REVIEW OF OPTOMETRY ■

The Neuroimaging Dilemma: Should You Scan All Oculomotor Defect Patients?, p .30 VOL. 155 NO. 11 ■

November 15, 2018 www.reviewofoptometry.com NOVEMBER 15, 2018 ■

Lids LID EXAMINATION ■

OCULAR SURFACE

DRY EYE TESTING ■ Cornea HEALTH

• How to Evaluate the Lid and Ocular Surface, p. 34

COMORBIDITIES OF DRY EYE ■ • Point-of-care Tools for Dry Eye, p. 42 • Master the Maze of Artificial Tears, p. 48 Conjunctiva • Simple Strategies for Dry Eye, p. 58 • Comorbidities of Dry Eye, p. 67

DILATION PROTOCOLS

ALSO: The Dilated Exam in the Age of Ultra-widefield Imaging, p. 76

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WO1118_Reichert.indd 3 10/30/18 4:18 PM News Review

IN THE NEWS Oklahoma Rejects Researchers found an independent association between obstructive sleep apnea (OSA) and both hypertension and Big Box Eye Care Type 2 diabetes—and the retinopathy associated with each is also associated ODs were thrilled to see a controversial ballot with OSA, suggesting that patients with initiative voted down. By Bill Kekevian, Senior Editor diabetic retinopathy or retinopathy of hypertension could also be experi- mong the recent election in unsuccessful attempts to bring encing OSA without even realizing it. night’s fervor, as Americans optometric services into its stores. Evidence also suggests a link between Ain red or blue hats rode Oklahoma has a strict “two-door” OSA and two other ocular conditions: the ups and downs of the political policy that requires companies central serous retinopathy and nonarter- tide, optometrists in Oklahoma to entirely separate doctors from itic anterior ischemic optic neuropathy. were celebrating a vote of their their stores. Wong B, Fraser C. Obstructive sleep apnea in neuro- own—not one of an elected repre- In addition to overriding the ophthalmology. J Neuro-Ophthalmol. October 8, 2018. [ePub ahead of print]. sentative, but rather a state ballot state’s board of optometry, the question strung together by retail- text of the question reads that People of Arabic ethnicity have a ers that could have changed eye the measure “does not prohibit high rate of keratoconus (KC), and a care as Oklahomans know it. optometrists and opticians from new study found the highest levels yet The proposal, State Ques- agreeing with retail mercantile documented. Saudi researchers enrolled tion 793, would have stripped establishments to limit their prac- 522 pediatric patients in a prospective the state’s board of the power to tice.” study that noted a KC prevalence of dictate what constitutes a com- This passage, Oklahoma 4.79%, or a ratio of 1:21 patients. These prehensive eye exam, say doctors optometrists feared, could estab- results showed a 95-fold increase in from the state. Optometric and lish a protocol by which patients prevalence vs. earlier studies. Prior other medical groups opposing receive refractive exams with- to this latest study, the highest rate the move eked out a victory when out undergoing a clinical exam. reported was 3.30% (approximately one voters rejected it by a mere 5,589 While Walmart has denied that in 30 patients) in a Lebanese popula- votes, according to newsok.com. accusation, the company did tion. Another study, conducted in Israel, “An extremely close result, but confi rm that their doctors would found a KC prevalence of 3.18%. in the end, the hard work by the not perform some of the surgical Torres Netto EA, Al-Otaibi WM, Hafezi NL, et al. Prevalence Oklahoma Association of Opto- procedures that other optometrists of keratoconus in pediatric patients in Riyadh, Saudi Arabia. Br J Opthalmol. 2018 Oct;102(10):1436-41. metric Physicians, our doctors, in the state can provide under and our friends and colleagues Oklahoma’s broad scope-of-prac- Eyes with tilted disc syndrome (TDS) from across the nation delivered tice laws. are likely to experience a superotem- the result we were hoping for,” “The citizens of Oklahoma said poral shifting of the line of sight, says Oklahoman Nathan Light- no to an out-of-state corporation according analysis of 80 subjects with hizer, OD, a prominent advocate trying to change our state con- TDS and 70 controls. The investigators for the advancement of optometric stitution to benefi t their business say the shift must be accounted for to scope of practice. model,” explains Dr. Lighthizer. prevent decentralization and provide The proposal was backed by a He attributes the victory to op- satisfactory outcomes for refractive and committee that included Walmart, tometrists communicating their multifocal intraocular lens implantation. a retailer that has clashed with concerns directly with patients as Kosekahya P, Sarac O, Koc M, Caglayan M, Hondur optometrists in the state before well as the efforts of the OAOP. G, Cagil N. Shifting of the line of sight in tilted disk syndrome. Eye & Contact Lens 2018;44: S33–S36. NEWS STORIES POST EVERY WEEKDAY MORNING AT www.reviewofoptometry.com/news

4 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

0003_ro1118_news.indd03_ro1118_news.indd 4 111/16/181/16/18 3:583:58 PMPM THE JOURNEY TO IMPROVED VISION STARTS WITH YOU

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References: 1. Alcon sales data on fi le. 2. Wirtitsch MG, Findl O, Menapace R, et al. Eff ect of haptic design on change in axial position after cataract surgery. J Cataract Refract Surg. 2004;30(1):45-51. 3. Visser N, Bauer NJ, Nuijts RM. Toric intraocular lenses: Historical overview, patient selection, IOL calculation, surgical techniques, clinical outcomes, and complications. J Cataract Refract Surg. 2013;39(4):624-637. 4. Potvin R, Kramer BA, Hardten DR, Berdahl JP. Toric intraocular lens orientation and residual refractive astigmatism: An analysis. Clin Ophthalmol. 2016;10:1829-1836. © 2018 Novartis 04/18 US-ODE-18-E-0547a

RO0518_Alcon Acrysof.indd 1 5/3/18 10:22 AM AcrySof® Family of Single-Piece IOLs Important Product Information (AcrySof® UV, AcrySof® IQ, AcrySof® IQ Toric, AcrySof® IQ ReSTOR®, and AcrySof® IQ ReSTOR® News Review For more, visit www.reviewofoptometry.com/news Toric IOLs) CAUTION: Federal law restricts these devices to sale by or on the order of a physician. INDICATION: The family of AcrySof® single-piece intraocular lenses (IOLs) includes AcrySof® UV-absorbing IOLs (“AcrySof® UV”), AcrySof® IQ, AcrySof® IQ Toric ‘Big Data’ Anticipates and AcrySof® IQ ReSTOR® and AcrySof® IQ ReSTOR® Toric IOLs. Each of these IOLs is indicated for visual correction of aphakia in adult patients following cataract surgery. In addition, the AcrySof Toric Myopia Disease Course IOLs are indicated to correct pre-existing corneal astigmatism at the time of cataract surgery. The AcrySof IQ ReSTOR IOLs are for cataract patients Refraction at age 18 could be predicted as early as age 10. with or without presbyopia, who desire increased spectacle independence with a multifocal vision. esearchers in Guangzhou, the prediction is reduced when the All of these IOLs are intended for placement in the capsular bag. WARNINGS/PRECAUTIONS: China have used large-scale targeted prediction time increases. General cautions for all AcrySof® and Rdata analysis from electronic Still, the 95% predicted diopter of AcrySof® UV IOLs: Careful preoperative health records to develop an algo- refraction was within 0.5D to 0.8D evaluation and sound clinical judgment should be used by the surgeon to decide the risk/benefi t ratio rithm that can predict high myopia of the true value at eight years. before implanting any IOL in a patient with any of the onset among Chinese school-aged Large-scale, long-term electronic conditions described in the Directions for Use that children with clinically acceptable medical records and machine learn- accompany each IOL. Caution should be used prior to lens encapsulation to avoid lens decentration or accuracy. They trained and vali- ing algorithms provide unique dislocation. Viscoelastic should be removed from the dated the algorithm using a large opportunities for the development eye at the close of surgery. Additional Cautions real-world dataset. of prediction models for progres- associated with AcrySof® IQ ReSTOR® IOLs: Some patients may experience visual disturbances This study analyzed 687,063 sive diseases. School-age myopia and/or discomfort due to multifocality, especially longitudinal electronic medical is the most prevalent eye disease under dim light conditions. A reduction in contrast records from the largest ophthalmic in the Chinese population and the sensitivity may occur in low light conditions. Visual symptoms may be signifi cant enough that the patient centers in China, and developed researchers note that their work will request explant of the multifocal IOL. Spectacle and validated individualized predic- can help change current approaches independence rates vary with all multifocal IOLs; as tion models for myopia prediction used to manage school myopia by such, some patients may need glasses when reading small print or looking at small objects. Clinical studies based on machine learning tech- pediatric and general ophthalmolo- indicate that posterior capsule opacifi cation (PCO), niques. Researchers believe that gists as well as general practitioners when present, may develop earlier into clinically their algorithm can predict spherical and optometrists, who are often the signifi cant PCO with multifocal IOLs. Additional Cautions associated with AcrySof® IQ equivalent and onset of high myo- fi rst point of care. Toric, AcrySof® UV Toric and ReSTOR® pia at 18 years of age at a clinically Lin H, Long E, Ding X, et al. Prediction of myopia development among Toric IOLs: Optical theory suggests that, high Chinese school-aged children using refraction data from electronic acceptable accuracy as early as 10 medical records: A retrospective, multicentre machine learning study. astigmatic patients (i.e. > 2.5 D) may experience PLOS Medicine. November 6, 2018. [Epub ahead of print]. spatial distortions. Possible toric IOL related factors years old. However, the accuracy of may include residual cylindrical error or axis misalignments. Toric IOLs should not be implanted if the posterior capsule is ruptured, if the zonules are damaged, or if a primary posterior capsulotomy is FDA Updates CyPass Protocol planned. Rotation can reduce astigmatic correction; if necessary lens repositioning should occur as eriodically evaluate patients implanted during cataract surgery, early as possible prior to lens encapsulation. Prior to surgery, physicians should provide prospective implanted with the CyPass compared with patients who under- patients with a copy of the appropriate Patient P(Alcon) stent for potential went cataract surgery alone. Information Brochure available from Alcon informing endothelial cell loss, says advice “Eye care providers should them of possible risks and benefi ts associated with the AcrySof® IQ Toric, AcrySof® IQ ReSTOR® and issued by the FDA. Specifi cally, look evaluate all patients with CyPass to AcrySof® IQ ReSTOR® Toric IOLs. Do not resterilize. at endothelial cell density using assess device positioning by visual- Do not store at temperatures over 45° C. Use only specular microscopy until the rate ization of the number of retention sterile irrigating solutions to rinse or soak IOLs. ATTENTION: Refer to the Directions for Use labeling of loss stabilizes. rings visible on the proximal end for the specifi c IOL for a complete list of indications, Alcon voluntarily withdrew of the device. Patients with two or warnings and precautions. the product in August after it was more rings visible upon examina- connected to potential eye damage. tion should be evaluated for endo- The company became aware of thelial cell loss as soon as possible,” the issue when a fi ve-year study’s the FDA’s statement notes. Surgeons results showed statistically signifi - have also been advised to discontin- cant endothelial cell loss in patient’s ue implanting the device and return who received the device, which is it to the company.

© 2018 Novartis 04/18 US-ODE-18-E-0547a

0003_ro1118_news.indd03_ro1118_news.indd 6 111/16/181/16/18 3:583:58 PMPM RO0618_Menicon.indd 1 5/25/18 10:20 AM News Review For more, visit www.reviewofoptometry.com/news More Evidence Links OPP to POAG he complex pressure gra- The study enrolled 9,877 partic- SOPP levels, suggesting a “U- dients in the eye are easily ipants (19,587 eyes), including 213 shaped” association between SOPP Tdisrupted, potentially predis- POAG cases (293 eyes). Research- and POAG. “Third, low SBP was posing a patient to primary open- ers found eyes with the lowest lev- also associated with POAG and angle glaucoma (POAG). Low els of systolic OPP (<110mm Hg) this effect was especially more pro- systolic ocular perfusion pressure were 1.85x more likely to have nounced among eyes with ocular (SOPP) may be associated with the POAG compared with eyes with hypertension, further indicating condition, and this association may mid-range levels (123-137mm Hg). that identifi cation of concurrent be secondary to low systolic blood Investigators consistently found low SBP and ocular hypertension pressure (SBP) and high intraocu- the lowest quartile of systolic BP may also be a useful approach in lar pressure (IOP), according to a (<12 mm Hg) was 1.69x more stratifying POAG risk group,” the new study published in the British likely to have POAG compared researchers wrote in their paper. Journal of Ophthalmology. with mid-range SBP levels (138- They concluded, “To date, this Researchers in Singapore inves- 153mm Hg). Also, researchers is the fi rst population-based study tigated the relationship between noted the effect of lower SBP on which comprehensively demon- POAG and ocular perfusion pres- POAG was more pronounced in strated that the effect of OPP sure (OPP), blood pressure (BP), eyes with IOP ≥21mm Hg. surrogates on POAG was in part and IOP profi les in this population- In contrast with previous stud- secondary to either high IOP or based sample of nearly 10,000 ies, mean ocular perfusion pressure low SBP. Our fi ndings collectively Asian individuals from three ethnic and diastolic OPP were not associ- provided additional clarity on the groups in Singapore: Malays, Indi- ated with glaucoma after adjusting roles of OPP surrogates and BP ans and Chinese. Participants were for relevant confounders and IOP, profi les in POAG.” recruited from the Singapore Epi- researchers said. Investigators also Tham YC, Lim SH, Gupta P, et al. Inter-relationship between demiology of Eye Diseases Study reported both low and high levels ocular perfusion pressure, blood pressure, intraocular pres- sure profi les and primary open-angle glaucoma: the Singa- and underwent standardized ocular of SOPP were associated with pore Epidemiology of Eye Diseases study. Br J Ophthalmol. and systemic examinations. POAG compared with mid-range 2018 Oct;102(10):1402-06. Small-particle Air Pollution May Increase IOP

mbient black carbon exposure may be a risk They found the association of black carbon with IOP factor for increased intraocular pressure (IOP) in was greater in individuals with a high oxidative stress Aindividuals susceptible to other biological oxida- allelic score. When patients with high or low oxidative tive stressors. The results of a recent study may point stress allelic risk scores were compared, the study de- to the potential need to broaden the factors considered tected a moderate difference in mean IOP (0.73mm Hg) when evaluating and managing elevated IOP. for an increase in one year of black carbon exposure. Researchers investigated the association of long- The team is interested in whether their fi ndings persist term ambient black carbon (a byproduct of combus- in more diverse populations experiencing greater pollu- tion processes) exposure with intraocular pressure in tion and in study designs that can demonstrate causality. community-dwelling older adults. The effort used data If future studies substantiate their association, integrated from the Normative Aging Study of the US Department initiatives—combining environmental improvement, of Veterans Affairs, an analysis that included 419 older socioeconomic outreach and targeted pharmaceutical men based in New England with a total of 911 follow- interventions—may prove useful for future policy or up visits. Of those exams, 57.1% had a high endothelial public health initiatives aimed at addressing eye disease.

function allelic risk score, 70.7% had a high metal-pro- Nwanaji-Enwerem JC, Wang W, Nwanaji-Enwerem O, et al. Association of long-term ambient cessing allelic risk score and 68.4% had a high oxidative black carbon exposure and oxidative stress allelic variants with intraocular pressure in older stress allelic risk score. men. JAMA Ophthalmol. November 8, 2018. [Epub ahead of print].

8 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

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RO1018_Kala.indd 1 10/1/18 2:35 PM News Review For more, visit www.reviewofoptometry.com/news Post-Cataract Pain Masquerades as Dry Eye

f a patient complains of nagging naire Five (DEQ-5) score greater insomnia medications. PPP patients dry eye symptoms months after than six and those without PPP also reported more frequent use of Icataract surgery, their real diag- with a DEQ-5 score of less than six, artifi cial tears, higher ocular pain nosis could be persistent postsurgical half a year following the procedure. levels and greater neuropathic ocular pain (PPP), a new study suggests. The average age of the participants pain symptoms, specifi cally burning, A group of Miami researchers was 73. wind sensitivity and light sensitivity. found PPP in the form of persistent Based on the results of the “Dry eye symptoms are classi- dry eye–like symptoms was present DEQ-5, 41 individuals reported cally believed to arise because of a in approximately 34% of individu- having PPP (34%) and 78 individu- disturbance in either the tear fi lm or als six months after cataract surgery. als reported having no symptoms. the orbital structures that give rise Additionally, the study found the Researchers noted the frequency of to or interact with the tear fi lm, but frequency of PPP after cataract sur- severe PPP was 18% (22 people). recent consensus has highlighted gery mirrored other post-procedure Investigators found most medical a concomitant role of neurogenic periods, including laser refractive comorbidities and medications were stress and ocular surface infl amma- surgery, dental implants and genito- not associated with an increased risk tion,” the researchers wrote in their urinary procedures, which suggests of PPP. However, they found indi- paper. “Dense innervation of the cataract surgery could be classifi ed viduals with an autoimmune disease cornea and the known corneal nerve as a medium-risk procedure. such as rheumatoid arthritis, sys- injury that occurs at a surgical inci- Since the cornea is among the temic lupus, Sjögren’s, polymyalgia sion likely form the backdrop for the most densely innervated tissues in rheumatica or multiple sclerosis had development of PPP after cataract the body, investigators sought to an increased risk of PPP. Patients surgery.” fi nd out whether PPP occurred after who had pain disorders—head- Symptom management after ocular procedures. Researchers con- ache, migraine, lower back pain or cataract surgery may focus on mini- ducted phone interviews with 119 fi bromyalgia—were also more prone mizing ocular surface nerve dam- individuals who had cataract sur- to PPP. And for those patients who age by careful surgical dissection, gery performed by a single surgeon had dry eye issues before cataract pre-surgical treatment of modifi able at the Bascom Palmer Eye Institute. surgery, their risk also increased. comorbid risk factors like anxiety, Investigators did the interviews Patients at a greater risk of PPP and perioperative pain control, the six months following the surgery were female, had an autoimmune study noted. and placed the participants in two or non-ocular chronic pain disorder Sajnani R, Raia S, Gibbons A, et al. Epidemiology of persistent groups: patients with postsurgical or used antihistamines, anti-refl ux postsurgical pain manifesting as dry eye-like symptoms after pain who had a Dry Eye Question- medication, antidepressants or anti- cataract surgery. Cornea. 2018 Dec;37(12):1535-41. Iron Supplements Linked to Retinal Hemorrhage on-anemic patients with VEGF treatments for neovascular In AMD patients, iron supple- neovascular age-related AMD. Among 1,165 participants, ments may interact with genetics to Nmacular degeneration baseline retinal/subretinal hemor- damage vascular endothelial cells, (AMD) who take oral iron supple- rhage was present in the study eye the authors propose. Researchers ments may be at risk of retinal/ in 71% of 181 iron users and in believe further investigations should subretinal hemorrhage. Particularly 61% of 984 participants without help elucidate the mechanisms of among those with hypertension, the iron use. The significant association iron and complement dysregulation association was dose-dependent. was strongest among those taking in retinal pigment epithelium and A recent study investigated the as- an iron dose of 18mg to 36mg. The retinal vascular endothelial cells. sociation among participants in the association also remained signifi cant Song, D, Ying GS, Dunaief JL, et al. Association between oral iron supplementation and retinal or subretinal hemorrhage in Comparison of AMD Treatments among hypertensive participants the comparison of age-related macular degeneration treatments trial, a multicenter study of anti- without anemia. trials. Retina. August 28, 2018. [Epub ahead of print].

10 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

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RP1118_BL Loteprednol.indd 1 10/23/18 10:42 AM Contents OCULAR SURFACE HEALTH Review of Optometry November 15, 2018 Checking Under the Hood: How to 34 Evaluate the Lid and Ocular Surface Recognizing minor signs of underlying ocular surface or lid disease requires a thorough evaluation. Here’s a guide to a comprehensive exam of the ocular surface. BY MARLON J. DEMERITT, OD, AND BEATA I. LEWANDOWSKA, OD

Familiarize Yourself with 42 Point-of-care Tools for Dry Eye A plethora of new tools are rewriting the anterior segment disease monitoring protocol. BY SUZANNE SHERMAN, OD, AND FIZA SHUJA, OD Master the Maze 48 of Artificial Tears Having so many choices can be overwhelming, but knowing what each one offers can help you steer patients in the right direction. BY MEAGHAN HORTON, OD, MATT HORTON, OD, AND ERIC REINHARD, OD

Dry Eye Therapy: 58 Keeping it Simple Not everything you recommend has to cost a fortune. These low- budget tricks can help patients combat dry eye and stay on budget. BY BARBARA CAFFERY, OD, PhD

OF OPTO EW ME VI T E R Earn 2 CE Credits: R Y 67 Dry Eye Disease: Know Your Comorbidities Dry, irritated eyes can be one of the trickiest clinical findings. These systemic associations may be the key. BY CECELIA KOETTING, OD

ALSO INSIDE

The Dilated Exam in the Age of Ultra-widefield Imaging The technology’s pros and cons have made it a hot topic in recent years. Here’s where it currently stands in clinical practice. BY HEIDI WAGNER, OD, MPH

PAGE 76

REVIEW OF OPTOMETRY NOVEMBER 15, 2018 13

013_ro1118_toc.indd 13 11/19/18 11:08 AM Departments Review of Optometry November 15, 2018

4 News Review 18 Outlook The Revolution that Wasn’t JACK PERSICO BUSINESS OFFICES 20 Through My Eyes 11 CAMPUS BLVD., SUITE 100 Hiding in Plain Sight NEWTOWN SQUARE, PA 19073 PAUL M. KARPECKI, OD CEO, INFORMATION SERVICES GROUP MARC FERRARA 22 Chairside (212) 274-7062 • [email protected] Wanted: An Eye For Business PUBLISHER MONTGOMERY VICKERS, OD JAMES HENNE 24 (610) 492-1017 • [email protected] 24 Clinical Quandaries REGIONAL SALES MANAGER Widefield Tech Not a Solo Act MICHELE BARRETT PAUL C. AJAMIAN, OD (610) 492-1014 • [email protected]

REGIONAL SALES MANAGER 26 Coding Connection MICHAEL HOSTER Take on Point-of-care Testing (610) 492-1028 • [email protected] JOHN RUMPAKIS, OD, MBA, VICE PRESIDENT, OPERATIONS CLINICAL CODING EDITOR CASEY FOSTER (610) 492-1007 • [email protected]

28 The Essentials VICE PRESIDENT, CLINICAL CONTENT Why SVP Matters PAUL M. KARPECKI, OD, FAAO MARC B. TAUB, OD, MS, AND [email protected] PAUL HARRIS, OD PRODUCTION MANAGER SCOTT TOBIN 30 Neuro Clinic (610) 492-1011 • [email protected] The Neuroimaging Dilemma 30 SENIOR CIRCULATION MANAGER MICHAEL TROTTINI, OD, AND HAMILTON MAHER MICHAEL DELGIODICE, OD (212) 219-7870 • [email protected]

CLASSIFIED ADVERTISING 84 Cornea + Contact Lens Q&A (888) 498-1460 Breaking Down Resistance JOSEPH P. SHOVLIN, OD SUBSCRIPTIONS $56 A YEAR, $88 (US) IN CANADA, $209 (US) IN ALL OTHER COUNTRIES. 87 Ocular Surface Review The Many Methods of MGD SUBSCRIPTION INQUIRIES PAUL M. KARPECKI, OD (877) 529-1746 (US ONLY) OUTSIDE US CALL: (845) 267-3065

91 Urgent Care CIRCULATION Hydrops it Like it’s Hot PO BOX 81 AZINDA MORROW, OD, AND CONGERS, NY 10920 TEL: (TOLL FREE): (877) 529-1746 RICHARD MANGAN, OD OUTSIDE US: (845) 267-3065 95 Review of Systems 84 ION: Low Pressure, High Risk CARLO J. PELINO, OD, AND JOSEPH J. PIZZIMENTI, OD CEO, INFORMATION SERVICES GROUP MARC FERRARA

99 Retina Quiz SENIOR VICE PRESIDENT, OPERATIONS A Hazy, Shaded Vision JEFF LEVITZ MARK T. DUNBAR, OD VICE PRESIDENT, HUMAN RESOURCES TAMMY GARCIA 101 Classifieds VICE PRESIDENT, CREATIVE SERVICES & PRODUCTION 105 Meetings + Conference MONICA TETTAMANZI CORPORATE PRODUCTION DIRECTOR 105 Advertisers Index JOHN ANTHONY CAGGIANO VICE PRESIDENT, CIRCULATION 106 Diagnostic Quiz EMELDA BAREA Not Fade Away 106 ANDREW S. GURWOOD, OD

14 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

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Crystal Brimer Wilmington, NC OD, FAAO

RO1118_Dry Eye Institute.indd 1 11/1/18 1:59 PM CONTRIBUTING EDITORS PAUL C. AJAMIAN, OD, ATLANTA DRY EYE DISEASE: AARON BRONNER, OD, KENNEWICK, WASH. MILE BRUJIC, OD, BOWLING GREEN, OHIO NOT ONLY A MEDICAL DEREK N. CUNNINGHAM, OD, AUSTIN, TEXAS MARK T. DUNBAR, OD, MIAMI CONDITION, BUT A ARTHUR B. EPSTEIN, OD, PHOENIX JAMES L. FANELLI, OD, WILMINGTON, NC QUALITY-OF-LIFE CONDITION! FRANK FONTANA, OD, ST. LOUIS GARY S. GERBER, OD, HAWTHORNE, NJ ANDREW S. GURWOOD, OD, PHILADELPHIA ALAN G. KABAT, OD, MEMPHIS, TENN. DAVID KADING, OD, SEATTLE PAUL M. KARPECKI, OD, LEXINGTON, KY. JEROME A. LEGERTON, OD, MBA, SAN DIEGO JASON R. MILLER, OD, MBA, POWELL, OHIO CHERYL G. MURPHY, OD, BABYLON, NY CARLO J. PELINO, OD, JENKINTOWN, PA. JOSEPH PIZZIMENTI, OD, FORT LAUDERDALE, FLA. JOHN RUMPAKIS, OD, MBA, PORTLAND, ORE. DIANA L. SHECHTMAN, OD, FORT LAUDERDALE, FLA. JEROME SHERMAN, OD, NEW YORK JOSEPH P. SHOVLIN, OD, SCRANTON, PA. JOSEPH W. SOWKA, OD, FORT LAUDERDALE, FLA. MONTGOMERY VICKERS, OD, ST. ALBANS, W.VA. “I love long bike WALTER O. WHITLEY, OD, MBA, VIRGINIA BEACH, VA. rides off the beaten path. Eye drops EDITORIAL REVIEW BOARD limited my freedom. JEFFREY R. ANSHEL, OD, ENCINITAS, CALIF. Occlusion Therapy JILL AUTRY, OD, RPH, HOUSTON not only relieved my SHERRY J. BASS, OD, NEW YORK dry eye symptoms, EDWARD S. BENNETT, OD, ST. LOUIS but eliminated the MARC R. BLOOMENSTEIN, OD, SCOTTSDALE, ARIZ. need for eye drops. CHRIS J. CAKANAC, OD, MURRYSVILLE, PA. JERRY CAVALLERANO, OD, PHD, BOSTON The back country 1 WALTER L. CHOATE, OD, MADISON, TENN. is mine again!” BRIAN CHOU, OD, SAN DIEGO A. PAUL CHOUS, MA, OD, TACOMA, WASH. ROBERT M. COLE, III, OD, BRIDGETON, NJ GLENN S. CORBIN, OD, WYOMISSING, PA. ANTHONY S. DIECIDUE, OD, STROUDSBURG, PA. S. BARRY EIDEN, OD, DEERFIELD, ILL. STEVEN FERRUCCI, OD, SEPULVEDA, CALIF. MURRAY FINGERET, OD, HEWLETT, NY IAN BEN GADDIE, OD, LOUISVILLE, KY. PAUL HARRIS, OD, MEMPHIS, TN MILTON HOM, OD, AZUSA, CALIF. BLAIR B. LONSBERRY, MS, OD, MED, PORTLAND, ORE. ® THOMAS L. LEWIS, OD, PHD, PHILADELPHIA VisiPlugs and DOMINICK MAINO, OD, MED, CHICAGO KELLY A. MALLOY, OD, PHILADELPHIA LacriPro® Punctum Plugs: RICHARD B. MANGAN, OD, LEXINGTON, KY. RON MELTON, OD, CHARLOTTE, NC For all your PAMELA J. MILLER, OD, JD, HIGHLAND, CALIF. BRUCE MUCHNICK, OD, COATESVILLE, PA. MARC MYERS, OD, COATESVILLE, PA. dry eye patients! WILLIAM B. POTTER, OD, FREEHOLD, NJ CHRISTOPHER J. QUINN, OD, ISELIN, NJ MICHAEL C. RADOIU, OD, STAUNTON, VA. MOHAMMAD RAFIEETARY, OD, MEMPHIS, TN JOHN L. SCHACHET, OD, ENGLEWOOD, COLO. JACK SCHAEFFER, OD, BIRMINGHAM, ALA. LEO P. SEMES, OD, BIRMINGHAM, ALA. LEONID SKORIN, JR., OD, DO, ROCHESTER, MINN. JOSEPH W. SOWKA, OD, FORT LAUDERDALE, FLA. SRUTHI SRINIVASAN, PhD, BS OPTOM, WATERLOO, ONT. BRAD M. SUTTON, OD, INDIANAPOLIS LORETTA B. SZCZOTKA, OD, PHD, CLEVELAND MARC TAUB, OD, MEMPHIS, TN (800) 367-8327 TAMMY P. THAN, MS, OD, BIRMINGHAM, ALA. E-mail: [email protected] RANDALL THOMAS, OD, CONCORD, NC www.lacrimedics.com SARA WEIDMAYER, OD, ANN ARBOR, MI KATHY C. WILLIAMS, OD, SEATTLE KAREN YEUNG, OD, LOS ANGELES 1Dramatization. Not a real patient. ©2017 Lacrimedics, Inc.

