Contact Lens Practice

EARN 2 CE CREDITS — Understanding AMD Presentations and Prognoses, p. 64 • 911 in the Exam Lane, p. 56

August 15, 2020 www.reviewofoptometry.com Grow Your CONTACT LENS PRACTICE

A little nurturing now can set you up for an abundant future. Disposables

Multifocals Sclerals

INFUSED FOR BALANCE The only44th silicone Annual hydrogel Contact daily disposable Lens Report with a next-generation material infused with ProBalance Technology ™ to help maintain ocular surface homeostasis 1 Find balance at BauschINFUSE.com The Building Blocks for a Specialty Lens Practice, p. 30 • Are You Making the Most of the Newest Soft Lenses?, p. 38 REFERENCE: 1. Data on fi le. Bausch & Lomb Incorporated. Rochester, NY. ®/™ are trademarks of Bausch & LombAdd Incorporated Multifocals or its affi liates. to Your Myopia Toolbox, p. 44 • Don’t Let the Scleral Surge Pass You By, p. 50 ©2020 Bausch & Lomb Incorporated or its affi liates. INF.0151.USA.20

EARN 2 CE CREDITS — Understanding AMD Presentations and Prognoses, p. 64 • 911 in the Exam Lane, p. 56

August 15, 2020 www.reviewofoptometry.com Grow Your CONTACT LENS PRACTICE

A little nurturing now can set you up for an abundant future. Disposables

Multifocals

Sclerals

44th Annual Contact Lens Report

The Building Blocks for a Specialty Lens Practice, p. 30 • Are You Making the Most of the Newest Soft Lenses?, p. 38 Add Multifocals to Your Myopia Toolbox, p. 44 • Don’t Let the Scleral Surge Pass You By, p. 50 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 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 News Review

VOL. 157 NO. 8 n AUGUST 15, 2020

IN THE NEWS Desk Work Tied to Dry Eye A study investigated differing perceptions Computer use and drier working environments of marijuana as glaucoma therapy. With may be factors. By Jane Cole, Contributing Editor

few glaucoma specialists recom- Photo: Candice Tolud, OD mending marijuana (7.6%), and even espite sustained exposure fewer patients using it (2.6%), while to dust, debris and other half of marijuana dispensaries en- environmental factors, dorse its use, public confusion seems D construction workers are four likely. “As legal access and public acceptance of marijuana escalates, times less likely to develop dry physicians should be aware of these eye symptoms compared with perceptions when educating patients,” ofﬁce workers, a study in BMC the researchers noted. Ophthalmology suggests.

Weldy E, Stanley J, Koduri V, et al. Perceptions of marijuana The cross-sectional, observa- use for glaucoma from patients, cannabis retailers, and tional investigation evaluated dry glaucoma specialists. Ophthalmology. July 2, 2020. [Epub ahead of print]. eye symptoms and associated risk factors in 304 subjects (149 con- This DED patient has punctate epithelial A new study suggests a combined struction workers and 155 office keratitis and decreased tear break-up time. treatment of 0.01% atropine and workers) who were given an Ocular orthokeratology may be effective for Surface Disease Index (OSDI) ques- Offices in the study were 50% drier childhood myopia control. The study tionnaire. Participants were approx- than the outdoor air, they add. enrolled 154 children (ages eight to 12) who had a spherical equivalent of -1D to imately 34 years old and worked The findings underline the serious -6D. It found subfoveal choroidal thick- at their current job for at least six need to inform the population that ness significantly increased in the atro- months. Most of the individuals office work—which represents pine and ortho-K, ortho-K and placebo were male (63.5%). the largest job-force in Western and atropine groups. The one-month More than half (55%) of the sub- countries—may increase the risk change in subfoveal choroidal thick- jects presented dry eye symptoms of developing dry eye symptoms. ness was larger in the atropine and with an OSDI score greater than 12. Researchers also suggest the ortho-K group compared with patients The average OSDI score was 21.30, importance of educating individuals prescribed atropine alone. and was lower in the construction on how to minimize these risks, Li Z, Hu Y, Cui D, et al. Short-term effects of atropine group (12.45) compared with the including the avoidance of long, combined with orthokeratology (ACO) on choroidal thickness. Contact Lens & Anterior Eye. June 30, 2020. [Epub office workers (28.51). Considering uninterrupted periods of computer ahead of print]. participants who had moderate and work, breaks to allow for regular severe symptoms (23 to 100 points), blinking and ciliary relaxation and In elderly patients with large cup-to- disc ratios, a positive temporal raphe office workers had dry eye symp- to demand better humidity controls sign on OCT imaging is associated toms 4.15 times more frequently in the workplace. with faster conversion to normal-ten- than construction workers. “This highlights the pernicious sion glaucoma (NTG). A study evaluated Additionally, women had higher effects on the ocular surface of the 72 eyes of untreated patients at least 65 OSDI scores than men (32.47 vs. office environment, which poses a years old with large vertical cup-to-disc 14.87, respectively). significant risk for the development ratios (≥0.7). During 5.5 years of follow- The researchers suggest dif- or worsening of dry eye symp- up, the researchers found that 19 eyes ferent factors may have affected toms,” the researchers wrote in converted to NTG. The temporal raphe the results, but the outcome was their paper. sign was seen in 94.7% of converters but likely influenced by office workers’ only 5.7% of non-converters at baseline. Hernandez-Llamas S, Paz-Ramos AK, Marcos-Gonzalez P, et al. exposure to sustained computer use Symptoms of ocular surface disease in construction workers: Ha A, Kim YK, Kim JS, et al. Temporal raphe sign in elderly comparative study with office workers. BMC Ophthalmology. July patients with large optic disc cupping: its evaluation as a in significantly drier environments. 20, 2020. [Epub ahead of print]. predictive factor for glaucoma conversion. Am J Ophthalmol. July 8, 2020. [Epub ahead of print]. NEWS STORIES POST EVERY WEEKDAY MORNING AT www.reviewofoptometry.com/news

4 REVIEW OF OPTOMETRY AUGUST 15, 2020 Iowa Gains Expanded Scope of Practice ODs win battle to treat patients with injectable meds. owa optometrists recently joined “We are very pleased to get that looking to implement these treat- the growing number of practi- kind of support among our state ment modalities must have suffi- Itioners allowed to treat certain legislators,” Dr. Kirschling says. cient education and clinical train- ocular conditions with injections. “There is an ophthalmologist serving ing, whether from an accredited Iowa’s bill (HF 310), approved on in the Iowa senate, which has been a college or university or equivalent June 29, now clarifies that ODs roadblock in the last couple of years, education provider. The Iowa with the proper training and board but we are happy to still support in Optometric Association has already approval can administer subcon- the senate despite that.” been offering workshops to ODs junctival injections to treat ocular Part of the success is due to excep- for several years in preparation for conditions, intralesional injections tional leadership, according to Dr. the expanded scope. to treat chalazia, botulinum toxin Kirschling. The Association’s execu- “Going forward, we will continue (including for cosmetic purposes) tive director, Gary Ellis, has been at to offer that on an expanded basis and injections to counteract an the helm for 25 years. for our ODs who don’t have that anaphylactic reaction.1 “It is very helpful to have longev- skillset; our younger ODs graduat- “This is the culmination of ity when it comes to our optometric ing from optometry school already several years of work—four years of association’s front office,” he says. have that training and skillset under legislative battles, but five years of “Those relationships built at the their belt,” Dr. Kirschling explains. work,” says Brian Kirschling, OD, state capital with legislators don’t “For docs who wish to learn those president of the Iowa Optometric happen overnight. Gary and his crew skills, the opportunities are avail- Association. “We are very pleased to deserve a lot of the accolades, along able to them.” get it to the governor’s desk and get with our docs who sat in and fought The expanded scope will vastly it signed.” the subcommittee and committee affect patient care in rural states Already through the house, the battles.” like Iowa, Dr. Kirschling adds. “Op- bill passed in the senate at the begin- tometrists practice in nearly all of ning of March on a 41 to eight vote, Training Opportunities Iowa’s 99 counties and, tradition- he explains. Then COVID hit and While the update was expected, as ally, that has allowed Iowa optom- everything shut down. The bill had it’s been in the works since 2015, the etrists to be front-line providers of some language changes that required timing of the decision in light of CO- full-scope eye care.” another round in the house, and on VID-19 is disappointing, says Brian 1. Iowa Legislature. House File 310, an Act relating to the June 3rd, the house passed the bill Chou, OD, of San Diego. practice of optometry. www.legis.iowa.gov/legislation/ on a 91 to six vote. The bill also specifies that those BillBook?ga=88&ba=HF310. Accessed July 1, 2020. Peripheral CXL Helps Clear Neovascularization orneal crosslinking (CXL) performed before or in combination all transplants remained clear and may be able to reduce corne- with PK, and researchers assessed without immune reactions with an Cal neovascularization and, in the effect of CXL on neovascular- approximate follow-up of 16 weeks. turn, serve as a novel treatment op- ization based on slit-lamp images. The findings suggest peripheral tion to improve graft survival after Patients were followed to determine CXL may be a new option to regress high-risk penetrating keratoplasty the incidence of adverse effects and pathologic corneal blood vessels in (PK), a study in Cornea suggests. graft rejection. patients and may be a new treatment The retrospective case series in- None of the patients had any option, especially in those who are cluded five patients with progressive intraoperative or postoperative high-risk patients before keratoplas- corneal neovascularization and the complications. Researchers found ty, the investigators note. n need for high-risk PK due to graft re- peripheral CXL resulted in a mean Choy BNK, Ng ALK, Zhu MM, et al. Randomized control trial on jection and/or keratitis who received reduction of 70.5% with no revas- the effectiveness of collagen crosslinking on bullous keratopa- CXL and PK recently. CXL was cularization issues. Additionally, thy. Cornea. July 1, 2020. [Epub ahead of print].

REVIEW OF OPTOMETRY AUGUST 15, 2020 5 News Review For more, visit www.reviewofoptometry.com/news Hoster Succeeds Henne as Publisher obson Medical Information our editorial and sales teams,” said magazine’s Managing Editor from has announced that Michael Marc Ferrara, president of Jobson’s 2012 through 2014. Mr. Hoster JHoster, a 13-year veteran of Optical Group. “Of course, we transitioned to Review’s sales team the company, has been named will all miss Jim Henne, who has in 2015. “Mike has become an Publisher of the Review Group done an outstanding job leading extremely valuable team member of publications and services. the Review Group. Jim’s insights, over this period and has developed This includes the titles Review leadership skills and witty charm a keen understanding of the of Optometry, Review of make him a very unique leader.” markets we serve and the products Ophthalmology, Review of Cornea Mr. Hoster has spent his entire we deliver,” added Mr. Ferrara. and Contact Lenses and Retina professional career at Jobson, “The Review Group has a Specialist, as well as a host of beginning as an Associate Editor sterling reputation for providing affiliated websites, e-newsletters for Review of Optometry in the most cutting-edge, clinically and other digital products designed 2007. He also served as the relevant information available to to provide robust clinical the eye care community,” insight and education said Mr. Hoster. “Jim has to optometrists and been an invaluable leader to ophthalmologists. our group, a consummate Mr. Hoster assumed the mentor to me and a true position previously held inspiration to our entire by veteran publisher and company. I look forward to industry icon James Henne following in his footsteps since 2014. “Mike has been and working with our team an instrumental player at in an effort to serve all the the Review Group for 13 needs of our readers and years, playing key roles on Michael Hoster, at left, and James Henne. industry partners.” CXL Risky for Bullous Keratopathy orneal collagen crosslinking group that received the same control group, suggesting a placebo (CXL) appears to reduce riboflavin solution, but underwent effect, the researchers say. Ccorneal thickness in patients a sham debridement and UV light Of note: CXL was associated with bullous keratopathy (BK), at treatment. The patients were with more recurrent epithelial least in the initial four weeks after assessed at baseline and up to 12 defect (12%), and two of the three surgery, researchers from Hong months after treatment. subjects with epithelial defect Kong suggest. However, their study The central corneal thickness in required amniotic membrane also found that patients who under- the CXL group was reduced by transplant. went CXL had no greater improve- 37.6µm and 63.8µm at two and “Considering its side effects of ments in pain, corneal clarity or four weeks, respectively, which recurrent epithelial defect, which vision compared with the control was significantly higher than the might require further treatment, group and that the short-term ben- control group. However, there was including amniotic membrane efits of the procedure were unlikely no statistical difference in central transplant, CXL might not be war- to outweigh its potential risk of corneal thickness reduction between ranted as a treatment alternative in recurrent epithelial defect. the two groups at 12 weeks and patients with BK,” the researchers The study enrolled 42 patients during later follow-ups. While the wrote in their paper. n with BK, of whom 26 were CXL group reported lower pain Choy BNK, Ng ALK, Zhu MM, et al. Randomized control trial randomized to receive CXL, and scores throughout the one-year on the effectiveness of collagen cross-linking on bullous 16 were placed in the placebo follow-up, the same was true of the keratopathy. Cornea. July 1, 2020. [Epub ahead of print].

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Be a Part of Our AI Helps Triage Glaucoma 2020 Income Survey

any optometrists had high hopes Patients During COVID-19 Mfor 2020. “The year of vision” was n light of COVID-19, research- which ones are in greater need for expected to put eye care front and center ers recently explored ways clini- follow-up care ahead of others, mak- in the public’s mind—then COVID-19 hit Icians can best prioritize glau- ing it easier to identify those who and forced the fi eld to readjust. Practices coma patients who need to be seen would most benefi t from coming in are riding out regional lockdowns, social and who can wait—and they found to the clinic, Dr. Stein adds. distancing has become the norm and PPE artifi cial intelligence can help. The study identifi ed 1,034 patients is now a line item in everyone’s budgets. Researchers from the University of with upcoming glaucoma clinic As part of our annual income survey, Michigan analyzed data from a large appointments from March to April we want to hear how all this has affected electronic health record repository to 2020. The team developed a risk you fi nancially. create a scoring system that consid- stratifi cation tool that calculated a For some, the shift toward medical ered a patient’s glaucoma severity glaucoma severity and progression practice and urgent care has been a and their risk of disease progression risk score and a COVID-19 mor- saving grace; for others, it’s been tough against their risk of morbidity from bidity risk score that were added to stay in the black as patients reconsider COVID-19. together for a total score for each online glasses and contact lens sales. “Since the COVID pandemic patient. If you’re an OD practicing in the United began, ophthalmologists and op- The mean glaucoma severity and States, please take a few minutes to tometrists have been trying to decide progression risk score was four respond to our annual income survey and which of our patients’ clinic appoint- points, while the mean morbidity share your fi nancial experience over the ments should get postponed and risk score was 27.2 points— a mean last year. The results will be published rescheduled and which ones should total score of 31.2 points. anonymously in the December issue. be kept, carefully considering the The study assessed different All personal and fi nancial information benefi ts and risks of their coming in triage thresholds (zero, 25 and 50) is confi dential and used for no other to the clinic to see us,” says research- to demonstrate varying degrees purpose than this survey. er Joshua D. Stein, MD. of caution regarding the adverse Just in case you need a little extra For patients with sight-threaten- outcomes, whether related to push, here’s an incentive: upon completing conditions such as glaucoma, COVID-19 exposure or the risk ing all of the questions in the survey, this can be a diffi cult decision of glaucoma progression. In you’ll be entered to win a $100 American because delays in care can result in this sample, a threshold of zero Express Gift Card. It only takes a few progression that can lead to irrevers- meant 93.8% of the scheduled minutes, as there are only a handful of ible blindness, he adds. Yet, on the appointments could safely be questions. fl ipside, many patients with glauco- postponed for up to three months. This is also your chance to share ma are also elderly with other medi- The total score thresholds of 25 candid stories from the front lines of cal comorbidities, and if they are and 50 points suggested 64.6% and what will hopefully be a once-in-a-career exposed to COVID-19 as a result of 26.6% of appointments could safely disruption. Tell us what you’ve been seeking eye care services, the risk of be postponed, respectively. through! morbidity and mortality can be high, The study also validated the Thank you for your participation—we Dr. Stein says. total scores from the algorithm wouldn’t know where the fi eld stood The study’s automated system against glaucoma specialists’ fi nancially without you! generated a score that captures recommendations based on the these competing risks for each review of patients’ records and Take the Survey patient, he explains. found the two aligned. ■ Visit www.survey- Furthermore, as federal, state and Bommakanti NK, Zhou Y, Ehrlich JR, et al. Application of monkey.com/ local restrictions are lifted and it is the sight outcomes research collaborative ophthalmology r/2020incomesurvey or safer for patients to come in to seek data repository for triaging patients with glaucoma and clinic appointments during pandemics such as COVID-19. scan the QR code. eye care, clinicians can also make use JAMA Ophthalmology. July 17, 2020. [Epub ahead of of the algorithm scores to prioritize print].

8 REVIEW OF OPTOMETRY AUGUST 15, 2020

Contents 44TH ANNUAL CONTACT LENS REPORT Review of Optometry August 15, 2020 The Building Blocks Add Multifocals to Your 30 for a Specialty Contact 44 Myopia Toolbox Lens Practice These contact lenses are proving themselves to be an Shifting your focus offers rewards for both your patients excellent treatment option. Here’s what you need to know. and practice, but roll up your sleeves for the work needed to By Kara Tison, OD, and Carol B. Parker, OD become an expert. By Jane Cole, Contributing Editor Are You Making the Most of Don’t Let the Scleral Surge 38 the New Soft Lenses? 50 Pass You By Improvements in comfort, function and design can make the There’s no better time than now to take advantage of the rising wear experience better for patients. By Melissa Barnett, OD demand for this lens modality. By Brooke Messer, OD

EARN 2 CE CREDITS: 56 911 In the Exam Lane 64 Understanding AMD Handling medical emergencies in the office can be stressful. Presentations and Prognoses Here’s how to be prepared. These clinical pearls can help you identify at-risk patients in By Chris Kruthoff, OD your practice and care for them over the long haul. By Jessica Haynes, OD

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4 News Review 16 Outlook Dueling Pandemics JACK PERSICO BUSINESS OFFICES 19 CAMPUS BLVD., SUITE 101 18 Through My Eyes NEWTOWN SQUARE, PA 19073 Updates Come in Threes CEO, INFORMATION SERVICES GROUP PAUL M. KARPECKI, OD MARC FERRARA (212) 274-7062 • [email protected]

20 Chairside EXECUTIVE DIRECTOR You’ve Won an Island Getaway! JAMES HENNE 22 (610) 492-1017 • [email protected] MONTGOMERY VICKERS, OD

PUBLISHER 22 Clinical Quandaries MICHAEL HOSTER (610) 492-1017 • [email protected] Curtain Call PAUL C. AJAMIAN, OD REGIONAL SALES MANAGER MICHELE BARRETT (610) 492-1014 • [email protected] 24 Focus on Refraction A Little VT Goes a Long Way VICE PRESIDENT, OPERATIONS CASEY FOSTER MARC B. TAUB, OD, MS, AND (610) 492-1007 • [email protected] PAUL HARRIS, OD VICE PRESIDENT, CLINICAL CONTENT PAUL M. KARPECKI, OD, FAAO 28 Coding Connection [email protected]

Special Rules for Special Lenses PRODUCTION MANAGER JOHN RUMPAKIS, OD, MBA FARRAH APONTE 24 (212) 274-7057 • [email protected] 74 Cornea + Contact Lens Q&A SENIOR CIRCULATION MANAGER KCN Options: Stiff Competition HAMILTON MAHER (212) 219-7870 • [email protected] JOSEPH P. SHOVLIN, OD CLASSIFIED ADVERTISING 76 Retina Quiz (888) 498-1460 Don’t Strain Yourself SUBSCRIPTIONS $56 A YEAR, $88 (US) IN CANADA, MARK T. DUNBAR, OD $209 (US) IN ALL OTHER COUNTRIES.

SUBSCRIPTION INQUIRIES 78 Glaucoma Grand Rounds (877) 529-1746 (US ONLY) The Art of Juggling OUTSIDE US CALL: (845) 267-3065 JAMES L. FANELLI, OD CIRCULATION PO BOX 81 82 Surgical Minute CONGERS, NY 10920 76 TEL: (TOLL FREE): (877) 529-1746 Stop the Drop? OUTSIDE US: (845) 267-3065 DEREK N. CUNNINGHAM, OD, AND

WALTER WHITLEY, OD, MBA CEO, INFORMATION SERVICES GROUP MARC FERRARA

84 Therapeutic Review SENIOR VICE PRESIDENT, OPERATIONS When to Treat Ocular Hypertension JEFF LEVITZ JOSEPH W. SOWKA, OD VICE PRESIDENT, HUMAN RESOURCES TAMMY GARCIA 87 Advertisers Index VICE PRESIDENT, CREATIVE SERVICES & PRODUCTION MONICA TETTAMANZI 88 Classifieds CORPORATE PRODUCTION DIRECTOR JOHN ANTHONY CAGGIANO 90 Diagnostic Quiz It’s Not Your Imagination VICE PRESIDENT, CIRCULATION 82 EMELDA BAREA ANDREW S. GURWOOD, OD

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Scan here or visit Toll free 888-519-5375 www.oculususa.com/lensfitting [email protected] CONTRIBUTING EDITORS A. PAUL CHOUS, MA, OD, TACOMA, WASH. PAUL C. AJAMIAN, OD, ATLANTA ROBERT M. COLE, III, OD, BRIDGETON, NJ AARON BRONNER, OD, KENNEWICK, WASH. GLENN S. CORBIN, OD, WYOMISSING, PA. MILE BRUJIC, OD, BOWLING GREEN, OHIO ANTHONY S. DIECIDUE, OD, STROUDSBURG, PA. DEREK N. CUNNINGHAM, OD, AUSTIN, TEXAS S. BARRY EIDEN, OD, DEERFIELD, ILL. MARK T. DUNBAR, OD, MIAMI STEVEN FERRUCCI, OD, SEPULVEDA, CALIF. ARTHUR B. EPSTEIN, OD, PHOENIX MURRAY FINGERET, OD, HEWLETT, NY JAMES L. FANELLI, OD, WILMINGTON, NC IAN BEN GADDIE, OD, LOUISVILLE, KY. GARY S. GERBER, OD, HAWTHORNE, NJ PAUL HARRIS, OD, MEMPHIS, TN ANDREW S. GURWOOD, OD, PHILADELPHIA MILTON HOM, OD, AZUSA, CALIF. DAVID KADING, OD, SEATTLE BLAIR B. LONSBERRY, MS, OD, MED, PORTLAND, ORE. PAUL M. KARPECKI, OD, LEXINGTON, KY. THOMAS L. LEWIS, OD, PHD, PHILADELPHIA JEROME A. LEGERTON, OD, MBA, SAN DIEGO DOMINICK MAINO, OD, MED, CHICAGO JASON R. MILLER, OD, MBA, POWELL, OHIO KELLY A. MALLOY, OD, PHILADELPHIA CHERYL G. MURPHY, OD, BABYLON, NY RICHARD B. MANGAN, OD, LEXINGTON, KY. CARLO J. PELINO, OD, JENKINTOWN, PA. RON MELTON, OD, CHARLOTTE, NC JOSEPH PIZZIMENTI, OD, FORT LAUDERDALE, FLA. PAMELA J. MILLER, OD, JD, HIGHLAND, CALIF. JOHN RUMPAKIS, OD, MBA, PORTLAND, ORE. BRUCE MUCHNICK, OD, COATESVILLE, PA. DIANA L. SHECHTMAN, OD, FORT LAUDERDALE, FLA. MARC MYERS, OD, COATESVILLE, PA. JEROME SHERMAN, OD, NEW YORK CHRISTOPHER J. QUINN, OD, ISELIN, NJ JOSEPH P. SHOVLIN, OD, SCRANTON, PA. MICHAEL C. RADOIU, OD, STAUNTON, VA. JOSEPH W. SOWKA, OD, FORT LAUDERDALE, FLA. MOHAMMAD RAFIEETARY, OD, MEMPHIS, TN MONTGOMERY VICKERS, OD, ST. ALBANS, W.VA. JOHN L. SCHACHET, OD, ENGLEWOOD, COLO. WALTER O. WHITLEY, OD, MBA, VIRGINIA BEACH, VA. JACK SCHAEFFER, OD, BIRMINGHAM, ALA. LEO P. SEMES, OD, BIRMINGHAM, ALA. EDITORIAL REVIEW BOARD LEONID SKORIN, JR., OD, DO, ROCHESTER, MINN. JEFFREY R. ANSHEL, OD, ENCINITAS, CALIF. JOSEPH W. SOWKA, OD, FORT LAUDERDALE, FLA. JILL AUTRY, OD, RPH, HOUSTON BRAD M. SUTTON, OD, INDIANAPOLIS SHERRY J. BASS, OD, NEW YORK LORETTA B. SZCZOTKA, OD, PHD, CLEVELAND EDWARD S. BENNETT, OD, ST. LOUIS MARC TAUB, OD, MEMPHIS, TN MARC R. BLOOMENSTEIN, OD, SCOTTSDALE, ARIZ. TAMMY P. THAN, MS, OD, BIRMINGHAM, ALA. CHRIS J. CAKANAC, OD, MURRYSVILLE, PA. RANDALL THOMAS, OD, CONCORD, NC OM_BRUDER_Kit-Half-Horz-Ad_2020-07 PRINT2.pdf 1 6/19/2020 3:53:38 PM JERRY CAVALLERANO, OD, PHD, BOSTON SARA WEIDMAYER, OD, ANN ARBOR, MI WALTER L. CHOATE, OD, MADISON, TENN. KATHY C. WILLIAMS, OD, SEATTLE BRIAN CHOU, OD, SAN DIEGO KAREN YEUNG, OD, LOS ANGELES HEALTHY EYES START HERE

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FOUNDING EDITOR, FREDERICK BOGER 1891-1913 Dueling Pandemics EDITORIAL OFFICES 19 CAMPUS BLVD., SUITE 101 NEWTOWN SQUARE, PA 19073 Will COVID-driven changes in behavior accelerate

SUBSCRIPTION INQUIRIES myopia development? 1-877-529-1746

CONTINUING EDUCATION INQUIRIES he COVID stories that con- for most families, we’re all spending 1-800-825-4696 sume most of our attention enormously more time indoors. As concern its tragic death toll school reopening looks dicey, some EDITOR-IN-CHIEF • JACK PERSICO T (610) 492-1006 • [email protected] and the anxiety that pervades our kids could be forced to live for a year MANAGING EDITOR • REBECCA HEPP efforts to respond to the threat, or under circumstances least conducive (610) 492-1005 • [email protected] even just live through it. But a global to emmetropization: home-schooling ASSOCIATE EDITOR • CATHERINE MANTHORP phenomenon also brings with it in front of a screen for hours a day (610) 492-1043 • [email protected] ASSOCIATE EDITOR • MARK DE LEON second-order effects—unanticipated with outdoor time severely limited. (610) 492-1021 • [email protected] “consequences of consequences” Being the father of a four-year-old, SPECIAL PROJECTS MANAGER • JILL GALLAGHER playing out in the background. this has crossed my mind more than (610) 492-1037 • [email protected] For instance, the shelter-at-home once. With no other kids to play with ART DIRECTOR • JARED ARAUJO (610) 492-1032 • [email protected] orders yielded a research bonanza thanks to social distancing and not DIRECTOR OF CE ADMINISTRATION • REGINA COMBS for environmental scientists. Since even an open playground to enjoy, (212) 274-7160 • [email protected] March, they’ve been recording pollu- we’re lucky to keep my son outside tion levels that reflect actual, rather for 30 minutes a day. The rest of his EDITORIAL BOARD than hypothetical, low levels of auto time is devoted to an endless array of CHIEF CLINICAL EDITOR • PAUL M. KARPECKI, OD emissions. They’ll now be able to near vision tasks indoors. ASSOCIATE CLINICAL EDITORS • JOSEPH P. SHOVLIN, OD; model the effects of reduced traffic If my son ends up myopic when CHRISTINE W. SINDT, OD with much greater accuracy. he might not have otherwise, that’s DIRECTOR OPTOMETRIC PROGRAMS • ARTHUR EPSTEIN, OD What second-order effects do we unfortunate but certainly negligible CLINICAL & EDUCATION CONFERENCE ADVISOR PAUL M. KARPECKI, OD see in eye care? For one, COVID has compared with the horrific first-order

CASE REPORTS COORDINATOR • ANDREW S. GURWOOD, OD brought telehealth to mainstream COVID consequences. Still, myopia

CLINICAL CODING EDITOR • JOHN RUMPAKIS, OD, MBA practice. While impractical for most was already a pandemic in its own clinical responsibilities, telehealth right before COVID barged in and

COLUMNISTS should stick around for follow-up potentially kicked it into high gear.

