • Hypersensitivity [see Contraindications (4)] 30 mg/kg/day, representing five, 400-fold the human plasma exposure at the RHOD of Xiidra, based on AUC. No teratogenicity was observed in the 6.1 Clinical Trials Experience rat at 10 mg/kg/day (460-fold the human plasma exposure at the RHOD, Because clinical trials are conducted under widely varying conditions, based on AUC). In the rabbit, an increased incidence of omphalocele was adverse reaction rates observed in clinical trials of a drug cannot be observed at the lowest dose tested, 3 mg/kg/day (400-fold the human directly compared to rates in the clinical trials of another drug and may plasma exposure at the RHOD, based on AUC), when administered by not reflect the rates observed in practice. IV injection daily from gestation Days 7 through 19. A fetal no observed In five clinical studies of DED conducted with lifitegrast ophthalmic solu- adverse effect level (NOAEL) was not identified in the rabbit. tion, 1401 patients received at least one dose of lifitegrast (1287 of which 8.2 Lactation received lifitegrast 5%). The majority of patients (84%) had ≤ 3 months Risk Summary of treatment exposure. One hundred-seventy patients were exposed to There are no data on the presence of lifitegrast in human milk, the effects lifitegrast for approximately 12 months. The majority of the treated patients on the breastfed infant, or the effects on milk production. However, sys- were female (77%). The most common adverse reactions reported in temic exposure to lifitegrast from ocular administration is low [see Clinical 5%-25% of patients were instillation-site irritation, dysgeusia, and reduced Pharmacology (12.3) in the full prescribing information]. The develop- visual acuity. mental and health benefits of breastfeeding should be considered, along Other adverse reactions reported in 1%-5% of the patients were blurred with the mother’s clinical need for Xiidra and any potential adverse effects vision, conjunctival hyperemia, eye irritation, headache, increased lacri- on the breastfed child from Xiidra. mation, eye discharge, eye discomfort, eye pruritus, and sinusitis. 8.4 Pediatric Use 6.2 Postmarketing Experience Safety and efficacy in pediatric patients below the age of 17 years have The following adverse reactions have been identified during post-approval not been established. use of Xiidra. Because these reactions are reported voluntarily from a pop- 8.5 Geriatric Use ulation of uncertain size, it is not always possible to reliably estimate their No overall differences in safety or effectiveness have been observed frequency or establish a causal relationship to drug exposure. between elderly and younger adult patients. Rare cases of hypersensitivity, including anaphylactic reaction, broncho- spasm, respiratory distress, pharyngeal edema, swollen tongue, and urti- caria have been reported. Eye swelling and rash have been reported [see Manufactured for: Contraindications (4)]. Novartis Pharmaceuticals Corporation One Health Plaza 8 USE IN SPECIFIC POPULATIONS East Hanover, NJ 07936 8.1 Pregnancy Risk Summary T2019-110 There are no available data on Xiidra use in pregnant women to inform any drug-associated risks. Intravenous (IV) administration of lifitegrast to pregnant rats, from pre-mating through gestation Day 17, did not produce News Review

VOL. 157 NO. 7 n JULY 15, 2020

IN THE NEWS Severe Sleep Apnea Leads Researchers recently reported that increased exercise intensity is associated with decreased glaucoma to Corneal Changes risk. A team assessed objective exercise Intraocular procedures should be done with intensity based on measurements from accelerometers worn by 1,387 adults caution in these individuals. over one week. With Rotterdam criteria, participants who spent the day standing By Jane Cole, Contributing Editor or walking vs. sitting had 58% decreased odds of glaucoma, while each 10-min- atients with severe obstruc- hexagonal cell appearance was ute increase in moderate-to-vigorous tive sleep apnea-hypopnea significantly lower in the OSAHS activity per day was associated with 38% Psyndrome (OSAHS) may have group. Additionally, the investiga- decreased odds of glaucoma with disc distinct differences in their endothe- tors observed a significant negative image grading. lia compared with healthy subjects, correlation between central corneal Tseng VL, Yu F, Coleman AL. Association between exercise a team of researchers from Greece thickness and REM sleep. intensity and glaucoma in the National Health and Nutrition Examination Survey. Ophthalmology. June 7, 2020. [Epub suggests. Their study, published in “Our study highlighted the ahead of print]. Cornea, also found the low level of corneal endothelial alterations in REM sleep typically seen in these patients with severe obstructive Researchers in Australia found no cor- patients may contribute to an in- sleep apnea-hypopnea syndrome,” relation between quantitative values crease in corneal thickness. says researcher Evangelia Chalkia- of vitamin A intake and refractive error. Specifically, the study found daki, MD. “This is the first time Their data suggests increased vitamin A intake in childhood does little to greater pleomorphism and poly- that increased pleomorphism and stave off myopia in young adulthood. megethism in the corneal endothelia polymegethism of the central cor- Although they noted that those with of patients with severe OSAHS neal endothelium were observed in adequate vitamin intake were less likely compared with normal eyes. apnea patients, probably as a result to have myopia, that association became The comparative case series of chronic, intermittent hypoxia. insignificant after adjusting for cofound- examined a total of 190 eyes, which Apnea patients with a lower per- ers such as ocular sun exposure level, included 102 eyes of patients with centage of REM sleep had increased educational level and parental myopia. severe OSAHS and 88 eyes in the corneal thickness—an indicator of Ng FJ, Mackey DA, O’Sullivan TA, et al. Is dietary vitamin A control group. poor corneal oxygenation.” associated with myopia from adolescence to young adulthood? Trans Vis Sci Technol. 2020;9(6):29. After a detailed eye exam, the The study suggests clinicians researchers performed specular should be careful when dealing Researchers recently discovered that microscopy in all participants and with the eyes of patients with severe glaucoma patients with optic disc compared corneal parameters OSAHS, especially with intraocular hemorrhage (ODH) experience faster between the groups. They also as- procedures such as cataract surgery. visual field progression than those sessed the influence of the poly- Future controlled studies with without. Over an average of 64 months, somnographic findings on corneal larger sample sizes are needed to they found eyes with ODH in two different endothelial cell shape and central confirm the relationship between disc sectors showed worse progression corneal thickness. REM sleep and corneal thickness rates than eyes with either ODH in one The researchers noted the central and to determine their clinical sig- sector or no hemorrhages at all. Sectors endothelial cell density and central nificance, the researchers suggest. with one hemorrhage experienced a faster visual field progression rate than corneal thickness were not significantly different between the groups. Chalkiadaki E, Andreanos K, Florou C, et al. Corneal endo- those with none. thelial morphology and thickness alterations in patients with However, the variation of cell area severe obstructive sleep apnea–hypopnea syndrome. Cornea. An D, House P, Barry C, et al. Recurrent optic disc hemor- June 10, 2020. [Epub ahead of print]. rhage and its association with visual field deterioration in was significantly higher and the glaucoma. Ophthalmol Glaucoma. June 9, 2020. [Epub ahead of print]. NEWS STORIES POST EVERY WEEKDAY MORNING AT www.reviewofoptometry.com/news

4 REVIEW OF OPTOMETRY JULY 15, 2020 FTC Finalizes Hot Button CL Rule Prescribers must document and confirm patients received their prescriptions.

ollowing four years of re- An Extra Burden retain a record of the patient’s view and thousands of public While the update was expected, as consent for three years. The Final Fcomments, the Federal Trade it’s been in the works since 2015, Rule will also require prescribers Commission (FTC) recently voted to the timing of the decision in light to give patients or their designated amend the Contact Lens Rule—re- of COVID-19 is disappointing, agents an additional copy of their ferred to as the Final Rule—which says optometrist Brian Chou of San prescriptions on request within 40 “facilitates shopping for contact Diego. business hours. lenses by requiring prescribers to Currently, most optometrists are The Final Rule will put an ad- automatically provide a copy of a navigating a dramatically differ- ditional administrative burden patient’s prescription to the patient ent practice landscape due to the on optometric practices’ staff and and to verify or provide prescrip- pandemic, including increased software, Dr. Chou says. tions to third-party sellers.” administrative burdens with PPP “This adds insult to injury during Prescribers will also need to loan accounting, greater costs for a time when optometric practices request patients’ confirmation that PPE and cleaning, re-staffing issues, are recovering from closure and they received their Rx, but the Final additional time spent on safety having to do more work than Rule provides some flexibility in the measures and slowing schedules ever,” he notes. “The ideal scenario way the prescription and confirma- to enhance physical distancing, he is for the FTC to provision ad- tion are provided, the FTC claims. says. equate time for the various opto- From 2015 to 2019, the FTC “It would’ve been nice if the FTC metric electronic medical records hammered out the Final Rule by displayed greater awareness of the (EMRs) to catch up in development considering public input, surveys, COVID-19 fallout on optomet- and release software builds that studies, analyses and other informa- ric practices by giving more lead seamlessly document conveyance tion about the evolving contact lens time for implementation of these of contact lens prescriptions to pa- marketplace. updates. The FTC definitely lost tients. That way, staff don’t need to Under the Final Rule, prescribers points with me by their insensitive obtain patient signatures and scan will be required to do one of the fol- timing,” Dr. Chou says. them into document management.” lowing actions to confirm a patient Unfortunately, EMR develop- received their prescription following Bring on the Red Tape ment takes time, likely up to 12 a contact lens fitting: Adding another hurdle for prescrib- months, he adds. “I would recom- • Ask the patient to acknowledge ers, they now must maintain proof mend optometrists let their EMR the receipt of the contact lens they satisfied the confirmation of companies know loud and clear prescription by signing a separate the Rx release requirement for at that they need this enhanced func- confirmation statement. least three years. If a patient refuses tionality ASAP to help reduce the • Ask the patient to sign a prescrib- to sign a confirmation, prescribers additional administrative burden of er-retained copy of the prescrip- must note this and save the record the Rule’s update,” he says. tion that contains a statement to prove they are in compliance. Still, the FTC ruling has a bright confirming the patient received it. The Final Rule adds a new defini- side, Dr. Chou adds, since he • Request the patient sign a tion of the term “provide to the pa- believes it may force optometry to prescriber-retained copy of the re- tient a copy,” which will now allow reduce its reliance on product sales ceipt for the exam that contains a the prescriber—with the patient’s and shift the profession further statement confirming the patient verifiable consent—to provide a toward service. Patients may end received the prescription. digital copy of the prescription in up paying less for their disposable • Give the patient a digital copy of lieu of a paper one. lenses but more for their service the prescription and retain evi- When seeking a patient’s consent, fees in part to subsidize meeting dence it was sent and received or doctors will need to tell the patient the update’s administrative require- made accessible, downloadable the specific method of electronic ments, he suggests. and printable. delivery they will use and also (Continued on p. 6)

REVIEW OF OPTOMETRY JULY 15, 2020 5 News Review For more, visit www.reviewofoptometry.com/news

ROCK Inhibitor Improves Fuchs’ Outcomes n ARVO abstract suggests keratoplasty and from normal donor control specimens and were that treatment with the rho- corneas unsuitable for transplanta- maintained for up to 72 hours of Akinase (ROCK) inhibitor ri- tion. The team analyzed gene and incubation. They observed discrete pasudil may suppress the expression protein expression with and without changes in the expression levels of of genes responsible for abnormal a dose of 30µM ripasudil. a number of components of the extracellular matrix deposition and They found the ROCK inhibitor signaling pathways upon treatment. guttae formation in Fuchs’ endo- caused significant downregulation The study authors conclude that thelial corneal dystrophy (FECD). of FECD-specific genes—both at the this approach could serve as a novel Researchers took endothelial cell– mRNA and protein level—compared anti-fibrotic treatment in patients Descemet’s membrane (EDM) com- with untreated controls. Suppressive with early-stage FECD.

plexes from FECD patients during effects were more pronounced in Kruse FE, Zenkel M, Tourtas T, et al. Inhibition of the rho-ROCK pathway modulates abnormal matrix production in Fuchs’ corneal endothelial Descemet’s membrane endothelial FECD specimens than in normal dystrophy. ARVO 2020. Abstract #1182. ODs respond to Updated FTC Rule (Continued from p. 5) medically-indicated lenses,” Dr. destructive plan, and they’re wrong New Rules for Sellers Chou says. today in seeking to implement it. The Final Rule includes several new The danger is that patients in med- More than 100 US Senators and requirements for sellers as well. To ically indicated contact lenses for House members—Republicans and address concerns about such services issues such as keratoconus, corneal Democrats—have joined with the verifying Rxs by leaving incomplete transplantation and graft-vs.-host AOA since 2016 to fight back, and or incomprehensible automated disease will mistakenly believe they we will do what it takes to increase telephone messages with prescrib- can purchase their custom lenses this support going forward. This is ers, sellers who use those services for through any online retailer and their a completely misguided attack on verification must do the following: doctor can readily perform lens ex- law-abiding, frontline optometry • Record the entire call, and pre- changes in this manner, he adds. practices that is coming at a time serve the complete recording. “Not the case,” Dr. Chou says. when we’ve been providing essential, • Start the call by identifying it as a “Whether intended or not, the FTC primary care through every stage prescription verification request is externalizing onto eye doctor of- of the COVID-19 public health made in accordance with the fices the burden of explaining to pa- emergency.” Contact Lens Rule. tients that custom lenses cannot be Instead of responding to the • Deliver the verification message filled through just any contact lens pandemic by supporting small health in a slow and deliberate manner company.” In effect, he explains, the care practices serving their commu- and at a volume that the prescrib- doctor’s office becomes the bearer of nities and heeding the Federal direc- er can understand. bad news, “whereas the FTC could tives to ease regulatory burdens, this • Make the message repeatable at instead be taking the leadership of government agency has chosen to the prescriber’s option. preemptively educating consumers attack doctors and penalize patients that medically-indicated lens designs with a destructive new record-keep- Specialty Lens Changes can only be successfully prescribed ing requirement, the AOA noted. “Since my practice is skewed toward when the doctor works directly with The Rule changes go into effect 60 managing keratoconus and eye the contact lens laboratory.” days after publication in the Federal disease with specialty lenses, I am Register notice. The Contact Lens disappointed that the FTC has not The AOA Reacts Rule has been in place since 2004. n yet educated consumers that their In a statement, incoming AOA presi- intent with this update is to improve dent William T. Reynolds, OD, says, FTC Announces Final Amendments to the Agency’s Contact Lens Rule. www.ftc.gov/news-events/press-releas- competition in the soft disposable “The FTC was wrong four years es/2020/06/ftc-announces-final-amendments-agencys- contact lens space, not custom ago when they first proposed this contact-lens-rule. Federal Trade Commission. June 23, 2020.

6 REVIEW OF OPTOMETRY JULY 15, 2020 BRIEF SUMMARY OF PRESCRIBING INFORMATION and malrotation, abdominal distension and edema. Latanoprostene bunod was not teratogenic in the rat when administered IV at 150 mcg/kg/day (87 times the clinical dose) [see Data]. This Brief Summary does not include all the information needed to use VYZULTA safely and effectively. See full Prescribing Information for VYZULTA. The background risk of major birth defects and miscarriage for the indicated population is unknown. However, the background risk in the U.S. general population of major birth defects ® VYZULTA (latanoprostene bunod ophthalmic solution), 0.024%, for topical is 2 to 4%, and of miscarriage is 15 to 20%, of clinically recognized pregnancies. ophthalmic use. Data Initial U.S. Approval: 2017 Animal Data 1 INDICATIONS AND USAGE ® Embryofetal studies were conducted in pregnant rabbits administered latanoprostene bunod daily VYZULTA (latanoprostene bunod ophthalmic solution) 0.024% is indicated for the reduction by intravenous injection on gestation days 7 through 19, to target the period of organogenesis. The of intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension. doses administered ranged from 0.24 to 80 mcg/kg/day. Abortion occurred at doses ≥ 0.24 mcg/kg/day 4 CONTRAINDICATIONS latanoprostene bunod (0.28 times the clinical dose, on a body surface area basis, assuming None 100% absorption). Embryofetal lethality (resorption) was increased in latanoprostene bunod treatment groups, as evidenced by increases in early resorptions at doses ≥ 0.24 mcg/kg/day 5 WARNINGS AND PRECAUTIONS and late resorptions at doses ≥ 6 mcg/kg/day (approximately 7 times the clinical dose). 5.1 Pigmentation No fetuses survived in any rabbit pregnancy at doses of 20 mcg/kg/day (23 times the clinical dose) VYZULTA® (latanoprostene bunod ophthalmic solution), 0.024% may cause changes to or greater. Latanoprostene bunod produced structural abnormalities at doses ≥ 0.24 mcg/kg/day pigmented tissues. The most frequently reported changes with prostaglandin analogs (0.28 times the clinical dose). Malformations included anomalies of sternum, coarctation have been increased pigmentation of the iris and periorbital tissue (eyelid). of the aorta with pulmonary trunk dilation, retroesophageal subclavian artery with absent brachiocephalic artery, domed head, forepaw hyperextension and hindlimb malrotation, Pigmentation is expected to increase as long as latanoprostene bunod ophthalmic solution abdominal distention/edema, and missing/fused caudal vertebrae. is administered. The pigmentation change is due to increased melanin content in the melanocytes rather than to an increase in the number of melanocytes. After discontinuation An embryofetal study was conducted in pregnant rats administered latanoprostene bunod daily of VYZULTA, pigmentation of the iris is likely to be permanent, while pigmentation of the by intravenous injection on gestation days 7 through 17, to target the period of organogenesis. periorbital tissue and eyelash changes are likely to be reversible in most patients. Patients The doses administered ranged from 150 to 1500 mcg/kg/day. Maternal toxicity was produced who receive prostaglandin analogs, including VYZULTA, should be informed of the possibility at 1500 mcg/kg/day (870 times the clinical dose, on a body surface area basis, assuming 100% of increased pigmentation, including permanent changes. The long-term effects of increased absorption), as evidenced by reduced maternal weight gain. Embryofetal lethality (resorption pigmentation are not known. and fetal death) and structural anomalies were produced at doses ≥ 300 mcg/kg/day (174 times the clinical dose). Malformations included anomalies of the sternum, domed head, forepaw Iris color change may not be noticeable for several months to years. Typically, the brown pigmentation hyperextension and hindlimb malrotation, vertebral anomalies and delayed ossication of distal around the pupil spreads concentrically towards the periphery of the iris and the entire iris or parts of limb bones. A no observed adverse effect level (NOAEL) was established at 150 mcg/kg/day the iris become more brownish. Neither nevi nor freckles of the iris appear to be affected by treatment. (87 times the clinical dose) in this study. While treatment with VYZULTA® (latanoprostene bunod ophthalmic solution), 0.024% can be continued in patients who develop noticeably increased iris pigmentation, these patients should be examined 8.2 Lactation regularly [see Patient Counseling Information (17) in full Prescribing Information]. Risk Summary 5.2 Eyelash Changes There are no data on the presence of VYZULTA in human milk, the effects on the breastfed VYZULTA may gradually change eyelashes and vellus hair in the treated eye. These changes infant, or the effects on milk production. The developmental and health benets of breastfeeding include increased length, thickness, and the number of lashes or hairs. Eyelash changes are should be considered, along with the mother’s clinical need for VYZULTA, and any potential usually reversible upon discontinuation of treatment. adverse effects on the breastfed infant from VYZULTA. 5.3 Intraocular In ammation 8.4 Pediatric Use VYZULTA should be used with caution in patients with a history of intraocular in ammation Use in pediatric patients aged 16 years and younger is not recommended because of potential (iritis/uveitis) and should generally not be used in patients with active intraocular in ammation safety concerns related to increased pigmentation following long-term chronic use. as it may exacerbate this condition. 8.5 Geriatric Use 5.4 Macular Edema No overall clinical differences in safety or effectiveness have been observed between elderly Macular edema, including cystoid macular edema, has been reported during treatment and other adult patients. with prostaglandin analogs. VYZULTA should be used with caution in aphakic patients, in 13 NONCLINICAL TOXICOLOGY pseudophakic patients with a torn posterior lens capsule, or in patients with known risk 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility factors for macular edema. Latanoprostene bunod was not mutagenic in bacteria and did not induce micronuclei formation 5.5 Bacterial Keratitis in the in vivo rat bone marrow micronucleus assay. Chromosomal aberrations were observed There have been reports of bacterial keratitis associated with the use of multiple-dose in vitro with human lymphocytes in the absence of metabolic activation. containers of topical ophthalmic products. These containers had been inadvertently Latanoprostene bunod has not been tested for carcinogenic activity in long-term animal studies. contaminated by patients who, in most cases, had a concurrent corneal disease or a Latanoprost acid is a main metabolite of latanoprostene bunod. Exposure of rats and mice to disruption of the ocular epithelial surface. latanoprost acid, resulting from oral dosing with latanoprost in lifetime rodent bioassays, was 5.6 Use with Contact Lens not carcinogenic. Contact lenses should be removed prior to the administration of VYZULTA because this product Fertility studies have not been conducted with latanoprostene bunod. The potential to impact contains benzalkonium chloride. Lenses may be reinserted 15 minutes after administration. fertility can be partially characterized by exposure to latanoprost acid, a common metabolite of 6 ADVERSE REACTIONS both latanoprostene bunod and latanoprost. Latanoprost acid has not been found to have any effect on male or female fertility in animal studies. The following adverse reactions are described in the Warnings and Precautions section: pigmentation (5.1), eyelash changes (5.2), intraocular in ammation (5.3), macular edema (5.4), 13.2 Animal Toxicology and/or Pharmacology bacterial keratitis (5.5), use with contact lens (5.6). A 9-month toxicology study administered topical ocular doses of latanoprostene bunod to one 6.1 Clinical Trials Experience eye of cynomolgus monkeys: control (vehicle only), one drop of 0.024% bid, one drop of 0.04% bid and two drops of 0.04% per dose, bid. The systemic exposures are equivalent to 4.2-fold, Because clinical trials are conducted under widely varying conditions, adverse reaction 7.9-fold, and 13.5-fold the clinical dose, respectively, on a body surface area basis (assuming rates observed in the clinical trials of a drug cannot be directly compared to rates in the 100% absorption). Microscopic evaluation of the lungs after 9 months observed pleural/subpleural clinical trials of another drug and may not re ect the rates observed in practice. chronic brosis/in ammation in the 0.04% dose male groups, with increasing incidence and VYZULTA was evaluated in 811 patients in 2 controlled clinical trials of up to 12 months severity compared to controls. Lung toxicity was not observed at the 0.024% dose. duration. The most common ocular adverse reactions observed in patients treated with U.S. Patent Numbers: 7,273,946; 7,629,345; 7,910,767; 8,058,467. latanoprostene bunod were: conjunctival hyperemia (6%), eye irritation (4%), eye pain (3%), and instillation site pain (2%). Approximately 0.6% of patients discontinued therapy due to VYZULTA is a trademark of Bausch & Lomb Incorporated or its afliates. ocular adverse reactions including ocular hyperemia, conjunctival irritation, eye irritation, © 2020 Bausch & Lomb Incorporated or its afliates. eye pain, conjunctival edema, vision blurred, punctate keratitis and foreign body sensation. Distributed by: 8 USE IN SPECIFIC POPULATIONS Bausch + Lomb, a division of 8.1 Pregnancy Bausch Health US, LLC Risk Summary Bridgewater, NJ 08807 USA There are no available human data for the use of VYZULTA during pregnancy to inform any drug Based on 9612403 (Folded), 9612303 (Flat) 5/2019 associated risks. VYZ.0109.USA.20 Issued: 5/2020 Latanoprostene bunod has caused miscarriages, abortion, and fetal harm in rabbits. Latanoprostene bunod was shown to be abortifacient and teratogenic when administered intravenously (IV) to pregnant rabbits at exposures ≥ 0.28 times the clinical dose. Doses ≥ 20 μg/kg/day (23 times the clinical dose) produced 100% embryofetal lethality. Structural abnormalities observed in rabbit fetuses included anomalies of the great vessels and aortic arch vessels, domed head, sternebral and vertebral skeletal anomalies, limb hyperextension Only dual-action VYZULTA reduces intraocular pressure (IOP) by targeting the trabecular meshwork with nitric oxide and the uveoscleral pathway with latanoprost acid

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VYZULTA achieved significant and sustained VYZULTA demonstrated safety profile long-term IOP reductions vs Timolol in clinical trials in pivotal trials Only out of patients discontinued due Visit VYZULTANOW.com P vs baseline at all pre-specified to ocular adverse events in APOLLO and to see our e cacy results visits over months in a pooled analysis of LUNAR clinical trials APOLLO and LUNAR clinical trials (N)

INDICATION IMPORTANT SAFETY INFORMATION cont’d VYZULTA® (latanoprostene bunod ophthalmic solution), 0.024% is • There have been reports of bacterial keratitis associated with the indicated for the reduction of intraocular pressure (IOP) in patients use of multiple-dose containers of topical ophthalmic products with open-angle glaucoma or ocular hypertension. that were inadvertently contaminated by patients • Contact lenses should be removed prior to the administration of IMPORTANT SAFETY INFORMATION VYZULTA and may be reinserted 15 minutes after administration • Increased pigmentation of the iris and periorbital tissue (eyelid) • Most common ocular adverse reactions with incidence ≥2% are can occur. Iris pigmentation is likely to be permanent conjunctival hyperemia (6%), eye irritation (4%), eye pain (3%), • Gradual changes to eyelashes, including increased length, and instillation site pain (2%) increased thickness, and number of eyelashes, may occur. These For more information, please see Brief Summary of Prescribing changes are usually reversible upon treatment discontinuation Information on adjacent page. • Use with caution in patients with a history of intraocular References: 1. VYZULTA Prescribing Information. Bausch & Lomb Incorporated. inﬂ ammation (iritis/uveitis). VYZULTA should generally not 2. Cavet ME. J Ocul Pharmacol Ther. 2018;34(1):52-60. DOI:10.1089/ be used in patients with active intraocular inﬂ ammation jop.2016.0188. 3. Wareham LK. Nitric Oxide. 2018;77:75-87. DOI:10.1016/j. • Macular edema, including cystoid macular edema, has been niox.2018.04.010. 4. Stamer DW. Curr Opin Ophthalmol. 2012;23:135-143. reported during treatment with prostaglandin analogs. Use DOI:10.1097/ICU.0b013e32834° 23e. 5. Cavet ME. Invest Ophthalmol Vis with caution in aphakic patients, in pseudophakic patients Sci. 2015;56(6):4108-4116. 6. Kaufman PL. Exp Eye Research. 2008;861:3-17. with a torn posterior lens capsule, or in patients with known DOI:10.1016/j.exer.2007.10.007. 7. Weinreb RN. J Glaucoma. 2018;27:7-15. Weinreb RN. Ophthalmology. 2016;123(5):965-973. Medeiros FA. Am J risk factors for macular edema 8. 9. Ophthalmol. 2016;168:250-259.

VYZULTA and the V design are trademarks of Bausch & Lomb Incorporated or its a² liates. ©2020 Bausch & Lomb Incorporated or its a² liates. All rights reserved. VYZ.0116.USA.20 Contents Review of Optometry July 15, 2020

26TH ANNUAL GLAUCOMA REPORT Glaucoma: 38 The Perils of Progression Controlling this disease requires a long-term, fluid management plan. These six tips can help you navigate the complicated road ahead. By Brian D. Fisher, OD, David W. Johnson, OD, and April J. Fisher, OD

Earn 2 CE Credits: Seven Ways Glaucoma Care A Practical Approach to 54 is Changing 60 Angle-closure Better drugs, safer surgeries, smarter diagnostics and new Learn to triage these patients and intervene appropriately approaches are easing the burden on patients—and their ODs. with in-office treatments or swift referrals as needed. By Michael Chaglasian, OD, and Sarah B. Klein, OD By Michael Cymbor, OD, and Nicole Stout, OD

24 Satisfying the Complicated 32 Optometry’s Role in the Diabetes Presbyope Epidemic Concurrent issues such as dry eye, prior surgery or binocular If you can get all patients—but especially those at risk—to disorders can compromise visual quality. Optometrists can focus on these five lifestyle modifications, the benefits would help restore it. be immense. By Christopher Luft, OD, and Gregory Barbush, OD By Kevin Cornwell, OD

46 What’s Your Disc Diagnosis? These cases can help you better differentiate tough optic disc abnormalities. By Ashley Kay Maglione, OD, and Kelly Seidler, OD

REVIEW OF OPTOMETRY JULY 15, 2020 9 Departments Review of Optometry July 15, 2020

4 News Review 12 Outlook A Bitter Pill

JACK PERSICO BUSINESS OFFICES 19 CAMPUS BLVD., SUITE 101 14 Through My Eyes NEWTOWN SQUARE, PA 19073 Glaucoma Updates Post-COVID CEO, INFORMATION SERVICES GROUP MARC FERRARA PAUL M. KARPECKI, OD (212) 274-7062 • [email protected]

PUBLISHER 16 Chairside JAMES HENNE 18 (610) 492-1017 • [email protected] PPE: Tales From the Trenches MONTGOMERY VICKERS, OD REGIONAL SALES MANAGER MICHELE BARRETT (610) 492-1014 • [email protected] 18 Clinical Quandaries REGIONAL SALES MANAGER An Optic Neuritis Outlier MICHAEL HOSTER PAUL C. AJAMIAN, OD (610) 492-1028 • [email protected]

VICE PRESIDENT, OPERATIONS CASEY FOSTER 20 The Essentials (610) 492-1007 • [email protected] RVOs: Detour Ahead VICE PRESIDENT, CLINICAL CONTENT BISANT A. LABIB, OD PAUL M. KARPECKI, OD, FAAO [email protected]

22 Coding Connection PRODUCTION MANAGER Coding a Suspect FARRAH APONTE 20 (212) 274-7057 • [email protected] JOHN RUMPAKIS, OD, MBA SENIOR CIRCULATION MANAGER HAMILTON MAHER 68 Cornea + Contact Lens Q&A (212) 219-7870 • [email protected] Riboflavin vs. Rose Bengal CLASSIFIED ADVERTISING (888) 498-1460 JOSEPH P. SHOVLIN, OD SUBSCRIPTIONS $56 A YEAR, $88 (US) IN CANADA, 70 Urgent Care $209 (US) IN ALL OTHER COUNTRIES. Navigating Retinal Necrosis SUBSCRIPTION INQUIRIES RAMI ABOUMOURAD, OD, AND (877) 529-1746 (US ONLY) RICHARD MANGAN, OD OUTSIDE US CALL: (845) 267-3065

CIRCULATION PO BOX 81 74 Review of Systems CONGERS, NY 10920 When Facial Paralysis Strikes 68 TEL: (TOLL FREE): (877) 529-1746 OUTSIDE US: (845) 267-3065 SEAN GRETZ, OD, CARLO J. PELINO, OD, AND CEO, INFORMATION SERVICES GROUP JOSEPH J. PIZZIMENTI, OD MARC FERRARA

SENIOR VICE PRESIDENT, OPERATIONS 78 Meetings & Conferences JEFF LEVITZ

VICE PRESIDENT, HUMAN RESOURCES 78 Advertisers Index TAMMY GARCIA VICE PRESIDENT, CREATIVE SERVICES & PRODUCTION 80 Classifieds MONICA TETTAMANZI CORPORATE PRODUCTION DIRECTOR 82 Diagnostic Quiz JOHN ANTHONY CAGGIANO He Kept His Eye on the Ball VICE PRESIDENT, CIRCULATION 82 EMELDA BAREA ANDREW S. GURWOOD, OD