013_ro1118_toc.indd 17 070_ro0918_F5.indd 76 11/19/18 11:09 AM 9/10/18 12:07 PM Outlook By Jack Persico, Editor-in-Chief PRINTED IN USA

FOUNDING EDITOR, FREDERICK BOGER 1891-1913 EDITORIAL OFFICES The Revolution that Wasn’t 11 CAMPUS BLVD., SUITE 100 NEWTOWN SQUARE, PA 19073 Expect artificial intelligence to come to optometry

SUBSCRIPTION INQUIRIES 1-877-529-1746 gradually. In fact, it’s already here. CONTINUING EDUCATION INQUIRIES 1-800-825-4696 t’s tempting to be weary of arti- real-time interaction between doctor

EDITOR-IN-CHIEF • JACK PERSICO ficial intelligence (AI) discussions and patient decreases. While some (610) 492-1006 • [email protected] right now. As it’s one of the domi- doctors may find this troublesome, MANAGING EDITOR • REBECCA HEPP I (610) 492-1005 • [email protected] nant topics whenever anyone talks others see it as liberating. It “can cre- SENIOR EDITOR • BILL KEKEVIAN about the future of health care, we’re ate an environment that improves (610) 492-1003 • [email protected] possibly at the saturation point where outcomes and provides more care for ASSOCIATE EDITOR • CATHERINE MANTHORP (610) 492-1043 • [email protected] people get a little fed up hearing more individuals—the right place, ASSOCIATE EDITOR • MARK DE LEON about the utopia—or, depending on the right care, the right time,” said (610) 492-1021 • [email protected] the speaker, doomsday—it will bring. Anthony Cavallerano, OD, in his talk SPECIAL PROJECTS MANAGER • JILL HOFFMAN (610) 492-1037 • [email protected] I propose a more modest view: AI’s on telemedicine during the plenary ART DIRECTOR • JARED ARAUJO effect will be unobtrusive, imperfect session of the recent American Acad- (610) 492-1032 • [email protected] and kind of annoying. Think C-3PO, emy of Optometry annual meeting. DIRECTOR OF CE ADMINISTRATION • REGINA COMBS (212) 274-7160 • [email protected] not HAL-9000. But again, this will happen incremen- People sometimes assume AI is tally, not overnight. EDITORIAL BOARD CHIEF CLINICAL EDITOR • PAUL M. KARPECKI, OD going to happen in a radical and A previous speaker at the plenary, ASSOCIATE CLINICAL EDITORS • JOSEPH P. SHOVLIN, OD; practice-changing way all at once— Ezekiel Emanuel, MD, PhD, noted ALAN G. KABAT, OD; CHRISTINE W. SINDT, OD boom, one day the computers will do that health care is decentralizing away DIRECTOR OPTOMETRIC PROGRAMS • ARTHUR EPSTEIN, OD CLINICAL & EDUCATION CONFERENCE ADVISOR all the work and doctors will just be from hospitals and doctors’ offices PAUL M. KARPECKI, OD clerks. Fact is, you’ve been using AI and out into the communities, includ- CASE REPORTS COORDINATOR • ANDREW S. GURWOOD, OD for years without quite realizing it. ing chains like CVS and Walmart. CLINICAL CODING EDITOR • JOHN RUMPAKIS, OD, MBA If you have an OCT, the normative This ‘retail medicine’ has been alarm- CONSULTING EDITOR • FRANK FONTANA, OD databases in those devices are an early ing to some, but Dr. Emanuel said it COLUMNISTS form of AI. And the reliability indices helps people with chronic diseases CHAIRSIDE • MONTGOMERY VICKERS, OD on automated perimeters have been work their healthcare needs into their CLINICAL QUANDARIES • PAUL C. AJAMIAN, OD CODING CONNECTION • JOHN RUMPAKIS, OD giving eye doctors a helping hand for everyday lives. With a telemedicine CORNEA & CONTACT LENS Q+A • JOSEPH P. SHOVLIN, OD far longer than that. link back to a qualified doctor, this DIAGNOSTIC QUIZ • ANDREW S. GURWOOD, OD Expect AI integration to continue ‘bring the mountain to Mohammed’ THE ESSENTIALS • BISANT A. LABIB, OD along established and familiar vec- approach stands to be a net positive. FOCUS ON REFRACTION • MARC TAUB, OD; tors like those. The next wave of AI Dr. Cavallerano noted that one the PAUL HARRIS, OD GLAUCOMA GRAND ROUNDS • JAMES L. FANELLI, OD will enter your office by way of a biggest proponents of television in its NEURO CLINIC • MICHAEL TROTTINI, OD; perfunctory software download, not earliest days was RCA. Maybe that’s MICHAEL DELGIODICE, OD a battering ram to the door. Topcon not surprising, until you learn that the OCULAR SURFACE REVIEW • PAUL M. KARPECKI, OD RETINA DILEMMAS • DIANA L. SHECHTMAN, OD; just bought a small company that acronym stands for Radio Corpora- JAY M. HAYNIE, OD specializes in using AI for diagnostic tion of America. The company in RETINA QUIZ • MARK T. DUNBAR, OD purposes, most notably diabetic reti- control of the dominant medium of REVIEW OF SYSTEMS • CARLO J. PELINO, OD; JOSEPH J. PIZZIMENTI, OD nopathy screening, and will be adding communication was eager to move to SURGICAL MINUTE • DEREK N. CUNNINGHAM, OD; those capabilities to its imaging prod- the next big thing, and ushered it in. WALTER O. WHITLEY, OD, MBA uct lines at some point. The message: don’t fear the future, THERAPEUTIC REVIEW • JOSEPH W. SOWKA, OD; ALAN G. KABAT, OD AI’s future is inevitably going to help invent it yourself. THROUGH MY EYES • PAUL M. KARPECKI, OD linked with that of telemedicine, too. Because all intelligence—human URGENT CARE • RICHARD B. MANGAN, OD As computers get better at scanning and otherwise—is fallible, doctors’ large datasets for anomalies they can expertise will always remain the JOBSON MEDICAL INFORMATION LLC then apply prospectively to patient linchpin. AI will help you be a better screenings, the need for face-to-face doctor, not an unemployed one. ■

18 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

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RP0918_Keeler Trade.indd 1 8/22/18 11:28 AM Through My Eyes

Hiding in Plain Sight Dry eye patients are everywhere—and yet, too often we fail to get them identified and treated. By Paul M. Karpecki, OD, Chief Clinical Editor

ere in the US, where I see a solution in point-of-care New devices specifically for MGD approximately 30 million (POC) testing. In our field—where include LipiFlow for thermal pulsa- Hpeople live with dry eye dis- a single tear sample could identify tion, iLux for thermal expression ease (DED) each day, and perhaps as allergic conjunctivitis, adenovirus or and Blephex for blepharoexfoliation. few as 1.5 million of those are being an array of other systemic diseases These preventative care solutions actively treated, we need to ask our- without needing to draw blood can even help patients avoid contact selves what causes so many sufferers or conduct invasive exams—POC lens intolerance and dropout. to fall through the cracks. Though testing truly presents a way to In prescription DED therapy, a many issues contribute to that gap, accomplish more in less time than new 0.09% concentration of cyclo- to me the answer comes down to conventional methods of diagnosis. sporine, Cequa (Sun Pharma), has diagnosis. A wide swathe of condi- I’d even say that without POC test- recently come to market; other new tions promote dry eye—and an even ing, I could not run my clinic. cyclosporines are anticipated. bigger swathe masquerades as it. If osmolarity testing in one Although treating DED requires Known masqueraders include tri- of these patients falls between us to treat the inflammation with geminal dysphoria, fixation dispar- 280mOsmol/L and 295mOsmol/L drugs such as lifitegrast, cyclospo- ity, convergence insufficiency, GPC, in each eye and within 8mOsmol/L rine, corticosteroids or omega fatty conjunctival concretions, allergic between the two eyes, meibomian acids, palliative care between dosing conjunctivitis, epithelial basement gland expression shows normal to has an important role, too. membrane dystrophies, mucin fish- mildly turbid meibum and there are Systane Complete is a new for- ing syndrome, conjunctivochalasis, only subtle corneal signs like mild mulation containing more HP Guar several forms of blepharitis, contact inferior staining, they’ve most likely than Systane Balance but with the lens solution reactions, pingeuculi- been misdiagnosed. Meanwhile, comfort of Systane Ultra. The new tis, pterygia, exposure keratopathy, high osmolarity values or high dis- TheraTears Xtra contains trehalose medicamentosa, limbal stem cell cordance between the eyes tells me to protect cellular structures and deficiency, Salzmann’s nodular to strongly suspect dry eye. Other provide for greater water bind- degeneration, floppy eyelid syn- POC tests, like tear film testing of ing. And, lastly, Lumify for dry eye drome, episcleritis, superior limbic matrix metalloproteinase-9, can help patients with injection is the first keratoconjunctivitis and others. hone the DED diagnosis. redness remover that works on the Whew! That’s quite a list. I truly veins as opposed to constricting believe the ultimate achievement of a Only Half the Battle the arteries, an older concept that doctor who focuses on dry eye is the Of course, once DED patients are caused ischemia and led to rebound ability to differentiate it from condi- identified, they need interventions. hyperemia and tachyphylaxis. tions that clearly sound like dry eye There are many new treatment but don’t behave like it. Each day options worthy of review. The point is, although DED is in clinic, I encounter many patients As 86% of all DED involves mei- complex and patient care can be who complain of dry, gritty, burn- bomian gland dysfunction (MGD), tricky, an abundance of advances ing eyes, sometimes accompanied it’s safe to start with treating the lids. simplify both diagnosis and manage- by redness and/or fluctuating vision. In today’s digital world, we are hold- ment. We can finally give patients Symptoms, signs, systemic health ing a fixed gaze and blinking less. the attention they deserve. ■ and history can all vary widely. It As a result, we see more meibomian Note: Dr. Karpecki consults for makes it hard to even find a starting gland dysfunction, exposure, evapo- a number of manufacturers with point. ration and a build-up of biofilm. products relevant to this topic.

20 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

020_ro1118_TME.indd 20 11/14/18 2:25 PM RO1118_FocusLabs.indd 1 10/26/18 12:30 PM Chair Side

Wanted: An Eye For Business I feel bad for all of you who thought knowing how to perform a refraction was the key to optometry. By Montgomery Vickers, OD

y now we all know if you but do I make a good point? Why face another patient whose progres- give everyone a raise or hire would someone with a doctorate in sive adds drive everyone crazy. Now, Bnew employees, business will optometry offer a free exam if you that is a business plan! plummet before the ink dries on the buy glasses next door? One business I know, I know. There are plenty contract. If you decide things are class would have saved their soul. of optometrists who do great in pri- good enough to get the family out of Now that I think about it, we did vate practice. In fact, probably the town for a week or two, cash flow have a business class in school and worst optometrist in America still will decline at least twice as long as it was taught by a well-respected has a nice car and is a member of you and the crew were lollygagging and successful private practice the country club. I guess that could at the beach. Oh, and you know if OD. During the two-hour class, he be because he doesn’t really prac- you buy a new car, suddenly every- showed slides of his very success- tice optometry and drives for Uber. one wants to get their glasses online. ful practice. There were at least 20 The point is, he has a Doctor of Why? Well, either Satan runs your slides of his bathroom. It was quite Optometry and is doing just fine. business or God has an unusual nice and the toilet paper appeared Also, I know optometrists who sense of humor. Either way, my to be of excellent quality. His décor have MBAs. This additional finan- advice is to stay calm and, if all else was velvety and filled with Japanese cial training gives them not only the fails, fire everyone. As soon as you tapestries, Ming vase wannabees ability to accurately analyze every are grossly understaffed, business and various Samurai swords. facet of their small business, but will explode. Soon your office will I guess I should have decorated also another diploma to hang on be full of patients who would love to my office more like his. the wall. They never hang Samurai buy stuff from you, if you only had swords on their office walls—makes someone in the office who actually Filling the Void it too easy to commit harakiri when knew how to post a check. There are, of course, business their checkbooks don’t balance. courses offered at CE meetings, Remember: fire everyone and The Missing Link mostly sponsored by labs and other watch the phones Handling these ups and downs is vendors. The extremely engaging explode! ■ the crux of running a successful speaker assures you that if you buy small business—one thing we were the stuff produced by the sponsor- never taught in school, even though ing labs and vendors, your business it’s probably more important in will be healthy and growing. The optometry than all the dials on a speaker’s own speaking business phoropter. Of course, if our profes- will be healthy and sors actually knew anything about growing too, running a successful small business as they will they wouldn’t be professors, right? never have I am sorry if any professors took to offense to that. Those of you who have successfully run a small busi- ness can reach out and I’ll apologize to both of you. And selling quilted glasses cases on Etsy does not count. Am I being too harsh? Maybe,

22 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

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RP0118_Akon Zioptan.indd 1 12/19/17 2:42 PM Clinical Quandaries

Widefield Tech Not a Solo Act Don’t get complacent with ultra-wide imaging alone; remember to dilate and avoid trouble. Edited by Paul C. Ajamian, OD Q I don’t dilate my patients much The macular chorioretinal scars were anymore due to ultra-wide prominent and easily noted. non-dilated photography. Is this the standard of care and am I at risk of The Appropriate Standard missing something? Both patients and doctors have “Although widefield reasons to avoid dilation. Patients A photography is a useful dislike the examination process and screening tool, it has limitations,” the resultant blurred vision and light says Robert Vandervort, OD, of sensitivity. Doctors would sometimes Heartland Eye Consultants in rather not interrupt a packed sched- Omaha, NE. He suggests that ule by convincing patients of the periodic dilated fundus examinations value of dilation and the additional should always be performed in exam procedures needed to examine addition to any widefield screening. the fundus. Dr. Vandervort notes that, while While Dr. Vandervort agree sthat the technology is improving, practitioners should be considerate widefield imaging remains a of a patient’s wishes and comfort, he screening tool that frequently does still recommends periodic dilation to not allow proper examination of avoid missing important and vision the peripheral fundus, especially in threatening findings. Widefield pho- the superior and inferior portions The standard fundus photo (below) tos can be used in between dilated of the retina. In addition, the lower was able to detect a superior retinal examinations, he adds. magnification of widefield imaging detachment that UWI (top) did not catch. “Just like any test we do, wide- reduces its value in assessing the field imaging has value when subtle signs of vascular disease or any vision loss or any visual symp- appropriately balanced as part of early glaucomatous cupping. toms. Interestingly, while performing the traditional examination tech- On the other hand, the technol- a dilated fundus examination of the niques and tools we have available ogy does provide the doctor with a right eye with BIO, he detected a to us,” Dr. Vandervort explains. stable image to review and, many superior retinal detachment (RD) Overreliance on widefield imaging, times, picks up problems that might with a pigment demarcation line in and using it as a substitute for a have been missed with a binocular addition to the chorioretinal atrophy thorough dilated fundus examina- indirect ophthalmoscope (BIO) or in the macula the referring doctor tion, can lead doctors into trouble. 90D fundus lens. However, it is not noted. Dr. Vandervort referred the Dilation is the still the standard an outright replacement for a dilated patient to a local retina specialist for of care, especially in higher risk fundus examination with binocular treatment with laser retinopexy. patients. Dr. Vandervort advises that indirect ophthalmoscopy. Analyzing the widefield images patients often have more than one sent to him, Dr. Vandervort noted condition —meaning that if they A Thorough Look that the inferior and superior retinal present with a red eye, don’t forget A patient was referred to Dr. images provided limited views due to to examine the fundus. “When you Vandervort’s office after a routine interference from the eyelashes and need a thorough examination of the eye examination for evaluation of a narrow palpebral fissure width. retina, there is no substitute for dila- chorioretinal atrophy in the macula. This caused the retinal detachment tion by a capable and experienced The patient was asymptomatic for to be obscured and go unnoticed. clinician,” he adds. ■

24 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

024_ro1118_CQ.indd 24 11/14/18 1:33 PM RO1118_Bruder.indd 1 11/2/18 9:27 AM Coding Connection

Take on Point-of-care Testing Follow the proper certification steps and benefit from its impact on clincial outcomes. By John Rumpakis, OD, MBA, Clinical Coding Editor ecause our health care sys- and, second, one of the doctors that may or may not be within your tem rewards quality of care must be designated and approved state’s scope of practice. Keep in Brather than quantity of care, as a clinical lab director. To do this, mind that while the patient may be it underscores the importance of you must apply with the Centers for able to stick their own finger for the early and accurate diagnosis of clini- Medicare and Medicaid Services to blood sample, you may not be. If cal conditions. Using point-of-care get your CLIA certification.1 This you are, this collection is described (POC) testing helps us counteract certification is absolutely critical. with CPT code 36415 (routine this issue. Lab tests are paid from a national venipuncture) and pays about $3. POC testing is becoming more laboratory fee schedule and do not It is important to realize that prevalent in the average optometric follow the RBRVS reimbursement quantifying and interpreting the practice as technology improves and model. The codes are designated results in the medical record— weaves its way into our daily clinical in the 8XXXX range in the CPT. should you have to defend them— regimen. Much of the POC testing Additionally, you can only perform is an important part of the clinical we do today concerns the anterior tests that have the “waived” regimen. There should always be surface, specifically TearLab osmo- designation and carry the –QW signs, symptoms, complaints or a larity testing, AdenoPlus (Quidel), modifier designation. personal history of disease recorded InflammaDry (Quidel) and Sjö For testing both eyes and coding in the medical record that would (Bausch + Lomb). The number of for them, include two lines. The prompt your testing and establish tests and type of testing for condi- claim form looks like the following: medical necessity for point-of- tions, such as macular degeneration, • 8XXXX-QW-LT care tests performed. There are Sjögren’s syndrome and diabetes, • 8XXXX-QW-RT no limitations on the quantity of continue to increase as new entries Tests that we typically perform in tests that you can perform in a come to market. our practice are: clinical episode of care, but the TearLab—83861-QW number should be reasonable Getting Started (Microfluidic analysis utilizing an and demonstrate that the testing POC testing is easy and important integrated collection and analysis influenced your clinical decision- to incorporate into your daily device, tear osmolarity) making. routine; however, there are some AdenoPlus—87809-QW basics to understand before (Infectious agent antigen detection Delivering better outcomes by deciding to test, code and bill. In by immunoassay with direct optical incorporating testing that allows order to incorporate this simple yet observation; adenovirus) us to diagnose earlier and treat important aspect of clinical care into InflammaDry—83516-QW with greater specificity is vitally your practice, you must be familiar (Immunoassay for analyte other important in today’s healthcare and accredited with your Clinical than infectious agent antibody or environment. Incorporating point- Lab Improvement Amendments infectious agent antigen; qualita- of-care testing allows you to be able (CLIA) certification. tive or semiquantitative, multiple to do so in an efficient and effective Assuming that performing CLIA- step method) manner. ■ waived tests are within your scope Send questions and comments to of practice, you must do two things Covering Your Bases [email protected]. before you can perform and get However, not all POC testing reimbursed for CLIA-waived tests. is clinical or requires CLIA 1. Clinical laboratory improvement amendments (CLIA) application for certification. Centers for Medicare and Medicaid First, your office must be designated certification. Tests for Sjögren’s and Services. www.cms.gov/Medicare/CMS-Forms/CMS-Forms/ as a CLIA-approved laboratory, diabetes require collection of blood Downloads/CMS116.pdf. Accessed November 1, 2018.

26 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

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RO1118_Eyevance.indd 1 11/1/18 11:06 AM The EssentialsEssentials

Why SVP Matters In medicine as in life, it’s good to be spontaneous. By Bisant A. Labib, OD he evaluation of the optic Because portions of the ON and nerve is an essential part of central retinal vein are exposed Tany ocular health examina- to the subarachnoid space before tion. The structure and integrity traversing the lamina cribrosa, the of the neuroretinal rim must be pressure difference between the assessed, as well as the presence of subarachnoid space and intraocu- adequate optic nerve perfusion. The lar space gives rise to the SVP—in presence or absence of distinct disc essence, the SVP is a physical margins is noted as it is an essential manifestation of this pressure dif- clue in determining the etiology of ference.2,3 disc swelling and/or suspected pap- Typically, the intraocular pressure illedema. is greater than the intracranial CSF Frequently, the optometrist is pressure. However, when there is faced with very subtle findings and is Optic nerve swelling secondary to a rise in intracranial CSF pressure forced to decide whether these repre- increased intracranial pressure with such that it equates to the intraocu- sent normal variations or something loss of SVP. lar pulse pressure, the SVP ceases that warrants an emergent workup to occur. This is because there is no and referral. In such cases, the most With the exception of the intra- longer a pressure gradient to pro- helpful element of the examination ocular segment, the entirety of the duce the venous pulsation.2,4 This is the presence or absence of a spon- ON is surrounded by the same fact makes SVP an essential com- taneous venous pulse (SVP). meningeal layers as the brain—pia, ponent in the evaluation of patients arachnoid and dura. Furthermore, with suspected papilledema second- Clues in the Anatomy the subarachnoid space of the brain ary to increased intracranial pres- To understand the clinical and physi- is contiguous with the subarachnoid sure—the documentation of an SVP ologic importance of the SVP, it is space around the ON. Finally, it is will often rule out papilledema. important to recall the course of important to remember that the cen- Since only 80% to 90% of nor- the optic nerve (ON). The ON runs tral retinal vein and artery enter the mal, healthy eyes will exhibit SVP, from the retina towards the optic intraorbital segment of the ON and its absence does not necessarily chiasm and is classified into four continue towards the retina. indicate an underlying pathological segments. The first is the intraocular Because of these anatomic orien- condition.2,5 An SVP may be absent segment, which measures only 1mm tations, the ON and central retinal in healthy patients due to certain in length and is evident on routine vein are exposed to, and influenced optic disc configurations in which funduscopic examinations at the by, changes in intracranial cerebro- the pulsating retinal vein may be level of the lamina cribrosa. The spinal fluid (CSF) pressure.1 obscured by overlying retinal arter- ON continues on as the intraorbital ies or glial tissue as it enters the segment, which measures 20mm to What are SVPs? cup.4,6,7 Additional congenital varia- 30mm and extends from the poste- The phenomenon is defined as tions, wherein the veins enter the rior globe to the orbital apex. Next rhythmic pulsations occurring in optic disc peripherally instead of is the intracanalicular segment (4mm the retinal vein(s) as they cross the centrally in a shallow cup, may also to 9mm), which travels within the optic disc.2 These pulsations are obscure visibility.4 bony optic canal. Finally, the intra- synchronized with the patient’s car- Even in patients with disc swell- cranial segment (10mm) extends diac cycle, with the venous caliber ing that is not secondary to a rise from the optic canal to the optic steadily narrowing during systole in intracranial pressure, an SVP chiasm.1 and expanding with diastole.2-4 may be difficult to observe due to

28 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

028_ro1118_Essentials.indd 28 11/14/18 1:40 PM the local mechanical compression ing. The best way to check for an be a harbinger of underlying intra- of the superficial veins.4 Because of SVP is to use the direct ophthalmo- cranial pathology in the setting of these normal variants and special scope, as it offers 15x magnification suspected papilledema. Furthermore, cases, the absence of an SVP in and to best visualize the vessels through loss of a SVP may also indicate of itself is not particularly helpful. a dilated eye.2 worsening glaucoma, possibly sug- Rather, the presence of an SVP or A great deal of emphasis has been gesting the need for more aggressive the loss of a previously documented placed on the significance of SVPs in management. ■ SVP proves of the greatest clinical cases of suspected papilledema, but 1. Gala F. Magnetic resonance imaging of optic nerve. Indian J value in suspicious cases. they also play a role in glaucoma, Radiol Imaging. 2015;25(4): 421–438. where SVPs are present in only 54% 2. Jacks AS, Miller NR. Spontaneous retinal venous pulsation: Clinical Relevance of patients.7,8 The subset of glau- aetiology and significance. J Neurol Neurosurg Psychiatry. 2003;74:7-9. SVPs are often crucial in the man- coma patients most affected by a 3. Kim M, Ji Lee E, Seo Je, et al. Relationship of Spontaneous agement of patients with subtle disc loss of SVP is normotensive, as they Retinal Vein Pulsation with Ocular Circulatory Cycle. PLoS ONE. 2014;9(5):1-5. elevation in determining the need have been shown to have alterations 4. Lascaratos G, Ahmed S, Madill S. Spontaneous venous for an emergent workup to exclude in ocular and systemic perfusion and pulsation and its role in differentiating papilledema from pseu- 8 dopapilledema. Neurology. 2010:e53-e54. a pathological manifestation of blood flow velocities. Preliminary 5. Morgan WH, et al. Retinal Vein Pulsation is in Phase with intracranial disease. As such, the eye studies suggest that the loss of an Intracranial Pressure and Not Intraocular Pressure. Physiology and Pharmacology. 2012;53:4676-4681. care provider should be comfortable SVP may serve as a marker for glau- 6. Donelly SJ, Subramanian PS. Relationship of Intraocular 8 and skilled in looking for this subtle coma severity and progression. Pulse Pressure and Spontaneous Venous Pulsations. finding as part of a routine ocular Although a subtle finding, a SVP 2009;147(1):51-55. 7. Morgan WH, et al. Intraocular Pressure Reduction is health assessment, to either aid in can be a very telling sign and should Associated with Reduced Venous Pulsation Pressure. PLOS ruling out disease processes or to be documented on routine ocular ONE. 2016:1-9. 8. Pinto LA, et al. Lack of spontaneous venous pulsation: document its presence or absence in health assessments. The loss of a possible risk indicator in normal tension glaucoma? Acta healthy patients for future monitor- previously documented SVP may Ophthalmologica. 2012;91:514-520.

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028_ro1118_Essentials.indd 29 11/14/18 1:41 PM Neuro Clinic

The Neuroimaging Dilemma Progress and proper detection can offer early diagnosis and other benefits. By Michael Trottini, OD, and Michael DelGiodice, OD

any have debated whether In ambiguous cases, it is vital that a all acute isolated ocular neuroradiologist interprets the study Mmotor cranial neuropa- before one discounts an aneurysm. thies in patients older than 50 with or without vascular factors should Fourth Nerve Palsy undergo neuroimaging. While con- The most common causes of fourth ventional wisdom demonstrates nerve palsy (FNP) are congenital, that isolated third, fourth and sixth traumatic and vasculopathic. cranial neuropathies are a frequent While the etiology of truly cause of presumed microvascular isolated FNP in older patients is ischemia, identifiable causes of non- often vasculopathic, many report microvascular mononeuropathies Three dark lesions within the frontal- isolated palsies as manifestations have ranged from 1% to 15%.1-3 parietal-occipital region represents of midbrain hemorrhages, pituitary Based on these findings, some edema from ischemia in a patient with macroadenoma, posterior fossa authors offer evidence to suggest acute, isolated SNP. tumors, dural fistulas, schwannomas the clinical rationale for imaging all and cavernomas.9-17 acute isolated third, fourth and sixth of patients with aneurysmal TNP A small number of isolated FNP nerve palsies. and in up to 50% with presumed cases were identified as having microvascular cause. Aneurysms a trochlear nerve schwannoma, Third Nerve Palsy are likely to affect pupillo-motor as well as etiologies which The third nerve’s two major func- fibers in complete TNP but spare included cavernous meningioma, tions are oculomotor and pupillo- its function in superior division intra-cavernous carotid artery motor. Both partial and complete palsies.6 Conversely, up to 20% of aneurysm and a carotid-cavernous third nerve palsy (TNP) can be a patients with microvascular TNP fistula.13,18,19,20 While it may be manifestation of presumed ischemia may have pupil involvement, with reasonable to observe truly isolated in the setting of diabetes, hyperten- anisocoria of 1.5mm or less.6 The cases, one might miss an important sion and more serious pathology.4 relative incidence of aneurysm as a lesion, especially if the patient were Common pathologies involving the cause of isolated TNP ranged from to develop additional neurologic oculomotor nerve include ischemic 14% to 56%.7,8 While evidence sup- symptoms. We recommend that and hemorrhagic infarctions, aneu- ports observation in acute, complete, contrast-enhanced MRI of the brain rysm, cavernous malformation and isolated TNP without pupil involve- be obtained, with attention to the demyelinating disease.5 ment, numerous cases implicate cavernous sinus. Knowing which cases require midbrain strokes, neoplasms, infec- neuroimaging can be thought- tions, vasculitis, pituitary apoplexy Sixth Nerve Palsy provoking, as many have debated and carotid artery occlusion. Sixth nerve palsy (SNP) is the which cases need emergent testing. Our recommendation is to obtain most common ocular motor nerve TNP can be differentiated as either an emergent neuroimaging with palsy.21 The etiology of SNP is partial or complete and pupil- computed tomography (CT) com- most often attributed to ischemia; sparing or pupil-involving. While puted tomography angiography however, a brain MRI is not acute headache and TNP may sug- (CTA) or magnetic resonance imag- routinely performed in all patients. gest an ominous cause, cases report ing (MRI)/ magnetic resonance angi- Non-microvascular causes of co-involvement in as few as 30% ography (MRA) in all cases of TNP. SNP may include: demyelinating

30 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

030_ro1118_Neuro.indd 30 11/14/18 2:31 PM THE LFA-1 ANTAGONIIST THAT’S FIRST IN ITS CLASS As the only lymphocyte function-associated antigen-1 (LFA-1) antagonist available for Dry Eye Disease, Xiidra is in a class of its own1,2