CHAIRSIDE • MONTGOMERY VICKERS, OD visits and other aspects of care that I can understand if you’ve had

CLINICAL QUANDARIES • PAUL C. AJAMIAN, OD don’t require specialized equipment. enough myopia control articles for

CODING CONNECTION • JOHN RUMPAKIS, OD It also decimated CE conferences. a while. It surely has dominated

CORNEA & CONTACT LENS Q+A • JOSEPH P. SHOVLIN, OD Meeting planners are nervously wait- optometric education of late. But, for

DIAGNOSTIC QUIZ • ANDREW S. GURWOOD, OD ing to see if attendees will be content those who are interested, this month’s

THE ESSENTIALS • BISANT A. LABIB, OD with, or even prefer, virtual events as article, “Add Multifocals to Your

FOCUS ON REFRACTION • MARC TAUB, OD; a staple of education from now on. Myopia Toolbox” is a good place to PAUL HARRIS, OD But I wonder if COVID’s biggest start. The authors lay out a plan for GLAUCOMA GRAND ROUNDS • JAMES L. FANELLI, OD unforeseen effect is to essentially making this technique work in your OCULAR SURFACE REVIEW • PAUL M. KARPECKI, OD launch a giant clinical trial of myo- practice—something few ODs are RETINA QUIZ • MARK T. DUNBAR, OD pia’s environmental influences. The doing despite all the media coverage. SURGICAL MINUTE • DEREK N. CUNNINGHAM, OD; literature says children need at least As noted in the article, only 6.8% of WALTER O. WHITLEY, OD, MBA two hours of outdoor time each day all contact lens fits in 2018 were for THERAPEUTIC REVIEW • JOSEPH W. SOWKA, OD to mitigate myopia development. myopia control, which amounted to THROUGH MY EYES • PAUL M. KARPECKI, OD We’re now six months into a pan- just 2.3% of contact lens fits for kids. URGENT CARE • RICHARD B. MANGAN, OD demic that fundamentally reshaped COVID will be brought under con- of our daily routines. With schools trol one day. Will myopia? The need JOBSON MEDICAL INFORMATION LLC and daycares closed, and summer for interventions, and the opportuni- camps and vacations off the table ties they offer, are manifestly clear. n

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Updates Come in Threes Consider replacing or upgrading tests patients and doctors dislike. By Paul M. Karpecki, OD, Chief Clinical Editor

hen I ask patients which refractors (VMax), the latter of pigmentary changes isn’t easy. A tests they dislike most, which uses a different stimuli that is cross-sectional study of 644 adults visual field (VF) testing, easier for patients to differentiate.5 revealed that doctors missed AMD W 8 IOP measurements and, believe it or These systems allow you to show about 25% of the time. A new not, refraction are the top three. A the patient their previous refraction objective test that may help with simple plan to improve your patient’s and the new one to help them decide the early identification of AMD is positive experience—and boost on a new pair of spectacles. dark adaptometry (AdaptDx, Macu- your practice success—might be to logix).9 In addition, a new device increase education and upgrade your Three Tests ODs Don’t Like for measuring carotenoids that can technology for these tests. There are also clinically important assist in testing and monitoring for Visual fields. New algorithms tests clinicians and staff struggle AMD is the BioPhotonic scanner such as SITA Fast could help patients with: (Pharmanex). Research suggests this complete the test sooner. Although The swinging flashlight test. objective hand scanner is a more SITA Standard is more precise than Although extremely valuable to rule accurate corollary to macular pig- SITA Fast at lower VF sensitivities, out a brain tumor and other life- ment than the current subjective this difference is unlikely to affect the threatening neurological conditions, macular testing methods.10 monitoring of change or deteriora- pupillary testing challenges even We know what patients dis- tion.1 the most seasoned clinician. One like and what isn’t providing us Fully objective VF testing with solution is Eyekinetix (Konan Medi- with accurate clinical information. the ObjectiveField analyzer (Konan cal), a 40-second objective test that Armed with this knowledge and new Medical) shows equal accuracy to provides an accurate assessment of technologies, we can make changes the standard subjective testing.2,3 The pupillary function, including RAPD to enhance our practice and provide tool depicts statistically independent measurements. patients a better experience. n clusters of visual stimuli at multiple Phoria testing. Approximately 1% Note: Dr. Karpecki consults for locations in the patient’s visual field.4 to 3% of all glasses have prism in companies with products and ser- The resulting pupillary responses them, yet both clinicians and patients vices relevant to this topic. from each visual stimuli provides a often struggle with the necessary 1. Saunders LJ, Russell RA, Crabb DP. Standard or Fast? - Differences in map of VF function. testing for prism, such as the Mad- precision between SITA Standard and SITA Fast testing algorithms and their utility for detecting visual field deterioration. Invest Ophthalmol Vis IOP measurements. It’s no secret dox Rod and Von Graefe phoropter Sci. 2014;55:3010. 6,7 2. Maddess T, Kolic M, Essex RW, James AC. High versus low density that patients hate the air-puff test. tests. The neuroLens is a new auto- multifocal pupillographic objective perimetry in glaucoma. Clin Exp Oph- Today, clinicians can use new tools mated device that takes one to three thal. 2012;21:571-78. 3. Carle CF, James AC, Kolic M, et. al. High resolution multifocal pupil- such as the iCare ic100 tonometer minutes to provide a comprehensive lographic objective perimetry in glaucoma. Invest Ophthalmol Vis Sci. 2011;52:604-10. and the Ocular Response Analyzer assessment of the patient’s eye align- 4. Maddess T, Bedford S, Goh XL, James AC. Multifocal pupillographic visual field testing in glaucoma. Clin Exp Ophthalmol. 2009;30:678-86. (ORA, Reichert) instead. The iCare ment and synchronization. It then 5. Geffen D. Your phoropter on steroids. Rev Optom. 2017;154(9):30-38. 6. Vision Council. VisionWatch–The Vision Council Member Benefit ic100 uses rebound technology to provides the precise amount of prism Report. 2016. measure IOP, while the ORA mea- recommended, which can be used to 7. Cantó-Cerdán M, Cacho-Martínez P, García-Muñoz A. Measuring the heterophoria: Agreement between two methods in non-presbyopic and sures hysteresis, corneal-compensat- create a contoured prism that, in my presbyopic patients. J Optom. 2018;11(3):153-59. 8. Neely DC, Bray KJ, Huisingh CE, et al. Prevalence of undiagnosed ed IOP and Goldman tonometry. opinion, far exceeds the success of age-related macular degeneration in primary eye care. JAMA Ophthalmol. 2017;135(6):570-5. Refraction. New patient-friendly previous prism options. 9. Jackson GR, Scott IU, Kim IK, et al. Diagnostic sensitivity and specificity of dark adaptometry for detection of age-related macular degeneration. systems have grown in the last AMD testing. Examination with Invest Ophthalmol Vis Sci. 2014;55(3):1427-31. 10. Conrady CD, Bell JE, Besch BM, et al. Interrelationships between decade, ranging from digital refrac- a 90D lens and evaluating fun- macular, skin, and serum carotenoids. Invest Ophthalmol Vis Sci. tors to point-spread function (PSF) dus photos for small drusen and 2016;57:3628.

18 REVIEW OF OPTOMETRY AUGUST 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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You’ve Won an Island Getaway! Just kidding, but working in private practice is more like being on a deserted island than you might think. By Montgomery Vickers, OD

ges ago, after I saw the movie rather be in private practice with all decisions based on who takes their Castaway with Tom Hanks of its challenges and accomplish- insurance (or who their sister’s hair- Aas a poor FedEx executive ments, good days and bad. I would dresser sees) and increased online stranded on a remote and uninhab- never give up the shared joy of competition that’s drifting toward ited island in the South Pacific, I providing patients victories in their online eye exams that might as well started to wonder how I would have visual and personal lives. Nor would be performed by unknown and handled the situation—you know, I give up the shared hugs when they, unvetted techs in the South Pacific. being a FedEx executive. Seems like or I, experience life’s losses. Some days it may even seem like a tough job. How in the world can I encourage all of you doctors, it would be easier to search for they put something in a box and new and seasoned, to carefully con- water on a lost island than recheck deliver it anywhere in the world sider your future and your profes- a recent refraction on a patient who within just a couple of days? Being sion’s. Where do you want to be in bought crappy glasses online. stranded on a deserted island must your life? Our education has set us Just remember, no matter where be easier. free so why not fly off the island or, or how you practice, you will But if I were stranded on an better yet, create your own beautiful always have the relationship you island, would I be able to survive paradise right where you are? build with each and every patient with the same determination that At a certain point Hanks, the who needs your help. Hanks’s character displayed over the stranded fellow, had to accept real- Unfortunately, some would rather four long years he was stuck there? ity. And so do we. The reality is that save a few bucks than see their Now, Hanks was only acting, some doctors are just not the private world at its clearest. It doesn’t mat- and he was even nominated for an practice kind. Plus, financial realities ter. It doesn’t matter. You can’t leave Academy Award—no small feat con- might make the corporate-run prac- them stranded. Care for them and sidering he only had to remember tice the best choice for some. That’s you’ll thrive as an optometrist. It two pages of dialog, most of it spent OK; they are just as educated, hard has to be easier than being a FedEx chatting with a volleyball. working and caring as any given pri- executive. n vate practice doctor. So, as we say in Your Own Island Texas, get off your high horse. Anyway, imagine yourself in his position. You have to fend for your- We’re Not Alone self. You alone must acquire food Going into private practice can be and drink, or die trying. challenging. Reimbursements are Sounds more and more like pri- always threatened, vate practice optometry, doesn’t it? patients make No wonder the corporate world more and seems so attractive. You show up, more follow their system and never have a volleyball as your best friend. Of course, Hanks was stranded for four years. Barring a lottery pay- out, private practice will last 30+. He had it easy. Still, all things considered, I would

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Curtain Call Understanding a vision loss patient’s symptoms clearly will help identify TIA. Edited by Paul C. Ajamian, OD

I just saw a 64-year-old female and carry the same risk of stroke and Q patient who casually mentioned cardiovascular disease. According to that she noted a ‘black shade’ a 2012 study, nearly 25% of patients temporarily obscuring her superior with acute retinal ischemia had acute field in one eye. How seriously do I brain infarctions.1 take this? “We should refer our TMVL “A chief complaint of transient patients with a suspected vascular A monocular vision loss (TMVL) etiology to a stroke center or hospi- should always raise a red flag,” tal emergency department (ED) for says Kristen Thelen, OD, assistant a same-day work-up,” Dr. Thelen professor of ophthalmology at advises. “We send hemispheric TIAs Emory Eye Center in Atlanta. “Slow without a second thought, so we down, and take a detailed look at should have the same standard for the patient’s medical history and retinal TIAs.” chief complaint to assess the gravity Make sure to follow appropriate of the situation.” A well-timed CTA can rule out an ischemic stroke guidelines. Calling the ED or hemorrhagic event for your patient. ahead of time and sending patient Retinal Ischemia records always helps, Dr. Thelen There are ample causes of TMVL, Symptom Assessment adds. The initial work-up will but transient ischemic attack (TIA) is Transient vascular events are typical- include a CT scan of the brain to the most common. Retinal ischemia ly painless and occur within seconds. rule out bleeding, and labs to rule can be a result of underlying vascu- Patients often describe a progressive out GCA. If the patient is a six or lar disease, such as giant cell arteritis “shade” or “curtain” that leads to higher on the NIH stroke scale, (GCA), atherosclerosis or cardiac “dim” or “black” vision. The entire computed tomography angiography abnormalities. These conditions can episode usually lasts a few minutes (CTA) is usually ordered to rule out be visually devastating or, worse yet, but never more than an hour. large vessel occlusion (i.e., middle result in a stroke. Photopic symptoms such as cerebral artery stroke). Additional Due to the gravity of these vascu- flashes, jagged lines and colors are tests include carotid duplex, MRI of lar etiologies, evaluate patients with rarely associated with vascular the brain and orbits and MRA of the TMVL urgently. “Age is a key factor occlusive events. Those tend to be head and neck. when determining the most appro- more migrainous or caused by reti- “I connect with the patient a week priate next step,” Dr. Thelen says. nal traction. “Remember that ocular after sending them to the ED to “Patients older than 50 who experi- migraines with visual auras are typi- make sure everything went smooth- ence TMVL need a work-up to rule cally binocular,” Dr. Thelen points ly,” Dr. Thelen notes. “Patients are out GCA.” out. Showing your patient a picture typically grateful you sent them for Asking your patients about jaw of a typical migraine aura can help a work-up, and they appreciate the claudication, headache and scalp in ruling that diagnosis in or out. follow-up call as well.” There is tenderness is important, but even usually no need for a follow-up eye in the absence of symptoms, order Don’t Delay exam, so use the phone call as an blood work in a timely fashion. Retinal TIAs, such as branch retinal, opportunity to remind them to keep Also consider cartotid artery disease central retinal and ophthalmic artery their annual eye appointments. I and listen for bruits in-office as an occlusions, have the same mecha- 1. Dattilo M, Newman NJ, Biousse V. Acute retinal arterial initial screening. nism as central nervous system TIAs ischemia. Ann Eye Sci. 2018; 3:28.

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A Little VT Goes a Long Way This pair of cases highlights the technique’s usefulness in those patients who could never get by with lenses alone. By Marc B. Taub, OD, MS, and Paul Harris, OD

hus far, our column has the patient’s exotropia at near. focused on concepts related Ensuring the patient understood Tto corrective lens prescribing, the “feeling” of binocular vision giving detailed advice on managing and depth at near was the key to astigmatism, hyperopia, exotropia transferring those skills to distance. and more. We have yet to tackle Without an understanding of what cases that, upon exam, scream convergence feels like, a patient “vision therapy.” Over the next two would have trouble voluntarily installments, we’ll show the benefits converging. of VT, first in younger patients and We used traditional vision then in an older population. This therapy equipment, including a intervention has its detractors to Brock string and vectograms, along be sure, and some ODs may view with home support, such as the it as worthwhile but too onerous Home Therapy System computer to implement in practice, but we program. After 21 sessions of have had ongoing success with it in VT, the patient’s complaints had appropriate patients. subsided, and cover testing showed 16 prism diopters of intermittent Case One Among other things, vision therapy helps exotropia occurring 10% of the Stuart was 15 years old when patients go on to find success in their time at distance and eight prism he was referred from another educational endeavors. diopters of exophoria at near. office to be included in a study These findings were consistent on convergence insufficiency. He On the Worth Four-Dot Test, he for a year post–vision therapy, at had double vision, with one eye reported seeing only two red dots which point he left for college and turned outward, and had been at distance, an indication of right was more successful in school. He experiencing headaches while eye suppression. planned to attend graduate school reading for two years by the time The tricky part of this case was to study business. he presented. He struggled in the patient’s greater frequency of school and performed poorly on exotropia at distance. We have Case Two standardized testing. many tools that stress near point Jake was eight years old when he Once in the exam room, it distance but few that focus on first came into our office. He was became obvious that, although further distances. It didn’t help that falling behind in school, specifically the patient would not qualify this case took place prior to the reading, and in danger of being for the study, he would need invention of many of the options held back. His mother had learned vision therapy. Cover testing we have now that enable vision about vision therapy and knew that showed 16 prism diopters of therapy at distance. it would help her son improve. constant alternating exotropia at At the start of VT, we focused The patient’s primary care distance and 16 prism diopters of on near tasks, as there was a examination showed nothing out of intermittent alternating exotropia greater chance of success with this the ordinary, so a visual processing at near, which occurred about half approach due to the intermittent exam came next. This evaluates of the time. nature and better functioning of eye movements, vision and visual

24 REVIEW OF OPTOMETRY AUGUST 15, 2020 spatial skills with different tests, Photo: Marie Bodack, OD, and Erin Jenewein, OD In cases like this, where there including the ReadAlyzer, Test of are so many challenges, VT must Visual Perceptual Skills, Gardner take a global approach and work Test of Reversal Frequency and on building skills from the ground Beery-Buktenica Developmental up. This is not a quick process by Test of Visual-Motor Integration. any means; good vision therapy and To put it bluntly, this kid’s meaningful change take time. vision was a train wreck; not one Slowly but surely, Jake started test result was above the 20th performing better in vision therapy percentile. sessions and, most importantly, in Over the course of 18 months, school. His grades started creeping we made serious progress in up into the B- and C-range, and helping our patient get on the right occasionally, an A would show up track. Not only did we focus on on his report card. He is now an visual processing and oculomotor accomplished college student. skills, but we also targeted visual In both cases, we were able to efficiency skills. We believe that to help kids find short- and long-term best help a person optimize their success. Undoubtedly, lenses are visual performance, we must also Home support allows patients to immensely powerful tools. VT can work on accommodation and complete vision therapy exercises be just as powerful and is worth binocular skills. through computerized systems. including on your tool belt. n OPHTHALMIC Product Guide Innovative products to enhance your practice The future is in your hands. One tap, many possibilities.

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REVIEW OF OPTOMETRY AUGUST 15, 2020 25 PUT YOUR PATIENTS WITH DIABETIC RETINOPATHY (DR) ON THE PATH TOWARD MANAGING THEIR DISEASE AND

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Educate your patients about the severity of DR, especially when left untreated3,4 • Your early and frequent discussions about disease progression, treatment options, and referral will empower patients, which could help them avoid significant vision loss3,4

According to the AOA, you should refer patients with3: • Severe nonproliferative DR (NPDR) within 2 to 4 weeks • Proliferative DR (PDR) within 2 to 4 weeks • High-risk PDR with or without macular edema within 24 to 48 hours

Ensure patients have followed up with a retina specialist who can treat DR

Monitor your patients with DR3,4

The AOA recommends frequent monitoring of patients3 • At least every 6 to 8 months in patients with moderate NPDR and more frequently for patients with greater disease severity3

Refer patients to a specialist who can treat DR 3,4

Regeneron is committed to helping you partner with your patients for comprehensive care of DR, as well as for care of other retinal diseases.

AOA = American Optometric Association.

References: 1. Diabetic Retinopathy. Centers for Disease Control and Prevention website. http:// bit.ly/2BKTVCTS. Accessed August 7, 2019. 2. Early Treatment Diabetic Retinopathy Study Research Group. Fundus photographic risk factors for progression of diabetic retinopathy. ETDRS report number 12. Ophthalmology. 1991;98(5 suppl):823-833. 3. Care of the Patient With Diabetes Mellitus: Quick Reference Guide. American Optometric Association website. http://bit.ly/2M22OUJ. Accessed August 7, 2019. 4. Ferrucci S, Yeh B. Diabetic retinopathy by the numbers. Rev Optom. June 15, 2016. http://bit. ly/2KNNJ4E. Accessed August 7, 2019.

Special Rules for Special Lenses Carriers and contract language dictate how you handle the paperwork for medically necessary contact lenses. By John Rumpakis, OD, MBA, Clinical Coding Editor espite a decline in profit- Providing selective benefits when 9921X or 92012 code to follow the ability for refractive correc- you are a contracted provider and keratoconic cornea. The contact lens Dtions, specialty practices are the patient has coverage can create is the treatment paradigm.) booming as the demand for specialty significant exposure for audit and In many situations, revision of contact lenses increases. financial penalties. the lens during the training period Here, we take a deep dive into the and medical supervision of adapta- world of coding for medically nec- Code Services Correctly tion are accomplished during the essary and specialty contact lenses The CPT’s contact lens fit section first dispensing visit. Once you have because it often differs based on the begins: “The fitting of a contact lens either ordered the final lenses or pro- carrier and the contract language includes instruction and training of vided the patient with their prescrip- you must abide by. the wearer and incidental revision of tion, the patient is considered fit for the lens during the training period.” the lenses, and the service period for No Cherry-picking These codes describe the fit if per- that particular code is over. Many make medically necessary formed according to the CPT, all of Should complications arise, bill contact lenses a profit center in their which begin with, “prescription of for office visits using the established practice, sometimes charging $2,000 optical and physical characteristics patient ophthalmologic (9201X) or to $3,000 for a medically necessary of and fitting of contact lens, with E/M (9921X) codes because you are contact lens “package” consisting of medical supervision of adaptation”: managing an ocular condition or professional services and materials, • 92310: corneal lens, both eyes, complication, not performing a con- even if the patient has coverage for except for aphakia tact lens check. those services under a contracted • 92311: corneal lens for apha- plan that may reimburse much less. kia, one eye Materials Are Separate However, a practitioner con- • 92312: corneal lens for apha- Typically, we use only a few HCPCS tracted with a plan cannot ignore kia, both eyes Level II contact lens material codes: one portion of a plan’s coverage. • 92313: corneoscleral lens • V2530: contact lens, scleral, When you provide specialty contact Note: While CPT’s 92313 code gas impermeable, per lens lens services for a patient, you must description does not specify lateral- • V2531: contact lens, scleral, use all of their coverage benefits, ity, the CMS indicates that it is con- gas permeable, per lens even if it doesn’t reimburse as much. sidered a unilateral fit. • V2627: scleral cover shell Additional useful codes include: • V2599: contact lens, other What’s Wrong Matters • 92071: Fitting of contact lens type (N/A) In addition to medical carriers, many man- for treatment of ocular surface dis- These are all based on a per-lens aged vision care plans provide coverage for ease (considered a bilateral code). reimbursement, and the lens type medically necessary contact lenses. • 92072: Fitting of a contact lens and V codes must match. Many car- These clinical conditions typically have for management of keratoconus, riers now request invoices to support coverage: aphakia, nystagmus, keratoco- initial fit. (Because this is a bilateral the lenses provided. nus, aniridia, corneal transplant, hereditary code, also report materials using Lens advances are allowing us to corneal dystrophies, anisometropia ≥3.00D either 99070 or the appropriate treat a broader array of diagnoses in any meridian, high ametropia ≥10.00D in HCPCS Level II material code. with better outcomes; knowing how any meridian, irregular astigmatism, achro- According to the CPT, “For sub- to code and bill properly is just as matopsia, albinism, polychoria, anisocoria sequent fittings, report using E/M important. n (congenital), pupillary abnormalities. service or general ophthalmological Send your coding questions to services.” For every follow up, use a [email protected].

28 REVIEW OF OPTOMETRY AUGUST 15, 2020 Biotrue® is the only multi-purpose solution enhanced Biotrue with hyaluronan helps provide with hyaluronan

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44th Annual Contact Lens Report

The Building Blocks for a Specialty Contact Lens Practice

Shifting your focus offers rewards for both your patients and practice, but roll up your sleeves for the work needed to become an expert. By Jane Cole, Contributing Editor Image: Brian Fischer, OD hile any optometrist cialize, too, although the path can dispense mass- is more challenging, Dr. Son- market soft contact sino says. Wlenses, fitting the full The knowledge required to complement of contact lenses— appropriately treat patients including specialty lenses such using advanced contact lenses as rigid gas permeables (GPs), can’t be accomplished with sclerals, orthokeratology a one-day course with a lab (ortho-K) and hybrids—takes manufacturer, Dr. Sonsino time and commitment. Still, says. Instead, he first suggests experts say, no matter where a serious study of textbooks, you are in your career, becom- including optometrist Edward ing a contact lens specialist Bennett’s classic Clinical offers significant benefits for the Manual of Contact Lenses practitioner, the patient and the and Contemporary Scleral practice. Dr. Fischer fits a patient with 7.50D of corneal Lenses: Theory and Applica- “Becoming an expert in any- astigmatism in a scleral lens. After the fitting, she tion by Melissa Barnett, OD, thing starts with a passion for experienced much clearer and more stable vision and Lynette John, OD, along the subject. A specialty in con- during her daily activities, including sports. with a careful review of recent tact lenses can be exceptionally literature such as the Collab- rewarding; however, it will take a Learn From the Best orative Longitudinal Evaluation of level of dedication that requires true To become a contact lens special- Keratoconus (CLEK) studies and clinical interest, not simply a finan- ist, proper training is crucial, says papers on scleral lenses authored cial goal,” says Cory Collier, OD, Jeffrey Sonsino, OD, a contact lens by Langis Michaud, OD, and Greg co-owner of a specialty lens practice specialist in Nashville. Students and DeNaeyer, OD. in Florida. recent graduates who already know “It’s not sexy or easy to tell people Here, contact lens experts offer they want to focus on a contact lens to go read, but my first question to some pearls on the steps you can specialty can consider completing a docs who send me questions is, did take to grow your contact lens prac- cornea and contact lens residency. you put in the time and effort?” Dr. tice beyond the basics. Those already in practice can spe- Sonsino says.

30 REVIEW OF OPTOMETRY AUGUST 15, 2020 Image: Stephanie Woo, OD As for in-person learning, contact you can add more as you go. lens seminars abound and practitio- “Once you have a relationship ners should be selective on which with a lab, some will loan out sets ones they choose, experts advise. for specific patients or allow you Continuing education lectures at the opportunity to try the product the major meetings typically gather before purchasing,” Dr. Collier the best and brightest. At these meet- adds. ings, you can find practical work- Your first fitting sets should shops that will allow you to test provide options for a wide variety drive the lenses and learn about best of corneas, explains Heidi Miller, practices, evaluation techniques and OD, of the UC Davis Eye Center. fitting tips and tricks. However, with “Select a few options, and become limited time, don’t expect to learn an well versed in them. Otherwise, entire area of optometry; instead, set each lens fit will feel like ‘the first your expectations to picking up one lens fit.’” This post-LASIK patient was successfully fit or two clinical pearls per hour of According to Stephanie Woo, with a scleral lens. attendance, Dr. Sonsino says. OD, who practices in Nevada, it’s Other non-branded educational best to start with one fitting set of You can’t call yourself a contact events run the gamut in contact lens scleral lenses until you know it well. lens specialist unless you are well education. The non-profit Gas Per- Then, once you are comfortable, versed in every type of specialty lens, meable Lens Institute (GPLI) hosts you can add other types. according to Dr. Sonsino. “Check free monthly webinars by leaders in Still, scleral lenses aren’t the “be- the rule book, it’s in there,” he jokes. the field, according to Dr. Sonsino. all and end-all” for a true contact This means developing profi- lens expert, says Dr. Fischer. ciency with each lens type, and that Start Slowly “It’s important to weigh multiple includes the multifocal versions of Once you hit the books and build factors during the fitting process, each modality. your educational background, it’s including a patient’s personality and “Again, you treat the patient in time for hands-on learning. The next vision expectations, expected lens front of you. If that includes pres- step is simply to start fitting lenses adaptation, cost to the patient and byopes, you must have the most and keep doing it, according to corneal health, when considering advanced treatment options in your Andrew Fischer, OD, who practices which modality to choose,” he says. tool belt,” Dr. Sonsino says. in Indiana. “It’s a learning process, If the clinician lays the proper Even if you are still working on so, with time, a contact lens special- groundwork and completes a sig- your expertise with a given lens, ist will slowly learn the nuances nificant review of the available “you have to be able to understand and become comfortable with more literature, most will be champing at the benefits and limitations of each, advanced fits.” the bit to get started with advanced feel confident identifying appropri- When starting out, Dr. Fischer cases, Dr. Sonsino says. “The lens ate patients for each and be willing suggests fitting normal corneas or designs will be dictated by the to refer to colleagues in the event the mild keratoconic eyes for an easy patient’s case. But it is always a good best option for the patient isn’t an introduction. idea to identify a few options within option you are comfortable working An up-and-coming specialist each category. The key is to make with,” Dr. Collier says. should focus on two to three specific sure that you are open-minded to lens designs in each category, learn each category.” Specializing the Specialized everything about those designs and Two billion people had myopia in gain relevant clinical experience with No Lens Left Behind 2010, and that number is expected each, Dr. Collier says. “Having an Next, interested optometrists have to grow to nearly five billion by expert level of knowledge on select to consider all the lens options and 2050.1 Thus, myopia management options is far more valuable than become comfortable with each, options, such as ortho-K and soft, a superficial level of knowledge on including commercial soft lenses, center-distance multifocal lenses, are many designs,” he says. After you’ve custom soft lenses, corneal GPs, crucial tools for a specialty contact mastered a selection of fitting sets, hybrids and scleral lenses. lens practice, according to Dr. Miller.