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1IRI Artificial tears preservative-free dollar and unit sales by manufacturer, 52 weeks ending 04/19/2020. © 2020 Allergan. All rights reserved. All trademarks are the property of their respective owners. REF137616 06/20 Outlook By Jack Persico, Editor-in-Chief PRINTED IN USA

FOUNDING EDITOR, FREDERICK BOGER 1891-1913 A Bitter Pill EDITORIAL OFFICES 11 CAMPUS BLVD., SUITE 100 NEWTOWN SQUARE, PA 19073 Taking the profit out of contact lens sales looks to be

SUBSCRIPTION INQUIRIES devastating. But could it also be liberating? 1-877-529-1746 CONTINUING EDUCATION INQUIRIES think we can all agree that the Think about it: practice finances are 1-800-825-4696 Federal Trade Commission’s so off the rails this year anyway that

new Final Contact Lens Rule, it might be the best time in recent EDITOR-IN-CHIEF • JACK PERSICO I (610) 492-1006 • [email protected] adopted in late June after four years memory to rejigger your fee struc- MANAGING EDITOR • REBECCA HEPP of debate, is a lousy deal for optom- ture to value your skills more than (610) 492-1005 • [email protected] etry. First on everyone’s minds is the your inventory. ASSOCIATE EDITOR • CATHERINE MANTHORP (610) 492-1043 • [email protected] financial hit. A policy that mandates That strategy has been advocated ASSOCIATE EDITOR • MARK DE LEON prescription release, and takes great for decades, and the comeback has (610) 492-1021 • [email protected] pains to make clear that patients always been: easier said than done. SPECIAL PROJECTS MANAGER • JILL GALLAGHER will know they have the freedom to Many practices simply need prod- (610) 492-1037 • [email protected] ART DIRECTOR • JARED ARAUJO price shop, will cause the bottom to uct revenue to survive (or at least (610) 492-1032 • [email protected] drop out of many practices’ materi- maintain the expected returns). Since DIRECTOR OF CE ADMINISTRATION • REGINA COMBS als sales. COVID-19 has forced most practices (212) 274-7160 • [email protected] Then there’s the red tape. Prac- to make tough calls about changes

EDITORIAL BOARD tices are expected to provide the Rx, to their staffing, supplies and services CHIEF CLINICAL EDITOR • PAUL M. KARPECKI, OD document this exchange, maintain already, what’s a little more? As ASSOCIATE CLINICAL EDITORS • JOSEPH P. SHOVLIN, OD; proof of Rx release for at least three Winston Churchill said, “If you’re CHRISTINE W. SINDT, OD years and still deal with the litany of going through hell, keep going.” DIRECTOR OPTOMETRIC PROGRAMS • ARTHUR EPSTEIN, OD robo-calls for prescription confirma- Raising your contact lens fitting CLINICAL & EDUCATION CONFERENCE ADVISOR PAUL M. KARPECKI, OD tions from big-box sellers. If you fees wouldn’t go down easy with CASE REPORTS COORDINATOR • ANDREW S. GURWOOD, OD have concerns about these verifica- established patients who are accus- CLINICAL CODING EDITOR • JOHN RUMPAKIS, OD, MBA tion requests from retailers, you’re tomed to what they’ve been paying. free to chase them down for clarifi- What could justify a sudden hike? COLUMNISTS cation. Good luck with that. It’s not like you suddenly got 20% CHAIRSIDE • MONTGOMERY VICKERS, OD Finally, there’s the risk to patients. better at fitting lenses, right? They’ll CLINICAL QUANDARIES • PAUL C. AJAMIAN, OD CODING CONNECTION • JOHN RUMPAKIS, OD Putting price front and center in likely need a loyalty discount of CORNEA & CONTACT LENS Q+A • JOSEPH P. SHOVLIN, OD the minds of contact lens wearers is some kind to prevent bad blood. But DIAGNOSTIC QUIZ • ANDREW S. GURWOOD, OD going to foster a mindset that cost adding specialty services like scleral THE ESSENTIALS • BISANT A. LABIB, OD concerns should drive their deci- lens fitting and even a renewed push FOCUS ON REFRACTION • MARC TAUB, OD; sions. The prospect of cheap lenses into multifocals (still a distressingly PAUL HARRIS, OD delivered in 24 hours will hold much small portion of lens sales in most GLAUCOMA GRAND ROUNDS • JAMES L. FANELLI, OD NEURO CLINIC • MICHAEL TROTTINI, OD; more sway than nebulous concepts practices) could add to the complex- MICHAEL DELGIODICE, OD like lens design, visual acuity, eye ity of your offerings and help justify OCULAR SURFACE REVIEW • PAUL M. KARPECKI, OD health, routine check-ups and all the a new approach to how you bill for RETINA QUIZ • MARK T. DUNBAR, OD rest. Prices are clear, unambiguous contact lens services. REVIEW OF SYSTEMS • CARLO J. PELINO, OD; signals people use to evaluate their Product sales revenue won’t go JOSEPH J. PIZZIMENTI, OD options. Quality of care is far less away overnight; it’s too ingrained SURGICAL MINUTE • DEREK N. CUNNINGHAM, OD; WALTER O. WHITLEY, OD, MBA measurable. in most traditional optometry prac- THERAPEUTIC REVIEW • JOSEPH W. SOWKA, OD Even in a good year, none of this tices. But starting to wean off that THROUGH MY EYES • PAUL M. KARPECKI, OD would be met with enthusiasm. And reliance will add some distance URGENT CARE • RICHARD B. MANGAN, OD this is certainly not a good year. But between you and cut-throat retailers, maybe the chaos of 2020 creates a who’ll always have a price advan- JOBSON MEDICAL INFORMATION LLC perfect opportunity to start moving tage. Focus instead on yours: clinical beyond reliance on product sales. expertise. n

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Glaucoma Updates Post-COVID The pandemic hasn’t slowed progress in new care options. By Paul M. Karpecki, OD, Chief Clinical Editor

espite the COVID-19 poor compliance. Now, more ODs ments for telemedicine exams are lockdown, the FDA has are suggesting selective laser trabec- now on par with live exams. While Dcontinued to approve new uloplasty or preservative-free drops.3 glaucoma may not seem to fit the therapeutics, many of which will Another potentially useful proce- usual virtual visit profile, many impact how we manage glaucoma. dure is MIGS at the time of cataract opportunities exist. For example, The approval of Durysta (bima- surgery. At this year’s AGS meeting, patients may come in for OCT, visual toprost implant, Allergan), for the four-year Hydrus (Ivantis) pivotal fields, hysteresis and an IOP check— example, yields the first intracameral trial data was released, showing that and then schedule a telemedicine visit sustained-release implant to lower 71.4% of patients (vs. 44.2% who to discuss the findings. intraocular pressure (IOP). In two had cataract surgery alone) who Keep in mind that the patient must Phase III studies, Durysta lowered started the trial on one medication request the telemedicine visit, which IOP by approximately 30%; though remain medication free post-op.4 means you need to educate them it dissolves in about three months, that you provide virtual care. Docu- the effects continue for years. Many Telemedicine ment the same way you would with other changes are on the horizon: With COVID-19 mandating less a live visit but record the amount of Diagnostic advances. Hysteresis, time with and greater distance from time spent with the patient. Then, measured with the Ocular Response patients, more clinicians have gone email them a video or voice record- Analyzer (Reichert), is becoming virtual. Not only that, reimburse- ing of the discussion, follow-up and increasingly useful. Research shows any medication instructions. I even this measurement may be a predictor New Tools for DED include an animation pertinent to of glaucoma progression risk.1 For The FDA has also been busy approving glaucoma (via Rendia) that provides me, it’s often the measurement that new treatment options for dry eye: them an archivable recording regard- determines if I should or should not The agency accepted the resub- ing drops and dosing, which decreas- treat a borderline glaucoma patient, mission of the New Drug Application es call backs and patient confusion. or helps me better understand why for Eysuvis (loteprednol etabonate The world of glaucoma is chang- they are progressing. ophthalmic suspension 0.25%, Kala ing, in a good way. We have myriad Another new diagnostic tool for Pharmaceuticals) for the short-term new opportunities to improve the glaucoma is the Eyekinetix (Konan treatment of the signs and symp- lives of our patients with this vision- 1 Medical). Most cases of glaucoma toms of DED. Also, the iTear100 threatening disease. n Neurostimulator (Olympic Ophthalmics) involve asymmetric nerve changes, Note: Dr. Karpecki consults for was approved as a non-drug, exter- and the device accurately and quick- companies with products and ser- nal neurostimulator to temporarily ly measures pupils, including subtle vices relevant to this topic. increase acute tear production.2 Finally, relative afferent pupillary defect, Bausch + Lomb recently received 1. Medeiros FA, Meira-Freitas D, Lisboa R, et al. Corneal hys- overcoming the shortcomings of the approval for the Infuse daily dispos- teresis as a risk factor for glaucoma progression: a prospective 2 longitudinal study. Ophthalmology. 2013;120:1533-40. swinging flashlight test. able silicone hydrogel contact lens, 2. Pillai MR, Sinha S, Aggarwal P, et al. Quantification of RAPD by Doctors are an automated pupillometer in asymmetric glaucoma and its cor- Treatment updates. made with a new material (kalifilcon A) relation with manual pupillary assessment. Indian J Ophthalmol. now closely addressing the ocular 2019 Feb;67(2):227-32. designed with those who experience 3. American Academy of Ophthalmology. Selective laser trabecu- surface of glaucoma patients, as contact lens dryness. loplasty effective as a first-line treatment for open-angle glaucoma. chronic preservatives combined with https://www.aao.org/editors-choice/selective-laser-trabeculoplas- 1. Kala Pharmaceuticals resubmits New Drug Application for ty-effective-as-first. March 28, 2019. Accessed June 8, 2020. inflammation-inducing drops, such EYSUVIS for Dry Eye Disease. Business Wire. May 4, 2020. 4. Rhee D. Reduction in incisional glaucoma surgery after 4-years as prostaglandin analogs, can cause 2. Olympic Ophthalmics receives FDA clearance for iTear100 with a Schlemm’s canal microstent combined with cataract surgery neurostimulator. PR Newswire. May 14, 2020. for treatment of primary open angle glaucoma. AGS Annual Meet- discomfort, quality of life issues and ing, Washington, DC; February 27, 2020.

14 REVIEW OF OPTOMETRY JULY 15, 2020 As you adjust to the changes our industry is facing, you’ll find there is also opportunity. Increasing medical revenue and staff efficiency will be paramount.

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PPE: Tales From the Trenches These safety measures have proven tricky, but I’ve got a few pointers. By Montgomery Vickers, OD

ell, folks, we are almost multifocal contact lenses, whether more months, unless, you have a all back to work by the you can see with them or not. licensed grief counselor on staff. Wtime this prints. I think 3. If you have a reusable cloth 9. Your mask should not look like you will agree that the transition mask, wash it, for goodness’s sake! a skeleton’s grin. Stick with puppies into the nouveau optometric practice If you are wearing a disposable or Mick Jagger’s lips or something. has been a little smoother than we paper surgical mask, uh, dispose of 10. People ask me, ”What about thought it would be. it before the inside looks like a three- wearing gloves?” Well, gloves are Now, don’t get me wrong. I, too, year-old’s pull up. probably less sanitary than your had to convince myself that I was 4. Use a mask that’s tight enough carefully washed hands (see #7), but unlikely to catch a potentially deadly for a decent seal but not so tight that patients who come in with things disease while refracting a 10-year- you look like Jeff Sessions. stuck in their eyes that have to be old who was messing with his mask, 5. Remember, your patient can- removed by your filthy hands actu- but, day by day, it has become easier not tell you if are smiling, so clap or ally may like to see you in gloves. for me to ease into this new world. something. Also, laughing behind 11. Speaking of gloves, please (a) But a lot has changed, and some the mask must be handled delicately buy decent quality gloves so they of it has been surprising. For exam- or they may think you are hacking don’t split like a jilted boyfriend and ple, we hardly have any no-shows your lungs out. (b) practice putting them on and off now. Oh, 20-something males still 6. Do not automatically shake so you don’t look like a dork. Being never show up, but that’s expected. hands with someone who sticks an optometrist is dorky enough. Everyone else is showing up. I have his out to you. Me? I give the foot I am keeping track of all things mixed emotions about that trend, bump. Patients seem to think it is related to reopening in the COVID since 83.4% of my humor is related funny and laugh… or maybe they era. You can be sure that once to griping about no-shows in this are hacking their lungs out. patients start no-showing again, I column. Still, if almost every one of 7. When you wash your hands, will get back to being funny. n my usual no-shows actually show make sure you do it in front of the up, all things considered, it’s a good patient—and be sure it’s for 20 sec- thing, right? onds. I’ve gotten called out on skip- ping a few seconds more than once Coverup Considerations by the hand-washing police. You will agree that the personal pro- 8. Always remember that your tective equipment (PPE) has taken patients are pretty freaked out some time to get used to. I’m learn- these days. Maybe ing what works for me, and I would their first bifo- like to share with you some practical cal can wait PPE and other hygienic wisdom I a couple have gained: 1. Do not put the mask on immediately after eating cheese. Trust me. 2. To avoid fogging up your glasses just as you are picking rust out of someone’s cornea with a needle, go back to wearing your

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An Optic Neuritis Outlier This condition, as well as MS, can still affect patients outside the typical age demographic. Edited by Paul C. Ajamian, OD

A 51-year-old presented as an Hypertension can reach such Q emergency during the shelter- elevated stages that it can cause at-home period. She had complaints bilateral swollen optic nerves, also of a streak in front of her right eye, known as malignant hypertension. but her acuity was 20/20. A swollen “If an older patient presents nerve was noted without an afferent with a history of obesity, high pupillary defect (APD). What is my blood pressure for an extended differential diagnosis here? period of time or uncontrolled “When looking at the diabetes, then non-arteritic isch- A nerve—any unilateral emic optic neuropathy (NAION) swollen optic nerve—you have is a much more likely diagnosis to consider optic neuritis,” says because of their vascular history,” Nate Lighthizer, OD, an associate Dr. Lighthizer says. professor at the Oklahoma College of Optometry. One of Treat Accordingly the most common causes of a While not the case with this patient, an APD, The good news with optic neuri- unilateral swollen nerve is optic decreased vision and pain on eye movement often tis is that it usually resolves even neuritis. And one of the most accompany optic neuritis. without treatment. However, high common underlying causes of dose IV methylprednisolone for optic neuritis is multiple sclerosis counts: older age, and no APD or three days can accelerate healing (MS). pain on eye movements. and visual recovery. This is some- “Usually, if you’re asking for the “When a unilateral swollen optic times followed by oral steroids for typical demographics of optic neuri- nerve presents, ask if the patient about two weeks with a slow taper. tis that you see in all the textbooks has been diagnosed with MS,” Dr. “Usually the neurologist or the neu- and in the clinical trenches, those Lighthizer says. If the answer is no, ro-ophthalmologist will make the patients are in their 20s to 40s with they may be presenting to you with call to order the IV steroids,” notes a unilateral presentation of sudden one of the classic signs of multiple Dr. Lighthizer. vision loss,” Dr. Lighthizer notes. sclerosis. To rule out multiple scle- He recommends that optometrists While this patient was not within rosis, you will need to have neu- follow their patients every other this age range, he didn’t think she roimaging done, according to Dr. week once they are out of the hos- was too old for optic neuritis. Lighthizer. You can either order the pital. It is especially important to scan yourself, or send the patient monitor their vision, pupils, visual Ask Questions to a neuro-ophthalmologist or a field and nerve status in these cases. “When you see unilateral nerve neurologist,” Dr. Lighthizer notes. Be sure to communicate your find- swelling in a patient no older than In our case, the MRI helped confirm ings clearly and regularly with the 50, have optic neuritis near the top the suspicion of MS. specialist. of your differential,” Dr. Lighthizer Optic neuritis and MS can happen says. Optometrists should look care- Check History at any time to anyone of any age. fully for an APD using a very bright Dr. Lighthizer reminds us to review Keep it on your radar, and remem- light source, such as a binocular the med the patient is on, along ber to advocate for the patient and indirect ophthalmoscope. Also, ask with conducting a detailed medical get them into the neurology system about pain on eye movements. This history, to eliminate other potential in a timely fashion. Be mindful this patient was an exception on all causes of the swollen optic nerve. is not always an easy task. I

18 REVIEW OF OPTOMETRY JULY 15, 2020 save the date October 7-10, 2020 • Music City Convention Center

Enhance your vision for the future over the course of four invigorating days packed with clinically relevant CE and the latest cutting edge research. Discover the latest products and technology in the spacious exhibit hall to help improve patient care and take your Find your inspiration practice to the next level. Network with the for excellence. best and brightest in optometry from around the world and enjoy numerous exciting social events. Get your groove on in the vibrant city of Nashville while you explore its popular attractions and diverse blend of music. Come find your inspiration for excellence at Academy 2020 Nashville.

Registration opens on April 20, 2020 at w.academymting.org The Essentials

RVOs: Detour Ahead The formation of collateral vessels may help you understand the severity of the occlusion. By Bisant A. Labib, OD Photo: Joseph W. he vascular network that structed channels that ultimately nourishes the retina is a lead to the central retinal vein, complex and essential part where intraretinal collateral forma- T Sowka, OD, and Alan G. Kabat, OD of vision. Obstructions may occur tion arises to restore blood flow in a within these blood vessels—namely, BRVO, developing within weeks of vein or artery occlusions—that the occlusion.1,4 impair the normal pathway of On funduscopic examination, blood throughout the retina, poten- these areas appear as intrareti- tially leading to devastating visual nal tortuous blood vessels within loss. the deep capillary bed, across the Much like many other parts of temporal raphe and other sites to the body, the retinal vasculature bypass the occluded area. They attempts to troubleshoot these may be difficult to distinguish from occlusions and form alternative neovascularization; here, fluorescein routes to restore flow. In the case of This patient’s retina exhibits collateral angiography (FA) is useful. Initially venous occlusions specifically, these vessels bypassing an occluded vessel. following BRVO, there is minimal mechanisms may appear as collat- leakage of collateral vessels due to eral vessels, which are identifiable channels in an effort to bypass the limited capacity and weak endothe- on clinical examination and may vein occlusion.1-4 lial cells. With maturation, the ves- affect the prognosis or course of Unlike other vascular responses sels become larger and more stable.5 venous occlusion. in the retina, collaterals connect an Conversely, CRVO occurs at the obstructed vein to a neighboring level of the lamina cribrosa, where Collateral FAQs unobstructed vein.2,3 In contrast, a all branches of the central retinal When a retinal vein occlusion vascular shunt, for example, con- vein are affected. As such, these (RVO) occurs, collateral channels nects dissimilar blood vessels, such collaterals are not intraretinal but often form to bypass the site of as arteries, to veins.1,3 are usually located on or around occlusion and offer an alterna- The most common cause of col- the optic disc and use the choroidal tive path for blood to nourish the lateral formation is either branch or venous system for drainage.4 affected retinal area. Unlike neovas- central RVOs; of these two, branch These vessels appear tortuous, cularization, these vessels are pre- retinal vein occlusions (BRVOs) with slow blood flow and cross the existing deep within the capillary more frequently lead to collateral horizontal raphe, but may straighten bed and only fill when necessary. formation.1 over time or disappear when the The filling of collateral vessels Because BRVOs and central reti- obstructed site reopens.2,3,5 They is thought to depend heavily on nal vein occlusions (CRVOs) occur take on the same caliber as a normal hemodynamic factors. Increases in different locations, collaterals retinal vein, which is the type of ves- in hydrostatic pressure within the that form in each case will also sel collaterals appear to replace.5 occluded area direct blood into appear different clinically.4 areas of lower capillary pressure. In a BRVO, the obstruction Warning Signs This pressure gradient, resulting occurs at sites where the retinal Generally, the number or severity from hemodynamic stress, eventu- artery crosses a vein, or an arterio- of collaterals seen in both types of ally leads to enlargement and filling venous crossing.5 The vein occluded RVO is associated with the extent of these already existing capillary at that site has surrounding, unob- of capillary nonperfusion; thus,

20 REVIEW OF OPTOMETRY JULY 15, 2020 the identification of collaterals on OCT-A: Go with the Flow clinical examination is a potential Optical coherence tomography angiography (OCT-A) is a newer tool that allows for non- marker for the degree of retinal invasive visualization and analysis of retinal blood flow.1 OCT-A images are created with ischemia that has taken place sec- successive images of OCT B-scans that detect flow of motion from red blood cells within ondary to the occlusive event.2 the retinal vasculature.6 The technology is faster, safer and less invasive than FA, and can It is difficult to ascertain whether also image deep capillary plexuses better than FA. Both FA and OCT-A can offer informa- collateral formation yields an tion on the location of ischemic retinal areas.7 Quantifying the area of nonperfusion allows improvement in visual outcome the clinician to predict the severity and outcome of the ischemic event.6 in RVOs or if they simply serve as markers for severity. In BRVO, additional clinical fusion prior to this can impair col- features are associated with collat- lateral vessel formation. However, eral formation, including a greater using a laser to destroy collaterals length of time of macular edema. that have formed can increase neo- This is potentially due to the longer vascular leakage.5 duration of the ischemic event, gen- While collateral vessel formation erally, and the subsequent oppor- is a natural mechanism to restore tunity to develop collaterals in that blood flow and reduce ischemic timeframe. damage, research shows patients Patients with collaterals have a with CRVO and collaterals actually smaller area of retinal hemorrhages have poorer visual outcomes. One These collaterals formed over the optic that can be attributed to chronicity study found 52% of patients had disc in response to a CRVO. and resorption of hemes. Research acuity of 20/70 or worse, compared also shows a correlation between with 35% of CRVO eyes without tool in determining the severity younger patients with BRVO and collaterals.2,4 Patients with collater- of the ischemic event and provide the formation of collaterals, likely als also had macular edema for a clue as to the patient’s ultimate due to their ability to more readily twice as long and a lower chance of visual prognosis. n undergo vascular remodeling.4 visual improvement compared with 4 1. Freund KB, Sarraf D, Leong BCS, et al. Association of optical those who didn’t have collaterals. coherence tomography angiography of collaterals in retinal vein occlusion with major venous outflow through the deep vascular Road to Recovery These factors indicate that CRVO complex. JAMA Ophthalmol. 2018;136(11):1252-70. The timing of laser therapy in the with collateral formation is more of 2. Lee HE, Wang Y, Fayed AE, et al. Exploring the relationship between collaterals and vessel density in retinal vein occlusions treatment of BRVO complications a marker for severity of ischemia. using optical coherence tomography angiography. PLoS One. 2019;14(7):1-13. such as macular edema or neovas- With the reduction in capillary den- 3. Henkind P, Wise GN. Retinal neovascularization, collaterals, cularization is critical for prognosis. sity in severe cases, collaterals are and vascular shunts. Br J Ophthalmol. 1974;58:413-22. 4. Weinberg DV, Wahle AE, Ip MS, et al. Score Study Report 12: Based on the Branch Retinal Vein more likely to arise, or patients who development of venous collaterals in the Score Study. Retina. 2013;33(2):287-95. Occlusion Study, laser treatment is develop collaterals may have fewer 5. Im CY, Lee SY, Kwon OW. Collateral vessels in branch retinal 2 vein occlusion. Korean J Ophthalmol. 2002;16:82-87. considered three to six months fol- available tributaries. 6. Heiferman MJ, Griebenow EJ, Gill MK, et al. Morphological lowing the BRVO. The typical time implications of vascular structures not visualized on optical coherence tomography angiography in retinal vein occlusion. for collaterals to form and mature In any vein occlusion case, iden- Ophthalmic Surg Lasers Imaging Retina. 2018;49(6):392-6. 7. Tsai G, Banaee T, Conti FF, et al. Optical coherence tomog- is approximately six to 24 months. tifying collaterals through clinical raphy angiography in eyes with retinal vein occlusion. J Laser treatment in areas of nonper- examination can be an important Ophthalmic Vis Res. 2018;13:315-32.

Collaterals vs. Neovascularization

Origin Appearance and Location FA Testing

Pre-existing vessels that fill to bypass Tortuous and larger caliber vessels Minimal leakage in very early stages; Collaterals an occlusion. around the peripapillary plexus. no leakage in mature vessels.

New vessels formed by angiogenic Fine meshwork of vessels at the Neovascularization cytokines and endothelial proliferation in Permeable to fluorescein. level of the vitreous.7 response to ischemia.1

REVIEW OF OPTOMETRY JULY 15, 2020 21 Coding Connection

Coding a Suspect The rules differ when monitoring a patient who hasn’t converted to glaucoma—yet. By John Rumpakis, OD, MBA, Clinical Coding Editor valuating a patient for the sue the necessary additional diag- condition and the insurance carrier’s presence of glaucoma is part nostic tests and are the only codes guidelines. Most carriers allow one Eof the daily routine for any to be used for proper diagnosis of a to two OCTs per year, generally optometrist. Still, knowing current glaucoma suspect: alternated with a visual field. For parameters on what constitutes a • H40.00X: Pre-glaucoma stereoscopic photos, clinicians must glaucoma suspect and the appropri- • H40.01X: Open-angle with bor- establish necessity in the medical ate coding may require a refresher, derline findings, low risk record each time they take a photo. since the ICD-10 code for a glau- • H40.02X: Open-angle with bor- Thus, if there is no change in the coma suspect is invalid to use—and derline findings, high risk optic nerve noted in the physical with the frequency it is used, it can • H40.05X: Ocular hypertension exam, there is no necessity to photo- spell trouble for your practice. The physician must specifically document “no change.” identify with the highest level of If clinicians must perform an Setting a Diagnosis specificity the patient’s type of “sus- extended optic nerve exam, the new Although 304 ICD-10 codes contain pect.” Using the same code for all (January 2020) code is 92202: oph- the word glaucoma, only one exists suspects because of convenience or thalmoscopy, extended; with optic for glaucoma suspect (H40.0). Yet, routine is inappropriate. nerve or macula drawing and I/R, it’s not a proper code to use for diag- When testing, clinicians should unilateral or bilateral. nosis or for submitting to a carrier map the appropriate ICD-10 code to The additional criteria clinicians because it lacks specificity. the appropriate procedure they are must meet stem from the National According to the American performing. Although the list of pro- Correct Coding Initiative, or CCI Academy of Ophthalmology (AAO), cedures is broad, clinicians should edits. These rules stipulate what pro- the diagnosis of a primary open- not perform the same tests on every cedure codes can or cannot be per- angle glaucoma (POAG) suspect is patient. Instead, they must consider formed on the same date of service. established by the presence of one of each patient on an individual basis Too often, practitioners ignore the following: consistently elevated and only order clinically relevant the insurance carriers’ and the CCI intraocular pressure (IOP), suspi- and necessary tests. edits’ rules. This leads to inappropri- cious optic nerve or abnormal visual ate use of modifiers (specifically -59) field. It could also have associated Ongoing Care because claims get rejected. This is risks of elevated IOP, family history Once the clinician establishes the highly scrutinized by carriers, and of glaucoma or glaucoma suspect, diagnosis—whether a specific form doctors are fined for inappropriate thin central cornea, race, older age, of glaucoma or simply at risk— clinical and coding procedures. myopia and type 2 diabetes.1 they then use that ICD-10 code on The proper identification of The diagnostic testing associated subsequent visits when performing glaucoma is a vital part of the clini- with a patient at risk, but not diag- follow-up tests to monitor progress cal evaluation, and clinicians must nosed, includes gonioscopy, pachym- and treatment effect. understand the CPT and ICD-10 etry, tonometry, perimetry, careful According to the AAO’s Preferred rules it requires. n optic nerve observation and ocular Practice Pattern for POAG, the Send your coding questions to imaging. The term “ocular imaging” ongoing clinical testing for a patient [email protected]. can include fundus photography and includes:2 92250 (stereo photogra- 1. AAO. Primary Open-Angle Glaucoma Suspect PPP – 2015. OCT based on the specific medical phy), 92133 (OCT of optic nerve) www.aao.org/preferred-practice-pattern/primary-open-angle- necessity of the patient. and 92083 (visual fields, threshold). glaucoma-suspect-ppp-2015. Accessed June 2, 2020. 2. AAO. Primary Open-Angle Glaucoma PPP – 2015. www.aao. These diagnosis codes (highest The frequency of testing is now org/preferred-practice-pattern/primary-open-angle-glaucoma- specificity only) can be used to pur- based on two criteria: the patient’s ppp-2015. Accessed June 2, 2020.