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

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

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RRO1118_Shire.inddO1118_Shire.indd 1 111/1/181/1/18 11:4311:43 AMAM VGUVGFOIMIFC[ HQNFVJGJWOCPRNCUOCGZRQUWTGCV the recommended human ophthalmic dose [RHOD], based on VJGCTGCWPFGTVJGEWTXG=#7%?NGXGN 5KPEGJWOCPU[UVGOKE GZRQUWTGVQNKƂVGITCUVHQNNQYKPIQEWNCTCFOKPKUVTCVKQPQH:KKFTC Rx Only CVVJG4*1&KUNQYVJGCRRNKECDKNKV[QHCPKOCNƂPFKPIUVQVJG risk of Xiidra use in humans during pregnancy is unclear. Animal Data BRIEF SUMMARY: .KƂVGITCUVCFOKPKUVGTGFFCKN[D[KPVTCXGPQWU +8 KPLGEVKQP Consult the Full Prescribing Information for complete product VQTCVUHTQORTGOCVKPIVJTQWIJIGUVCVKQPFC[ECWUGF information. an increase in mean preimplantation loss and an increased INDICATIONS AND USAGE KPEKFGPEGQHUGXGTCNOKPQTUMGNGVCNCPQOCNKGUCVOIMI Xiidra® NKƂVGITCUVQRJVJCNOKEUQNWVKQP KUKPFKECVGFHQTVJG FC[TGRTGUGPVKPIHQNFVJGJWOCPRNCUOCGZRQUWTGCV VTGCVOGPVQHVJGUKIPUCPFU[ORVQOUQHFT[G[GFKUGCUG &'&  the RHOD of Xiidra, based on AUC. No teratogenicity was QDUGTXGFKPVJGTCVCVOIMIFC[ HQNFVJGJWOCP DOSAGE AND ADMINISTRATION RNCUOCGZRQUWTGCVVJG4*1&DCUGFQP#7% +PVJGTCDDKV Instill one drop of Xiidra twice daily (approximately 12 hours an increased incidence of omphalocele was observed at the CRCTV KPVQGCEJG[GWUKPICUKPINGWUGEQPVCKPGT&KUECTF NQYGUVFQUGVGUVGFOIMIFC[ HQNFVJGJWOCPRNCUOC VJGUKPINGWUGEQPVCKPGTKOOGFKCVGN[CHVGTWUKPIKPGCEJG[G GZRQUWTGCVVJG4*1&DCUGFQP#7% YJGPCFOKPKUVGTGFD[ Contact lenses should be removed prior to the administration +8KPLGEVKQPFCKN[HTQOIGUVCVKQPFC[UVJTQWIJ#HGVCN0Q QH:KKFTCCPFOC[DGTGKPUGTVGFOKPWVGUHQNNQYKPI 1DUGTXGF#FXGTUG'HHGEV.GXGN 01#'. YCUPQVKFGPVKƂGFKP administration. the rabbit. CONTRAINDICATIONS Lactation 6JGTGCTGPQFCVCQPVJGRTGUGPEGQHNKƂVGITCUVKPJWOCP Xiidra is contraindicated in patients with known hypersensitivity VQNKƂVGITCUVQTVQCP[QHVJGQVJGTKPITGFKGPVUKPVJG milk, the effects on the breastfed infant, or the effects on milk RTQFWEVKQP*QYGXGTU[UVGOKEGZRQUWTGVQNKƂVGITCUVHTQO formulation. ocular administration is low. The developmental and health ADVERSE REACTIONS DGPGƂVUQHDTGCUVHGGFKPIUJQWNFDGEQPUKFGTGFCNQPIYKVJ Clinical Trials Experience the mother’s clinical need for Xiidra and any potential adverse Because clinical studies are conducted under widely varying effects on the breastfed child from Xiidra. conditions, adverse reaction rates observed in clinical studies Pediatric Use of a drug cannot be directly compared to rates in the clinical 5CHGV[CPFGHƂECE[KPRGFKCVTKERCVKGPVUDGNQYVJGCIGQH VTKCNUQHCPQVJGTFTWICPFOC[PQVTGƃGEVVJGTCVGUQDUGTXGF years have not been established. KPRTCEVKEG+PƂXGENKPKECNUVWFKGUQHFT[G[GFKUGCUGEQPFWEVGF YKVJNKƂVGITCUVQRJVJCNOKEUQNWVKQPRCVKGPVUTGEGKXGFCV Geriatric Use NGCUVFQUGQHNKƂVGITCUV QHYJKEJTGEGKXGFNKƂVGITCUV  No overall differences in safety or effectiveness have been 6JGOCLQTKV[QHRCVKGPVU  JCFŰOQPVJUQHVTGCVOGPV observed between elderly and younger adult patients. GZRQUWTGRCVKGPVUYGTGGZRQUGFVQNKƂVGITCUVHQT NONCLINICAL TOXICOLOGY approximately 12 months. The majority of the treated patients Carcinogenesis, Mutagenesis, Impairment of Fertility YGTGHGOCNG  6JGOQUVEQOOQPCFXGTUGTGCEVKQPU Carcinogenesis: Animal studies have not been conducted TGRQTVGFKPQHRCVKGPVUYGTGKPUVKNNCVKQPUKVGKTTKVCVKQP VQFGVGTOKPGVJGECTEKPQIGPKERQVGPVKCNQHNKƂVGITCUV dysgeusia and reduced visual acuity. Other adverse reactions Mutagenesis: .KƂVGITCUVYCUPQVOWVCIGPKEKPVJGin vitro TGRQTVGFKPVQQHVJGRCVKGPVUYGTGDNWTTGFXKUKQP #OGUCUUC[.KƂVGITCUVYCUPQVENCUVQIGPKEKPVJGin vivo conjunctival hyperemia, eye irritation, headache, increased mouse micronucleus assay. In an in vitro chromosomal lacrimation, eye discharge, eye discomfort, eye pruritus and aberration assay using mammalian cells (Chinese sinusitis. JCOUVGTQXCT[EGNNU NKƂVGITCUVYCURQUKVKXGCVVJGJKIJGUV Postmarketing Experience concentration tested, without metabolic activation. 6JGHQNNQYKPICFXGTUGTGCEVKQPUJCXGDGGPKFGPVKƂGFFWTKPI Impairment of fertility: .KƂVGITCUVCFOKPKUVGTGFCV postapproval use of Xiidra. Because these reactions are KPVTCXGPQWU +8 FQUGUQHWRVQOIMIFC[ reported voluntarily from a population of uncertain size, it is not HQNFVJGJWOCPRNCUOCGZRQUWTGCVVJG always possible to reliably estimate their frequency or establish TGEQOOGPFGFJWOCPQRJVJCNOKEFQUG 4*1& QH a causal relationship to drug exposure. NKƂVGITCUVQRJVJCNOKEUQNWVKQP JCFPQGHHGEVQP Rare cases of hypersensitivity, including anaphylactic reaction, fertility and reproductive performance in male and bronchospasm, respiratory distress, pharyngeal edema, swollen female treated rats. tongue, and urticaria have been reported. Eye swelling and rash have been reported. USE IN SPECIFIC POPULATIONS Pregnancy /CPWHCEVWTGFHQT5JKTG75+PE5JKTG9C[.GZKPIVQP/# There are no available data on Xiidra use in pregnant women to (QTOQTGKPHQTOCVKQPIQVQYYY:KKFTCEQOQTECNN KPHQTOCP[FTWICUUQEKCVGFTKUMU+PVTCXGPQWU +8 CFOKPKUVTCVKQP Marks designated ®CPFvCTGQYPGFD[5JKTGQTCPCHƂNKCVGFEQORCP[ QHNKƂVGITCUVVQRTGIPCPVTCVUHTQORTGOCVKPIVJTQWIJ 5JKTG75+PE5*+4'CPFVJG5JKTG.QIQCTGVTCFGOCTMUQT IGUVCVKQPFC[FKFPQVRTQFWEGVGTCVQIGPKEKV[CVENKPKECNN[ TGIKUVGTGFVTCFGOCTMUQH5JKTG2JCTOCEGWVKECN*QNFKPIU+TGNCPF relevant systemic exposures. Intravenous administration of .KOKVGFQTKVUCHƂNKCVGU NKƂVGITCUVVQRTGIPCPVTCDDKVUFWTKPIQTICPQIGPGUKURTQFWEGF Patented: please see JVVRUYYYUJKTGEQONGICNPQVKEGRTQFWEVRCVGPVU an increased incidence of omphalocele at the lowest dose .CUV/QFKƂGF5

RRO1118_ShireO1118_Shire PPI.inddI.indd 1 111/1/181/1/18 11:5011:50 AMAM Neuro Clinic

disease, metastasis, aneurysm 11% of patients with a significant Neurol 2007;27:257–68. 6. Trobe JD. Managing oculomotor nerve palsy. Arch Ophthal- 22 and intracranial hypertension. etiology, including neoplasm, brain- mol. 1998;116:798-802. However, because hypertension and stem infarct, demyelinating disease 7. Lee AG, Hayman LA, Brazis PW. The evaluation of isolated 28 third nerve palsy revisited: an update on the evolving role of diabetes cause SNP in up to 35% of and pituitary apoplexy. We believe magnetic resonance, computed tomography, and catheter angi- patients, some argue that monthly there is sufficient data for arguing ography. Surv Ophthalmol. 2002;47:137-157. follow ups are the best approach in that all acute cranial nerve palsies 8. Mathew MR, Teasdale E, McFadzean RM. Multidetector com- puted tomographic angiography in isolated third nerve palsy. the absence of associated neurologic undergo imaging, regardless of Ophthalmology. 2008;115(8):1411-15. findings or history of cancer sans the lack of associated neurological 9. Galetta SL, Balcer LJ. Isolated fourth nerve palsy from MRI confirmation.23,24 Additionally, symptoms. midbrain hemorrhage: case report. J Neuroophthalmol. 1998;18:204- 205. research shows the potential for One observational case series 10. Petermann SH, Newman NJ. Pituitary macroadenoma spontaneous recovery of SNP in estimated the proportion of patients manifesting as an isolated fourth nerve palsy. Am J Ophthalmol. 1999;127:235-236. the presence of extramedullary suffering from isolated ocular 11. Krohel GB, Mansour AM, Petersen WL, et al. Isolated troch- compression by a tumor at the base motor nerve palsies from presumed lear nerve palsy secondary to a juvenile pilocytic astrocytoma. J of the brain.25 microvascular ischemia versus other Clin Neuroophthalmol. 1982;2:119-123. 12. Mielke C, Alexander MS, Anand N. Isolated bilateral Published research does not causes by using contrast-enhanced trochlear nerve palsy as the first clinical sign of a metastatic [cor- support observation alone. With MRI of the brain in patients 50 rection of metastasic] bronchial carcinoma. Am J Ophthalmol. the risk of delaying a potential and older with acute isolated third, 2001;132(4):593-4. 13. Selky AK, Purvin VA. Isolated trochlear nerve palsy second- 3 serious intracranial pathology, we fourth and sixth nerve palsies. Due ary to dural carotid-cavernous sinus fistula. J Neuroophthalmol. recommend obtaining an initial to advances in medical and surgical 1994;14:52-54. contrast-enhanced MRI of the brain management, these patients benefit- 14. Feinberg AS, Newman NJ. Schwannoma in patients with isolated unilateral trochlear nerve palsy. Am J Ophthalmol. in those with acute isolated SNP, as ted from early diagnosis. 1999;127:183-188. previous studies have shown a lack Possible exceptions for ordering 15. Maurice-Williams RS. Isolated schwannoma of the fourth cranial nerve: case report. J Neurol Neurosurg Psychiatry. 1989; of diagnostic benefit from computed imaging may include a combination 52:1442-1443.2001;132:593-594. tomography (CT).26 of the following: no insurance cover- 16. Leibovitch I, Pakrou D, Selva D, et al. Neuro-ophthalmic age in patients older than 50 with manifestations of intracranial cavernous hemangiomas. Eur J Ophthalmol. 2006;16:148-152. Discussion isolated fourth or sixth nerve palsies, 17. Surucu O, Sure U, Mittelbronn M, et al. Cavernoma of the With the advent of MRI, it’s now positive vasculopathic risk factors, trochlear nerve. Clin Neurol Neurosurg. 2007;109:791-793. possible to detect small ischemic, low risk medical history and palsies 18. Feinberg AS1, Newman NJ. Schwannoma in patients with isolated unilateral trochlear nerve palsy. Am J Ophthalmol. inflammatory and space-occupying that resolve within three months. 1999;127(2):183-8. lesions that would have been missed 19. Slavin M. Isolated trochlear nerve palsy secondary to cavern- ous sinus meningioma. Am J Ophthalmol. 1987;104:433-4. on CT. Observation seemed reason- Each clinician must know their 20. Arruga J, de Rivas P, Espinet H, Conesa G. Chronic isolated able since much of the past literature threshold for imaging. High quality trochlear nerve palsy produced by intracavernous internal carotid identified a low rate of non-ischemic neuroimaging is now safe, accessible artery aneurysm. J Clin Neuro-ophthalmol. 1991;11:104-8. 2 21. Rosenberg RN. Comprehensive Neurology. New York: Raven causes in isolated neuropathies. and readily available, and withhold- Press, 1991. However, in a review of all MRIs ing a possibly life-saving diagnosis 22. Richards BW, Jones FR, Younge BR. Causes and prognosis in ordered for varying ophthalmologic seems counterintuitive. While a 4,278 cases of paralysis of the oculomotor, trochlear, and abdu- cens cranial nerves. Am J Ophthalmol. 1992;113(5):489–496. pathologies, 28% of patients had “normal” imaging study may seem 23. Patel S. V., Mutyala S., Leske D. A. et al. Incidence, associa- relevant findings, like demyelinating useless, it can provide both a psy- tions, and evaluation of sixth nerve palsy using a population- 27 based method. Ophthalmology. 2004;111:369-75. disease, stroke and metastases. chological and emotional benefit for 24. Moster ML, Savino PJ, Sergott RC, et al. Isolated sixth-nerve Until recently, no well-designed the patient and clinician. ■ palsies in younger adults. Arch Ophthalmol. 1984;102:1328-30. studies or prospective case series 25. Volpe NJ, Lessell S. Remitting sixth nerve palsy in skull base tumors. Arch Opthalmol. 1993;111:1391–5. existed. One study followed patients 1. Patel SV, Mutyala S, Leske DA, et al. Incidence, associations, and evaluation of sixth nerve palsy using a population-based 26. Nolan J. Diplopia. Br J Ophthalmol. 1968; 52:166-71. with acute, non-traumatic, isolated method. Ophthalmology. 2004;111:369–75. 27. Volpe NJ. Socioecomics of neuroimaging in neuroophthal- ocular motor nerve palsies.28 Of 2. Bendszus M, Beck A, Koltzenburg M, et al. MRI in isolated mology. Oral presentation at NANOS Annual Meeting; March 2008; Orlando, FL. collections.lib.utah.edu/details?id=180818& sixth nerve palsies. Neuroradiology.2001;43:742–5. the 66 patients, nine had significant q=identifier_t%3A20080313_nanos_diagnostneuroimagsympo 3. Tamhankar MA, Biousse V, Ying GS, et al. Isolated third, s_01%2A&fd=title_t%2Ccreator_t%2Cdescription_t%2Ciden causes: four patients with third nerve fourth, and sixth cranial nerve palsies from presumed microvas- tifier_t&sort=facet_title_s+asc&facet_setname_s=ehsl_novel_ cular versus other causes: a prospective study. Ophthalmology. palsy, two of which were pupil- nam. Accessed November 1, 2018. 2013; 120(11):2264–2269. involving; one patient with fourth 28. Volpe N. The Work Up of Isolated Ocular Motor Palsy: Who 4. Jacobson DM, McCanna TD, Layde PM. Risk factors to Scan and Why. Oral presentation at NANOS Annual Meeting; nerve palsy and four patients with for ischemic ocular motor nerve palsies. Arch Ophthalmol. February 2009; Lake Tahoe, CA. pdfs.semanticscholar.org/03f sixth nerve palsy. Excluding pupil- 1994;112:961-966. 9/295c3712be8cf794492739c9a2d342122427.pdf. Accessed involving TNP, the study identified 5. Bruce BB, Biousse V, Newman NJ. Third nerve palsies. Semin November 1, 2018.

REVIEW OF OPTOMETRY NOVEMBER 15, 2018 33

0030_ro1118_Neuro.indd30_ro1118_Neuro.indd 3333 111/14/181/14/18 1:441:44 PMPM Lid Exam

Checking Under the Hood: How to Evaluate the Lid and Ocular Surface

Recognizing minor signs of underlying ocular surface or lid disease requires a thorough evaluation. Here’s a guide to a comprehensive exam of the ocular surface. By Marlon J. Demeritt, OD, and Beata I. Lewandowska, OD

he ocular surface is com- prised of the cornea, con- junctiva, eyelids, eyelashes, Ttear film, main and acces- sory lacrimal glands and meibo- mian glands.1 The eyelids play a major role in protecting and spreading the moisture over the ocular surface. The lower eyelid At left, this anterior segment photo depicts severe meibomian gland capping and a supports the tear film, and the small squamous cell papilloma of the eyelid margin. The image on the right shows glands of Zeiss and Moll, as well as cylindrical dandruff around the roots of the lashes. the meibomian glands, secrete lip- ids. The blinking action stimulates pathology, such as papillomas, superior and superotemporal bul- the release of lipids into the tear molluscum contagiosum, herpeti- bar conjunctiva. Blebs created dur- film as well as moves the tear film form vesicles, hordeola or chalazia. ing trabeculectomy will be visible towards the puncta. Any disruption Ask yourself: are the puncta open? superior to the cornea. Evert the in the normal anatomy and physi- While scanning the eyelashes, upper eyelid and scan the superior ology of this system can cause the direct your attention to any greasy palpebral conjunctiva looking for patient to become symptomatic of scales, cylindrical dandruff around foreign bodies, concretions, papil- ocular surface pathology. the roots of the lashes, or dis- lae or hyperemia. charge. Check for any misdirected Ask the patient to look up, so The Grand Tour lashes rubbing against the ocular you can pull down the lower eyelid When scanning the closed eyelids, surface. Ask the patient to look to scan the eyelid margin. Apply pay attention to the epidermis (e.g., down, and while pulling up the pressure to the glands express- peeling, scaling) and dermis (e.g., upper eyelid to scan the eyelid ing the meibum and evaluate the hyperemia, edema, ecchymosis), as margin. Observe the meibomian appearance of the secretion. Pull well as the position of the eyelids to gland orifices and the tissue around down a little farther to examine the rule out entropion and ectropion. them. Note any capping or telan- lower palpebral conjunctiva look- Additionally, be on the lookout for gectasias, as well as any changes in ing for cystic changes, concretions, any lesions that disrupt the proper the normal contour of the eyelid follicles, papillae, hyperemia and anatomy or cause inflammatory margins. Examine the superonasal, foreign bodies. While the patient

34 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

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is still looking upward, scan the inferonasal, inferior and infero- temporal bulbar conjunctiva while asking the patient to change gazes. Scan the nasal canthus then nasal bulbar conjunctiva, for it is not uncommon to note pinguecula and pterygium as you approach the limbus. Scan the temporal bulbar conjunctiva looking for lid-parallel These photos show patients with pinguecula (left) and pterygium (right). conjunctival folds that could indi- cate conjunctivochalasis (CCH). tation, tearing and pain. Trichiasis occur without entropion. Due to Next, proceed to examine the is commonly caused by trachoma, the frictional forces that occur with corneal epithelium, stroma and which can lead to significant cor- blinking, both conditions can cause endothelium, looking for punctate neal scarring. However, trachoma significant punctate erosions on epithelial erosions, limbal neovascu- is uncommon in the United States, the cornea, which may cause the larization, dystrophies and degenera- so cases here are usually deemed patients to present with complaints tions, old scars from foreign bodies, idiopathic or secondary to a trau- of redness, foreign body sensation, trauma, refractive surgery or previ- matic etiology, ocular cicatrical irritation and tearing. ous infections, as well as pannus, pemphigoid, Stevens-Johnson The ocular surface and patho- infiltrates, edema, guttatae, endothe- syndrome, chemical burn or severe logic eyelid findings associated with lial pigment and endothelial folds. blepharitis.4 involutional entropion include lat- It is not uncommon for the signs eral canthal tendon laxity (78%), Lid abnormalities and symptoms of punctate epithe- dry eye (72%), superficial punctate In most countries, life expectancy is lial erosions, along with tearing, keratopathy (62%), lower retrac- increasing, so an expected increase foreign body sensation and redness tor laxity (53%), chronic blepha- in ophthalmic conditions due to to be shared between trichiasis ritis (49%), chronic conjunctivitis involutional changes are expected and entropion. Left untreated, (23%), and medical canthal tendon as well. It is not uncommon to trichiasis may result in serious laxity (15%).3 diagnose involutional entropion or ocular sequelae such as corneal ectropion in middle-aged and older ulcers, punctate keratopathy, abra- Ectropion adults. Although increasing age is sions and scarring.4 The quality On the other hand, during exami- not the sole cause of lid anomalies, of these patients’ vision, as well as nation you may notice an outward such as entropion and ectropion, the ocular surface, can be severely turning of the eyelid (ectropion). involutional changes are deemed impacted in these cases, so it is This has several possible causes, the most common.2 It is not imperative to be aware of misdi- but an age-related or involutional uncommon to find more women rected lashes when evaluating ocu- etiology is the most common. Like to be afflicted with involutional lar health. Because some patients involutional entropion, ectropion entropion than men.3 In addition may be asymptomatic, clinicians has a gender bias as well. Older to involutional causes, entropion must have astute observation skills. males are more likely to be afflicted and ectropion can also stem from a with involutional ectropion.3 cicatricial etiology. Entropion Because of the ectropion, you During the initial assessment of may notice punctate epithelial Trichiasis the ocular health, you may notice erosions secondary to rapid tear This is a condition in which lashes inward turning of the eyelid. If you evaporation and chronic exposure can grow or be misdirected toward do, you must determine if there is of the ocular surface. Ocular the eye. Every time the patient only trichiasis (an inward turning surface and eyelid abnormalities blinks or even rubs their eyes, the of the eyelid margin). associated with involution possibility of the lashes scratch- Entropion always presents with ectropion include lateral canthal ing against the ocular surfaces trichiasis (assuming the patient tendon laxity (80%), dry eye increases. Trichiasis can cause irri- has eyelashes), but trichiasis can (52%), chronic blepharitis (43%),

36 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

034_ro1118_F1.indd 36 11/14/18 1:50 PM Review Group Earn up to Vision Care Education, LLC NEWNEEWTEW TECHNOLOGIEST CHNOLOGIESES 18-28 CE 2019 & TTREATMENTS IN Credits* EyeEy Care Join us for our 2019 MEETINGS FEBRUARY 15-19, 2019 - ASPEN, CO Annual Winter Ophthalmic Conference Westin Snowmass Conference Center Program Co-chairs: Murray Fingeret, OD, and Leo Semes, OD REGISTER ONLINE: www.skivision.com

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prevent disruption of the suspected protective mechanism.10 However, practitioners should remember that punctal plugs and stenosed punctum may be contraindicated in cases of inflammatory-based dry eye disease due to the possibility of exacerbating the condition from Above, this patient has a pink, raised, retained inflammatory cytokines in limbal lesion extending over the cornea the tear film. with tortuous dilated feeder vessels and keratinized central surface plaque. In Blepharitis and Demodicosis addition, corkscrew vessels are seen, Meibomian gland dysfunction giving the lesion a strawberry-like stenosis, practitioners should be (MGD) plays a major role in ocular appearance. The patient at right portrays aware of the possible relationship surface pathology. Terminal duct an opalescent cornea from 7 o’clock to 9 between EPS and long-term use of obstruction and qualitative as well o’clock with feeder vessels. topical anti-glaucoma medications. as quantitative changes in the glan- Because practitioners commonly dular secretion result in altered tear chronic conjunctivitis (40%), lower encounter patients with ectropion, film. retractor laxity (40%).3 they should also be aware of the The spectrum and severity of the relationship between ectropion signs associated with blepharitis Punctal Stenosis and punctal stenosis. It has been depends on the location and the Punctal stenosis may be easy to postulated that the cause of punc- degree of inflammation. In one overlook during the clinical exam— tal stenosis in relationship to lid form of anterior blepharitis, the in fact, if you quickly gloss over ectropion is due to underuse of an skin of the eyelids, the base of the the punctum during your biomi- external punctum unopposed to eyelashes, and the eyelash follicles croscopic exam, stenosed or closed the tear meniscus or secondary to are affected by Staphylococcus, puncta may not even be observed. inflammation.9 leading to scaling, crusting and However, in patients older than 80, Patients with punctal stenosis erythema of the eyelid margin with it is common. may also present with dry eye collarette formation at the base of Clinically, patients are diagnosed disease. Punctal plugs are com- the cilia, which can cause eyelash with dry eye disease due to their monly used in the management loss and corneal punctate epithelial epiphora complaints; however, of patients with dry eye disease. erosions, marginal infiltrates and instilling artificial tears in a patient Clinically, stenosed puncta func- neovascularization. In the sebor- with punctal stenosis only exac- tion similarly to punctal plugs, rheic type of anterior blepharitis, erbates their complaints. In cases so patients, especially the elderly, greasy, foamy scales called scurf such as these, it is best to observe a may benefit from having stenosed surround the bases of the cilia. The stenosed puncta when the patient puncta. One study suggested not patient may also present with signs has complaints of epiphora. Inter- to promote surgical intervention in of both types as well as with co- estingly, punctal stenosis, also cases of punctal stenosis in order to existing meibomianitis.11 known as external punctal stenosis (EPS), results from one of two possible etiologies, acquired and age-related. Acquired causes can be due to topical or systemic medi- cation use, various infections, lid malposition, trauma or tumors.5-7 Age-related changes are mostly due fibrosing of the tissue surrounding the puncta.8 In cases of acquired punctal This patient displays punctal stenosis in both the right (at left) and left eyes.

38 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

034_ro1118_F1.indd 38 11/14/18 1:51 PM In posterior blepharitis, the inflammation affects the meibomian glands and their orifices. Prominent blood vessels crossing the mucocutaneous junction, frothy dis- charge along the eyelid margin, pouting or plugging of meibomian orifices, expression of meibomian secretions that range from turbid fluid to thick, cheese-like mate- rial, thickening and scalloping of the eyelid margin, trichiasis and chalazia may all be observed.11 Ocular demodicosis, characterized by cylindrical dandruff around the root of the eyelashes, is often asso- ciated with blepharitis, chalazia and keratitis.12 Both Demodex follicularum and Demodex brevis can cause chronic and recurrent inflammation of the eyelid mar- gin, as well as trichiasis, distichiasis and madarosis.12 While the larger D. follicularum mites congregate in the hair follicles, the smaller D. brevis mites reside in the sebaceous glands.12 Dry Eye Disease In 2017, the Tear Film & Ocular Surface Society’s ™ International Dry Eye Workshop II set out to create an NuLids evidence-based definition and a contemporary classifi- cation system for dry eye disease.1 As a result, the fol- transformational lowing definition was accepted: “Dry eye is a multifactorial disease of the ocular sur- face characterized by a loss of homeostasis of the tear dry eye therapy film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface Transforms your patients’ lives inflammation and damage, and neurosensory abnor- malities play etiological roles.”1 Finally… A doctor- Clinical signs include diffuse conjunctival hyperemia directed at-home as well as corneal punctate epithelial erosions. Tissue staining with fluorescein, lissamine green or rose bengal treatment for dry eye are clinically beneficial in determination of the severity disease that is safe, of ocular surface dryness. effective and easy Conjunctivochalasis to use. Conjunctival folds, also known as conjunctivochala- A multi-center study1 showed: sis (CCH), are more prevalent in the elderly, and only • 50% decrease in dry eye symptoms increase with age.13-15 Patients with CCH may experi- • ence epiphora or dry eye disease symptoms such as irri- 65% improvement in TBUT tation, burning and foreign body sensation.16-18 • 80% increase in meibomian glands Clinically, you should look for a delayed tear clear- yielding liquid secretions. ance and tear film instability. Due to anatomical obstruction of the punctum by the redundant con- For more information visit junctival folds, destruction of the lacrimal lake and www.NuSightMedical.comÉÀœ«Ì££ Ê impediment of the tear flow by the conjunctival folds, or call us at 833-Î68-5437 the patient may experience delayed tear clearance.19-23 As the flow of tears is impeded, the conjunctival folds 1 Schanzlin, Olkowski, Coble, Gross. NuLids II Study, April 2018 cause instability of the tear film, which can lead to ocu- lar surface inflammation.18,19,24

Doctor prescribed, at-home dry eye relief

034_ro1118_F1.indd 39 11/14/18 1:51 PM Lid Exam

The clinical suspicion of con- junctival folds is confirmed by bio- microscopic examination and use of vital dyes. While examining the anterior segment with the slit lamp, you may find redundant conjunc- tival folds over the inferior eyelid margin, which move with blinking. During your clinical exam, you can change the appearance of the folds based on how you manipulate the Here, a patient shows map-dot-fingerprint dystrophy. eyelids. If you press upward on the lower lid, you’ll notice worsening Another commonly encountered ment of each etiology varies, it is of the folds. Conversely, pulling the finding in the nasal limbal area, imperative for the practitioner to lid away from the globe while the especially in patients exposed to carefully evaluate the ocular surface patient looks up will cause the folds UV radiation, is a pterygium.26 and the cause of damage to the to disappear.18 This wing-like hypertrophy of the surface before initiating treatment. Vital dyes can help the clinician subconjunctival connective tissue Corneal epithelial defects are a fre- further assess the redundant folds and overlying epithelium drags the quent cause of ocular irritation, for- as well as the tear film. Fluorescein conjunctival vessels as it crosses the eign body sensation, tearing, pain, staining will show the classic pre- limbus and approaches the visual redness and, quite possibly, photo- corneal tear film as well as punctate axis. These lesions may be thin phobia. While performing biomi- erosions. Additionally, it will show and flat or elevated and gelatinous. croscopy, the astute clinician may the folds along with the interrupted They may be quiet or inflamed. detect corneal irregularities beneath or decimated tear meniscus. Unlike Stocker’s line, a punctate, brownish the epithelial layer. With the use of dry eye disease where rose bengal subepithelial iron line passing verti- sodium fluorescein, the practitioner and Llssamine green reveal stain- cally in front of the invasive apex may notice negative staining on the ing in the exposure zone of the of the pterygium, may often be cornea, which helps to delineate conjunctiva, these two dyes will observed and is a sign of chronic- the corneal irregularities commonly stain non-exposure zones of the ity.27 Pterygia may induce astigma- associated with epithelial basement conjunctiva as well as detect punc- tism, decrease visual acuity as they membrane dystrophy (EBMD), also tate erosions over the redundant obscure the visual axis, cause symp- known clinically as anterior base- conjunctival folds.18 toms of irritation when inflamed, ment membrane dystrophy or map- and be cosmetically displeasing to dot-fingerprint dystrophy. Pinguecula, Pterygium and the patient. It is not uncommon for the clini- Squamous Neoplasia It is important to examine lim- cian to notice corneal irregularities Approaching the limbus while bal lesions closely to differentiate during biomicroscopy or decreased scanning the nasal and temporal them from ocular surface squamous visual acuity because of a compro- bulbar conjunctiva within the pal- neoplasia (OSSN). A pink, gelati- mised ocular surface. If you suspect pebral fissure, the clinician will nous lesion along the limbus with EBMD, ask the patient if they have often observe a round, yellowish tortuous, dilated feeder vessels and ever had symptoms of recurrent elevation. Pinguecula, which is sometimes with keratinized plaques corneal erosion (RCE), because more commonly found on the nasal on its surface is likely to be a form approximately 10% of EBMD aspect of the limbus, is a condition of OSSN.28 These typically show patients experience symptoms of of abnormal differentiation char- abrupt onset and rapid progression pain or decreased vision secondary acterized by squamous metaplasia may present as opalescence on the to corneal surface irregularity.29,30 with proliferation.25 While the con- cornea or chronic conjunctivitis.28 Ocular surface dryness can have a dition is benign, its presence results tremendous impact on patients with in tear film instability that may lead Ocular Surface Conditions EBMD, as they are highly likely to symptoms of irritation and signs Disruption to the ocular surface has to rub their epithelial surface off of inflammation. various etiologies. Because treat- if they rub their eye aggressively