REVIEW OF OPTOMETRY AUGUST 15, 2020 31 Specialty Lenses Images: Stephanie Woo, OD

Scleral lenses with blanching at the edge, at left, or edge impingement, center, require modification to find a good edge alignment, such as the lens at right.

“As the general public learns more Add Technology to the Mix is among the most critical deci- about myopia and its increasing A corneal topographer is an absolute sions.” prevalence, they will be looking for must for a contact lens specialty Dr. Miller recommends you con- practices that can provide treatment practice, Dr. Collier says. “It’s an sider geographic location of the lab, options to manage myopia progres- essential piece of equipment in the the shape of the eyes you’re trying to sion.” evaluation of the corneal surface, fit and add-on options such as mul- While discussing myopia man- contact lens design and follow-up tifocal choices, front surface toric agement options with all pediatric care.” power, Hydra-PEG (Tangible Sci- families, it is also critical to bring up Topographers provide a more ence) coating, a variety of lens mate- the need for outdoor exposure, she comprehensive evaluation of the rials with varying Dk for increased adds. cornea than traditional manual kera- oxygen permeability and quadrant- Ortho-K uses custom GP con- tometers, which measure only about specific changes to landing zone. tact lenses to reshape the cornea to 3mm to 4mm of the central cornea; She also adds that warranty periods temporarily reduce refractive error.2 topographers measure the entire cor- and availability of consultation are Ortho-K is primarily used as a corneal surface.3 Corneal curvature can important when choosing a lab. rection for low-to-moderate myopia be assessed on any portion of the Dr. Sonsino suggests you consider (up to -6.00D) with or without cornea, a virtue that’s particularly several business-specific attributes astigmatism (up to -1.75D).2 useful when designing larger diam- when deciding on potential lab With soft multifocals, the center eter GP lenses.3 partners, including whether the lab of the lens provides the distance In addition to a topographer, Dr. supports the Contact Lens Manu- vision correction while the periph- Sonsino suggests adding a pachym- facturer’s Association and GPLI and ery is designed to reduce hyperopic eter and anterior segment optical whether it is an independent lab or defocus.2 This mechanism minimizes coherence tomography. “The good if it is owned by a larger corporation the stimulus for myopia progression news is that with this equipment, damaging your business in other by focusing the light in front of the the rest of your patients benefit as ways (soft lenses). peripheral retina.2 well. You will be picking up more Labs can also provide valuable “Offering myopia management keratoconus, glaucoma and retinal trouble-shooting advice—a perk is very important,” Dr. Fischer says. problems as a result.” that shouldn’t be overlooked when “As we continue to learn more choosing labs. “The lab consultants about myopia and its associated Get Close With Your Labs know their lenses the best, so when risks at higher levels, we recognize A good relationship with your GP you run into problems, reaching out how important it is to intervene labs is paramount, Dr. Sonsino says. to them for help is definitely the first early and do all we can to limit “Labs is plural because it is never a step,” Dr. Woo says. “They can help myopic progression and try to miti- good idea to depend on one design you make necessary adjustments to gate future ocular health risks.” or one supplier. Choosing your labs the lenses.”

32 REVIEW OF OPTOMETRY AUGUST 15, 2020 Keep a close relationship with your patients . . . at a distance.

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During your first year as a contact for conditions such as keratoconus, To help with the increased lens specialist, Dr. Miller suggests pellucid marginal degeneration, demands on your time, Dr. Fischer you talk through the fitting pro- corneal scarring, high ametropia suggests training one or two staff cess with a consultant. “I receive and high anisometropia, he says. members to serve as the “specialty a wealth of knowledge each time The best way to verify what is lens liaison.” I speak to a consultant. I may fit a covered is to speak with the insur- “The liaisons can help with the patient in a certain type of lens a few ance provider and get prior autho- pretesting measurements, initial days a week, but these consultants rizations before submitting, which insertion of trial lenses, insurance have experience troubleshooting can help prevent problems after the questions, insertion and removal hundreds of patient cases.” They fitting process and also avoid unex- training and even ordering,” Dr. are also known to pass along rec- pected expenses to the patient, Dr. Fischer says. “This frees up a lot of ommendations and tricks gleaned Fischer says. time for the doctor or contact lens from other doctors, she adds. “Their On the other hand, Dr. Fischer fitter and allows them to provide expertise helps you excel during the has found other medical conditions care to more patients.” learning curve.” such as dry eye do not have as good For new contact lens specialists, coverage and reimbursement when allow for extra time in the begin- Billing Tips From the Experts it comes to contact lens fitting fees ning, such as a one-to-two hour Many resources are available to and materials. Typically, the exam timeframe for a new fitting, Dr. help contact lens specialists get codes and appropriate special test- Woo suggests. “Then as you get over any billing hurdles, including ing such as topography, pachym- more comfortable and proficient, the GPLI, which offers numerous etry and endothelial cell count can you may adjust the schedule.” lectures and webinars on the topic, apply to medical insurance deduct- Dr. Fischer says. “I leaned heavily ibles, but contact lens fitting and Enjoy the Benefits on these resources early on. I also material fees are rarely covered, he Offering specialty contact lens ser- sought advice from my mentors adds. vices in your practice is an incred- who have been fitting and billing ibly rewarding experience, Dr. specialty lenses much longer. Their Schedule Adjustments Collier says. “Patients consistently experience is invaluable.” Since specialty lens fittings gener- tell me they don’t know what they As for the cost of these specialty ally take more time than garden- would do without the lenses we lenses, doctors should be transpar- variety soft contact lenses, it may provide them. The life-changing ent with patients, Dr. Woo explains. be necessary to make some schedul- capability of specialty contact Let patients know what is covered ing adjustments. lenses is extraordinary.”

as far as services and materials and Eiden, OD Image: Daniel Press, OD, and Barry then present any additional costs. Prior to initiating a fit, Dr. Fischer shows patients printed handouts that include pricing for different modalities, and he reviews the information with them. The pricing sheets outline everything from standard soft lenses and myopia management options to corneal GP lenses and sclerals, he says. Needless to say, when tangling with insurance, coverage varies widely from one plan to another, as well as vision care plans vs. medical plans. But Dr. Fischer says most Topograpy is an essential tool for a specialty contact lens fitter. These refractive of the vision care plans his office difference maps help illustrate ortho-K’s treatment effect. In map A, the patient is accepts have great coverage for wearing a multifocal lens. Map B is the naked cornea, and map C is the same patient medically necessary contact lenses after a night of ortho-K.

34 REVIEW OF OPTOMETRY AUGUST 15, 2020 Advances in contact lenses: An opportunity to better serve patients

Fellow of the American Academy of Optometry and owner April Jasper, OD of a Florida-based eyecare practice looks at the contact Advanced Eyecare Specialists lens market and shares patient-centered strategies West Palm Beach, FL

Contact lens wearers remain a substantial strong interest in a contact lens that could “What are your goals for today?” This helps and growing proportion of the patient base prevent or reduce dryness, suggesting a need me further understand what is important to for most eyecare practitioners (ECPs). In a for further innovation in this category.4 the patient—what their ideal outcome would 2019 survey, 55% of ECPs said they expect be at the end of the visit. their contact lens practice to increase in the LISTENING TO PATIENTS Setting the stage with these questions coming year.1 Contact lens wearers may attribute their helps facilitate a positive interaction later Perhaps not surprisingly, this survey also dryness symptoms to a variety of sources, in the exam, when I can, for example, tell found that daily disposable lenses accounted such as the use of digital devices.4 And a patient about an innovative contact lens for 39% to 50% of contact lens fits and refits while it is true that sustained screen time option that may allow greater freedom from in 2019. Daily disposable lenses are favored is often associated with reduced blink rate spectacles, facilitate overnight wear, or offer for their convenience and are associated and increased tear film instability, we must more comfort. Knowing more about the with better patient-reported adherence to address other factors that can contribute to patient’s wishes and goals helps guide my the wearing schedule than lenses that are contact lens dryness and discomfort.5 recommendations and how I frame them, replaced every 2 weeks.3 Indeed, 64% of ECPs setting a firm foundation for future visits Often enough, the slit-lamp exam reveals an said they thought the daily disposable soft lens in which a patient’s needs, vision, or the underlying issue, such as meibomian gland category had the greatest potential for growth.1 available contact lens technology changes. dysfunction, that must be addressed before The most popular contact lens material successful contact lens wear can commence. LOOKING AHEAD regardless of replacement frequency is And sometimes it is clear either from the silicone hydrogel, which accounts for 65% appearance of their existing contact lens While contact lens technology has advanced of fits.1 Since their introduction to the surface or from the patient’s comments enormously over the last two decades, more market two decades ago, silicone hydrogel that overwearing may be to blame for innovation is coming. Patients in my practice materials have undergone continual their symptoms. know when they come back each year that evolution, aimed at preserving their high I will be there, listening to their wishes and However, building a relationship that oxygen permeability while increasing water goals, and ready to tell them about innovative enables us to understand patients’ goals and content and wettability.2 options for their vision correction needs. expectations for contact lens wear can be almost as important as the physical exam. At 82% of silicone hydrogel daily the beginning of a visit, our patients fill out disposable wearers expressed a brief questionnaire about their occupation, hobbies, and ocular symptoms. This allows of ECPs believe daily strong interest in a contact lens me to enter the exam room with a fact or two disposables are the that could prevent or reduce to initiate a conversation. A warm greeting soft lens category with and a personal comment at the beginning of 64% dryness, suggesting a need for the greatest growth the exam can go a long way toward opening further innovation in this category 4 potential1 up the flow of dialogue. Through the course of each exam, I try to find The trends toward increasing adoption of of contact lens fits in a way to ask two essential questions. First, the daily disposable modality and advances 2019 were in silicone “What about your current glasses or contact 65% 1 in silicone hydrogel material chemistry hydrogel materials lenses do you wish were different or better?” have converged in recent years with the Framing the question in this way—as a development of silicone hydrogel daily “wish”—gives patients an opportunity to share of current silicone disposable lenses. even those things that they may think are hydrogel daily Despite the popularity of these lenses, survey impossible or that I would frown upon. Maybe disposable wearers data indicates that half of silicone hydrogel daily they wish they could be less dependent on 69% are settling for less disposable wearers experience symptoms of glasses, maybe they would like to wear their comfort in order to lens dryness and 69% settle for less comfort contacts overnight, or maybe they wish their wear lenses all day 4 in order to wear lenses for the entire day.4 contact lenses were more comfortable at the Additionally, 82% of these wearers expressed end of the day. The second question I ask is,

1. Nichols JJ, Starcher L. CONTACT LENSES 2019. Contact Lens Spectrum 2020; 35:18, 19, 21-25. Available at https://www.clspectrum.com/issues/2020/january-2020/contact-lenses-2019 Accessed March 27, 2020. 2. Keir N, Jones L. Wettability and silicone hydrogel lenses: a review. Eye Contact Lens. 2013;39(1):100-8. 3. Dumbleton K, Woods C, Jones L, Fonn D, Sarwer DB. Patient and practitioner compliance with silicone hydrogel and daily disposable lens replacement in the United States. Eye Contact Lens. 2009 Jul 1;35(4):164-71. 4. Kadence International. Results of a consumer symptoms survey of 318 silicone hydrogel daily disposable contact lens wearers. April 2019. 5. Coles-Brennan C, Sulley A, Young G. Management of digital eye strain. Clin Exp Optom. 2019;102(1):18-29 ®/™ are trademarks of Bausch & Lomb Incorporated or its affiliates. Any other brand/product names and/or logos are trademarks of the respective owners. Content © 2020 Bausch & Lomb Incorporated or its affiliates. BOD.0202.USA.20 Specialty Lenses

Creating a niche within the prac- lens sellers because these lenses are If you’re at the stage where you tice builds a loyal patient base and is highly specific and cannot be pur- are going to consider yourself a an asset to any practice that wants to chased online, Dr. Fischer says. contact lens specialist and incorpo- provide services beyond the standard Additionally, increased fees allow rate custom soft and GP lenses into dilated exam and glasses, Dr. Fischer doctors to focus their attention on your practice, you need to be all says. Many patients who need spe- fewer patients while reaping higher in, the experts agree. “If you’re not cialty lenses have had poor experi- net gains, Dr. Collier adds. fully committed, please do what’s ences in the past and have dropped For Dr. Sonsino, the reduced best for the patient, which would out or are discouraged, he says. patient caseload has been a boon. be to send them to a practitioner “By being fully invested in your “When you schedule half the who is proficient in GP lens fitting,” patients and specialty contact lens number of patients, it makes your Dr. Woo says. “Think about how care, you are providing a service life much more enjoyable,” he says. you would want to be treated as a that many offices will not be able to “When I went from an academic patient.” n provide. This alone will keep your medical practice where I saw 25 1. Holden BA, Fricke TR, Wilson DA, et al. Global prevalence patients happy, seeing well and in patients in a half-day to private of myopia and high myopia and temporal trends from 2000 your practice.” practice where I see 14 in a full day, I through 2050. Ophthalmology. 2016;123(5):1036-42. 2. Tyler J, Wagner H. Myopia treatments: how to choose and Specialty lens practices are also saw my quality of life improve dras- when to use? Rev Optom. 2019;156(1):46-53. more insulated from online contact tically. My kids know my name!” 3. Woo S. Surveyor of the surface. RCCL. 2014;151(4):10-11.

Finding the Motivation to Be a Specialist “This was, by far, the best career choice I could have made.” Even the pros were once new to the game. Here, a few contact lens After her residency, Dr. Woo returned to Arizona and joined a specialists share anecdotes about their humble beginnings: private practice that did zero specialty contact lens fits. Early interest. Throughout high school and during his undergrad “I implemented specialty lenses slowly but surely,” she says. studies, Dr. Fischer worked as a technician at his local optometrist’s Inspired by the Academy. Early in Dr. Sonsino’s schooling, he office. Prior to starting optometry school, he sat down with the was exposed to the Cornea and Contact Lens Diplomates of the practice owners and shared his goal of working with them after Academy, which gave him the impression almost everyone at the graduation. helm of optometry—the leaders, researchers and inventors—was a “Thankfully, they were open to exploring that opportunity, too.” member of this elite group. Together, they identified a few services not offered within a few “It was intoxicating, and I knew I wanted to be among them.” hours of their location: dry eye and specialty contact lenses. Dr. Sonsino says it took the first 10 years of his career to build “Since then, I’ve done all I could to learn and grow in these the expertise and confidence, but in 2012, he was accepted as a areas.” Diplomate of the Academy’s Cornea, Contact Lenses and Refractive During Dr. Fischer’s fourth-year rotations, he worked in locations Technologies Section. “Since then, the giants in the field have not that had dry eye clinics and/or a thriving specialty lens practice, only mentored me but have become my friends.” which solidified his drive to focus on these specialties. After One case changed everything. Dr. Miller’s interest in contact graduation, he elected to do a residency, where he was matched lenses began during in her third year of optometry school when she with a dry eye and specialty contact lens focused private practice started shadowing contact lens residents. in Seattle. The residency laid the groundwork for Dr. Fischer to take An encounter on dispense day with a keratoconus patient who his knowledge and set up his Dry Eye and Contact Lens Center back was new to GP contact lenses sealed her fate as a contact lens home at his practice in southern Indiana. specialist. Swayed by happy patients. Dr. Woo, a scleral lens expert, first “Seeing how emotional that day was for this patient and how became interested in contact lenses during her third year as an excited they were to finally see the leaves on trees and ‘in HD,’ I optometry student. knew I wanted to fit specialty contact lenses and impact my patients’ “Witnessing keratoconus patients see clearly for the first time was lives forever. It is a very rewarding experience despite the difficulty incredibly rewarding,” she said. and time it may take to fit a patient in a specialty contact lens.” From there, Dr. Woo decided to pursue a cornea and contact lens Dr. Miller later completed a cornea and contact lens residency and residency, which gave her the opportunity to work with a variety of was hired at an office that wanted to incorporate specialty contact lens types, in addition to an extra year spent with specialty contact lenses into their practice. She eventually developed an ortho-K clinic lens patients. and then added scleral and prosthetic lenses to the practice.

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

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44th Annual Contact Lens Report Are You Making the Most of the Newest Soft Lenses? Improvements in function, comfort and design can make the wear experience better for patients. By Melissa Barnett, OD

specific contact lens recom- Always take into account the mendation can make all the patient’s occupation and daily activ- difference in a patient’s con- ities. Inquire if the patient is inter- Atact lens wearing success. ested in changing their eye color. While a robust arsenal of soft con- Explain to them that the choice tact lens options is available on the of contact lens can help elevate market, the practitioner may find it their vision and comfort through- difficult to select the right contact out their day, and the more specific lens for each patient. Even more they can be, the more you can be, options have come out in just the too. last year or two, compounding the Make sure to ask if the patient problem—and the opportunity. Let’s desires lenses that provide relief examine some of the newest state- when using digital devices or tran- of-the-art contact lens technologies sitioning between different light available today. conditions. Perhaps there is a need for Keep It Personal reading correction. It is also Commence this process with tak- important to take note of any ing your patient’s history. First, ask history of dry eyes, allergies or if there is a history of contact lens ocular surface disease. wear. If so, inquire whether they are happy with their lenses or if there The Eyeris display senses that trial Dryness and Discomfort is something that could improve lenses of a particular power have been The main reason why patients dis- their wearing experience. Ask if they removed and automatically orders the continue contact lens wear is due to would like to improve their vision, missing trials. poor vision and reduced comfort. stability of vision and comfort. Take Furthermore, approximately 20% note of how long during the day Inquire about the specific issue with of neophyte contact lens wear- and how often during the week they prior contact lens wear. ers discontinue contact lens wear wear their lenses. If there is no history of contact within the first year.1 Asking about a history of contact lens wear, ask the patient how often In the global market, contact lens lens wear or discontinuation of they plan to wear their lenses, all- dropout is approximately equal contact lens wear is also important. day or only occasionally. to the number of new wearers

38 REVIEW OF OPTOMETRY AUGUST 15, 2020 each year.1 The rate of contact Tear film stability is important in Precision1 is made with a lens dropout ranges from 15% contact lens wearers. If ocular sur- thin layer of moisture at the lens to more than 20%.2,3 These rates face disease is present, the quality of surface to help support a stable are incredibly high, especially the tear film is diminished, increas- tear film and deliver lasting visual with the advancements in contact ing contact lens discomfort. Dry eye performance from morning to lens materials and designs. In a significantly increases the chance of night, according to company study that evaluated the impact of contact lens drop out.7 literature.8 The water content at contemporary materials and designs For contact lens wearers, espe- the lens core is 51% and is greater on contact lens discontinuation, cially those with dry eye, it is impor- than 80% at the surface.8 As soon the primary reasons for stopping tant to ask which products are being as I began fitting patients with this were discomfort and dryness; the used for the face and eyes. Many lens, they reported good vision and secondary reasons were red eyes cosmetic products contain chemicals comfort. and cost.4 that may increase ocular irritation, The Eyeris daily contact lens is The Tear Film and Ocular blepharitis, meibomian gland toxic- another new daily disposable, made Surface Society’s International ity and even cause, or exacerbate, from hioxifilcon A material. The Workshop on Contact Lens DED. It is pertinent to discuss prod- lens has a Dk/t of 31.25. With the Discomfort recommends multiple uct use with all patients in order lowest modulus in the industry, it approaches to manage this chronic to optimize the ocular surface for was designed for comfort and to problem.5 Recommendations all contact lens wearers, especially resist end-of-day drying. The pow- include eliminating the lens care those with dry eye. ers range from -13.00D to +6.00D system by changing to a daily Switching to a daily disposable in quarter-diopter steps from replacement modality, changing the may result in a more comfortable, -7.50D to +4.50D. lens care solution or care system, clean and healthier wear experience. Eyeris lenses are available online, altering the frequency of contact These lenses are thinner and lighter, but only through the company lens replacement, or changing which may improve dryness and directly and participating doctors, the lens design or material. Tear comfort. Also, these lenses are con- to guard against improper order supplementation may be added, venient since they do not need to be filling. including topical artificial tears cleaned or disinfected each night. We can also look forward to the or prescription eyedrops, lacrimal Precision1 by Alcon is a recent imminent arrival of the Infuse daily inserts and punctal occlusion. mainstream daily disposable disposable silicone hydrogel lens To decide which lens to contact lens option. It can address from Bausch + Lomb within the recommend for each patient, also the common reasons why new next few months, in a new mate- consider the effects of dry eye wearers discontinue contact lens rial called kalifilcon A. Infuse has disease (DED). This can negatively wear within the first year: poor a Dk/t of 134, a water content of affect quality of life, with symptoms vision, poor comfort and handling 55% and is designed to increase such as grittiness, foreign body issues. This daily disposable, silicone ocular surface homeostasis, accord- sensation, debilitating ocular hydrogel contact lens is available ing to B+L. The company says pain and photophobia.6 Visual in a new lens material, verofilcon the lens’s ability to improve water fluctuation and distortion may also A, with Class 1 ultraviolet blocking retention will help encourage long- occur. capabilities. term wear.

Novel daily replacement lenses can alleviate issues that drive dropout.

REVIEW OF OPTOMETRY AUGUST 15, 2020 39 Soft Lens Selection

ing vision with digital device use at the end of the day. In a study of emerging presby- opes, the reasons for drop out were divided between vision and discomfort. Convenience was also noted as a reason for discontinuation. Contact lenses that correct for astigmatism are the second largest contact lens segment, and nearly one third of all adults who require vision correction could benefit from this design.15 Bausch + Lomb’s Ultra for Astigmatism’s stable toric lens design might benefit these patients. Their latest option, the Ultra Multi- focal for Astigmatism contact lenses, introduced in 2019, are an excellent This patient who complained about eye strain from computer and digital device use option for patients with refractive did well using Acuvue Oasys with Transitions in both eyes. error including astigmatism who have presbyopia. Photosensitivity designed as a substitute for sun- This monthly replacement option Many patients spend long hours on glasses, my patients who are athletes combines the Ultra’s lens design their computers, phones and tablets, also appreciate the automatic adjust- with the 3-Zone Progressive mul- as well as reading, driving or playing ment to different lighting conditions. tifocal design from the Ultra for sports. They often ask for ways to I have my patients trial these Presbyopia lens. These lenses correct reduce digital eye strain symptoms. lenses for 10 to 14 days, then wear for astigmatism and provide good Acuvue Oasys with Transitions their habitual lens for a few days. binocular distance and near vision, (Johnson & Johnson Vision Care) This process enables the majority of along with lasting comfort. is a new option you can offer my patients to appreciate the ben- These new multifocals are these patients. The lenses adapt to efits of this technology. straightforward to fit and provide changes in light intensity, filter blue an excellent option for presbyopic light and provide UV protection. Two Problems, One Lens astigmatic patients. Multifocal Computer and digital device users The patient’s type and amount of optics are designed to provide clear experience relief as the lenses refractive error, astigmatism and vision at all distances, including adjust during use. Acuvue Oasys presbyopia are critical for contact intermediate vision and enhanced with Transitions lenses filter up to lens selection. Historically, a high binocular vision. These lenses 15% of light in the blue light range percentage of those who have dis- have been a helpful option for indoors and 55% outdoors.9,10 continued lens wear are astigmatic.11 my patients with astigmatism and The lenses protect against indoor Astigmats remain over-represented presbyopia. light, glare, squinting and fatigue. in the dropout population, and yet Another option to correct both Those who are bothered by light toric contact lenses are still under- astigmatism and presbyopia is the and glare indoors or outdoors are prescribed.12 A high proportion of new Biofinity Toric Multifocal by good candidates, and many of astigmats, including those who have CooperVision. The company says my patients with headaches and previously dropped out, can be suc- this lens’s toric geometry is designed migraines have found relief with cessfully refit with lenses that correct to provide a predictable orientation these lenses. For night driving, the for astigmatism.13 In addition, toric and stable fit for consistently clear lenses reduce glare and halos, which lenses can deliver additional visual vision at all distances with multiple my patients with mild to moderate quality-of-life benefits.14 correction zones as well as help cataracts especially appreciate. In my practice, astigmats specifi- reduce dryness and maintain good Although these lenses are not cally complain of blurry or fluctuat- comfort throughout the day.

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In-office diagnostic fitting sets of toric multifocal lenses can help you properly fit patients with astigmatism and presbyopia.

Color Lenses ing patients worldwide, particularly and axial length were highly cor- This category tends to be a missed in Asia.16 Escalating rates of myo- related. opportunity in many practices. I ask pia prevalence are associated with Children as young as eight years every patient if they are interested in increased risk of retinal detachment, old may be fit with MiSight lenses. changing their eye color, whether on glaucoma, cataract and myopic reti- Sharing clinical studies with a daily basis or occasionally. nopathy.17-20 patients and their parents and For those interested in changing In January 2020, CooperVision explaining long-term risks associ- or enhancing their eye color, Alcon’s introduced MiSight, a single-use ated with myopia helps educate new lens line, Dailies Colors, offers contact lens FDA approved to slow them and encourages to choose a a daily replacement option for color myopia progression. A clinical trial myopia management option. Even if enhancement. The company says it compared MiSight’s dual-focus a parent is not interested in myopia designed these for natural-looking optics with a single vision contact management, I document the discus- color enhancement: the inner ring lens of the same material and overall sion to revisit at a later time. provides brightness and adds depth, geometry.21 the primary color enhances eye Of 109 patients who completed Offer the Best color and the outer ring defines and the clinical trial, the unadjusted There are various ways to gather emphasizes the iris. I find patients change in spherical equivalent information about new contact lens like the color options and find that refraction was -0.73 D (59%) less options. Lectures at live or virtual these lenses look natural on the eye. in the test group compared with the meetings provide the latest think- control group. The mean change in ing from experts. Published articles Myopia axial length was 0.32mm (52%) less can also direct you to the best ways Interest in myopia management in the test group compared with the to obtain knowledge about these continues to grow. Myopia is an control group. Of interest, changes novel and up-and-coming designs emergent public health issue, affect- in spherical equivalent refraction and technologies. Each of your contact lens representatives can also be wealth of knowledge and are superb at providing valuable information. In my practice, I like to be the first to offer new technologies to my patients. I want my patients to hear about the latest and greatest contact lenses from our practice first. Even if a patient is not receptive to contact lenses or a new type of lens at that Patients who like color enhancement lenses may not be aware of daily replacement time, I document their response to options. revisit at a later time.