22 REVIEW OF OPTOMETRY JULY 15, 2020 PASSIONATELY AT WORK IN EVERY ASPECT OF EYE HEALTH

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

Satisfying the Complicated Presbyope Concurrent issues such as dry eye, prior surgery or binocular disorders can compromise visual quality. Optometrists can help restore it. By Christopher Luft, OD, and Gregory Barbush, OD

hen patients in their early Prism and Progressive Lenses from the optical center.5-7 Measur- to mid-forties remark, Purposeful prism can certainly be ing the interpupillary distance is “Doc, I used to always introduced into progressive lenses very important in progressive lenses Whave great vision, but for presbyopic patients with diplo- and needs to be done with the head now I feel as though I can’t see pia, strabismus and other binocular properly aligned. Remember to anything without my glasses,” any vision conditions.2,4 Success with maintain normal head posture while optometrist knows they’re likely prism requires a delicate balance of performing cover testing as well as dealing with presbyopia. This per- objective and subjective tolerances; while measuring for spectacles.7 Any vasive condition affects roughly a thus, doctors must tailor parameters head tilts or turns can throw off the quarter of the entire global popula- for prescribing to the individual desired prismatic effect and may tion.1 Unfortunately, 826 million are patient, taking into account their cause unwanted diplopia in itself.6,7 likely to have limited daily function age, systemic and ocular histories, When considering the binocular because they don’t have adequate and common patterns of visual prismatic consequence of spectacles, management or correction.1 demands.2-4 we focus on the net prismatic effect Optometrists can make the dif- While cover test and prismatic between the right and left lenses.5-7 ference and offer patients corrective implementation into a trial frame This is known as the prismatic lenses and other solutions.2,3 But can be rudimentary, there are some imbalance, which affects binocular that’s not the end of their problems. pearls to keep in mind when fitting fusion. For vertical prism, bases Presbyopia can complicate, and be progressive lenses. Prism appears in oriented in the same direction complicated by, a number of other spectacles whenever the thickness of between the two eyes have canceling conditions. Optometric physicians the lens varies between two points.5,6 effects, while the opposite is true for will need to consider the impact of Keep this in mind as we move into horizontal prism.6,7 Make sure the their patient’s visual condition when progressive lenses that combine amount of prism can be tolerated fighting conditions such as dry eye, multiple powers across one lens by the fusional vergence system by cataracts, retinal disease or prior surface.6,7 As we have learned with using a trial frame, along with the refractive surgery. This article helps Prentice’s rule, the prismatic effect correct orientation of prism between ODs navigate the necessary consid- on any point of a lens is directly the two eyes.6,7 erations when managing presbyopia proportional to the power of the Fresnel prisms can accommodate in complex situations. lens, and the distance of that point high ranges of prismatic correction.8

24 REVIEW OF OPTOMETRY JULY 15, 2020 They consist of continuous thin, narrow prisms arranged on a plastic sheet.8 Because their design is dependent upon prismatic angle vs. thickness of the lens, they are thin, flexible, and discrete on the surface of spectacles.8 Fresnel prisms come in powers up to around 40 diopters.8 They are a good trial prism for patients using prism for the first time or in cases with a large change in prismatic correction. Fresnel prism, while very useful, does tend to degrade image quality and can be noticeable to the naked eye. Once the patient reports good success and comfort with stick-on Fresnel, prism can then be ground into lenses, a more permanent modality to prismatic correction. Some diplopic patients with stra- bismic amblyopia may not achieve single vision with any amount of prism and may warrant patching to resolve symptoms.5,7,8 The same may be true for other types of diplopia secondary to neurologic concurrent pathologies causing progressive amblyopia over time. Some patients may also have some latent The trial frame is a valuable clinical tool that allows our patients to see what we strabismus and may need multiple intend on prescribing, and feel how the prescription acts on their visual system. Prism follow-up visits to ensure proper and astigmatism can cause disruption to the vergence system and should be tried at compensation and resolution in all ranges before prescribing. This is an underused technique that all optometrists symptoms. should rely on for most refractive and prismatic exams. Here, the patient is holding Adaptation to progressive lenses a near card with her prescription in the trial frame at the desired focal point. She is can take time and requires patience new to reading glasses and was given the “wow” factor before ordering her glasses. in addition to careful consideration. In a study, patients who couldn’t ments such as those created when Statistics, 65% of the civilian labor adapt to progressives demonstrated using progressive lenses.4 The ability force is age 35 or older, and this slower peak velocities in conver- to change convergence peak veloc- category is projected to maintain gence responses, a weaker ability ity had the greatest sensitivity and that average through 2028.9-11 This to modify convergence responses, a specificity compared to the other places eye care physicians in a piv- reduced rate and magnitude of pho- parameters.4 otal position. Our aging patient ria adaptation and a reduced ver- population is learning to battle func- gence facility compared to successful The Ocular Surface tional, progressive visual changes wearers.4 These results suggest that In all varieties of dry eye, especially and adapting to these changes on when the accommodative system in cases of severe ocular surface top of the use of glasses can be dif- decreases in presbyopic subjects, the disease, presbyopia adds a lay\er of ficult to navigate. adaptive role of vergence and phoria complexity to the already compro- As stated by the epidemiology systems may become critical when mised patient. According to 2018 report from the Tear Film and Ocu- adapting to new visual environ- data from the US Bureau of Labor lar Surface Society’s second Dry Eye

REVIEW OF OPTOMETRY JULY 15, 2020 25 Vision Correction

people older than 60 titioner-involved process to service engage in polypharmacy chronic lid margin disease. at a rate of approxi- Anti-allergy drops prior to or mately 37%.15 after lens removal, allergen avoid- The main strategy ance and daily disposable lens wear we try to employ with are all modalities we employ to aid presbyopes that suffer in the varying degrees of patients’ contact lens discomfort red, itchy eyes suffering from ocular related to dry eye dis- allergies. ease (DED) or allergy Objective improvement indica- is early detection and tors cited in the DEWS reports management. If we can that ODs should look for at the slit detect clinical signs of lamp include improved corneal and A bandage contact lens used on a keratoconjunctivitis ocular surface disease conjunctival staining, prolonged sicca patient with significant epithelial staining, after in the early stages, TBUT (improved over baseline) and which symptoms resolved and redness subsided. Note we can reduce patient improved quality of meibomian the frothing along the lower lid margin, indicative symptoms, chair time gland presentation with less cap- of meibomian gland dysfunction and reduced tear and contact lens drop- ping and increase in lipid secretion quality. Patients with ocular surface compromise often out.16,17 Prior to initiat- quality.12,15,22 Clinical testing outside experience visual fluctuations that reduce the quality of ing lens wear for a new the slit lamp that indicates improve- multifocal contact lens wear. presbyope, look for ment would be a decrease in tear clinical signs of meibo- osmolarity detectable using a clinical Workshop report (DEWS II), for all mian gland dysfunction, lid wiper osmometer (like that from Tear- subgroups analyzed the prevalence epitheliopathy, injection and any Lab).20 In 2014, researchers deter- of dry eye increased significantly and reduction in tear-film break-up time mined that osmolarity appears to be showed a linear association with (TBUT). the best marker across all levels of age.12 Research suggests that mul- Dry eye treatment plan discus- disease severity as well as in different tiple factors, including uncorrected sions are often a fluid blend of subtypes of dry eye disease.21 presbyopia, are associated with both clinical and therapeutic recommen- Restoring the function of the ocular and nonocular symptoms.13 dations along with lifestyle modifica- meibomian glands, improving the In fact, a 2017 study showed an tions. Preservative-free artificial tears clinical corneal presentation and increase in dry eye disease in patients can reduce contact lens discomfort increasing tear film stability will who are presbyopic.14 by reducing friction at the ocular allow for initial and long-term suc- Environmental factors such as surface that can lead to the initiation cess.17 If we are able to identify the pollen or dander allergies, prolonged of the inflammatory cascade.18 Man- combination of therapy given each digital screen time and contact lens aging meibomian gland dysfunction presbyopic patient’s clinical findings, wear can worsen dry eye signs and with therapeutic warm compresses ideally at an early phase, we can symptoms. In advanced stages of and lid hygiene effectively improves open their options up to different the condition, the severity of dry TBUT and lid health.18 modalities of clear, stable vision at eye damage may become sight- Existing and new technologies multiple ranges. threatening.15 And the medications like Lipiflow (Johnson & Johnson that patients use—including anti- Vision), iLux (Alcon), TearCare Contact Lens Options histamines, hormonal replacement (Sight Sciences) and intense-pulsed Monovision contact lenses correct therapy and androgen therapy—can light (Lumenis and others) offer one eye for distance and the other worsen dry eye symptoms, too.10 in-office opportunities for patients for near ranges (or a modified ver- According to DEWS II, 18 classes of all ages but especially those of sion of this); patients who are able of drugs can negatively impact dry mature age with conceivable abil- to tolerate the disparity do well eye.12,15,22 Polypharmacy, where ity or willingness to pay for these without the need for additional near multiple medications are used con- premium services. These hands-on spectacle help. One disadvantage currently, may also exacerbate dry options are also excellent consider- of monovision is the lack of depth eye symptoms. Researchers note that ations for those preferring a prac- perception and binocularity. We

26 REVIEW OF OPTOMETRY JULY 15, 2020 LCD Visual Acuity System VA-1VA 1 find monovision works preferably recommended scleral lenses if other in patients who have notable one- conservative treatment options eye dominance, amblyopia or other such as artificial tears, lid therapy, conditions that already limit binocu- topical pharmaceuticals or punctal larity. plugs were inadequate in controlling Some patients are not good candi- ocular surface disease.22 This was dates for this option or are unable to upheld in DEWS II as a therapeutic adapt well; for them, consider multi- consideration for patients with mod- focal contact lenses. The advantages erate to severe dry eye.12,15,22 Scler- of this modality are numerous, als may help prevent or delay the including the ability to provide patient from having procedures like simultaneous vision and binocular amniotic membrane transplantation, function at all ranges. Gas perme- tarsorrhaphy, mucous membrane or able, hybrid and scleral lenses with salivary gland transplant, or other ComprehensiveComprehensive multifocal optics exist in several lid surgeries.20-22 Their many advan- Visual Acuity Solution different designs, but can usually tages include protecting the ocular be incorporated into current user’s surface from further desiccation, lenses. In the case of someone with providing continuous hydration Multiple optotype selections keratoconus and prominent apical to the cornea to repair underlying All acuity slides presented with scarring, de-centering optics or vary- epithelial pathology (e.g., punctate ETDRS Spacing ing zone sizes can be a triumph for corneal staining), allowing for best these patients if we are able to adjust correctable vision and improving the Contrast sensitivity testing the optic zones accordingly where patient’s quality of life.10,22,23 Crowding bars (for pediatrics) the impact of the scarring is mini- Scleral lenses also protect the ocu- mized in a multifocal design. lar surface from irregular lid margins Multimedia system and more! Soft toric multifocals can be a or, in cases of entropion that create solution for the unmet need of our exposure keratopathy and neuro- presbyopic patients who have oth- trophic changes, lead to increased erwise not had success secondary to patient comfort.22,23 Research shows their astigmatism. These manufac- that scleral lens therapy promotes turers offer a broad range of param- healing of surface epitheliopathy eters to correct or help significant while reducing pain and photopho- toricity while performing well at bia.24,25 It is especially notable in near and intermediate ranges with cases refractory to standard treat- stable vision. Beyond the standard ments involving patients with ocular available toric multifocals (Ultra pain, burning, stinging, foreign body Multifocal for Astigmatism, Bausch sensation, blurred vision and pho- + Lomb), custom lens labs also offer tophobia resulting from keratocon- a wide variety of soft lens designs junctivitis sicca secondary to chronic and prescription parameters to tailor graft-vs.-host disease.23-25 No longer the optics for each patient. are reading glasses the only presby- Scleral lenses can also provide opic option for contact lens wearers; stable, clear vision while alleviating scleral lenses present an opportunity symptoms of dry eye disease.10 The to treat ocular surface disease while vault of the lens over the cornea providing satisfying optical correc- allows for a fluid reservoir (“mois- tion.9,25,26 ture bath”) that acts to optically neutralize corneal irregularities and Retinal Concerns keep the ocular surface hydrated Preoperative management is a during wear.21 keystone of optometric care with The DEWS report from 2013 regard to ocular and visual health,

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Left & middle: Fundus photos taken in the office of a 73-year-old woman sent for cataract surgery. These photos were sent along with the patient’s chart, helping the surgeon to visualize the underlying RPE mottling and surrounding atrophy most dense superior nasal to the fovea OD and a widespread epiretinal membrane OS. Right: We recommended a monofocal implant, seen here with retroillumination, as the retinal pathology would cause too much variability and thus undermine the success of a multifocal IOL.

in addition to personality type and refraction through the implant, Prior Refractive Surgery priorities. Notes to the surgeon that respectively.27-29 In patients with Here is another scenario where reflect patient habits, prior suc- concurrent pathology, the way presbyopia gets the best of us, no cess with monovision or multifocal light is bent and strikes a diseased matter what procedure we had contacts or any clinical findings retina typically produces low rates to correct our distance vision in unique to the patient are helpful in of success with problems of dys- the past: “Doc, I had LASIK so I the surgical process. Any pathol- photopsia, worsening higher order wouldn’t need glasses for distance; ogy can result in decreased contrast aberrations and poor overall image now you are telling me I need them sensitivity, decreased acuity and an resolution.27,28 Due to the fragile again to read? You must be jok- unhappy patient experience.27-29 grasp we have on good vision with ing… right?” Document in detail epiretinal mem- these patients, we typically recom- According to the refractive sur- branes, macular degeneration or mend single vision (monofocal) lens gery council, the number of refrac- any form of retinal pathology that implants to keep the visual system tive surgery cases has grown just may affect vision. As such, a proper as balanced as possible.28,29 over 6% since 2017 alone.30 This is dilated exam and well-written sum- Any time we have any form of a true test to the advances in tech- mary to the surgeon are imperative posterior segment pathology, visual nology and high success rates for to success of any cataract surgery. A potential will change as retinal the industry, though it does affect macular OCT before cataract sur- disease progresses, which may our patients’ response to presbyopia gery is very important and helps in be exacerbated by premium IOL and tends to complicate matters the diagnosis of any suspecting and options.27,29 We usually will discuss when calculating IOL powers.30-32 subtle pathology.27-29 daily activities and what zone of Because of the improved technol- Studies show no single type of clear vision each patient values the ogy and high success rates, these IOL for these patients is completely most. From there we can make sure patients are so used to seeing well without complications; therefore, to maximize their visual potential at that any change in vision will be we try to keep our explanations their desired focal point in order to noticeable, putting more pressure simple.27-29 Research also shows that create a solid foundation for a posi- on the optometrist and ophthalmol- it is not possible to infer a direct tive visual outcome. ogist for superior visual outcomes relationship between cataract sur- For those patients who have mild without spectacle correction.31,32 gery and age-related maculopathies; cataracts and mild retinal pathol- The best thing to do here is to instead, we must use our clinical ogy, we may even steer them into keep our patient’s thinking as posi- judgment and that of the surgeon a non-surgical option for the time tive as possible and manage their to determine if cataract surgery will being. This way we can still modify expectation for all viewing dis- help the patients’ quality of life.27 their prescription while letting tances. Highlight how their experi- Diffractive and refractive optics mother nature run her course with ence is a lot easier to manage post (or both) with multifocal IOLs possible progression of these con- refractive surgery vs. prior. It has cause light interference or light current etiologies.29 been a blessing that they have seen

28 REVIEW OF OPTOMETRY JULY 15, 2020 Slit Lamps so well for so long, reiterating that 1. Fricke T, Tahhan N, Resnikoff S, et al. Global prevalence of presbyopia and vision impairment from uncorrected presbyopia. Ophthalmol. LED SLIT LAMP they only need to wear correction 2018;125(10):1492–9. 2. Mancil G, Bailey I, et al. Optometric Clinical Practice Guideline Care for part of the day because their Of The Patient With Presbyopia. www.aoa.org/documents/optometrists/ MW50D distance vision is still so clear. CPG-17.pdf. 2010. Accessed June 1, 2020. 3. Charman N. Developments in the correction of presbyopia: spectacle The goal of any lenticular and contact lenses. Ophthalmic and Physiologic Optics. 2014;34(1):8- 29. implant is to maximize clear vision 4. Alvarez T, Kim E, Granger-Donetti B. Adaptation to progressive addi- tive lenses: potential factors to consider. Sci Rep. 2017;7(1):2529. at the patient’s specific desired 5. Gray L. The prescribing of prisms in clinical practice. Graefes Arch ranges while reducing glare and Clin Exp Ophthalmol. 2008:246(5):627-9. 6. Meister, D. Understanding Prisms In Lenses. 18 February 2014. minimizing post-surgical distor- http://experiencevelocity.com/static_exentriqdotcom/documents/ 31,32 Zeiss_83466/825b9e6c-ca80-490f-9c2b-e87b3ecc2612.pdf. tion. Patients with previous 7. Cook P. Prisms and progressives. 20/20. 2013;40(12):66-72 refractive surgery are already more www.2020mag.com/article/prisms-and-progressives. 8. Antony J. Prisms in Clinical Practice. Kerala Journal of Ophthalmol- likely to have a higher risk for post- ogy. 2017; 29(2): 79-85. 9. Barnett M. Multifocal scleral lenses. Contact Lens Spectrum. www. operative dryness and higher-order clspectrum.com/issues/2015/december-2015/multifocal-scleral- aberrations.31,32 While there is no lenses. December 1, 2015. Accessed April 9, 2020. 10. Barnett M. 10 tips to enhance scleral contact lens success. cure-all implant for our patients, Optometry Times. www.optometrytimes.com/article/10-tips-enhance- scleral-contact-lens-success/page/0/4. June 20, 2017. Accessed historical refractive data is very April 9, 2020. important for the surgeon prior to 11. Employment Projections. Civilian labor force by age, sex, race, and ethnicity. U.S. Bureau of Labor Statistics. www.bls.gov/emp/tables/ IOL calculation. civilian-labor-force-summary.htm. September 4, 2019. Accessed April 25, 2020. 12. Stapleton F, Alves M, Bunya VY, et al. TFOS DEWS II Epidemiology Just as presbyopia motivates Report. Ocul Surf. 2017;15(3):334–65. 13. ColesBC, Sulley A, Young G. Management of digital eye strain. Clin patients into the exam chair, it can Exp Optom. 2019;102(1):18-29. 14. Chang C. Presbyopia aggravates dry eye disease. J Clin Exp Oph- also motivate them to put their thalmol. 2017;8:3(Suppl). trust in their eye care providers. 15. Craig J, Nichols K, Akpek E, et al. TFOS DEWS II Definition and classification report. The Ocular Surface. 2017;15(3):276-83. The importance of dialogue cannot 16. Gu Q, Dillon CF, Burt VL NCHS Data Brief. Prescription drug use continues to increase: U.S. prescription drug data for 2007-2008. be stressed enough; simply knowing 2010;(42):1-8. how to talk to the patient in your 17. Markoulli M, Kolanu S. Contact lens wear and dry eyes: challenges and solutions. Clin Optom (Auckl). 2017;9(2):41–8. chair can be the difference between 18. Olson M, Korb D, Greiner J. Increase in tear film lipid layer thickness following treatment with warm compresses in patients with mei- management success and failure. bomian gland dysfunction. Eye Contact Lens. 2003;29(2):96–9. Clean, ergonomic design Knowing your audience is indis- 19. Nichols K, Foulks G, Bron A, et al. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol combined with exceptional pensable, and using this can help Vis. Sci. 2011;52(4):1922-9. 20. Urgacz A, Mrukwa E, Gawlik R. Adverse events in allergy sufferers 50X High-Mag Optics patients better absorb the science wearing contact lenses. Postepy Dermatol Alergol. 2015;32(3):204–9. of presbyopia correction. The solu- 21. Haines L. Scleral lens use in dry eye syndrome. Contact Lens Update. www.contactlensupdate.com/2017/07/26/scleral-lens-use-in- tions are as ever changing as the dry-eye-syndrome. July 26, 2017. Accessed April 10, 2020. Employs a natural color LED light source 22. Foulks GN, et al. 2007 Report of the International Dry Eye Work- problem itself and this realization is shop (DEWS). The Ocular Surface. 2007; 5(2):114. (closest wavelength to a halogen lamp), imperative to our patient’s progress. 23. Harthan JS, Shorter E. Therapeutic uses of scleral contact lenses for ocular surface disease: patient selection and special considerations. e ectively reducing the blueish light that There is not one right answer Clin Optom (Auckl). 2018;10:65–74. 24. Takahide K, Parker PM, Wu M, et al. Use of fluid-ventilated, gas- when satisfying near vision permeable scleral lens for management of severe keratoconjunctivitis appears on most slit images. demands, but knowing the process sicca secondary to chronic graft-versus-host disease. Biol Blood Mar- row Transplant. 2007;13(9):1016-21. and how to manage each type of 25. Norman C. Prescribing for presbyopia. Contact Lens Spectrum. Wide magnication range enables both www.clspectrum.com/issues/2017/july-2017/prescribing-for-presby- presbyopic patient will spell contin- opia. July 1, 2017. Accessed April 24, 2020. wide angle view and detailed observation. uous financial and practice growth 26. Gall R, Wick B, Bedell H. Vergence facility: establishing clinical utility. Optom Vis Sci. 1998; 75(10): 731-742. for years to come. ■ 27. Casparis H, Lindsley K, Kuo I, et al. Surgery for cataracts in people with age-related macular degeneration. Cochrane Database Syst Rev. All optics are multi-coated and provide a Maj. Luft practices at Towne 2017;2(2):CD006757. Lake Eye Associates in Woodstock, 28. Grzybowski A, Wasinska-Borowiec W, Alio J, et al. Intraocular lenses brighter viewing system with 22% higher. in age-related macular degeneration. Graefes Arch Clin Exp Ophthal- GA. He is a Fellow of the American mol. 2017;255(9):1687–96. 29. Lamoureux E, Hooper C, et al. Impact Of cataract surgery on quality Academy of Optometry. of life in patients with early age-related macular degeneration. Optom O ers a unique drum magnication from Dr. Barbush practices at Levin Vis Sci. 2007;84(8)683-8. 30. Number of LASIK surgeries in the United States from 1996 to 2020 5X to 50X. Eye Care in Baltimore, MD. He is (in 1,000). Statista. www.statista.com/statistics/271478/number-of- lasik-surgeries-in-the-us. July 18, 2016. Accessed June 10, 2020. an Adjunct Assistant Clinical Pro- 31. Patel R, Karp C, Yoo S, et al. Cataract surgery after refractive sur- fessor and preceptor for SUNY and gery. Int Ophthalmol Clin. 2016;56(2):169–180. 32. Savini G, Hoffer K. Intraocular lens power calculation in eyes with Salus Colleges of Optometry. previous corneal refractive surgery. Eye and Vis. 2018; (5):18. MEASURE BEYOND PRESSURE WITH CORNEAL HYSTERESIS & GET A BETTER PRESSURE MEASUREMENT WITH IOPcc.

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· © 2020 AMETEK, Inc. & Reichert, Inc. (06-2020) · Ocular Response Analyzer, Tono-Pen AVIA, and Quick-Tap are registered trademarks of Reichert, Inc. · Designed & assembled in USA · References: 1. Medeiros FA, Meira-Freitas D, Lisboa R, Kuang TM, Zangwill LM, Weinreb RN. Corneal hysteresis as a risk factor for glaucoma progression: a prospective longitudinal study. Ophthalmology. 2013 Aug;120(8):1533-40. 2. De Moraes CV, Hill V, Tello C, Liebmann JM, Ritch R. Lower corneal hysteresis is associated with more rapid glaucomatous visual field progression. J Glaucoma. 2012 Apr-May;21(4):209-13. 3. Susanna CN, Diniz-Filho A, Daga FB, Susanna BN, Zhu F, Ogata NG, Medeiros FA. Am J Ophthalmol. A Prospective Longitudinal Study to Investigate Corneal Hysteresis as a Risk Factor for Predicting Development of Glaucoma. 2018 Mar;187:148- 152. doi: 10.1016/j.ajo.2017.12.018. 4. Felipe A. Medeiros, MD and Robert N. Weinreb, MD. Evaluation of the Influence of Corneal Biomechanical Properties on Intraocular Pressure Measurements Using the Ocular Response Analyzer. J Glaucoma 2006;15:364–370. 5. Goldmann and error correcting tonometry prisms compared to intracameral pressure. McCafferty S, Levine J, Schwiegerling J, Enikov ET. BMC Ophthalmol. 2018 Jan 4;18(1):2. *CATS™ Tonometer Prism is distributed by Reichert Techonologies · CATS is a trademark of CATS Tonometer, LLC · CATS logo is a registered trademark of CATS Tonometer, LLC. Lifestyle Intervention

Optometry’s Role in the Diabetes Epidemic If you can get all patients—but especially those at risk—to focus on these five lifestyle modifications, the benefits would be immense. By Kevin Cornwell, OD

ver the past several decades, optometrists have moved from the Osidelines into a more integral role when it comes to providing care for diabetes patients. Given optometrists’ position as frontline healthcare providers, our involvement in diabetes management should begin, not end, at a patient’s initial diagnosis. Many patients with prediabetes or type 2 diabetes believe A 58-year-old female presented for her first eye exam without knowing she had type 2 they have an irreversible heredi- diabetes and was found to have diabetic retinal changes OU. tary condition. While this may be the case for those with type 1 (DR) and serve as an adjunct to After considering the fact that one diabetes, a completely different the breakthrough treatments we’re in three adults has prediabetes, we story exists for patients with type 2 continuing to see. can see that almost half of the US diabetes. adult population is at risk of sight- This article discusses the optom- Prevalence and Cost threatening retinopathy, morbidity etrist’s expanding role in managing According to the CDC, more than and mortality, as diabetes is among type 2 diabetes (and prediabetes) 34 million US adults have diabetes, the leading causes primarily due to and offers different lifestyle recom- seven million of whom are undiag- its association with cardiovascular mendations that can help patients nosed.1 The number of Americans disease.1,3 manage their health and overcome diagnosed with diabetes has almost Approximately one in three dia- potential long-term diabetic ocular doubled over the past 20 years, betic patients have some form of complications. While these inter- with 95% of cases being type DR, with up to 24,000 new cases ventions do not replace standard- 2 diabetes.1 Optometrists alone occurring each year—a number of-care diabetes management, they diagnose type 2 diabetes in more that is expected to increase 40% can prevent the onset and slow the than a quarter-million patients by 2050.4-6 DR is the leading cause progression of diabetic retinopathy each year based on our eye exams.2 of vision loss among US adults.7

32 REVIEW OF OPTOMETRY JULY 15, 2020 Each year, the US continued encourage- healthcare system ment, all while building spends $327 billion to a good rapport. manage diabetes, its Patients should be complications and the advised to collaborate resulting loss in produc- with their PCP prior to tivity.8 Healthcare costs engaging in any dietary for diabetes patients are or lifestyle interven- more than double those tion, as modification to of unaffected patients.8 insulin dosage or other Regardless of changes medications may be to US healthcare policy, necessary. no amount of reform Here are five changes can indefinitely sustain to advocate for all this growing economic A 66-year-old female had a history of uncontrolled type 2 diabetes and patients, but vulnerable burden. severe nonproliferative retinopathy with diabetic macular edema OU. patients in particular: Given these stagger- ing statistics, this is an all-hands- mation or slow results and find it 1. Cut Sugar Consumption on-deck scenario for healthcare harder to commit to a healthier life- One of the first topics to address providers who interact with style. Motivate them to stick it out is excessive sugar consumption, patients who have type 2 diabetes, and put in the work now so it pays including fructose and artificial prediabetes or metabolic syndrome. off later. sweeteners.9-14 In 1822, consump- It is no longer solely the responsi- Start by identifying one area tion of added sugars in the Ameri- bility of the primary care provider for the patient to focus on and can diet was equivalent to one (PCP) or dietician to discuss the provide tangible steps for them to 12oz can of soda every five days.11 importance of lifestyle intervention. work toward. Encourage habits Today, the average American con- that are feasible for them, and ask sumes this amount of sugar every Start the Conversation them to determine how a healthier seven hours.11 Do not assume When discussing lifestyle interven- lifestyle would benefit them person- patients have already addressed tion with patients, it’s crucial to ally. Making this connection could excess sugar consumption in an meet them where they’re comfort- ultimately lead to a more positive effort to control their diabetes and able and tailor the conversation in a outcome. optimize their health. way that is manageable so they can It can also be useful to have Fructose consumption often flies engage in and benefit from the con- patients keep a journal of their fast- under the radar for patients trying versation. Asking open-ended ques- ing and postprandial blood sugars to make healthy dietary changes. tions can help start and continue the so they can track exactly what Average fructose consumption dialogue in a non-threatening way. works for them (and what doesn’t). in the United States exceeds 50g For ODs with access to a patient’s This can help provide clarification per day and is higher among lab work, mentioning their last for those who may otherwise be adolescents.12 Excess fructose A1c and including specific results overwhelmed or unsure of where to consumption is directly associ- can be another beneficial conversa- start. ated with elevated fasting blood tion starter. Have printed resources These patients must understand glucose levels, hyperinsulinemia, available to patients that they can that improving their retinopathy, metabolic syndrome and cardio- reference on their own time. blood sugar and overall health is a vascular disease.13,14 Limiting daily Patients who are more moti- slower process, with diabetic reti- fructose intake to less than 20g per vated to make the necessary dietary nal changes taking more than six day (the equivalent of 1.5 apples) and lifestyle changes are likely to weeks to improve in most cases, but and avoiding products containing respond more proactively and posi- failing to do so could have destruc- high-fructose corn syrup are good tively to discussion. Some patients tive effects. It can help to check in starting points for patients with may feel uncomfortable with change with patients periodically to recap metabolic problems, including type or frustrated with conflicting infor- previous conversations and provide 2 diabetes.13

REVIEW OF OPTOMETRY JULY 15, 2020 33 Lifestyle Intervention

2. Limit Eating Time carbohydrate restric- Intermittent fasting and tion.19 Tracking apps, time-restricted eating such as “MyFitnessPal,” (TRE) were common are useful tools for help- practices over 100 years ing patients understand ago in the pre-insulin their daily intake and days that were used identify where their cal- by doctors to optimize ories are coming from. health and longevity for One of the most their diabetic patients. heavily researched Newer research shows nutritional interven- that TRE remains prom- tions for carbohy- ising as an effective drate restriction is the adjunct therapy for con- Mediterranean-style trolling blood glucose Mild diabetic retinopathy OS with early parafoveal macular edema in dietary approach. By levels in type 2 diabetes. a 62-year-old male improved with TRE and carbohydrate restriction. definition, the Mediter- TRE can optimize ranean diet is lower in insulin resistance, fasting blood Hemoglobin A1c was reduced by carbohydrates and higher in healthy glucose level, body composition almost 1%, and liver enzymes, fats.20 Studies consistently show and circadian rhythm.15 TRE also which are classic in non-alcoholic improvements in glycemic control, improves cardiovascular biomark- fatty liver disease, were reduced by weight loss, hemoglobin A1c and ers, such as total cholesterol, roughly 10%.15 Diet quality and other cardiovascular risk factors triglycerides, blood pressure and physical activity remained stable.15 with this diet.20 The Mediterranean high sensitivity C-reactive protein No adverse events were reported.15 diet is more efficacious than both (hs-CRP). The recent literature on TRE may arguably be the easiest low-fat and vegetarian-style dietary meal timing is so promising that lifestyle intervention for patients to interventions for type 2 diabetes.21 the American Heart Association understand and implement, as they Other popular low-carb approaches advocates for it to optimize cardio- do not have to learn and adhere to include the paleo, whole30 and metabolic health.16 a new diet or meal plan. This is the ketogenic diets. The typical daily feeding win- best option for patients who would Using telemedicine to educate dow exceeds 15 hours on aver- rather change not what they eat, patients with type 2 diabetes on the age.17 In TRE, meal-timing is but when they eat. benefits of sustainable carbohydrate limited to an eight- to 12-hour restriction, one company’s recent window. Essentially, the patient’s 3. Cut the Carbs two-year trial reported a remission daily caloric intake remains the This is probably where you’ll rate in diabetes of approximately same, but breakfast is pushed later encounter the most resistance, but 7% and an average A1c reduction and dinner is pushed forward. it cannot be ignored. The literature of 0.9%.19 This is encouraging, Only one in 10 adults habitually on the efficacy of dietary interven- given that less than 2% of patients maintains a 12-hour fasting win- tion in type 2 diabetes is vast and with type 2 diabetes achieve dow every day.15 conflicting at times. Regardless of long-term remission with current A recent study looking at TRE which nutritional approach patients standard-of-care management.22 in patients with metabolic syn- adopt, studies seem to consistently By contrast, one in three patients drome found that timing meals demonstrate a direct relationship with type 2 diabetes who undergo within a 10-hour window (allow- between carbohydrate restriction (a bariatric surgery achieve long-term ing a 14-hour nightly fast) over daily glycemic carbohydrate intake remission.23 12 weeks had the most favorable less than 45% of total calories) and outcomes on many cardiometa- improvements in insulin resistance 4. Optimize Sleep Schedule bolic markers.15 These included and A1c.18 Cardiovascular risk fac- Consistent, quality sleep is one of improved insulin resistance, body tors, including total cholesterol, the most underrated factors when mass index, low-density lipoprotein triglycerides, blood pressure and hs- it comes to metabolic health. Get- cholesterol and blood pressure.15 CRP, also significantly improve with ting seven to eight hours of sleep

34 REVIEW OF OPTOMETRY JULY 15, 2020 TREAT OCULAR INFLAMMATION AND INFECTION, AND... TURN ON RELIEF

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Indications and Usage WARNINGS & PRECAUTIONS: • Viral infections – Use with history of The development of secondary infection • IOP increase – Prolonged use may result herpes simplex requires great caution. has occurred. Fungal infections of the For steroid responsive infl ammatory ocular The course and severity of many viral cornea may occur. Secondary bacterial conditions of the palpebral and bulbar in glaucoma with damage to the optic conjunctiva, cornea, and anterior segment nerve, defects in visual acuity and fi elds infections of the eye (including herpes ocular infection following suppression of the globe and chronic anterior uveitis, of vision. IOP should be monitored. simplex) may be exacerbated. of host responses also occurs. corneal injury from chemical, radiation or • Aminoglycoside sensitivity – Sensitivity • Fungal infections – Fungal infections Non-ocular adverse events (0.5% to 1%) thermal burns, or penetration of foreign of the cornea may occur and should included headache and increased bodies for which a corticosteroid is to topically applied aminoglycosides may occur. be considered in any persistent blood pressure. indicated and where the risk of superfi cial corneal ulceration. Please see Brief Summary bacterial ocular infection is high or where • Cataracts – Posterior subcapsular there is an expectation that potentially • Use with systemic aminoglycosides – of Full Prescribing Information cataract formation may occur. dangerous numbers of bacteria will be Total serum concentration of on the adjacent page. present in the eye. • Delayed healing – May delay healing tobramycin should be monitored. and increase the incidence of bleb a ADVERSE REACTIONS: Randomized, investigator-masked, active-controlled, formation. Perforations of the cornea parallel-group trial conducted at 7 private practice The most frequent adverse reactions Important Safety or sclera have occurred. Slit lamp clinical sites in the United States with 122 adult Information (<4%) to topical ocular tobramycin are patients who had moderate to severe blepharitis/ biomicroscopy, and fl uorescein staining hypersensitivity and localized ocular blepharoconjunctivitis.1 CONTRAINDICATIONS: should be conducted. toxicity, including eye pain, eyelid pruritus, bMulticente r, double-blind, parallel-group, single-dose Most viral disease of the cornea and eyelid edema, and conjunctival hyperemia. study of 987 patients receiving a single dose of • Bacterial infections – May suppress 2 conjunctiva including epithelial herpes TOBRADEX ST or TobraDex ophthalmic suspension. host response and increase secondary simplex keratitis (dendritic keratitis), The reactions due to the steroid References: 1. Torkildsen GL, Cockrum P, Meier E, et al. vaccinia, and varicella, and also in ocular infections. In acute purulent component are increased intraocular Curr Med Res Opin. 2011;27(1):171-178. 2. Scoper SV, mycobacterial infection of the eye conditions, steroids may mask infection pressure with possible development Kabat AG, Owen GR, et al. Adv Ther. 2008;25(2):77-88. and fungal disease of ocular structures. or enhance existing infection. If signs and of glaucoma, and infrequent optic Hypersensitivity to any components symptoms fail to improve after 2 days, nerve disorder; subcapsular cataract; of the medication. the patient should be re-evaluated. and impaired healing.