40 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

034_ro1118_F1.indd 40 11/14/18 1:51 PM NuLids™ transformational or have their epithelial surface adhere to their superior palpebral conjunctival when they open their eyes in the dry eye therapy morning. Because EBMD patients are at increased risk of RCE due to their corneal irregularities, judicious use of artificial tears, lubricating ointment or 5% NaCl Transforms your practice ointment at bedtime may help minimize the risk of ero- sion. ■ The NuLids System helps reduce Dr. Demeritt is an assistant professor at Nova South- patient out-of-pocket expenses eastern University College of Optometry. while creating an additional revenue Dr. Lewandowska is an assistant professor at Nova stream for the practice – all without Southeastern University College of Optometry. impacting overhead costs or 1. Craig J, Nichols K, Akpek E, Et al. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017;15:276-283. disrupting other in-office 2. Hintschich C. Correction of entropion and ectropion. Dev Ophthalmol. 2008;41:85-102. 3. Damasceno R, Osaki M, Dantas P, Belfort R. Involutional entropion and ectropion of the lower treatments. eyelid: prevalence and associated risk factors in the elderly population. Ophthalmic Plast Reconstr Surg. 2011;27(5):317-20. A multi-center study1 showed 95% 4. Choo P. Distichiasis, trichiasis, and entropion: advances in management. Int Ophthalmol Clin. 2002 Spring;42(2):75-87. were satisfied or very satisfied with 5. Seiff S, Shorr N, Adams T. Surgical treatment of punctal canalicular fibrosis from 5 fluorouracil therapy. Cancer. 1985;56(8):2148-9. the treatment. 6. Tabbara, K. F., & Bobb, A. A. (1980). Lacrimal system complications in trachoma. Ophthalmol. 1980;87(4):298-301. 7. Brink H, Beex L. Punctal and canalicular stenosis associated with systemic fluorouracil therapy. For more information visit Documenta Ophthalmologica. 1995;90(1):1-6. 8. Kristan R. Treatment of lacrimal punctal stenosis with a one-snip canaliculotomy and temporary www.NuSightMedical.comÉÀœ«Ì££ punctal plugs. Arch Ophthalmol. 1988;106(7):878-9. 9. Soiberman U, Kakizaki H, Selva D, Leibovitch I. Punctal stenosis: definition, diagnosis, and treat- or call us at 833-Î68-5437 ment. Clin ophthalmol. 2012;6:1011-8. 10. Ulusoy M, Kıvanç S, Atakan M, Akova-Budak B. How important is the etiology in the treatment 1 Schanzlin, Olkowski, Coble, Gross. NuLids II Study, of epiphora? Journal of Ophthalmology. www.hindawi.com/journals/joph/2016/1438376/. 11. American Academy of Ophthalmology (AAO) Cornea/External Disease Preferred Practice Pattern April 2018 Panel. Preferred practice pattern guidelines. Blepharitis. www.aao.org/preferred-practice-pattern/ blepharitis-ppp--2013. October 2013. Accessed October 24, 2018. 12. Luo X, Li J, Chen C, et al. Ocular demodicosis as a potential cause of ocular surface inflamma- tion. Cornea. 2017;36:S9-S14. 13. Hashemi H, Rastad H, Emamian M, Fotouhi A. Conjunctivochalasis and related factors in an adult population of Iran. Eye & contact lens. 2018;44:S206-S209. 14. Watanabe A, Yokoi N, Kinoshita S, et al. Clinicopathologic study of conjunctivochalasis. Cornea. 2004;23(3):294-8. 15. Zhang X, Li Q, Zou H, et al. Assessing the severity of conjunctivochalasis in a senile population: a community-based epidemiology study in Shanghai, China. BMC Public Health. 2011;11(1):198. Doctor prescribed, at-home dry eye relief 16. Balci O. Clinical characteristics of patients with conjunctivochalasis. Clin. Ophthalmol. 2014;8:1655-60. 17. Chhadva P, Alexander A, McClellan A, et al. The impact of conjunctivochalasis on dry eye symp- toms and signs. Invest Ophthalmol Vis Sci. 2015;56(5):2867-71. 18. Meller D, Tseng S. Conjunctivochalasis: literature review and possible pathophysiology. Survey of ophthalmology, 1998;43(3):225-32. 19. Di Pascuale M, Espana E, Kawakita T, Tseng S. Clinical characteristics of conjunctivochalasis with or without aqueous tear deficiency. Bri J Ophthalmol. 2004;88(3):388-92. 20. Erdogan-Poyraz C, Mocan M, Irkec M, Orhan M. Delayed tear clearance in patients with con- junctivochalasis is associated with punctal occlusion. Cornea. 2007;26(3):290-3. 21. Huang Y, Sheha H, Tseng S. Conjunctivochalasis interferes with tear flow from fornix to tear meniscus. Ophthalmol. 2013;120(8):1681-7. 22. Liu D. Conjunctivochalasis. A cause of tearing and its management. Ophthalmic plastic and reconstructive surgery. 1986;2(1):25-8. 23. Prabhasawat P, Tseng S. Frequent association of delayed tear clearance in ocular irritation. Bri J Ophthalmol. 1998;82(6):666-75. 24. Yokoi N, Komuro A, Nishii M, et al. Clinical impact of conjunctivochalasis on the ocular surface. Cornea. 2005;24(8):S24-S31. 25. Dong N, Li W, Lin H, et al. Abnormal epithelial differentiation and tear film alteration in pin- guecula. Invest Ophthalmol Vis Sci. 2009;50(6):2710-5. 26. Moran D, Hollows F. Pterygium and ultraviolet radiation: a positive correlation. Bri J of Ophthal- mol. 1984;68(5):343-6. 27. Hansen A, Norn M. Astigmatism and surface phenomena in pterygium. Acta ophthalmologica. 1980;58(2):174-81. 28. Cicinelli M, Marchese A, Bandello F, Modorati G. Clinical management of ocular surface squamous neoplasia: A review of the current evidence. Ophthalmol Ther. link.springer.com/ article/10.1007/s40123-018-0140-z. July 20, 2018. Accessed October 24, 2018. 29. Waring III G, Rodrigues M, Laibson P. Corneal dystrophies. I. Dystrophies of the epithelium, Bow- man’s layer and stroma. Surv ophthalmol. 1978;23(2):71-122. 30. Werblin T, Hirst L, Stark W, Maumenee I. Prevalence of map-dot-fingerprint changes in the cor- nea. Bri J Ophthalmol. 1981;65(6):401-9.

034_ro1118_F1.indd 41 11/14/18 1:51 PM Diagnostic Testing

Familiarize Yourself with Point-of-care Tools for Dry Eye A plethora of new tools are rewriting the anterior segment disease monitoring protocol. By Suzanne Sherman, OD, and Fiza Shuja, OD

eibomian gland dys- function and tear film insufficiency can severely affect Mthe ocular surface and, if not addressed, can make treatment difficult.1 But any management is dependent upon proper disease identification, which can be tricky with the varied presentations of conditions such as dry eye disease The LipiScan image shows the meibomian glands using near infrared illumination in a (DED), meibomian gland dysfunc- quick, noninvasive, in-office test. tion (MGD), allergic conjunctivitis and viral conjunctivitis. provides a guide on what POC bility and hyperosmolarity, ocular Point-of-care (POC) testing tests are available for patients with surface inflammation and damage, allows diagnostic equipment to ocular surface conditions, when to and neurosensory abnormalities aid the ophthalmic exam and to apply them and how to incorporate play etiological roles.”4 facilitate optimal patient care them into your standard testing Any clinical exam used in con- while reducing patient cost and the protocol to assure your patients junction with POC testing must optometrist’s time.2 These tests, are diagnoses accurately and moni- focus on distinguishing what however, can only help when the tored regularly. amount of their disease is evapora- clinician understands the nature of tive in nature—such as MGD—and these tests and how to use them for Meibomian Glands what amount stems from aqueous best patient care. According to the recent publication deficiency.4 Prior to this recent pub- POC testing provides quick in the 2017 Tear Film and Ocular lication, researchers suggested that diagnosis and rapid treatment.3 Surface Society DEWS II report, these two types of dry eye did not Nevertheless, they are only adjunc- dry eye is “a multifactorial disease overlap, but that thinking has since tive tests meant to complement a of the ocular surface characterized been turned on its head.4 However, clinical exam that includes patient by loss of homeostasis of the tear POC testing can provide the kind history, slit lamp evaluation and film, and accompanied by ocular of information that can guide an dilated fundus exam. This article symptoms, in which tear film insta- optometrist’s next step. One exam-

42 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

042_ro1118_F2.indd 42 11/16/18 11:14 AM ANTARES

The Keratograph 5M (Oculus) is a multi-functional, noninvasive, in-office device that can provides information about meibomian glands and the tear film. It also offers advanced placido ring corneal topography with a built-in real keratometer with a color camera included for external imaging. Corneal Topography & More!

Meibomian Gland ple is the state of the meibomian sources, minimizing reflection and Imaging & Analysis glands. MGD can result in altera- modifying the light intensity across tion of the tear film, symptoms of the surface to compensate for lid eye irritation, clinically apparent thickness variations.5 inflammation and ocular surface The LipiView II (TearScience) disease. Fluorescein staining, tear offers the same high definition break-up time and clinical imaging imaging along with new functions, of the glands will give the practi- including real-time visualization tioner a hint about the root of the of the lipid layer to evaluate the Non-Invasive Tear Film patient’s symptoms. dynamic response of lipids to Break-up Analysis Meibography has become a blinking, noise canceling tech- critical tool in how optometrists nology to measure submicron diagnose and treat MGD. Tools thickness of the lipid layer and like these can help establish the video analysis of blink dynamics. patient’s level of gland atrophy Unlike the LipiScan, the LipiView and help the clinicians determine does not have a screen monitor whether treatments such as a attached. To display the results warm compresses will suffice, or if on a screen for patients, an extra their disease is too far progressed monitor needs to be attached. for that kind of solution. Meibox (Box Medical Solutions) LipiScan (TearScience) pro- is a portable slit-lamp mounted Tear Meniscus Height vides a noninvasive image of the meibographer compatible with glands in 10 seconds. The glands more than 35 slit lamp models. are imaged using near infrared The Meibox offers image pro- illumination from multiple light cessing, which includes dynamic

250 Cooper Ave., Suite 100 Tonawanda NY 14150 www.s4optik.com I 888-224-6012 Sensible equipment. Well made, well priced.

042_ro1118_F2.indd 43 11/16/18 11:14 AM Diagnostic Testing

ment technique with TearLab. Ability to rule out disease Various cut-off values have been Sensitivity (if the test is negative) reported in the literature ranging Test from 305mOsm/L all the way to Specificity Ability to rule out disease 316mOsm/L, as well as a variety of (if the test is positive) sensitivities, specificities and posi- tive predictive values have been Quantitative Qualitative published, which differ from the LipiScan/LipiView manufacturer’s data.4 Expressed Even though we are still learning Descriptions and researching the proper way to numerically Keratograph measure tear osmolarity, TearLab

Observed Meibography Measured Osmolarity System gives us objec- attributes & Meibox tive quantitative measurements properties that allow practitioners to follow appropriate dry eye management These flowcharts are designed to help guide clinicians in the terminology and use of in office. point-of-care tests. Another option to test tear osmolarity is the I-Pen (I-Med images that enhance the outlines of film particle velocity by tracking Pharma). That device employs the meibomian glands. The images the reflective particles in the tear single-use sensors to gather a are stored on cloud-based software film. The Keratograph uses blue sample with approximately two and can be accessed anywhere. The diodes for fluo-images, which can to five seconds of contact with the Meibox can be attached to your be used for documentation of your tear-soaked palpebral conjunctiva, computer via a USB cord. Similar slit lamp fluorescein exam. After rather than a liquid sample as the to LipiScan and LipiView, Meibox the Keratograph has collected this TearLab system uses. This may is technician friendly, and due to its data, it offers a final report that be appropriate for patients with portability, technicians can bring offers visual pie graphs, explana- severe dry eye as it may be difficult the Meibox to the patient, reduc- tions and abbreviations the patient to obtain a tear sample from them. ing chair time. will understand. Once a sample is obtained, the The Keratograph 5M (Oculus) I-Pen measures the electrical imped- provides information about both Osmolarity ance in the tear-soaked tissues and the meibomian glands and the tear Tear osmolarity is the central calculates the osmolarity of the tear film as well as advanced placido pathophysiologic mechanism for film.9 ring corneal topography, with a all forms of dry eye disease.4 It built-in keratometer and a color reduces the ability of mucins to MMP-9 camera included for external imag- lubricate due to inflammation and Usually, dry eye treatment involves ing.6 Its Meibo-Scan software uses cell apoptosis. This ultimately artificial tears and, possibly, punc- infrared light to image the mei- leads to breakdown of homeostatic tal plugs. But if the patient has bomian glands in high definition. control and eventually causes tear an inflammatory component, Tear film dynamics are measured film instability.7 practitioners need to think twice with white light, and a quantitative The Tearlab Tear Osmolarity about plugs and instead consider measurement of the tear meniscus system has 88% specificity and anti-inflammatory agents. The height and the non-invasive tear 75% sensitivity in detecting mild MMP-9 Rapid Pathogen Screening break up time. to moderate dry eye disease, and InflammaDry test (Quidel) is a non- Along with the tear meniscus 95% sensitivity in detecting severe specific measure of the presence of height and non-invasive tear dry eye disease, according to the matrix metalloproteinase-9 (MMP- breakup time, a lipid layer inter- manufacturer.8 The DEWS II sec- 9), an enzyme that is elevated in ference and particle flow assess- tion on tear osmolarity reports dry eye patients.10 MMP-9 testing ment are available. The particle that new questions arise about the should be performed before admin- flow assessment measures the tear variability of the current measure- istering ocular anesthetic, topical

44 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

0042_ro1118_F2.indd42_ro1118_F2.indd 4444 111/16/181/16/18 11:1411:14 AMAM COMBO CHAIRS & STANDS dyes or Schirmer test. Tear samples are collected from the palpebral conjunctiva with a sample collector fleece. When it starts to glisten, this indicates that the sample fleece is saturated. This is then placed within the test cassette with the addition of OptimizeOptimize buffer solution. If there is an MMP-9 antibody- The Meibox produces enhanced images spacespace anandd antigen interaction on the immu- of the meibomian glands that can be noassay test trip, the result window stored on cloud-based software for functionality.functionality. will read positive with two lines access from any location. (one blue and one red) within 10 minutes. This is the qualitative A viral etiology can comprise result (yes or no). According to the 20% to 70% of infectious conjunc- manufacturer, the intensity of the tivitis, with adenovirus compris- red lines should be directly related ing 60% to 90% of the causes.14 to the amount of MMP-9 present.8 Adenovirus can cause pharyngo- The lower detection limit is 40ng/ conjunctival fever, epidemic kera- ml, which means that at 40ng/ml, toconjunctivitis, acute nonspecific 100% of people will see a positive follicular conjunctivitis and chronic result. Between 30ng/ml to 40ng/ml, keratoconjunctivitis.15 Research a significant number of patients will shows misdiagnosis of conjunctivi- be perceived as positive, with more tis is extremely common amongst faint positive lines. A negative result clinicians.15 The similarities in signs will only show a blue line present.8 and symptoms are often to blame Studies suggest that MMP-9 pres- for the incorrect diagnoses, leading ence or absence tell you whether to inappropriate treatment, pro- or not a patient will respond to longing and spreading the disease. treatment with cyclosporine, doxy- It is always important to watch for cycline or steroids, helping reach a the hallmark signs of the disease, more efficient treatment plan with such as serous discharge, chemosis, patients.11,12 pseudomembranes or a follicular reaction.15 Viral conjunctivitis can Viral Infection also be accompanied by preauricu- Conjunctivitis affects approximately lar lymphadenopathy, which clini- six million Americans annually.13 cians can easily test for in-office. Affordable,Affordable, The common presentation and Viral conjunctivitis can take symptom of “red eye” requires cli- longer to culture for a definitive space-savingspace-saving nicians to include conjunctivitis in diagnosis. Laboratory testing for their list of differentials, while also the adenovirus is not commonly cchairhair & standstand making sure to rule out other etiol- used, however, because of the ogies, such as dry eye and uveitis.13 delay in obtaining results; viral cell solutions. Viral conjunctivitis, unlike bacte- culture with confirmatory immu- rial conjunctivitis, can present with nofluorescence assay (CC-IFA) Small footprint varied symptoms that coincide with need to be evaluated over a 14-day 41.2” x 34.2” other diseases, even bacterial or growth period.13 Polymerase chain allergic conjunctivitis.13 A timeline reaction (PCR) is increasingly used of symptoms should be noted in the more often because it has higher patient history to ensure accurate sensitivity than CC-IFA and can diagnosis. produce results in four hours, but

042_ro1118_F2.indd 45 11/16/18 11:14 AM Diagnostic Testing

The IgE-mediated response in the conjunctiva is well documented in allergic conjunctivitis, vernal and atopic keratoconjunctivitis.17 With vernal, there is greater involvement by T-cells, eosinophils and cyto- kines. Atopic keratoconjunctivitis also has T-cell participation, with more TH1-mediated cells. Advanced Tear Diagnostics has produced a microassay test called Tear Scan that can specifically test for IgE and lactoferrin.17 The The Meibox device helps physicians determine the grade of gland drop out in MGD. test checks for total IgE antibod- ies in the tear sample. A 0.5µl tear still requires a laboratory to ana- Allergic Conjunctivitis sample mixed with a diluent is lyze the test sample.14 The difficulty Ocular allergy is an inflamma- placed on the test strip, and after with CC-IFA, PCR and antigen tory disease that affects the ocular approximately three minutes, the testing, such as enzyme immuno- surface. It can be divided into four test results can be evaluated. This assays, is the laboratory service. categories: allergic conjunctivitis is beneficial in obtaining an appro- Most clinicians either do not have (including seasonal and perennial), priate diagnosis for a patient’s labs within their office or do not atopic keratoconjunctivitis (AKC), symptoms, ruling out aqueous dry have access to labs that can deliver vernal keratoconjunctivitis (VKC) eye disease as a potential diagnosis, results as quickly as required for and giant papillary conjunctivitis leading to appropriate treatment. accurate diagnosis. Because these (GPC).15 The latter three are more The second portion of the Tear tests require multiple steps, a CLIA severe forms of the disease. Scan microassay system evaluates waiver cannot be obtained for in- Type 1 hypersensitivity reactions lactoferrin, a protein with anti- office testing. more commonly occur, wherein an bacterial, antiviral, antifungal and There is, however, the FDA offending antigen triggers the allergy antiparasitic properties found in a approved and CLIA waived Adeno- cascade. The early-phase reaction variety of human fluids, including Plus (Quidel). The practitioner occurs with the release of chemi- tears.18 The main lacrimal gland cost is estimated at $105 per box, cal mediators, including histamine, secretes a majority of lactofer- with 10 tests per box. The test uses leukotriene and prostaglandin, into rin, but ocular epithelial cells and immunoassay technology and deliv- the conjunctiva after degranulation meibomian glands are also con- ers results within 10 minutes.13,14 of mast cells.16 This is where mast tributors.18 An average lactoferrin Tear fluid is taken from the inferior cell stabilizers, (e.g., Pataday, Zadi- amount is approximately 1.42mg/ palpebral conjunctiva and placed tor) and antihistamine agents (e.g., ml. Over time, with age and con- onto a sample collector, which is Azelastine, Bepreve, Lastacaft) treat ditions such as dry eye, keratitis transferred to a test strip. The strip the disease process. The late-phase and conjunctivitis, a person’s natu- is dipped into a buffer that allows reaction occurs with the presence of rally produced ocular lactoferrin the antigens to bind to the antibod- eosinophils and type 2 helper cells.16 decreases.19 The loss of lactoferrin ies, resulting in either a positive or This is treated with corticosteroids causes greater susceptibility to negative result. and immunosuppressive agents. infections.19 The Tear Scan micro- Reading the test is also simple Determining the presence of the assay for lactoferrin has a similar because it displays one line for a chemical mediators and cells present protocol to the IgE test.17 A 0.5µl negative result and two lines for in the conjunctiva is key to appro- sample of tear fluid is mixed with a positive result, a similar reading priately treating the disease. The a diluent, shaken and deposited like the ones found in pregnancy need to test for specific biomarkers into a well. The microassay then tests. The process is said to be on the ocular surface aids in identi- measures the amount of lactoferrin. able to identify the 53 serotypes of fying the target area for treatment Any amount lower than 1.4mg/ml adenovirus.13 and improved patient care. is considered abnormal.20

46 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

042_ro1118_F2.indd 46 11/16/18 11:15 AM LCD Visual Acuity System VVA-1A 1 The ability to test for both IgE in complex and medically neces- and lactoferrin in combination sary contact lens fittings and ocular allows for better diagnosis of aque- disease. ous deficient dry eye excluding or Dr. Shuja is an optometrist at including ocular allergy. Being able New York-Presbyterian Hospital.

to diagnose both conditions allows 1. Scott C, Catania L, Larkin K. Care of the patient with ocular for a better approach to treatment surface disorders. American Optometric Association. www.aoa. org/documents/optometrists/CPG-10.pdf. December 2010. because now treatment can be initi- Accessed October 23, 2018. ated for each disease. 2. Bowling E. How point-of-care diagnostic lab tests help clinical decisions. Optometry Times. www.optometrytimes. The Ocular Allergy Diagnos- com/modern-medicine-cases/how-point-care-diagnostic-lab- tic System-Doctor’s Rx (Bausch tests-help-clinical-decisions. May 9 2016. Accessed October 23, 2018. + Lomb) offers another in-office 3. Yesterday, Today & Tomorrow: NIH Research Timelines. test for allergy testing.21 The Doc- National Institutes of Health, U.S. Department of Health and Human Services. www.report.nih.gov/nihfactsheets. June 30, tor’s Rx is FDA approved and 2018. Accessed October 31, 2018. ComprehensiveComprehensive can be billed to insurance. It is a 4. Craig J, Nichols K, Akpek E. TFOS DEWS II Report Executive Summary. The Ocular Surface. Ocul Surf. 2017;15(3):276-83. Visual Acuity Solution noninvasive, requires no needles 5. A Versatile Range of MGD Products Suited to Your Practice. and responds to at least 58 aller- TearScience. tearscience.com. Accessed October 31, 2018. 6. Oculus, Inc. Oculus Keratograph 5M—Topography High- Multiple optotype selections 21 gens, according to B+L. The lights. www.oculus.de/us/products/topography/keratograph- test involves a plastic applicator 5m/highlights/. Accessed October 31, 2018. All acuity slides presented with 7. Bowling E. The clinical use of ophthalmic point-of-care that is applied to the patient’s diagnostic lab tests. American Academy of Optometry 2014. ETDRS Spacing forearm, but it does not prick or www.aaopt.org/docs/default-document-library/as-15-outline. pdf?sfvrsn=85b3f99e_0. American Academy of Optometry. Contrast sensitivity testing draw blood. The test takes three November 15, 2014. Accessed October 31, 2018. minutes to perform and provides 8. Foulks G, Lemp M, Berg M, et al. TearLab Osmolarity as a biomarker for disease severity in mild to moderate dry eye Crowding bars (for pediatrics) results within 15 minutes. Test- disease. American Academy of Ophthalmology PO382, 2009. ing for allergens, especially those www.tearlab.com/pdfs/2009%20AAO%20Poster%20Hand- Multimedia system and more! out%20-%20Reduced.pdf. Accessed October 31, 2018. specific to a region, makes it easier 9. Hessen M. All about osmolarity. Rev Optom. 2018;155(5):42-8. 10. Sambursky R, Davitt W, Friedberg M, Tauber S. Prospective, to identify an appropriate treat- multicenter, clinical evaluation of point-of-care matrix metal- ment course and how to remove loproteinase-9 test for confirming dry eye disease. Cornea. 2014;33(8):812–8. the offending agent. This will only 11. Chotikavanich S, de Paiva CS, Li de Q, et al. Production increase improvement in patient and activity of matrix metalloproteinase-9 on the ocular surface increase in dysfunctional tear syndrome. Invest Ophthalmol Vis care and satisfaction. Sci. 2009;50:7:3203-9. 12. Gürdal C, Genç I, Saraç O, et al. Topical cyclosporine in thyroid orbitopathy-related dry eye: Clinical findings, conjuncti- Forego The Lab val epithelial apoptosis, and MMP-9 expression. Curr Eye Res. As new technologies are developed, 2010;35:9:771-7. 13. Azari A, Barney N. Conjunctivitis: a systematic review of practitioners can develop novel diagnosis and treatment. JAMA. 2013;310(16);1721-9. ways to treat patients, monitor 14. Sambursky R, Trattler W, Tauber S, et al. Sensitivity and specificity of the AdenoPlus test for diagnosing adenoviral con- their compliance and track their junctivitis. JAMA Ophthalmol. 2013;131:17-22. outcome. Each of these tests can 15. O’Brien T, Jeng B, McDonald M, Raizman M. Acute conjunctivitis: Truth and misconceptions. Curr Med Res Opin. be performed by the OD—or a 2009;25(8):1953-61. properly trained technician, adding 16. Shoji J, Aso H, Inada N. Clinical usefulness of simultaneous measurement of the tear levels of CCL17, CCL24, and IL-16 for efficiency to a busy daily schedule. the biomarkers of allergic conjunctival disorders. Curr Eye Res. With these tests, optometrists are 2017;42(5):677-84. 17. Sanchez-Hernandez, M, Montero J, Rondon C, et.al. Con- no longer limited in our ability to sensus document on allergic conjunctivitis. J Invest Allergol Clin diagnose and monitor by the time Immunol. 2015;25(2);94-106. 18. Rageh A, Ferrington D, Roehrich H. Lactoferrin expression constrains and expense of lab test- in human and murine ocular tissue. Curr Eye Res. 2016;41(7): ing for our patients’ many ocular 883-9. 19. Rusciano D, Pezzino S, Oliveri M. Age-related dry eye lacto- surface issues. ■ ferrin and lactobionic acid. Ophthal Res. 2018;60:94-9. 20. Bethke W. An objective look at dry eye syndrome. Rev Oph- Dr. Sherman is an instructor in thalmol. 2012;19(12):12-3. Optometric Science (in Ophthal- 21. Doctor’s Rx Allergy Formula: Ocular Allergy Diagnostic System. Bausch + Lomb. www.bausch.com/ecp/our-products/ mology) at Columbia University diagnostics/ocular-allergy-diagnostic-system.Accessed October Medical Center, NY. She specializes 31, 2018.

250 Cooper Ave., Suite 100 Tonawanda NY 14150 www.s4optik.com I 888-224-6012 Sensible equipment. Well made, well priced.

042_ro1118_F2.indd 47 11/16/18 11:15 AM Artificial Tears

Master the Maze of Artificial Tears Having so many choices can be overwhelming,but knowing what each one offers can help you steer patients in the right direction. By Meaghan Horton, OD, Matt Horton, OD, and Eric Reinhard, OD

lthough the prevalence Photo: Christine W. Sindt, OD ingredients and concentrations, and incidence of dry eye specific labeling requirements disease (DED) varies and good manufacturing pro- Awidely due to a lack of cesses (Table 1). standardized testing and criteria, The primary active ingre- a recent report estimates more dients found in most artificial than 16 million adults in the tears are either ophthalmic United States are diagnosed with demulcents or emollients. DED.1 Dry eye accounts for Demulcents are substances almost 25% of medical eye care that soothe mucous membranes visits and has been estimated to and, in the case of artificial cost the US healthcare system This patient has chemical toxicity secondary tears, provide lubrication in $3.84 billion annually—this to multiple topical antimicrobial medications. the form of a mucoprotective number increases to $55.4 bil- Clinicians should avoid iatrogenic DED by film. They can alleviate dis- lion when considering societal considering all concurrent ocular drops before comfort, aid in water retention costs.2-4 While optometrists are recommending a preserved artificial tear. and decrease friction across the fortunate to have an expand- ocular surface. The FDA has ing armamentarium, artificial tears mon commercially available arti- established six categories of ophthal- remain an integral part of the basic ficial tears, the FDA-approved mic demulcents that must fall within management strategy as a recom- ingredients they use and the factors a specified range of concentrations: mended first-line option.5-7 Although to consider when making treatment cellulose derivatives, dextran 70, they do not directly address the decisions and recommendations. gelatin, liquid polyols, polyvinyl underlying etiology of dry eye, arti- alcohol (PVA) and povidone. These ficial tears can effectively control Approving Agents products can be used alone or in symptoms and may be the primary The FDA provides guidelines to combinations of up to three.9 therapeutic component for many facilitate and streamline the artificial One of the most commonly used with mild or episodic dry eye.8 tear approval process. The mono- demulcents is carboxymethylcel- Here, we review the most com- graph includes approved active lulose (CMC), a cellulose derivative.