42 REVIEW OF OPTOMETRY AUGUST 15, 2020 If a patient is unsure if they want of Optometry, a diplomate of the to try contact lenses, I provide American Board of Certification resources, such as brochures or in Medical Optometry and a website information about the lens fellow of the British Contact Lens that might pique their interest. An Association. Dr. Barnett serves in-office contact lens diagnostic trial on the Board of the American lens fitting may also persuade them. Optometric Association Contact I always give them the option of Lens and Cornea Section. returning to their prior lenses if they Dr. Barnett is a consultant for do not like the new ones. Alcon, Bausch + Lomb, CooperVi- I liken trying new contact lenses sion and Johnson & Johnson Vision to test driving a new car. Even if a Care. person is currently happy with their 1. Sulley A, Young G, Hunt C. Retention rates in new contact lens car, added features and benefits with wearers. Eye and Contact Lens 2018; 44:S273-S282. 2. Rumpakis J. New data on contact lens dropouts: an interna- the newer models may interest them tional perspective. Rev Optom. 2010;147(11):37-42. or be a major benefit to them; the 3. Dumbleton K, Woods CA, Jones LW, et al. The impact of contemporary contact lenses on contact lens discontinuation. Eye same applies for contact lenses. Contact Lens. 2013;39(1):92-9. 4. Gayton JL. Etiology, prevalence, and treatment of dry eye I like to inform my patients about disease. Clin Ophthalmol. 2009;3:405-12. imminent technologies even before 5. Nichols JJ, Willcox MD, Bron AJ, et al. The TFOS International Workshop on Contact Lens Discomfort: executive summary. they are available, such as the new Educate parents on myopia management Invest Ophthalmol Vis Sci. 2013 Oct 18;54(11):TFOS7-13. Infuse silicone hydrogel lens by options to select the best-suited option 6. Paulsen AJ, Cruickshanks KJ, Fischer ME, et al. Dry eye in the beaver dam offspring study: prevalence, risk factors, and health- Bausch + Lomb, the one-day Acu- for their child. related quality of life. Am J Ophthalmol. 2014;157(4):799-806. vue Oasys and other novel daily 7. Pucker AD, Jones-Jordan LA, Marx S. Clinical factors associated with contact lens dropout. Cont Lens Anterior Eye. replacement lenses currently in the • “We have a personalized 2019;42(3):318-24. 8. Alcon data on file, 2018. pipeline. contact lens that is made just 9. JJV data on file, 2018. Material properties. Acuvue Oasys Even if my patient is not a for you. It will provide [insert with Hydraclear Plus, Acuvue Oasys with Transitions Light Intel- ligent Technology and other reusable contact lenses. Accessed candidate for a specific lens, their characteristic] to help with July 21, 2020. friend or family member might be. your [vision/comfort needs]. 10. JJV data on file, 2018. Definition of Acuvue Oasys with Tran- sitions Light Intelligent Technology. Accessed July 21, 2020. For example, a longstanding patient • “You deserve the opportunity 11. Young G, Veys J, Pritchard N et al. A multicenter study of with keratoconus who wears scleral to try the best contact lenses lapsed contact lens wearers. Ophthal Physiol Opt 2002;22:516- 27. lenses was in for an appointment. that are available. That is 12. Young G, Sulley A and Hunt C. Prevalence of astigmatism in From our conversations, I learned why I want you to try [name] relation to soft contact lens usage. Eye & Contact Lens 2011;37: 20-25. that his daughter was an excellent contact lens.” 13. Sulley A, Young G, Lorenz KO, Hunt C. Clinical evaluation of fitting toric soft lenses to current non-users. Ophthal Physiol Opt. high school tennis player. I discussed Developing these conversations is 2013;33(2):94-103. a new contact lens technology that beneficial to have a clear, consistent 14. Nichols J, Berntsen D, Bickle K et al. A comparison of toric and spherical soft contact lenses on visual quality of life and may be perfect for tennis players, messaging in the practice. ease of fitting in astigmatic patients. Paper presentation at Ned- which prompted him to bring in his It is incredibly rewarding to have erlands Contactlens Congress, March 2016. 15. Tiwari P. Bausch Lomb Receives 510(K) clearance From daughter for a contact lens refit for a variety of contact lens options to FDA For Bausch Lomb Ultra Multifocal For Astigmatism Contact this updated technology. Building provide good vision and comfort Lenses. Bausch Consumer. www.bausch.com/our-company/ recent-news/artmid/11336/articleid/460/1252018-wednesday. this relationship not only helps and provides the opportunity to ful- Published December 5, 2018. Accessed July 15, 2020. 16. Wu PC, Huang HM, Yu HJ, Fang PC, Chen CT. Epidemiology the patient trust the doctor, it’s a fill a need, solve a problem or both. of myopia. Asia Pac J Ophthalmol (Phila). 2016;5(6):386–93. practice building opportunity. Narrowing down the right recom- 17. Risk factors for idiopathic rhegmatogenous retinal detachment. The Eye Disease Case-control Study Group. Am J Epide- Some practices have talking mendation for each patient requires miol. 1993;137(7):749–57. points that the doctor, technician clear communication and close 18. Mitchell P, Hourihan F, Sandbach J, et al. The relationship between glaucoma and myopia: The Blue Mountains Eye Study. and staff can use to help explain attention to their vision and comfort Ophthalmology 1999;106(10):2010–5. new contact lens technologies. goals while optimizing their ocular 19. Lim R, Mitchell P, Cumming RG. Refractive associations with cataract: the Blue Mountains Eye Study. Invest Ophthalmol Vis Some key phrases include: health. n Sci 1999;40(12):3021–6. • “We have a new, innovative Dr. Barnett is a principal 20.Vongphanit J, Mitchell P, Wang JJ. Prevalence and Progres- sion of Myopic Retinopathy in an Older Population. Ophthalmol- contact lens that provides optometrist at the UC Davis Eye ogy 2002;109:704–11. 21.Chamberlain P, Piexoto-de-Matos SC, Logan NS, et al. A additional convenience and Center in Sacramento, CA. She is three-year randomized cinical trial of MiSight lenses for myopia health benefits.” a fellow of the American Academy control. Optom Vis Sci. 2019;96(8):556-67.

REVIEW OF OPTOMETRY AUGUST 15, 2020 43 Myopia

44th Annual Contact Lens Report Add Multifocals to Your Myopia Toolbox These contact lenses are proving themselves to be an excellent treatment option. Here’s what you need to know. By Kara Tison, OD, and Carol B. Parker, OD

urrently, 34% of the world Uncorrected Myope Traditional Correction Optimal Correction? is myopic—approximately 42% of the US population and 80% of some Asian C 1-3 populations. Projections show that more than 50% of the global population will be myopic by 2050 with one billion at risk of subsequent sight-threatening com- Image shell plications.1-3 In addition to rising numbers, the severity of the condi- Fig. 1. This graphic illustrates myopic and hyperopic defocus, and the possible target tion is also increasing. for ideal correction. Image: adapted from Smith EL. Optom Vis Sci. 2011;88(9):1029-14. The pathogenesis of myopia is tied to a combination of envi- Now more than ever is the time for becoming myopic.8 Clinicians ronmental and genetic factors. to start implementing myopia con- should monitor children yearly, as Researchers believe myopia pro- trol therapies in your practice. Sev- myopia progresses at an increased gresses due to peripheral hyper- eral treatment options exist, ranging rate for children between the ages opic defocus along the horizontal from lifestyle changes to corneal of seven and 12, those who have a meridian.4 This defocus stimulates reshaping. But one modality, multi- higher baseline myopia and patients the growth or elongation of the focal contact lenses, fits neatly into who have experienced a prior myo- eye. As axial length increases, the the optometrist’s toolbox. pia progression of >-0.50D a year.5 risk for myopic macular degenera- Axial elongation has the greatest tion, glaucoma, retinal detachment Starting Therapy occurrence the year before the onset and cataract increase.1,3,5-7 Highly Cycloplegic spherical equivalent of myopia, and once myopia is pres- myopic patients (refractive error refractive errors are the best pre- ent, axial length growth continues >-6.00D, axial length >26mm) have dictors for myopia onset.8 For for an average of five years.5 an increased risk for visual impair- example, research shows six-year- In addition, myopia shows ment, as one-third will experience olds with a low degree of hypero- a higher increase in the winter blindness or low vision.1,4-6 pia (+0.75D or less) are at risk months. The exact reason for this is

44 REVIEW OF OPTOMETRY AUGUST 15, 2020 unclear but may be due to more elongation can be delayed by schoolwork or less outdoor time.4 creating a myopic defocus on It is thought that younger age is the peripheral retina. Ortho- inversely related to effectiveness; keratology and soft multifocal thus, it is important to intervene contact lenses are both thought when the patient is younger to eliminate the hyperopic defo- because they tend to progress cus and provide a peripheral more aggressively. myopic blur to the retina, which When starting myopia control, slows eye growth.4,7,12 Little is clinicians should consider the known regarding the amount age of onset, current refractive of myopic blur needed to effec- errors, previous myopia control tively slow growth, although treatments, rate of progression, current research suggests that ethnicity, lifestyle and family increasing the degree and extent history of myopia. We should of peripheral myopic defocus not recommend myopia control I treatment zones I correction zones can improve myopia control therapies until myopia is visually creating myopic defocus outcomes (Table 2).2,5,7 significant (greater or equal to -0.50DS).5,9,10 Some practitioners Fig. 2. The MiSight lens has two treatment zones, Multifocal Benefits choose to wait until they observe creating a peripheral myopic defocus that causes Historically, multifocal soft progression to initiate myopia the image to focus in front of the retina and slow contact lenses were designed for therapy.11 axial elongation. Myopia is corrected in all gaze correcting presbyopia; however, The ultimate goal of myopia positions. Image: adapted from CooperVision. they have also been used for control is halting axial elongation myopia control and one lens with a secondary effect of slowing the central part of the eye. With tra- is now FDA approved for myopia refractive error. Clinically, most ditional contact lenses and glasses, management.14 Research suggests practitioners are only able to mea- the central retina is in focus, while the center-distance, or extended sure success by monitoring progres- the peripheral retina experiences depth-of-focus, lenses slow myopia sion of refractive error. a hyperopic defocus (Figure 1). by reducing peripheral hyperopic Without intervention, refrac- Researchers first suggested hyper- defocus.14 Research suggests this tive errors, on average, continue to opic retinal defocus in the 1970s as lens modality can slow myopia by change by 0.50D to 1.00D per year a potential mechanism for myopia approximately 50% to 87.5%.14,15 during eye elongation.5 Fortunately, progression.12,13 The lenses can provide benefits we now have viable treatment Research shows that axial for those who do not want to wear options to help slow the progression of myopia, with some showing Table 1. Myopia Control Research more success than others (Table 1). Therapy Method Conclusion Low-dose atropine, orthokeratol- Under-correction of myopic Ineffective ogy and soft multifocal contact refractive error lenses are current popular myopia Gas-permeable contact Ineffective control treatment options. Here, we lenses focus on multifocal contact lenses. Outdoor time Effective at reducing onset of myopia, ineffective for myopia control Myopia Control Theories Bifocal/multifocal spectacles Statistically significant but clinically not significant4,15 The mechanism behind myopia Executive bifocal Approximately 39% slowing of refractive error9 control is not well understood, as *Did not assess axial elongation little is known about the specific Orthokeratology Approximately 45% reduction of axial elongation2,4 signal and pathways that regulate Bifocal/multifocal contact 50% to 87.5% effect on refractive error, 29% to 55% effect eye growth.4,7,12 When regulating lenses on axial elongation14,15 eye growth, the peripheral portion 0.01% atropine Approximately 59% slowing of refractive error and no effect 5,21 of the eye plays a larger role than on axial elongation

REVIEW OF OPTOMETRY AUGUST 15, 2020 45 Myopia

Factors Influencing Myopia Development seven to eight hours a day.13 Genetics is just one component of the inheritance pattern of myopia development. For The add power of a lens is what example, a child with two myopic parents is at a higher risk of developing the condi- induces myopic blur and halts tion than children whose parents are not myopic.4,14 Research shows East Asian children eye growth, and research shows between the ages of 11 and 15 are eight times more likely to be myopic than Caucasians.5 improved myopia control with Additionally, time spent outdoors, a close working distance while reading and length of higher add powers.19 The BLINK time of reading are environmental factors that may affect the development of the condi- study is the first trial to evalu- tion.4,5,27 ate soft multifocal contact lenses Few preventative measures exist for this condition, although research shows that an (distance-center design) with a low average of two hours of outdoor time per day can help reduce the onset of myopia.14 The (+1.50D) vs. high (+2.50D) add exact mechanism is unknown, but theories include brightness of light exposure, increased over a three-year period.20 The short wavelength and ultraviolet exposure (UV) exposure.5 results of the BLINK study were Once a patient does become myopic, outdoor time does not slow the progression of not available at the time of publica- myopia.7,28,29 Additionally, one study showed a 50% reduction in the number of children tion, but once they are, they may progressing into myopia with the use of 0.025% atropine.4 modify the previous recommenda- tion of high add powers for soft multifocal contact lenses to achieve spectacles or use long-term medica- ules.17 Most of the newer myopia- adequate myopia control therapies.5 tion. Contact lenses can improve control contact lenses are daily Some children may have dif- the visual quality of life for myopic disposable designs.1 ficulty adapting to multifocal soft children and can improve self- contact lenses with high add pow- esteem, athletic competence and Fitting Tips ers. Practitioners should consider societal acceptance.15,16 In addition, The multifocal soft contact lens visual acuity, contrast sensitivity research shows one lens can reduce parameters, such as wear time, add and subjective quality of vision lag of accommodation and showed power and pupil size, vary with when adjusting the prescribed con- improvement in accommodative each patient and may affect the fit- tact lens power. amplitude in patients.2 ting and clinical outcomes of myo- An increase by -0.25D to -0.75D Another advantage of this treat- pia control.13 may improve distance visual acuity ment option is that most optom- Wear time is an important factor and decrease symptoms. If visual etrists are already familiar with soft in slowing myopia progression.18 function does not improve, clini- multifocal lenses. When evaluating efficacy of a lens, cians can consider adjusting the add Some parents have concerns studies usually require a minimum power, if available.15 regarding contact lens use with of six hours of wear time per day.13 Pupil size can affect both the children. However, with proper In daily practice, the suggested wear refractive power of the multifocal education on wear time, modality time for adequate myopia control is lens and the patient’s visual function and lens hygiene, clini- and should be consid- cians can help reduce the Image: CooperVision ered when fitting these risk of adverse events such contact lenses.13,21,22 as microbial keratitis.1 A Visual distortions can child has more risk of visual increase in low lighting impairment from complica- and when larger pupil tions of high myopia than sizes are measured with from microbial keratitis.1 the light distortion Daily replacement con- index.21 tact lenses can help to reduce the risk of infections, Multifocal Options as one study found this Industry is begin- modality had 12.5 times ning to offer products lower risk of inflammatory Fig. 3. CooperVision’s Proclear and Biofinity both employ a designed—or at least issues compared with other distance-center design that is an effective off-label option for effective off-label—for lens replacement sched- myopia control. myopia management.

46 REVIEW OF OPTOMETRY AUGUST 15, 2020 SLIT LAMPS

MiSight (CooperVision) is cur- NaturalVue multifocal rently the only FDA approved (Visioneering Technologies) is NEW LED multifocal lens for myopia manage- a daily disposable lens used for ment, and the company’s online myopia control in other countries Illumination training (https://coopervision.com/ but remains an off-label option in practitioner/myopia-management) the United States. The lens uses More than 50,000 is required to fit the lens. The lens an extended depth-of-focus design hours of clear, cool is indicated for myopia control in to help slow myopia progression. illumination. patients between the ages of eight Because of the design, the expecta- and 12 with a myopia correction of tion is that visual acuity is similar -0.75D to -4.00D with ≤0.75D of to that with spectacles.2 The lens astigmatism.24 has a universal add power effective MiSight is a daily disposable lens up to +3.00D. The manufacturer with a dual focus design (Figure 2). recommends starting with the best The four-ring structure combines spectacle refraction, using the red/ distance correction zones with green (duochrome) test for the peripheral treatment zones designed final binocular sphere power and to control the progression rate of then using one click into the green myopia.23,24 The lens power is cho- (-0.25D) as the starting lens.25 sen by refracting to the most plus NaturalVue shows an 81.25% or least minus and calculating the halting of myopia progression and spherical equivalent for any astig- 6.25% regression over a six to matism.24 If the patient has 1.00D 25-month period.2 It also shows a or greater of astigmatism, spectacles 55% reduction in axial length.26 over the contact lenses are sug- NaturalVue parameters range from gested to minimize ghosting. +4.00D to -12.25D in 0.25D steps. Research shows the lens provides Patients with up to 1.00D of astig- a 59% reduction in mean cyclople- matism may be successfully fit in gic spherical equivalent refractive these lenses. error and 52% reduction in axial CooperVision has two monthly elongation compared with spherical replacement distance-center mul- lens wearers in a three-year study.23 tifocal lens designs that can be

Table 2. Center-distance Dual-focus Lenses for Myopia MiSight NaturalVue MF Biofinity MF Proclear MF Power -0.25D to -6.00D +4.00D to-12.25D +6.00D to -10.00D +6.00D to -8.00D Base Curve 8.7 8.3 8.6 8.7 Diameter 14.2 14.5 14.0 14.4 Add one single design one single design +2.50/+2.00 recommended Easier observation of Design concentric ring extended depth-of-focus minute details. Tint visitint UV none class 2 none none Color temperature Material omafilcon A etafilcon A comfilcon A omafilcon B maintained through the full Water Content 60% 58% 48% 62% Dk 27 20 128 21 range of illumination Replacement daily daily monthly monthly adjustment. Fitting minimum minus duochrome first studies show -0.50 to -0.75sph green; use manu- over-minus as needed facturer calculator for starting lens

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used off label for myopia therapy: When using the Proclear and Bio- Proclear Toric multifocal, Proclear Proclear and Biofinity (Figure 3). A finity multifocal designs for myopia Toric multifocal XR and Biofinity two-year study using the Proclear control, clinicians should first con- toric multifocal are available. If cli- lens showed a 50% reduction in sider using a +2.50D add power. nicians choose to use a custom lens, myopia and 29% reduction in axial There are no current studies a smaller optical zone is preferred elongation.4,16 The ongoing BLINK regarding multifocal toric contact to affect a larger retinal area and study will provide information lenses and the impact of myopia allow greater myopia control.4 regarding the Biofinity multifocal progression. However, if the patient Ongoing research will provide lens for myopia control. has over 1.00D of astigmatism, the more information for future treatments and rebound effects, opti- Other Treatment Options mum designs and exact amounts of To complement contact lenses, or supplant that option in unsuitable patients, clinicians have peripheral myopia defocus needed. other avenues to explore: Atropine is a nonspecific muscarinic receptor antagonist that causes cycloplegia and Follow Up and Discontinuation mydriasis. Muscarinic receptors are found in the human ciliary muscle, retina and sclera.27 Once clinicians successfully initi- The exact mechanism of action is unknown, but data suggests atropine acts on the retina or ate treatment, regardless of the sclera to inhibit elongation and prevent eye growth.4,5,7,27 Because the patient is dilated, UV approach, they should evaluate the light may also increase collagen crosslinking within the sclera, which slows scleral growth.4 patient at least every six months to Studies suggest 0.01% atropine has similar effects on refractive error compared with ensure treatment safety and efficacy. higher concentrations.30 Low-dose atropine has fewer reported side effects and less Soft multifocal contact lenses can rebounding effects once discontinued compared with higher doses. So far, research shows be continued as long as no ocular no signs of retinal damage in patients with long-term atropine use.4 While 0.01% atropine health issues arise. Most studies can slow myopia progression by 59%, axial elongation is not affected.4,31 evaluate one to five years of treat- Currently, the World Health Organization recommends limiting atropine treatment to two ment, so long-term effectiveness years.5 Due to the long-term daily use, clinicians should take into account the corneal toxic- remains unknown. In addition, ity from preservatives or prescribe preservative-free atropine.5 questions remain regarding the Orthokeratology, a long-established treatment for myopia control, shows a reduction in mechanism of action and if any axial length by approximately 45%.4 With this modality, clinicians can only monitor effective- rebounding effect occurs with soft ness due to axial length because the treatment eliminates the refractive error, and once multifocal lenses.4,13 orthokeratology is stopped, a baseline return of the refractive error is variable and usually When deciding when to discon- incomplete.32 tinue myopia control treatments, Orthokeratology uses a rigid gas-permeable contact lens to reshape the cornea. The lens clinicians should note that every is worn during the night (>8 hours recommended). Physicians using orthokeratology for additional year of education is asso- myopia control have better outcomes with patients who have moderate myopia (-1.25D to ciated with an increase refractive -4.00D) and larger pupils.4 error of -0.27D.5 One study of post- The FDA has refractive error limitations with orthokeratology of 6.00D of myopia and university graduates who were in 1.75D of cylinder. Effects on axial length are encouraging and studies show it is a useful front of computers for an extended myopia control option for those who are already moderately myopic.7 It is recommended period of time found they experi- that orthokeratology treatment is maintained until the age of 14, as there may be a greater enced a 10% myopia progression.4 rebound if discontinued at a younger age.4 The COMET study showed peak Combination treatments may be more effective than stand-alone treatment due to the myopia deceleration was 11.95 different mechanisms of action. One study shows a decrease in axial elongation when com- years of age.10 Further research sug- bining orthokeratology and atropine vs. orthokeratology alone.4 However, limited research gests the average age of myopia sta- exists on combining therapies, and if initiated, clinicians should have guarded expectations.15 bilization is between the ages of 15 Advances in the pipeline may soon help prevent and control myopia. With new designs and 16; however, a large majority of orthokeratology, contact lenses and novel spectacle lenses, the future is exciting for myo- of myopes will continue to progress pia management. Newer research has focused on Defocus Incorporated Multiple Segments into their 20s.5,10 (DIMS) lenses and has shown decrease in axial length by 60% and slowed refractive error Knowing the estimated age of progression by 59%.33 These lenses are currently marketed outside the United States. progression and stabilization, while Additionally, there are other novel spectacle lenses being investigated that affect peripheral also closely monitoring the patient’s contrast but will have no effect on central vision.34 refractive status, can help clinicians

48 REVIEW OF OPTOMETRY AUGUST 15, 2020 SLITLAMPS SLIT LAMPS determine when to discontinue 7. Walline JJ. Myopia control. Eye Cont Lens. 2016;42(1):3-8. 8. Zadnik K, Sinnott LT, Cotter SA, et al. Prediction of juvenile- myopia control treatment. Once onset myopia. JAMA Ophthalmol. 2015;133(6):683-89. EXCEPTIONAL OPTICS 9. Efron N, Morgan PB, Woods CA, et al. International survey of treatment is discontinued, continue contact lens fitting for myopia control in children. Cont Lens Ant close monitoring of the refractive Eye. 2020;43(1):4-8. 10. Myopia Stabilization and Associated Factors Among Par- error to ensure that there is no pro- ticipants in the Correction of Myopia Evaluation Trial (COMET). Invest Ophthalmol Vis Sci. 2013;54(13):7871-84. gression. 11. Wolffsohn JS, Calossi A, Cho P, et al. Global trends in Multifocal soft contact lenses myopia management attitudes and strategies in clinical practice - 2019 Update. Cont Lens Ant Eye. 2020;43(1):9-17. S4OPTIK’s are one of the best ways to control 12. Sankaridurg P. Contact lenses to slow progression of myo- myopia. However, only a small per- pia. Clin Exper Optom. 2017;100(5):432-37. converging 13. Zhu Q, Liu Y, Tighe S, et al. Retardation of myopia progres- centage of practitioners are fitting sion by multifocal soft contact lenses. Internat J Med Sci. binoculars the lenses for this condition. An 2019;16(2):198-202. 14. Pucker A. Myopia control: decisions and discussions. Rev allow effortless international survey indicated only Optom. 2020;157(1):28-33. 15. Tyler J, Wagner H. Myopia treatments: how to choose and 6.8% of contact lens fits in 2018 when to use? Rev Optom. 2019;156(1):46-53. maintenance of 16. Sha J, Tilia D, Diec J, et al. Visual performance of myopia were for myopia control, albeit this control soft contact lenses in non-presbyopic myopes. Clin fusion. is up from 0.2% in 2011.9 Of those, Optom. 2018;10:75-86. 9 17. Chalmers RL, Keay L, McNally J, Kern J. Multicenter case- only 47.9% were with soft lenses. control study of the role of lens materials and care products Hopefully, myopia fittings will on the development of corneal infiltrates. Optom Vis Sci. 2012;89(3):316-25. continue to increase with a better 18. Lam CSY, Tang WC, Tse DY, et al. Defocus incorporated European understanding of the advantages soft contact (disc) lens slows myopia progression in Hong Kong Chinese schoolchildren: a 2-year randomized clinical trial. Br J craftsmanship and of soft multifocal contact lenses to Ophthalmol. 2013;98(1):40-45. 19. Plainis S, Atchison DA, Charman WN. Power profiles of reduce myopia rather than leaving multifocal contact lenses and their interpretation. Optom Vis Sci. engineering provide 2013;90(10):1066-77. patients at a greater risk of future 20. Walline JJ, Gaume Giannoni A, BLINK Study Group, et reliable optics at myopic pathologies. ■ al. A randomized trial of soft multifocal contact lenses for myopia control: baseline data and methods. Optom Vis Sci. all magnifications Dr. Tison is an assistant profes- 2017;94(9):856-66. sor at the University of Louisville 21. De Leon M. Multifocal optics explored. RCCL. 2020:18-21. for confident 22. Wagner S, Conrad F, Bakaraju RC, et al. Power profiles of Department of Ophthalmology single vision and multifocal soft contact lenses. Cont Lens Ant Eye. 2015;38(1):2-14. examinations. and Visual Sciences. She also sees 23. Chamberlain P, Peixoto-de-Matos SC, Logan NS, et al. A patients at the Robley Rex VAMC. 3-year randomized clinical trial of misight lenses for myopia control. Optom Vis Sci. 2019;96(8):556-67. She is residency-trained in pediatrics 24. CooperVision. MiSight 1 day. coopervision.com/practitioner/ our-products/misight-1-day/misight-1-day. Accessed June and vision therapy. 22, 2020. Dr. Parker has more than 32 25. Visioneering Technologies. Fitting guidelines and vision enhancement guide. vtivision.com/wp-content/ years of experience fitting specialty uploads/2020/05/FittingGuidesUpdated.pdf. Accessed June contact lenses in private practice, 22, 2020. 26. Aller T. Poster: myopia management with NaturalVue (eta- where she continues to be a con- filcon A) multifocal 1 day contact lenses: continuing evidence Z-Series from clinical practice. BCLA Clinical Conference; Manchester, H-Series sultative research optometrist. She England, 2019. recently joined the Robley Rex 27. WSPOS Myopia Consensus Statement. World Society of Pediatric Ophthalmology and Strabismus. 2019. www.wspos. VAMC, where she is starting the org/wspos-myopia-consensus-statement. Accessed June 22, Contact Lens service. 2020. 28. Jones-Jordan LA, Sinnott LT, Cotter SA, et al. Time outdoors, visual activity, and myopia progression in juvenile-onset 1. Gifford KL. Childhood and lifetime risk comparison of myopia myopes. Invest Ophthalmol Vis Sci. 2012;53(11):7169-75. control with contact lenses. Cont Lens Ant Eye. 2020;43(1):26- 29. Xiong S, Sankaridurg P, Naduvilath T, et al. Time spent in 32. outdoor activities in relation to myopia prevention and control: 2. Cooper J, O’connor B, Watanabe R, et al. Case series a meta-analysis and systematic review. Acta Ophthalmologica. analysis of myopic progression control with a unique extended 2017;95(6):551-66. depth of focus multifocal contact lens. Eye Cont Lens. 30. Gong Q, Janowski M, Luo M. Efficacy and adverse 2018;44(5):e16-e24. effects of atropine in childhood myopia. JAMA Ophthalmol. 3. Holden BA, Fricke TR, Wilson DA, et al. Global prevalence 2017;135(6):624-30. of myopia and high myopia and temporal trends from 2000 31. Bullimore MA, Berntsen DA. Low-dose atropine for myopia through 2050. Ophthalmology. 2016;123(5):1036-42. control. JAMA Ophthalmol. 2018;136(3):303. 4. Cooper J, Tkatchenko AV. A review of current concepts 32. Walline JJ. Myopia control evidence. Cont Lens Spectrum. Vertical and compact of the etiology and treatment of myopia. Eye Cont Lens. 2020;35:18-23. 2018;44(4):231-47. 33. Lam CSY, Tang EC, Tse DY, et al. Defocus Incorporated configurations available. 5. Gifford KL, Richdale K, Kang P, et al. IMI – clinical man- Multiple Segments (DIMS) spectacle lenses slow myopia pro- agement guidelines report. Invest Ophthalmol Vis Sci. gression: a 2-year randomized clinical trial. Br J Ophthalmol. 2019;60(3):M184-M203. 2020;104:363-68. 6. Verhoeven VJ, Wong KT, Buitendijk GH, et al. visual conse- 34. Rappon J, Woods J, Jones D, Jones LW. Tolerability of novel quences of refractive errors in the general population. Ophthal- myopia control spectacle designs. Invest Ophthalmol Vis Sci. mology. 2015;122(1):101-9. 2019;60(9):5845-45.

www.s4optik.com l 888.224.6012 Sensible equipment. Well made, well priced. For today’s modern ofﬁce. . Scleral Lenses