© 2020 Eyevance Pharmaceuticals LLC. All rights reserved. TOBRADEX® ST and XanGen™ are trademarks of Eyevance Pharmaceuticals LLC. All other trademarks are the property of their respective owners. TST-01-20-AD-04 TOBRADEX® ST (tobramycin/dexamethasone Delayed healing: May delay healing and increase the ophthalmic suspension) 0.3%/0.05% incidence of bleb formation after cataract surgery. In those diseases causing thinning of the cornea or sclera, Brief Summary perforations have been known to occur with the use of topical steroids. This Brief Summary does not include all the information needed to use TOBRADEX ST safely and Bacterial infections: May suppress the host response and effectively. Please see Full Prescribing Information thus increase the hazard of secondary ocular infections. In acute purulent conditions, steroids may mask infection for TOBRADEX ST at MyTobraDexST.com. or enhance existing infection. If signs and symptoms fail to improve after 2 days, the patient should be re-evaluated. INDICATIONS AND USAGE Viral infections: Treatment in patients with a history of TOBRADEX ST is a topical antibiotic and corticosteroid herpes simplex requires great caution. Use of ocular steroids combination for steroid-responsive inflammatory ocular may prolong the course and may exacerbate the severity of conditions for which a corticosteroid is indicated and where many viral infections of the eye (including herpes simplex). superficial bacterial ocular infection or a risk of bacterial ocular infection exists. Fungal infections: Fungal infections of the cornea are particularly prone to develop with long-term use. Ocular steroids are indicated in inflammatory conditions Fungal invasion must be considered in any persistent of the palpebral and bulbar conjunctiva, cornea and anterior corneal ulceration. segment of the globe where the inherent risk of steroid use in certain infective conjunctivitides is accepted to obtain Use with systemic aminoglycosides: Use with systemic a diminution in edema and inflammation. They are also aminoglycoside antibiotics requires monitoring for total indicated in chronic anterior uveitis and corneal injury from serum concentration of tobramycin. chemical, radiation or thermal burns, or penetration of foreign bodies. ADVERSE REACTIONS The use of a combination drug with an anti-infective The most frequent adverse reactions to topical ocular ® component is indicated where the risk of superficial ocular tobramycin (TOBREX ) are hypersensitivity and localized infection is high or where there is an expectation that ocular toxicity, including eye pain, eyelids pruritis, eyelid potentially dangerous numbers of bacteria will be present edema, and conjunctival hyperemia. These reactions occur in the eye. in less than 4% of patients. Similar reactions may occur with the topical use of other aminoglycoside antibiotics. DOSAGE AND ADMINISTRATION Non-ocular adverse events occurring at an incidence of 0.5% Recommended Dosing: Instill one drop into the to 1% included headache and increased blood pressure. conjunctival sac(s) every four to six hours. During the initial The reactions due to the steroid component are: increased 24 to 48 hours, dosage may be increased to one drop every intraocular pressure (IOP) with possible development of 2 hours. Frequency should be decreased gradually as glaucoma, and infrequent optic nerve disorder; subcapsular warranted by improvement in clinical signs. Care should be cataract; and impaired healing. taken not to discontinue therapy prematurely. Secondary Infection. The development of secondary infection has occurred. Fungal CONTRAINDICATIONS infections of the cornea are particularly prone to develop with Nonbacterial Etiology: TOBRADEX ST is contraindicated long-term use. Fungal invasion must be considered in any in most viral diseases of the cornea and conjunctiva persistent corneal ulceration. Secondary bacterial ocular including epithelial herpes simplex keratitis (dendritic infection following suppression of host responses also occurs. keratitis), vaccinia, and varicella, and also in mycobacterial infection of the eye and fungal diseases of ocular structures. USE IN SPECIFIC POPULATIONS Pregnancy and Nursing Mothers Hypersensitivity: Hypersensitivity to any component of There are no adequate and well controlled studies in the medication. pregnant women. TOBRADEX® ST ophthalmic suspension should be used during pregnancy only if the potential benefit WARNINGS AND PRECAUTIONS justifies the potential risk to the fetus. Caution should be IOP increase: Prolonged use of corticosteroids may result exercised when TOBRADEX® ST is administered to a nursing in glaucoma with damage to the optic nerve, defects in woman. visual acuity and fields of vision. IOP should be monitored. Pediatric Use: Safety and effectiveness in pediatric Aminoglycoside sensitivity: Sensitivity to topically patients below the age of 2 years have not been established. applied aminoglycosides may occur. Geriatric Use: No overall differences in safety or Cataracts: May result in posterior subcapsular effectiveness have been observed between elderly and cataract formation. younger patients. Rx Only Distributed by: Eyevance Pharmaceuticals LLC. Fort Worth, TX 76102

© 2020 Eyevance Pharmaceuticals LLC. All rights reserved. TOBRADEX® ST is a trademark of Eyevance Pharmaceuticals LLC. All other trademarks are the property of their respective owners. TST-01-20-MS-05 Lifestyle Intervention per night is crucial for patients Depending on practice modality, type 2 diabetes in the Etude Epidemiologique Aupres Des Femmes De La Mutuelle Generale De L’Education Nationale- looking to manage their type 2 dia- office location and insurance plan, European Prospective Investigation into Cancer and Nutrition betes and overall health.24 The risk some patients may even be eligible Cohort. Am J Clin Nutr. 2013;97(3):517-23. 10. Nettleton JA, Lutsey PL, Wang Y, et al. Diet soda intake of developing or worsening diabe- for discounted or free gym mem- and risk of incident metabolic syndrome and type 2 diabetes tes increases with sleep durations berships. Share this with patients in the Multi-ethnic Study of Atherosclerosis (MESA). Diabetes 24 Care. 2009;32(4):688-94. outside this range. so they know their options. 11. Guyenet S. By 2606, the US diet will be 100 percent When patients report poor qual- sugar. Whole Health Source. February 18, 2012. whole- healthsource.blogspot.com/2012/02/by-2606-us-diet-will- ity sleep, it opens the door for As integral members of the health- be-100-percent.html. Accessed June 4, 2020. optometrists to discuss potential care team, optometrists have been 12. Vos MB, Kimmons JE, Gillespie C, et al. Dietary fructose underlying issues, such as sleep consumption among US children and adults: the third encountering a growing num- National Health and Nutrition Examination Survey. Medscape apnea and excessive exposure to ber of patients presenting with J Med. 2008;10(7):160. blue light at night. Sleep apnea uncontrolled (and undiagnosed) 13. Kelishadi R, Mansourian M, Heidari-Beni M. Associa- tion of fructose consumption and components of metabolic can be a common comorbidity in metabolic diseases, such as type 2 syndrome in human studies: a systematic review and meta- metabolic syndrome, diabetes and diabetes. No longer can we defer analysis. Nutrition. 2014;30(5):503-10. 14. Brown CM, Dulloo AG, Montani JP. Sugary drinks in the glaucoma, so referring appropri- to a patient’s other healthcare pathogenesis of obesity and cardiovascular diseases. Int J ate patients for a sleep study could providers to discuss the impor- Obes. 2008;32:S28-34. 15. Wilkinson MJ, Manoogian EMC, Zadourian A, et al. Ten- have a significant impact on their tance of evidence-based behavioral hour time-restricted eating reduces weight, blood pressure, health. Explaining that blue light changes in managing their health. and atherogenic lipids in patients with metabolic syndrome. Cell Metab. 2020;31(1):92-104. can cause circadian rhythm disrup- By educating patients on the risk of 16. St-Onge MP, Ard J, Baskin ML, et al. Meal timing and tion and melatonin suppression can permanent vision loss due to their frequency: implications for cardiovascular disease prevention: a scientific statement from the American Heart Associa- open the conversation up to the diabetes, we can help them lessen tion. Circulation. 2017;135(9):e96-121. importance of blue-blocking lens the risk of or altogether avoid long- 17. Gupta NJ, Kumar V, Panda S. A camera-phone based study reveals erratic eating pattern and disrupted daily technologies or apps for use before term ocular complications. n eating-fasting cycle among adults in India. PloS One. bedtime if screen time is unavoid- Dr. Cornwell graduated from 2017;12(3):e0172852. able.25,26 18. Snorgaard O, Poulsen GM, Andersen HK, et al. Sys- the New England College of tematic review and meta-analysis of dietary carbohydrate Optometry in 2015 and completed restriction in patients with type 2 diabetes. BMJ Open Diabe- 5. Value Consistent Exercise tes Res Care. 2017;5(1):e000354. a residency in ocular disease with 19. Athinarayanan SJ, Adams RN, Hallberg SJ, et al. Long- The discussion would be incom- the Indian Health Service. He term effects of a novel continuous remote care intervention plete without addressing the works at a rural community health including nutritional ketosis for the management of type 2 diabetes: a 2-year non-randomized clinical trial. Frontiers. importance of regular exercise and center in northern California where June 5, 2019. www.frontiersin.org/articles/10.3389/ movement. Some patients may feel he provides eye care to populations fendo.2019.00348/full#B4. Accessed June 4, 2020. 20. Huo R, Du T, Xu Y, et al. Effects of Mediterranean-style discouraged by or overwhelmed in need and helps patients manage diet on glycemic control, weight loss and cardiovascular risk with a new fitness routine. It is ocular manifestations of various factors among type 2 diabetes individuals: a meta-analysis. Eur J Clin Nutr. 2015;69(11):1200-8. important to convey that even systemic diseases. 21. Schwingshackl , Chaimani A, Hoffmann G, et al. A net- basic exercises, such as walking work meta-analysis on the comparative efficacy of different 1. CDC. National Diabetes Statistics Report, 2020. www. dietary approaches on glycaemic control in patients with type for 20 minutes per day, can signifi- cdc.gov/diabetes/library/features/diabetes-stat-report.html. 2 diabetes mellitus. Eur J Epidemiol. 2018;33(2):157-70. cantly benefit patients’ metabolic Accessed June 4, 2020. 22. Karter AJ, Nundy S, Parker MM, et al. Incidence of remis- 27 2. AOA. 21st-century optometric care for the 21st-century sion in adults with type 2 diabetes: the diabetes & aging health. Consistency matters more pandemic. www.aoa.org/news/clinical-eye-care/21st- study. Diabetes Care. 2014;37(12):3188-95. than intensity of exertion. century-optometric-care. Accessed June 4, 2020. 23. Sjöström Lars, Peltonen M, Jacobson P, et al. Association 3. CDC. National Diabetes Statistics Report, 2017. dev. of bariatric surgery with long-term remission of type 2 dia- Comorbidities (e.g., rheumatoid diabetes.org/sites/default/files/2019-06/cdc-statistics- betes and with microvascular and macrovascular complica- report-2017.pdf. Accessed June 4, 2020. arthritis, obesity) may prevent 4. Lee R, Wong TY, Sabanayagam C. Epidemiology of diabetic tions. JAMA. 2014;311(22):2297-304. patients from engaging in pro- retinopathy, diabetic macular edema and related vision loss. 24. Shan , Ma H, Xie M, et al. Sleep duration and risk of type Eye Vis (Lond). 2015;2:17. 2 diabetes: a meta-analysis of prospective studies. Diabetes longed periods of weight-bearing 5. CDC. Economic studies. www.cdc.gov/visionhealth/proj- Care. 2015;38(3):529-37. movement. Non-weight-bearing ects/economic_studies.htm. Accessed June 4, 2020. 25. Chang AM, Aeschbach D, Duffy JF, et al. Evening use of 6. NEI. Diabetic retinopathy data and statistics. www.nei.nih. light-emitting eReaders negatively affects sleep, circadian exercises such as swimming, aqua gov/learn-about-eye-health/resources-for-health-educators/ timing, and next-morning alertness. Proc Natl Acad Sci USA. aerobics and stationary cycling eye-health-data-and-statistics/diabetic-retinopathy-data- 2015;112(4):1232-7. and-statistics. Accessed June 4, 2020. 26. Green A, Cohen-Zion M, Haim A, et al. Evening light are viable alternatives. Remind 7. CDC. Watch out for diabetic retinopathy. www.cdc.gov/ exposure to computer screens disrupts human sleep, features/diabeticretinopathy/index.html. Accessed June 4, proactive patients that whatever 2020. biological rhythms, and attention abilities. Chronobiol Int. they enjoy doing to stay active will 8. ADA. Economic costs of diabetes in the U.S. in 2017. care. 2017;34(7):855-65. diabetesjournals.org/content/early/2018/03/20/dci18-0007. 27. Qiu S, Cai X, Schumann U, et al. Impact of walk- likely be the most sustainable rou- Accessed June 4, 2020. ing on glycemic control and other cardiovascular risk 9. Fagherazzi G, Vilier A, Sartorelli DS, et al. Consumption factors in type 2 diabetes: a meta-analysis. PloS One. tine for them moving forward. of artificially and sugar-sweetened beverages and incident 2014;9(10):e109767.

REVIEW OF OPTOMETRY JULY 15, 2020 37 Progression

26th Annual Glaucoma Report Glaucoma: The Perils of Progression Controlling this disease requires a long-term, fluid management plan. These six tips can help you navigate the complicated road ahead. By Brian D. Fisher, OD, David W. Johnson, OD, and April J. Fisher, OD

pen-angle glaucoma decline.2 This article discusses (OAG) is a chronic six considerations to help clini- and visually devastat- cians navigate the complicated Oing disease with mini- management decisions necessary mal symptoms until it reaches once a patient shows signs of the advanced stage. The goal glaucoma progression. throughout treatment is to stave off progression and ensure a life- 1. Assess Risk Factors time of preserved vision.1 Unfortunately, disease progres- But once progression is sion isn’t always cut-and-dry. detected, the practitioner is faced Many patients progress slowly with a challenging decision: with little impact on their vision re-educate the patient on the while others progress rapidly current regimen to boost medi- with devastating consequences.1 cation adherence or change the To help detect rapid and severe treatment course. Thoroughly progression, clinicians should educating patients about the pro- perform three visual fields in the gressive nature of glaucoma and first year (i.e., at diagnosis, six its treatments can help patients months and 12 months); in year understand the importance of Fig. 1. This patient’s 24-2 field shows moderate two, patients should have one medication compliance. visual field damage with central involvement. visual field every six months. If If compliance is not the issue, the examination rules out rapid clinicians should ensure the patient current management, clinicians must progression (i.e., greater than 0.5dB/ is using proper drop instillation evaluate the risk factor profile for year on mean deviation or pattern techniques, as some patients may progression, target intraocular pres- standard deviation), clinicians can struggle with dexterity. sures (IOPs), and medication adher- scale back to one visual field per Once clinicians address these ence and burden. Other important year if the patient remains stable issues, they can then reconsider the considerations include the potential (i.e., 0.1dB/year). efficacy of the medication regimen benefits and risks of surgery and the Thus, one of the most important prescribed. risks of functional vision impair- factors in advancing glaucoma is the Before considering a change in the ment if left untreated vs. age-related rate of progression. Ancillary testing

38 REVIEW OF OPTOMETRY JULY 15, 2020 with optical coherence tomography of decreased vision related quality comes, clinicians must consider the (OCT) and visual fields can help of life due to glaucoma and the risks risks and benefits before establishing clinicians document structural and of treatment.5 While insufficient a target IOP for each patient.5 Con- functional changes associated with evidence shows setting target IOPs siderations include short and long- progression (Tables 1-3). is associated with better clinical out- term IOP fluctuations, inter-observer Once progression is determined, clinicians must consider the patient’s Table 1. OCT RNFL Progression19-25 age, general health status, life expec- • No current reference standard on limit of RNFL thinning that confirms progression. tancy and expected rate of decline • Event-based change: repeatable inter-visit change in average thickness ≥5µm. with current treatment to design the • Trend-based change of global average thickness loss equaling 2µm to 3µm/year. best adjunctive therapeutic approach • Widening of existing thinning and defect on guided progression analysis. Inferotemporal based on each patient’s risk of visual widening and thinning is more common than supratemporal. decline.1,2 For example, patients aged 70 or older with slowly progressing glaucoma likely require less intense treatment or sometimes no additional treatment at all, while young glaucoma patients with fast progressing disease require quick action, an aggressive approach and possibly surgery. Certain optic disc features can indicate a higher risk of visual decline in glaucoma patients. These include an increasing vertical cup- to-disc ratio with preferential rim loss to the inferior, inferotemporal, supratemporal and superior regions, the presence of Drance hemorrhages, increasing size of the parapapillary beta zone and new localized retinal nerve fiber layer (RNFL) defects.3 Other important clinical features putting the patient at risk for further disease progression include severe staging at the time of diagnosis, type of glaucoma (i.e., pseudoexfoliation, pigment dispersion) and large mean deviation (<-12.00dB) on perimetry. Higher peak and average IOPs at baseline, higher mean IOP or large IOP variation also put the patient at a higher risk for visual decline.1,2

2. Be Wary of Target IOPs Studies show each 1mm Hg of increased IOP is associated with a 10% to 19% increased risk of progression.4 The best IOP for each patient isn’t necessarily a static num- Fig. 2. This visual field readout shows trend-based change, which indicates visual ber—it’s a balance between the risk field progression.

REVIEW OF OPTOMETRY JULY 15, 2020 39 Progression

variability, patient life expectancy glaucomatous damage is occurring cians may do better focusing on and treatment adherence. and the status of the fellow eye.5 reducing treatment side effects rather When resetting target IOPs after Researchers suggests target IOPs than achieving a particular IOP.5 adjusting a patient’s glaucoma regi- may be particularly useful for To complicate matters further, men, clinicians must evaluate the patients at high risk of substantial a patient’s target IOP will likely amount of glaucomatous damage, vision loss and blindness.5 For those change over time, especially if they the average range of IOPs at which with low risk for visual loss, clini- experience accelerated progression with the current target or if the fel- Shedding LiGHT on SLT low eye’s visual status becomes sig- The LiGHT Study Group conducted a large, prospective, randomized controlled trial with 718 nificantly reduced.4 patients (1,235 eyes) to compare standardized 360° SLT with eye drops in treatment-naïve Target IOPs are useful broad patients. The majority of patients in each treatment arm were diagnosed with either OHTN or guidelines in OAG therapy but mild OAG—approximately 30% and 50%, respectively. Prostaglandin analogs were offered should not be used in isolation from as the primary topical agent followed by adjunctive therapy with β-blockers, then carbonic other information. Serial ancillary anhydrase inhibitors or α-agonists. The patients were monitored for three years.7 SLT was not testing can help clinicians highlight associated with any serious adverse events, but approximately one-third of patients experi- progression and modify therapeutic enced transient effects such as discomfort, blur, photophobia and ocular hyperemia. measures when indicated. The SLT-first group experienced fewer drop-related side effects (5.7%) compared with the With an appropriate IOP target medication-first arm (20.2%), likely secondary to the reduction in the mean number of drops range and continuous reassessment, necessary in the former group.7 This is consistent with reports from pooled analyses compar- glaucoma progression can be con- ing SLT with eye drops for OAG, including data from the LiGHT Study Group, demonstrating siderably slowed to reduce the prob- that SLT is effective at significantly reducing the number of topical medications necessary for ability of decreased vision-related adequate IOP control.8 The percentage of visits at target IOP was slightly higher for the SLT quality of life.4 group when compared with the medication-first group: 93% vs. 91.3%. Fewer treatment escalations occurred in the SLT-first arm, none of which led to trabeculec- 3. Set New Baselines tomy compared with 11 eyes in the medication-first group. Ultimately, 74% of patients treated Once new therapy is initiated, clini- with SLT first were stable at three years without using any topical therapy. A second SLT was cians must establish new baselines necessary in 25.7% of eyes. There were no significant differences in visual acuity, IOP or for perimetry, OCT RNFL and gan- mean deviation loss on visual field testing between the two groups at the study’s conclusion.7 glion cell analysis (GCA), and photo The LiGHT Study Group did not report data on medication adherence or persistence, which documentation. The practitioner can significantly impact treatment escalations and outcomes. Studies show as few as 33% to does not need to perform additional 39% of patients persist with the initially prescribed medication at one year.28 tests when setting these new baseline The LiGHT trial design is clinically relevant due to its individualized treatment approach in parameters. Instead, they can refer- which patients with more severe disease were assigned a lower initial target IOP with modifi- ence the last two tests performed to cations made according to widely accepted and implemented clinical guidelines. Furthermore, set a new baseline.1,2 Furthermore, it measured SLT success as controlling progression of neuropathy, rather than a percentage guided progression analysis will of IOP reduction. By stratifying these data based on disease stage, it showed a single SLT was support the analysis for trend-based far more likely to result in a controlled status without drops at three years in patients having change with these tests. either OHTN (72.8%) or mild OAG (64.3%) when compared with eyes with moderate (33.3%) and severe (9.6%) OAG.7 4. Consider SLT That is not to say SLT was ineffective in lowering IOP in more advanced stages. The mean Selective laser trabeculoplasty (SLT) treatment effect was similar among all stages (approximately 8mm Hg). It more likely reflects was approved by the FDA in 2001 a standalone inability to meet the more stringent IOP goals newly diagnosed advanced dis- and has since proven itself an effec- ease warrants.6 tive method for lowering IOP.6 SLT In another study, 180° SLT was successful in 50% of eyes with advanced OAG when mea- is often considered in cases of inad- sured against the criteria of 30% IOP reduction from pre-treatment value and <18mm Hg.29 equate IOP reduction with medica- However, randomized controlled trial studies comparing SLT with medication-only treatment tions, intolerance, allergy or poor groups largely include milder cases of glaucoma, so further research is necessary to elucidate adherence to medications (e.g., due the role of SLT in advanced cases; for now, filtration surgery remains the standard in the con- to cost, cognitive decline, insufficient text of progressive neuropathy.8,29 dexterity or tremor) and may be recommended at various points in the

40 REVIEW OF OPTOMETRY JULY 15, 2020

Progression

Table 2. OCT GCA Progression19-25 advanced disease or lower base- 6. Prepare for the Last Defense • No current reference standard on limit of line IOP can still benefit from SLT Medical therapy is effective for the GCA thinning that confirms progression. but may need adjunctive medical majority of glaucoma patients, but • Event-based change: repeatable inter- therapy; however, it is likely fewer surgical means are recommended visit change in average thickness ≥4µm. drops will be necessary—relatively when patients experience fast rates • Trend-based change of global average sparing the ocular surface and of functional and/or structural pro- loss equaling 1µm to 1.5µm/year. potentially improving the patient’s gression, central visual field loss, • Widening of existing ganglion cell-inner medication adherence.7,8 suboptimal hypotensive IOP control plexiform layer thinning and defect. with medical therapy and SLT, or Inferotemporal more common than 5. Do Your MIGS Research they have uncontrolled moderate- supratemporal due to inferotemporal In particular circumstances, mini- severe disease.15 axons projecting to the macular mally invasive glaucoma surgery Incisional glaucoma filtration vulnerability zone. (MIGS) may be a good option for surgery includes trabeculectomy and mild to moderate glaucoma patients glaucoma drainage devices such as undergoing cataract surgery. A the Ahmed glaucoma valve or Baer- treatment arc, including as the initial recent study shows 22% of cataract veldt glaucoma implant.11 treatment option. surgeries performed by glaucoma Despite an increasing safety pro- Currently, SLT is less commonly specialists in 2016 included a MIGS file over the years, these techniques offered as first-line therapy com- procedure.10 Numerous MIGS have higher postoperative risks pared with topical medications for procedures exist, and they are mini- compared with nonincisional surger- ocular hypertension (OHTN) or mally traumatic to the surrounding ies, such as late-onset bleb infection OAG. Recent evidence suggests SLT tissue and exhibit minimal tissue dis- and endophthalmitis, hypotony should be considered as a safe, effec- ruption. The various safety profiles maculopathy, choroidal effusion or tive alternative to medication as a are excellent compared with inci- hemorrhage, flat anterior chamber, primary therapy for a large subset of sional surgery and glaucoma drain- corneal damage and cataract.11 these patients.7,8 age device implantation.11-13 Wound Because of these risks, incisional The Laser in Glaucoma and healing is rapid with Ocular Hypertension Trial (LiGHT) good preservation Study Group found SLT could suc- of vision.11-13 cessfully arrest progression in 74% Furthermore, of patients with OHTN and newly MIGS are combined diagnosed OAG for a period of at with cataract sur- least three years without medica- gery, and efficacy tions—a finding that should encour- shows moderate to age providers to consider SLT as high IOP-lowering first-line therapy.7 capabilities. One Clinicians must consider many meta-analysis shows factors before recommending SLT a decrease in IOP to a patient, but they have fewer and a reduction in factors to consider if the goal is an glaucoma medica- attempt to eliminate glaucoma medi- tions after MIGS cation burden. It is well-established surgery with low that a high baseline IOP positively complication rates.14 correlates with the conventional This therapeutic measure of SLT success of ≥20% option could allow IOP reduction.9 a significant number The LiGHT Trial shows us that of OAG patients to patients with OHTN and mild reduce their medica- OAG are the most likely cohorts to tion burden with a achieve drop-free disease control lower risk of com- Fig. 3. This visual field readout shows event-based change, at three years.6 Patients with more plications.3,14 indicating visual field progression.

42 REVIEW OF OPTOMETRY JULY 15, 2020 26 Amsterdam: Kugler Publications; 2010. Table 3. Visual Field Progression Despite these disadvantages, 6. Garg A, Vickerstaff V, Nathwani N, et al. Primary selective • Requires at least three visual fields. incisional surgery does provide laser trabeculoplasty for open-angle glaucoma and ocular hypertension: Clinical outcomes, predictors of success, and • The last two consecutive visual fields must be an IOP reduction of 30% to safety from the laser in glaucoma and ocular hypertension trial. reliable and repeatable. 50% and should be strongly Ophthalmology. 2019;126(9):1238-48. 7. Gazzard G, Konstantakopoulou E, Garway-Heath D, et • Event-based change of new defects in a previ- considered when the ben- al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma ous normal area showing: efits of surgery outweigh the (LiGHT): A multicentre randomised controlled trial. Lancet. • 1-point with greater than 10dB regression. risks.18 Therapeutic surgical 2019;393(10180):1505-16. 8. Chi SC, Kang Y, Hwang D, Liu CJ. Selective laser trabeculo- • Within the central 10° with two or more management should not only plasty versus medication for open-angle glaucoma: Systematic points with more than 5dB regression. maintain the patients’ visual review and meta-analysis of randomised clinical trials. Br J Ophthalmol. February 12, 2020. [Epub ahead of print]. • Outside the central 10° with three or more field and functional vision 9. Garg A, Gazzard G. Selective laser trabeculoplasty: Past, present, and future. Eye (London). 2018;32(5):863-76. points with more than 5dB regression. but also preserve their quality 10. Vinod K, Gedde SJ, Feuer WJ, et al. Practice preferences for • Event-based change within existing defects: of life and independence.12,13 glaucoma surgery: a survey of the American Glaucoma Society. J Glaucoma. 2017;26(8):687-93. • 1-point with greater than 15dB regression. Clinicians must weigh the 11. Francis BA, Sarkisian SR, Tan JC. Minimally Invasive Glau- • Within the central 10° with any point with risks and benefits of incisional coma Surgery: A Practical Guide. New York: Thieme. 2017;1-2. 12. Janz NK, Wren PA, Lichter PR, et al. Quality of life in newly more than 10dB regression. surgery and only recommend diagnosed glaucoma patients: the Collaborative Initial Glaucoma Treatment Study. Ophthalmol. 2001;108:887-97. • Outside the central 10° with three or more these options when absolutely 13. Pahlitzsch M, Klamann MKJ, Pahlitzsch M, et al. Is there a points with more than 10dB regression on critical to stabilize aggressive change in the quality of life comparing the micro-invasive glaucoma surgery (MIGS) and the filtration technique trabeculec- two consecutive fields or more than 5dB glaucomatous progression. tomy in glaucoma patients? Graefes Arch Clin Exp Ophthalmol. on three consecutive fields. 2017;255:351-57. 14. Lavia C, Dallorto L, Maule M, et al. Minimally invasive glau- • Trend-based change on guided progression Optometrists’ primary goal in coma surgeries (MIGS) for open angle glaucoma: A systematic review and meta-analysis. PLoS One. 2017;12(8):e0182142. analysis of: the management of glaucoma 15. Weinreb RN. Glaucoma Surgery: The 11th Consensus • Slope of p<1% on visual field index. is to ensure a lifetime of visual Report of the World Glaucoma Association. Amsterdam: Kugler Publications; 2019. • “Likely progression.” function to meet patients’ 16. Shah M. Micro-invasive glaucoma surgery - an interven- • Glaucoma Rate Index27 visual demands. No perfect tional glaucoma revolution. Eye Vis (Lond). 2019;6:29. 17. Bhartiya S, Dhingra D, Shaarawy T. Revisiting results of con- • Newer method to detect long-term visual formula exists to determine ventional surgery: trabeculectomy, glaucoma drainage devices, and deep sclerectomy in the era of MIGS. J Curr Glaucoma field progression in glaucoma. which therapeutic approach Pract. 2019;13(2):45-49. • Studies show it can provide earlier detec- is best. By evaluating patients’ 18. Zhou, M., Wang, W., et al. Trabeculectomy with verses without releasable sutures for glaucoma: a meta-analysis of tion compared with point linear regression risk for visual decline, medica- randomized controlled trials. BMC Ophthalmol. 2014; 14(1):41. and guided progression analyses. 19. MacDonald D. OCT interpretation for glaucoma diagnosis tion adherence and burden, and management. 2019 American Academy of Optometry • Validation with future studies for general- and the pros and cons of Conference. Orlando, fL, October 23, 2019. 20. Leung CK, Yu M, Weinreb RN, et al. Retinal nerve fiber layer ized use are still needed. surgery, clinicians can indi- imaging with spectral-domain optical coherence tomography: vidualize a therapeutic plan to patterns of retinal nerve fiber layer progression. Ophthalmology. 2012;119:1858-66. surgery is reserved for those with address any apparent progres- 21. Leung CK. Diagnosing glaucoma progression with optical coherence tomography. Curr Opin Ophthalmol. 2014;25:104- rapidly progressing glaucoma sion—and preserve vision as long as 11. regardless of stage, those with severe possible. n 22. Wollstein G, Kagemann L, Bilonick RA, et al. Retinal nerve fibre layer and visual function loss in glaucoma: the tipping glaucoma who failed with medical Drs. Brian Fisher and David point. Br J Ophthalmol. 2012;96:47-52. and noninvasive therapies and those Johnson work at The Villages VA 23. Mwanza JC, Durbin MK, Budenz DL, et al. Interocular symmetry in peripapillary retinal nerve fiber layer thickness with risk of visual impairment due Outpatient Clinic, The Villages, Fla. measured with the Cirrus HD-OCT in healthy eyes. Am J Oph- thalmol. 2011;151:514-21. to progressing central visual field Dr. April Fisher is an optometrist 24. Sullivan-Mee M, Ruegg CC, Pensyl D, et al. Diagnostic loss.16,17 Furthermore, incisional at Ocala West VA Community precision of retinal nerve fiber layer and macular thickness asymmetry parameters for identifying early primary open-angle surgery requires intense postopera- Based Outpatient Clinic, Ocala, Fla. glaucoma. Am J Ophthalmol. 2013;156:567-77. tive healing, wound modulation and 25. Mwanza JC, Oakley JD, Budenz DL, et al. Ability of Cirrus 1. Weinreb RN. Progression of Glaucoma: The 8th Consensus HD-OCT optic nerve head parameters to discriminate normal strict follow-up exams to manage Report of the World Glaucoma Association. Amsterdam: Kugler from glaucomatous eyes. Ophthalmology. 2011;118:241-8. postoperative complications. Publications; 2011. 26. Chu E, Hicks D. 50 Glaucoma facts: an evidence based 2. Weinreb RN. Diagnosis of Primary Open Angle Glaucoma: overview for the primary care practitioner. 2019 American There can be more disadvantages The 10th Consensus Report of the World Glaucoma Association. Academy of Optometry Conference. Orlando, fL, October 25, Amsterdam: Kugler Publications; 2017. 2019. than benefits in the mild to moder- 3. Cymbor M, Lifferth A. Progressing glaucoma: When to man- 27. Salazar D, Morales E, Rabiolo A, et al. Pointwise methods to ate glaucoma patient or for patients age with meds, laser, and surgery. 2019 American Academy of measure long-term visual field progression in glaucoma. JAMA Optometry Conference. Orlando, fL, October 24, 2019. Ophthalmol. 2020;138(5):536-43. who want to reduce the medication 4. Sihota R, Angmo D, Ramaswamy D, Dada T. Simplifying “tar- 28. Schwartz GF, Quigley HA. Adherence and persistence with get” intraocular pressure for different stages of primary open- glaucoma therapy. Surv Ophthalmol. 2008;53(6):S57-S68. burden because therapeutic efficacy angle glaucoma and primary angle-closure glaucoma. Indian J 29. Schlote T, Schlote T, Kynigopoulos M, Kynigopoulos can gradually decrease over time, Ophthalmol. 2018;66:495-505. M. Selective laser trabeculoplasty (SLT): 1-year results in 5. Liebmann J, Weinreb RN. Medical Treatment of Glaucoma: 17 early and advanced open angle glaucoma. Int Ophthalmol. requiring repeat surgery. The 7th Consensus Report of the World Glaucoma Association. 2016;36(1):55-61.