48 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

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CMC increases the viscosity of tears Polysorbate 80 is Table 1. FDA-approved Demulcents for and has mucoadhesive properties included in eye drops to Artificial Tears by Group9 that allow it to remain on the ocular aid in the emulsification Active Concentration Function(s) 10 surface for long periods of time. of formulations with Ingredient The commercially available artifi- oil, such as Soothe XP Cellulose Derivatives cial tear concentration can range (Bausch + Lomb) and CMC 0.2% to 2.5% (up to Increases viscosity from 0.2% to 1%.9 The increased Refresh Optive Mega-3 1% commercially) viscosity of higher concentrations (Allergan). The latter Hydroxyethyl 0.2% to 2.5% (up to Crosslinks with ocular can cause transient blur and eyelid includes polysorbate 80, cellulose, HPMC, 0.8% commercially) surface, increases debris, which is why these artifi- glycerin 1% and castor methylcellulose viscosity cial tears should only be applied at oil, all of which are inac- Dextran 70 0.1% Increases mechanical strength of tear film night and to treat more severe DED. tive ingredients in Resta- Liquid Polyols Another commonly used cellulose sis (Allergan). PEG 300 0.2% to 1% Increases viscosity derivative is hydroxypropyl methyl- Emollients, such as cellulose (HPMC), or hypromellose. fats or oils, increase the PEG 400 0.2% to 1% Increases viscosity HPMC increases viscosity by cross- lipid layer thickness of Glycerin 0.2% to 1% Increases viscosity, is linking after contact with the ocular the tear film, stabilize an osmoprotectant surface. Cellulose derivatives are the tear film and reduce Polysorbate 80 0.2% to 1% Stabilizes emulsions found in products like Refresh Tears evaporation. More arti- PVA 0.1% to 4% (up to Lowers viscosity (Allergan), GenTeal Tears (Alcon) ficial tears containing 1.4% commercially) and TheraTears (Akorn). lipids are becoming avail- Povidone 0.1% to 2% Increases viscosity Dextran 70 must be combined able due to an increased with another demulcent due to the awareness of the role meibomian and Retaine MGD (mineral oil and compound’s low viscosity.9 This gland dysfunction (MGD) plays in light mineral oil, Ocusoft). With ingredient increases the mechanical DED.11 Emollients, found in oint- the exceptions of Refresh Optive strength of the tear film. ments and lipid-based tears, typically Advanced and Refresh Optive PVA, one of the oldest demul- use a combination of mineral oil, Mega-3, most lipid-based artificial cents, lowers a solution’s viscosity. light mineral oil and white petrola- tears require shaking prior to use to It is no longer found frequently in tum. ensure a uniform concentration. branded artificial tears due to the Artificial tears that contain lipids While more research needs to availability of more effective ingre- must be formulated as an emulsion, compare artificial tears with and dients. Povidone, a water-soluble which can be classified based on without lipids in patients with MGD synthetic polymer, is also used in the size of the oil droplet it con- and DED, several studies have found products like Betadine (Purdue tains: macroemulsions (larger than that lipid-based drops improve dry Pharma) due to its antiseptic prop- 100nm), nanoemulsions (10nm to eye symptoms.12-15 erties when combined with iodine. 100nm), microemulsions (less than Povidone and PVA are found in 10nm). Both the particle size and Gray Areas drops like Refresh Classic (Allergan), lipid concentration can affect visual Inactive ingredients are not specified FreshKote (Eyevance Pharmaceuti- blur on instillation. Manufacturers in the FDA’s ophthalmic monograph, cals) and Murine (Care Pharmaceu- employ various methods to enhance but the guidelines state that ingredi- ticals). emulsion stability, increase even ents must be suitable and safe and Other demulcents include liquid spreading, enhance bioavailability cannot interfere with a product’s polyols, such as propylene glycol of active ingredients and reduce effectiveness.16 The FDA maintains a (PPG), polyethylene glycol (PEG) unwanted side effects. Current lipid- vast list of approved inactive ingre- and glycerin. These increase viscosity based artificial tears include Systane dients that may function as buffers, by forming a mucoprotective layer Balance and Systane Complete electrolytes, emulsifiers, osmoprotec- and are found in Systane (Alcon), (mineral oil, Alcon), Refresh Optive tants or viscosity-enhancers. These Blink (Johnson & Johnson Vision) Advanced (castor oil, Allergan) ingredients set individual drops apart and Soothe (Bausch + Lomb). Glyc- and Refresh Optive Mega-3 (cas- from one another. erin is used in Oasis (Oasis Medical) tor oil and flaxseed oil), Soothe XP Buffers and electrolytes can adjust and Refresh Optive (Allergan). (mineral oil and light mineral oil) the pH and osmolarity of artificial

50 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

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RO1118_Lacrivera.indd 1 11/1/18 11:34 AM Artificial Tears

tears. Many studies have looked Although artificial tear osmolarity is and TheraTears Extra, stabilizes cell into the association between tear not widely reported, TheraTears, a membrane lipids and proteins and film osmolarity and DED, which hypo-osmolar drop with an osmo- can protect corneal epithelial cells was highlighted in the TFOS DEWS larity well below that of other arti- from death by desiccation.21 report.17 Research shows a reduc- ficial tears, may relieve patients of Sodium hyaluronate, a glycos- tion in tear osmolarity correlates their dry eye symptoms.19,20 aminoglycan, is added to drops like with reduced dry eye symptoms in Trehalose, an osmoprotectant Blink and Oasis to increase lubrica- patients treated with artificial tears.18 found in Refresh Optive Mega-3 tion and enhance viscosity. Refresh Optive Repair (Allergan) is a new Table 2. Commercially Available Artificial Tears option, the first in the United States Name Concentration Preservative to contain both CMC and sodium hyaluronate.22 PEG and PPG Another unique inactive ingredi- Blink/PF 0.25% OcuPure/None ent is hydroxypropyl-guar (HP- Blink Gel 0.25% PEG OcuPure guar), a polymetric thickener that Systane Gel 0.4% PEG, 0.3% PPG, HP-guar (inactive) Polyquaternium-1 acts as a gelling agent in the Systane Systane Ultra/PF 0.4% PEG, 0.3% PPG, HP-guar (inactive) Polyquaternium-1/None line of artificial tears. HP-guar com- Soothe PF 0.6% PPG (also 0.6% glycerin) None bines with the two demulcents in Systane Balance and 0.6% PPG, mineral oil (inactive); Systane Polyquaternium-1 Systane Complete Complete has “nano-droplets” Systane to form a low viscosity gel Rohto Dry-aid 0.3% PPG (also 0.68% povidone) Polyaminopropyl biguanide that activates as it interacts with the ocular surface and the pH changes.23 CMC Homeopathic artificial tears, such TheraTears/PF 0.25% Sodium perborate/None as Similasan, do not fall under the TheraTears Extra 0.25% (trehalose inactive) Sodium perborate ophthalmic monograph and are not Refresh Tears/Plus 0.5% Sodium chlorite/None evaluated by the FDA for safety and Refresh Tears Liquigel/ 1% Sodium chlorite/None Celluvisc effectiveness. Instead, they fall under the Federal Food, Drug and Cos- Hypromellose/Dextran 70 metic Act.24 Currently, homeopathic GenTeal Tears Mild 0.3%/0.1% Polyquaternium-1 drug use is allowed in over-the-coun- GenTeal Tears Moderate/PF 0.3%/0.1% (also glycerin 0.2%) Polyquaternium-1/None ter (OTC) artificial tears so long as GenTeal Tears Gel 0.3% (no dextran 70) Sodium perborate the drugs are listed in the Homoeo- Glycerin pathic Pharmacopoeia of the United Oasis 0.2% (15%) None States (HPUS). The FDA requires Oasis Plus 0.2% (30%) None these homeopathic drugs meet stan- Refresh Optive/Sensitive 0.9% (also 0.5% CMC) Sodium chlorite/None dards of active ingredients regarding Refresh Optive Repair 0.9% (also 0.5% CMC), sodium Sodium chlorite hyaluronate (inactive) strength, quality and purity as speci- 24,25 Refresh Optive Advanced/PF 1% (also 0.5% CMC, polysorbate 80 Sodium chlorite/None fied in the HPUS. 0.5%), castor oil (inactive) Refresh Optive Mega-3 1% (also 0.5% CMC, polysorbate 80 None Keeping it Fresh 0.5%), castor oil, flaxseed, trehalose All multidose artificial tears must (inactive) contain at least one substance to Clear Eyes Pure Relief 0.25% None (PF multidose) inhibit microbial growth and include PVA appropriate guidelines for proper Refresh Classic 1.4% (also 0.4% povidone) None use (Table 2). In the United States, FreshKote 2.7% (also 2.0% povidone) Polixetonium multidose eye care products undergo Murine 0.5% (also 0.6% povidone) BAK preservative testing that must pass Clear Eyes Artificial Tears 0.5% (also 0.6% povidone) BAK the United States Pharmacopeia pre- Mineral Oil servative effectiveness test. Retaine MGD 0.5% light mineral pol, 0.5% mineral oil None The most commonly used pre- Soothe XP/PF 1.0% light mineral oil, 4.5% mineral oil Polyquaternium-1/None servative in ophthalmic drops is benzalkonium chloride (BAK), a

52 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

0048_ro1118_F3.indd48_ro1118_F3.indd 5252 111/14/181/14/18 1:551:55 PMPM Welcome a new addition to the PreserVision® family

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RP0618_BL Preservision.indd 1 5/11/18 11:07 AM Artificial Tears Photos: Jason Miller, OD quaternary ammonium ing many times daily). compound that is an • Burning or sting- efficacious antimicro- ing, which can occur bial. It can range in when a patient’s tear concentration from pH does not align with 0.004% to 0.02% but the pH of the instilled is usually 0.01% in drop, during instilla- artificial tear formula- tion can significantly tions. BAK can cause NaFl corneal staining (left) and lissamine green conjunctival staining deter compliance with both corneal and con- (right) significantly correlate when diagnosing DED. Patients at each drop regimens, and a junctival cell apoptosis stage of disease severity may benefit from artificial tear substitutes. trial may be necessary (in a dose-dependent to find the artificial manner, particularly in doses above with artificial tears experience better tear that best matches a patient’s 0.005%), delay wound healing, symptom relief than those treated own tear pH.33 Discomfort can decrease goblet cell density and dam- with placebo tears or not treated at also be addressed by switching to a age corneal nerves.26-29 all, it is unclear whether some arti- preservative-free drop. While the most common artificial ficial tears are better than others at • In-office education with artificial tears recommended by optometrists relieving patient symptoms.8 tears is integral. Studies show that do not contain BAK, most OTC An optimal artificial tear provides the majority of patients, particularly drops by major company and large efficacious, long-lasting relief from elderly patients, who use chronic store brands are preserved with symptoms and has good instillation drop therapy have poor instillation 0.01% BAK. Even “softer” preser- comfort and low blur. These can technique.34,35 Unit-dose vials may vatives, such as sodium chlorite, can be imparted by the drop’s surface present more challenges to these have potential negative effects on the tension, pH, viscosity, duration of patients, but results are mixed.36,37 ocular surface, although more stud- action and the presence or absence Artificial tear substitutes gener- ies are needed to compare them with of preservatives. Other factors to ally target at least one tear film non-preserved formulations.30 consider include the ease of instilla- layer, so understanding the primary Most artificial tear brands now tion and the cost: deficiency of your patient’s tear film have unit-dose vials available in • Drops of higher viscosity can should help guide your treatment preservative-free formulations. In provide a longer duration of effect strategy. However, many patients 2016, the FDA approved the first but may also come with a higher have overlap in different areas of preservative-free multidose artificial incidence of visual blur.31 Lower tear film deficiency, and those with tear, Clear Eyes Pure Relief (Prestige viscosity drops tend to be bet- a primary lacrimal insufficiency will Brands). This drop uses a gas perme- ter solutions for daytime use, and represent a minority of your patient able unidirectional filter in the bottle higher viscosity gel drops should be population. New formulations, such tip to avoid contamination. reserved for nighttime application. as Refresh Optive Advanced and • Cost can be the primary reason Systane Complete, target multiple Making the Right Choice patients discontinue treatment.32 The tear components to appeal to a There is a dearth of randomized cheapest artificial tears are generic broader range of patients. controlled trials that compare the brand PVA tears, which cost less A significant portion of patients efficacy of commercially available than $2 per 15mL. Branded artificial using artificial tears may also wear artificial tears. The FDA approval tears can cost two to seven times contact lenses. Several artificial tears process for artificial tears does not more, with prices typically ranging have been studied in contact lens require individual study submis- from $8 to $13 for a 10mL to 15mL wear, but most artificial tears are sions, and much of the available bottle. Generic formulations may be used off-label in contact lens patients research is industry-funded—which available for many branded artificial without incidence. can further complicate drawing clini- tears, but the inactive ingredients cally applicable evidence. A 2016 and preservatives will vary signifi- Treatment Pearls meta-analysis reviewed 43 head-to- cantly. When recommending preser- Keep in mind these practice tips head artificial tear trial studies and vative-free drops, costs may increase when recommending artificial tears concluded that while patients treated significantly (particularly when dos- to DED patients:

54 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

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16.Code of Federal Regulations. Over-the-counter (OTC) human • Most of your patients will likely artificial tear. Using a drop that drugs which are generally recognized as safe and effective and not misbranded. 21CFRI.330.1. www.ecfr.gov/cgi-bin/text-idx?SID=5b have mild DED and should start simply increases aqueous volume in 9cfa96ac759f232cdf16c19ac5f9cb&mc=true&node=se21.5.330 with a low viscosity artificial tear. patients with a deficient tear lipid _11&rgn=div8. Accessed June 15, 2018. 17. The definition and classification of dry eye disease: report of 38 Modern lubricants outperform older layer may increase symptoms. the definition and classification subcommittee of The International Dry Eye WorkShop. Ocular Surface. 2007;5(2):75-92. lubricants, such as povidone and 18. Cömez AT, Tufan HA, Kocabıyık O, Gencer B. Effects of lubricat- PVA, so clinicians should recom- Thanks in part to the FDA oph- ing agents with different osmolalities on tear osmolarity and other tear function tests in patients with dry eye. Current Eye Research. mend more efficacious lubricants thalmic monograph for OTC oph- 2013;38(11):1095-1103. 11 19. Tong L, Petznick A, Lee S, Tan J. Choice of artificial tear unless cost is a major concern. thalmic drug products, a plethora formulation for patients with dry eye: where do we start? Cornea. Generic preserved drops should only of artificial tear options exists. As 2012;31(Suppl 1):S32-36. 20. Stahl U, Willcox M, Stapleton F. Role of hypo-osmotic saline be considered for occasional use in front-line eye care providers for dry drops in ocular comfort during contact lens wear. Cont Lens Ant Eye. 2010;33(2):68-75. mild DED patients with episodic eye patients, we must be equipped 21. Hill-Bator A, Misiuk-Hojło M, Marycz K, Grzesiak J. Trehalose- symptoms due to the overwhelming to offer our patients specific recom- based eye drops preserve viability and functionality of cultured human corneal epithelial cells during desiccation. Biomed presence of BAK in these drops. mendations for drops, as no single Research International. 2014;2014:292139. 22. Allergan Expands Refresh Portfolio With New Refresh Repair • When an artificial tear is not drop works in all clinical scenarios. Lubricant Eye Drops.Chicago: PR Newswire. 2018. www.prnews- well tolerated or is insufficient for The art of medicine is applying our wire.com/news-releases/allergan-expands-refresh-portfolio- with-new-refresh-repair-lubricant-eye-drops-300677992.htm. relief, consider active ingredients and science to meet the needs of our Accessed September 5, 2018. ■ 23. Christensen MT. Corneal staining reductions observed after mechanisms of action when choos- diverse patient populations. treatment with Systane. Advances in Therapy. 2008;25(11):1191- ing an alternative. Move toward Drs. Horton, Reinhard and Hor- 9. 24. US Food and Drug Administration. Manual of Compliance Pol- higher viscosity gel drops when ton are optometrists at the Cincin- icy Guides. Sec. 400.400. Conditions Under Which Homeopathic Drugs May Be Marketed. www.fda.gov/ICECI/ComplianceManuals/ symptoms are not well controlled nati VA Medical Center and adjunct CompliancePolicyGuidanceManual/ucm074360.htm. Accessed after dosing every four to six hours. faculty members at the Ohio State May 30, 2018. 25. US Food and Drug Administration. Drug Products Labeled as • All patients with moderate to University College of Optometry. Homeopathic. Guidance for FDA Staff and Industry. 2017. www. severe disease should ideally be on fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInforma- 1. Farrand KF, Fridman M, Stillman IO, Schaumberg DA. Preva- tion/Guidances/UCM589373.pdf. Accessed May 30, 2018. preservative-free formulations, as lence of diagnosed dry eye disease in the United States among 26. Chung SH, Lee SK, Cristol SM, et. al. Impact of short-term adults aged 18 years and older. Am J Ophthalmol. 2017;182:90- exposure of commercial eyedrops preserved with benzalkonium should any patient using artificial 8. chloride on precorneal mucin. Molecular Vision. 2006;12:415-21. tears more than four times daily. 2. Hikichi T, Yoshida A, Fukui Y, et al. Prevalence of dry eye 27. Lin Z, He H, Zhou T, et al. A mouse model of limbal stem in Japanese eye centers. Graef Arch Clin Exp Ophthalmol. cell deficiency induced by topical medication with the pre- • Preservative-free drops should 1995;233(9):555-8. servative benzalkonium chloride. Invest Ophthalmol Vis Sci. 3. Doughty MJ, Fonn D, Richter D, et al. A patient questionnaire 2013;54(9):6314-25. also be used for glaucoma patients approach to estimating the prevalence of dry eye symptoms in 28. Chen W, Zhang Z, Hu J, et al. Changes in rabbit corneal inner- on chronic-preserved glaucoma med- patient presenting to optometric practices across Canada. Optom vation induced by the topical application of benzalkonium chloride. Vis Sci. 1997;74(8):624-31. Cornea. 2013;32(12):1599-1606. ications, postoperative patients who 4. Yu J, Asche CV, Fairchild CJ. The economic burden of dry eye 29. Pinheiro R, Panfil C, Schrage N, Dutescu RM. The impact of disease in the United States: a decision tree analysis. Cornea. glaucoma medications on corneal wound healing. J Glaucoma. require lubrication and patients with 2011;30(4):379-87. 2016;25(1):122-7. 5. Jones L, Downie LE, Korb D, et al. TFOS DEWS II management 30. Schrage N, Frentz M, Spoeler F. The Ex Vivo Eye Irritation acute keratoconjunctivitis. and therapy report. Ocular Surface. 2017;15(3):575-628. Test (EVEIT) in evaluation of artificial tears: Purite-preserved • DED and significant MGD 6. Optometric Clinical Practice Guideline. Care of the patient with versus unpreserved eye drops. Graef Arch Clin Exper Ophthalmol. ocular surface disorders. www.aoa.org/documents/optometrists/ 2012;250(9):1333-40. should be targeted with a lipid-based CPG-10.pdf. Accessed May 30, 2018. 31. LaMotte JO, Ridder WH, Kuan T, et al. The effect of artificial 7. American Academy of Ophthalmology. Preferred Practice tears with different CMC formulations on contrast sensitivity. Invest Photo: Jacob R. Lang, OD Pattern Guidelines. Dry eye syndrome. www.aao.org/ppp. Ophthalmol Vis Sci. 2002;43(13):3151. Accessed June 15, 2018. 32. Taylor SA, Galbraith SM, Mills RP. Causes of non-compliance 8. Pucker AD, Ng SM, Nichols JJ. Over the counter (OTC) with drug regimens in glaucoma patients: a qualitative study. J artificial tear drops for dry eye syndrome. Cochrane. 2016;2. Ocular Pharmacol Thera. 2002;18(5):401-9. 9. Food and Drug Administration: Ophthalmic Drug Products 33. Asbell PA. Increasing importance of dry eye syndrome and the for Over-the-counter Human use; Final Monograph. 21 CFR ideal artificial tear: consensus views from a roundtable discussion. Parts 349 and 369. Federal Register 1988;53(43):7076-93. Curr Med Res Opin. 2006;22:11:2149-57. 10. Qian G, Simmons PA, Xu S, et al. Carboxymethylcellulose 34. Tatham AJ, Sarodia U, Gatrad F, Awan A. Eye drop instillation binds to human corneal epithelial cells and is a modulator of technique in patients with glaucoma. Eye. 2013;27(11):1293-8. corneal epithelial wound healing. Invest Ophthalmol Vis Sci. 35. Gao X, Yang Q, Huang W, et al. Evaluating eye drop instillation 2007;48(4):1559-67. technique and its determinants in glaucoma patients. J Ophthal- 11. Moshirfar M, Pierson K, Hanamaikai K, et al. Artificial tears potpourri: a literature review. Clin Ophthalmol. mol. 2018;1376020. 2014;8:1419-1433. 36. Parkkari M, Latvala T, Ropo A. Handling test of eye drop dis- 12. Korb DR, Scaffidi RC, Greiner JV, et al. The effect of penser—Comparison of unit-dose pipettes with conventional eye two novel lubricant eye drops on tear film lipid layer thick- drop bottles. J Ocular Pharmacol Thera. 2010;26(3):273-6. ness in subjects with dry eye symptoms. Optom Vis Sci. 37. Dietlein TS, Jordan JF, Luke C, et al. Self-application of single- 2005;82(7):594-601. use eyedrop containers in an elderly population: comparisons with 13. Scaffidi RC, Korb DR. Comparison of the efficacy of two standard eyedrop bottle and with younger patients. Acta Ophthal- lipid emulsion eyedrops in increasing tear film lipid layer mologica. 2008;86(8):856-9. thickness. Eye Contact Lens. 2007;33(1):38-44. 38. Calvao-Santos G, Borges C, Nunes S, et al. Efficacy of 3 14. Simmons PA, Carlisle-Wilcox C, Chen R, et al. Efficacy, difference artificial tears for the treatment of dry eye in frequent Because many glaucoma drugs and generic safety, and acceptability of a lipid-based artificial tear for- computer users and/or contact lens users. European J Ophthalmol. mulation: a randomized, controlled, multicenter clinical trial. 2011;21(5):538-44. artificial tears that contain BAK can cause Clinical Therapeutics. 2015;37(4):858-68. 39. Sullivan BD, Crews LA, Messmer EM, et al. Correlations punctate epitheliopathy, glaucoma patients 15. Simmons P, Carlisle C, Shi G, Vehige J. Clinical compari- between commonly used objective signs and symptoms for the son of lipid-based and aqueous lubricant eye drops. Invest diagnosis of dry eye disease: clinical implications. Acta Ophthalmol. should avoid using preserved artificial tears. Ophthalmol Vis Sci. 2013;54(15):4329. 2014;92:161-6.

56 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

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RP1018_Vital Tears.indd 1 9/18/18 9:48 AM Dry Eye

Dry Eye Therapy: Keeping it Simple Not everything you recommend has to cost a fortune. These low-budget tricks can help patients combat dry eye and stay on budget. By Barbara Caffery, OD, PhD

ry eye disease Photo: Jalaiah Varikooty, Centre for Contact Lens Research Gear Up for the Challenge (DED) is a com- The first step of dry eye man- mon presentation agement is a thorough diagno- Din eye care offices. sis and categorization of the Studies of the prevalence disease based on the new Tear of DED vary significantly Film and Ocular Surface Soci- depending on the defini- ety’s (TFOS) Dry Eye Work tion, the study popula- Shop II (DEWS II) definition: tion and the criterion for “Dry eye is a multifactorial diagnosis. North American disease of the ocular surface studies show a prevalence characterized by a loss of of symptomatic dry eye in homeostasis of the tear film, males as low as 4.3%, and TFOS DEWS II lists ocular surface staining, seen here with and accompanied by ocular as high as 21.6% in the lissamine green, as an important diagnostic tool for dry symptoms, in which tear film elderly.1,2 eye—the first step in the management process. instability and hyperosmolar- DED is often chronic ity, ocular surface inflamma- and therefore requires ongoing management. However, tion and damage, and neurosensory abnormalities play patients are rarely prepared for the true complexity of etiological roles.”3 the disease and the sometimes equally complex treat- As highlighted by this definition, dry eye is a com- ment plan. Unprepared patients are prone to noncom- plex disease that recently got even a little more compli- pliance—the biggest obstacle for long-term therapy cated. In addition to the well-known fact that signs of regimens such as those often required for dry eye. DED don’t always correlate with symptoms, the newest These diagnostic, pharmaceutical and lifestyle tips aspect of the disease is the neurosensory component.3 can help you prepare DED patients for the therapy Based on current literature, we now know that some road ahead, and shift their mindset from one of bur- patients can present with pristine-looking ocular sur- densome treatment to ongoing eye care. faces but suffer from dry eye symptoms that are, in

58 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

058_ro1118_F4.indd 58 11/14/18 2:26 PM ONLY

RP0318_Akorn Azasite.indd 1 2/23/18 10:11 AM Dry Eye

fact, a neuropathy.4 We refer to patients must understand that these patients as having “pain they are in for a lifetime of care. I without stain.” In these cases, a liken this new eye care approach diagnosis of pre-clinical ocular to that of their dental care. With- surface disease (OSD) or neuro- out thinking, most of us floss, pathic pain—not DED—comes brush and see our dentist regu- long before clinical signs. larly. Similarly, all patients, and To get to the bottom of a dry eye patients in particular, need patient’s dry eye symptoms, clini- to care for and maintain a healthy cians should follow the TFOS ocular surface over their lifetime. DEWS II essential diagnostic Patients are confronted with a multitude of A second barrier to compliant test recommendations: a dry lubricating drops at the drug store. It’s the dry eye care is the cost. Topical eye questionnaire followed OD’s job to help them narrow their options. over-the-counter lubricants can by tear break-up time (TBUT, cost as much as $50 per bottle, noninvasive diagnosis <10sec, F-BUT diagnosis <5sec), and the cost of prescription medications such as Resta- osmolarity (diagnosis ≤308mOsm/L) and ocular surface sis (cyclosporine, Allergan) and Xiidra (lifitegrast, staining (diagnosis >5 corneal spots or conjunctiva >9 Shire) can overwhelm the patient. Both of these fac- spots).5 Not all testing is available to each clinician, and tors play an important part in the patient’s decision to only one of these tests needs to be abnormal to move adhere to the treatment plan you discuss with them. the diagnosis forward. Lubricants. In almost every form of DED, a lubri- The categorization of DED is also integral to direct cant is needed. However, the sheer number of ocular treatment, and it help the patient better understand lubricants on drug store shelves is overwhelming. the mechanism underlying their particular form of dry Patients need guidance in choosing the correct product eye, whether it’s aqueous deficient, evaporative or a for their specific form of dry eye, especially regarding mixture of the two. Clinicians can determine much of generic brands, in which the preservatives often differ this by measuring the tear meniscus height (categorized from branded products. For example, patients with as mild with 0.2mm, moderate with 0.1mm and severe predominantly MGD-induced evaporative dry eye will with 0.0mm) and analyzing meibomian gland function likely do better with a lipid-based drop, at least until (graded as mild, moderate or severe). Treatments usu- those glands are functioning normally. ally begin in a step-like manner going from simple to For those who do not need the extra lipid or those complex, depending on the severity of the condition who do not do well on a lipid-based drop, the biggest and the response to treatments. At the end of a dry eye decision is whether to recommend preserved or non- workup, the clinician will have not only the diagnosis, preserved drops. Clearly, benzalkonium chloride (BAK) but also valuable information about its etiology, sever- should be avoided if possible, but the effects of other ity and any meibomian gland dysfunction (MGD). preservatives have yet to be studied on a clinical level. Armed with this information, clinicians should then The rising trend is to use non-preserved drops, a clini- spend time properly educating the patient. Whether cal wisdom without clear clinical scientific evidence. it’s a female, age-related post-menopausal dry eye, an In theory, preservative free formulations eliminate one aqueous deficient dry eye related to an autoimmune possible irritant; in practice, many of the new preserva- disease such as Sjögren’s syndrome or strictly a meibo- tives seem to work well for patients and the formula- mian gland disease, that information is invaluable for tions are often less expensive. patients. When they understand the particular charac- The problems associated with the use of BAK- teristics of their disease state, they are more likely to preserved drops are well-known, and this preservative comply with the treatment. should be avoided if possible.6-9 However, we do not have comparative studies that show the ocular insult Climbing the Management Mountain associated with other “modern” preservatives such Dry eye therapy is often incredibly daunting to patients. as polyquad, sodium perborate, Purite, Ocupure and Most people are familiar with diseases treated with a PHMD. In addition, ridding a drop of preservatives course of medication, surgery or a few weeks of pallia- does not negate the effect of the active ingredients, tive measures as their body fights off the untreatable which can themselves be toxic. virus. Unfortunately, dry eye tends to be chronic and While choosing a non-preserved drop eliminates

60 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

058_ro1118_F4.indd 60 11/14/18 2:06 PM # Over 4 million households in Biotruth 52 the US made Biotrue® MPS #1*

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RO1118_BLBiotrue.indd 1 11/1/18 11:15 AM Photo: Alan G. Kabat, OD, and Joseph W. Sowka, OD any iatrogenic toxic complication Also, if cost is a factor, patients from preservatives, the cost can can use hot water compresses with be overwhelming. My particular a clean face cloth, but they will style is to begin with a preserved, invariably struggle to keep the tem- less expensive drop to first under- perature at 40°C. Other methods stand the treatment effect on that to keep the temperature up longer, particular patient. This starts the such as using tea bags, rice in a sock patient at the lowest end of the and potatoes wrapped in cloths, treatment scale: easy, effective may help, but have a tendency to (hopefully) and inexpensive. Car- overheat. Clinicians should counsel rying a bottle of artificial tears in patients accordingly if they express a purse or pocket is much easier interest in these alternatives. and safer than carrying a unit-dose Cleaning lashes and massaging vial that has been opened and will Conventional therapy for most patients the oil glands are both integral to be reused during the day, whether with MGD includes warm compresses and MGD and anterior blepharitis treat- we like it or not. lid massage. ment. Many excellent and expen- If a non-preserved drop is neces- sive lid wipes exist, including those sary, clinicians must emphasize to the patient that the with medicinal additives such as tea tree oil. Patients extra cost is warranted. Most patients are aware that unwilling to use these items can use their clean fingers their sensitive eyes need special care. and a lubricant face wash, such as off-label Spectro Jel Compliance is always a problem when expense is (GlaxoSmithKline), to clean their lids in the shower. A considered. Reminding patients that using drops for toothbrush-like back and forth motion of scrubbing the dry eyes is the same as using creams for dry skin can lids while counting to 10 and then rubbing the base of be helpful. Many patients understand quite well that the glands at the orbital side of the lids helps to clean moisturizing cream does not go on once and solve the lashes and massage the meibomian glands. problem. It must be applied daily, and many also use a Clinicians should keep in mind that studies now night cream as well. show that baby shampoo does not solve anterior The prescription medications Restasis and Xiidra are blepharitis and may make it worse, as it often contains expensive for those without drug plans. If a patient’s cocamidopropyl betaine, a surfactant and lathering treatment plan includes these medications, the manu- agent that can cause eyelid dermatitis.13,14 facturers have provided cost-reduction cards to most Oral supplements. For years we have prescribed practitioners to help offset the cost. Cost limitations omega-3 fatty acids (FA) for MGD and dry eye. may prompt patients to use one vial per day—once in Recently, the DREAM study has changed how we see the morning and again at night—rather than two vials this practice.15 Basically, the study demonstrated that per day as instructed. However, this is risky because of the particular FA supplements used in the well-designed the non-preserved nature of the vials. The new Restasis trial did not help MGD any more than the sham pills multidose non-preserved bottle would be a safer choice. that contained small amounts of olive oil determined to Lids. Evaporative dry eye is the most prevalent form be easily met by most North American diets. With the of DED, and MGD is one of the most common causes. heart community also finding little benefit to omega-3 Researchers have studied the prevalence of MGD supplements, many practitioners are discontinuing that outside the United States and have found it as low as recommendation.16 Patients probably won’t complain, 30.5% in Spain and as high as 68.3% in China.10,11 considering the high cost of these supplements. When dysfunctional, the meibomian glands can be Environment. Many environmental changes are treated with massage and heat. However, achieving the inexpensive and particularly effective. Patients should necessary 40° Celsius (roughly 104° Fahrenheit) heat use wraparound glasses and sunglasses when outside for at least 10 minutes is no easy task without expendi- to prevent wind current from drying the eyes. In our tures.12 Several eye masks work well that can be heated office, we keep examples of Pantoptix glasses and other in the microwave, but some are expensive and usually forms of protection such as Cocoon (Live Eyewear) last no more than one year. More affordable masks, that can be worn over regular glasses. such as the TheraPearl eye mask (Bausch + Lomb), A small humidifier placed on the work desk can often work well. reduce dryness and artificial tear use while using the

62 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

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computer. If cost is a factor, a bowl of water with as fier. A recent study also suggests sleep position may much surface area as possible will also add moisture to play a small part in dry eye symptoms. Researchers the air. Patients should redirect any vents in the room found elevated Ocular Surface Disease Index scores in away from their face. patients who slept on their sides compared with those For patients who use a computer throughout the day, who slept on their back and a statistically significant clinicians should recommend they sit a little higher in difference with back sleeping compared with left side their chair or lower the desk to ensure the gaze down at sleeping using lissamine green staining.25 Clinicians the computer. This allows the upper lid to cover more can consider recommending patients try to adjust their of the ocular surface, thus protecting more cells and habitual sleeping position to better protect their eyes thickening the tear film. from overnight drying. Blinking is free, as are several easy blinking exercise Also, those who use a continuous positive airway apps. Patients should adhere to the 20/20/20/20 rule: pressure machine for obstructive sleep apnea may expe- every 20 minutes take 20 seconds to look 20 feet away rience worse dry eye in the morning, as air can leak and blink 20 times. For those who struggle to incorpo- from the mask directly onto the ocular surface. These rate regular blinking exercises, free apps, such as such patients can use goggles to protect the eyes overnight as the Donald Korb Blink Training App (TearScience) and minimize ocular involvement. and EyeLeo, encourage proper blinking with reminders Cosmetics can cause or exacerbate any number of and proper pacing.17,18 ocular issues, including dry eye. Patients should never Patients should always keep airflow away from their wear eyeliner inside the lash line, as it can plug the mei- eyes to avoid exacerbating dry eye. Counsel them to bomian glands and cause inflammation. In addition, avoid long-term exposure to ceiling and box fans (espe- many eyeliners use BAK as the preservative, which, cially at night) and to keep the heat and air condition- when it remains in contact with the lid cells, can cause ing in the car at their feet, not in their face. damage.26 Clinicians should counsel patients to take all Lifestyle. Those who smoke should be counseled on of their makeup off before bed, and use a soft cloth to the myriad benefits of quitting, including the benefits wipe and massage the lids as they remove the makeup. for their ocular health. Research shows tobacco smoke Hydration is important for everyone, but especially can exacerbate dry eye, as it causes tear film instability for dry eye patients. Although a simple recommenda- and increases ocular surface staining.19-21 In fact, one tion, asking patients to remember to drink plenty of study found patients who smokers are nearly twice as water and avoid diuretic drinks like alcohol and coffee likely to have dry eyes.20 Encouraging smoking cessa- can have a significant impact on ocular dryness.27 tion and avoidance of smoke will save them a fortune As inflammation is a known part of dry eye, an and prolong their life. anti-inflammatory diet may be worth recommending Getting enough sleep is an inexpensive way to help to patients in search of alternative dry eye remedies.28 protect the eyes from symptoms of dry eye.22 Over- Fresh food with few additives as described in the mayo sleeping is unnecessary, but getting enough sleep is Clinic diet may make a difference to joints and the eyes.

essential, as one study Photo: Leslie O’Dell, OD found 45% of dry eye Dry eye disease requires patients reported poor a concerted effort on the sleep quality.23 Other patient’s part to modify researchers conducted their external and inter- focus group sessions with nal environment to help 38 patients with dry eye encourage ocular health. to better understand their It also requires regular various coping methods use of lubricants and lid and found sufficient, good- care. Optometrists serve quality sleep helped many their patients well if they participants.24 diagnose, and then edu- Patients should go to bed cate them about the type at regular hours and keep and degree of dry eye that the bedroom moist with Even when applied properly, makeup debris can migrate to is present. Time spent pans of water or a humidi- the lid and conjunctiva, contributing to dry eye symptoms. explaining the options for

64 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

058_ro1118_F4.indd 64 11/14/18 2:06 PM Contact treatments that include less expensive forms, is time Lens well spent to improve patient outcomes. ■ Dr. Caffery practices at Toronto Eye Care in Discomfort Toronto. She also participates in two hospital-based clinics: the University Health Network Multidisci- plinary Sjögren’s Syndrome Clinic and the Therapeutic Contact Lens Clinic at Kensington Eye Institute. She has served on the Board of Directors of the American Academy of Optometry since 2006 and is the current president. She has also served on the Medical Advisory panel of the Sjögren’s Society of Canada since 2008.