44th Annual Contact Lens Report Don’t Let the Scleral Surge Pass You By

There’s no better time than now to take advantage of the rising demand for this lens modality. By Brooke Messer, OD

t’s no secret that scleral lenses walk through your door. These the surface of the lens are ideal single-handedly revived and sets should cover a range of lens places for deposits to attach and now dominate the gas perme- parameters and shapes, such as contribute to additional glare and Iable (GP) contact lens market. 15mm to 18mm diameters in pro- starburst issues.1 Some practitioners jumped on the late and oblate designs. Prior to insertion, the lens is scleral lens bandwagon 10 to 15 Handling tools. Stock up on filled with a preservative-free saline years ago, while others are just plungers, which are tools used to solution. There are a number of now starting to get their feet wet. handle lenses. A larger plunger is FDA-approved and off-label filling This article, geared toward nov- used to insert scleral lenses and acts solutions available. Make specific ice fitters, outlines how to begin like a golf tee to balance the lens product recommendations and providing scleral lens care for as it is applied to the eye. Smaller periodically confirm which prod- appropriate patients. plungers adhere to the surface of ucts your patients are using. Due the lens for easy removal. to the preservative-free nature of Stocking Equipment You can find insertion and filling solutions, recommending After you’ve decided to take the removal educational videos at products packaged in a vial is the plunge, you’ll need to equip your www.sclerallens.org, a site that is safest approach. office for scleral lens fitting. There supported by the Scleral Lens Edu- are a few items you should have cation Society. Determining Candidacy handy: Have a few mirrors to help The first step in prescribing scleral Fitting sets. Start by considering patients learn how to apply the lenses is understanding who ben- the types of patients in your clinic lenses. efits from them. These patients who might need scleral lenses. Lens solutions. Scleral lenses are commonly have irregular corneas, Then, do your research and speak comprised of a GP material, but ocular surface disease or both.2 with lab consultants and colleagues because they typically have a high Those with irregular corneas about which lens designs and fit- Dk/t, they must be handled accord- benefit from the surface of a GP ting sets best fit your practice pro- ingly. lens and its ability to correct irreg- file. Disinfecting solutions should ular astigmatism. They may have Most scleral lens experts suggest be non-abrasive, as the higher keratoconus, a post-surgical cor- having at least two fitting sets in the Dk/t, the easier it is to cause nea—including corneal transplan- your office so you can accommo- scratches or micro-abrasions to tation—or corneal scarring. If a date the majority of patients who the lens surface. Imperfections on patient could optically benefit from

50 REVIEW OF OPTOMETRY AUGUST 15, 2020 a corneal GP lens, patient and the it’s likely they are a practitioner when good candidate for vision is still limited scleral lenses. by a cataract after Sclerals are also completing a scleral ideal for patients fitting. who could not At this time, adapt to corneal enough information GP lenses due to should have been vision or comfort collected for the issues. prescriber to deter- Patients with mine the patient’s ocular surface dis- candidacy for scleral ease benefit from lenses. the fluid reservoir If you are still located against the unsure whether cornea in scleral the patient could lenses—the post- benefit from scleral lens tear layer. This Fig. 1. Observe the sheen of NaFl across the limbus to ensure proper clearance. lenses due to a sig- reservoir (filled nificant corneal scar, with preservative-free saline solu- evaluation and binocular vision cataract or other concern, place a tion, artificial tears or even autolo- assessment. Complete refractions diagnostic scleral lens on one eye gous serum) bathes the cornea and to measure best-corrected acuity, and perform retinoscopy to evalu- better protects it to allow healing, even in cases of advanced corneal ate vision potential. This is also a promote comfort and reduce pain. irregularity, for long-term monitor- great way to judge the potential for Other scleral lens candidates ing purposes and to justify the need relief in the case of ocular surface may include patients with lens dry- for custom contact lenses to insur- disease. ness or a regular cornea shape who ance panels. Corneal topography struggle to achieve adequate vision will shed light on a patient’s ocular Patient Education with other lens options, including surface profile. When a candidate for scleral lenses those with high ametropia or astig- In addition to conducting a typi- presents in your office, it’s impor- matism.2 cal slit lamp evaluation, note fine tant to take a consistent step-by- The stability of a well-designed ocular surface details and irregu- step approach, especially as your large lens offers a consistent visual larities, including conjunctival pin- practice relies on you evaluating, experience that is ideal for active gueculae, melanosis and irregular educating and fitting every patient patients who need sharp acuity at vessel appearance. Record corneal according to policy. Not only all times. findings, such as neovasculariza- does this promote professionalism tion, haze and scars, with measure- within the field, but it also creates a Evaluation Process ments or photos for continued foundation for growth. As with any new patient, obtain monitoring after initiating lens Since there is so much informa- a detailed medical and family his- wear. tion available on scleral lenses, tory, with a focus on ocular history. Make sure to determine the taking the time to cover several key Ask the patient if they have had visual impact of any lenticular points with patients right away can any previous contact lens experi- opacities and retinal or optic nerve save time and money later in the ence, either positive or negative, disease. If a cataract is present, process. These patients typically and if they are able to successfully consider referring the patient for respond better to transparency and wear glasses (in cases of irregular surgical intervention first to remove are more compliant. corneas). the cataract, reduce the amount Consider putting together Next comes basic entrance of spherical refractive error and a contract-like form of all the testing, including refraction, bio- improve vision with contact lenses. information you cover that requires microscopy, posterior segment It can be frustrating for both the your patient’s signature after they

REVIEW OF OPTOMETRY AUGUST 15, 2020 51 Scleral Lenses

have been evaluated but before you Lens diameter. Larger corneas lenses, while regular corneas are pursue further action. This protects need larger lens diameters to typically shallower. your office by limiting the services appropriately vault the limbus. When selecting your first diag- that a patient may have otherwise A larger lens diameter (at least nostic lens, start with a shallower declined. Think about having a 16.5mm) should also be used for sagittal depth for normal-shaped qualified staff member present the very severe ocular surface disease eyes, and move to a deeper sagittal contract and answer any questions, to ensure more surface cover- depth for severe ectasia requiring a as this discussion can be time- age. Smaller lenses (15.0mm to larger lens. consuming. 16.0mm) can be used for patients Include the following in the with regular corneas and milder Lens Fitting patient education part of the pro- dryness. After selecting the lens, rub it with cess: Lab consultants can help you conditioning solution to wet the • Lens costs and warranty select diagnostic sets with appro- surface, set it on a large plunger, fill period priate corresponding diameters it with preservative-free saline, dab • Service fees and insurance and, from there, fine-tune measure- it with a sodium fluorescein (NaFl) coverage ments. strip to dye what will become the • Payment timing and refund Corneal shape. Regular and post-lens tear layer and apply it to policy ectatic corneas typically require a the eye. • Care products and wearing/ prolate lens shape that is steepest Because scleral lenses are large replacement schedule in the center and flatter toward the and stable, they are usually fairly • Follow-up commitment and periphery. Post-surgical corneas are comfortable for the patient, and no troubleshooting flatter centrally and steeper in the proparacaine is needed. mid-periphery. This oblate shape is With a diffuse light and cobalt Lens Selection seen with post-LASIK, post-radial filter, evaluate for any bubbles Once the patient reviews and signs keratotomy, corneal transplants between the lens and the cornea. the form, the fitting process can and Intacs (AJL Ophthalmics) rings Very small bubbles do not war- begin. From the diagnostic set, in some cases of keratoconus. rant removal, but if moderate to select the lens according to the Some scleral lens diagnostic sets large bubbles are present, the lens corresponding fitting guide. While have both oblate and prolate lens should be removed and re-inserted. scleral lens diagnostic sets are all shapes to better align with the cor- The primary causes of insertion slightly different, these general neal shape and aid in centration. bubbles are lid interference during aspects can help with your initial Sagittal depth. More severe the application process and lack selection: ectatic conditions require deeper of saline in the lens bowl prior to

Fig. 2. Anterior segment OCT of the limbal area shows conjunctival prolapse.

52 REVIEW OF OPTOMETRY AUGUST 15, 2020 LIVE COPE CREDITS*

Dry Eye Colloquium Improving Diagnosis, Treatment, and Patient Outcomes

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Administered by *Approval pending Supported by an unrestricted educational grant from Alcon EEDUCAVIETION GROUPW Review Education Group partners with Salus University for those ODs who are licensed in states that require university credit. Scleral Lenses

ment OCT (AS-OCT) scans are very helpful when troubleshooting the limbal vault (Figure 2). Evaluate the landing curves, or haptics, on the scleral surface. The conjunctival vasculature should appear normal in caliber and uninterrupted in blood flow under the lens at the lens edge. The landing zone should be evaluated in three parts: where the lens meets the conjunctival surface just outside the limbus, or the “heel,” under the lens haptics and at the edge of the lens, or the “toe.” When speaking to a lens consultant and adjusting these peripheral curves, describe the lens as “toe- Fig. 3. Blanching occurs under the peripheral curves and can cause limbal vessel down” if the edge is digging into engorgement. and impinging the conjunctiva. Impingement often leaves a gutter- application. Rarely is the patient’s desired.3 The diagnostic fitting like indentation on the scleral scleral shape too atypical or toric set you choose will indicate the surface after the lens is removed that it is difficult for the lens to appropriate lens thickness, and and stains with NaFl. This is not create a seal to the eye. you can use that knowledge to to be confused with a mild, wide Once there are no bubbles, eval- estimate the vault of the post-lens compression ring that patients uate the limbal area. You should tear layer over the cornea. often note after lens removal. see a very faint amount of fluores- Keep in mind that the scleral This compression ring does not cein covering it (Figure 1). lens will settle by about 96µm to stain with NaFl, and the surface With an optic section and white 146µm over a few hours, so you’ll bounces back fairly quickly after light, evaluate the entire system. want to aim for about 400µm of lens removal, similar to a mark Posteriorly, you will see the cor- vault at your initial fitting.4 Shal- on your wrist after taking off a neal layers, then the fluorescent low vaults will eventually settle watch. post-lens tear layer and finally the and touch the cornea, which could “Heel-down” describes a clear scleral lens. cause corneal abrasions in the lens that shows interrupted or Compare the thickness of the short-term and contribute to scar- blocked blood vessels under the post-lens tear layer and the scleral ring if worn long-term. Excessive lens landing curves closer to the lens itself at the point of thinnest vaults decrease oxygen available limbus. The cessation of blood clearance over the cornea, or the to the cornea. flow is called “blanching” and scleral lens vault. A common mis- Moving outward, evaluate the can occur under the heel or toe take new scleral lens practitioners limbus with your optic section to of the peripheral curve system. make is evaluating the lens clear- attempt to quantify the amount Heel-down peripheral curves often ance over the line of sight, not at of clearance. The desired limbal cause engorgement of the blood the point of thinnest clearance. vault is a minimal amount, around vessels around the limbal area This may be at the apex of the 20µm to 40µm.3 (Figure 3). cornea in a patient with keratoco- Shallow vaults over the lim- Lastly, look at the overall posi- nus or in the mid-peripheral cor- bus can damage the limbal stem tion of the lens. Is it significantly nea on a post-surgical eye. cells and long-term health of the decentered inferiorly or laterally? The desired vault of a scleral cornea, and excessive vaults can Does it move significantly with lens varies by lens design, but cause conjunctival prolapse and blink? Is there edge lift with eye on average, 100µm to 250µm is neovascularization. Anterior seg- movements?

54 REVIEW OF OPTOMETRY AUGUST 15, 2020 Aberrometry can highlight ommended cleaning, storing camera on the slit lamp that can higher-order aberrations produced and filling solutions, along with take photos and videos for a by a decentered scleral lens. Ide- a few plungers. Also, provide a consultant to review and suggest ally, a scleral lens should be cen- form that lists the recommended changes. tered or nearly centered in primary solutions and how to use them, Ferris State University’s scleral gaze with little to no movement on websites for insertion and removal lens fitting guide can also come in blink. Lens centration and move- help and the expiration date handy.5 ment will improve as you modify on the specialty lens warranty. Once the prescribing process the central vault, limbal clearance Patients are given a lot of informa- is complete, follow-ups are based and landing zone. tion at the dispense visit, so it’s on the corneal condition of the Upon completing your lens eval- easy for them to get confused or patient and the comfort level of uation, perform an over-refrac- forget instructions. This form will the practitioner. tion. This is a great opportunity ensure that doesn’t happen. Delicate corneas prone to dam- to sharpen your retinoscopy skills, When the patient arrives, briefly age, neovascularization or inflam- especially as an autorefractor can review their history and check mation should be seen several sometimes be unpredictable with a their acuities and corneal health to times per year to monitor corneal scleral lens. ensure it’s safe to insert the lenses. health; whereas, corneas that Obtain the best-corrected acuity After the lenses have been are less likely to have an adverse with a spherical over-refraction placed, use the same evaluation reaction to a scleral lens can be first, and then add in cylinder and over-refraction technique as seen less often, perhaps every six to improve vision quality. In with the diagnostic lenses. Follow months. nearly all cases, you should order with insertion and removal train- Mastering the art of scleral a spherical lens power first, as ing, and dispense the lenses if the lens fitting presents a personal over-refractive astigmatism can fit and vision are adequate. and professional commitment. decrease as you improve the fit Adjusted lenses can be ordered However, the benefits are certainly and centering of the lens. with the lab consultants. If no worth it. Lab consultants offer a wealth reorder is needed, the patient can The information presented in of knowledge for new scleral lens return in about seven to 10 days this article is just the tip of the fitters. Consider speaking with for a follow-up corneal and lens iceberg, but there are plenty of a consultant prior to your first evaluation. resources readily available for you patient for information about to learn more. n their lens designs and preferred Follow-ups and Dr. Messer received her doctor way of collecting data. Then, Troubleshooting of optometry degree and com- reach out again to place your first As you follow your patient pleted a cornea and contact lens few orders until you feel confident through the warranty period, residency at the Southern Cali- enough to complete the process on changes to the lens fit will need fornia College of Optometry. She your own. Consultants can guide to be made. Follow-up visits can now practices in Edina, MN, with you in material selection and other be a challenge to a new scleral special interests in scleral, multifo- lens treatment add-ons. lens fitter because patients usually cal and orthokeratology contact present with the lenses on, and the lenses. Dispense Visit practitioner must evaluate them This is an exciting day for both without using NaFl. With practice, 1. DeNaeyer GW. The scleral lens vault. Contact Lens Spectrum. 2018;33:42. the patient and the practitioner. you’ll become comfortable evalu- 2. Nau CB, Harthan J, Shorter E, et al. Demo- The scleral lenses should be pre- ating the central vault without the graphic characteristics and prescribing patterns of scleral lens fitters: the SCOPE Study. Eye Con- pared for wear according to lab use of dye. tact Lens. 2018;44(Suppl 1):S265-72. instructions. Some lenses come Evaluation of the limbal area 3. Jedlicka J. Critical measurements to improve ready to wear, while others arrive can be more difficult without NaFl scleral lens fitting. RCCL. 2015;152(6):26-31. 4. Caroline PJ, André MP. Scleral lens settling. dry and need to be cleaned and dye; this is where using AS-OCT Contact Lens Spectrum. 2012;27:56. conditioned. can be valuable. 5. Ferris State University. Scleral lens fit scales. www.ferris.edu/optometry/vision-research- Have a dispense kit for the Another useful tool for trouble- institute/pdfs-docs/Scleral-lens-fit-scales_v2.pdf. patient ready that includes rec- shooting is an anterior segment July 9, 2020.

REVIEW OF OPTOMETRY AUGUST 15, 2020 55 Emergency Care 911 In the Exam Lane Handling medical emergencies in the office can be stressful. Here’s how to be prepared. By Chris Kruthoff, OD

s optometrists, we are medical emergencies you may • Circulation: evaluate skin acutely familiar with and encounter in the office and how color, sweating, capillary refill regularly encounter ocular quick thinking and an appropriate time (ideally below two sec- Aemergencies, be it chemical response can play a critical role in onds) and blood pressure. Stem burns, macula-on retinal detach- achieving positive outcomes for any bleeding, if present, and ments or acute angle-closure glau- your patients. elevate the legs to return blood coma. We are also prepared for flow to the head, if necessary. conditions with ocular manifesta- Initial Assessment • Disability: evaluate the tions, such as pupil-involving third Patient emergencies are stressful patient’s level of conscious- nerve palsy, papilledema or central situations, and it may be difficult to ness—is the patient alert, voice retinal artery occlusions. However, think and react clearly. To make the responsive, pain responsive we may be less prepared for sys- initial assessment easier, start with (i.e., via sternal rub with temic emergencies that can arise in the “ABCDE” approach: Airway, knuckles) or unresponsive— the office. Breathing, Circulation, Disability and limb movements and Studies suggest that non- and Exposure:2-4 pupillary reflex. hospital medical offices are often • Airway: assess the patient’s • Exposure: keeping patient ill-equipped and unprepared for breath sounds for any strain privacy and dignity in mind, medical emergencies due to rarity, and check the patient’s voice expose skin to evaluate for time and financial constraints for (normal voice means a patent any clues to cause of patient’s training.1,2 In addition, some offices passageway). Stabilize this pas- emergency episode. may not invest in emergency pre- sageway with a head tilt and This systemic approach is appli- paredness because of the perceived chin lift. cable in all clinical emergencies proximity to hospitals for easy • Breathing: check respiratory (aside from cardiac arrest, see transfer.1,2 While medical emergen- rate, chest wall movements and below), is applicable for children cies in the office may be uncom- pulse oximetry, if possible. Seat and adults alike and is used by mon, proper management is critical the patient comfortably (or those who deal with clinical emer- to avoid serious complications have them lie down, if needed) gencies often, including EMTs, when they do happen. and provide rescue breaths or critical care specialists and trauma This article reviews common further ventilation, if needed. specialists. This technique provides

56 REVIEW OF OPTOMETRY AUGUST 15, 2020 Photo: Paul Hammond, OD a good starting point should evaluate repeat in the proper care for episodes or unknown the patient. Further cause of a syncope epi- intervention is case sode to rule out other dependent. Here is underlying systemic dis- how to manage symp- orders.5,7 toms that may be more commonly seen Anaphylaxis in optometry offices: This is a serious systemic hypersensitivity Fainting reaction that can be Syncope is defined life-threatening. Inci- as a transient, sud- dence of anaphylaxis is den and temporary on the rise, particularly loss of consciousness due to food allergies in with spontaneous younger patients; insect and relatively prompt stings and medication recovery.5,6 The most responses continue to common form of syn- Diabetic patients, such as this one with moderate nonproliferative be more prevalent in cope optometrists are diabetic retinopathy, are commonplace in the optometry practice, and adult patients.8,9 likely to encounter are more prone to hypoglycemic symptoms, especially those who need This allergic response is vasovagal syncope insulin to control their blood glucose. is driven by IgE anti- (i.e., fainting), which bodies that form after can be triggered by an number be avoided with early interven- initial exposure to an antigen and of common ocular examination tion by having the patient sit or lie bind to mast cells and basophils; components including tonometry, down if they start noting the above subsequent exposure leads to gonioscopy, punctal plug insertion, symptoms.7 Blood flow should be crosslinking of the bound IgE and contact lens insertion and eyedrop directed towards the head by ele- release of mediators such as hista- instillation. vating the patient’s legs (the Tren- mine.10 This reflex is complex, involv- delenburg position), if possible, to Patients exhibiting anaphylaxis ing emotional or orthostatic stress help return blood flow to the head, may present with a sudden onset that stimulates the vagal neurons in and you should follow the standard of a variety of signs and symp- the central nervous system, causing ABCDE evaluation. toms, including hives, itching, a decrease in sympathetic output The patient should return to con- swollen lips/tongue/uvula, short- (and concurrent increase in para- sciousness in a short period of time, ness of breath, wheezing, reduced sympathetic output) to the heart and while they may be weak, it is blood pressure (age-dependent for and vasculature of the body. This rare for the patient to exhibit severe children, <90mm Hg systolic for process results in marked vasodila- confusion.7 Once the patient has adults), gastrointestinal symptoms tion, bradycardia and hypoten- regained consciousness, allow them such as nausea, vomiting and sion.5,7 Ultimately, this combination to remain supine and relaxed, dur- diarrhea and acute coronary syn- may lead to inadequate cerebral ing which time you should reassure drome.9,10 perfusion, triggering a loss of con- and monitor them with periodic According to the National sciousness.6 Patients undergoing an checking of blood pressure and Institute of Allergy and Infectious episode may exhibit sweating, pal- pulse strength and rate. Disease, to diagnose anaphylaxis lor and hyperventilation and may It is prudent to document the or the suspicion of it, the patient note symptoms of fatigue, dizzi- episode and note it for future vis- should meet one of these three ness, blurred vision, loss of hearing its, especially if it helps you avoid clinical criteria:11 and nausea.5,7 potential triggers. A single episode • Acute onset (minutes to hours) Recognizing a possible oncom- of vasovagal syncope with a known of an illness with involvement ing episode of vasovagal syncope is trigger usually does not warrant of the skin, mucosal tissue or key, as loss of consciousness may medical workup; however, you both and at least one:

REVIEW OF OPTOMETRY AUGUST 15, 2020 57 Emergency Care

• Respiratory compromise acceptable substitute for epineph- insufficient consumption of food, • Reduced blood pressure rine during an acute attack.9,12 although it may occur due to physi- or associated symptoms of Patients experiencing an ana- cal exercise, stress, miscalculation end-organ failure phylactic episode should be laid of insulin dose or oscillating blood • Two or more of the following in the Trendelenburg position to sugar levels.18 Hypoglycemia is that occur rapidly after expo- maximize blood flow to the head defined in stages:19 sure to a likely allergen: while blood pressure, heart rate and 1. Mild hypoglycemia (blood • Involvement of skin and respiratory status are monitored.9 sugar between 56 and 70mg/ mucosal tissue Patients may need a second injec- dL): autonomic symptoms • Respiratory compromise tion if they do not respond to the present, patient may be aware • Reduced blood pressure or initial dose. All patients should be and self-treat associated symptoms seen by emergency services after 2. Moderate hypoglycemia • Persistent gastrointestinal injection, regardless of response, for (blood sugar between 40 and symptoms further monitoring. 55mg/dL): autonomic and neu- • Reduced blood pressure after Anaphylaxis can occur with any roglycopenic symptoms both exposure to a known allergen medication, and you should prepare present, patient may be aware While a major finding in most your staff to respond when neces- and self-treat cases of anaphylaxis, skin symp- sary. Some states allow optometrists 3. Severe hypoglycemia (blood toms such as hives may be absent to perform fluorescein angiography, sugar <40mg/dL): more severe in around 10% of cases and may which has been known to cause symptoms, patient needs be delayed in their onset when they rash/urticaria, laryngeal edema assistance with treatment and do occur, so you should not rely on or bronchospasm, cardiovascular may become unconscious with them as the only determinant when events and even death.14,15 Reports potential for coma or seizure considering anaphylaxis.8 also highlight the potential for ana- As we encounter diabetic patients After calling for emergency phylactic reactions to topical eye in increasing levels in practice, it is medical services, the essential first- drop use.16,17 While the occurrence important to recognize these mani- line treatment for an anaphylactic of an anaphylactic episode in office festations of hypoglycemia and episode is an intramuscular injec- is rare, it is important to know the treat them before potentially seri- tion of epinephrine into the mid signs and symptoms and initiate ous or fatal complications occur. outer thigh, which may be given prompt treatment. For patients who are conscious, through clothing if needed.8,9,12,13 the American Diabetes Association Dosage is dependent on size and Hypoglycemia recommends the “15-15” rule— age: adults should receive a maxi- This is the most common and most ingest 15g of a simple carbohy- mum of 0.5mg, and children should serious side effect of treatment to drate, such as glucose tablets, four receive a maximum of 0.3mg.9 This lower blood glucose in diabetic ounces (1/2 cup) of juice or regular may be delivered via a needle and patients.18 Aggressive treatment to soda, one tablespoon of sugar or syringe or an autoinjector such as decrease hemoglobin A1c may lead honey or hard candies (amount an EpiPen (epinephrine injection, to higher risk of hypoglycemic epi- varies by what is being eaten), and Mylan) or Auvi-Q (epinephrine sodes, and this risk is particularly check blood sugar after 15 minutes; injection, Kaléo). high in patients who are on insulin if blood sugar remains below 70mg/ Epinephrine acts quickly through to control their blood glucose.18 dL, provide the patient another alpha and beta sympathomimetic Symptoms of hypoglycemia present serving.20 This should be adjusted actions to cause vasoconstriction, as autonomic changes—trembling, for young children, who usually increased cardiac output, broncho- sweating, anxiety, hunger, nausea need less than 15g to return to nor- dilation and inhibition of further or tingling—and neuroglycopenic mal blood sugar readings.20 Patients inflammatory mediators from mast changes such as confusion, dif- in severe hypoglycemia may require cells and basophils.8,9 Second-line ficulty concentrating, drowsiness, more initial carbohydrate consump- agents such as steroids, histamine-1 vision changes, dizziness and head- tion (20g) to get a more robust ini- antagonists or beta-2 adrenergic ache.18,19 tial spike in blood sugar.19 agonists may be helpful in more Any number of these signs Those who are unconscious chronic situations but are not an are caused, most commonly, by require urgent care, and emergency

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response should be contacted cholesterol and those who smoke attack, as studies show a mortality immediately. In these cases, it is are at higher risk of developing car- rate of 37.7% compared with 4% important to avoid injection of diovascular disease that may result of heart attack patients who do not insulin, as it would further reduce in heart attack.22 progress to SCA. blood sugar levels, or to attempt Symptoms of heart attack You should bypass the ABCDE to provide food, drink or other include chest pain or discomfort, assessment for patients experienc- oral therapies, as these are choking jaw or neck pain, arm or shoulder ing SCA.3 If you encounter an hazards. These patients may have pain and shortness of breath.24 unresponsive patient, the American glucagon injections that can be Women may also have more atypi- Heart Association recommends administered by a family member cal symptoms including nausea, beginning the administration of intramuscularly or subcutane- vomiting, unexplained fatigue and cardiopulmonary resuscitation (see, ously.19 More recently, glucagon pressure in the lower chest and “CPR First Aid Emergency Proce- has been formulated as an intra- upper abdomen.25 dure”):28 nasal spray, which may be easier One of the most important steps With any concern for heart to administer to patients in need.21 in managing heart attack is get- attack, and especially in cardiac Patients who are administered glu- ting these patients to a hospital arrest, prompt emergency response cagon may regain consciousness for emergency cardiac care.26 For is vital.29 Perhaps the next most with resulting nausea or vomiting.20 patients who are symptomatic for important step towards patient heart attack, call 911 immediately. survival is the use of an automated Heart Attack and Give the patient a dose of 325mg external defibrillator (AED). A Cardiac Arrest aspirin (without enteric coating) to recent study shows that bystander Heart disease is among the lead- chew for faster systemic absorp- use of AED for SCA provides a ing causes of death in the United tion and provide water for them to significant increase in survival rate States.22 Among the potential swallow.25,26 Monitor the patient (66.5% vs. 43.0%) and favorable manifestations of heart disease is until EMTs arrive for transfer to an outcome after hospital discharge acute myocardial infarction, or emergency room with cardiac care. (57.1% vs. 32.7%) compared with heart attack, which is caused by Roughly one in 20 cases of heart SCA patients who were first given a decrease or stoppage of blood attack may lead to sudden car- cardioversion by emergency medi- flow to part of the heart, leading to diac arrest (SCA), where the heart cal services.30 necrosis of the heart muscle, most ceases beating altogether.27 The All AEDs provide step-by-step commonly due to atherosclerosis.23 progression to SCA is perhaps the instructions in its use, and come Patients with hypertension, high most devastating outcome of heart equipped with the tools necessary CPR FIRST AID EMERGENCY PROCEDURE

1. 2. 3. 4. 5. 6. 1. Call 911. by two breaths with the patient’s head tilted back to open the 2. Call for assistance from those around and have them find an airway, then repeat. If there are concerns for COVID-19 transmis- automated external defibrillator (AED). If nobody is near, quickly sion and for those who are untrained or not up-to-date on CPR, a get the AED yourself and return to the patient. hands-only technique without breaths is still an effective option. 3. Check for breathing and pulse. 5. Once the AED arrives, attach the leads to the patient and follow 4. If neither is present, start CPR; it should be administered at a the instructions provided by the device. rate of 100 to 120 pushes per minute in the center of the chest. 6. CPR should be continued until the patient starts to move or If you use traditional CPR, start with 30 compressions followed breathe or until emergency services arrive.