REVIEW OF OPTOMETRY JULY 15, 2020 43 12th Annual OPTOMETRIC GLAUCOMA SYMPOSIUM Join our faculty of renowned ODs and MDs for a highly interactive meeting covering the most up-to-date information in glaucoma care. Earn up to 12 CE credits*

SOUTHWEST October 2-3, 2020 Austin Marriot Downtown 304 East Chavez Street Austin, TX 78701 Phone: 512-457-1111

Discounted room rate: $299 plus tax Please book with the hotel directly at 512-457-1111. Identify yourself as a participant of Southwest Optometric Glaucoma Symposium for group rate. Rooms are limited. Early bird registration: $275 Full conference after August 7: $325 See event website for daily fees. REGISTER ONLINE: www.reviewedu.com/SWOGS2020 EMAIL: [email protected]

Administered by:

*Approval pending Review Education Group partners with Salus University for those ODs who are licensed in states that require university credit. Earn up to COVID-19 Statement: See Website for Important Updates 12 CE Credits*

PROGRAM CO-CHAIRS

Murray Fingeret, OD, FAAO Robert N. Weinreb, MD Chief of the Optometry Section, Chairman & Distinguished Professor of Ophthalmology Brooklyn/St. Albans Campus, Director of the Shiley Eye Institute Department of Veterans Administration Director of the Hamilton Glaucoma Center New York Harbor Health Care System Morris Gleich, M.D. Chair in Glaucoma Clinical Professor, University of California San Diego SUNY, College of Optometry

WEST COAST December 11-12, 2020 Hyatt Regency Huntington Beach 21500 Paciﬁ c Coast Highway Huntington Beach, CA 92648 Phone: 714-698-1234 Discounted room rate: $239 plus tax Please book with the hotel directly at 877-803-7534. Identify yourself as a participant of West Coast Optometric Glaucoma Symposium for group rate. Rooms are limited. Early bird registration: $275 Full conference after October 16: $325 See event website for daily fees. REGISTER ONLINE: www.reviewedu.com/WCOGS2020 EMAIL: [email protected]

Administered by:

*Approval pending Optic Disc

What’s Your Disc Diagnosis? These cases can help you better differentiate tough optic disc abnormalities. By Ashley Kay Maglione, OD, and Kelly Seidler, OD

ccurate evaluation of the optic disc is a critical part of optometric practice. When Aa disc is not “perfused, healthy, distinct and flat,” it can be difficult to differentiate between anatomic variations and pathology. Clinicians must take a systematic approach to optic disc evaluation, carefully assessing the margins, color of the neuroretinal rim, cup- to-disc ratio and overall size of the nerve. This case-based review provides photos and clinical pearls to Fig. 1. Despite unremarkable entrance testing with no visual complaints, the patient’s help you enhance your assessment optic disc evaluation shows mild elevation with sectoral blurred margins nasally and of optic disc abnormalities. superiorly OU.

Case 1: Surprise Elevation lopia and a 2 to 4 prism diopter Discussion. The optic disc pho- A 43-year-old African American comitant esophoria in all gazes. tos demonstrate elevation OS>OD, female presented for her annual Her anterior segment exam was raising the question of papilledema exam without any visual com- remarkable for palpebral conjunc- vs. pseudopapilledema (Table 1). plaints. Her health history was tival pallor, consistent with her When asked about symptoms of remarkable for hypothyroidism, history of anemia. Intraocular pres- increased intracranial pressure— asthma and iron-deficiency anemia. sures (IOPs) measured 16mm Hg such as headaches, pulsatile tinni- Entrance testing was unremarkable OD and 15mm Hg OS. Her blood tus, nausea, vomiting, diplopia and with 20/20 vision uncorrected OD pressure was elevated at 142/86mm transient visual obscurations—the and OS, full confrontation visual Hg RAS. She was above her ideal patient reported occasional head- fields bilaterally and no relative body weight at 240lbs. Her dilated aches and “seeing stars” when she afferent pupillary defect. fundus exam revealed subtle eleva- bent down. She denied any other She exhibited 90% of normal tion more so in the left eye than the symptoms or use of tetracyclines, abduction bilaterally with no dip- right (Figure 1). vitamin A derivatives or oral

46 REVIEW OF OPTOMETRY JULY 15, 2020 contraceptives. She exhibited ered patent. Therefore, she was no spontaneous venous pulse scheduled for follow-up with (SVP). In addition, upon analy- neurology on an outpatient sis of the vitreoretinal interface basis for presumed idiopathic on optical coherence tomogra- intracranial hypertension. phy (OCT), she demonstrated Treatment was initiated with subtle peripapillary wrinkles in acetazolamide and weight loss the left eye, suggestive of mild was recommended. papilledema (Figure 2). The presence of peripapil- Due to her ocular findings, lary wrinkles on the vitreo- she was sent for urgent neuroretinal interface was important imaging that included magnetic in raising the suspicion of resonance imaging (MRI) of papilledema on initial exam. the brain and magnetic reso- Subsequent close optometric nance venography of the head monitoring with assessment to rule out a mass and venous of the afferent system, dilated sinus thrombosis. MRI is the Fig. 2. In this patient’s en face OCT vitreoretinal fundus exam and serial OCT preferred neuroimaging modal- interface image of the left eye, note the wrinkles scans is now indicated to assess ity due to superior soft tissue superior temporal, consistent with Paton’s lines or the effectiveness of treatment resolution and better visual- peripapillary wrinkles that are not readily visible and thus verity the working ization of particular findings funduscopically. diagnosis. consistent with intracranial hypertension such as optic nerve a relationship.2,3 The coexistence Case 2: Problem Rising sheath distension, empty sella and of Chiari 1 malformation and to the Surface posterior globe flattening.1 Imaging pseudotumor cerebri in patients A 17-year-old Caucasian female showed no evidence of intracranial with papilledema can create diag- presented for a routine examina- mass or venous sinus thrombosis; nostic and treatment dilemmas. In tion. Her health history was unre- however, she did exhibit low-lying patients with papilledema, Chiari markable, and her only medication cerebellar tonsils concerning for I malformation may be considered was oral contraceptives. She denied Chiari I malformation. causative if there is obstruction of symptoms of increased intracranial Chiari 1 malformation is eight cerebrospinal fluid (CSF) flow.2,3 pressure. times more common in patients In this patient, lumbar puncture Her best-corrected visual acuity with pseudotumor cerebri than was deferred due to cerebellar ecto- was 20/15 OD and OS. She exhib- the general population, suggesting pia; however, CSF flow was consid- ited a subtle, 0.3 log unit relative

Table 1. Papilledema vs. Pseudopapilledema Differentiating these clinical entities can be quite challenging. • B-scan remains the standard for assessing presence of buried Causes of pseudopapilledema are relatively benign and include optic nerve head drusen. buried optic disc drusen and small, anomalous and/or hypoplastic • As technology improves, OCT is increasingly used in the discs. Papilledema is, by definition, optic disc edema in the setting diagnosis of optic disc drusen. The ODDS Consortium of increased intracranial pressure and is a medical emergency. recommends the use of enhanced-depth OCT imaging for Several tests can aid in the evaluation: adequate visualization of disc drusen. With OCT, the optic • OCT of the peripapillary RNFL can be particularly helpful, as disc drusen appear as hyporeflective structures with a hyper- the en face images can reveal subtle peripapillary wrinkles reflective margin. Additionally, no RNFL thickness value reliably that would otherwise be difficult to view funduscopically. differentiates papilledema from pseudopapilledema. • Fundus autofluorescence may help to highlight optic disc • The presence of an SVP viewed upon direct ophthalmoscopy drusen, which appear hyper-autofluorescent. However, may suggest that an elevated disc is not secondary to patients with optic disc drusen may also have overlying increased intracranial pressure. Clinicians should view several edema, and the buried disc drusen will not hyper- rhythmic beats of a vein, as eye movement can occasionally autofluoresce. mimic the appearance of a non-sustained pulse.

REVIEW OF OPTOMETRY JULY 15, 2020 47 Optic Disc

afferent pupillary defect Clinicians must also in the left eye. Humphrey consider the possibility of a automated visual fields simultaneous presentation of revealed a normal field in disc edema and disc drusen; the right eye and a supe- however, in this case overly- rior nasal defect with an ing papilledema was con- enlarged blind spot in the sidered less likely given the left (Figure 3). Efferent test- presence of a definite SVP ing was unremarkable with and the absence of symptoms no abduction deficit. She associated with increased exhibited no proptosis or intracranial pressure. None- ptosis. Pressures were 14mm theless, close serial monitor- Hg bilaterally. ing of the disc appearance, Her dilated fundus exam afferent system and OCT is revealed significant findings indicated to ensure no atypi- (Figures 4 and 5). cal progression. Discussion. While also exhibiting indistinct margins Case 3: Systemic of the optic disc as in case Suspicion 1, this patient’s presentation A 76-year-old Caucasian was attributed to optic disc male presented with a com- drusen. Fundus autofluores- plaint of a progressively cence (FAF) was an impor- Fig. 3. The patient’s 24-2 visual field OS demonstrates a worsening “cloud” over tant examination element small superior nasal step and enlarged blind spot. his vision OS. He had seen in this case, as it helped to another eye care provider confirm the presence of superficial Optic disc drusen are small, cal- approximately two months prior drusen in the left eye. cified deposits that become more and the previous fundus photo dem- In the absence of drusen, the apparent with age. They are typi- onstrated diffuse disc swelling OS. optic disc appears dark on fundus cally buried during childhood and His ocular history was otherwise autofluorescence whereas super- may initially appear as an optic disc remarkable for a traumatic retinal ficial drusen appear bright, or with indistinct margins. With age, detachment OD with resultant poor hyper-autofluorescent. The Optic they gradually become more super- vision. Disc Drusen Studies Consortium ficial and present with a bumpy His medical history was remark- (ODDS) found that the major- appearance. able for seropositive generalized ity of eyes with one superficial Optic disc drusen may pre- myasthenia gravis. He was diag- druse also had at least one buried dispose a patient to visual field nosed four months prior and was druse.4 Deeply buried drusen are defects, as seen in this patient, non- treated with pyridostigmine as well not visible with FAF, but B-scan arteritic anterior ischemic optic as prednisone and intravenous ultrasonography can be used to neuropathy (NAION), subretinal immunoglobulin during exacerba- detect buried drusen and is often hemorrhages and peripapillary cho- tions. His history was also signifi- indicated.5 roidal neovascular membranes.6 cant for orthostatic hypotension. His best-corrected visual acuity Table 2. True Disc Edema vs. Traction was counting fingers at one foot OD and 20/40- OS. The exam Unilateral Disc Edema Vitreopapillary Traction revealed a 3+ afferent pupillary Decrease in afferent function. Afferent function is largely intact in isolated VPT. defect OD. Confrontation visual Sectoral or diffuse elevation of optic disc. Tractional elevation of disc seen on OCT. fields were severely restricted OD Often associated with vasculopathic, and exhibited inferior constriction infectious and inflammatory etiologies, Often without associated pathology but may be OS (Figure 6). which should be assessed with seen in diabetic and other retinopathies. His anterior segment exam was appropriate blood work. unremarkable OS. Upon dilated

48 REVIEW OF OPTOMETRY JULY 15, 2020

Optic Disc

fundus examination, the disc was complaints of vision loss, and the While causation may be difficult flat and distinct OD, while the disc examination will demonstrate a to establish with certainty here, it showed significant findings OS corresponding decrease in visual was important to identify his sys- (Figure 7). acuity, visual field loss and an temic Lyme infection, which could, Discussion. The patient was afferent pupillary defect. Optic if untreated, lead to further vision diagnosed with sectoral disc edema papillitis can be caused by inflam- loss in a patient with already sig- in the left eye evidenced by blurred matory conditions, such as sarcoid- nificant vision impairment. hyperemic disc margins inferiorly. osis, and infectious diseases, such Note that there is no longer as Lyme disease and syphilis.7 Case 4: Gaining Traction swelling of the superior neuroreti- The patient was asked to A 52-year-old Caucasian male nal rim as documented by previous complete laboratory testing that presented for evaluation of bin- examination, and it appears that included ESR, CRP, FTA-ABS, ocular vertical diplopia that began he has subsequently developed pal- RPR, ACE, Lyme titer and ANA. following a recent stroke. His lor with a corresponding inferior If suspicion for sarcoidosis medical history was remarkable visual field defect. is high, consider ordering chest for type II diabetes, hypertension, Potential differentials of unilat- imaging, as ACE can be falsely hypercholesterolemia, a right tha- eral disc edema include arteritic low. Results were remarkable for lamic stroke, a myocardial infarc- and non-arteritic AION and optic elevated Lyme disease IgG and IgM tion, asthma, sleep apnea, anxiety, papillitis. Arteritic AION was con- antibodies on Western blot. depression and schizophrenia. sidered less likely as the patient did not present with symptoms of giant cell arteritis (GCA) such as headache, jaw claudi- cation, scalp tenderness, weight loss, reduced appetite, fatigue, amau- rosis fugax or pallid disc swelling. However, given his age and the potential devastating consequences, testing to rule out GCA—in the form of serum platelet, Fig. 4. These color fundus photos of the optic discs show that the margins of the right optic disc, ESR and CRP stud- at left, are indistinct nasally but are otherwise preserved temporal. The left optic disc, at right, has ies—was indicated and more indistinct margins with a notable superficial druse superior nasal. ordered. Non-arteritic AION may be considered in this case given the patient’s age and history of orthostatic hypotension; however, given his monocular status and risk of further vision loss, laboratory workup to rule out any potential etiology of papillitis was indicated. Patients with papil- Fig. 5. The patient’s fundus autofluorescent photos demonstrate significant autofluorescence of the litis often present with left optic disc, suggestive of more prominent drusen than what is evident funduscopically.

50 REVIEW OF OPTOMETRY JULY 15, 2020 Table 3. Pallor vs. Pseudo-pallor Pallor Pseudo-pallor OCT may show sloping of the OCT typically shows loss of peripapil- neuroretinal rim, scleral crescent or lary RNFL and GCL. large cupping without loss of RNFL. Corresponding afferent dysfunction (reduced visu-al acuity, dyschromatop- If afferent testing is intact and pseudo- sia, visual field defect, af-ferent pupil- pallor is suspected, serial monitoring lary defect, reduced brightness sense can be used to confirm the diagnosis. or red desaturation). May be associated with infectious, inflammatory, compressive and toxic/ Associated with tilted discs, high nutritional etiologies, which should be myopia, pseudophakia, large assessed with appropriate blood work physiologic cupping. and neuroimaging.

hyaloid face, can be and vein occlusion. Given the pres- visualized on the 5-line ence of telangiectatic vessels on OCT raster. the optic disc and systemic history, In addition to eleva- concurrent diabetic papillopathy tion of the optic disc, could be considered in this case; VPT can result in indis- but ultimately, long-term follow-up Fig. 6. The 24-2 automated visual field demonstrates tinct optic disc margins was helpful in excluding this diag- an inferior defect OS. and peripapillary hem- nosis.10,11 orrhage, making it diffi- This patient’s case demonstrates The patient’s best-corrected cult to differentiate from true optic the importance of considering VPT visual acuity was 20/20 OD and disc swelling, such as in AION and in optic disc elevation and looking OS. There was no afferent pupil- optic papillitis (Table 2).8 closely at the vitreoretinal interface lary defect and confrontation visual Therefore, clinicians must rule on OCT. fields were normal, as was color out these etiologies vision. with serum lab testing. Efferent testing demonstrated a As such, CBC, ESR, vertical misalignment diagnosed CRP, ACE, ANA and as skew deviation attributed to his RPR were ordered and history of known right thalamic unremarkable in this stroke. His dilated fundus exam case. His negative blood was unremarkable in the right eye. work results, along with His left eye showed significant normal afferent func- changes in optic disc appearance tion, helped to support and OCT imaging (Figure 8). the diagnosis of VPT as Discussion. As with case 3, this afferent visual function patient also exhibited sectoral disc is often affected in cases elevation; however, the etiology is of AION and optic pap- not true disc swelling but is instead illitis.9 tractional in nature. Vitreopapil- VPT has been lary traction (VPT) is a condition described in both eyes caused by adherence of a fibrotic without ocular pathol- membrane or incomplete posterior ogy, as well as in eyes vitreous detachment that raises the with pathology that may Fig. 7. The patient’s optic disc photo demonstrates optic disc margin. This patient’s result in fibrotic mem- inferior sectoral elevation with hyperemia. tractional elevation, induced by brane proliferation such Additionally, there is sectoral pallor of the superior partial detachment of the posterior as diabetic retinopathy neuroretinal rim OS.

REVIEW OF OPTOMETRY JULY 15, 2020 51 Optic Disc

Additionally, tilted optic discs can have a similar appearance and, in this case, a subtle tilt of the disc can be appreciated by viewing the horizontal tomogram on the OCT in which the temporal neuroretinal rim is lower and sloped. However, interpreting OCT of the peripapillary RNFL for thinning can be complicated by anatomical variation, such as shifted RNFL Fig. 8. Imaging reveals superior neuro- bundles, or even pathology, such as retinal rim elevation with telangeictatic disc swelling. Ganglion cell layer vessels. The OCT 5-line raster, at left, (GCL) analysis, in contrast, may not demonstrates vitreopapillary adhesion. be as affected by anatomical difference/swelling and can be a valuable Case 5: A Pale Masquerader true pallor is typically associated adjunctive tool for detecting retinal A 15-year-old African American with afferent pupillary defect, color ganglion cell death, implicating an male presented for re-evaluation vision loss, visual field defect or a optic neuropathy.12,13 Therefore, of his optic disc OS. He was seen combination of all three (Table 3). GCL analysis was beneficial as this one year prior by another provider OCT of the optic disc and peri- ruled out any thinning or loss sug- and was diagnosed with refrac- papillary retinal nerve fiber layer gestive of an optic neuropathy. tive amblyopia OD and suspected (RNFL) is a valuable tool to look Other conditions that a clinician pseudo-temporal pallor OS. He for anatomic variations or anoma- may be confronted with that can denied any visual complaints or lies that can give rise to the appear- mimic pallor include pseudophakic changes. He denied any history of ance of pseudo-pallor. For example, pallor, which is caused by change trauma or neurologic symptoms note in the patient’s OCT the in the lens optics, and large physi- such as headaches. His medical his- asymmetric disc diameter with the ologic cupping.14 In addition to a tory was remarkable for asthma. left disc (the one in question) being thorough afferent evaluation and His best-corrected visual acu- notably smaller than the right. This RNFL/GCL OCT, repeat evalua- ity was stable at 20/40 OD, 20/20 is important in this case, as small/ tion to ensure stability is helpful OS. Pupils were equal, round and hypoplastic discs may appear pale in confirming pseudo-pallor, as reactive to light with no afferent temporally, especially if there is a opposed to pallor caused by an pupillary defect OS. Confrontation concurrent scleral crescent active process. and automated visual fields were full without defects OU and color vision was normal. Refraction was remarkable for amblyogenic hyperopia OD. His posterior segment exam and OCT measurements were repeated and compared to findings from one year prior, with significant findings (Figures 9 and 10). Discussion. The diagnosis of stable pseudo-temporal pallor OS was made based on normal afferent function in the left eye and OCT. While some anomalous discs may exhibit associated afferent findings, the lack of any abnormalities Fig. 9. This patient’s fundus photo suggests a pale temporal neuroretinal rim in the OS was significant in this case, as left eye.

52 REVIEW OF OPTOMETRY JULY 15, 2020 Ultimately, while these tools can help differentiate true pallor from pseudo-pallor, if the judgement cannot be made with confi- dence, further work-up to rule out potentially treatable causes of optic neuropathy may be indicated.

Careful clinical examination in conjunction with ancillary testing such as OCT and visual fields are important in differentiating benign processes from potential neuro-ophthal- mologic emergencies. Critical assessment of the peripapillary region and optic nerve head for neuroretinal rim thinning, pallor and elevation is important in all patients to identify subtle disc anomalies and make the correct diagnosis. n Dr. Maglione works in the neuro-ophthalmic disease services at The Eye Institute and teaches didactically in Fig. 10. These are the patient’s OCT images upon initial exam, at left, and one year later, at right. The neuro-anatomy and OCT demonstrates an intact RNFL and GCL in both eyes. Note the small disc area OS compared with neuro-ophthlamic OD, as well as gradual sloping of the temporal aspect of the cup OS compared with the symmetric disease courses at the margins of the cup OD. Pennsylvania College of 1. Hingwala DR, Kesavadas C, Thomas B, et al. Imaging signs clinical update. Eye Brain. 2015;7:59-81. Optometry at Salus University. in idiopathic intracranial hypertension: Are these signs seen in 8. Hedges TR, Flattem NL, Bagga A. Vitreopapillary traction confirmed secondary intracranial hypertension too?. Ann Indian Acad Neurol. by optical coherence tomography. Arch Ophthalmol. 2006;124(2):279- Dr. Seidler graduated from the 2013;16(2):229-33. 81. 2. Alnemari A, Mansour TR, Gregory S, et al. Chiari I malformation with 9. Gabriel RS, Boisvert CJ, Mehta MC. Review of vitreopapillary traction Pennsylvania College of Optometry underlying pseudotumor cerebri: Poor symptom relief following posterior syndrome. Neuro-ophthalmol. February 26, 202. [Epub ahead of print]. decompression surgery. Int J Surg Case Rep. 2017;38:136-41. 10. Regillo CD, Brown GC, Savino PJ, et al. Diabetic papillopathy: at Salus University and recently 3. Aiken AH, Hoots JA, Saindane AM, Hudgins PA. Incidence of cerebel- patient characteristics and fundus findings. Arch Ophthalmol. completed a two-year advanced res- lar tonsillar ectopia in idiopathic intracranial hypertension: a mimic of 1995;113(7):889-95. the Chiari I malformation. AJNR Am J Neuroradiol. 2012;33(10):1901- 11. Sayin N, Kara N, Pekel G. Ocular complications of diabetes mellitus. idency program at The Eye Institute 06. World J Diabetes. 2015;6(1):92-108. 4. Malmqvist L, Bursztyn L, Costello F, et al. The Optic Disc Drusen 12. Chen JJ, Kardon RH. Avoiding clinical misinterpretation and in neuro-ophthalmic disease. Studies Consortium recommendations for diagnosis of optic disc artifacts of optical coherence tomography analysis of the optic nerve, drusen using optical coherence tomography, J Neuro-Ophthalmol. retinal nerve fiber layer, and ganglion cell layer. J Neuro-ophthalmol. The authors would like to thank 2018;38(3):299-307. 2016;36(4):417-38. 5. Tugcu B, Özdemir H. Imaging methods in the diagnosis of optic disc 13. Vieira LMC, Silva NFA, Dias dos Santos AM, et al. Retinal ganglion Erin Draper, OD, and Kelly Mal- drusen. Turk J Ophthalmol. 2016;46(5):232-36. cell layer analysis by optical coherence tomography in toxic and nutri- loy, OD, for their mentorship and 6. Palmer E, Gale J, Crowston JG, Wells AP. Optic nerve head drusen: tional optic neuropathy. J Neuro-ophthalmol. 2015;35(3):242-45. an update. Neuro-Ophthalmol. 2018;42(6):367-84. 14. Digre KB, Corbett JJ. Is the disc pale? In: Practical Viewing of the guidance. 7. Kahloun R, Abroug N, Ksiaa I, et al. Infectious optic neuropathies: a Optic Disc. Amsterdam: Butterworth-Heinemann; 2003:193-200.

REVIEW OF OPTOMETRY JULY 15, 2020 53 Cover Story

26th Annual Glaucoma Report Seven Ways Glaucoma Care is Changing Better drugs, safer surgeries, smarter diagnostics and new approaches are easing the burden on patients—and their ODs. By Michael Chaglasian, OD, and Sarah B. Klein, OD

n the ever-changing health care optometrist has a crucial role in for mild to moderate glaucoma, due landscape, optometrists have to determining the best way to do so, to an improved safety profile and constantly adapt to new needs whether it be through pharmaceuti- decreased risk of complications com- and responsibilities. Glaucoma cal intervention or surgical recom- pared with traditional glaucoma sur- I 2 in particular is emblematic of our mendations. With that, any chosen gery options. While efficacy may be evolving role, as advances in technol- method of IOP control necessitates modest as a whole compared with ogy, pharmaceuticals and research regular monitoring, which is more trabeculectomy, so too are side provide opportunities to expand our available to ODs than ever before, effects. Therein lies the category’s management of this sight-threaten- and allows us to effectively manage chief strength: the risk/benefit bal- ing condition. With the number of and comanage these patients with ance is decisively in its favor. glaucoma patients growing steadily, our ophthalmology colleagues. MIGS is also an excellent option even some ophthalmologists agree Here, we take a look at seven vital for patients who are noncompliant that optometrists have a vital role to advancements that have helped put with drops or have not responded play in glaucoma management and patient care into the hands of the well to procedures such as selective comanagement.1 primary care optometrist and how laser trabeculoplasty (SLT).3 Among To do so, we need to stay on we can use these technologies and the top players in this arena cur- top of improvements in glaucoma techniques to our patients’ advan- rently are the iStent Inject (Glaukos), care so that we can make the best, tage while moving the needle on the Hydrus Microstent (Ivantis), the evidence-based recommendations scope of practice expansion. Xen gel stent (Allergan) and vari- for our patients and be a crucial part ous canal-based procedures such as of a team whose ultimate goal is MIGS elevates the role of sur- iTrack (Ellex) and the Omni Surgi- to preserve sight for years to come. 1 gery. Minimally invasive glau- cal System (Sight Sciences). Though Lowering IOP is still the only known coma surgery (MIGS) has exploded ODs should be well-versed in all modifiable risk factor for glaucoma- over the past few years as one of the options, for the sake of brevity we’ll tous progression, and the average fastest-growing treatment categories review the iStent and Hydrus here.