1. Schaumberg D, Dana R, Buring J, Sullivan D. Prevalence of dry eye disease among us men: estimates from the physicians’ health studies. Arch Ophthalmol. 2009;127:763-8. 2. Moss S, Klein R, Klein B. Long term incidence of dry eye in an older population. Optom Vis Sci. 2008;85:668-74. 3. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II definition and classification report. Ocul Surf. 2017;15(3):276-83. 4. Belmonte C, Nichols JJ, Cox SM, et al. TFOS DEWS II pain and sensation report. Ocul Surf. 2017 Jul;15(3):404-37. 5. Wolffsohn JS, Arita R, Chalmers R, et al. TFOS DEWS II diagnostic methodology report. Ocul Surf. 2017;15(3):539-74. 6. Chung SH, Lee SK, Cristol SM, et. al. Impact of short-term exposure of commercial eyedrops preserved with benzalkonium chloride on precorneal mucin. Molecular Vision. 2006;12:415-21. 7. Lin Z, He H, Zhou T, et al. A mouse model of limbal stem cell deficiency induced by topi- cal medication with the preservative benzalkonium chloride. Invest Ophthalmol Vis Sci. 2013;54(9):6314-25. 8. Chen W, Zhang Z, Hu J, et al. Changes in rabbit corneal innervation induced by the topical application of benzalkonium chloride. Cornea. 2013;32(12):1599-1606. 9. Pinheiro R, Panfil C, Schrage N, Dutescu RM. The impact of glaucoma medications on corneal wound healing. J Glaucoma. 2016;25(1):122-7. 10. Viso E, Gude F, Rodriguez-Ares M. The association of meibomian gland dysfunction and other common ocular diseases with dry eye: apopulation based study in Spain. Cornea. 2011;30:1-6. 11. Jie Y, Xu L, Wu Y, Jonas J. Prevalence of dry eye among adult Chinese in the Bejing Eye t
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DPOUBDU Study. Eye (Lond). 2009;23:688-93. 12. Olson MC, Korb DR, Greiner JV. Increase in tear film lipid layer thickness following treat- ment with warm compresses in patients with meibomian gland dysfunction. Eye Contact


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TFTTJPOT Lens. 2003;29(2):96-9. 13. Welling JD, et al. Chronic eyelid dermatitis secondary to cocamidopropyl betaine allergy in a patient using baby shampoo eyelid scrubs. JAMA Ophthalmol. 2014;132(3):357-9. t
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BXBSFOFTT 15. Maguire M, Asbell P, Group DSR. N-3 fatty acid supplementation and dry eye disease. N Engl J Med. 2018;378:1681-90. 16. Abdelhamid A, Brown T, Brainard J, et al. Omega 3 fatty acids for the primary and sec- t
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TFOTBUJPO id941412795?mt=8. Accessed August 30, 2018. 18. Eyeleo PC application. eyeleo.com. Accessed August 30, 2018. 19. Thomas J, Jacorb GP, Abraham L, Noushad B. The effect of smoking on the ocular sur- t
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MFOTFT face and the precorneal tear film. Australas Med J. 2012;5(4):221-6. 20. Moss SE, Klein R, Klein BE. Prevalence of and risk factors for dry eye syndrome. Archives of Ophthalmology. 2000;118(9):1264-8. 21. Xu L, Zhang W, Zhu X, et al. Smoking and the risk of dry eye: a meta-analysis. Int J Oph- Free Trial Pack thalmol. 2016;9:1480-6. 22. Lee W, Lim SS, Won JU, et al. The association between sleep duration and dry eye syn- Call today drome among korean adults. Sleep Medicine. 2015;16:1327-31. 23. Kawashima M, Uchino M, Yokoi N, et al. The association of sleep quality with dry eye dis- 877-220-9710 ease: the Osaka study. Clin Ophthalmol. 2016;10:1015-21. 24. Yeo S, Louis Tong L. Coping with dry eyes: a qualitative approach. BMC Ophthalmol. 2018;18:8. 25. Alevi D, Perry HD, Wedel A, et al. Effect of sleep position on the ocular surface. Cornea. 2017;36:567-71. 26. Chen X, Sullivan D, Sullivan A, et al. Toxicity of cosmetic preservatives on human ocular surface and adnexal cells. Exp Eye Res. 2018;170:188-97. 27. Caffery B. Influence of diet on tear function. Optom Vis Sci. 1991;68:58-72. 28. Sears B. Anti-inflammatory diets. J Am Coll Nutr. 2015;34:14-21.

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DRY EYE DISEASE: KNOW YOUR COMORBIDITIES Dry, irritated eyes can be one of the trickiest clinical findings. These systemic associations may be the key. By Cecelia Koetting, OD

s a multifactorial disease tion (MGD)—particularly in post- current literature and mechanisms affecting more than 30 menopausal women.1,2 Added to of action will help clinicians better million people within this complex clinical picture is the recognize patients presenting with the United States, dry association between DED and many multiple diagnoses contributing to Aeye disease (DED) is an unavoid- systemic conditions such as diabe- one another. able clinical finding in optometric tes, inflammatory diseases, thyroid practice.1 Although race, sex and dysfunction and dermatological, Who’s Hung Out to Dry age are all factors that can affect psychological and neurological Some of the common systemic dis- a patient’s likelihood of DED, the diagnoses. With myriad comorbidi- eases associated with dry eye ODs condition can manifest in just about ties causing and contributing to a may encounter in clinical practice any patient population with vari- patient’s dry eye, clinicians must include: able signs and symptoms, or none have a basic understanding of many Diabetes. The estimated 30.2 mil- at all. For example, studies have health arenas to properly diagnose lion Americans (12.2% of the popu- shown that women have a 50% to and manage the disease. lation) with diabetes mellitus (DM) 70% increased risk of DED and This article highlights many com- type 1 or 2—and another estimated worsening of signs—decreased tear mon systemic conditions that may 84.1 million who are prediabetic— osmolarity, Schirmer’s score and be contributing to your patient’s are all more prone to DED and ocu- increased meibomian gland dysfunc- dry eye. A brief discussion of the lar surface disease.3,4 A recent study

Release Date: November 15, 2018 Faculty/Editorial Board: Cecelia Koetting, OD Expiration Date: October 22, 2021 Credit Statement: This course is COPE approved for 2 hours of CE credit. Course ID is 59742-AS. Check with your local state licens- Goal Statement: Dry eye disease can manifest in just about any patient population with variable signs and symptoms, or none at all. ing board to see if this counts toward your CE requirement for Myriad systemic conditions can cause and contribute to a patient’s relicensure. dry eye, and clinicians must have a basic understanding of many Disclosure Statements: health arenas to properly diagnose dry eye and its etiology. This Authors: The author has no relationships to disclose. article discusses the current literature and mechanisms of action for many common systemic conditions that can contribute to dry eye Editorial staff: Jack Persico, Rebecca Hepp, William Kekevian, to help clinicians better recognize patients presenting with multiple Catherine Manthorp and Mark De Leon all have no relationships to diagnoses. disclose.

REVIEWREVIEW OF OPTOMETRY OF OPTOMETRY NOVEMBER JULY 15, 2018 67

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found that 51.3% of the par- lems, a reduced reflex and basal ticipants with diabetes had DED tear secretion.5 These patients are but were undiagnosed.5 These at a higher risk for DED progres- patients often have a decreased sion and non-compliance with tear break-up time (TBUT) and treatment because they don’t tear instability related to the note early dry eye symptoms. decreased mucin layer caused by The recommended yearly dia- a reduction in goblet cell density betic eye exam to monitor for in the conjunctiva.1,4 When test- ocular signs of complications ing diabetes patients for DED, should include a careful assess- clinicians should be aware that ment of the ocular surface for not all tests are equal. One study signs of dry eye.6,10 At the very compared diagnostic tests in this least, this ought to involve TBUT patient population and found that and both corneal and conjunc- the Ocular Surface Disease Index tival staining. Clinicians should (OSDI) only detected 17.1% of also consider adding tear osmo- DED patients, which was the low- larity and meibography.6 est compared with TBUT, Schirm- Chronic inflammatory dis- er’s score, corneal/conjunctival eases. These conditions, includ- staining and tear osmolarity.6 This Sjögren’s syndrome patient has filamentary ing rheumatoid arthritis (RA), MGD is also a major cause of keratitis. Sjögren’s syndrome (SS), inflam- DED in patients with type 2 dia- matory bowel disease (IBD) and betes. A study of diabetic patients population, and clinicians should sarcoidosis can all contribute to an and DED patients without DM treat any signs of DED, regardless increase in DED. One study found looked at the OSDI score, TBUT, of whether DM patients are com- that 11% of RA patients had per- Schirmer’s score, corneal staining, plaining of symptoms.7 sistent ocular and oral dryness, and lipid layer thickness, meibomian Research also suggests these 17.5% had sporadic dryness—a gland parameters, HbA1C and patients may experience damage 1.24x increased risk compared with duration of diabetes.7 The research- to the microvascular supply of the patients not diagnosed with RA.11 ers found tear volume in DED lacrimal gland, causing decreased The prevalence of ocular dryness patients without DM was higher production and reduced lacrimal also increased by 10% to 13% than in patients with DM; however, innervation from the autonomic for every 10 years of treatment.11 the meibomian gland parameters neuropathy and decreased con- Higher rates of self-reported body were higher with normal OSDI junctival injection.1,5,8 Notably, a pain and fatigue were also noted to scores in the diabetic patients with- decrease in tear secretion may be have the highest clinical correlation out DED.7 Thus, MGD likely pres- more severe in patients with non- to dryness.11 A study in the United ents before ocular symptoms in this proliferative diabetic retinopathy Kingdom also found that 70% of (NPDR) com- RA patients had dry eye, but only pared with 12% were being treated for it.12 those without SS is most typically identified by NPDR.4,9 the altered lacrimal and salivary In conjunc- gland function and may be pres- tion, patients ent in conjunction with other with diabetes autoimmune syndromes such as experience a RA, Wegener’s granulomatosis decrease in and systemic lupus erythematosus corneal sen- (SLE).13,14 One study found 57% of sitivity and patients with SLE also suffered from wound heal- pathological dry eye.15 ing known to With SS, the exocrine glands are In this meibography of a diabetic patient with MGD, note the gland lead to, among infiltrated by lymphocytes CD4+ truncation and poor gland structure. other prob- T- and B-cells causing dysfunction

68 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

067_ro1118_f5_osc.indd 68 11/14/18 2:09 PM and destruction.16 The Photo: Matt Dixon, OD lems and DED. One study most commonly affected estimates as many as 85% are the salivary and lac- of Graves’ orbitopathy rimal glands, which can patients experience dry eye be biopsied to confirm symptoms.22 diagnosis. Research shows Physical changes such increased expression of cell as lagophthalmos and surface adhesion molecule exophthalmos can lead to ICAM-1, which binds to poor lid closure, causing LFA-1 on lymphocytes dryness from exposure and and recruits antigen- incomplete blinking.22 This presenting cells that initi- may also result in high tear ate an immune-mediated osmolarity secondary to inflammatory response.16 evaporation.22 Research- This chronic inflammation Dry eye is a common ocular side effect of both hyper- and ers suspect the reduction leads to worsening of DED hypothyroidism. in tear production occurs and keratoconjunctivita due to the inflammatory sicca, which can be monitored with Pathophysiology of this increased process that causes lacrimal gland corneal/conjunctival staining, TBUT diagnosis of DED in IBD patients is deficiency.22 These physical changes and tear osmolarity.16 poorly understood, but researchers may also be an indicator in patients The inflammatory disease sar- suspect an increased inflammation who are being treated for dry eye coidosis causes collections of due to local action of antigen-anti- that a thyroid issue may be present granulomas to form within organs body complexes that are produced and warrant bloodwork, including throughout the body. Most com- against the bowel wall vessels and T3, T4, TSH and TSI. monly, these non-caseating granulo- transported via the blood stream.21 These patients often experience mas form in the lungs, lymph nodes, Thyroid dysfunction. Graves’ an active phase of Graves’ orbitopa- lacrimal glands and skin.17 Approxi- orbitopathy, or thyroid eye disease, thy within 12 to 18 months of the mately 40% of sarcoidosis patients is an autoimmune disease where manifestation of systemic symptoms have ocular manifestations, with the patient’s thyroid-stimulating and then go into remission, with uveitis being the most common, but hormone receptor auto-antibodies the possibility of reactivation in exocrine gland and lacrimal gland cause excess thyroid hormone pro- the future.22 Once out of the active involvement can occur.17,18 When duction. It is most frequently seen phase, symptoms of Graves’ orbi- the exocrine gland is affected, it can in patients with hyperthyroidism topathy may lessen or even resolve, cause symptoms of both dry eye and but can also be found with hypo- depending on severity.22 mouth similar to SS.17,19 thyroidism and euthyroid states.22 Working with the patient’s physi- Because sarcoidosis and SS pres- This condition causes orbital tissue cian is important for systemic treat- ent similarly, bloodwork and a inflammation, leaving these patients ment to decrease ocular effects of biopsy are often necessary to differ- more prone to ocular surface prob- thyroid imbalance. entiate the two. When the lacrimal gland develops granulomas, it can Migraines: Double-edged Swords cause ocular adnexa swelling and Unfortunately for patients known to suffer from migraines, DED can both exacerbate the a decrease in lacrimal production, condition and be caused by it at the same time.1 A study found that patients who experience leading to both aqueous deficiency migraines had decreased mean TBUT and Schirmer’s scores and increased OSDI scores and and mechanical exposure from lissamine green staining when compared with the control group.1 These patients may also be potential lagophthalmos.17-19 more likely to experience dry eye because of corneal physiological changes. One study used Patients with IBD often experi- confocal microscopy to view the sub-basal corneal nerve plexus in chronic migraine patients. ence ocular manifestations such Compared with non-migraine sufferers, these patients had significantly decreased nerve fiber as episcleritis, scleritis, iritis and density, decreased nerve fiber length and symptoms of DED.2 DED.20,21 One study found that 1. Koktekir BE, Celik G, Karalezli A, Kal A. Dry eyes and migraines: is there really a correlation? Cornea. 2012;31(12):1414-6. 22% of patients with IBD experi- 2. Kinard KI, Smith AG, Singleton JR, et al. Chronic migraine is associated with reduced corneal nerve fiber density and symptoms of dry enced DED, in comparison with eye. Headache. 2015;55(4):543-9. only 11% of the control patients.20

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tion and meibomian gland dropout, cals) and Ritalin (methylphenidate the DED will not likely resolve with hydrochloride, Novartis), can also discontinuation of the medication.26 cause dry eye.29 One study found Psychological conditions. For patients with ADHD had a higher patients with anxiety or depression, OSDI score and rate of DED symp- DED can be exacerbated by both toms compared with non-ADHD the medication and physiological patients.29 However, limited infor- changes. Research shows chronic mation exists and the mechanism is depression can worsen DED because poorly understood, indicating further This patient with OSA has DED and of an increase in pro-inflammatory studies are necessary to further inves- anterior membrane dystrophy. cytokines production.27 It can also tigate the validity of this claim. hinder the patient’s ability to deal Parkinson’s disease (PD). These Dermatological conditions. Acne with the discomfort and pain of the patients are predisposed to dry eye rosacea and acne vulgaris can mani- condition, as well as feed into a neg- caused by both motor function and fest with ocular sequelae, including ative feedback loop that exacerbates physiological changes. Blink rate eye dryness. In the case of rosacea, the depression or anxiety.27 Unre- is significantly decreased, allow- this chronic skin disorder affects sponsive dry eye patients who also ing for more exposure time of the the sebaceous glands, and ocular exhibit depressive behavior can be cornea and an increase in dryness. involvement can include irritation, referred for an evaluation with their One study found PD patients had an blepharitis, epiphora and eyelid primary care provider if not already average blink rate of 12.7 times per margin erythema telangiectasia.23 diagnosed and under treatment. minute, significantly lower than the Ocular findings can occur with or A large Veterans Affairs study control patients’ average blink rate without the primary skin findings, found patients who experienced of 21.8 times per minute.30 The same and the estimated incidence var- DED had a higher odds ratio for study noted that PD patients had ies between 6% and 72%.23 The both post-traumatic stress disorder significantly decreased meibomian mechanism isn’t well understood, but (PTSD) and depression.27,28 The data gland function and tear meniscus chronic inflammation is at the root showed that 19% of male patients height.30 Another study found lower of ocular symptoms.23 Inflammation and 22% of female patients diag- Schirmer scores and higher overall of the meibomian glands can cause nosed with PTSD were also diag- OSDI scores.31 Researchers speculate abnormal lipid secretion and clogged nosed with DED. An odds ratio of this is due to decreased androgen glands, leading to tear film quality 1.92 DED risk was calculated for levels and autonomic dysfunction changes clinicians can measure with PTSD patients. An increased risk caused by Lewy bodies at the sym- both TBUT and tear osmolarity.23 was found for the same patients who pathetic ganglia, substantia nigra Dry eye in patients with acne were using multiple systemic medica- and peripheral parasympathetic gan- vulgaris is usually related to the tions.28 glia.32,33 medication rather than the disease. Attention deficit hyperactive dis- Also, researchers believe oxidative Isotretinoin, which is commonly order (ADHD) has been linked to an stress occurs in both Parkinson’s and used to treat acne vulgaris, causes increased incidence of DED, and the Alzheimer’s disease, further exacer- decreased density and atrophy of medications used to treat ADHD, bating DED.19 Mice studies found the meibomian glands, leading to Adderall (dextroamphetamine/ that the functional knockout of the ocular surface problems.24 One study amphetamine, Teva Pharmaceuti- mev-1 gene caused a decrease in tear

noted a decreased TBUT in 69.1% Photo: Victoria Roan, OD production, lacrimal dysfunction and of patients and the development DED and conclude that oxidative of blepharitis in 40% of patients.25 stress causes inflammation and leads Another study found similar results to these problems.34,35 of decreased TBUT in 50% of Future studies with human sub- patients and blepharitis in 55%.26 jects may one day show the same In both studies, the changes disap- correlation, providing an earlier indi- peared within one month of patients This patient’s elastic, easily pliant cator of DED and the need for early discontinuing the medication.25,26 eyelids prompt a diagnosis of FES, which intervention for those who suffer However, when a patient experiences is linked to several severe ocular and from diseases with known oxidative permanent sebaceous gland dysfunc- systemic diseases. stress.

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067_ro1118_f5_osc.indd 70 11/14/18 2:10 PM Neuropathic pain. This is caused Table 1. Common Medications Causing or Aggravating Dry Eye1,2 by a lesion or disease of the somato- sensory system, leading to sensitiza- Amphetamines Antineoplastics Dextroamphetamine/amphetamine tion of the peripheral and central Anti-Parkinson’s nerves. In turn, this causes maladap- Methylphenidate hydrochloride Antipsychotics tive neuroplastic changes to both the Antiarrhythmics Thioridazine PNS and CNS sensory processing Propranolol pathways. A discrepancy in signs and Chlorpromazine Oxprenolol symptoms can be found in a sub- Pimozide Clonidine group of DED. These patients also Pindolol Antirheumatics show signs of ocular neuropathic Nadolol pain, including abnormal sensations, Antispasmodics Metoprolol spontaneous pain, pain from light or Carvedilol Decongestants wind and exaggerated pain to nor- mal stimulus.27 Antidepressants Dermatologic Ocular neuropathic pain can Sertraline Isotretinoin happen with reoccurring corneal Paroxetine Gastrointestinal nerve injury or inflammation, which Amitriptyline Lansoprazole causes chronic changes to both Doxepin Omeprazole the peripheral and central corneal Esomeprazole magnesium Antihistamines somatosensory pathways. Research Ranitidine Diphenhydramine has found this same mechanism of Cimetidine corneal nerve injury and regeneration Chlorpheniramine in LASIK patients, which is believed Loratadine Hormone replacement therapy to be the cause of dry eye symptoms Cetirizine Estrogen post-surgery.27 Desloratadine Progestines Studies have also shown chronic Fexofenadine Neurotoxins pain syndrome (CPS) is associated Botulinum toxins A and B with DED. One study of 154 patients Antihypertensives found that patients with CPS had Thiazides Pain relief worse dry eye symptoms and ocu- Hydrochlorothiazide Opioids lar pain compared with controls.27 Furosamide Hydrocodone/acetaminophen These patients may also be more Atenolol Propoxyphene napsylate/acetometaphin prone to neuropathic ocular pain, Acebutolol Ibuprofen which would exhibit in the clinic as Antimalarials Sedatives pain out of proportion with ocular Hydroxychloroquine Primidone signs of DED.27 Sleep disorders. The lack of qual- 1. Bowling E. Which oral meds cause dry eye? RCCL. June 2011. ity sleep—the right amount of REM 2. Fraunfelder FT. Sciubba JJ, Mathers WD. The role of medications in causing dry eye. J Ophthalmol. 2012;2012:285851. cycles, or deep sleep—can lead to myriad adverse outcomes, including Nearly 18 million adults in by the lacrimal gland caused by circadian rhythm disruption, hyper- America suffer from obstructive chronic intermittent hypoxia. This in tension, metabolic syndrome and sleep apnea (OSA), according to turn damages the meibomian glands even ocular sequelae.36-38 A recent the National Sleep Foundation.40 and goblet cells, decreases corneal study of the association between This condition has also been linked sensitivity and reduces tear produc- sleep quality and DED found 45% to floppy eyelid syndrome (FES), tion.41,42 of DED patients also reported poor corneal erosions, keratitis and punc- Studies looking at DED in patients sleep quality.36 Prior studies found tate corneal epitheliopathy.41 These with OSA without FES found tear instability and decreased secre- patients often experience a continual higher OSDI scores and significantly tion related to changes in circadian state of inflammation in the eye due decreased TBUT and Schirmer scores rhythm, as well as lower tear secre- to increased accumulation of pro- in moderate and severe sleep apnea tion in metabolic syndrome.36,38,39 inflammatory cytokines produced patients when compared with those

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Photo: Mile Brujic, OD, and Jason Miller, OD, MBA 1. Stapleton F, Alves M, Bunya VY, et al. TFOS DEWS II epidemiology 41 in the control group. Dryness can report. Ocul Surf. 2017;15(3):334-65. also be exacerbated by ill-fitting 2. Sullivan DA, Rocha EM, Aragona P, et al. TFOS DEWS II sex, gender, and hormones report. Ocul Surf. 2017;15(3):284-333. continuous positive airway pressure 3. Center for Disease Control. National Diabetes Statistics Report, 2017. www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes- masks that leak air toward the eye. statistics-report.pdf. July 18, 2017. Accessed August 20, 2018. FES is caused by lid laxity due to 4. Skarbez K, Priestley Y, Huepf M, Koevary SB. Comprehensive review of the effects of diabetes on ocular health. Expert Rev Ophthalmol. a decrease in elastin content, lending 2010;5:557-77. the patient to spontaneous inversion, 5. Schwartz S, Halleran C, Doll T, et al. Does diabetes make a differ- 43 ence in dry eye? ARVO 2018. Abstract 956-B0134. eversion or both. The spontaneous 6. Najafi L, Malek M, Valojerdi AE, et al. Dry eye disease in type 2 nocturnal eyelid eversion leads to diabetes mellitus; comparison of the tear osmolarity test with other common diagnostic tests: a diagnostic accuracy study using STARD irritation of the conjunctiva and pos- standard. J Diabetes Metab Disord. 2015;14:39. sible corneal abrasions. Poor apposi- 7. Wu H, Xie F, Luo S, et al. Meibomian gland dysfunction is an early sign and major cause of dry eye in Type 2 diabetes. ARVO 2018. tion of the lids causes a compromise Abstract 4900-C0345. of the tear film, in theory leading to Significant corneal staining in a patient 8. Kaiserman I, Kaiserman N, Nakar A, Vinker S. Dry eye in diabetic 43 patients. Am J Ophthalmol. 2005;139:498-503. DED. with Sjögren’s, fibromyalgia and 9. Yoon KC, Im SK, Seo MA. Changes in tear film and ocular surface in Although not all patients with rheumatoid arthritis. diabetes mellitus. Korean J Ophthalmol. 2004;18:168-74. 10. American Optometric Association. Evidence-based clinical practice OSA have FES, an increased inci- guideline: Eye care of the patient with diabetes mellitus. 2014. dence exists in patients with OSA. uncover more concrete evidence of 11. Wolfe F, Kaleb M. Prevalence, risk, and risk factors for oral and ocular dryness with particular emphasis on rheumatoid arthritis. J Those with both conditions have these associations, as many studies Rheumatol. 2008;35(6):1023-30. a higher correlation of DED than have yet to discern the true cause of 12. Piper H, Douglas KM, Treharne GJ, et al. Prevalence and predictors 41 of ocular manifestations of RA: is there a need for routine screening? patients with OSA only. DED—the systemic condition or the Musculoskeletal Care. 2007;5(2):102-17. systemic medication. Because neither 13. Gilboe IM, Kvien T, Uhlig T, Husby G. Sicca symptoms and secondary Sjögren’s syndrome in systemic lupus erythematosus: Medication Woes one is often modifiable, ODs must comparison with rheumatoid arthritis and correlation with disease Many pharmaceuticals used to treat be prepared for the ongoing care and variables. Ann Rheumatic Dis. 2001;60(12):1103-9. 14. Bron AJ, de Paiva CS, Chauhan SK, et al. TFOS DEWS II patho- psychological conditions, dermato- comanagement these patients need. physiology report. Ocul Surf. 2017;15(3):438-510. logical conditions, allergies, epilepsy The first step is identifying the 15. Ostanek L. Ocular manifestations in patients with systemic lupus erythematosus and antiphospholipid syndrome. Pol Arch Med Wewn. and seizure disorders can cause or comorbidities themselves. Only then 2007;117 Suppl:18-23. exacerbate DED (Table 1). When can clinicians make informed treat- 16. Stern ME, Gao J, Schwalb TA, et al. Conjunctival T-cell subpopula- tions in Sjogren’s and non-Sjogren’s patients with dry eye. Invest discussing a patient’s systemic dis- ment decisions to improve patient Ophthalmol Vis Sci. 2002;43(8):2609-14. order and related medications, it is comfort and satisfaction. ■ 17. Drosos AA, Constantopoulos SH, Psychos D, et al. The forgotten cause of sicca complex; sarcoidosis. J Rheumatol. 1989;16(12):1548- important to be thorough, as many Dr. Koetting is the referral opto- 51. metric care and externship program 18. Groen F, Rothova A. Ocular involvement in sarcoidosis. Semin patients may be resistant to discuss- Respir Crit Care Med. 2017;38(4):514-22. ing their health history without coordinator at Virginia Eye Con- 19. Zoukhri D. Effect of inflammation on lacrimal gland function. Exp Eye Res. 2006;82(5):885-98. understanding the connection with sultants in Norfolk, VA. She is a 20. Felekis T, Katsanos K, Kitsanou M, et al. Spectrum and frequency their ocular health. fellow of the American Academy of of ophthalmologic manifestations in patients with inflammatory bowel disease: a prospective single center study. Inflamm Bowel Dis. Often, discontinuing an offending Optometry and a trustee of the Vir- 2009;15(1):29-34. medication is not an option. In these ginia Optometric Association. 21. Troncoso LL, Biancardi AL, de Moraes HV Jr, Zaltman C. Oph- thalmic manifestations in patients with inflammatory bowel disease: a cases, optometrists must address the review. World J Gastroenterol. 2017;23(32):5836-48. patient’s ocular signs and symptoms 22. Selter JH, Gire AI, Sikder S. The relationship between Graves’ oph- thalmopathy and dry eye syndrome. Clin Ophthalmol. 2015;9:57-62. as best as possible. Clinicians should 23. Arman A, Demirseren DD, Takmaz T. Treatment of ocular rosacea: always comanage with the treat- comparative study of topical cyclosporine and oral doxycycline. Intern J Ophthalmol. 2015;8(3):544-9. ing physician to discuss alternatives 24. Mathers WD, Shields WJ, Sachdev MS, et al. Meibomian gland when DED therapy isn’t working morphology and tear osmolarity: changes with Accutane therapy. Cornea. 1991;10(4):286-90. and the patient’s vision is at risk. 25. Egger SF, Huber-Spitzy V, Böhler K, et al. Ocular side effects While all patients should be treat- associated with 13 cis retinoic acid therapy for acne vulgaris: clinical features, alterations of tearfilm and conjunctival flora. Acta Ophthalmo- ed as a whole, those with DED may logica Scandinavica. 1995;73(4):355-7. warrant a little extra care. Many 26. Bozkurt B, Irkec MT, Atakan N, et al. Lacrimal function and ocular complications in patients treated with systemic isotretinoin. Eur J systemic conditions can cause or Ophthalmol. 2002;12:3:173-6. exacerbate dry eye, as can the vari- 27. Han SB, Yang HK, Hyon JY, Wee WR. Association of dry eye dis- ease with psychiatric or neurological disorders in elderly patients. Clin ous treatments necessary to maintain Interv Aging. 2017;12:785-92. a patient’s quality of life. This DED patient on medication for 28. Galor A, Feuer W, Lee DJ, et al. Depression, post-traumatic stress disorder, and dry eye syndrome: a study utilizing the national United Optometrist should remain famil- depression has diffuse superficial States Veterans Affairs administrative database. Am J Ophthalmol. iar with ongoing research to help punctate keratitis. 2012;154(2):340-6.e2.