60 REVIEW OF OPTOMETRY AUGUST 15, 2020 occur. Keep emer- 6. Sutton R. Reflex syncope: Diagnosis and treatment. J Arrhythmia. 2017;33(6):545-552. gency items such 7. Fenton AM, Hammill SC, Rea RF, et al. Vasovagal syncope. Ann Intern Med. 2000;133(9):714-25. as a first aid kit, 8. Anagnostou K, Turner PJ. Myths, facts and controversies blood pressure in the diagnosis and management of anaphylaxis. Arch Dis Child. 2019;104(1):83-90. cuff, pulse oxim- 9. Simons FER, Ardusso LRF, Bilò MB, et al. World Allergy Organization guidelines for the assessment and management eter and an AED of anaphylaxis. World Allergy Organ J. 2011;4(2):13-37. in a well-marked 10. Reber LL, Hernandez JD, Galli SJ. The pathophysiology of anaphylaxis. J Allergy Clin Immu-nol. 2017;140(2):335-48. place and ensure 11. Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second symposium on the definition and management that all staff of anaphylaxis: summary report—Second National Insti- know where to tute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol. access this equip- 2006;117(2):391-97. 12. Ring J, Grosber M, Möhrenschlager M, Brockow K. Ana- ment. Keeping phylaxis: acute treatment and man-agement. Chem Immunol sugary drinks or Allergy. 2010;95:201-10. 13. Simons FER, Ardusso LR, Bilò MB, et al. International foods in the office consensus on (ICON) anaphylaxis. World Allergy Organ J. 2014;7(1):9. to provide to 14. Ha SO, Kim DY, Sohn CH, Lim KS. Anaphylaxis caused by diabetes patients intravenous fluorescein: clinical characteristics and review of literature. Intern Emerg Med. 2014;9(3):325-30. entering a hypo- 15. Anaphylactoid reactions to fluorescein. J Allergy Clin Immunol. 1998;101(6):S519-S520. glycemic episode 16. Shahid H, Salmon JF. Anaphylactic response to topical An office emergency preparedness kit may include items such is prudent. fluorescein 2% eye drops: a case report. J Med Case Reports. 2010;4:27. as blood pressure cuffs, first aid kit and an AED. Place these A set prepared- 17. Anderson D, Faltay B, Haller NA. Anaphylaxis with use of items in a well-marked location that is easy to access. eye-drops containing benzalkonium chloride preservative. Clin ness plan will Exp Optom. 2009;92(5):444-46. help guide your 18. Kalra S, Mukherjee JJ, Venkataraman S, et al. Hypoglyce- mia: The neglected complication. Indian J Endocrinol Metab. to monitor for pulse and deliver team in the case of emergency. 2013;17(5):819-34. electric shock, when needed. Many versions exist through mul- 19. Clayton D, Woo V, Yale J-F. Hypoglycemia. Can J Diabetes. 2013;37:S69-S71. If your office has access to this tiple regulatory bodies, including 20. Hypoglycemia (Low Blood Glucose). American Diabetes Association. www.diabetes.org/diabetes/medication-man- device, ensure that all doctors and the Centers for Disease Control agement/blood-glucose-testing-and-control/hypoglycemia. staff know where it is so they can and Prevention.31 Regular review of Accessed June 15, 2020. 21. Yale J-F, Dulude H, Egeth M, et al. Faster use and fewer quickly retrieve it in an emergency. these plans with your staff may be failures with needle-free nasal glucagon versus injectable glucagon in severe hypoglycemia rescue: a simulation study. Some offices may not be equipped helpful. Diabetes Technol Ther. 2017;19(7):423-32. with an AED due to the high cost However rare these emergen- 22. Fryar CD, Chen TC, Li X. Prevalence of uncontrolled risk factors for cardiovascular disease: United States, 1999-2010. and rarity of in-office SCA. In this cies may be in clinical practice, is NCHS Data Brief. 2012;(103):1-8. 23. Saleh M, Ambrose JA. Understanding myocardial infarc- case, you can consult with other important that we remain prepared tion. F1000Research. 2018;7. medical practices or businesses for whatever walks through the 24. Centers for Disease Control and Prevention. Heart attack symptoms, risk factors, and recovery. www.cdc.gov/heartdis- nearby to see if they have a device door. Prompt and proper man- ease/heart_attack.htm. Published May 19, 2020. Accessed June 15, 2020. that you can access in the event of agement may play a vital role in 25. Zagaria, MAE. Myocardial infarction in women: an emergency. achieving a positive outcome for milder symptoms, aspirin, and angioplasty. US Pharma. 2017;42(2):5-7. your patient. n 26. Reddy K, Khaliq A, Henning RJ. Recent advances in the diagnosis and treatment of acute myocardial infarction. World Preparation is Key Dr. Kruthoff is an optometrist J Cardiol. 2015;7(5):243-76. These emergencies are, fortunately, at Northwest Eye Clinic in Golden 27. Karam N, Bataille S, Marijon E, et al. Incidence, mortality, and outcome-predictors of sud-den cardiac arrest complicat- a rare occurrence in an optome- Valley, MN. He is a fellow of the ing myocardial infarction prior to hospital admission. Circ Cardiovasc Interv. 2019;12(1):e007081. trist’s day-to-day practice, but being American Academy of Optometry. 28. American Heart Association. Emergency treatment of car- ready to react when they do happen diac arrest. www.heart.org/en/health-topics/cardiac-arrest/ 1. Toback SL. Medical emergency preparedness in office emergency-treatment-of-cardiac-arrest. Accessed June 15, is critical. Regular refreshers on practice. Am Fam Physician. 2007;75(11):1679-84. 2020. both CPR and Basic Life Support 2. Wheeler DS, Kiefer ML, Poss WB. Pediatric emer- 29. Andersson PO, Lawesson SS, Karlsson J-E, et al, on gency preparedness in the office. Am Fam Physician. behalf of the SymTime Study Group. Characteristics of training will provide you and your 2000;61(11):3333-42. patients with acute myocardial infarction contacting primary 3. Thim T, Krarup NHV, Grove EL, et al. Initial assessment and healthcare before hospitalisation: a cross-sectional study. staff any new recommendations. treatment with the Airway, Breathing, Circulation, Disability, BMC Fam Pract. 2018;19(1):167. Many states require optometrists to Exposure (ABCDE) approach. Int J Gen Med. 2012;5:117- 30. Pollack RA, Brown SP, Rea T, et al. Impact of bystander 21. automated external defibrillator use on survival and functional be current with these certifications. 4. Rothkopf L, Wirshup MB. A practical guide to emergency outcomes in shockable observed public cardiac arrests. Cir- preparedness for office-based family physicians. Fam Pract culation. 2018;137(20):2104-13. You should also have plans in Manag. 2013;20(2):13-18. 31. Centers for Disease Control and Prevention. Medical place that prepare staff to jump 5. Aydin MA, Salukhe TV, Wilke I, Willems S. Management office preparedness planner. www.cdc.gov/cpr/readiness/ and therapy of vasovagal syncope: A review. World J Cardiol. healthcare/documents/Medical__Office_Preparedness_Plan- into quick action when these events 2010;2(10):308-15. ner.PDF. Accessed June 15, 2020.

REVIEW OF OPTOMETRY AUGUST 15, 2020 61 FALL AND WINTER 2020 New Technologies & Treatments in Eye Care

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EEDUCAVIETION GROUPW 2 CE Credits (COPE approved)

UNDERSTANDING AMD PRESENTATIONS AND PROGNOSES These clinical pearls can help you identify at-risk patients in your practice and care for them over the long haul. By Jessica Haynes, OD

o achieve best outcomes, Funduscopic Evaluation from nutritional supplementation.1 patients with all levels Even with significant advances in This type of misdiagnosis presents of age-related macular retinal imaging, the diagnosis of a huge missed opportunity for risk Tdegeneration (AMD) must AMD is still most likely to stem modification and appropriate patient be identified, properly educated from a thorough fundus exam. Find- education. Findings such as drusen, and managed according to current ings associated with AMD may not pigmentary alterations, geographic evidence-based standards. Staging always present in a dramatic fashion atrophy (GA) and macular hemor- of the disease is crucial to determine and can be masked by media opacity rhage can be signs of AMD and risk of progression, recommended (e.g., cataract) or simply by a less- should be evaluated carefully, often treatment/management and set an than-cooperative patient. This, along with additional diagnostic tools. appropriate follow-up schedule. with other factors, may explain the Drusen are the hallmark finding Clinical evaluation begins with the results of a recent study that found of AMD. Their size is important fundus exam, but additional diag- 25% of AMD patients were misdi- in staging AMD and determining nostic tools can help to further evalu- agnosed as having a normal macula. risk of progression. They are classi- ate those with AMD, identify risk Of those misdiagnosed, 30% had fied as small (<63µm), intermediate factors of progression and allow for signs consistent with intermediate (between 63µm and 124µm) or large earlier detection of all disease stages. AMD and would have benefited (≥125µm).2,3

Release Date: August 15, 2020 activity has been planned and implemented by the Postgraduate Expiration Date: August 15, 2023 Institute for Medicine and Review Education Group. Postgraduate Estimated Time to Complete Activity: 2 hours Institute for Medicine is jointly accredited by the Accreditation Council Jointly provided by Postgraduate Institute for for Continuing Medical Education, the Accreditation Council for Medicine (PIM) and Review Education Group Pharmacy Education, and the American Nurses Credentialing Center, to provide continuing education for the healthcare team. Postgraduate Educational Objectives: After completing this activity, the participant Institute for Medicine is accredited by COPE to provide continuing edu- should be better able to: cation to optometrists. • Identify the early signs of AMD. Faculty/Editorial Board: Jessica Haynes, OD, Charles Retina Institute • Discuss the clinical metrics that can document AMD-related changes. Credit Statement: This course is COPE approved for 2 hours of CE • Identify dry AMD and the signs of conversion to wet AMD. credit. Course ID is 68805-PS. Check with your local state licensing • Describe how disease progression will affect vision. board to see if this counts toward your CE requirement for relicensure. • Review the changing prognosis of AMD given new therapeutic Disclosure Statements: options. Dr. Hayes has nothing to disclose. Target Audience: This activity is intended for optometrists engaged in Managers and Editorial Staff: The PIM planners and managers have the care of patients with AMD. nothing to disclose. The Review Education Group planners, managers Accreditation Statement: In support of improving patient care, this and editorial staff have nothing to disclose.

64 REVIEW OF OPTOMETRY AUGUST 15, 2020 Small drusen are subtle and Vision) for early detection of con- require careful evaluation to version to wet AMD. visualize. A druse that is easily Early identification of CNV visible is likely medium to large remains of the utmost importance sized. A major branch retinal ves- in preserving vision in those with sel is about 125µm in width as it AMD. Approximately 10% to crosses the edge of the optic disc 15% of AMD patients will go on and is a good reference for grad- to develop CNV, risking quickly ing drusen size funduscopically progressive and severe central (Figure 1).4 vision loss.8 The classic teaching AMD classification schemes of CNV appearance describes it used in major studies, such as the as a “grey-green subretinal mem- AREDS trials, are fairly involved brane,” but CNV can vary widely and not easily incorporated into in its fundus appearance. clinical practice.5 Fortunately, Fig. 1. In these diagonal OCT cross section Certain features should raise various authors have provided scans, the black arrow points to a subtle small a red flag for suspicion. These more clinically applicable sum- sized druse, the white arrow points toward a include the presence of macular maries (Table 1).6 medium sized drusen measuring 120µm and the hemorrhage, particularly subreti- In general, patients with only a blue arrow points toward a druse that is easily nal hemorrhage, macular exudates few small drusen are considered large sized measuring at 380µm. and macular thickening or eleva- to have age-related changes, not tion that could indicate intra- or AMD. Those with significant Patients with large drusen or any subretinal fluid as well as large small drusen or any intermediate presence of pigmentary changes pigment epithelial detachments drusen are diagnosed with early are at increased risk of developing (PEDs) (Figure 2).9 AMD. Those with significant medi- advanced AMD. AREDS I Report In the setting of AMD, these find- um sized drusen, any large drusen No. 18 developed a point system ings with or without patient symp- or pigmentary alterations should that can help clinicians determine the toms warrant further investigation be classified as intermediate AMD. five-year risk of progression to late- with additional diagnostic tools. Patients with the presence of either stage AMD based on the presence of GA or choroidal neovascularization these findings in each eye (Table 2).7 Diagnostic Imaging (CNV) have advanced stages of the Patients with these findings must Many tried-and-true tools, as well as condition. be educated regarding the benefit new technology, can help clinicians Patients with CNV have exu- of nutritional supplementation and identify AMD: dative, or wet, AMD, and those their risk for conversion to advanced Dye-based angiography. Intrave- without have non-exudative, or dry, AMD. They should be monitored nous fluorescein angiography (IVFA) AMD. Most notably, the AREDS with increased frequency and heavily was historically the go-to method for trials found that those with inter- educated about the importance of detection and classification of CNV. mediate-stage AMD benefited from home monitoring with the Amsler IVFA allows for classification of nutritional supplementation.2 grid or ForeseeHome system (Notal CNV as either classic or occult.

Table 1. AMD Classification & Management AMD Stage Fundus Findings Management Age-related Changes Rare, small drusen Reduce systemic and environmental risks. Monitor yearly. Early AMD Significant small drusen or any Reduce systemic and environmental risks. Recommend home monitoring with tech- medium sized drusen niques such as Amsler grid. Monitor every six to 12 months, depending on risk. Intermediate AMD Significant medium sized drusen, Reduce systemic and environmental risks. Discuss benefits of nutritional supplemen- any large drusen or pigmentary tation. Consider home monitoring device such as the ForeseeHome system. Monitor alterations every four to six months, depending on risk. Advanced AMD Presence of GA or CNV Reduce systemic and environmental risks. Discuss benefits of nutritional supplementation. Recommend home monitoring with techniques such as Amsler grid. Immediate referral for possible anti-VEGF injections for those with CNV. Monitor GA every six to 12 months, depending on risk. Consider low vision referral.

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Table 2. AMD Staging tion alone, and these drusen appear clinically as small- or medium-sized drusen. Despite the size of RPD, patients with this presentation are at increased risk for both CNV and GA. Their risk is even higher than that of patients with large, soft drusen.20-26 Patients with RPD may also have poorer visual function than those without RPD.27-29 Identification of this finding warrants increased frequency of monitoring and patient education regarding higher risk of progression to advanced disease. Classic CNV shows early, well- Drusen are transient, and over OCT imaging can also help clini- defined hyperfluorescence. Occult the course of the disease they can cians identify GA, a sight-threatening CNV shows patchy, ill-defined increase in size as well as resorb. A complication of dry AMD. GA hyperfluorescence that appears large regression of drusen can lead to causes atrophy of the RPE and pho- later in the study (Figure 3).10 Due new onset visual symptoms such as toreceptors, leading to OCT findings to these characteristics, researchers metamorphopsias, and it may be a of increased light penetrance into the described classic CNV as a net that precursor of advanced AMD, either choroid, loss of the photoreceptor was located primarily between the formation of GA or CNV. Increased integrity line and ONL atrophy.30 retinal pigment epithelium (RPE) and monitoring should be considered Perhaps the most notable benefit the neurosensory retina, allowing during periods of drusen regression. of OCT in AMD is identifying CNV easy visualization, and occult CNV OCT can be used to monitor this and monitoring response to treat- as nets located primarily between the clinical course (Figure 4).16-19 ment. OCT imaging may detect RPE and Bruch’s membrane where OCT can also help to identify a CNV before clinical exam alone they could not be easily imaged. particular phenotype of drusen called and should be considered for AMD These findings were verified with reticular pseudodrusen (RPD), which patients with new visual symptoms histological studies and optical presents as small, hyperreflective or any clinical suspicion of CNV. coherence tomography (OCT) find- deposits that sit on top of the RPE OCT findings present in CNV are ings. Occult CNV is more commonly and project upward toward the outer variable and can include subretinal found in AMD than classic CNV.10,11 nuclear layer (ONL). They may fluid, intraretinal fluid, PEDs and Dye-based angiography has largely project through the photoreceptor hyper-reflective subretinal mate- been replaced in clinical practice integrity line (Figure 5). This AMD rial.12-14 Any sign of possible fluid on with OCT for the diagnosis and phenotype is especially difficult to OCT should raise a red flag for con- management of CNV; however, this differentiate with fundus evalua- cern of CNV in a patient with AMD. information remains relevant as it sheds light on the variable pheno- typical presentation of CNV.12-14 OCT. This has become the most widely used diagnostic tool in posterior segment disease, and its value in the evaluation and treatment of AMD is undeniable. OCT allows for visualization of retinal drusen, and many instruments also allow for measurement of drusen size. Typical drusen appear as moderately reflec- Fig. 2. Possible CNV findings such as subretinal hemorrhage (white arrows), exudates tive deposits between the RPE and (red arrow) or macular thickening (not readily visible in photo, OCT shows macular Bruch’s membrane.15 thickening from large PEDs) should raise a red flag for further testing.

66 REVIEW OF OPTOMETRY AUGUST 15, 2020 Fig. 3a. This classic CNV shows early hyper-fluorescence at 28 Fig. 3b. This occult CNV shows no leakage early at one minute, seconds on IVFA with localized area of leakage at one minute. and delayed patchy leakage in the later phases. OCT shows the OCT shows the lesion primarily on top of the RPE (red arrow) with lesion is a large PED (red arrow) with overlying subretinal hyper- overlying intraretinal fluid (yellow arrow) and adjacent subretinal reflective material (yellow arrow) and adjacent subretinal fluid fluid (white arrow). (white arrows).

Finally, it is important in patients fluorophores, will pick up the light tifying areas of GA and evaluating with outer retinal disease to consider source and autofluoresce. The most change over time. GA appears as the status of the choroid, which can prevalent fluorophore in the retina is very dense hypo-autofluorescence. be visualized with OCT. Certain lipofuscin, primarily housed within GA with surrounding regions of OCT imaging strategies, such as the RPE. Disruptions to the RPE hyper-autofluorescence is at an enhanced-depth imaging, allow for alter the autofluorescent signal. As increased risk of growth.36 better visualization of the choroid RPE decreases and loses the ability FAF is also helpful for patient edu- and should be used when available. for proper metabolism, increased cation, allowing patients and family In patients with AMD, the choroid lipofuscin concentration in the cells to understand that there are portions tends to be relatively thin.31-33 Nor- causes hyper-autofluorescence. In of the retina that see well, while mal choroidal thickness varies due contrast, RPE cells that have atro- other areas have atrophied, causing to factors such as age and refractive phied show hypo-autofluorescence.35 missing areas of vision. error but could be considered around FAF is particularly useful in iden- This tool can also identify RPD, 250µm. Choroidal thickness which has a very distinct alone is not indicative of a FAF pattern. RPD present singular disease, but trends as small, hypo-autofluo- can be observed that are rescent circles in a reticular useful in developing a more pattern on FAF. These complete clinical picture. hypo-autofluorescent circles Evaluating the choroid sometimes have a hyper- on OCT can help to differ- autofluorescent core.35,37 entiate AMD from certain In addition, FAF can masqueraders such as cen- be thought of as a general tral serous retinopathy that lipofuscin map or a map of tends to have thicker than the RPE health. Increased average choroid (Figure 6).34 alterations to the normal Fundus autofluorescence autofluorescent pattern (FAF). This is an impor- develop as there is worsen- tant diagnostic tool for Fig. 4. On FAF, at left, GA shows as prominent hypo- ing disease and decline in patients with outer retinal autofluorescence (red arrow). On OCT, at right, GA results RPE function. FAF may disease. A light source of in atrophy of the outer retinal layers, including loss of the demonstrate areas of dis- a particular wavelength is photoreceptor integrity line and ONL. In addition, there is ease that are not visible on introduced into the eye and increased light penetrance into the choroid due to atrophy of fundus evaluation alone. certain molecules, called the highly reflective RPE layer. Patients can present with

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similar funduscopic findings, visible macular degeneration but a more altered FAF likely by up to three years.48 Adapt- indicates more advanced dis- Dx (MacuLogix) can be used ease (Figure 7).35,37 to measure dark adaptation OCT-angiography (OCT- in-office. This instrument was A). The use of OCT-A in found to be 90% sensitive and AMD primarily pertains to its 90% specific for identifying ability to detect vascular flow patients with AMD.49 in the outer retina or avascular This can be a useful tool for region of the neurosensory ret- early identification of at-risk ina, which allows for detection patients and early modifica- of CNV. OCT-A can effec- tion of environmental and tively identify both classic and systemic risk factors for occult CNV; in some cases, it Fig. 5. Fundus examination shows small- to intermediate- progression. It can also aid can delineate the size of CNV sized drusen; however, FAF and OCT show presence of RPD. patient education to demon- better than IVFA. OCT-A is strate how visual function, dyeless with fast image acquisition, B-scans or that does not appear to and not just retinal structure, is allowing for more frequent testing leak on IVFA.44-47 affected.50 Dark adaptometry results with less risk.38,39 Patients with this finding have must always be taken into context of As a fairly new technology, physi- higher risk of developing exudation, the full clinical picture to arrive at an cians are still determining how to but controversy still exists on the accurate diagnosis. best interpret and use OCT-A test right time to refer or begin treatment. results. In regard to CNV detection, About 20% of subclinical CNV will Progression and Vision image artifacts can lead to both false develop exudation, and if the clini- The physiological and functional positives and false negatives. Projec- cian elects to monitor these patients, milestones of AMD differ by type, as tion artifacts are an inherent problem they must be followed closely.45,46 do our recommendations to patients: with the technology. Essentially, Clinicians should blood flow in more superficial layers consider a referral is projected into deeper slabs, mak- to a retina specialist ing it seem that there is flow in these (Figure 8). areas when there is not. Current systems all have algo- Visual Function rithms to decrease projection arti- Testing facts, but they are not eliminated While these tools entirely. If projection artifacts lead to each give unique the appearance of flow in the avascu- insights into struc- lar region, this can give a false posi- tural alterations of tive for detection of CNV when there the retina that occur is no true flow present.40-42 Other in AMD, they do not artifacts include movement artifacts, provide a measure segmentation errors and shadowing. of visual function. OCT-A images must be properly While multiple obtained and interpreted alongside methods for testing additional clinical information to visual function exist, minimize diagnostic errors.40-43 dark adaptation has With new technology often comes become a hot topic new clinical challenges, and OCT-A in AMD. Fig. 6. The top image is a patient with chronic central serous has identified a new subset of CNV. Recently, research retinopathy and subfoveal choroidal thickness measuring The terms non-exudative CNV or has found that 451µm. The middle image is a patient with large drusen subclinical CNV are used to describe delayed dark adapta- from AMD and subfoveal choroidal thickness of 188µm. The a CNV visible with OCT-A that has tion precedes devel- bottom image is a patient with RPD and subfoveal choroidal no evidence of fluid on the OCT opment of clinically thickness of 121µm.

68 REVIEW OF OPTOMETRY AUGUST 15, 2020 Wet AMD. Among patients with 94% of those monitored with Fore- For example, AMD patients need a AMD, 10% to 15% will develop seeHome who converted to wet longer time for their vision to adjust CNV or wet AMD.8 This can lead AMD maintained 20/40 or better before leaving the exam room after a to a sudden alteration in vision with vision with treatment compared with dilated fundus evaluation. This trans- symptoms such as blur, metamor- only 62% of patients who converted lates to many real-life challenges such phopsia and scotomas. Without while using standard monitoring as ambulating between rooms of dif- treatment, patients are at a high risk techniques such as the Amsler grid.53 fering illuminations or seeing to drive for long-term, severe central vision Dry AMD. Fortunately, 85% to at night with oncoming headlights. loss. Early detection of wet AMD 90% of patients with AMD never In addition, AMD may cause and prompt referral for treatment develop CNV.8 However, these visual distortions, reduced color leads to better visual outcomes.51 patients may still suffer vision loss vision, scotomas and decreased read- Patients at significant risk for con- with variable severity and, unfor- ing speeds.57 These factors should be version to wet AMD, such as those tunately, treatment options are still considered when prescribing optical with large drusen, pigmentary altera- severely limited. The most visu- correction or low vision devices for tions or RPD, should be monitored ally devastating consequence of dry those with macular degeneration. more frequently. In addition, these AMD is the development of GA, It is important to educate patients at-risk patients should be educated which can lead to destruction of cen- with both dry and wet AMD that extensively about monitoring mon- tral vision and legal blindness. while central vision can be severely ocular vision on a daily basis with Many patients with dry AMD affected, AMD does not lead to com- tools such as the Amsler grid or maintain good visual acuity through- plete blindness. Many patients do ForeseeHome. out their lifetime, but AMD affects not understand that there are varying The ForeseeHome system relies vision in more ways than just central levels of “blindness,” and instead on hyperacuity to detect conversion acuity. AMD is a degenerative, pro- assume that all blinding diseases lead to wet AMD. Patients can use the gressive disease of the choroid, RPE to total darkness. device at home to test their monocu- and photoreceptors. It is well estab- lar vision daily. The results are moni- lished that patients with AMD suffer Treatment and Management tored remotely through complex from decreased contrast sensitiv- The approach to intervention is also algorithms to detect alterations in the ity.54-56 While a patient may see 20/20 dictated by the dry/wet distinction: retinal structure. on a high-contrast vision chart, they Wet AMD. Historically, wet Doctors receive an alert if the may struggle to read the newspaper AMD, although present in only patient has been flagged for possible or see a restaurant menu in poor 10% to 15% of AMD patients, was conversion. It is FDA approved for lighting. responsible for 90% of legal blind- use in patients with intermediate, dry AMD also decreases the retina’s ness from AMD. However, this is AMD.52 In a trial of 1,520 patients, ability to both light and dark adapt. a statistic from the pre-anti-VEGF

Fig. 7. Both of these patients have small- to intermediate-sized retinal drusen. Patient A’s FAF shows fairly normal autofluorescent signal, while patient B has alteration to the FAF greater than the extent of disease seen clinically.