54 REVIEW OF OPTOMETRY JULY 15, 2020 greater decrease with two iStents, as New drugs target different IOP- well as allow for a reduction in the 2 lowering mechanisms. After a number of postoperative IOP-low- 15-year drought in the United States ering medications needed to achieve without the approval of any glau- goal IOP.6 coma therapies, several new once- Postoperative care is similar to daily topical IOP-lowering that of cataract surgery alone, with medications have become FDA- no additional visits or medications approved over the past several years. needed, and is therefore straightfor- As prescribing IOP-lowering medica- ward for the comanaging optom- tions is in the domain of the optome- etrist.7 However, you may be able to trist in nearly every state, this is start discontinuing topical glaucoma exciting news that gives us addi- medication(s) as early as the day-one tional treatment options that do not This patient’s glaucoma was progressing post-op visit, adding them back as require comanagement. despite being on two medications. He necessary depending on the result.8 The first category involves the then developed an early cataract that Proper patient selection is always advent of the long-awaited rho was causing glare while driving at night. the key to success with any proce- kinase (ROCK) inhibitor netarsudil A MIGS device (iStent Inject) was used dure. Due to its excellent safety pro- 0.02%, an entirely new class of glau- in conjunction with his cataract surgery. file, iStent Inject can be confidently coma drug that works by decreasing Post-op IOP was 16mm Hg after stopping recommended for patients with ocu- episcleral venous pressure, decreas- one of his two meds. lar hypertension or mild to moderate ing trabecular meshwork resistance open-angle glaucoma (OAG) who and possibly reducing aqueous The iStent and iStent Inject are have concurrent visually significant production.10 It is available pack- tiny trabecular stents made of a bio- cataracts and healthy, open angles, aged alone as Rhopressa (netarsudil compatible titanium that provides an in the absence of inflammation, neo- 0.02%, Aerie Pharmaceuticals) or excellent safety profile with minimal vascular glaucoma or other innate or in combination with latanoprost as complications.4 The original iStent acquired angle abnormalities. They Rocklatan (Aerie Pharmaceuticals), device, which was 1mm/0.3mm in would need to be educated on the size, was implanted manually into risks (nearly none), benefits (poten- the trabecular meshwork (TM) in tial for reducing drop dependence) combination with cataract surgery, and cost, which varies based on with some technical difficulty and insurance coverage and copays. learning curve effect.5 The newer The Hydrus Microstent (Ivantis) iStent Inject boasts an even smaller is a small, flexible drainage device size (360/230µm) and is now the inserted in the TM parallel to Sch- smallest medical device implantable lemm’s canal; this procedure is also in the human body. Two stents are combined with cataract surgery. present in each preloaded applicator, Once inserted, it causes scaffolding and they are placed perpendicularly of the TM and increases outflow, into the TM two to three clock with increased likelihood of target- hours apart with relative technical ing collector channels due to its This patient was on two topical meds ease for the surgeon. 90-degree span in the anterior cham- for her glaucoma, a prostaglandin The two stents placed in this ber angle. Compared with phaco analog and a fixed-dose combination fashion improve access to aqueous alone, Hydrus has been shown to (brimonidine/timolol), and had SLT collector channels and improve the reduce IOP another 2.3mm Hg and within the last year. IOP was 20mm Hg chances of reaching an episcleral med use following surgery by 30% when this disc hemorrhage was noted vein, therefore improving the poten- through 24 months, with an average in the right eye. The patient declined tial for IOP reduction.5 Research reduction in IOP of 7.6mm Hg at surgical options. Rocklatan (netarsudil/ shows the original iStent reduces two years.9 Post-op care is again sim- latanoprost) was prescribed (one drop IOP significantly compared with ilar to phaco alone and can be easily every evening) as a substitute for the cataract surgery alone, with an even performed by the comanaging OD. PGA. The IOP was reduced to 16mm Hg.

REVIEW OF OPTOMETRY JULY 15, 2020 55 Cover Story

both for once-daily dosing. Netar- eral implants (Travoprost XR/ Durysta’s side effect profile is sudil has been proven effective alone, ENV515, Envisia) to punctal plugs similar to topical bimatoprost and lowering IOP up to 5mm Hg in its (OTX-TP travoprost insert, Ocular other prostaglandin analogs, but clinical trials, and in fixed combina- Theraputix) to scleral implants causes minimal to no ocular surface tion with latanoprost, it showed a (iDose, Glaukos). However, only one irritation due to its presence in the statistically superior IOP reduction has achieved FDA approval at this anterior chamber. However, given over latanoprost and netarsudil time. Durysta (bimatoprost implant its physical location, it is contrain- alone at every measured time point.11 10mcg, Allergan), a biodegradable dicated in patients with Fuchs’ dys- It has a unique side effect profile, intracameral implant, gained FDA trophy, prior corneal or endothelial with no serious systemic adverse approval in March 2020.16 cell transplant, and in the absence of events reported.10 The main ocular Durysta is a sustained-release drug a posterior lens capsule or posterior side effect is conjunctival hyperemia, delivery system injected through capsular tear.18 Considering the well- reported in 53% of patients on a clear corneal incision into the documented statistics regarding poor netarsudil alone and up to 59% of anterior chamber and rests in the patient compliance with topical glau- patients using Rocklatan. In clinical inferior chamber angle. It slowly coma meds, this implant will take practice, however, we have seen that releases bimatoprost and dissolves the responsibility out of the hands the hyperemia is most noted within over time. Durysta’s efficacy is com- of the patient at least for a period of the first few days of using the drug, parable to topical bimatoprost, with time, and will likely prove a reliable and is worse immediately following an IOP-lowering effect that lasts up treatment option going forward. administration, and therefore is rec- to six months.17 The FDA approval ommended at bedtime. is based on results from the two SLT gets the green LiGHT. SLT Launched in early 2018, Vyzulta 20-month Phase III ARTEMIS stud- 4 has long been recognized as an (latanoprostene bunod, Bausch ies evaluating safety and efficacy in effective treatment for IOP lowering + Lomb), a nitric oxide-donating 1,122 subjects vs. twice-daily topical in mild to moderate glaucoma prostaglandin analog, is another timolol drops in patients with OAG patients, since its original approval in relative newcomer to the market. It or ocular hypertension. In these stud- 2001. SLT’s predecessor, argon laser lowers IOP by a dual mechanism of ies, Durysta reduced IOP by approx- trabeculoplasty (ALT), has been enhancing uveoscleral outflow while imately 30% from baseline over the extensively studied and demon- also enhancing TM/Schlemm’s canal 12-week primary efficacy period. strated efficacy comparable to medi- outflow by inducing trabecular cyto- cal therapy as an initial treatment for skeletal relaxation.12 Research shows glaucoma.19 Vyzulta is more effective than latano- ALT and SLT have similar effi- prost alone, with an additional 2mm cacy but, as SLT is less destructive Hg or more of IOP-lowering ability histopathologically, it has the benefit in 42% of patients, and was proven of being able to be repeated.20 How- to have a greater IOP reduction than ever, in the US and other countries, timolol at nearly all time points mea- IOP-lowering medication is still the sured.13-15 The side effect profile is primary treatment offered in most minimal and comparable to earlier cases for early glaucoma and ocular generation prostaglandin analogs. hypertension. All three of these drugs are dosed This conventional wisdom is now once daily, which is always ideal for in question, and for good reason. compliance. Insurance coverage is In 2019, the results from the Laser improving across the country as well. This patient demonstrates rapid in Glaucoma and Ocular Hyperten- progression in the left eye. One of the sion (LiGHT) study were released, Sustained-release drug deliv- main reasons is her inability to remain and may lead to a paradigm shift 3 ery eases compliance burden. compliant with topical medications. in glaucoma treatment with more Many new and exciting sustained- She is also fearful of surgery and has patients being offered SLT as an ini- release drug delivery systems are in declined several options. She is being tial treatment option. The results of the pipeline for the treatment of considered for a drug delivery system this observer-masked, randomized glaucoma, ranging from intracam- such as Allergan’s Durysta. controlled trial performed in the UK

56 REVIEW OF OPTOMETRY JULY 15, 2020 support the theory that SLT is just Home-based as, if not more, effective than medi- 5 monitoring cation for maintaining goal IOP.21 In reduces dependence on fact, at 36-month follow up, 74.2% the exam room. If the of SLT eyes required no drops to last few months have maintain goal IOP and were within taught us anything, it’s target at more visits (93%) than in that times are chang- the medication group (91.3%).22 ing. With the onset of The iCare Home measurement report gives the highest None of the SLT patients required COVID-19 and the and lowest IOP for each eye, as well as the day and time. glaucoma surgery to maintain goal evolution of how we It provides clinicians a quick overview of IOP measures IOP during the follow-up period vs. are living our daily outside of office hours. 11 patients in the eye drop group.22 lives in healthcare and This efficacy, along with a favor- beyond, we clinicians may be asked when taken over a seven-day period, able side effect profile and improved (or forced) to adapt our methods. and has demonstrated what we think cost effectiveness compared with that We are questioning the most safe and we know already about diurnal flux, of topical meds, makes SLT a great sanitary way to check IOP in the with IOP measurements tending to choice for first-line therapy.21 It also office with the debate vacillating be highest in the early morning and eliminates the issue of compliance, between disposable Goldmann lower later in the day.23 Although which is a constant struggle that’s applanation tips (Tonosafe, Haag it has been accused of correlating frustrating to ODs everywhere when Streit) to Tonopen to iCare. There poorly with Goldmann applanation trying to manage glaucoma with are also some interesting home care tonometry readings, it can be a use- topical medications that are left in options for glaucoma management ful tool to gain the bigger picture the hands of the patient. This pivotal now available that may take on a in patients that may be progressing study should influence our decision larger role in months and years to despite showing normal readings in making going forward when consid- come if we find our patients avoiding the exam room.24 Multiple studies ering initial treatment for glaucoma the office setting due to safety con- have proven that higher degrees of and ocular hypertension. It forces cerns related to the pandemic. IOP fluctuation are an independent us to have a conversation with our The iCare Home is a “rebound” risk factor for glaucoma progression, patients about their initial treatment tonometer that patients can use at and many glaucoma experts agree options, and at the very least to con- home to measure their own IOP, that the consideration of IOP vari- sider referral to a glaucoma specialist which can be helpful in monitoring ability should be a piece of the puzzle capable of performing SLT—includ- the status of their disease and the when managing glaucoma patients.24 ing ODs in some states. risk for progression. It is a handheld The iCare Home tonometer provides device with a dispos- an opportunity to accomplish this able probe that gently feat without having the patient spend touches the eye (with- 12 hours in the exam room. out the need for anes- Peristat online perimetry, available thetic) and takes six since 2002, is a free and portable rapid measurements. way to screen for field loss outside The machine does of the office. The test is available at not display the IOP www.keepyoursight.org and requires readings to the patient nothing more than a computer with but rather saves them a 17” or larger screen.25 The test This POAG patient’s pre-treatment IOP was 24mm Hg OD internally; they are takes less than five minutes, and and OS. OCT shows RNFL loss with a clear inferior bundle retrieved later on by results have been shown to correlate defect in the right eye. The visual field is just starting the eye care provider. well with those of the gold standard to show some abnormal points. After discussing all iCare Home has 24-2 Humphrey field test.26,27 treatment options with the patient, he elected to have SLT been shown to give a The Melbourne Rapid Fields to avoid the topical side effects of medical therapy and helpful clinical picture (MRF, M&S Technologies) perime- the challenges of being compliant. At nine months post- of diurnal IOP fluc- try test has also been shown to corre- SLT OU his IOP is 17mm Hg OU. tuations, especially late well with traditional Humphrey

REVIEW OF OPTOMETRY JULY 15, 2020 57 Cover Story

results.28 This program can be used to be able to use it to detect progres- at the nerve is no longer helpful. on a tablet or computer screen at sion of glaucoma as well. Macular thickness, however, is still home as a web-based exam for glau- One of the most important mea- valuable, as it will continue to show coma patients who are concerned sures to look for when trying to decline in late-stage disease.30 Visual about coming into the office during detect progression of glaucoma on fields are crucial in advanced disease the ongoing COVID-19 crisis. Also, OCT is repeatable, significant RNFL as well, as vision loss can and will many virtual reality programs offer loss, at both the nerve head and continue to occur with progression, at-home visual field screening. the macular ganglion cell complex despite RNFL thickness readings In addition to acting as a screen- (GCC). But what constitutes “signifi- becoming stagnant. ing tool for undiagnosed glaucoma cant”? Most experts agree that nor- Obtaining an OCT of both the patients, the use of these portable mal aging accounts for less than one RNFL and GCC at the macula is and at-home perimetry tests may micron per year of average RNFL crucial early on in the diagnosis of provide information to us as pro- loss on OCT.30,31 The machine itself glaucoma. In addition to abnormal viders that can help to supplement has a test-retest variability of about scans being predictive of future results from more traditional test- five microns; in light of that, experts visual field loss and progression, ing methods in the office.25 They agree that about 10 microns (two these early tests can be used for can also act an opportunity for the standard deviations of the machines comparison to future scans for many patient to “practice,” and thereby inter-test variability) of repeatable years to come in the attempt to catch improve accuracy of field testing in change on a reliable test would progression early and to modify the office at future visits. We learned constitute progression.30 A reliable therapy as needed.32 from the OHTS study years ago that test has a signal strength of 7/10 or the best accuracy of field test results better, which is easier to achieve on Better visual field testing pro- comes after three or more tests.29 a dilated pupil, and is most accurate 7 tocols yield new clues. In when performed in the same state recent years, there have been several OCT allows earlier detection of each time (dilated vs. undilated). important advances in visual field 6 progression. OCT has been OCT is generally recommended testing for glaucoma. One big available for nearly 20 years now, once per year on a glaucoma suspect change has been increased use of the with the newer generation (spectral or mild glaucoma patient who has 10-2 visual field strategy for detect- domain) models becoming widely not shown progression, but is valu- ing central defects. One study found available in the past 10 years. While able to do more often when progres- central field defects were missed in this technology is amazingly helpful sion is suspected, to either confirm nearly 40% of glaucoma suspects in diagnosing early glaucoma in a past change or look for more.30 and 35% of presumed OHTN typical suspect with apparent optic Progression confirmed on OCT patients on 24-2 SITA Standard (SS) nerve cupping on exam, we’ve now alone or with a concurrent new field testing but revealed with the 10-2 had the technology for long enough defect should emphasize the need strategy.32 for additional treat- This is an important finding, as ment measures and central field loss leads to decline lower target IOP. In in vision-related quality of life, advanced glaucoma, decreased central acuity and is pre- clinicians need to dictive of risk for future field pro- beware of the “floor gression, especially in patients with effect,” which occurs normal tension glaucoma.33 Current when OCT technol- thinking suggests 10-2 testing should ogy ceases to detect be considered at baseline for all further change in glaucoma suspects and those with RNFL thickness at diagnosed glaucoma, along with the nerve head, which 24-2, to improve detection of small, Progression analysis showing significant RNFL loss to the occurs when read- central defects. The 10-2 pattern is superior and inferior temporal regions over a six-year time ings approach 40-50 also indicated in cases where OCT period. Despite aggressive treatment approaches, this microns.30,31 In this macular scan (GCA, GCC) shows patient continued to progress with IOP in the low teens. case, RNFL OCT loss or thinning.34

58 REVIEW OF OPTOMETRY JULY 15, 2020 1. Jalkiewicz JF. Glaucoma treatment takes teamwork. Ophthalmology Manage- periods due to physical limitations. ment. March 2020:44-46. 2. Kim WI. Combining Minimally Invasive Glaucoma Surgeries. Glaucoma Physi- Another advantage is the ability to cian. December 2019:16-19. perform more frequent VF tests, 3. Fingeret MA. Improved approaches to MIGS for better patient outcomes, Review Education Group. March 5, 2018. www.revieweducationgroup.com/ce/improved- which will help provide better pro- approaches-to-migs-for-better-patient-outcomes 4. Guedes R, Gravina DM, Lake JC, Guedes V, Chaoubah A. One-Year Comparative gression analysis. Most of us have Evaluation of iStent or iStent inject Implantation Combined with Cataract Surgery in a Single Center. Advances in Therapy. 2019;36(10):2797–2810. many patients that traditionally 5. Berdahl J. iStent inject Versus iStent: The iStent inject Advantage. CRST. https://crstoday.com/articles/maximize-efficacy-minimize-concerns/istent-inject- “hate” perimetry, and a shorter test versus-istent-the-istent-inject-advantage/ 6. Samuelson TW, et al. Prospective, randomized, controlled pivotal trial of an ab duration could certainly attempt to Interno implanted trabecular micro-bypass in primary open-angle glaucoma and cataract. Ophthalmology. 2019;126:811-821 change that mindset. It also helps us 7. Malvankar-Mehta MS, Iordanous Y, Chen YN, Wang WW, Patel SS, Costella J, Hutnik CM. iStent with Phacoemulsification versus Phacoemulsification as providers to keep things moving Alone for Patients with Glaucoma and Cataract: A Meta-Analysis. PloS one. in a busy clinical setting without sac- 2015;10(7):e0131770. 8. Singh IP. Keys to success with the iStent inject, Glaucoma Today. Jan/Feb rificing quality patient care. 2020:35-37. 9. Samuelson et al. A Schlemm canal microstent for intraocular pressure reduction Lastly, in the spirit of combining in primary open-angle glaucoma and cataract: the HORIZON study. Ophthalmology 2019;126:29-37. both the need for central testing and 10. Samples JR. The glaucoma therapy pipeline. Glaucoma Physician, March 2020:20-25. The central 24-2C test pattern the benefit of increased speed, Zeiss 11. Asrani S, Bacharach J, Holland E, McKee H, Sheng H, Lewis RA, Kopczynski CC, Heah T. Fixed-dose combination of netarsudil and latanoprost in ocular incorporates the new SITA-Faster now offers a software package that hypertension and open-angle glaucoma: pooled efficacy/safety analysis of phase 3 MERCURY-1 and -2. Advances in Therapy 2020;37(4):1620–1631. testing strategy along with 10 extra test includes the “SITA Faster 24-2C.” 12. Kaufman PL. Latanoprostene bunod ophthalmic solution 0.024% for IOP lowering in glaucoma and ocular hypertension, Expert Opinion on Pharmacotherapy. locations to the traditional 24-2 grid The 24-2C test pattern combines all 2017;18(4):4433-444. pattern. This has the potential to replace 24-2 points plus 10 points from the 13. Weinreb RN, Sforzolini BS, Vittitow J, Liebmann J. Latanoprostene bunod 0.024% versus timolol maleate 0.5% in subjects with open-angle glaucoma or the 10-2 test for central field testing. 10-2 strategy centrally, and theoreti- ocular hypertension: the APOLLO study. Ophthalmology. 2016;123(5):965-973. 14. Medeiros FA, Martin KR, Peace J, et al. Comparison of latanoprostene bunod cally could provide the information 0.024% and timolol maleate 0.5% in open-angle glaucoma or ocular hypertension: the LUNAR study. Am J Ophthalmol. 2016;168:250-259. Another new advance is develop- from the two separate tests into one. 15. Weinreb RN, Ong T, Scassellati SB, Vittitow JL, Singh K, Kaufman PL. A randomised, controlled comparison of latanoprostene bunod and latanoprost 0.005% ment of the SITA Faster test strategy This may be an excellent clinical in the treatment of ocular hypertension and open angle glaucoma: the VOYAGER study. Br J Ophthalmol. 2015;99(6):738-745. for the Humphrey 24-2. SITA Fast choice moving forward to save time 16. Durysta FAQ, Allergan. https://www.durystahcp.com/#faq 17. Lewis RA, et al. Bimatoprost sustained-release implants for glaucoma therapy: has been around for many years, but provide important information 6-month results from a phase I/II clinical trial. Am J Ophthalm. 2017;175:137-147. 18. Durysta prescribing information, Allergan. https://media.allergan.com/ as long as SITA Standard (SS); they regarding peripheral and central products/durysta_pi.pdf were both developed in 1990s to visual function in glaucoma patients. 19. The Glaucoma Laser Trial Research Group. Results of argon laser trabeculoplasty versus topical medicines. Ophthalmology : Journal of the American replace older, slower full threshold Academy of Ophthalmology, 1990;97(11), 1403–1413. 20. https://eyewiki.aao.org/Laser_Trabeculoplasty:_ALT_vs_SLT test modalities.35 They were found to In any given patient, glaucoma usu- 21. Dewundara SD. SLT earns a place as first-line therapy. Glaucoma Physician. March 2020:16-18. save time and be more accurate. SITA ally progresses slowly, giving us 22. Gazzard G. et al: Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicenter, randomised Faster, which has a duration 30% ample time to consider our options. controlled trial. Lancet. 2019;393:1505-16. 23. Huang J. et al. Diurnal intraocular pressure fluctuations with self-tonometry in shorter than SITA Fast and 53% But the research supporting our glaucoma patients and suspects: a clinical trial. Optom Vis Sci. 2018;5(2):88-95. 24. Asrani S. Diurnal IOP control: how important is it? Glaucoma Today. July/ shorter than SITA Standard, has been care protocols moves quickly, and Aug 2014:36-7. 35 25. Lowry EA, Ianchulev S, Han Y. Perimetry comes online. Glaucoma Today. July/ available since 2019. So far, it has it’s incumbent on all of us to keep Aug 2017:40-41. proved to be nearly identical to SITA up with the advances to ensure we 26. Lowry EA, Hou J, Hennein L, et al. Comparison of peristat online perimetry with the humphrey perimetry in a clinic-based setting. Transl Vis Sci Technol. Fast in accuracy and comparability do the best job possible in limiting 2016;5(4):4. 27. Ianchulev T, Pham P, Makarov V, Francis B, Minckler D. Peristat: A computer- to SS; this is a good thing, as prior glaucoma’s impact in every affected based perimetry self-test for cost-effective population screening of glaucoma, Current Eye Research. 2005;30(1):1-6. studies found that there was no sig- patient we see. n 28. Xiang Y, Kong G, He M, Crowston JG, Vingrys AJ. A comparison of perimetric results from a tablet perimeter and humphrey field analyzer in glaucoma patients. nificant difference in the ability to Dr. Chaglasian is an associate pro- Trans. Vis. Sci. Tech. 2016;5(6):2. 29. Keltner JL, Johnson CA, Quigg JM, et al. Confirmation of visual field detect glaucomatous field progression fessor at Illinois College of Optom- abnormalities in the Ocular Hypertension Treatment Study. Arch Ophthalmol. 2000;118(9):1187-1194. between the two test strategies, and etry and chief of staff of the Illinois 30. Kent C. Using tech to track glaucoma progression. Review of Ophthalmology. Dec 2017:30-40. only a slight increase in precision of Eye Institute in Chicago. He is also 31. Saunders LJ, et al: What rates of glaucoma progression are clinically signifi- defects with SS.36 the current president of the Opto- cant? Expert Rev Ophthalmol. 2016;11(3):227–234. 32. De Moraes CG et al. 24-2 visual fields miss central defects shown on 10-2 One downside to the faster test metric Glaucoma Society. tests in glaucoma suspects, ocular hypertensives, and early glaucoma. Ophthal- mology. 2017;124:1449-1456. has been a higher false positive Dr. Klein is a fellow of the Ameri- 33. Puspha R. et al. Baseline central visual field defect as a risk factor for NTG progression: a 5-Year prospective study. J Glaucoma. 2019;28:952–957. rate, which can lead to unreliable can Academy of Optometry and a 34. Hood D, De Moraes CG. Four questions for every clinician diagnosing and 37 monitoring glaucoma. J Glaucoma. 2018;27:657–664. results. The advantage lies in hav- Diplomate of the American Board of 35. Heijl A, et al. A new SITA perimetric threshold testing algorithm: construction and a multicenter clinical study. Am J Ophthal. 2019:198:154-165. ing a shorter option for patients Optometry. She is Chief of Optom- 36. Saunders L, et al. Measurement precision in a series of visual fields acquired by the standard and fast versions of SITA analysis of large-scale data from clinics. who have tended to tire easily or fall etry at the Flaum Eye Institute of JAMA Ophthalmol. 2015;133(1):74-80. 37. Phu J, et al. Clinical evaluation of SITA–faster compared with SITA–standard in asleep on past tests, or those who the University of Rochester Medical normal subjects, glaucoma suspects, and patients with glaucoma. Am J Ophthal. may have trouble sitting for longer Center in Rochester, NY. 2019; 208: 251-264.

REVIEW OF OPTOMETRY JULY 15, 2020 59 2 CE Credits (COPE approved)

26th Annual Glaucoma Report

A PRACTICAL APPROACH TO ANGLE-CLOSURE Learn to triage these patients and how to intervene appropriately with in-office treatments or swift referrals as needed. By Michael Cymbor, OD, and Nicole Stout, OD

hen a patient com- and surgical treatments of angle- When it comes to angle assess- plains of recent eye closure over the continuum of the ment in the management of glau- injection, deep eye disease. Angle-closure is not a single coma, several older terms such as Wpain and nausea, and diagnosis but rather a spectrum.1 occludable, sub-acute, latent or has an intraocular pressure (IOP) of The urgency and treatment should intermittent, may not be helpful 52mm Hg, our first thought is angle- reflect the location on this spectrum. given there is a lack of consensus on closure crisis, and every optom- their meaning. etrist takes an “all hands on deck” Angle-closure by the Numbers Angle-closure disease may be approach until the crisis is under Angle-closure glaucoma (ACG) primary, secondary or, more likely, control. However, the steps neces- affects approximately 23 million a combination of both. It may occur sary in the more common scenario of people, and the number is expected suddenly as an angle-closure crisis, the asymptomatic patient presenting to increase to 32 million by 2040.2 or be chronic, progressing slowly with an IOP of 18mm Hg with nar- ACG is responsible for nearly half over the course of years. Although row angles are much less clear. of all blindness caused by glaucoma a traditional approach views angle- This article reviews the medical worldwide.3 closure as a single disease entity,

Release Date: July 15, 2020 Institute for Medicine and Review Education Group. Postgraduate Expiration Date: July 15, 2023 Institute for Medicine is jointly accredited by the Accreditation Council Estimated Time to Complete Activity: 2 hours for Continuing Medical Education, the Accreditation Council for Jointly provided by Postgraduate Institute for Pharmacy Education, and the American Nurses Credentialing Center, Medicine (PIM) and Review Education Group to provide continuing education for the healthcare team. Postgraduate Institute for Medicine is accredited by COPE to provide continuing edu- Educational Objectives: After completing this activity, the participant cation to optometrists. should be better able to: Faculty/Editorial Board: Michael Cymbor, OD, Nittany Eye Associates, • Describe clinical factors that define chronic, intermittent and acute and Nicole Stout, OD, Northeastern State University Oklahoma College angle-closure. of Optometry. • Explain the differences between primary and secondary angle- Credit Statement: This course is COPE approved for 2 hours of CE closure. • Discuss how the various classifications affect the long-term credit. Course ID is 68529-GL. Check with your local state licensing outcomes. board to see if this counts toward your CE requirement for relicensure. • Manage angle-closure patients. Disclosure Statements: • Determine when to refer patients for surgical management. Dr. Cymbor receives fees for non-CME/CE services from Optovue. Target Audience: This activity is intended for optometrists engaged in Dr. Stout has no disclosures. the care of patients with angle-closure. Managers and Editorial Staff: The PIM planners and managers have Accreditation Statement: In support of improving patient care, this nothing to disclose. The Review Education Group planners, managers activity has been planned and implemented by the Postgraduate and editorial staff have nothing to disclose.

60 REVIEW OF OPTOMETRY JULY 15, 2020 OPTOMETRIC STUDY CENTER

angle-closure is a heterogenous • PAS secondary to inflamma- disease involving different mecha- tion that can occur following ante- nisms that should be identified by rior segment surgery or in chronic the clinician. uveitis; • Endothelial membrane Case Example obstructing the angle in iridocor- A 63-year-old white male was neal endothelial (ICE) syndrome referred to a glaucoma specialist or posterior polymorphous corneal by his local optometrist due to dystrophy; or increasing IOP and worsening • Epithelial membrane from glaucoma. The patient’s mother, Fig 1. This patient’s initial gonioscopy shows a epithelial downgrowth following father and brother all have glau- narrow angle with the TM barely visible. ocular trauma. coma. He reported taking 0.2% Conversely, it may also occur brimonidine BID and 0.5% timolol Primary vs. Secondary through a posterior “pushing” mech- qAM, both OU, for several years. Primary angle-closure (PAC) covers anism where the iris or ciliary body is Best-corrected visual acuity was a broad spectrum of angle disease. pushed forward to occlude the angle, 20/30 OD and 20/25 OS. He had The common feature to all primary such as:1-7 an afferent pupillary defect OD. angle-closure is the presence of nar- • Absolute pupillary block occur- His IOP was 23.7mm Hg OD and row drainage angles characterized ring when 360 degrees of posterior 21.8mm Hg OS. His corneal hyster- by the apposition of the TM and synechiae cause iris bombe (a form esis was 7.3 OD and 7.8 OS. Central the peripheral iris. The currently of secondary pupillary block). This corneal thickness was 523µm OD accepted classification system in pri- occurs as a result of inflammatory and 530µm OS. Visual field test- mary angle-closure disease is primary conditions, such as uveitis, that cause ing revealed a severely reduced field angle-closure suspect (PACS), PAC the iris to fibrose to the anterior sur- OD>OS with a mean defect of 22.6 and primary angle-closure glaucoma face of the lens, impeding the normal OD and 14.8 OS. (PACG).4 PACS includes patients flow of aqueous; Optical coherence tomography who have greater than 180 degrees • Lens-induced angle-closure (OCT) revealed severely reduced of iridotrabecular contact with a nor- through subluxation, anterior lens retinal nerve fiber layer and ganglion mal IOP and no optic nerve damage. displacement, malpositioning of an cell complex OD and moderately PAC has greater than 180 degrees of intraocular lens or phacomorphic reduced OS. OCT angiography iridotrabecular contact with periph- glaucoma (all forms of secondary showed reduced vessel density eral anterior synechiae (PAS) or ele- pupillary block); OD>OS. vated IOP but no optic neuropathy. • Aphakic pupillary block, which The cup-to-disc ratio was graded PACG has everything contained with occurs as a result of anterior vitreous at 0.8/0.8 OD and 0.65/0.65 OS. PAC along with glaucomatous optic displacement and adhesion between Gonioscopy showed minimal tra- neuropathy or the presence of glau- the vitreous humor and the iris (a becular meshwork (TM) visible with comatous visual field defects.5 form of secondary pupillary block); grade 2 pigment OU in all quadrants Secondary ACG occurs as a result • Ciliary body cysts or tumors, (Figure 1). Anterior segment OCT of an underlying pathological pro- which can cause anterior displace- (AS-OCT) confirmed narrow angles cess. It can be classified as resulting ment of the peripheral iris; (Figure 2). from an anterior “pulling” mecha- • Posterior segment space- The patient was diagnosed with nism by which the peripheral iris is occupying lesions, such as tumors, severe angle-closure glaucoma OD pulled into the angle, occluding the silicone oil or a gas bubble, that and moderate ACG OS, staged based TM, such as:1-7 cause anterior displacement of the on the visual field defect. We per- • Neovascular membrane form- lens-iris diaphragm; formed a bilateral YAG laser periph- ing in the anterior chamber angle • Choroidal effusion, which most eral iridotomy (LPI). This had little secondary to retinal ischemia, which commonly occurs as a complication effect on IOPs or angle opening. We can occur in conditions such as pro- following glaucoma surgery, but may proceeded with cataract surgery with liferative diabetic retinopathy, central also be secondary to other intraocu- the hope of also performing gonio- retinal vein occlusion, central retinal lar surgeries, inflammatory or infec- synecialysis and Kahook Dual Blade artery occlusion and ocular ischemic tious diseases, trauma, neoplasms, goniotomy (New World Medical). syndrome; drug reactions (topiramate and