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067_ro1118_f5_osc.indd 72 11/14/18 2:10 PM 29. Cho KJ, Kim HK, Lim MH, et al. Depression, ADHD, job stress 34. Uchino Y, Kawakita T, Miyazawa M, et al. Oxidative stress induced 39. Yaguchi S, Ogawa Y, Shimmura S, et al. Angiotensin II type 1 and sleep problems with dry eye disease in Korea. Am J Psychiatry. inflammation initiates functional decline of tear production. PLoS One. receptor antagonist attenuates lacrimal gland, lung, and liver fibrosis 2015;18:331. 2012;7(10):e45805. in a murine model of chronic graft-versus-host disease. PLoS One. 30. Cengaver T, Melek IM, Duman T, Oksüz H. Tear film tests in Parkin- 35. Yi W, Asbell PA. The core mechanism of dry eye disease (DED) is 2013;8:e64724. son’s disease patients. Ophthalmology. 2005;112(10):1795. inflammation. Eye Contact Lens. 2014;40(4):248-56. 40. Hauri P. The Sleep Disorders. National Sleep Foundation. 2018. 31. Nowacka B, Lubinski W, Honczarenko K, et al. Ophthalmological 36. Kawashima M, Uchino M, Yokoi N, et al. The association of sleep 41. Karaca EE, Akçam HT, Uzun F, et al. Evaluation of ocular surface features of Parkinson disease. Med Sci Monit. 2014 Nov;20:2243-9. quality with dry eye disease: the Osaka study. Clin Ophthalmol. 2016 health in patients with obstructive sleep apnea syndrome. Turk J Oph- 32. Kandel ER, Schwartz, Jessell TM. Principles of Neural Science. 3rd Jun 1;10:1015-21. thalmol. 2016;46(3):104-8. ed. New York: Elsevier; 1991. 37. Gangwisch JE. Epidemiological evidence for the links between 42. Acar M, Firat H, Acar U, Ardic S. Ocular surface assessment in 33. Okun MS, McDonald WM, DeLong MR. Refractory nonmotor sleep, circadian rhythms and metabolism. Obes Rev. 2009;10(Suppl patients with obstructive sleep apnea-hypopnea syndrome. Sleep symptoms in male patients with Parkinson disease due to testoster- 2):37-45. Breath. 2013;17:583-8. one deficiency: a common unrecognized comorbidity. Arch Neurol. 38. Wolk R, Somers VK. Sleep and the metabolic syndrome. Exp 43. Miyamoto C, Santo LCE, Roisman L, Osaki M. Floppy eyelid syn- 2002;59:807-11. Physiol. 2007;92:67-78. drome. Arquivos Brasileiros de Oftalmologia. 2011;74(1):64-6.

OSC QUIZ

ou can obtain transcript-quality b. Systemic lupus erythematosus. 9. Which disease causes reduced corneal continuing education credit through c. Wegeners granulomatosis. sensitivity, thereby making patients less Ythe Optometric Study Center. Com- d. Ankylosing spondylitis. symptomatic to dryness? plete the test form and return it with the a. Thyroid eye disease. $35 fee to: Jobson Medical Information, 4. What percentage of patients with thyroid b. Acne. Dept.: Optometric CE, 440 9th Avenue, eye disease experience dry eye symptoms? c. Diabetes. 14th Floor, New York, NY 10001. To be a. 65% to 85%. d. Rheumatoid arthritis. eligible, please return the card within one b. 100%. year of publication. You can also access c. 25% to 30%. 10. Which of these medications is commonly the test form and submit your answers d. 45% to 60%. used to treat acne vulgaris and causes dry and payment via credit card at Review of eye symptoms? Optometry online, www.reviewsce.com. 5. Which of the following is not a sign/ a. Diflucan. You must achieve a score of 70 or symptom of thyroid eye disease? b. Isotretinoin. higher to receive credit. Allow four weeks a. Dry eye. c. Metformin. for processing. For each Optomet ric Study b. Lagophthalmos. d. Prolensa. Center course you pass, you earn 2 hours c. Dry mouth. of transcript-quality credit from Pennsyl- d. Exophthalmos. 11. Parkinson’s disease patients usually have vania College of Optometry and double dry eyes because: credit toward the AOA Optom et ric Recog- 6. Which of these is a cause of dry eye in a. They blink less. nition Award—Cate gory 1. patients with diabetes? b. It increases production of pro- Please check with your state licensing a. Infiltration of exocrine glands by inflammatory cytokines. board to see if this approval counts toward lymphocytes. c. Of chronic intermittent hypoxia. your CE requirement for relicensure. b. Reduced goblet cell density in the d. Of damage to the goblet cells. conjunctiva. 1. Which two systemic diseases that c. Lacrimal gland secreting thyroid- 12. Depression worsens dry eye disease by: contribute to dry eye manifest similarly to stimulating hormone receptors that are a. Increasing production of pro-inflammatory one another? attacked by autoantibodies. cytokines. a. Sarcoid and thyroid disease. d. Formation of granulomas. b. Decreasing patient’s ability to deal with b. Sjögren’s syndrome and diabetes. discomfort and pain. c. Sjögren’s syndrome and sarcoid. 7. Which condition presents with dry eye c. Feeding into a negative feedback loop that d. Diabetes and hypertension. symptoms due to the medication moreso makes depression worse. than the disease process itself? d. All of the above. 2. Which of the following conditions causes a. Diabetes. potential damage to the microvascular b. Sjögren’s syndrome. 13. Ocular neuropathic pain: supply of the lacrimal gland, thereby leading c. Sarcoid. a. Could be the cause of dry eye symptoms to decreased tear production? d. Acne. post-LASIK. a. Thyroid disease. b. Increases tear function. b. Diabetes. 8. Which condition causes granulomas in c. Causes chronic changes only to the c. Rheumatoid arthritis. the lacrimal gland, leading to ocular adnexa peripheral somatosensory pathway. d. Acne vulgaris. swelling and decreased tear production? d. Occurs with an acute episode of corneal a. Sarcoid. abrasion. 3. Sjögren’s syndrome has been found in b. Diabetes. conjunction with all of the following, except: c. Sjögren’s syndrome. 14. Sleep disturbance is linked to: a. Rheumatoid arthritis. d. Acne rosacea. a. Circadian rhythm disruption.

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Examination Answer Sheet OSC QUIZ Dry Eye Disease: Know Your Comorbidities b. Hypertension. Valid for credit through October 22, 2021 c. Metabolic syndrome. Online: This exam can be taken online at www.reviewsce.com. Upon passing the exam, you can view your d. All of the above. results immediately and download a real-time CE certificate. You can also view your test history at any time from the website. 15. Sleep apnea is associated with all of Directions: Select one answer for each question in the exam and completely darken the appropriate circle. A the following, except: minimum score of 70% is required to earn credit. a. Keratitis. Mail to: Jobson Healthcare Information, LLC, Attn.: CE Processing, 395 Hudson Street, 3rd Floor, New b. Punctate corneal epitheliopathy. York, NY 10014. c. Floppy eyelid syndrome. Payment: Remit $35 with this exam. Make check payable to Jobson Healthcare Information, LLC. d. Retinal hemorrhages. Credit: This course is COPE approved for 2 hours of CE credit. Course ID is 59742-AS. Sponsorship: This course is joint-sponsored by the Pennsylvania College of Optometry. 16. Sleep apnea: Processing: There is a four-week processing time for this exam. a. Damages the glands of zeiss. b. Increases corneal sensitivity. Answers to CE exam: Post-activity evaluation questions: c. Reduces accumulation of cytokines. 1. A B C D Rate how well the activity supported your achievement of these learning objectives: d. Causes a decreased state of 2. A B C D 1=Poor, 2=Fair, 3=Neutral, 4=Good, 5=Excellent inflammation. 3. A B C D 21. Improve my understanding of the prevalence of dry eye associated with various systemic conditions. 1 2 3 4 5 4. A B C D 22. Become familiar with the mechanisms of action 17. Floppy eyelid syndrome is associated 5. A B C D contributing to dry eye associated with systemic conditions. 1 2 3 4 5 with: 6. A B C D 23. Increase my understanding of the complex interplay a. Parkinson’s disease. 7. A B C D between dry eye, systemic disease and systemic therapies. 1 2 3 4 5 b. PTSD patients. 8. A B C D 24. Better understand the connection between dry eye and c. Keratoconus. 1 2 3 4 5 9. A B C D diabetes. d. Depression. 10. A B C D 25. Increase my knowledge of the role chronic inflammatory diseases and thyroid dysfunction play in dry eye. 1 2 3 4 5 11. A B C D 18. Research shows migraine patients 26. Improve my ability to recognize the impact of 12. A B C D have: psychological and dermatological conditions on dry eye. 1 2 3 4 5 a. Increased TBUT. 13. A B C D Rate the quality of the material provided: 14. A B C D b. Increased OSDI scores. 1=Strongly disagree, 2=Somewhat disagree, 3=Neutral, 4=Somewhat agree, 5=Strongly agree c. Increased Schirmer’s scores. 15. A B C D 27. The content was evidence-based. 1 2 3 4 5 d. All of the above. 16. A B C D 28. The content was balanced and free of bias. 1 2 3 4 5 17. A B C D 29. The presentation was clear and effective. 1 2 3 4 5 19. Decreased nerve fiber density in the 18. A B C D 30. Additional comments on this course: corneal nerve plexus was seen in patients 19. A B C D with: 20. A B C D a. Sleep apnea. b. Migraines. Please retain a copy for your records. Please print clearly. c. ADHD. d. Depression. First Name Last Name 20. Obstructive sleep apnea has been linked to all the following, except: E-Mail a. Guttata. The following is your: Home Address Business Address b. Floppy eyelid syndrome. c. Corneal erosions. Business Name d. Punctate corneal epitheliopathy. Address

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By submitting this answer sheet, I certify that I have read the lesson in its entirety and completed the self- assessment exam personally based on the material presented. I have not obtained the answers to this exam TAKE THE TEST ONLINE TODAY! by any fraudulent or improper means. https://www.reviewsce.com

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Lesson 117237 RO-OSC-1118

74 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

0067_ro1118_f5_osc.indd67_ro1118_f5_osc.indd 7744 111/14/181/14/18 2:112:11 PMPM It may seem like a war...

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RO1018_Xcel.indd 1 10/8/18 11:13 AM Dilation

The Dilated Exam in the Age of Ultra-widefield Imaging The technology’s pros and cons have made it a hot topic in recent years. Here’s where it currently stands in clinical practice. By Amanda S. Legge, OD

he advent of and improve- to identify disease that could be view of a direct ophthalmoscope or ments in ultra-widefield imag- reasonably proven was present at undilated indirect exam and even ing (UWFI) technology now the time of the examination but fewer were in need of treatment or Tprovide clinicians an excel- was missed because of lack of dila- intervention.4 Despite the paucity of lent view of the posterior segment tion. DFEs remain the best method support in the literature, considering without dilation. On the surface, to maximally and stereoscopically the ocular disease we can identify in the technology offers many benefits. visualize the posterior segment those 5% of patients, it is ethically For the patient, it can decrease in- compared with UWFI alone from a and legally our responsibility to per- office wait time and eliminate any legal, ethical and clinical standpoint. form regular DFEs, even on asymp- side effects of dilation. For the clini- And when a UWFI instrument does tomatic patients. UWFI without cian, it can provide an opportunity image a suspicious retinal lesion, dilation should never be offered as a to use a patient’s own retinal image dilation is still the standard to fur- universal option to all patients, as it to discuss findings—thus improving ther evaluate and accurately diag- is below clinical standard of care. patient care with visual education. nose the finding.2 Given the current standard, the But limitations to these instru- Despite this, some question choice to image rather than dilate ments still exist, and most clinicians the support for routinely dilating remains a medical decision best continue to question their place in healthy, asymptomatic patients. made on a case-by-case basis. To clinical practice. This article takes a Studies show that routine DFE has make the right decision, clinicians closer look at the standards of care a low yield for discovery of serious must understand the evidence-based for when dilated fundus examina- ocular events and may be ineffec- studies, the pros and cons of UWFI tion (DFE) is indicated and where tive in altering the course and out- devices and dilation and the pitfalls this new technology fits in. come of incidental findings, even at of imaging alone. 10-year intervals in asymptomatic Set Your Standards Straight patients.3 Others have found that Consider the Evidence A dilated fundus examination is dilated exams yield clinical findings UWFI performance compared with considered the standard of care.1 in approximately 5% of asymp- DFE varies based on the disease In fact, an optometrist could be tomatic, low-risk patients and few studied. Clinicians should carefully legally liable if a UWFI image fails of these findings are beyond the consider the evidence of commonly

76 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

076_ro1118_f6.indd 76 11/16/18 10:52 AM Figs. 1 and 2. This patient has a longstanding choroidal nevus in the superior midperiphery that appears very light in color during funduscopy and could be easily overlooked if the biomicroscope is too bright and bleaches out the faint nevus. Even in the color UWFI image (left), it is somewhat difficult to appreciate; however, the green-free image (right) provides a clear view.

encountered posterior segment patient outcomes. In fact, data should be dilated on a regular basis symptoms and diseases before rec- shows a tendency for clinical grad- to best assess definitive optic nerve ommending UWFI to the patient. ing to be less severe than image head changes with stereopsis, which Diabetes. Given that nearly 86% grading, which could be a potential is still considered the standard for of individuals with type 1 diabetes source of clinical risk if it delays monitoring glaucoma.13 and 40% of those with type 2 diabe- treatment, as the disease severity Currently, no reliable studies tes have some form of clinically evi- changes the recommended follow- compare dilation with UWFI for dent diabetic retinopathy (DR), the up schedule.8 grading either cup-to-disc ratio or American Optometric Association’s Generally, studies conclude that (AOA) Evidence Based Clinical although results seem promising for Restricted Access Practical Guidelines and the Ameri- UWFI as a telemedicine screening In our practice, patients are only eligible can Academy of Ophthalmology’s tool in diabetes, a larger study size is for UWFI screening in lieu of dilation under (AAO) Preferred Practice Pattern, required before it can be considered several conditions: recommend individuals with dia- the standard of care.8-10 (1) They had a normal dilated betes receive at least annual dilated Primary open-angle glaucoma. examination within the past two years. eye examinations.5-7 More frequent The AOA and the AAO recom- (2) They do not have any known ocular exams may be needed depending on mend an examination of the optic pathology. the presence of DR, and the AOA nerve that requires stereoscopic (3) They are not at high risk for any outlines specific recommendations visualization with adequate magni- ocular disease, such as diabetic retinopathy. based on the severity.5 fication.11,12 To achieve stereopsis, Other considerations include the Several studies have demonstrated the pupils must be dilated and the patient’s refractive error, family history good agreement between Optomap patient examined with a 78D or and current list of medications. The UWFI UWFI (Optos) and dilated fundus- 90D lens. Evaluation of the optic screening option is only offered to patients copy of grading DR by doctors of nerve also includes ruling out other on a case-by-case basis by the doctors varying levels of expertise.8 Of the potential causes of optic atrophy and is never discussed as an option by our discrepancies noted, there were or subtle abnormalities that might staff. We do not have a universal option minimal to no instances where the result in visual field loss similar for patients to choose dilation vs. UWFI difference in grading would have to that caused by glaucoma.11,12 themselves. significantly or adversely affected Therefore, patients with glaucoma

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the rate of glaucoma diagnosis and biomicroscopic examination of of macular degeneration.19 management. However, several stud- the macula.17,18 Even conservative Patients diagnosed with AMD ies show good agreement and high recommendations include compre- require dilation at appropriate inter- reproducibility in the evaluation of hensive examinations with dilation vals, depending on disease severity, vertical cup-to-disc ratio compared every one to two years after the age to detect the earliest signs of choroi- with stereoscopic optic disc imaging, of 65 to catch the subtle early signs dal neovascularization. suggesting UWFI may be No studies show that helpful for glaucoma diag- color image UWFI has nosis in situations in which apparent benefits over standard color digital stere- dilated exams for the oscopy is not available.14 diagnosis or management In some instances, certain of macular degeneration. UWFI features that allow While ongoing studies easier assessment of the reti- are evaluating the ability nal nerve fiber layer (RNFL) to phenotype the retinal may help improve glaucoma periphery with UWFI to diagnosis and management, monitor peripheral patho- including red-free imaging logic changes in AMD, these and fundus autofluorescence peripheral grading criteria (FAF). Although UWFI is are difficult to assimilate not specifically designed to into clinical practice.20,21 quantifiably measure RNFL Posterior vitreous detach- loss, subtle RNFL defects ment and peripheral vitreo- seen using red-free images retinal disease. According may indicate early glauco- to the AOA, binocular indi- matous damage before the rect ophthalmoscopy with development of glaucoma- pupillary dilation is gener- tous optic nerve cupping. ally necessary to diagnose Visible RNFL loss on a peripheral retinal break red-free imaging should be or detachment with scleral further investigated as a depression, if indicated. The potential indicator of glau- AAO’s Preferred Practice coma or other optic neu- Patterns specifically states ropathy as you would with “wide-field color photogra- other clinically identifiable phy can detect some periph- risk factors. Red-free serial eral retinal breaks but does imaging can also be used to not replace careful ophthal- monitor for RNFL wedge moscopy” for peripheral defect progression over vitreoretinal disease.22,23 time.15 Additionally, FAF Figs. 3 and 4. Despite no entering symptoms, a DFE Several studies compare can detect and monitor the revealed a large operculum with four large retinal holes dilation with UWFI modali- extent of peripapillary atro- with surrounding subretinal fluid. Optomap imaging was ties for non-traumatic phy, although not enough recommended to photodocument the finding, and the initial retinal breaks, and most evidence exists to correlate photograph (top) was wide and reliable with the patient agree that UWFI is a useful hypo-FAF in peripapillary fixating straight as per routine protocol. After instructing adjunct for documenta- atrophy to functional glau- the patient to look in the direction of known pathology, the tion, but its ability to detect comatous damage.16 holes were easily detected by the instrument (bottom). If this the break, especially in the Age-related macular patient had not been dilated and UWFI were used to assess inferior and superior periph- degeneration (AMD). Both retinal health alone in primary gaze, her image would have ery, is low to moderate the AOA and the AAO been read as unremarkable. Instead, a thorough DFE enabled compared with DFE.24 One recommend stereoscopic prompt diagnosis and same-day laser retinopexy. study shows that for retinal

78 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

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Figs. 5 and 6. This patient has significant fine drusen throughout the posterior pole that was difficult to image using UWFI, left. If UWFI were the only modality used to monitor this patient’s retinal health, it would likely be interpreted as normal. Instead, this patient’s fundus photograph, right, clearly shows well defined, hard, small drusen scattered in the posterior pole, leading to further testing and a diagnosis of early AMD.

lesions posterior to the equator, sen- tic yield of DFEs in asymptomatic the side effects of dilation, it also sitivity of detection was 74%; how- patients is not high, particularly in impresses patients. Some may even ever, for anterior lesions it was only younger age groups.26,27 Both the seek out offices that are known to 45%.25 Furthermore, occasional AAO and AOA acknowledge the offer UWFI to avoid dilation if pos- instrument artifacts can result in a lack of published research to sup- sible, which makes this technology false positive diagnosis of retinal port or refute the use of routine quite profitable, as it is typically an detachment, choroidal lesions, vas- pharmacologic dilation in asymp- additional out-of-pocket charge. cular inflammation or retinal eleva- tomatic, low risk patients.1,19 It also provides the doctor several tion, which causes undue stress to The majority of studies compar- advantages. It creates a permanent the patient. Thus, dilation remains ing dilation with UWFI in asymp- visual record clinicians can use to the standard for detecting retinal tomatic, low-risk patients agree educate patients about their ocular tears in new symptomatic patients with a sensitivity and specificity of health and any findings suspicious for peripheral retinal break. approximately 75%, which draws for diabetes, hypertension and other the conclusion that UWFI is a diseases. It can also document serial The Asymptomatic, potential alternative to dilation. In imaging over years to prove change Low-risk Patient addition, because of the automated over time and track progression. In Few would argue that dilation is the red-free and green-free images addition, some pathology is actually preferred method of evaluation in offered with most devices, UWFI more noticeable in imaging than the presence of known ocular dis- can sometimes be more sensitive for dilated examinations when using ease or symptoms. However, signifi- subtle findings such as small periph- the red-free and green-free images. cant contradictory evidence exists eral hemorrhages or microaneu- For many conditions, seeing a wide on the subject of annual dilation for rysms and faint choroidal nevi.28,29 view of the retina provides context asymptomatic, low-risk patients. to more accurately diagnose lesions No strong evidence defines the The Pros of UWFI (Figures 1 and 2).30 optimal frequency of eye exams of Several benefits of using UWFI to patients younger than 65 with no examine posterior segment health The Limitations of UWFI ocular symptoms or signs. In fact, exist. In addition to patient con- The most significant limitation of some evidence suggests the diagnos- venience and the elimination of these devices is the inability to image

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screening for diabetic retinopathy by ultra-widefield scanning the entire retina. Approximately in diagnosing and managing periph- laser ophthalmoscopy (Optomap). Graefes Arch Clin Exp Oph- 18% of the retina cannot be imaged, eral as well as posterior retinal thalmol. 2008;246(2):229-35. 11. Fingeret M, Mancil GL, Baily IL, et al. Optometric Clinical even through a dilated pupil with pathology when used with other Practice Guideline: Care of the Patient with Open Angle Glau- 30 coma. 2010. www.aoa.org/documents/optometrists/CPG-9. current technology. Furthermore, widefield imaging modalities such pdf. Accessed September 12, 2018. this value is based on best-case sce- as red-free and green-free imaging, 12. American Academy of Ophthalmology Glaucoma Panel. Preferred Practice Pattern Guidelines. Primary Open-Angle nario imaging. In a clinic setting, fundus autofluorescence, fluorescein Glaucoma. American Academy of Ophthalmology. 2015. not every patient images well due angiography and indocyanine green 13. Thomas R, Loibl K, Parikh R. Evaluation of a glaucoma patient. Idian J Ophthalmol. 2011;59(Suppl1):S43-S52. to poor patient attention, dry eye, angiography. 14. Quinn N, Azuara-Blanco A, Graham K, et al. Can ultra-wide ocular media obscurations, lid ptosis field retinal imaging replace colour digital stereoscopy for glau- coma detection? Ophthal Epidem. 2017;5(1):63-9. or small pupils and/or dark choroid While standards have yet to for- 15. Sherman J, Patel H, Nath S, et al. Correlation between causing a dark image. Within most mally change, UWFI continues to Optos ultra widefield imaging and traditional diagnostic meth- ods in glaucoma. Ophthalmology. 2009;80(6):302-3. studies of UWFI, approximately affect the landscape of diagnosing 16. Reznicek L, Seidensticker F, Mann T, et al. Correlation 10% of images taken were of insuf- and monitoring retinal pathology. between peripapillary retinal nerve fiber layer thickness and fudus autofluorescence in primary open-angle glaucoma. Clin ficient quality to interpret. Some- It can be an invaluable adjunct to Ophthalmol. 2013;7:1883-8. 17. American Academy of Ophthalmology Glaucoma Panel. times the anterior retinal pathology the traditional DFE for improving Preferred Practice Pattern Guidelines. Age-Related Macular found during funduscopy cannot the rate of pathology detection, and Degeneration. American Academy of Ophthalmology. 2015. 18. AOA Consensus-based Optometry Committee. Consensus- be imaged with UWFI, even with a it can help to capture peripheral Based Clinical Practice Guideline. Care of the Patient with Age- fully dilated pupil (Figures 3 and 4). lesions for medical photodocumen- Related Macular Degeneration. 2004. 19. American Academy of Ophthalmology Preferred Practice Furthermore, because the UWFI tation. In cases of known disease, Patterns Guidelines. Comprehensive Adult Medical Eye Evalua- image is an artificial composite of UWFI cannot replace a dilated tion. American Academy of Ophthalmology. 2010. 20. Lengyel I, Csutak A, Florea D, et al. A population-based red and green light sources and fundus examination altogether. But ultra-widefield digital image grading study for age-related uses an elliptical mirror to capture in asymptomatic, low-risk patients, macular degeneration-like lesions at the peripheral retina. Ophthalmology. 2015;122(7):1340-7. the widefield image, most UWFI it may be a beneficial screening 21. Writing Committee for the OPTOS PEripheral RetinA devices often do not capture fine modality. It should never take away (OPERA) study (Ancillary Study of Age-Related Eye Disease Study 2). Peripheral retinal changes associated with age- macular detail to the degree that a from our ability to care for each related macular degeneration in the Age-Related Eye Disease DFE or a traditional dilated macula patient as an individual prior to Study 2: Age-Related Eye Disease Study 2 Report Number 12 by the Age-Related Eye Disease Study 2 Optos PEripheral photograph does. In some cases, advising a universal management RetinA (OPERA) Study Research Group. Ophthalmology. 2017 Apr;124(4):479-87. artifacts in the macular region can protocol in lieu of what is still con- 22. AOA Consensus-based Optometry Committee. Consensus- preclude accurate diagnosis of more sidered the standard of care. ■ Based Clinical Practice Guideline: Care of the Patient with Reti- nal Detachment and Peripheral Vitreoretinal Disease. 2004. subtle abnormalities, particularly in Dr. Legge is in private practice in 23. American Academy of Ophthalmology Preferred Practice the case of fine drusen that is indic- Wyomissing, PA. Patterns Guidelines. Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration. American Academy of Oph- ative of early macular degeneration thalmology. 2014. (Figures 5 and 6).31 1. AOA Evidence-based Optometry Committee. Evidence- 24. Kornberg DL, Klufas MA, Yannuzzi NA, et al. Clinical utility Based Clinical Practice Guideline. Comprehensive Adult Eye of ultra-widefield imaging with the Optos Optomap compared and Vision Examination. American Optometric Association. with indirect ophthalmoscopy in the setting of non-traumatic The Combo Approach 2015. rhegmatogenous retinal detachment. Semin Ophthalmol. 2. Bailey RN, Heitman E, eds. An Optometrist’s Guide to Clinical 2016;31(5):505-12. Ethics. American Optometric Association, 2000. www.aoa. One of the best clinical uses of 25. Mackenzie P, Russell M, Ma PE, et al. Sensitivity and org/documents/optometrists/book.pdf. Accessed September specificity of the Optos Optomap for detecting peripheral retinal UWFI is as an adjunct to DFE. 12, 2018. lesions. Retina. 2007;27(8):1119-24. 3. Varner P. How frequently should asymptomatic patients be Research shows an Optomap- dilated? J Optom. 2014;7(1):57-61. 26. Pollack AL, Brodie SE. Diagnostic yield of the routine dilated assisted fundus examination can 4. Pooack AL, Brodie SE. Diagnostic yield of the routine dilated fundus examination. Ophthalmology. 1998;105:382-6. fundus examination. Ophthalmology. 1998;105(2):382-6. 27. Batchelder TJ, Fireman B, Friedman GD, et al. The value of improve pathology detection and 5. AOA Evidence-based Optometry Committee. Evidence- routine dilated pupil screening examination. Arch Ophthalmol. help the clinician efficiently target based Clinical Practice Guideline: Eye Care of the Patient with 1997;115:1179-84. Diabetes Mellitus. 2014. 28. Nath S, Sherman J, Battaglia M. Is Optos imaging additive an area of the retina during fundus- 6. American Academy of Ophthalmology Retina/Vitreous Panel. of duplicative to a dilated fundus exam? Invest Ophthalmol Vis copy in need of further investiga- Preferred Practice Pattern Guidelines. Diabetic Retinopathy. Sci. 2005;46(13):1554. American Academy of Ophthalmology. 2017. 29. Nath S, Sherman J, Hossain SM. Comparison of panoramic tion. Having a widefield image prior 7. Hazin R, Barazi MK, Summerfield M. Challenges to estab- imaging (Optos P200C) with traditional dilated retinal evalua- lishing nationwide diabetic retinopathy screening programs. tion. Invest Ophthalmol Vis Sci. 2009;50(13):339. to performing the DFE improves the Curr Opin Ophthalmol. 2011;22(3):174-9. 30. Shoughy S, Arevalo JF, Kozak I. Update on wide- and rate and accuracy of posterior seg- 8. Purbrick R, Izadi S, Gupta A, Chong NV. Comparison of Opto- ultra-widefield retinal imaging. Indian J Ophthalmol. map ultrawide-field imaging versus slit-lamp biomicroscopy 2015;63(7):575-81. ment disease diagnosis. One study for assessment of diabetic retinopathy in a real-life clinic. Clin 31. Pandya AN, Friberg TR, Eller AW. Optos non-mydriatic showed a 30% increase in retinal Ophthalmol. 2014;8:1413-7. widefield imaging vs. clinical dilated fundus exam for retinal 9. Sallam A, Scanlon PH, Stratton IM, et al. Agreement and diagnosis and management. Invest Ophthalmol Vis Sci. lesion discovery compared with tra- reasons for disagreement between photographic and hospital 2002;43(13):2860. 32 biomicroscopy grading of diabetic retinopathy. Diabet Med. 32. Brown K, Sewell JM, Trempe C, et al. Comparison of ditional DFE alone. 2011; 28(6):741-6. image-assisted versus traditional fundus examination. Eye and UWFI can be particularly useful 10. Neubauer AS, Kernt M, Haritoglou C, et al. Nonmydriatic Brain. 2013;2013(5):1-8.