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era. Intravitreal anti-VEGF injections can allow for stabilization or even improvement of vision in those that convert to wet AMD, but early detection is crucial to maintain good vision. In the CATT trial, patients with better visual acuity and smaller CNV lesions at presentation were more likely to achieve better visual outcomes. Those with worse entering acuity gained more letters of acuity, but ultimately never achieved visual acuity levels as good as those with Fig. 8. This patient with CNV located within the choriocapillaris slab of the OCT-A (red better entering vision.58 arrows) shows negligible overlying fluid on OCT cross section scans. The patient was A retrospective study evaluated followed over the course of four months with stable findings. This type of patient is patients with entering acuity of 20/40 at increased risk for the development of exudation and must be followed carefully or or better treated with anti-VEGF referred for consideration of treatment. for CNV. At one year, 81% of eyes maintained 20/40 vision and 75% AREDS I trial found that nutritional for those with intermediate stage at two years.59 In many patients, this supplementation among patients AMD.71 Before recommending a type of early detection may be the with intermediate AMD resulted in supplement, clinicians must consider difference between maintaining driv- a 25% risk reduction in the develop- a patient’s systemic health, diet and ing level vision and an independent ment of advanced stages of AMD.62 medications, including other over- lifestyle or not. This is why patient The AREDS II trial modified the the-counter supplements they may education, including recommenda- original supplement formula based already be taking. tions for at-home vision monitoring, on its results, ultimately suggesting Another focus of dry AMD man- is so important. the following: 10mg lutein, 2mg zea- agement is modifying environmental In clinical trials for the most xanthin, 500mg vitamin C, 400 IU and systemic risk factors, such as recently approved anti-VEGF drug, vitamin E, 80mg zinc, 2mg copper.62 diet, exercise and healthy sun protec- Beovu (brolucizumab-dbll, Novartis), A discussion of vitamin supple- tion habits. The number one modifi- more than 50% of patients were mentation often devolves into con- able risk for AMD is smoking.72,73 maintained with 12-week dosing at troversy, as individual practitioners Systemic vascular disease, including the one-year mark, making it the dispute which supplement is best hypertension, hyperlipidemia and longest acting drug on the market.60 to use and when to recommend it. diabetes, along with obesity all con- However, the company recently Numerous studies report improve- tribute to the disease.3 updated Beovu’s label to include data ment of various metrics such as As treatment strategies for AMD on potential risks of retinal vasculitis microperimetry, macular pigment evolve, our obligations for earlier dis- and retinal vascular occlusion.61 optical density, contrast sensitivity ease detection grow larger. Now that No matter the drug used, anti- and subjective visual improvement, we can better treat CNV, early detec- VEGF therapy for wet AMD carries among others, with the use of vari- tion is critical in the preservation of a high treatment burden for patients ous vitamin supplements.63-70 and often their families or caregivers However, there remains a lack of Genetic Testing as well. Anti-VEGF is a treatment, evidence that vitamin supplementa- Commercially available genetic testing is now not a cure, and requires repeat injection reduces the risk of developing an option for patients with AMD.74 The Macula tions for years if not a lifetime. This advanced stages of disease in those Risk (ArcticDx) test aims to identify patients requires countless office visits and with early AMD, and standard at increased risk of progression with use of procedures. Treatments themselves recommendations, such as those zinc-based supplements.74 Controversy sur- may also cause anxiety or discomfort provided by the American Academy rounding genetic testing still exists with no for patients. of Ophthalmology’s Preferred Prac- true consensus regarding the potential harm Dry AMD. Treatment for this tice Patterns, still suggest AREDS II of vitamin supplementation.75-78 condition remains limited. The type supplementation be reserved

70 REVIEW OF OPTOMETRY AUGUST 15, 2020 vision. Clinicians must continue to 23. Marsiglia M, Boddu S, Bearelly S, et al. Association between home monitoring system for early detection of choroidal neovascu- geographic atrophy progression and reticular pseudodrusen in eyes larization home monitoring of the eye (HOME) study. Ophthalmology. be diligent with fundus examina- with dry age-related macular degeneration. Invest Ophthalmol Vis Sci. 2014;121(2):535-44. 2013;54(12):7362-9. 54. Pondorfer SG, Wintergerst MWM, Gorgi Zadeh S, et al. Association tions to correctly diagnose AMD and 24. Xu L, Blonska AM, Pumariega NM, et al. Reticular macular disease is of visual function measures with drusen volume in early stages of age- identify high-risk patients. In addi- associated with multilobular geographic atrophy in age-related macular related macular degeneration. Invest Opthalmol Vis Sci. 2020;61(3):55. degeneration. Retina. 2013;33(9):1850-62. 55. Enger C, Alexander MF, Fine SL. 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Optom Vis Sci. 2017;94(2):246-59. dant supplementation on macular function in age-related maculopathy: eye disease study (AREDS): Design implications AREDS report no. 1. 36. Choudhry N, Giani A, Miller JW. Fundus autofluorescence in geo- Control Clin Trials. 1999;20(6):573-600. graphic atrophy: a review. Semin Ophthalmol. 2010;25(5-6):206-13. a pilot study including electrophysiologic assessment. Ophthalmology. 6. Ferris FL, Wilkinson CP, Bird A, et al. Clinical classification of age- 37. Bindewald A, Bird AC, Dandekar SS, et al. Classification of fundus 2003;110(1):51-60. related macular degeneration. Ophthalmology. 2013;120(4):844-51. autofluorescence patterns in early age-related macular disease. Invest 65. Richer S, Devenport J, Lang JC. LAST II: Differential temporal 7. Ferris FL, Davis MD, Clemons TE, et al. A simplified sever- Opthalmol Vis Sci. 2005;46(9):3309-14. responses of macular pigment optical density in patients with atrophic ity scale for age-related macular degeneration. Arch Ophthalmol. 38. Soomro T, Talks J. The use of optical coherence tomography angiog- age-related macular degeneration to dietary supplementation with xan- 2005;123(11):1570-4. raphy for detecting choroidal neovascularization, compared to standard thophylls. Optometry. 2007;78(5):213-9. 8. American Academy of Ophthalmology. Age-related macular degenera- multimodal imaging. Eye (Lond). 2018;32(4):661-72. 66. Richer S, Stiles W, Statkute L, et al. Double-masked, placebo- tion. https://www.aao.org/bcscsnippetdetail.aspx?id=9711f063-ed7b- 39. Nikolopoulou E, Lorusso M, Micelli Ferrari L, et al. Optical coher- controlled, randomized trial of lutein and antioxidant supplementation in 452b-8708-c4dad0d893e8. ence tomography angiography versus dye angiography in age-related the intervention of atrophic age-related macular degeneration: The Veter- 9. Kanski JJ, Bowling B. Clinical Ophthalmology: a Systematic macular degeneration: sensitivity and specificity analysis. Biomed Res ans LAST study (Lutein Antioxidant Supplementation Trial). Optometry. Approach. 7th ed. Elsevier; 2011:611-28. Int. 2018; https://doi.org/10.1155/2018/6724818. 2004;75(4):216-29. 10. Tomi A, Marin I. Angiofluorographic aspects in age-related macular 40. Spaide RF, Fujimoto JG, Waheed NK. Image artifacts in optical 67. Beatty S, Chakravarthy U, Nolan JM, et al. Secondary outcomes in a degeneration. J Med Life. 2014;7(Spec Iss 4):4-17. coherence tomography angiography. Retina. 2015;35(11):2163-80. clinical trial of Carotenoids with coantioxidants versus placebo in early 11. Freund KB, Zweifel SA, Engelbert M. Do we need a new classification 41. Gao SS, Jia Y, Zhang M, et al. Optical Coherence Tomography Angi- age-related macular degeneration. Ophthalmology. 2013;120(3):600-6. for choroidal neovascularization in age-related macular degeneration? ography. Invest Ophthalmol Vis Sci. 2016;57(9):OCT27-36. 68. Evans JR, Lawrenson JG. Antioxidant vitamin and mineral supple- Retina. 2010;30(9):1333-49. 42. Enders C, Lang GE, Dreyhaupt J, et al. Quantity and quality of image ments for slowing the progression of age-related macular degeneration. 12. Regatieri CV, Branchini L, Duker JS. The role of spectral-domain artifacts in optical coherence tomography angiography. PLoS One. Cochrane Database Syst Rev. 2017. OCT in the diagnosis and management of neovascular age-related macu- 2019;14(1):e0210505. 69. Parravano M, Tedeschi M, Manca D, et al. Effects of Macuprev lar degeneration. Ophthalmic Surg Lasers Imaging. 2011;42(0):S56-66. 43. Lauermann JL, Woetzel AK, Treder M, et al. Prevalences of segmen- supplementation in age-related macular degeneration: a double-blind 13. Parekh PK, Folk JC, Gupta P, et al. fluorescein angiography does not tation errors and motion artifacts in OCT-angiography differ among reti- randomized morpho-functional study along 6 months of follow-up. Adv alter the initial clinical management of choroidal neovascularization in nal diseases. Graefes Arch Clin Exp Ophthalmol. 2018;256(10):1807-16. Ther. 2019;36(9):2493-2505. age-related macular degeneration. Ophthalmol Retin. 2018;2(7):659-66. 44. Lane M, Ferrara D, Louzada RN, et al. Diagnosis and follow- up of 70. Bartlett H, Eperjesi F. Age-related macular degeneration and 14. Gualino V, Tadayoni R, Cohen SY, et al. Optical coherence tomogra- nonexudative choroidal neovascularization with multiple optical coher- nutritional supplementation: A review of randomised controlled trials. phy, fluorescein angiography, and diagnosis of choroidal neovasculariza- ence tomography angiography devices: A case report. Ophthalmic Surg Ophthalmic Physiol Opt. 2003;23(5):383-99. tion in age-related macular degeneration. Retina. 2019;39(9):1664-71. Lasers Imaging Retin. 2016;47(8):778-81. 71. American Academy of Ophthalmology. Age-Related Macular Degen- 15. Jain N, Farsiu S, Khanifar AA, et al. Quantitative comparison of 45. de Oliveira Dias JR, Zhang Q, Garcia JMB, et al. Natural history of eration PPP 2019. www.aao.org/preferred-practice-pattern/age-related- drusen segmented on SD-OCT versus drusen delineated on color fundus subclinical neovascularization in nonexudative age-related macular macular-degeneration-ppp. Accessed July 15, 2020. photographs. Invest Ophthalmol Vis Sci. 2010;51(10):4875-83. degeneration using swept-source OCT angiography. Ophthalmology. 72. Myers CE, Klein BEK, Gangnon R, et al. Cigarette smoking and the 16. Spaide RF. Outer retinal atrophy after regression of subretinal natural history of age-related macular degeneration: the beaver dam eye drusenoid deposits as a newly recognized form of late age related macu- 2018:125(2):255-66. 46. Heiferman MJ, Fawzi AA. Progression of subclinical choroidal study. Ophthalmology. 2014;121(10):1949-55. lar degeneration. Retina. 2013;33(9):1800-8. 73. Velilla S, García-Medina JJ, García-Layana A, et al. Smoking and 17. Yehoshua Z, Wang F, Rosenfeld PJ, et al. Natural history of drusen neovascularization in age-related macular degeneration. PLoS One. morphology in age related macular degeneration using spectral domain 2019;14(6):e0217805. age-related macular degeneration: review and update. J Ophthalmol. optical coherence tomography. Ophthalmology. 2011;118(12):2434-41. 47. Bailey ST, Thaware O, Wang J, et al. Detection of nonexudative 2013;2013:895147. 18. Schlantz FG, Baumann B, Kundi M, et al. Drusen volume develop- choroidal neovascularization and progression to exudative choroidal 74. Arctic Medical Laboratories. https://arcticdx.com. Accessed July ment over time and its relevance to the course of age-related macular neovascularization using OCT angiography. Ophthalmol Retin. 15, 2020. degeneration. Br J Ophthalmol. 2019;3(8):629-36. 75. Chew EY, Klein ML, Clemons TE, et al. Genetic testing in persons 2017;101:198-203. 48. Loshin DS, White J. Contrast sensitivity: the visual reha- with age-related macular degeneration and the use of the AREDS supple- 19. Folgar FA, Yuan EL, Sevilla MB, et al. Drusen volume and retinal pig- bilitation of the patient with macular degeneration. Arch Ophthalmol. ments: to test or not to test? Ophthalmology. 2015;122(1):212-5. ment epithelium abnormal thinning volume predict 2-year progression of 1984;102(9):1303-6. 76. Awh CC, Lane A-M, Hawken S, et al. CFH and ARMS2 genetic age-related macular degeneration. Ophthalmology. 2016;123(1):39-50. 49. Jackson GR, Scott IU, Kim IK, et al. Diagnostic sensitivity and speci- polymorphisms predict response to antioxidants and zinc in patients with 20. Joachim N, Mitchell P, Rochtchina E, et al. Incidence and progres- ficity of dark adaptometry for detection of age-related macular degenera- age-related macular degeneration. Ophthalmology. 2013;120(11):2317- sion of reticular drusen in age-related macular degeneration: findings tion. Invest Ophthalmol Vis Sci. 2014;55(3):1427-31. 23. from an older Australian cohort. Ophthalmology. 2014;121(4):917–25 50. AdaptDx. https://www.maculogix.com/adaptdx. Accessed July 15, 77. Chew EY, Klein ML, Clemons TE, et al. No clinically significant asso- 21. Gil JQ, Marques JP, Hogg R, et al. Clinical features and long-term 2020. ciation between CFH and ARMS2 genotypes and response to nutritional progression of reticular pseudodrusen in age-related macular degenera- 51. Schwartz R, Loewenstein A. Early detection of age related macular supplements. Ophthalmology. 2014;121(11):2173-80. tion: findings from a multicenter cohort. Eye (Lond) 2017;31(3):364-71. degeneration: current status. Int J Retin Vitr. 2015;1(1):20. 78. Assel MJ, Li F, Wang Y, et al. Genetic polymorphisms of CFH and 22. Pumariega NM, Smith RT, Sohrab MA, et al. A prospective study of 52. ForeseeHome. www.foreseehome.com. Accessed JUly 15, 2020. ARMS2 do not predict response to antioxidants and zinc in patients with reticular macular disease. Ophthalmology. 2011;118(8):1619-25. 53. Chew EY, Clemons TE, Bressler SB, et al. Randomized trial of a age-related macular degeneration. Ophthalmology. 2018;125(3):391-7.

REVIEW OF OPTOMETRY AUGUST 15, 2020 71 OPTOMETRIC STUDY CENTER

OSC QUIZ

ou can obtain continuing education b. Improved visual function. a. No AMD but systemic risk factors. credit through the Optometric YStudy Center. Complete the test c. Improved macular pigment optical density. b. Early AMD. form and return it with the $35 fee to: d. Worsening of dark adaptation. c. Intermediate AMD. Jobson Healthcare Information, LLC, d. Advanced AMD. Attn.: CE Processing, 395 Hudson Street, 7. Which of these describes the appearance of 3rd Floor New York, New York 10014. RPD on OCT? 15. What medical intervention has most To be eligible, please return the card within three years of publication. You a. Hypo-reflective deposits beneath the RPE. dramatically improved patient outcomes in can also access the test form and submit b. Hypo-reflective deposits on top of the RPE. those who develop CNV? your answers and payment via credit c. Hyper-reflective deposits beneath the RPE. a. Intravitreal anti-VEGF. card at Review Education Group online, d. Hyper-reflective deposits on top of the RPE. b. AREDS II vitamins. revieweducationgroup.com. c. Photodynamic therapy. You must achieve a score of 70 or higher to receive credit. Allow four weeks for pro- 8. Where are typical drusen located? d. Laser photocoagulation. cessing. For each Optometric Study Center a. Between RPE and ONL. course you pass, you earn 2 hours of credit b. Between RPE and Bruch’s membrane. 16. Which of these characteristics was related from Pennsylvania College of Optometry. c. Within the nerve fiber layer. to better visual outcomes in the CATT trial? Please check with your state licensing d. In the choriocapillaris. a. Large CNV at presentation. board to see if this approval counts toward your CE requirement for relicensure. b. Worse entering visual acuity. 9. Which of the following is not true of RPD? c. Better entering visual acuity. 1. One study found ___ of AMD patients were a. They carry increased risk of conversion to d. Treatment with Avastin over Lucentis. misdiagnosed as having a normal macula. advanced AMD. a. 10%. b. Patients with RPD may have worse visual 17. What is both the sensitivity and specificity b. 25%. function than those without RPD. of AdaptDx in identifying those with AMD? c. 40%. c. OCT and FAF can help to visualize RPD. a. 60%. d. 55%. d. RPD are easily distinguished from normal b. 70%. drusen on funduscopic evaluation. c. 80%. 2. What is the size of a large druse? d. 90%. a. At least 63µm. 10. Where is lipofuscin primarily found? b. 100µm. a. In the RPE. 18. What best describes the current standard c. ≥125µm b. In the ONL. of care for medical management of GA? d. No objective standard exists. c. In the GCL. a. Reduce environmental/systemic risk d. In the RNFL. factors, monitor for conversion to wet AMD 3. Which of these findings indicate increased and consider risks/benefits of vitamin. risk for conversion to advanced AMD? 11. How does GA present on FAF? supplementation. a. Peripapillary atrophy. a. Hyper-reflective. b. Intravitreal anti-VEGF. b. Large sized drusen. b. Hypo-reflective. c. Complement factor inhibitors. c. Pigmentary alterations. c. Hyper-autofluorescent. d. Tea tree oil. d. Both b and c. d. Hypo-autofluorescent. 19. Why must there always be a strong 4. At what point does the AREDS I trial 12. Which of the following are artifacts that emphasis on early CNV detection with AMD? recommend nutritional supplementation? may be found on OCT-A? a. Early detection of CNV and prompt treatment a. No AMD but systemic risk factors. a. Projection artifacts. leads to better visual outcomes. b. Early AMD. b. Segmentation artifacts. b. Early detection of CNV allows for fewer anti- c. Intermediate AMD. c. Movement artifacts. VEGF injections. d. Advanced AMD. d. All of the above. c. Early detection of CNV gives the provider the opportunity to discuss vitamin 5. Patients with advanced AMD have: 13. What percentage of patients with AMD supplementation. a. Presence of CNV or GA. develop wet AMD? d. Early detection of CNV gives the patient b. Large drusen. a. 10% to 15%. more time to get set up with a retinal referral. c. Large drusen and pigmentary changes. b. 20% to 25%. d. Pigmentary changes. c. 30% to 35%. 20. Which of these is not a risk factor for AMD? d. 40% to 45%. a. Lupus. 6. A large regression of drusen/PEDs on OCT b. Smoking. has been associated with: 14. At what stage of AMD is the ForeseeHome c. Hypertension. a. Increased risk of developing advanced AMD. monitoring system FDA approved for? d. Obesity.

72 REVIEW OF OPTOMETRY AUGUST 15, 2020 Mail to: Jobson Healthcare Information, LLC, Attn.: CE Processing, 395 Examination Answer Sheet Hudson Street, 3rd Floor New York, New York 10014 Understanding AMD Presentations and Prognoses Payment: Remit $35 with this exam. Make check payable to Jobson Healthcare Information, LLC. Valid for credit through August 15, 2023 Credit: This course is COPE approved for 2 hours of CE credit. Course ID is Online: This exam can be taken online at revieweducationgroup.com. Upon pass- 68805-PS. ing the exam, you can view your results immediately and download a real-time CE Jointly provided by Postgraduate Institute for Medicine and Review Education certificate. You can also view your test history at any time from the website. Group. Directions: Select one answer for each question in the exam and completely Salus University has sponsored the review and approval of this activity. darken the appropriate circle. A minimum score of 70% is required to earn credit. Processing: There is a four-week processing time for this exam. Answers to CE exam: Post-activity evaluation questions: 1. A B C D Rate how well the activity supported your achievement of these learning objectives: 2. A B C D 1=Poor, 2=Fair, 3=Neutral, 4=Good, 5=Excellent 3. A B C D

4. A B C D 21. Identify the early signs of AMD. 1 2 3 4 5 A B C D 5. 22. Discuss the clinical metrics that can document AMD-related changes. 1 2 3 4 5 6. A B C D 23. Identify dry AMD and the signs of conversion to wet AMD. 1 2 3 4 5 7. A B C D 24. Describe how disease progression will affect vision. 1 2 3 4 5 8. A B C D 25. Review the changing prognosis of AMD given new therapeutic options. 1 2 3 4 5 9. A B C D 10. A B C D 26. Based upon your participation in this activity, do you intend to change your practice behavior? 11. A B C D (choose only one of the following options) A B C D 12. A I do plan to implement changes in my practice based on the information presented. 13. A B C D B My current practice has been reinforced by the information presented. 14. A B C D C I need more information before I will change my practice. 15. A B C D 27. Thinking about how your participation in this activity will influence your patient care, how many of your 16. A B C D 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 30. Which of the following do you anticipate will that apply) be the primary barrier to implementing these changes? a Apply latest guidelines b Change in pharmaceutical therapy c Choice of treatment/management approach a Formulary restrictions d Change in current practice for referral e Change in non-pharmaceutical therapy f Change in differential b Time constraints diagnosis g Change in diagnostic testing h Other, please specify: ______c System constraints ______d Insurance/financial issues

e Lack of interprofessional team support 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 ______Address

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

Fax # 1 2 3 4 5 OE Tracker Number 33. The content was balanced and free of bias.

1 2 3 4 5 By submitting this answer sheet, I certify that I have read the lesson in its entirety and completed the self- 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

Signature Date

Lesson 120000 RO-OSC-0820

REVIEW OF OPTOMETRY AUGUST 15, 2020 73 Cornea+Contact Lens Q+A

KCN Options: Stiff Competition If the obvious choices don’t suit your patient, alternatives can expand your capability to manage ectasia and its consequences. Edited by Joseph P. Shovlin, OD

I have several keratoco- • IOLs. Contact lens–intol- Q nus (KCN) patients who erant KCN patients who have aren’t doing well with their con- stable disease may benefit tact lenses. Are there any sta- from phakic intraocular lenses bilizing procedures other than (IOLs), suggests Dr. Lucas. corneal crosslinking (CXL) for IOLs can reduce refractive early disease and full-thickness Anterior segment OCT of corneal melt over an ICRS. error, myopia and astigmatism transplantation for late disease? in various KCN stages and can Yes, more than it may seem. that reduces UV exposure time by combined with CXL, ICRS and cor- A “Various methods are avail- increasing irradiance has shown neal transplantation.1 able for managing KCN depending promising results.1 CXL can also be • BLT. This technique reduces on the stage and progression status,” combined with photorefractive kera- ectasia in advanced KCN.4 Corneal according to Katelyn Lucas, OD, of tectomy, thermal keratoplasty, ICRS ectasia occurs as Bowman’s layer Price Vision Group in Indianapolis. or LASIK to improve visual acuity.1 destabilizes, necessitating a graft in Dr. Lucas says early stages can Crosslinking has succeeded the mid-stroma to prevent progres- be managed with glasses or con- because it’s effective and minimally sion and stabilize the cornea.1 A tact lenses, while Bowman’s layer invasive. Other choices may have preliminary study found decreased transplantation (BLT), deep anterior a narrower range of applicability K readings, improved visual acuity, lamellar keratoplasty (DALK) and but can play a role in well-selected reduced higher-order aberrations penetrating keratoplasty (PK) are patients. and stabilized disease progression.1,4 performed in advanced cases. She • ICRS. These arc-shaped pieces • DALK, PK. With thin corneas, notes that CXL prevents disease pro- of polymethyl methacrylate are significant anterior scarring or non- gression, and intrastromal corneal placed within the stroma to help flat- functional vision with contact lenses, ring segments (ICRS) and conductive ten and reshape the cornea in mild a DALK is typically recommended, keratoplasty (CK) reshape the cor- to moderate KCN, Dr. Lucas says. according to Dr. Lucas. The visual nea to reduce refractive error. ICRS improve visual outcomes by results are similar to those of PK, reducing myopia and astigmatism.2 but the patient’s own Descemet’s Weighing Your Options Combined ICRS/CXL can amplify membrane and endothelial cells are While no universally accepted treat- the flattening effect and reduce cor- retained, eliminating risk of endo- ment guidelines exist for ectasia, Dr. neal cylinder.1 thelial cell rejection and allowing Lucas offers her take on the options: • CK. Radio wave energy heats the graft to last the patient’s lifetime. • CXL. Topical riboflavin and and shrinks stromal collagen, induc- The wound also heals better and UVA light promote the formation of ing steepening in flat areas and cor- faster than in PK, and less topical strong chemical bonds between col- recting refractive error.3 Off-label steroid is needed. I lagen fibrils to strengthen the cornea, CK use for KCN can reshape the 1. Mohammadpour M, Heidari Z, Hashemi H. Updates on manage- notes Dr. Lucas. Studies investigating cornea, reduce astigmatism and ments for keratoconus. J Curr Ophthalmol. 2018;30(2):110-24. 3 2. Zadnik K, Money S, Lindsley K. Intrastromal corneal ring seg- the standard Dresden protocol have decrease keratometry readings. ments for treating keratoconus. Cochrane Database Syst Rev. reported high success rates in halting Dr. Lucas notes CK may need to be 2019;5(5):CD011150. 3. Kato N, Toda I, Kawakita T, et al. Topography-guided conductive disease progression and decreasing combined with other procedures to keratoplasty: treatment for advanced keratoconus. Am J Ophthalmol. 1 2010;150(4):481-9. keratometry readings. Epi-on CXL achieve the desired effect, such as 4. van Dijk K, Parker J, Tong CM, et al. Midstromal isolated Bowman layer graft for reduction of advanced keratoconus: a technique to has produced inconsistent findings, ICRS to correct high cylinder and postpone penetrating or deep anterior lamellar keratoplasty. JAMA while an accelerated version of CXL CXL to prevent disease progression. Ophthalmol. 2014;132(4):495-501.

74 REVIEW OF OPTOMETRY AUGUST 15, 2020 AMD Standard of Care is Not Enough

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SM-068.01 www.foreseehome.com/hcp Retina Quiz

Don’t Strain Yourself This patient cannot remember what led to this change in his vision. By Mark Dunbar, OD

20-year-old white male presented with a sudden Aloss of vision in his left eye that occurred two days prior. He reported going to a college party on Friday night and waking up the next day with a dark spot that had a red tinge in the center of his vision. His past ocular and medical histories were unremarkable. On examination, his best- corrected visual acuity was 20/20 OD, 20/200 OS. Extraocular motility testing was normal. His Figs. 1 and 2. These fundus photos of the left eye show a retinal hemorrhage confrontation visual fields were involving his macula. Where is the anatomic location of the blood? full-to-careful finger counting OU, and the pupils were equally round c. Retinal arterial macroaneurysm VEGF injections. and reactive to light; there was (RAM). d. Likely will develop disciform no afferent pupillary defect. On d. Valsalva retinopathy. scar formation. Amsler grid testing, he had a cen- For answers, see page 90. tral scotoma OS. 2. Where is the blood located? His anterior segment exam was a. Subretinal space. Diagnosis unremarkable. Tensions by appla- b. Between RPE and sensory Our patient has a classic nation measured 14mm Hg OU. retina. presentation of Valsalva On dilated fundus exam, the right c. Sub–internal limiting membrane retinopathy. This condition eye was completely normal. In the (ILM). is a rare retinopathy that is left eye, there was a small cup with d. Pre-retinal. characterized by a preretinal good rim coloration and perfusion. hemorrhage in the macula due to In the macula, there was a hemor- 3. How should this patient be man- the Valsalva maneuver. Valsalva rhage (Figures 1 and 2). The vessels aged? occurs when a person tries to and peripheral retinal were normal. a. Observation. exhale air forcibly with a closed We performed an OCT and OCT- b. Anti-VEGF injection. glottis (windpipe) so that no air A, which are available for review c. YAG membranotomy. goes out through the mouth or (Figures 3 and 4). d. Pars plana vitrectomy. nose. When this occurs, there is a sud- Take the Retina Quiz 4. What is the long-term den increase in intrathoracic or 1. What is the correct diagnosis? prognosis? intra-abdominal pressure. This a. Idiopathic choroidal a. Excellent with treatment. Valsalva maneuver occurs during neovascularization (CNV). b. Excellent with close various day-to-day activities that b. Hemorrhagic central serous reti- observation. cause straining, such as coughing, nopathy. c. Good with continued anti- sneezing, vomiting, exercise and

76 REVIEW OF OPTOMETRY AUGUST 15, 2020 blowing on musical instruments, among others.1

Discussion In addition to the sudden increase in intrathoracic/intra-abdominal pressure, there is also raised central venous pressure in the head and neck. Because there are no valves in the venous system beyond the heart, the sudden rise in venous pressure leads to the rupture of perifoveal superficial retinal capillaries that cause the preretinal hemorrhage. The exact anatomic location of the hemorrhage in our patient is not completely clear. On clinical exam, we know that the blood is anterior because it obscures the underlying retina and the top of the hemorrhage is flat or horizontal, almost having a boat shape. This is classic for a preretinal hemorrhage. However, Figs. 3 and 4. The SD-OCT (left) and OCT-A (right) of the left eye. The OCT-A is an 8mm x to be even more specific, it’s 8mm superficial cut through the macula. What does it show? difficult to know if the blood is under the ILM (sub-ILM) or inferiorly and clearing the visual We elected to follow-up our between the posterior vitreous axis.3 In some instances subretinal patient to determine if the face and sensory retina. Even with or vitreous hemorrhage can occur hemorrhage would spontaneously SD-OCT it can be difficult to necessitating surgical intervention. resolve. At the follow-up visit a discern.2 Pars plana vitrectomy may be indi- month later, he was still 20/200. In our patient, the posterior cated for patients with significant Even though the hemorrhage was vitreous face appears intact, and, retinal hemorrhages or dense vitre- smaller, there was still significant as you follow the OCT line scan, ous hemorrhage.4 involvement in his macula. As he it is contiguous with the ILM. Even though the clinical was getting anxious that vision was The blood appears posterior and presentation for our patient is not getting better, we scheduled indicates that it’s below the ILM. classic for Valsalva retinopathy, his him back in one month with a The natural history of Valsalva history is not. When we tried to retina specialist for consideration retinopathy is good, as the vast elicit a history of performing any of Nd:YAG membranotomy. n majority of patients make a com- strenuous activities that could result 1. Duane TD. Valsalva hemorrhagic retinopathy. Trans Am plete return to normal vision after in Valsalva maneuver, he didn’t Ophthalmol Soc. 1972;70:298-313. the blood resolves. However, this recall any. Even though he had been 2. Goel N, Kumar V, Seth A, et al. Spectral-domain optical coherence tomography findings of subinternal limiting mem- can be a slow process that can to a party the night before, he didn’t brane hemorrhage in the macula before and after Nd:YAG laser treatment. Ophthalmic Surg Lasers Imaging Retina. take up to several months. One vomit or remember having any kind 2011;42(3):222-8. treatment option becoming more of hard cough or sneeze. We also 3. Durukan AH, Kerimoglu H, Erdurman C, et al. Long-term results of Nd:YAG laser treatment for premacular subhyaloid common is Nd:YAG laser mem- questioned him about engaging in haemorrhage owing to Valsalva retinopathy. Eye (Lond). 2008;22(2):214-8. branotomy. During this, the laser vigorous sexual activity, as Valsalva 4. Khadka , Bhandari S, Bajimaya S, et al. Nd:YAG laser makes an opening in the posterior retinopathy has also been reported hyaloidotomy in the management of Premacular Subhyaloid 5 Hemorrhage. BMC Ophthalmol. 2016;16:41. hyaloid or ILM so the blood can during orgasm. He denied this as 5. Michaels L, et al. Postcoital visual loss due to valsalva reti- escape into the vitreous, settling well. nopathy BMJ Case. Rep 2014;2014:bcr-2014-207130.