REVIEW OF OPTOMETRY JULY 15, 2020 61 OPTOMETRIC STUDY CENTER

the scleral spur and Schwalbe’s line. It can be subdivided into anterior and posterior TM. It is typically light gray in younger patients and becomes more pigmented in older individuals. The anterior third of the TM is nonfunctional, while the posterior two-thirds filters aqueous Fig 2. The patient’s initial OCT shows a narrow angle. into Schlemm’s canal. Schwalbe’s line is the most anterior angle structure sulfonamide-induced angle-closure), elevated IOP, conjunctival injection and represents the end of a clear venous congestion or idiopathic with ciliary flush, corneal edema and cornea. While there are three main uveal effusion; or a mid-dilated pupil.3 angle classification systems—Scheie, • Ciliary block (also known as Demographic risk factors include Shaffer and Spaeth—the universally aqueous misdirection), which causes advancing age, female gender and accepted classification system is to shallowing of the anterior chamber Asian ancestry.14,15 Asian populations simply describe the most posterior as a result of aqueous humor being typically have thicker irises with a structure seen by quadrants.22-24 misdirected into the vitreous body more anterior lens position.16 Ocular Gonioscopy is critical for identify- displacing the lens-iris diaphragm risk factors include hyperopia, shal- ing some causes of secondary angle- forward. This condition can occur low anterior chamber, small anterior closure. Indentation gonioscopy can following ocular surgery. chamber volume and area, thicker help clinicians differentiate between Secondary angle-closure can peripheral iris and a higher insertion, iridocorneal apposition and periph- involve an aspect of secondary pupil- increased lens vault and an anterior eral anterior synechia. This technique lary block or can occur without ciliary body position.17,18 is performed using a small-diameter pupillary block.6-11 Gonioscopy is still the standard gonioscopy lens to apply pressure However, most cases of angle- when evaluating angle structures, to the central cornea, displacing the closure are due to pupillary block, and clinicians must be intimately aqueous humor towards the angle, which occurs when movement of the familiar with angle assessment. which separates the iris from the aqueous from the posterior to anteri- Unfortunately, angle assessment cornea and allows for better visual- or chamber is halted, creating a pres- may be among the most underused ization of the angle structures. Angle sure gradient that leads to forward aspects of glaucoma management. structure visibility with indentation bowing of the peripheral iris, result- One study found that 40% of diag- suggests iridocorneal apposition, ing in sudden obstruction of the TM. nosed open-angle glaucoma patients while synechial angle-closure should Of all acute angle-closure patients in actually had angle-closure.19 Other not improve angle structure visibility the United States, 90% present with studies show that gonioscopy/ upon indentation. pupillary block.12 angle assessment is performed less While gonioscopy remains the than 50% of the time in glaucoma standard, technologies such as AS- Diagnosing Angle Issues patients and suspects.20,21 OCT, ultrasound biomicroscopy Four factors help clinicians diagnose When the angle is open, the most (UBM) and Scheimpflug imaging are potential angle issues: symptoms, posterior angle structure visible is playing a more prominent role as signs, risk factors and angle assess- the ciliary body (CB), found between more doctors gain access. Further- ment. A careful history and clinical the iris root and the scleral spur. It more, angle-closure diagnosis rates exam are necessary to make the is usually brown but may appear as increase when objective analysis is proper diagnosis. light gray. The second most posterior included.25 AS-OCT acquires a high- Symptoms of a primary or second- structure is the scleral spur and can resolution cross-sectional image of ary angle-closure crisis include eye vary in color from white to gray. It the anterior chamber. It often shows redness, reduced vision, halos, ocu- is found in the posterior margin of the angle narrower than gonioscopy, lar or periocular pain, nausea and the scleral sulcus, between the CB particularly in the superior and infe- vomiting.3 While symptoms are com- and the TM. The scleral spur is com- rior quadrants.25 This may be due mon in an angle-closure crisis, most prised of collagen tissue and serves as to OCT’s ability to measure angles cases of chronic angle-closure are the anchor for the ciliary muscle. in scotopic conditions. One disad- asymptomatic.13 Ocular signs include The TM is next, found between vantage of AS-OCT is that current

62 REVIEW OF OPTOMETRY JULY 15, 2020 devices only sample a small section synechia, in addition to pharmaco- may be helpful to visualize the ante- of the angle at one time. logical interventions that attempt to riorly positioned ciliary processes. UBM is also an excellent tool for lower IOP and control inflamma- Argon laser peripheral iridoplasty imaging the anterior segment and tion. may help open the angle.29 This can be helpful in identifying the In practical terms, optomet- technique applies laser to the periph- underlying pathology; however, it is ric medical stabilization means eral iris, reducing its thickness and not readily available in most private achieving a significant in-office pulling it away from the TM. Laser practices.6,7,26 UBM has the advan- IOP decrease until an LPI can be iridoplasty may also reverse recent tage of being able to image behind performed the same day. Medical PAS.30 Prompt lens extraction sur- the iris, including the lens and the stabilization should be tailored to gery may also be considered. Single- CB, but is costly because it is typi- how quickly the LPI can be per- pass four-throw pupilloplasty, which cally a stand-alone instrument. formed. Once an angle-closure crisis reconstructs the pupil, can be an Scheimpflug imaging may is identified, the optometrist should option in persistent cases.31 also play a role in angle imaging. immediately investigate LPI options Most secondary angle-closure Scheimpflug imaging can sample a and have a clear idea of when it can glaucomas with a pupillary block much larger portion of the angle, but be performed. If the LPI can be per- component will require an LPI. the resolution is less than either AS- formed immediately on-site or at a Approximately 25% of patients OCT or UBM.27 referral destination close by, medical with pupillary block will continue While each technology has advan- stabilization might mean putting in to show iridotrabecular contact tages, objective angle analysis com- a round of pressure-lowering drops even after LPI.32 Factors that may plements gonioscopy. and/or a dose of acetazolamide prior adversely affect LPI success include to the LPI. If it cannot be performed eyes with greater than 180 degrees Acute Treatment Approaches until a few hours later, clinicians of PAS, higher baseline IOP and nar- Treatment of acute angle-closure should put more emphasis on medi- rower angles as determined by UBM crisis is typically prompt medical cal stabilization as to not subject the and AS-OCT.33 Even if LPI is initial- stabilization followed by laser and/ patient to a prolonged elevated IOP. ly successful, it should not be viewed or surgical stabilization. Laser treatment. Once medical as a long-term cure. The natural lens Medical stabilization. This may stabilization is achieved and the will continue to grow, narrowing include treatment with topical alpha iris can be visualized, the next step the anterior chamber over time and agonists, beta blockers, carbonic would historically be LPI. If the increasing lens vault.34 anhydrase inhibitors and rho-kinase optometrist practices in a state that Once LPI stabilization of both the (ROCK) inhibitors. Medical treat- permits optometric LPI, the optom- angle and IOP occurs, the clinician ment may also include topical ste- etrist would then perform an emer- faces several options. The patient roids to relieve inflammation. Oral gent LPI, which is generally effective may only require observation with treatment may include carbonic at relieving pupillary block. the initiation of topical medication anhydrase inhibitors. This approach If LPI does not open the angle and or adjustment of current therapy should be avoided in topiramate- or decrease IOP, plateau iris syndrome upon IOP increase. sulfonamide-induced angle-closure; (PIS) should be suspected. PIS is Provided that the TM is visible to instead, the causative medication when a large or anteriorly positioned at least 180 degrees, selective laser should be discontinued promptly.7,10 CB pushes the peripheral iris for- trabeculoplasty (SLT) may help Oral or intravenous hyperosmotic ward, potentially closing the angle. stabilize IOP. SLT may be limited in medications may be used when rapid This may be present in up to one- angles with 180 degrees or more of IOP lowering is not achieved with third of angle-closure cases.28 Plateau PAS and if the TM experiences sig- the above-mentioned treatments. iris can occur with or without pupil- nificant IOP-induced trauma during Compression gonioscopy performed lary block. Compression gonioscopy acute PAC. There appears to be no with a small-diameter lens may be is critical in the diagnosis and will difference in SLT outcomes between necessary to break recent iridotra- show a marked peripheral iris roll. patients with PAC and PACG.35 becular adhesion. In absolute pupil- This occurs because the iris follows Transscleral (delivery through the lary block, clinicians should use a the anatomy of the lens from central pars plana) and endoscopic cyclo- strong cycloplegic agent and 10% to peripheral and rises after the level photocoagulation are also options, phenylephrine ophthalmic solu- of the equatorial lens up to the ante- as they reduce CB aqueous formation to try and break the posterior riorly placed or enlarged CB. UBM tion and shrink the CB.36

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Surgical treatment. Even though glaucoma to pull the peripheral iris LPI is the most historically common away from the TM, it can cause con- choice of treatment after medical traction of the ciliary muscle, result- stabilization, moving directly to lens ing in anterior lens movement and extraction may be the better option. paradoxical worsening of the angle- The EAGLE study compared LPI closure in cases of secondary ACG.40 with clear lens extraction by looking Secondary angle-closure glaucoma at patients over 50 years old with resulting from anterior “pulling” mild to moderate PACG with a pre- mechanisms also often requires a senting IOP above 30mm Hg.37 The referral for surgical intervention, study found a reduction in the need such as in the case of secondary for further medications or glaucoma ACG caused by significant PAS surgeries in the clear lens extraction where goniosynecialysis could be group along with a better quality of performed. This procedure is more life and better cost-effectiveness. A likely to be successful if the synechia recent study suggests that lens extrac- are relatively new.7,10 tion should be performed early as a In neovascular glaucoma, after way to prevent PACG.4 In the case Fig. 3. This image depicts the patient’s attempting to get the IOP and of phacomorphic glaucoma, cataract angle after goniosynechialysis, cataract inflammation under control with surgery should be performed as the surgery and Kahook Dual Blade goniotomy. pharmacological therapies, the definitive treatment.10 patient should be referred to a retina Phacoemulsification with intra- lowering medications.38 specialist for treatment of the under- ocular lens implantation may relieve If phacoemulsification, and pos- lying retinal ischemia with panretinal iridotrabecular contact, lowering sibly goniosynecialysis, does not photocoagulation and/or anti-vascu- IOP. In some cases, goniosynecialysis relieve iridotrabecular contact, the lar endothelial growth factor agents. may be needed to break contact. This optometrist may need to refer the These patients will often also require involves mechanically disrupting PAS patient for a more aggressive MIGS a referral to a glaucoma specialist for by gently pushing on the peripheral such as the Xen gel stent (Allergan). more invasive glaucoma surgeries iris to break the attachment between A trabeculectomy or a tube proce- such as a tube procedure.7,8,10 the iris and the TM. dure may also be needed but both After the acutely elevated IOP is If successful, a variety of TM- have more postoperative complica- lowered and the underlying cause of targeting minimally invasive glau- tions for angle-closure than primary the primary or secondary ACG has coma surgeries (MIGS) may then open-angle glaucoma patients.39 been treated, clinicians should moni- be employed, such as Kahook Dual Secondary angle-closure consid- tor these patients regularly with IOP Blade goniotomy, Trabectome erations. Causes of secondary ACG checks, optic nerve head assessments, (Microsurgical Technolo) and iStent due to posterior “pushing” mecha- OCTs, angle assessments and visual (Glaukos). Trabeculectomies and nisms that do not involve pupillary fields to monitor for further glau- tubes are also an option for more block are often a result of the periph- comatous progression and to detect advanced cases. As with our patient, eral iris being displaced forward by if additional intervention becomes Kahook Dual Blade and gonio- the lens or CB. In these cases, the necessary. synecialysis combined with phaco- use of a cycloplegic agent to induce emulsification can provide reductions posterior rotation of the CB is often Caring for the Chronic Patient in both IOP and the need for IOP- indicated, in addition to topical IOP- While an acute angle-closure crisis is lowering drops and topical a clinical emergency requiring imme- steroids.7 diate care, chronic angle-closure Many of these conditions may be more insidious and progress require a referral to a glau- slowly. It remains a clinical challenge coma, retina or ocular oncol- to determine the ideal time to inter- ogy specialist to manage the vene. For instance, questions persist underlying cause. Although regarding whether LPI should be rec- Fig. 4. This is the patient’s corresponding AS-OCT pilocarpine can be used in pri- ommended for all PACS patients to after successful treatment. mary phakic pupillary block prevent PAC and/or PACG.

64 REVIEW OF OPTOMETRY JULY 15, 2020 2011;118(3):474-9. The recent ZAP trial showed a goniotomy (Figure 3). These three 17. Moghimi S, Fathollahzadeh N, Chen R, et al. Comparison of fellow statistically significant but clini- procedures stabilized aqueous out- eyes of acute primary angle closure and phacomorphic angle closure. J Glaucoma. 2019;28(3):194-200. cally small decrease in the risk of flow and IOP. One year later, his IOP 18. Mansouri M, Ramezani F, Moghimi S, et al. Anterior segment optical coherence tomography parameters in phacomorphic angle closure and PAC conversion and recommended is 11.4mm Hg OD and 10.4mm Hg mature cataracts. Invest Ophthalmol Vis Sci. 2014;55:7403-9. against the widespread use of pro- OS on no medications. His fields and 19. Vijaya L, George R, Baskaran M, et al. Prevalence of primary open- angle glaucoma in an urban south Indian population and comparison phylactic LPIs in their study popula- optic nerve OCTs are stable along with a rural population: the Chennai Glaucoma Study. Ophthalmology. 41 2008;115(4):648-54. tion. Further analysis of the ZAP with his AS-OCTs (Figure 4). 20. Fremont AM, Lee PP, Mangione CM, et al. Patterns of care for open- trial found that 44 PACS patients angle glaucoma in managed care. Arch Ophthalmol. 2003;121(6):777-83. 21. Stanley J, Huisingh CE, Swain TA, et al. Compliance with primary needed treatment to prevent one new As optometrists continue to play a open-angle glaucoma and primary open-angle glaucoma suspect 42 preferred practice patterns in a retail-based eye clinic. J Glaucoma. PAC case over six years. more significant role in all aspects of 2018;27(12):1068-72. 22. Scheie HG. Width and pigmentation of the angle of the anterior LPI is mostly benign, usually glaucoma management, it is critical chamber: a system of grading by gonioscopy. AMA Arch Ophthalmol. opens the angle to some extent and that we better appreciate the impor- 1957;58(4):510-2. 23. Becker B, Shaffer RN. Diagnosis and Therapy of the Glaucomas. St. potentially prevents an angle-closure tance of angle assessment, use all of Louis: CV Mosby; 1965:42-53. 24. Spaeth GL. The normal development of the human anterior chamber crisis. Nevertheless, side effects may our angle diagnostic options, refer angle: a new system of descriptive grading. Trans Ophthalmol Soc UK. occur, including dysphotopsia and patients when appropriate and moni- 1970;91:709-39. 25. Sakata LM, Lavanya R, Friedman DS, et al. Comparison of gonioscopy 43,44 accelerated cataract formation. tor and manage these patients over and anterior segment ocular coherence tomography in detecting angle closure in different quadrants of the anterior chamber angle. Ophthalmol- In our clinic, we typically follow the course of their lives. n ogy. 2008;115(5):769-74. most asymptomatic PACS patients 26. Maslin JS, Barkana Y, Dorairaj SK. Anterior segment imaging in glau- Dr. Cymbor is the medical direc- coma: an updated review. Indian J Ophthalmol. 2015;63(8):630-40. every six to 12 months. We monitor tor of the Glaucoma Institute of 27. Konstantopoulos A, Hossain P, Anderson DF. Recent advances in ophthalmic anterior segment imaging: a new era for ophthalmic diagnosis? for changes in the angle, optic nerve State College, a member of the Br J Ophthalmol. 2007;91(4):551-7. and visual field. While we approach 28. Kumar RS, Baskaran M, Chew PT, et al. Prevalence of plateau iris Optometric Glaucoma Society and in primary angle closure suspects: an ultrasound biomicroscopy study. each patient individually, we gener- a managing partner at Nittany Eye Ophthalmol. 2008;115(3):430-4. 29. Leong JC, O’Connor J, Ang GS, et al. Anterior segment optical ally perform LPI if the patient men- Associates. coherence tomography changes to the anterior chamber angle in the short-term following laser peripheral iridoplasty. J Curr Glaucoma Pract. tions symptoms suggestive of closure, Dr. Stout is an assistant profes- 2014;8(1):1-6. has a family history of angle-closure 30. Sun X, Liang YB, Wang NL, et al. Laser peripheral iridotomy with and sor at Northeastern State University without iridoplasty for primary angle-closure glaucoma: 1-year results of a or if they show progression of angle Oklahoma College of Optometry. randomized pilot study. American J Ophthalmol. 2010;150(1):68-73. 31. Narang P, Agarwal A, Kumar DA. Single-pass four-throw pupilloplasty narrowing. for angle-closure glaucoma. Indian J Ophthalmol. 2018;66(1):120-4. Eyes that develop PAC or PACG 1. Cumba RJ, Nagi KS, Bell NP, et al. Clinical outcomes of peripheral 32. Jiang Y, Chang DS, Zhu H, et al. Longitudinal changes of angle config- iridotomy in patients with the spectrum of chronic primary angle closure. uration in primary angle-closure suspects: the Zhongshan Angle-Closure should be treated.33 The treatment ISRN ophthalmology. 2013;2013:828972. Prevention Trial. Ophthalmology. 2014;121(9):1699-705. 2. Quigley HA, Broman AT. The number of people with glaucoma worldwide 33. Radhakrishnan S, Chen PP, Junk AK, et al. Laser peripheral iridotomy of chronic angle-closure is similar in 2010 and 2020. Br J Ophthalmol. 2006;90(3):262-7. in primary angle closure: a report by the American Academy of Ophthal- to the treatment for acute angle- 3. Weinreb RN, Friedman DS, eds. Angle Closure and Angle Closure mology. Ophthalmology. 2018;125(7):1110-20. Glaucoma - Consensus Series Book 3. Amsterdam: Kugler Publications; 34. Lee KS, Sung KR, Shon K, et al. Longitudinal changes in anterior closure: stabilize the IOP medically 2006:1-61. segment parameters after laser peripheral iridotomy assessed by anterior 4. Song MK, Sung KR, Shin JW, et al. Glaucomatous progression after lens segment optical coherence tomography. Invest Ophthalmol Vis Sci. or with SLT, evaluate the angle, extraction in primary angle closure disease spectrum. J Glaucoma. May 1, 2013;54(5):3166-70. 2020. [Epub ahead of print]. 35. Raj S, Tigari B, Faisal TT, et al. Efficacy of selective laser trabeculoplasty perform LPI when appropriate and 5. Prum BE, Herndon LW, Moroi SE, et al. Primary angle closure preferred in primary angle closure disease. Eye. 2018;32(11):1710-6. consider cataract or clear lens extrac- practice Pattern guidelines. Ophthalmology. 2016;123(1):P1-40. 36. Liu GJ, Mizukawa A, Okisaka S. 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Kahook dual blade excisional goniotomy and Glaucoma Panel: Primary Angle Closure PPP – 2015. www.aao.org/ goniosynechialysis combined with phacoemulsification for angle-closure may follow a course of years, rather preferred-practice-pattern/primary-angle-closure-ppp-2015. Accessed glaucoma: 6-month results. J Glaucoma. 2019;28(7):643-6. than days or months. Patients with June 22, 2020. 39. Sihota R, Gupta V, Agarwal HC. Longterm evaluation of trabeculectomy 10. Gerstenblith AT, Rabinowitz MP, eds. The Wills Eye Manual: Office and in primary open angle glaucoma and chronic primary angle closure glau- PAC or PACG who are followed Emergency Room Diagnosis and Treatment of Eye Disease, 6th ed. Phila- coma in an Asian population. Clin Exp Ophthalmol. 2004;32(1):23-8. delphia: Lippincott Williams & Wilkins; 2012. 40. Ritch R. The pilocarpine paradox. J Glaucoma. 1996;5(4):225-7. closely and treated more aggressively 11. Teekhasaenee C, Dorairaj S, Ritch R. Secondary angle-closure glau- 41. He M, Jiang Y, Huang S, et al. Laser peripheral iridotomy for the pre- than primary open-angle glaucoma coma. In: Shaaraway TM, Sherwood MB, Hitchings RA, Crowston JG, eds. vention of angle closure: a single-centre, randomised controlled trial. The Glaucoma. 2nd Edition. Elsevier Inc. 2015;401-9. Lancet. 2019;393(10181):1609-18. patients generally have favorable 12. Ritch R, Lowe RF, Reyes A. Angle-closure glaucoma: therapeutic over- 42. Gupta V, Dada T. Should we perform peripheral laser iridotomy in 45 view. The Glaucomas. 1996;2:1521-31. primary angle closure suspects: implications of the ZAP trial? Ann Transl long-term outcomes. 13. Foster PJ, Buhrmann R, Quigley HA, et al. The definition and classifica- Med. 2019;7(Suppl 3):S157. tion of glaucoma in prevalence surveys. Br J Ophthalmol. 2002;86:238-42. 43. Spaeth GL, Idowu O, Seligsohn A, et al. The effects of iridotomy size 14. Cheng JW, Zong Y, Zeng YY, et al. The prevalence of primary angle and position on symptoms following laser peripheral iridotomy. J Glau- Our Patient closure glaucoma in adult Asians: a systematic review and meta-analysis. coma. 2005;14(5):364-7. PLoS One. 2014;9(7):e103222. 44. Vijaya L, Asokan R, Panday M, et al. Is prophylactic laser peripheral Fortunately, phacoemulsification 15. Bonomi L, Marchini G, Marrafa M, et al. Epidemiology of angle-closure iridotomy for primary angle closure suspects a risk factor for cataract glaucoma. Prevalence, clinical types, and association with peripheral ante- progression? The Chennai Eye Disease Incidence Study. Br J Ophthalmol. combined with goniosynecialysis rior chamber depth in the Egna-Neumarkt Glaucoma Study. Ophthalmol. 2017;101(5):665-70. opened our patient’s angle enough 2000;107(5):998-1003. 45. Sihota R, Sood A, Gupta V, et al. A prospective longterm study of 16. Nongpiur ME, He M, Amerasinghe N, et al. Lens vault, thickness, primary chronic angle closure glaucoma. 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REVIEW OF OPTOMETRY JULY 15, 2020 65 OPTOMETRIC STUDYSTUDY CENTER

OSC QUIZ

ou can obtain continuing 6. Which of the following medications is 14. What is the most posterior angle education credit through the a possible medical treatment for angle- structure visible on gonioscopy when the YOptometric Study Center. Com- closure? angle is wide open? plete the test form and return it with the a. Beta blockers. a. Posterior trabecular meshwork. $35 fee to: Jobson Healthcare Information, b. Rock inhibitors. b. Scleral spur. LLC, Attn.: CE Processing, 395 Hudson c. Oral hyperosmotic. c. Ciliary body. Street, 3rd Floor New York, New York d. All of the above. d. Schwalbe’s line. 10014. To be eligible, please return the card within three years of publication. You 7. What is compression gonioscopy used 15. Which of the following causes of can also access the test form and submit for? secondary angle-closure glaucoma uses your answers and payment via credit a. Diagnosing plateau iris. an anterior pulling mechanism? card at Review Education Group online, b. Identifying posterior synechiae. a. Aphakic pupillary block. revieweducationgroup.com. c. Breaking recent iridotrabecular contact. b. ICE syndrome. You must achieve a score of 70 or d. a and c. c. Choroidal effusion. higher to receive credit. Allow four weeks d. Ciliary block. for processing. For each Optometric Study 8. Under which of the following situations Center course you pass, you earn 2 hours is LPI most successful? 16. In which of the following is the of credit from Pennsylvania College of a. 270 degrees of peripheral anterior use of carbonic anhydrase inhibitors Optometry. synechiae. contraindicated? Please check with your state b. Narrower angles. a. Primary pupillary block glaucoma. licensing board to see if this approval c. Lower baseline IOP. b. Neovascular glaucoma. counts toward your CE requirement for d. Ciliary body swelling. c. Ciliary block glaucoma. relicensure. d. Topiramate induced angle-closure 9. Which of the following is not a symptom glaucoma. 1. Angle-closure disease may present as: of acute angle-closure crisis? a. Primary. a. Reduced vision. 17. Which of the following involves a b. Secondary. b. Diplopia. secondary pupillary block component? c. A combination of both primary and c. Ocular/periocular pain. a. Ciliary body swelling following panretinal secondary. d. Nausea/vomiting. photocoagulation. d. All of the above. b. Phacomorphic glaucoma. 10. Plateau iris may be present in up to c. Glaucoma secondary posterior 2. Primary angle-closure glaucoma _____ of angle-closure cases. polymorphous corneal dystrophy. includes everything, except? a. One-half. d. Choroidal effusion. a. Greater than 180 degrees of b. One-third. iridotrabecular contact. c. One-fourth. 18. Which of the following would be b. Elevated intraocular pressure. d. One-fifth. least used in the treatment of secondary c. Reduced levels of nitric oxide. pupillary block from peripheral anterior d. Optic neuropathy. 11. Which of the following procedures can synechiae? break iridotrabecular contact? a. Timolol 0.5% ophthalmic solution. 3. Which of the following is a risk factor in a. Kahook Dual Blade. b. Cyclopentolate 1% ophthalmic solution. angle-closure disease? b. Goniosynecialysis. c. Pilocarpine 2% ophthalmic solution. a. Myopia. c. Cataract surgery. d. Phenylephrine 10% ophthalmic solution. b. Hyperopia. d. b and c. c. Lacquer cracks. 19. All of the following tests would be d. Staphyloma. 12. Which trial recommends the use of LPI useful in the diagnosis of angle-closure in most cases of primary angle-closure glaucoma, except: 4. All of the following are advantages of suspects? a. UBM. anterior segment OCT, except: a. Eagle. b. Anterior segment OCT. a. Resolution. b. ZAP. c. Pachymetry. b. Objective assessment. c. OHTS. d. Gonioscopy. c. Sampling a large angle area. d. None of the above. d. Scotopic imaging. 20. Which of the following causes of 13. Which of the following examination secondary angle-closure glaucoma involve 5. Most cases of acute angle-closure are techniques can be used to differentiate a posterior pushing mechanism? due to: between iridocorneal apposition and a. Ciliary body tumors. a. Pupillary block. peripheral anterior synechia? b. Peripheral anterior synechia. b. Hyperopia. a. AS-OCT. c. Neovascular glaucoma. c. Underdevelopment of trabecular b. Dilated fundus examination. d. Glaucoma secondary to epithelial meshwork. c. Gonioscopy. downgrowth following a penetrating d. Overdevelopment of the ciliary body. d. UBM. trauma.

66 REVIEW OF OPTOMETRY JULY 15, 2020 Mail to: Jobson Healthcare Information, LLC, Attn.: CE Processing, 395 Examination Answer Sheet Hudson Street, 3rd Floor New York, New York 10014 A Practical Approach to Angle-closure Payment: Remit $35 with this exam. Make check payable to Jobson Healthcare Valid for credit through July 15, 2023 Information, LLC. Credit: This course is COPE approved for 2 hours of CE credit. Course ID is 68529- Online: This exam can be taken online at revieweducationgroup.com. Upon passing GL. the exam, you can view your results immediately and download a real-time CE cer- Jointly provided by Postgraduate Institute for Medicine and Review Education tificate. You can also view your test history at any time from the website. Group. Directions: Select one answer for each question in the exam and completely dark- Salus University has sponsored the review and approval of this activity. en the appropriate circle. A minimum score of 70% is required to earn credit. Processing: There is a four-week processing time for this exam. Answers to CE exam: Post-activity evaluation questions: 1. A B C D Rate how well the activity supported your achievement of these learning objectives: 2. A B C D 1=Poor, 2=Fair, 3=Neutral, 4=Good, 5=Excellent 3. A B C D

4. A B C D 21. Describe clinical factors that define chronic, intermittent and acute angle-closure. 1 2 3 4 5 A B C D 5. 22. Explain the differences between primary and secondary angle-closure. 1 2 3 4 5 6. A B C D 23. Discuss how the various classifications affect the long-term outcomes. 1 2 3 4 5 7. A B C D 24. Manage angle-closure patients. 1 2 3 4 5 8. A B C D 25. Determine when to refer patients for surgical management. 1 2 3 4 5 9. A B C D

10. A B C D 11. A B C D 26. Based upon your participation in this activity, do you intend to change your practice behavior? 12. A B C D (choose only one of the following options) A 13. A B C D I do plan to implement changes in my practice based on the information presented. B 14. A B C D My current practice has been reinforced by the information presented. C I need more information before I will change my practice. 15. A B C D

16. A B C D 27. Thinking about how your participation in this activity will influence your patient care, how many of your patients are likely to benefit? (please use a number): 17. A B C D

18. A B C D

19. A B C D

20. A B C D 28. If you plan to change your practice behavior, what type of changes do you plan to implement? (check all that 30. Which of the following do you anticipate will apply) be the primary barrier to implementing these changes? a Apply latest guidelines b Change in pharmaceutical therapy c Choice of treatment/management approach a Formulary restrictions d Change in current practice for referral e Change in non-pharmaceutical therapy f Change in differential b Time constraints diagnosis g Change in diagnostic testing h Other, please specify: ______c System constraints ______d Insurance/financial issues

e Lack of interprofessional team support 29. How confident are you that you will be able to make your intended changes? f Treatment related adverse events a Very confident b Somewhat confident c Unsure d Not confident g Patient adherence/compliance

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

First Name 31. Additional comments on this course: Last Name ______E-Mail ______The following is your: Home Address Business Address ______Business Name ______

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Telephone # - - 32. The content was evidence-based.

Fax # - - 1 2 3 4 5 33. The content was balanced and free of bias. OE Tracker Number 1 2 3 4 5 By submitting this answer sheet, I certify that I have read the lesson in its entirety and completed the self- 34. The presentation was clear and effective. assessment exam personally based on the material presented. I have not obtained the answers to this exam by any fraudulent or improper means. 1 2 3 4 5

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Lesson 119917 RO-OSC-0720

REVIEW OF OPTOMETRY JULY 15, 2020 67 Cornea+Contact Lens Q+A

Riboflavin vs. Rose Bengal When considering photodynamic therapy, make sure to evaluate the efficacy of each photosensitizer. Edited by Joseph P. Shovlin, OD Photo: I’ve recently seen some discus- PDT with rose bengal may Kent, Delaney Q sion on treating fungal keratitis offer greater promise, Dr. Chou with rose bengal and photodynamic suggests. In vitro, rose bengal

therapy (PDT). How does this combi- OD, and green light (518nm) effec- nation’s efficacy compare with ribo- and Richard Mangan, tively inhibited fungal isolates flavin and corneal crosslinking (CXL)? (Fusarium, Aspergillus and Are there any indications for one pro- Candida), whereas riboflavin cedure over the other? with UVA (375nm) permitted “Most optometrists associ- OD unrestricted growth.10 A case A ate PDT with treating wet report of a 56-year-old rigid gas macular degeneration,” says Brian PDT with rose bengal can be a suitable permeable contact lens wearer Chou, OD, of San Diego. He notes option for fungal keratitis treatment. with culture-positive Fusarium that this light-activated treatment’s keratitis described a worsening capabilities don’t stop there. Upon he adds that treatment is limited, presentation with hourly natamycin activation, a photosensitizer releases and resolution often takes months. 5%, intrastromal amphotericin B reactive oxygen to targeted cells and PDT is a controversial treatment injection and oral fluconazole.11 On tissue to help manage a wide range for fungal keratitis, according to Dr. day 44, she had rose bengal PDT, of conditions, from acne to cancer. Chou. Several studies have proposed and within four days, she had expe- The most recognized form of using rose bengal or riboflavin as rienced significant improvement.11 PDT in eye care is currently CXL the PDT photosensitizer. A team of Keep rose bengal PDT on your for keratoconus and post-LASIK researchers found that riboflavin radar, and be on the lookout for ectasia.1 Riboflavin and ultraviolet and UVA irradiation reduced Fusar- more to come on its viability as a (UV) light increase and strengthen ium colony-forming units in vitro treatment option. I molecular bonding between corneal and improved the clinical appear- 1. Lim L, Lim EWL. A review of corneal collagen crosslink- collagen fibrils to prevent progres- ance of Fusarium keratitis in the in ing—current trends in practice applications. Open Ophthalmol J. 7 2018;12:181-213. sive ectasia. Other eye-related vivo mouse model. 2. Yoon KC, You IC, Kang IS, et al. Photodynamic therapy with verteporfin for corneal neovascularization. Am J Ophthalmol. applications of PDT include corneal However, Dr. Chou says there 2007;144(3):390-5. neovascularization, microbial kerati- is greater evidence that the com- 3. Alio JL, Abbouda A, Valle DD, et al. Corneal crosslinking and infectious keratitis: a systematic review with a meta-analysis of reported 2-4 tis and certain choroidal diseases. bination of riboflavin and UVA cases. J Ophthalmic Inflamm Infect. 2013;3(1):47. 4. van Dijk EHC, van Rijssen TJ, Subhi Y, et al. Photodynamic therapy does not effectively inhibit fungal for chorioretinal diseases: a practical approach. Ophthalmol Ther. 2020;9(2):329-42. Fungal Keratitis Management proliferation. A 2017 random- 5. Jurkunas U, Behlau I, Colby K. Fungal keratitis: changing patho- Of the total microbial keratitis cases ized clinical trial that looked into gens and risk factors. Cornea. 2009;28(6):638-43. 6. Mahmoudi S, Masoomi A, Ahmadikia K, et al. Fungal in the United States, 6% to 20% CXL treatment with riboflavin for keratitis: an overview of clinical and laboratory aspects. Mycoses. 5 2018;61(12):916-30. are fungal. The preferred topical deep stromal fungal keratitis was 7. Zhu Z, Zhang H, Yue J, et al. Antimicrobial efficacy of corneal crosslinking in vitro and in vivo for Fusarium solani: a potential new treatments are natamycin 5% for aborted because the clinical group treatment for fungal keratitis. BMC Ophthalmol. 2018;18(1):65. 8. Prajna VN, Prajna L, Muthiah S. Fungal keratitis: the Aravind experi- Fusarium (filamentous) and ampho- experienced more perforations than ence. Ind J Ophthalmol. 2017;65(10):912-9. tericin B 0.15% for Candida (yeast) the controls.8 Furthermore, recent 9. Prajna VN, Radhakrishnan N, Lalitha P, et al. Crosslinking-assisted infection reduction: a randomized clinical trial evaluating the effect of and Aspergillus (filamentous).6 Due results of an in vivo clinical trial adjuvant crosslinking on outcomes in fungal keratitis. Ophthalmology. 2020;127(2):159-66. to poor penetrance, deep stromal of 403 patients with filamentous 10. Arboleda A, Miller D, Cabot F, et al. Assessment of rose bengal vs. riboflavin photodynamic therapy for inhibition of fungal keratitis infections may also require repeated fungal keratitis published in Oph- isolates. Am J Ophthalmol. 2014;158(1):64-70. 11. Amescua G, Arboleda A, Nikpoor N, et al. Rose bengal photody- debridement, systemic antimycotics thalmology showed no benefit of namic antimicrobial therapy: a novel treatment for resistant Fusarium or both, advises Dr. Chou. Even so, adjuvant CXL.9 keratitis. Cornea. 2017;36(9):1141-4.

68 REVIEW OF OPTOMETRY JULY 15, 2020 Earn up to

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Navigating Retinal Necrosis This rare, acute disorder can be tied to a number of systemic diseases. By Rami Aboumourad, OD, and Richard Mangan, OD

19-year-old Caucasian male presented with symptoms Aof progressive, deteriorat- ing vision and a red painful left eye for six days. He had been seen at a local Urgent Care facility, where he was diagnosed with ocular allergies, and then by a local eye care provider who referred the patient to our tertiary care center. Fig. 1. These gross external slit lamp photos of the patient’s left eye shows significant The patient had a medical his- diffuse episcleral injection. A faint posterior corneal opacities can be see, although tory of seizures and was devel- the detail is poor. opmentally delayed secondary to neonatal herpes simplex virus type The exam did uncover grade 3 nitis, such as varicella zoster virus 2 (HSV-2) encephalitis. Review of optic disc edema (using the modi- (VZV), herpes simplex virus type 1 systems revealed symptoms con- fied Frisén scale). The retinal vas- or 2 (HSV-1 or HSV-2), cytomega- sistent with an upper respiratory culature was tortuous, and focal lovirus (CMV) and Epstein-Barr infection for seven days. All other retinal whitening and hemorrhag- virus (EBV). medical, ocular and family histories ing was seen in the superonasal Analysis of blood serum can were unremarkable, and the patient periphery. (Figures 2 and 3). evaluate for syphilis, tuberculosis was otherwise systemically healthy. and toxoplasmosis. Aqueous and Upon exam, unaided visual acu- Differential Diagnosis vitreous humor can be analyzed by ity was 20/400 in both eyes with A number of disease entities could polymerase chain reaction (PCR) pinhole improvement to 20/40 OD underly our patient’s presentation. to detect for the presence of VZV, and 20/80 OS. There was relative Conditions that can present with HSV-1, HSV-2, CMV and EBV. afferent pupillary defect in the left panuveitis could include sarcoid- When other diagnostic modalities eye; extraocular motility, confron- osis, tuberculosis, syphilis, Behçet have failed, send vitreous humor to tation visual fields and intraocular disease, Vogt-Koyanagi-Harada pathology for histological evalua- pressures were all otherwise unre- syndrome and toxoplasmosis. One tion. Computed tomography (CT) markable. must also consider the viral enti- of the chest is essential to evaluate The slit lamp exam showed bilat- ties that cause a necrotizing reti- for sarcoidosis and tuberculosis. eral palpebral conjunctival follicles but no palpable preauricular lymph nodes. The ocular exam of the right eye was otherwise unremarkable. The left eye had significant diffuse episcleral injection with inferior corneal stellate keratic precipitates (Figure 1). There were 2+ anterior chamber cell and flare (SUN classification) and moderate vitreous cell mildly obscuring the view of Fig. 1c and 1d. High-magnification slit lamp photographs of the left eye showing the fundus. inferior stellate keratic precipitates on the lower half of the cornea.

70 REVIEW OF OPTOMETRY JULY 15, 2020 Diagnosis for six to eight We saw reason weeks.3,4,10,12,14-17 to highly suspect Oral antiviral acute retinal options include necrosis due acyclovir, to the clinical valacyclovir, presentation famciclovir and and known valganciclovir; history of neo- except for acy- natal HSV-2 clovir, all are encephalitis. A pro-drugs. diagnostic ante- Fig. 2. (a) The patient’s fundus photo shows their left eye’s grade 3 optic disc Of the oral rior chamber edema, using the modified Frisén scale. Vascular tortuosity, faint retinal whitening antiviral agents, paracentesis and hemorrhaging is also visible superonasally. (b) This photo of the superonasal valacyclovir was performed peripheral fundus shows focal retinal whitening with hemorrhage obscured by has the greatest on the left eye, vitreous haze. bioavailability and the aqueous and penetration humor was sent for PCR analy- half of the year (winter and spring) of acyclovir into the vitreous cav- sis for VZV, HSV-1, HSV-2 and and peak incidence in February.9 ity.10,15,18 Moreover, high-dose oral CMV; only HSV-2 was detected. Prompt recognition and treatment valacyclovir (2g by mouth three Serological studies revealed normal is absolutely critical to optimize the times daily) can achieve vitreous blood composition and were nega- visual prognosis in these patients. concentrations comparable with IV tive for syphilis and toxoplasma ARN diagnosis is largely clini- acyclovir with a similar side effect titers. A negative CT ruled out sar- cal. The American Uveitis Society profile.10,16,19 coidosis and tuberculosis. (AUS) defines the diagnostic crite- Moorfields Eye Hospital com- ria as acute panuveitis with focal pared high-dose oral valacyclovir Discussion or multifocal peripheral retinal with IV acyclovir and demon- While rare, acute retinal necrosis necrosis, occlusive retinal vasculi- strated that they were clinically (ARN) is a potentially visually dev- tis (predominantly arterioles) and equivalent in best-corrected visual astating condition of immunocom- rapid (circumferential) disease acuity, risk to developing a reti- petent patients.1,2 Although initially progression in the absence of anti- nal detachment and safety.20 Oral unilateral, the fellow eye can be viral therapy.1,3 Supporting clinical valganciclovir can achieve concen- involved within three to four weeks findings may include optic nerve trations comparable with IV ganci- if untreated but can also occur involvement, scleritis and pain.1 clovir, but it’s reserved mainly for decades after the initial presenta- Diagnostic aqueous or vitreous CMV retinitis treatment.14 Intra- tion.3,4 humor PCR can confirm ARN and vitreal ganciclovir or foscarnet are Infectious etiology is due to the isolate an etiological organism; generally second-line options for Herpesviridae family, most com- samples from aqueous or vitreous aggressive or refractory cases not monly by VZV, followed by HSV-1 humor are thought to be equivocal, responding to systemic therapy and HSV-2; average age at onset is but some studies suggest vitreous alone; however, combined intravit- 52.4 years for VZV, 44.3 years for humor may have greater yield.8,10-13 real and systemic antiviral therapy HSV-1, and 24.3 years for HSV- may be better than systemic thera- 2.5,6 Researchers have published Therapeautics py alone (lower incidence of retinal no incidence data for ARN in the Goals of therapy are to halt pro- detachment and severe visual loss United States, but studies from the gression in the affected eye and of 20/200 or worse and higher United Kingdom show a minimum prevent involvement of the fellow incidence of better final visual acu- annual incidence of 0.63 cases per eye.3,14-16 The mainstay of treatment ity).10,14,17 million with a slight male predi- involves systemic antiviral therapy Given the robust inflammatory lection.7,8 Researchers suggested with intravenous (IV) acyclovir response seen in the immunocom- ARN has outbreak seasonality, for five to 10 days, followed by petent patients of ARN, cortico- with higher incidence in the first transition to an oral antiviral agent steroid therapy is often necessary

REVIEW OF OPTOMETRY JULY 15, 2020 71 Urgent Care

to minimize damage to ocular the patient was poorly compliant structures.14,15 Oral administration to maintenance dosing of oral vala- is best and should be administered cyclovir and eventually reactivated 24 to 48 hours after initiating with subsequent rhegmatogenous systemic antiviral therapy.3,12,14 retinal detachment. Best-corrected Platelet hyperaggregation has acuity in the left eye was 20/250 at been observed in ARN and can be most recent follow-up (nine years addressed with corticosteroids or since initial presentation). ■ anticoagulants such as aspirin.14 Dr. Aboumourad practices at Complications of ARN can the Bascom Palmer Eye Institute in include retinal detachment, optic Fig. 3. These montage fundus photos Miami. atrophy, vascular occlusion and portray the patient’s mild vitreous haze, 1. Holland G. Standard diagnostic criteria for the acute retinal 2,3,12 involvement of the fellow eye. optic disc edema, vascular tortuosity and necrosis syndrome. Executive Committee of the American Uveitis Society. Am J Ophthalmol. 1994;117(5): 663-7. Research shows a high propensity the posterior aspect of active retinitis 2. Fisher J, Lewis M, Blumenkranz M, et al., The acute retinal for retinas to detach, both from superonasally. necrosis syndrome. Part 1: Clinical manifestations. Ophthalmol. 1982;89(12):1309-16. the atrophic nature of the necrotic 3. Culbertson W, Atherton S. Acute retinal necrosis and similar retina as well as secondary to a plication of either active or prior retinitis syndromes. Int Ophthalmol Clin. 1993;33(1):129-43. 4. Rodriguez-Garcia A, Foster C. Advances in the diagnosis and tractional component from down- herpetic encephalitis.21,22 Given the management of uveitis. Intechopen. May 29, 2019. 3,4,10 5. Gass JD. Stereoscopic Atlas of Macular Diseases: Diagnosis stream vitreous contraction. rarity and mortality of herpetic and Treatment, vol. 2. St. Louis: C.V. Mosby Company; 1987. Some have favored prophy- encephalitis, very little data exists, 6. Yanoff M, Duker JS, eds. Ophthalmology. 5th ed. Philadel- phia: Elsevier; 2019. lactic laser photocoagulation to so it is poorly described and under- 7. Muthiah M, Michaelides M, Child C, Mitchell S. Acute retinal strengthen chorioretinal adhesions stood.21,22 necrosis: a national population-based study to assess the incidence, methods of diagnosis, treatment strategies and outcomes as a barricade posterior to areas of It would appear that anybody in the UK. Br J Ophthalmol. 2007;91(11):1452-5. 4,14 8. Cochrane T, Silvestri G, McDowell C, et al. Acute retinal retinitis. Although variable suc- who has suffered herpetic encepha- necrosis in the United Kingdom: results of a prospective surveil- cess has been reported, an obvious litis may be at an increased risk of lance study. Eye (Lond). 2012;26(3):370-8. 9. Hedayatfar A, Khorasani M, Behnia M, Sedaghat A. limitation to this option is vitreous herpetic eye disease given that the Seasonality of acute retinal necrosis. J Ophthalmic Vis Res. inflammation and poor visibil- eye is an extension of the central 2020;15(1):53-8. 10. Schoenberger S, Kim S, Thorne J, et al. Diagnosis and treat- ity impeding the ability to apply nervous system. Moreover, it may ment of acute retinal necrosis: A report by the American Acad- 3,4,12 emy of Ophthalmology. Ophthalmol. 2017;124(3):382-92. adequate laser. For this reason, be worthwhile to consider and dis- 11. Fine H, Burke S, Albini T, Toxoplasmosis retinitis masquer- less severe cases are likely to have a cuss lifelong prophylaxis with these ading as acute retinal necrosis. Ophthalmic Surg Lasers Imaging Retina. 2016;47(10):895-9. more favorable response and out- patients who have had herpetic 12. Hillenkamp J, Nölle B, Bruns C, et al. Acute retinal necrosis: come; conversely more severe cases encephalitis with or without ocular clinical features, early vitrectomy, and outcomes. Ophthalmol. 2009;116(10):1971-5.e2. are the ones that are more prone to involvement, as well as those who 13. Williams A, Nguyen V, Botsford B, Eller A. Bilateral acute 3,4,12 retinal necrosis caused by two separate viral etiologies. Am J retinal detachment. Neverthe- have had unilateral ocular involve- Ophthalmol Case Rep. 2020;18(2):100636. less, there is likely an indication to ment in efforts to spare the fellow 14. Shantha J, Weissman H, Debiec M, et al., Advances in the 21 management of acute retinal necrosis. Int Ophthalmol Clin, apply laser barricade as soon as the eye. 2015;55(3):1-13. 3,4 15. Taylor S, Hamilton R, Hooper C, et al, Valacyclovir in view allows. the treatment of acute retinal necrosis. BMC Ophthalmol. Although implementing early Following Up 2012;12(9):48. 16. Liu T, et al., Valacyclovir as initial treatment for acute retinal vitrectomy may reduce the rate Our patient’s immediate manage- necrosis: A pharmacokinetic modeling and aimulation study. of retinal detachment, one study ment included in-patient admission Curr Eye Res. 2017;42(7):1035-8. 17. Luu K, Scott I, Chaudhry N, et al. Intravitreal antiviral injec- showed final visual outcomes were for IV acyclovir with transition to tions as adjunctive therapy in the management of immuno- competent patients with necrotizing herpetic retinopathy. Am J equivalent with those who did not oral valacyclovir, atropine eye drops Ophthalmol. 2000;129(6):811-3. undergo early vitrectomy, likely and co-administration of predniso- 18. Acosta E, Fletcher C, Valacyclovir. Ann Pharmacother. 1997;31(2):185-91. owing to the multifactorial nature lone eye drops and oral prednisone 19. Huynh T, Johnson M, Comer G, et al., Vitreous penetra- of vision loss in this population and after regression of retinitis was dem- tion of orally administered valacyclovir. Am J Ophthalmol. 2008;145(4):682-6. significant role that optic atrophy onstrated at 36-hour follow-up. The 20. Baltinas J, Lightman S, Tomkins-Netzer O. Comparing 12 treatment of acute retinal necrosis with either oral valacyclovir or can play. patient received repeat intravitreal intravenous acyclovir. Am J Ophthalmol. 2018;188(4):173-80. ganciclovir injections, prophylactic 21. Kianersi F, Masjedi A, Ghanbari H. Acute retinal necrosis after herpetic encephalitis. Case Rep Ophthalmol. 2010;1(2):85-9. Herpes Association laser barricade, and was tapered off 22. Okafor K, Lu J, Thinda S, et al. Acute retinal necrosis Multiple case reports have hypoth- the steroids as the uveitis began to presenting in developmentally-delayed patients with neonatal encephalitis: A case series and literature review. Ocul Immunol esized that ARN can be a com- subside. Despite aggressive therapy, Inflamm. 2017;25(4):563-8.

72 REVIEW OF OPTOMETRY JULY 15, 2020 CE*

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Administered by *Approval pending Review Education Group partners with Salus University for those ODs who are licensed in states that OPTOMETRIC CORNEA, CATARACT EVIEWEDUCATION GROUP require university credit. AND REFRACTIVE SOCIETY Review of Systems Edited By Carlo J. Pelino, OD, and Joseph J. Pizzimenti, OD When Facial Paralysis Strikes Diagnosing and managing Bell’s palsy requires optometrists to rule out any underlying condition that could be triggering a patient’s signs and symptoms. By Sean Gretz, OD

65-year-old African Ameri- field testing to rule out field loss can male presented to the and cerebral involvement (Figure Aprimary care clinic com- 4). Our results were moderately plaining of irritation and foreign reliable and did not indicate cere- body sensation in his right eye. He bral involvement or neurological had excessive tearing and couldn’t field defect. Assessment of the close his right eye. His symptoms optic nerve found well-perfused began two weeks prior, following a tissue with distinct margins and no chemotherapy session. evidence of optic atrophy, edema The patient is currently being or excavation. OCT showed no treated for multiple myeloma and significant retinal nerve fiber layer hypertension. He recovered from (RNFL) dropout or signs of optic hepatitis and prostate cancer 15 neuropathy OD or OS (Figure 5). years ago, which was treated with We promptly referred the patient radiation. He also reported multi- for a gadolinium-enhanced MRI ple spinal fractures and open-heart Fig. 1. The patient suffers from paralysis of of the parotid gland, temporal surgery over 20 years ago. the right side of the face in primary gaze. bone and brain. The MRI did not The patient denied diplopia, reveal metastasis, neoplasm or tis- headache and loss of vision as well ble pathology. The patient displayed sue enhancement. Enhancement of as any neurological symptoms a right-sided facial palsy involving the cranial nerve VI nucleus in Bell’s of unilateral weakness or slurred the upper and lower face (Figures palsy is reported in 57% to 100% speech. His entering blood pressure 1-3). of patients. A lack of enhancement was high at 160/100mm Hg, but he Since motility and cover testing denied chest pain, headache, short- did not reveal any significant devia- ness of breath and dizziness. tion or underaction, we determined that cranial nerves III, IV and VI Case Findings were unaffected. The patient’s The patient’s entering best-corrected corneal sensation was intact, as visual acuities were 20/30 OD were the maxillary and mandibular and 20/20 OS. Pupil and motility branches of the trigeminal nerve. testing revealed no abnormalities. We assessed the patient for bal- His confrontation visual fields ance and gait issues to rule out were unremarkable OU. Slit lamp cranial nerve VIII involvement. He examination revealed a quiet ante- denied any dampening of sound rior chamber OU, conjunctival or hyperacusis, which would indi- injection with lagophthalmos OD cate involvement of the stapedius and significant superficial keratitis muscle—a common occurrence OD. His intraocular pressures were in Bell’s palsy. Our assessment of measured at 15mm Hg OU. Dilated cranial nerves IX through XII was Fig. 2. Weakness of the frontalis muscle, fundus examination revealed arte- unremarkable as well. orbicularis oculi and lower cheek are rial attenuation but no other nota- We performed Humphrey visual notable in stasis and while frowning.

74 REVIEW OF OPTOMETRY JULY 15, 2020 syndrome—and metabolic disorders, including diabetes.3 Idiopathic facial palsy is believed to have an inflammatory pathophysiology. Herpes simplex virus (HSV) activation has been implicated, though the evidence is not entirely conclusive.3,4 HSV-1 Fig. 3. The patient is unable to forcefully close his right eye due to orbicularis genomes were identified in the weakness. facial nerve endoneurial fluid and auricular muscles of 11 of 14 is considered a good prognostic muscles of facial expression.1,2 Bell’s patients undergoing decompression sign. palsy is the most common disorder surgery for Bell’s palsy but in no We ordered serologic testing, that affects the facial nerve and controls.3-5 including CBC with differential, is responsible for about 80% of Management is geared toward ESR, Lyme anti-body, Epstein-Barr all facial mononeuropathies.3 Its reducing facial nerve inflammation titer, FTA-ABS, RPR and ANA, annual incidence is 15 to 30 per and preventing corneal complica- in coordination with the patient’s 100,000 people, with equal num- tions that stem from paresis of the oncology team. There was no bers of men and women affected.2,3 facial muscles and depends on the indication of an inflammatory or Bell’s palsy is a diagnosis of underlying etiology. When Bell’s infectious cause of the patient’s con- exclusion; therefore, a thorough palsy presents acutely, stroke or dition. medical history and review of sys- cerebrovascular incident must be tems are paramount in assessing the ruled out as the cause of the facial Follow-up risk of a systemic cause.1-3 Condi- weakness.2,3,5 Signs of a stroke After two weeks of treatment tions that may mimic Bell’s palsy include slurred speech, unilateral with topical lubricants, the patient include CNS neoplasms, stroke, weakness, vision loss, dizziness and returned for a follow-up exam. HIV, multiple sclerosis, Guillain- disorientation. Immediate referral He reported good ocular comfort Barré syndrome, Ramsay Hunt to the emergency room is warranted with topical lubrication, and his syndrome, Melkersson-Rosenthal if any of these signs are noted. corneal epithelium had significantly syndrome, Lyme disease, otitis Corticosteroids are currently improved. His visual acuity had media, cholesteatoma, sarcoidosis, the drug of choice when medical improved to 20/25+1 OD, and we trauma to the facial nerve, autoim- therapy is needed.3,6 Early treatment observed a mild improvement in mune diseases—such as Sjögren’s with oral glucocorticoids within 72 his orbicularis oculi function. The patient could now completely close his right eye with minimal effort (Figure 6). He came in again after six weeks, during which time his muscle function had continued to improve with no residual weakness or synkinesis.

Discussion Bell’s palsy, also known as facial nerve palsy, is a common clinical presentation seen in the primary care setting. It is defined as an acute, ipsilateral facial nerve (cranial nerve VII) paralysis of unknown etiology that results in Fig. 4. Humphrey visual field testing of the left eye (left) and right eye (right) shows weakness of the platysma and some points of loss inferior to fixation OD and superior nasal OS.

REVIEW OF OPTOMETRY JULY 15, 2020 75 Review of Systems

their facial function can have vary- must selectively test the involved ing degrees of facial weakness, muscles of the face and order addi- hypertonia and synkinesis, which tional neurological and serological can all be managed with physical testing as necessary to further assess therapy.3,4,6 Synkinesis results from for pathology. post-paralytic re-innervation of dif- Although our suspicion for Bell’s ferent muscles by axons from the palsy was high at the onset, this same motor neuron. An example patient had several underlying con- found in (aberrant) Bell’s palsy ditions, including metastasis, stroke regeneration is eyelid closure when and infection, that complicated the a patient smiles. Botulinum toxin case. This highlights the impor- injections may benefit patients with tance of fully evaluating a high-risk synkinesis, facial spasm or hyper- patient who presents with neuro- lacrimation.3,6 Weight insertion into logical abnormalities in a primary the upper eyelid or tarsorrhaphy care setting. can improve eyelid closure. Cos- Dr. Gretz provides comprehen- Fig. 5. OCT imaging shows no evidence metic and functional improvement sive eye care with a focus on ocular of RNFL dropout OD and borderline thin may be possible with facial reani- disease and emergency medicine RNFL superior temporal to the disc OS. mation surgery. Most surgeons will at Simon Eye Associates and is a not perform reanimation surgery member of the Delaware Optomet- hours of onset has been shown to unless no improvement has been ric Association and the American expedite the resolution of paralysis noted for at least nine months. Optometric Association. He gradu- with limited residual symptoms.6 Patients with Bell’s palsy will ated from the Pennsylvania College The suggested regimen is 60mg to have a favorable prognosis if some of Optometry at Salus University 80mg of prednisone per day for one recovery is seen within the first in 2018, where he completed a resi- week, after which point it should be 21 days of onset and should have dency in primary care and ocular tapered off by 10mg per day.3,6,7 some notable recovery by four disease. Our patient in this case was months after the onset of symp- 3,6 1. Tiemstra JD, Khatkhate N. Bell’s palsy: diagnosis and manage- initially seen after the 72-hour toms. If no improvement is noted ment. Am Fam Physician. 2007;76(7):997-1002. window, so we did not prescribe by then, repeat imaging and addi- 2. May M, Klein SR. Differential diagnosis of facial nerve palsy. Oto- laryngol Clin North Am. 1991;24(3):613-45. an oral medication. Oral antivirals tional work-ups may be indicated. 3. Zandian A, Osiro S, Hudson R, et al. The neurologist’s dilemma: a have been widely prescribed as An MRI delineates the soft tissue comprehensive clinical review of Bell’s palsy, with emphasis on current management trends. Med Sci Monit. 2014;20:83-90. monotherapy or in combination structures and is the best way to 4. Baringer JR. Herpes simplex virus and Bell palsy. Ann Intern Med. with steroids; however, their effec- evaluate the intraparotid facial 1996;124(1 Pt 1):63-5. 5. May M, Galetta S. The facial nerve and related disorders of the tiveness for Bell’s palsy is widely nerve for inflammation, edema or face. In: Glaser JS (ed.), Neurophthalmology (2nd ed.), Philadelphia, debated.3,4,8 neoplasm. J. B. Lippincott Co., 1990:239-77. 6. Baugh RF, Basura GJ, Ishii LE, et al. Clinical practice guideline: The primary objective in cases of Bell’s palsy. Otolaryngol Head Neck Surg. 2013;149(3 Suppl):S1-27. Bell’s palsy is to maintain corneal When a patient presents with acute 7. Salinas RA, Alvarez G, Ferreira J. Corticosteroids for Bell’s palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. integrity. Topical lubrication is onset facial nerve palsy, a thorough 2004;(4):CD001942. the first-line treatment and can be history and physical examination 8. Hato N, Sawai N, Teraoka M, et al. Valacyclovir for the treatment prescribed QID or even as often as should be performed. The clinician of Bell’s palsy. Expert Opin Pharmacother. 2008;9(14):2531-6. Q1H depending on the severity of the condition. If corneal integrity is highly compromised, moisture gog- gles, amniotic membrane therapy or tarsorrhaphy may be indicated. The literature shows no consensus for the benefit of, or indication for, surgery in the treatment of Bell’s palsy.3,6 Patients who do not fully recover Fig. 6. The patient’s orbicularis function visibly improved by his six-week follow-up.

76 REVIEW OF OPTOMETRY JULY 15, 2020 CE*

NEW TECHNOLOGIES 2020 & TREATMENTS IN Eye Care

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August faculty: Whitney Hauser, Walt Whitley, Scott Schachter. CE hours: 8. For n 5. NJAO Annual Summer Seminar. Jumping Brook Country Club, more information, email Morris Berman at [email protected] or call Neptune, NJ. Host: New Jersey Academy of Optometry. CE hours: 6. 617-266-2030. For more information, email Dennis Lyons at [email protected] or go to www.aaopt.org/membership/us-and-international-chapters/njchapter. September n 8-9. Glaucoma in the Gorge. Best Western Conference Center, n 5-9. VT1/Visual Dysfunctions (Virtual). Host: Optometric Extension Hood River, OR. Host: Ocular Therapeutics Continuing Education. Key Program Foundation. Key faculty: John Abbondanza. CE hours: 35. For faculty: Tony Litwak, Jim Thimons. CE hours: 10. For more information, more information, email Karen Ruder at [email protected], call 410- email Tony Litwak at [email protected] or go to www.otce.net. 561-3791 or go to www.oepf.org. n 14-15. Envision Virtual Conference East 2020. Host: Envision n 6-10. Tropical CE Sonoma 2020. Hyatt Regency Sonoma, Sonoma, University. CE hours: Total: 32, maximum per OD: 11. For more CA. Host: Tropical CE. Key faculty: John Mc Greal, Jr., Jill Autry. CE information, email Michael Epp at [email protected], call hours: 14. For more information, email Stuart Autry at sautry@tropicalce. 316-440-1515 or go to www.envisionconference.org. com or go to www.tropicalce.com. n 21-23. UAB School of Optometry Fall Continuing Education n 7-8. Primary Eye Care Update. NSU Event Center, Tahlequah, Weekend (Virtual). Host: UAB School of Optometry. CE hours: 18. For OK. Host: Oklahoma College of Optometry. CE hours: 10. For more information, email Kathryn Trammell at [email protected], call more information, email Callie McAtee at [email protected], call 205-934-5701 or go to uab.edu/optometry/ce. 918-316-3602 or go to optometry.nsuok.edu/continuingeducation/ n 28-30. Northern Escape 2020. Delta Hotels by Marriott Quebec, scheduleofevents/primaryeyecareupdate.aspx. Quebec City. Host: Optometric Education Consultants. CE hours: 15. For more information, email Vanessa McDonald at [email protected], To list your meeting, please send the details to: call 954-612-4142 or go to www.optometricedu.com/home. Jane Cole, Contributing Editor n 30. NECO Ocular Surface Symposium with Dry Eye Coach. New Email: [email protected] England College of Optometry (NECO), Boston. Host: NECO. Key

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The Optometric Retina Society & Review Education Group present: RETINAUPDATE2020 REGISTRATION OPEN DECEMBER 45 | SCOTTSDALE, AZ

CHAIR FAIRMONT SCOTTSDALE PRINCESS ORS MISSION STATEMENT Mohammad Raﬁ eetary, OD, 7575 East Princess Drive The mission of the Optometric Retina FAAO Scottsdale, AZ 85255 Society (ORS) is to promote the advancement of vitreoretinal knowledge COCHAIR A limited number of rooms for clinicians, ophthalmic educators, Steven Ferrucci, OD, FAAO have been reserved residents, and students. The ORS is at $279 per night + applicable taxes dedicated to posterior segment disease and fees. prevention, diagnosis, management and co-management. Make your reservations with the hotel COVID-19 Statement: directly at 480-585-4848. REGISTRATION: See Website for Important Updates Mention “Retina Update 2020” Early Bird Special: $375 for group rate. Full Conference after October 9: $450 See event website for daily fees.

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He Kept His Eye on the Ball A patient develops worsening near vision three years after a blunt trauma. By Andrew S. Gurwood, OD

History A 44-year-old male presented to the office for a routine eye exam. He reported that his vision was fine at distance but that he now needed reading glasses. He denied previous surgery or any history of glaucoma, but he did say he incurred a blunt trauma—hit in the face with a football—to his right eye three years earlier. He denied systemic diseases and allergies of any kind.

Diagnostic Data After a little roughhousing injured His best-corrected entering visual his eye, a patient’s near vision got acuities were 20/20 OD and 20/20 progressively worse for three years. OS at distance and near. Refrac- Using this history, fundus photos and a tion uncovered mild hyperopia gonioscopy exam, can you help identify with presbyopia measuring why he suddenly needs reading glasses? +0.50/+1.75 OU. His external examination was unremarkable with no evidence of afferent pupil- Your Diagnosis lary defect. His biomicroscopic Does the case presented require examination was essentially any additional tests, history or normal with some pigmentation OD and 21mm Hg OS. The per- information? What would be your granules observed on the endothe- tinent anterior and posterior seg- diagnosis? What is the patient’s lium, OD. Goldmann applanation ment findings are demonstrated in likely prognosis? To find out, visit tonometry measured 30mm Hg the photographs. www.reviewofoptometry.com. n

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