REVIEW OF OPTOMETRY AUGUST 15, 2020 77 Glaucoma Grand Rounds

The Art of Juggling Put your thinking cap on when determining how to best manage different patients and conditions simultaneously. By James L. Fanelli, OD

busy day at the clinic prac- patient’s applanation tensions were tically dares you not 21mm Hg OD and 19mm Hg OS, A to fall behind schedule. and her pachymetry measures were On top of that, your caseload is 563µm OD and 551µm OS. full of complex patients, some Through dilated pupils, the presenting for the first time, with posterior chamber IOLs were clear multiple issues. How do you juggle and centered. The capsule in the these responsibilities in an effi- right eye was opened, and the IOL cient yet non-cavalier manner, was pitted from the YAG capsu- especially if your schedule, like lotomy. The capsule in the left eye mine, is packed with appoint- was clear and intact. Bilateral pos- ments backlogged by COVID-19? terior vitreous detachments were This column offers a case example noted. that illustrates the importance of Optic nerve exam demonstrated prioritizing patient care in a timely, Fig. 1. Observe the thin neuroretinal rim and the cup-to-disc ratios of 0.8/0.9 OD beneficial way. ERM just nasal to the foveal avascular zone. and 0.7/0.75 OS. The temporal neuroretinal rims were exceedingly The Case her first cataract surgery, she had thin (OD>OS) and consistent with A 72-year-old Caucasian female treatment with Jetrea (ocriplasmin, advanced glaucoma (Figure 1). presented as a new patient in mid- ThromboGenics) OD. During last The macular evaluation showed a June. She wanted to establish care year’s surgery, she also had two foveal aberration OD consistent with after recently moving to the area and iStent devices (Glaukos) implanted in a lamellar hole. There was also an heard that I specialize in glaucoma. the trabecular meshwork of her left epiretinal membrane (ERM) centered She also needed an updated pair of eye. This device was not available between the fovea and the disc OD glasses, as her current prescription when her first eye was done. (Figure 2). The left macula was char- was 2.5 years old and she noticed a The patient’s entering visual acu- acterized by RPE granulation. The change in her vision. ities were 20/40-2 OD and 20/25+1 retinal vasculature had both mild She was taking lansoprazole 30mg OS and best-corrected acuities were hypertensive and arteriolarsclerotic QD, levothyroxine 75mcg QD, sim- 20/25+3 OD and 20/20-2 OS. Her retinopathy OU. The peripheral reti- vastatin 40mg QD, citalopram 20mg pupils were equally round and reac- nal exam was normal OU. QD, cetirizine 10mg QD, Vyzulta tive to light with no afferent pupillary Following the posterior pole (latanoprostene bunod, Bausch + defects, and her extraocular muscles examination, I retook the patient’s Lomb) HS OU and generic Cosopt were full in all positions of gaze. intraocular pressures (IOPs) and (dorzolamide/timolol, Akorn) BID Slit lamp examination of the ante- found that they were similar to pre- OD. She had no allergies to meds. rior segment was fairly unremark- dilation measures. Significant in the patient’s ophthal- able. There was mild sectoral iris There is no question that this mic history were bilateral cataract transillumination OD, which is not patient has advanced glaucoma, extractions with posterior chamber uncommon following cataract sur- OD>OS. Close examination of blue intraocular lens (IOL) implantations. gery. One of the iStent devices in the laser imaging shows significant Her right eye was done in 2009 and left eye was visible through the slit loss of the retinal nerve fiber layer her left in 2019. A few years after lamp without angle gonioscopy. The (RNFL) in the right eye (Figure 3).

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Figs. 2 and 3. Green laser imaging highlights the ERM and the foveal abnormality, at left. Blue laser reflectance imaging shows some fine striations remaining in the superotemporal sector of the arcuate retinal nerve fibers and very few nerve fibers remaining inferiorly.

Though she’s only been in for one not pay for OCT and fundus pho- • IOPs to get a feel for how visit, I’m confident her IOPs are not tography in the same sitting (for the tenuous her IOP situation is, adequately controlled, given the level same disease). Regardless, patient knowing full well that when I of optic nerve damage. care and well-being trumps coding saw her in the afternoon, her and reimbursement issues, so if OCT IOPs were probably higher Discussion and imaging need to be done on the earlier in the day During an initial office visit, you same day, then so be it. • Slit lamp examination of the need to be aware of the patient’s full Keep insurance coverage in mind posterior pole to get an idea clinical story. Only then can you when deciding which tests are needed of how things look in vivo determine and prioritize care, includ- right away and which can wait. To Her next visit will include: ing what testing will be done, and a large extent, this depends on the • IOPs to document her diurnal when. patient and how advanced their dis- fluctuations Each of us has developed pro- ease is, how controlled their IOPs are • Standard automated perime- tocols for certain situations and and other clinical signals. We also try 24-2 visual field thresholds disease entities in our practices. At need to be mindful of juggling mul- to assess the extent of vision various times and with varying fre- tiple patients and managing office loss quencies, all my glaucoma patients flow, as there will inevitably be other • OCT and HRT-3 imaging will complete a series of testing and patients in the clinic at the same time of the optic nerves and OCT imaging, including the obvious data and we can’t get bogged down with imaging of the macula to points—IOP, visual fields, OCT one at the expense of three others. quantify the glaucomatous and gonioscopy. They will also damage eventually undergo fundus photog- Patient Management • Gonioscopy to evaluate the raphy, HRT-3 imaging (Heidelberg An adjustment to the patient’s spec- nuances of her angles and the Engineering) of the optic nerves, tacle prescription should improve her positions of the iStents OS anterior segment OCT and ultra- sight, so I updated her prescription to At the completion of the second sound biomicroscopy. That’s a lot get new glasses. The bigger issue at visit, I should have a reasonable set of data, and certainly too much to hand is her advanced glaucoma. This of data points that I can use to set obtain over a few visits, let alone on is how I prioritized her initial testing: and start working toward a target the initial presentation. • Pachymetry to get a sense of pressure for the patient. Compounding the issue of fig- her IOPs and progression risk There is a lot to take into consid- uring out an appropriate testing • Photography in the form of eration when juggling different con- schedule is the fact that certain items multimodal laser imaging to ditions and patients, especially the are not covered by insurance when see (and record) what’s hap- first time around. Luckily, the more performed on the same day as other pening in the neuroretinal cases we see, the easier it will become items. For example, Medicare will rim, macula and RNFL to prioritize testing. n

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Stop the Drop? Newer drug delivery options give us more control over the post-op care experience for cataract patients. By Derek N. Cunningham, OD, and Walter O. Whitley, OD, MBA

ith over four million cata- steroids or NSAIDs was significantly ract procedures performed lower in the treatment groups.2 Weach year, optometrists Compounded medications. A must be ready to provide the neces- few compounding pharmacies sary perioperative care. From the (Imprimis Rx and Ocular Science) initial diagnosis to the post-op care, have entered the ophthalmic market we communicate with patients and to help address issues of the five Cs. work with surgeons to ensure every- Drugs are compounded into either one is on the same page and moving intracameral injections or combina- toward the most desirable outcome. Dextenza has a reported 30 days’ tion drops. For example, we use duration of efficacy. gatifloxacin-bromfenac-prednisolone Ocular Drug Delivery QID for two weeks before switching One of the most difficult aspects of for up to 30 days. Following treat- to bromfenac-prednisolone QID for any ophthalmic procedure is choos- ment, Dextenza resorbs and exits three weeks. Other practices use the ing the drops that patients take pre- the nasolacrimal system without the dropless formulation of intracameral and post-op. There are numerous need for removal. injections of dexamethasone and factors to take into consideration, In each of three trials, a higher moxifloxacin at the end of surgery. including name brand vs. generic, proportion of Dextenza patients These medications are not FDA- dosage and the option of intracam- were pain-free on post-op day eight approved for this specific indication eral injections. Although efficacy vs. controls.1 On post-op day 14, and have not gone through large and safety are among the most two of the studies observed a higher randomized studies or regulated important, we must also consider the proportion of Dextenza patients quality control measures. However, five Cs: corneal toxicity, cost, conve- with a statistically significant absence they have been used for a long time nience, confusion and compliance. If of anterior chamber cells.1 in an off-label manner to address any one becomes too cumbersome, Dexycu. Approved by the FDA issues with on-label medications. many patients will not use their in February 2018, this single intra- Speaking from decades of experience medication as prescribed. To address ocular dose of 0.005mL of dexa- with various compounded medica- these concerns, several companies methasone 9% is administered in the tions, we advise that you must be have presented new approaches to posterior chamber to treat post-op prepared for varying levels of both ocular drug delivery for surgery: inflammation. Although steroid efficacy and adverse events. Dextenza. In November 2018, injections have been used off-label in It’s exciting to have so many new Ocular Therapeutix introduced the dropless cataract surgery, EyePoint medication options available for first therapeutic intracanalicular Pharmaceuticals’ Dexycu is the first ophthalmic surgery, but be mindful insert. It delivers 0.4mg of dexa- drug to have this on-label indication. to take the full clinical picture into methasone to treat pain and inflam- A trial reported the percentage account when selecting which is best mation following ocular surgery. of Dexycu patients with anterior for your patient. Only time will tell One preservative-free hydrogel insert chamber cell clearing on post-op day where these newer options fit in and can relieve postsurgical side effects eight was 20% in the placebo group what optimal outcomes they may be and 57% and 60% in the 342µg and capable of delivering. ■ For a video of this procedure, 517µg Dexycu groups, respectively.2 visit www.reviewofoptometry. 1. Dextenza. www.dextenza.com/wp-content/uploads/DEXTENZA-Full- com or scan the QR code. The percentage of participants who Prescribing-Information.pdf. July 7, 2020. 2. Dexycu. dexycu.com/downloads/DEXYCU%20Prescribing%20 received rescue medication of ocular Information_6-11-20.pdf. July 7, 2020.

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When to Treat Ocular Hypertension Consider many factors, but don’t rely on any one measurement alone before you make your move. By Joseph W. Sowka, OD

27-year-old male pre- the development of primary sented to the clinic open-angle glaucoma (POAG). after being referred However, no scientific assess- Afor management of ment of the probability of his markedly elevated intra- converting to POAG existed ocular pressure (IOP). His past and doctors had no data on ocular history was significant the whether it was useful to for ocular trauma to his left eye prophylactically lower IOP. that left him with poor vision. Anecdotally, clinicians who He had never been diagnosed had extensive clinical expe- with glaucoma before. rience with glaucoma and His best-corrected acuities OHTN patients generally were 20/20 OD and 20/400 felt that, without treatment, OS due to a traumatic macular approximately 10% of OHTN scar, choroidal rupture and patients would develop glau- fibrotic parapapillary traction. This fundus photo shows our 27-year-old patient’s coma, but that was just a rule His anterior chamber angles right eye. He has a large, healthy optic nerve despite an of thumb. Researchers had were gonioscopically open to intraocular pressure of 51mm Hg. no consensus on how best to the ciliary body OU, without manage OHTN. Some doctors abnormalities. He had large optic (OHTN). Clearly, the patient was chose to merely observe while others discs with a cup-to-disc ratio of not the prototypical ocular hyper- treated. 0.7/0.7 with smooth and regular tension case. Then, in 2002, the Ocular Hyper- neuroretinal rims and no focal tension Treatment Study (OHTS) damage, parapapillary atrophy, disc Risk of Progression was published. The main focus of hemorrhages or retinal nerve fiber OHTN—classically thought of as that research was to determine if layer (RNFL) defects. IOP above a statistically normal reducing IOP delayed or prevented His central corneal thicknesses level of 21mm Hg in the absence the development of glaucoma in eyes were 557µm OD and 560µm OS. of glaucomatous damage to the with OHTN.1 What the investiga- Optical coherence tomography optic disc, retinal nerve fiber layer tors found was that, prophylactically (OCT) showed a normal RNFL (RNFL) or visual field—is one of lowering IOP in eyes with OHTN in the right eye and abnormal the most common clinical entities reduced the risk of progression over measurements in the left, due to encountered. While diagnosis can the initial five years of the study. maculopathy. Threshold perimetry be straightforward, management is At 60 months, the cumulative was normal OD and unreliable OS. more challenging, especially when probability of developing POAG Except for pre-existing traumatic other variables come into play. was 4.4% among the prophylacti- maculopathy, he had no abnor- Patient age, comorbidities, level of cally medicated subjects, while it malities or damage attributable to IOP and other factors make this was 9.5% in the observation group.1 glaucoma. His IOPs, however, were common condition a sometimes- That nicely validated our previous quite remarkable at 51mm Hg OD complicated management issue. rule of thumb that approximately and 55mm Hg OS. He was subse- Historically, OHTN was seen 10% of OHTN patients convert to quently diagnosed with an extreme as a relatively benign condition glaucoma. Although IOP reduction degree of ocular hypertension that could predispose patients to imparted about a 60% reduced risk

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of conversion to glaucoma, the makes the calculated risk dubi- study results did not imply that ous at best. all patients with borderline or Practitioners often wonder elevated IOP should receive about a “magic number”— an medication, but that clinicians IOP measurement above which should consider initiating treatment should always be treatment for individuals with initiated. No such concept has OHTN who are at moderate any scientific validity. Most or high risk for developing experienced glaucoma practi- POAG.1 tioners have differing opinions Subsequent analysis of and trying to standardize treat- that data attempted to iden- ment in this manner indepen- tify patients who would be a dent of CCT, age, optic disc greater risk of converting to appearance, systemic health glaucoma. It found that older and numerous other factors baseline age, larger vertical oversimplifies OHTN and may and horizontal cup-disc ratio, put patients at risk of under- or greater visual field pattern overtreatment. standard deviation values, For those who demand a and greater IOP levels were “magic number,” look to the good predictors for the onset Ocular hypertension patients usually have visual fields design of OHTS.9 Eligibility of POAG in the OHTS.2 The with normal sensitivity and variability only slightly required that IOP be less than research also shows lower cen- higher than in normal subjects. 32mm Hg. Patients with IOP tral corneal thickness (CCT) is at or above 32mm Hg were a powerful POAG predictor.2 Balancing Parameters excluded, not for any scientific rea- A European study of OHTN While we have learned a great deal son, but likely due to the designers’ found similar results and the pooled from OHTS, the information pro- discomfort at possibly randomizing data from these two studies have led vides only general guidelines and eyes with this IOP level to observa- to the development of risk calcula- leaves many questions unanswered. tion. Hence, for those who demand tors to estimate the five-year risk of Thanks to this research, clinicians an absolute number, OHTS indicat- developing POAG and are useful now have risk calculators that can ed 32mm Hg to be the peak.9 for clinicians and patients in guiding help assess the five-year risk of con- management plans.2-4 Most experi- version from OHTN to POAG read- Targeting Treatment enced glaucoma clinicians recom- ily available online.7,8 Old wisdom suggests that doctors mend treatment when the calculated However, these risk calculators should treat elevated IOP if for no risk of glaucoma conversion exceeds must be used accurately. They are other reason than to prevent a reti- 15% for longer than five years. only useful for patients with OHTN nal vascular occlusion (RVO). This After a median of 7.5 years with- (and not pre-existing glaucoma) practice goes against much of what out treatment, the original OHTS within a specific IOP range (22mm we learned from the OHTS regard- observation group received medica- Hg to 32mm Hg). The calculators ing lowering IOP in ocular hyper- tion for a median of 5.5 years to have not been validated in patients tensive eyes to prevent glaucoma determine any problems from delay- younger than 30 years or older than formation. Do we really want to ing treatment. At a median follow- 80 years. Secondary conditions caus- lower IOP in every ocular hyper- up of 13 years, researchers saw little ing IOP elevation, such as pigment tensive eye due to fear of RVO? absolute benefit of early treatment dispersion, exfoliation or uveitis The most definitive answer to in individuals with OHTN at low are not part of the assessment. Fur- the question of prophylaxis against risk of developing POAG.5,6 Clini- thermore, accurate data in terms of RVO comes from a subsequent cians need to consider the patient’s several IOP measurements, CCT and publication from OHTS. In this age, health status, life expectancy visual field parameters need to be subanalysis, researchers noted and personal preferences when mak- entered, which can be time consum- that 26 RVOs occurred in 23 par- ing treatment decisions.5,6 ing. Deviating from these parameters ticipants (15 in the observation

86 REVIEW OF OPTOMETRY AUGUST 15, 2020 group and eight in the medica- diagnosis and not once saw a con- 1. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hypertension Treatment Study: a randomized trial determines tion group).10 They saw that the current RVO in any eye. In patients that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol. 10-year cumulative incidence of for whom I have seen POAG and 2002;120(6):701-13. RVO was 2.1% in the observation RVO concurrently, they have 2. Gordon MO, Beiser JA, Brandt JD, et al. The Ocular Hypertension Treatment Study: baseline factors that predict group with untreated ocular hyper- almost been exclusively in eyes with the onset of primary open-angle glaucoma. Arch Ophthalmol. tension and 1.4% in the medication well-treated IOP levels. As such, I 2002;120(6):714-20. 3. Miglior S, Pfeiffer N, Torri V, et al. European Glaucoma group.10 Although the incidence of don’t consider the fear of RVO in Prevention Study (EGPS) Group. Predictive factors for open- angle glaucoma among patients with ocular hypertension in the RVO was higher in the observation my OHTN decision-making. European Glaucoma Prevention Study. Ophthalmology. 2007 group than the medication group, In the patient described here, Jan;114(1):3-9. 4. Ocular Hypertension Treatment Study Group; European this difference was not statistically very little guidance from controlled Glaucoma Prevention Study Group, Gordon MO, Torri V, 10 Miglior S, Beiser et al. Validated prediction model for the significant. studies helps dictate his manage- development of primary open-angle glaucoma in individuals Based upon this evidence, we ment. His young age and markedly with ocular hypertension. Ophthalmology. 2007;114(1):10-19. 5. Kass MA, Gordon MO, Gao F, et al. Ocular Hypertension cannot justify recommending that elevated IOP exceeded ranges from Treatment Study Group. Delaying treatment of ocular hyperten- ocular hypertension be treated to any study on OHTN. Despite IOP sion: the ocular hypertension treatment study. Arch Ophthal- mol. 2010 Mar;128(3):276-87. protect against RVO. In fact, the in the 50s, his optics discs, RNFL 6. Gordon MO, Kass MA. What we have learned from the 10-year incidence of RVO in ocular and visual field were still normal. ocular hypertension treatment study. Am J Ophthalmol. 2018 May;189:24-7. hypertensive eyes is actually low.10 After a discussion of the risks, 7. Kass M. Ocular Hypertension Treatment Study (OHTS) Calculator. MD+CALC www.mdcalc.com/ocular-hypertension- RVO often occurs concurrent with benefits and the unusual nature of treatment-study-ohts-calculator. Accessed June 10, 2020. OHTN and POAG because they his condition, he was prescribed a 8. Ocular Hypertension Treatment Study. Risk Calculator. ohts. wustl.edu/risk/ as examples. Washington University School of are comorbidities affecting elderly topical prostaglandin analog which Medicine in St. Louis. 2006. Accessed June 10, 2020. patients with vascular diseases. I lowered his IOP to 20mm Hg OD 9. Gordon MO, Kass MA. The Ocular Hypertension Treatment Study: design and baseline description of the participants. Arch have encountered many patients and 18mm Hg OS and he is cur- Ophthalmol. 1999 May;117(5):573-83. 10. Barnett EM, Fantin A, Wilson BS, et al. The incidence of with IOP ranging from 50mm Hg rently being followed at appropri- retinal vein occlusion in the Ocular Hypertension Treatment to greater than 70mm Hg at time of ate intervals. n Study. Ophthalmol. 2010;117(3):484-8.

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REVIEW OF OPTOMETRY AUGUST 15, 2020 Review Classiﬁ eds

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Staff Optometrist Wanted Arinella-Williams Bard Optical is a family owned full-service ŝƐĂŶKƉŚƚŚĂůŵŽůŽŐǇͬKƉƚŽŵĞƚƌǇWƌĂĐƟĐĞŝŶ retail optometric practice with 22 offices (and tŽƌĐĞƐƚĞƌDĂƐƐĂĐŚƵƐĞƩƐ growing) throughout Central Illinois. Bard Optical prides itself on having a progressive We are searching for a skilled Optometrist optometric staff whose foundation is based on one-on-one patient service. We are currently dŚŝƐŝƐĂĨƵůůƟŵĞƉŽƐŝƟŽŶ͘tĞǁŽƵůĚĐŽŶƐŝĚĞƌ Practice Sales • Appraisals • Consulting accepting CV/resumes for Optometrists to join ĂŶĞǆƚĞŶĚĞĚĚĂǇĨŽƵƌĚĂǇǁŽƌŬǁĞĞŬ͘ www.PracticeConsultants.com our medical model optometric practice that DƵƐƚďĞDĂƐƐůŝĐĞŶƐĞĚ͘ includes extended testing. The practice PRACTICESFORSALE includes but is not limited to general optometry, tĞŽīĞƌĂĐŽŵƉĞƟƟǀĞƐĂůĂƌǇ͕ƉĂŝĚǀĂĐĂƟŽŶ͕ contact lenses and geriatric care. Salaried, ĐŽŶƟŶƵŝŶŐĞĚƌĞŝŵďƵƌƐĞŵĞŶƚ͕ŚĞĂůƚŚŝŶƐƵƌ- NATIONWIDE full-time positions are available with excellent ĂŶĐĞ͕ĂŶĚĂďŽŶƵƐƐƚƌƵĐƚƵƌĞŝƐŝŶƉůĂĐĞ Visit us on the Web or call us to learn base compensation and incentive programs and benefits. Some part-time opportunities Please contact: Michele Rickert more about our company and the may also be available. ƌŝĐŬĞƌƚŵŝΛĂŽů͘ĐŽŵ practices we have available. 508 853 2020 x 146 Current positions are available in [email protected] Bloomington/Normal, Decatur/Forsyth, Peoria, Sterling and Canton as we continue to grow with new and established offices. Please email your information to [email protected] or call www.PracticeConsultants.com Mick at 309-693-9540 ext 225. Mailing address if more convenient is: Targeting Optometrists? Bard Optical Attn: Mick Hall, Vice President CLASSIFIED ADVERTISING WORKS KƉƚŽŵĞƚƌǇͲKƉƟĐĂů 8309 N Knoxville Avenue ƵƐǇWƌĂĐƟĐĞĨŽƌ^ĂůĞ Peoria, IL 61615 • JOB OPENINGS • CME PROGRAMS • PRODUCTS & SERVICES • AND MORE... ƌŽǁĂƌĚŽƵŶƚǇ&ůŽƌŝĚĂ Bard Optical is a proud Associate Member of the Illinois Optometric Association. ϮϬϭϵ'ƌŽƐƐΨϵϬϲ͕ϬϯϬ͘ϬϬ Contact us today for classified advertising: www.bardoptical.com Toll free: 888-498-1460 KƉƚŽŵĞƚƌǇWƌĂĐƟĐĞϰ^ĂůĞ͘ĐŽŵ E-mail: [email protected] WƌĂĐƟĐĞĨŽƌ^ĂůĞ Equipment & Supplies ^ŽƵƚŚĞĂƐƚĞƌŶW͘ &ŽƵƌĚĂǇŽƉƚŽŵĞƚƌŝĐƉƌĂĐƟĐĞ ĂŶĚŽĸĐĞďƵŝůĚŝŶŐ͘ &ƵůůƐĐŽƉĞ͘tĞůůĞƋƵŝƉƉĞĚ͘ 'ƌŽƐƐΨϯϬϬŬ͘ Do you have dǁŽĂƉĂƌƚŵĞŶƚƐ Products and ΨϮϮŬĂŶŶƵĂůƌĞŶƚ͘ Services for sale? ZĞƉůǇƚŽ͗ĂƐŚϱϬϬǁΛŐŵĂŝů͘ĐŽŵ CLASSIFIED ADVERTISING WORKS WƌĂĐƟĐĞ&Žƌ^ĂůĞ • JOB OPENINGS ŽůƵŵďƵƐ͕'ĞŽƌŐŝĂ • CME PROGRAMS • PRODUCTS ϮĞǆĂŵƌŽŽŵƐĂŶĚKƉƟĐĂů • AND MORE... dƵƌŶŬĞǇƌĞĂĚǇ͕ĞĂƐǇƚƌĂŶƐŝƟŽŶ Contact us today for classified advertising: ĂůůŽƌƚĞǆƚϳϬϲͲϲϭϱͲϮϳϯϵ Toll free: 888-498-1460 ĨŽƌŵŽƌĞŝŶĨŽƌŵĂƟŽŶ E-mail: [email protected]

Do you have Products and Services for sale? Contact us today for classifi ed advertising. Toll free: 888-498-1460 E-mail: [email protected]

REVIEW OF OPTOMETRY AUGUST 15, 2020 Diagnostic Quiz

It’s Not Your Imagination She said she recently started “seeing spots” and losing vision. We soon learned why. By Andrew S. Gurwood, OD

History dispersion or gross A 65-year-old woman presented to trauma. Intraocular the ophthalmology department as pressures measured 18 an emergency consultation with a OU with Goldmann chief complaint of recently noticed applanation. vision changes “next to her nose” The patient had with new floating spots. She was gonioscopy com- a poor historian, not recalling any pleted OU to rule out ocular or systemic illnesses, and evidence of previous Automated perimetry yielded the field results above. confessed she had not been to a trauma (angle reces- Below are RNFL scans OS and OD. medical or eye doctor “in years.” sion), pseudo or true She reported no ocular or systemic exfoliation syndrome, histories, took no medications and pigment dispersion, denied allergies of any kind. synechial closure or evidence of plateau iris Diagnostic Data and both nerves were Her best entering acuities were photodocumented. 20/30 uncorrected at distance and OCT was completed 20/30 at near with use of a reading to gather information spectacle. There was an afferent regarding optic nerve defect OD; however, color vision fiber layer analysis and was intact with no red desatura- macular vulnerability tion and no brightness comparison zone thickness. Addi- loss. tional history questions The facial Amsler grid uncov- included presence of ered general constriction without sleep apnea, unusual any pathognomonic neurological routine such as yoga, symmetry, OD>OS. Extraocular contact sports or gym- motilities were intact. Refraction nastics and whether was negligible and her near acuity there was ever an epi- improved when her reading addi- sode of blunt trauma or tion was increased to +2.50 DS. blood loss. or information? What would Biomicroscopic exam of the be your diagnosis? What is anterior segment found normal Your Diagnosis the patient’s likely prognosis? structures with no evidence of iri- Does the case presented require To find out, please visit www. tis, rubeosis, exfoliation, pigment any additional tests, history reviewofoptometry.com. n

Retina Quiz Answers (from page 76)—Q1: a, Q2: b, Q3: d, Q4: e, Q5: a

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