82 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

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Breaking Down Resistance While non-responsiveness to drugs like acyclovir during herpes simplex treatment is rare, doctors must know how to proceed if they run into this problem. Edited by Joseph P. Shovlin, OD

I have a chronic herpes sim- Response to a Rarity Q plex patient with significant In this particular case, the pre- epithelial keratitis who might be scriber followed the appropriate resistant to acyclovir. Compliance treatment course but ran into does not appear to be an issue, but a rare situation, says Dr. Thi- Valtrex along with steroid use is no mons, who offers several treat- longer helping. How can I be cer- ment recommendations moving tain there is resistance? If there is, forward. His first suggestion is what is the best approach? switching the patient from acy- Managing herpes simplex clovir to famciclovir or topical A of the eye is mediated by ganciclovir, both of which do frequency of occurrence and not belong to the same family as relative risk of vision loss over acyclovir and contain different time, according to Jim Thimons, Pictured here is a large dendrite with end bulbs molecules that the patient could OD, medical director and that are stained with rose bengal. be sensitive to, he notes. Dr. founding partner of Ophthalmic Thimons also recommends ODs Consultants of Connecticut. nificant and persistent responses consider the use of “old school Of the possible treatments, Dr. to acyclovir, the primary agent drugs” like trifluridine and vida- Thimons says chronic oral ther- against which all sensitivities are rabine, which are less effective apy can help mitigate vision loss tested. Resistance is rare in these than current oral agents but play from tissue damage over time. patients—more than 99% are sen- an active role in managing viral Long-term therapy, however, can sitive to the drug, according to Dr. infectious processes, he notes. He pose potential problems. Thimons. Immuno-incompetent adds that these drugs have dif- Because patients are living lon- patients, on the other hand, ferent mechanisms of action, so ger, they are receiving oral antivi- develop resistance to treatment patients might be more sensitive ral therapy for extended periods the longer it is administered, and to them. of time, Dr. Thimons notes. they do so at a much higher rate, According to Dr. Thimons, the He adds that some could be on Dr. Thimons says. solution to this problem could be therapy indefinitely. As such, the as simple as switching medica- rate of resistance to treatment has A Mutating Case tions, but he warns doctors not been slowly but steadily rising. Resistance usually develops due to to wait too long or else they “With increased utilization, it mutations in the thymidine kinase could risk the chance of glaucoma is inevitable that the effect of the pathway that cause patients to developing in their patient. If new drug on the disease state is prob- become non-sensitive to acyclo- drugs are administered but are not ably going to be altered,” Dr. vir and its pro-drug valacyclovir, effective within a week or two, Thimons adds. according to Dr. Thimons. He Dr. Thimons advises referring to Regardless, Dr. Thimons notes adds that these mutations occur a corneal specialist for cellular that the majority of immuno- randomly in immuno-competent analysis to determine what type competent patients—those who patients but can be predicted by of mutation is present and, from have herpes simplex keratitis but the severity of the disease state in there, what path to take for the are healthy otherwise—have sig- immuno-incompetent patients. most successful results. ■

84 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

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References 1. Gabriel MM, Bartell J, Walters R, et al. Biocidal efficacy of a new hydrogen peroxide contact lens care system against bacteria, fungi, and Acanthamoeba species. Optom Vis Sci. 2014;91:E-abstract 145192. 2. Gabriel MM, McAnally C, Bartell J, et al. Biocidal efficacy of a hydrogen peroxide lens care solution incoporating a novel wetting agent. Eye & Contact Lens. 2018;Epub ahead of print. 3. Alcon data on file, 2016. 4. Alcon data on file, 2016. 5. Dumbleton KA, Woods CA, Jones LW, Fonn D. The relationship between compliance with lens replacement and contact lens- related problems in silicone hydrogel wearers. Cont Lens Anterior Eye. 2011;34:216-222. 6. Woods J, Srinivasan S, Jones L. Compliance with the use of hydrogen peroxide and multipurpose solution care regimens. Contact Lens Spectrum. In press. 7. Guthrie S, Dumbleton K, Jones L. Contact lens compliance: Is there a relationship between care system and compliance? Contact Lens Spectrum. 2016;31:40-43.

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The Many Methods of MGD More options for cleaning and treating the lid margins and meibomian glands means better patient care. By Paul M. Karpecki, OD

ecause a majority of Photo: Doan Huynh Kwak, OD biofilm may have a sig- patients with dry eye nificant impact on dry eye Bhave the evapora- disease, supporting thera- tive form that accompanies peutic interventions such as meibomian gland dysfunc- Blephex.7 More than just tion (MGD), with or with- a simple debridement, this out aqueous deficiency, procedure removes biofilm researchers, manufactur- contributing to MGD and ers and clinicians have all DEBS from the meibomian focused on methods to glands, lid margins and clear obstructed meibomian lashes. A spinning, dispos- glands and restore the flow able, medical-grade micro- of healthy lipids into the sponge removes scurf and tear film.1 This has led to These obstructed meibomian glands respond to digital debris, exfoliating the the rise of many in-office pressure by releasing thickened, cloudy meibum. Newer affected areas. The brush treatments that provide the treatments seek to improve results and patient comfort. cleans all four lids in seven promise of symptomatic to 10 minutes. relief for patients with MGD, as Adjunctive Therapies Intense pulsed light (IPL). well as new revenue opportunities A number of other in-office strate- Dermatologists have used these for clinicians and practices. gies can help to increase the effi- systems for years to treat acne cacy of home-based lid hygiene rosacea. Treatments are performed Tried and True measures and extend the effective- with 500nm to 1,200nm light The most established treatment ness of therapeutic treatments: pulses for 20 to 30 minutes, and for MGD is Lipiflow (Johnson & Lid debridement. Mechanical can be repeated every four to five Johnson Vision), which has many debridement/scaling of the line of weeks. Doctors with aesthetic peer-reviewed papers in the litera- Marx and the lid margin removes practices noticed that treatment ture to support its efficacy. The keratin from the meibomian often seemed to improve dry 12-minute, automated treatment gland orifices that can obstruct eye symptoms as well, and some heats the inner eyelid closest to the lipid expression to the ocular began performing IPL for MGD. meibomian glands and simultane- surface; these keratin deposits The theory is that high-intensity ously massages the lids to evacu- can also predispose the patient to light is absorbed by oxyhemo- ate gland contents. Several studies blepharitis. One study found that globin, potentially reducing the have reported sustained effects debridement on its own provided amount of inflammatory media- over 12 months or more follow- statistically significant symptom tors reaching the meibomian ing a single treatment, including relief and improved meibomian glands. Although preliminary significant reductions in symp- gland function.6 The technique results have shown some improve- toms and improvements in MG can have a synergistic effect when ment in tear break-up time secretions.2-4 Reports also note combined with other treatments (TBUT) with IPL, it is not entirely increased comfortable contact lens that heat or express the glands. clear which patients benefit most wear time of more than four hours Blephex. According to the dry and whether IPL should be con- following a single Lipiflow treat- eye blepharitis syndrome (DEBS) sidered a primary or adjunctive ment.5 theory, mechanical removal of treatment.8

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New to Market improvements in the signs and The More, the Merrier Recently launched by Tear Film symptoms of MGD, meeting the In-office treatment for meibo- Innovations, iLux is a small, cost- FDA criteria for approval. mian gland dysfunction can be a effective in-office treatment for great service for patients who are MGD that has a hand piece with In the Pipeline suffering from the symptoms of a detachable, disposable, sterile The TearCare system (Sight Sci- MGD and dry eye disease. The tip and a magnifying lens. It is ences)—an in-office treatment that importance of good eyelid health designed to provide better visu- just debuted at the Academy of and hygiene provides comfort, alization of the blocked meibo- Optometry meeting and is being reduces risk of blepharitis and mian gland orifices and expressed rolled out now—includes a single- protects the ocular surface from meibum before and during the use treatment kit that consists potential compromise. Care of treatment. Once the LED-based of four adhesive applicators that the lids and meibomian glands heat source warms the inner and deliver heat (at 41°C to 45°C) can also help set your patients up outer lids to a therapeutic temper- to the external lids. The applica- for success when preparing for ature range, the clinician applies tors are connected by a cable to cataract or refractive surgery or compression to express the melted a small, reusable handheld unit. experiencing decreased contact meibum. Patients are instructed to blink lens wearing time. Based on the patient’s needs, normally during the 12-minute These treatments can also be the clinician can move the tip to procedure to express meibum, and an important new revenue source different locations on the upper the clinician uses expression for- for an optometric practice. This and lower lids and adjust the ceps afterwards to further evacu- is a great time to evaluate avail- degree and duration of compres- ate the glands. able and upcoming treatments to sion needed at each location. Most A prospective, randomized, determine how they might best fit patients can be treated in under pilot study demonstrated that into your practice. ■ eight minutes. the treatment had an immedi- Note: Dr. Karpecki consults for In a randomized, open-label, ate improvement on objective a number of manufacturers with multisite clinical trial comparing measures (TBUT, MGS and cor- products relevant to this topic. the iLux system to a predicate neal and conjunctival staining) 1. Lemp MA, Crews LA, Bron AJ, et al. Distribu- device, 142 patients were random- that was sustained through six tion of aqueous-deficient and evaporative dry eye in a ized between treatment options. months, while no such improve- clinic-based patient cohort: a retrospective study. Cornea. 2012:31(5):472-8. Researchers looked at Meibomian ment was seen in the control 2. Lane SS, DuBiner HB, Epstein RJ, et al. A new system, Gland Score (MGS), TBUT and group using daily at-home warm the LipiFlow, for the treatment of meibomian gland dysfunc- the Ocular Surface Disease Index compresses with the washcloth tion. Cornea. 2012;31(4):396-404. 3. Blackie CA, Coleman CA, Holland EJ. The sustained (OSDI) questionnaire. bundle method.9 effect (12 months) of a single-dose vectored thermal MGS improved from pulsation procedure for meibomian gland dysfunction and evaporative dry eye. Clin 5.6 prior to treatment with Ophthalmol. 2016;10:1385-96. the iLux to 23.6 at week 4. Greiner JV. Long-term (3-year) effects of a single thermal pulsation system treatment on four, and tear-break-up meibomian gland function and dry eye symp- time improved by more toms. Eye Contact Lens. 2016;42(2):99-107. 5. Kading D. Presented at Vision Expo West than 75% by week four; (VEW), 2015; Las Vegas, NV. however, both improved 6. Korb DR, Blackie CA. Debridement- scaling: A new procedure that increases mei- as soon as two weeks. The bomian gland function and reduces dry eye OSDI scores also improved symptoms. Cornea. 2013;32(12):1554-7. 7. Rynerson JM, Perry HD. DEBS—a unifica- from more than 50 prior tion theory for dry eye and blepharitis. Clin to treatment to about 20 Ophthalmol. 2016;10:2455-67. 8. Toyos R, McGill W, Briscoe D. Intense by two weeks after treat- pulsed light treatment for dry eye disease due ment and improved fur- to meibomian gland dysfunction; A 3-year retrospective study. Photomedicine and Laser ther at four weeks. Surgery. 2015;33(1):41-6. Overall, both treatments 9. Badawi D. A novel system, TearCare, for the treatment of the signs and symptoms produced statistically Removing biofilm from the lid margin via Blephex reduces risk of dry eye disease. Clin Ophthalmol. and clinically significant of blepharitis and dry eye as well. 2018;12:683-94.

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Hydrops it Like it’s Hot If you can quickly resolve edema in these cases, you’ll reduce the need for a transplant. By Azinda Morrow, OD, and Richard Mangan, OD

dvanced imaging technolo- Fig. 1. At left, this patient’s right eye gies are showing that corneal shows grade 3+ global conjunctival Aectasias such as keratoconus injection, grade 3+ corneal edema, trace are more prevalent than previ- micro bullae and epithelial defects. ously thought—up to 265 cases per 100,000 people.1 Those with family Fig. 2. This anterior segment OCT shows history, eye rubbing and atopy, as a break in the patient’s Descemet’s well as Down syndrome tend to be membrane and corneal edema. more commonly affected, and are typically diagnosed during puberty.2 Acute corneal hydrops—a severe complication of corneal ectasia— occurs in as few as 2%, and up to 13%, of patients.3-5

History A 40-year-old African-American testing to be difficult. The left pupil relatively asymptomatic to severe male presented with sudden-onset was round, reactive and had no with visual impairment.4,6 Corneal pain in the right eye for the last two signs of an afferent pupillary defect. hydrops is more common in males days, and associated blurry vision. Confrontation visual fields were between the ages of 20 and 40, but He rated the pain an “eight out of full to hand motion in the right eye has no race predilection.3-6 10” in severity. He also complained and full to finger counting in the left Acute corneal hydrops is self-lim- of redness and photophobia but eye. Extraocular muscle testing was iting, with or without treatment, and denied any discharge, history of ocu- normal. Biomicroscopy of the right tends to resolve over the course of lar surgery, foreign material entering eye revealed grade 3+ global con- three to four months as Descemet’s the eye or trauma. This was the first junctival injection, grade 3+ corneal membrane re-seals.3 Depending occurrence of these symptoms. The edema, trace micro bullae and epi- on the size of the break and the patient attempted to use artificial thelial defects (Figure 1). Intraocular patient’s risk of corneal infection tears without relief. His ocular his- pressure was normotensive and or neovascularization, time to com- tory was significant, however, for dilated fundus exam was unremark- plete healing may be extended.3,4,6 keratoconus, for which he was pre- able. An anterior segment OCT Corneal perforation, although rare, scribed scleral lenses. was performed revealing a break in occurs in 3% of patients who devel- Descemet’s membrane and corneal op hydrops.3 To prevent secondary Examination edema (Figure 2). complications, minimize patient The patient’s entering uncorrected symptoms and limit corneal scar- visual acuity was 20/800 at one foot Diagnosis ring, initiation of medical manage- in the right eye, with mild improve- Corneal hydrops is caused by split- ment is typically warranted. ment on pinhole to 20/400 at two ting of Descemet’s membrane, lead- feet. Corrected visual acuity in the ing to an influx of aqueous into the Treatments left eye with the scleral lens was corneal stroma with resultant edema A variety of medical and surgical 20/20. An external examination and haze.6 Depending on the patient options are available to treat corneal revealed an area of corneal opacifi- and the extent of the tear, corneal hydrops. Topical hyperosmotics, cation in the right eye, causing pupil edema and pain can range from can reduce corneal edema (albeit

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slowly), and improve acuity. hydrops should be moni- To further manage corneal tored every two to three edema while also reducing days after initial onset, the risk for potential neo- followed by every one to vascularization, ODs can two weeks once healing prescribe topical steroids— has begun. However, usually starting with a twice- Fig. 3. This image shows the patient’s corneal thickness three if the cornea appears daily dose. weeks after treatment. It had thinned by approximately 400µm. significantly thinned, Since steroids have the more frequent follow-up potential to hinder corneal healing improve healing time but do not is prudent to prevent perforation. or cause corneal perforation, initiat- impact visual acuity outcomes, mak- Use of a fox shield is recommended. ing steroid treatment at onset, or ing them controversial due to poten- Once healed, these patients should even once Descemet’s membrane tial adverse events.9,10 For maximum follow-up every three months for heals, is controversial. A cycloplegic effect, these procedures must be per- repeat imaging. agent, typically dosed at twice per formed typically within days after day (more if pain persists), can be the initial onset of symptoms.9,10 Practitioners should strive to added to reduce ocular pain from minimize patient symptoms and a secondary uveitis. Other options Recovery avoid devastating long-term com- for pain relief include oral or topi- The longer the hydrops takes to plications with appropriate medical cal nonsteroidal anti-inflammatory heal, the more likely a transplant management. Diagnostic imaging agents or a bandage contact lens. will be required, due to residual equipment can be helpful not only However, depending on the severity scarring. If this scar is large, or with initial diagnosis, but also in of the patient’s keratoconus the lens directly on the visual axis, either monitoring resolution. While cor- may fail to fit appropriately with a deep anterior lamellar kerato- neal hydrops is rare, advances in significant edge fluting and decentra- plasty or a penetrating keratoplasty detection and treatments of kera- tion. As long as epithelial defects are may be performed, depending on toconus, with corneal crosslinking present, a prophylactic antibiotic the extent of the scarring.3 Some may reduce or eliminate it in the should be prescribed to decrease the surgeons advocate for earlier inter- future. ■ potential for infection. vention before any corneal neovas- Dr. Morrow is an assistant clini- Research shows oral doxycycline cularization occurs, to decrease the cal professor at the State University (10mg to 50mg twice per day) and risk of transplant rejection. Prior to of New York College of Optometry. vitamin C (1,000mg per day)— any surgical referral, attempting a 1. Godefrooij D, de Wit G, Uiterwaal C, et al. Age-specific typically dosed early in the course gas permeable contact lens fitting incidence and prevalence of keratoconus: a nationwide regis- of acute hydrops—can be benefi- will allow for assessment of best tration study. Am J Ophthalmol. 2017;175(3):169-72. 7,8 2. Gokhale N. Epidemiology of Keratoconus. Indian J Oph- cial. Doxycycline may also reduce visual acuity and can delay surgery, thalmol. 2013;61(8):382-3. matrix metalloproteinases, which if the patient can achieve functional 3. Barsam A, Petrushlin H, Brennan M, et al. Acute corneal hydrops in keratoconus: a national prospective study of inci- promotes corneal healing.8 Vitamin vision. dence and management. Eye (Lond). 2015;29(4):469-74. 4. Gokul A, Krishnan T, Emanuel P, et al. Persisting extreme C has a role in the extracellular In our patient’s case, we pre- acute corneal hydrops with a giant intrastromal cleft second- matrix and corneal composition, scribed a hyperosmotic ointment, ary to keratoconus. Clin Exp Optom. 2015;98(5):483-6. 5. Thimons J. Managing acute corneal hydrops in keratoco- and can decrease opacification and cycloplegic and antibiotic, along nus. Rev Cornea & Cont Lens. 2015;152(3):32-3. neovascularization.7 Other options with oral doxycycline and vitamin 6. Fuentes E, Sandali O, El Sanharawi M, et al. Anatomic predictive factors of acute corneal hydrops in keratoconus: to enhance corneal healing include C. Within three weeks, his corneal an optical coherence tomography study. Ophthalmol. amniotic membrane transplants and thickness was thinner by approxi- 2015;122(8):1653-9. 7. Cho Y, Yoo W, Kim S, et al. Efficacy of systemic vitamin c copious preservative-free artificial mately 400µm (Figure 3). Although supplementation in reducing corneal opacity resulting from infectious keratitis. Medicine (Balt). 2014;93(23):1-8. tears. standard pachymetry can be helpful 8. Perry H, Hodes L, Seedor J, et al. Effect of doxycycline Surgical interventions include to monitor for resolution, ‘global’ hyclate on corneal epithelial wound healing in the rabbit alkali burn model. Cornea. 1993;12(5):379-82. injection of air or gas, sulfur hexa- pachymetry or AS-OCT are more 9. Maharana P, Sharma N, Vajpayee R. Acute cor- fluoride (SF ) or perfluoropropane beneficial as a larger area of the cor- neal hydrops in keratoconus. Indian J Ophthalmol. 6 2013;61(8):461-4. (C3F8), into the anterior chamber nea can be imaged and healing of 10. Shaw J. Acute hydrops: rethinking treatment. EyeNet Magazine. www.aao.org/eyenet/article/acute-hydrops- to mechanically close the opening Descemet’s membrane can be visu- rethinking-treatment. June 2012. Accessed October 15, in Descemet’s membrane.9,10 These alized. Patients with acute corneal 2018.

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ION: Low Pressure, High Risk Infarction of the optic nerve has many systemic implications to guard against. By Carlo J. Pelino, OD, and Joseph J. Pizzimenti, OD

n 80-year-old white female from the ante- presented for acute vision rior to posterior Aloss in her left eye. She regions of the reported symptoms of mild fatigue nerve, are four and a recent 10-pound weight distinct sections: loss. While there were no reported intraocular (AKA, allergies, her history was positive the optic nerve for dyslipidemia, BP was 125/80 head or optic and she was showing signs of early disc), intraorbital, dementia. She reported that she intracanalicular smokes two cigarettes a day and and intracranial. takes Lipitor. The anterior In the left eye, the patient dem- segment of the onstrated light perception only optic nerve lies with pupils showing a grade 4 between the optic afferent pupillary defect (APD). A 60-year-old white male with systemic hypertension and disc and the site Counting fingers were full in optic nerve typical of a ‘disc at risk.’ A small nerve head with of entry where the right eye and non-existent a small c/d ratio is a risk factor for non-arteritic AION, as is the central retinal in the left. Intraocular pressure his hypertension. artery enters the was 14mm Hg in each eye and nerve. This part there was no anterior or poste- The Many Sides of ION is supplied by two vascular net- rior inflammation found. There Ischemic optic neuropathy (ION) works: the peripheral system and were no color plates in the left eye or infarction of the optic nerve can the axial vascular system, present and a posterior pole examination be anterior (AION) or posterior in 75% of optic nerves and sup- showed pale swelling of the left (PION). Both types can be arte- plied by 1–8 intraneural branches optic nerve. As these symptoms are ritic, non-arteritic, or periopera- of the central retinal artery.1 consistent with arteritic AION, an tive. Non-arteritic ION, which The posterior segment of the immediate neuro-ophthalmology occurs more frequently and affects optic nerve, on the other hand, consult was obtained. adults age 50 and older, tends to lies between the site of entry of Results from subsequent testing cause less severe vision loss than the central retinal artery and the demonstrated that her erythrocyte the arteritic variant. Arteritic on orbital apex, directly prior to sedimentation rate (ESR) was the other hand, affects an older entering the intracanalicular por- 100, she had elevated C-reactive population, age 70 an above. tion. This part of the nerve is pri- protein at 5 and elevated platelets. As the only common symptom marily supplied by the peripheral A temporal artery biopsy showed among the variants is painless vascular system and multiple small inflammation and intravenous (IV) vision loss, monitoring for the collateral arteries. These typically methylprednisolone was adminis- many systemic implications in stem directly from the ophthalmic tered at a dose of 1,000mg daily your patients can help prevent fur- artery and less often from other for three days. From there, she ther vision loss in the affected and orbital arteries.1,2 was put on high dose of oral pred- fellow eye. Since the intraorbital portion of nisone 80mg/day and he has been Let’s go right to the heart of the the nerve is supplied by more than treated on steroids for over a year. matter: the optic nerve. Moving one arterial system, watershed

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to atherosclerosis such as diabetes, ritic types, perimetry will often smoking, dyslipidemia and hyper- demonstrate a defect in the inferior tension, obstructive sleep apnea, and central fields. Additionally, certain drugs (e.g., amiodarone, small and crowded nerve head possibly phosphodiesterase-5 is a predisposing risk factor for inhibitors) and hypercoagulable the development of non-arteritic disorders.5 Vision loss on awaken- AION, while a large cup-to-disc ing leads clinicians to suspect noc- ratio in the fellow eye should make turnal hypotension as a potential one think about arteritic AION in cause of the non-arteritic AION.4,5 the affected eye.3-5 For this reason, Any of the inflammatory arte- when AION is suspected, the clini- An 80-year old white female with acute ritides, especially giant cell arteritis cian should examine the fellow loss. VA is light perception in the left (GCA), can precipitate the arteritic eye to see if it has a “disc at risk,” eye. Pale, swollen nerve is consistent type of infarction.1,3 Acute isch- as it’s called. OCT may be used with arteritic AION (GCA). emia in these cases can cause optic to further assess the disc edema, nerve edema, which will then fur- ganglion cell thickness and retinal vascular zones exist within the ther worsen the ischemia. nerve fiber layer thickness, as well nerve. Within these watershed as documenting resolution versus zones, the intraorbital optic nerve Making the Diagnosis stability or progression. suffers low perfusion pressure, Before making a diagnosis, key While diagnosis of optic nerve causing areas within the watershed clinical factors such as the state of infarction is based mainly on zone to be most vulnerable. the optic disc should be thoroughly clinical evaluation, ancillary testing Structural abnormalities of the investigated. In the presence of may be necessary. Most impor- optic nerve, such as a crowded AION, the optic disc will be edem- tantly, the clinician must first rule nerve head with a small cup and atous, and the swollen nerve fibers out the arteritic form, which would other vascular risk factors, leave will obscure the fine surface vessels require emergency treatment to many patients predisposed to the of the nerve. The disc edema may protect the fellow eye. Immediate development of AION. present in a sectoral fashion and tests should include ESR, complete While the development of AION hemorrhages may surround the blood count (CBC) and C-reactive is primarily due to ischemia of nerve head. The disc may appear protein. ESR is usually dramati- the prelaminar and laminar areas pale in the arteritic variety and cally elevated in the arteritic form, where the nerve exits the globe, hyperemic in the non-arteritic type. often exceeding 100mm/h, and PION has been linked primarily to In both arteritic and non-arte- typically normal in the non-arte- ischemia of the intraorbital por- tion. It’s important to note that this Table 1. Common Symptoms and Signs in Patients with ION 3-5 potentially devastating variant can • General malaise, especially in arteritic be characterized by the acute, pain- less vision loss in one or both eyes • Muscle aches and pains, especially in arteritic and can present without optic disc • Headaches over the temple (arteritic) swelling. • Pain when combing hair (arteritic) Risk Factors on the Radar • Jaw claudication (arteritic) When atherosclerotic narrowing • Tenderness over the temporal artery (arteritic) of the posterior ciliary arteries • Painless, rapid vision loss (over minutes, hours, or days) occurs, the eye may be predisposed • Afferent pupillary defect to non-arteritic AION, particularly • Optic disc is elevated and swollen in AION after a hypotensive episode.1,3 So, while there are typically no defined • Hemorrhages may surround the disc. medical conditions connected to • Pallor of swollen disc in arteritic; hyperemic swelling in non-arteritic non-arteritic ION, it’s important to • Visual fi eld defect in the inferior and central fi elds look out for factors contributing

96 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

095_ro1118_RoS.indd 96 11/16/18 1:59 PM ritic variant. CBC is done to iden- non-arteritic AION spontane- bin (A1C) and lipids.5 As always, tify thrombocytosis (>400×103/ ously recover some useful vision, patients should be encouraged to µL), which adds to the positive and it should be noted that vision loss maintain a healthy diet, exercise, negative predictive value of using in arteritic AION, when caused by and avoid smoking. ESR alone.3-5 GCA, will typically be irrevcover- With a watchful eye on the If GCA is suspected, a temporal able.5 Arteritic ION, for this rea- potential symptoms and systemic artery biopsy should be performed son, must be treated immediately implications of ischemic optic neu- as soon as possible. Monitoring with systemic high-dose steroids to ropathy, we as clinicians can make changes in C-reactive protein level prevent further loss and protect the an early diagnosis and initiate the will be necessary for tracking dis- fellow eye. Inadequate treatment proper treatment plan to prevent ease activity and the response to can cause relapses and additional further vision loss. ■ treatment. For isolated cases of vision loss. 1. Hayreh SS. Anterior ischaemic optic neuropathy I. progressive vision loss, neuroimag- Oral prednisone is the most Terminology and pathogenesis. Br J Ophthalmol 1974; ing may be obtained to rule out frequent first-line therapy, though 58:955–963. 5 2. Hayreh SS. Posterior ischaemic optic neuropathy: clini- compressive lesions. intravenous methylpredniso- cal features, pathogenesis, and management. Eye 2004; Lastly, narrowing the diagnosis lone has been recommended for 18:1188–1206. 3. Arnold, Anthony C. “Ischemic optic neuropathy.” Clinical for non-arteritic ION may include severe cases. It is prudent to seek neuro-ophthalmology 1 2005: 349-384. testing for obstructive sleep apnea, comanagement with neurology or 4. Sohan Singh Hayreh, Ischemic optic neuropathy, In Prog- ress in Retinal and Eye Research 2009; Volume 28, Issue 1, especially where symptoms such as neuro-ophthalmology in these such pp. 34-62. excessive daytime sleepiness, obe- cases.4,5 For non-arteritic ION, 5. Atkins EJ, Bruce BB, Newman NJ, Biousse V. Treatment of Nonarteritic Anterior Ischemic Optic Neuropathy. Survey of sity or loud snoring are present. the clinician should investigate ophthalmology. 2010;55(1):47-63. doi:10.1016/j.survoph- for vasculopathic risk factors and thal.2009.06.008. 6. Sadda SR, Nee M, Miller NR, Biousse V, Newman NJ, Treatment sleep apnea and also check blood Kouzis A. Clinical spectrum of posterior ischemic optic neu- While up to 40% of eyes with pressure, glycosylated hemoglo- ropathy. Am J Ophthalmol 2001; 132:743–750.

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RO0918_House Taye.indd 1 8/16/18 1:57 PM Retina Quiz

A Hazy, Shaded Vision A young, otherwise healthy patient is suddenly beset by floaters. By Mark T. Dunbar, OD

34-year-old Hispanic female presented with symptoms Aof hazy vision and floaters in her left eye for a few months. The eye was not red and she denied having any pain or discomfort. The right eye was unaffected. She reported good general health and had no prior ocular problems. She was not nursing or pregnant. Upon examination, her best-cor- rected visual acuity was 20/20 OD and 20/30 OS. Confrontation visual Fig. 1. Can this 34-year-old patient’s fundus images explain anything about her hazy fields were full to careful finger vision and influx of floaters? counting OU and ocular motilities were normal. c. Toxoplasmosis. Discussion Her pupils were equal, round d. Histoplasmosis. Our patient presented with symp- and reactive to light with no affer- toms of hazy vision with an increase ent pupillary defect. The right eye 3. What is the treatment for this in floaters. These symptoms are due was completely normal. The left eye patient? to the vitreous cells that were seen showed trace cell, but was other- a. Bactrim PO, clindamycin PO, ste- on her clinical exam once she was wise normal. roids PO, folic acid. dilated. She also has a fluffy-white On dilated fundus exam, the b. Azithromycin PO. lesion superotemporal that is adja- right eye was unremarkable. The c. Doxycycline PO. cent to a pigmented chorioretinal vitreous of the left eye had 2+ vitre- d. Observation. scar. This is a classic presentation ous cells. The exam did reveal some of active toxoplasmosis retinocho- other changes (Figure 1). An SD- 4. What additional testing would be roiditis. Because it is adjacent to the OCT of the macula in the left eye most helpful in making the correct pigmented chorioretinal scar, this was normal. diagnosis? likely represents reactivation of a a. Elisa blood test for IgG and IgM. previous infection. Take the Quiz b. Blood test for FTA-ABS, RPR. Toxoplasmosis is the most com- 1. What does the fluffy white lesion c. PPD. mon cause of posterior uveitis and represent? d. HLA-B27, HLA-A29. accounts for approximately 90% a. Myelinated nerve fiber (MNF). of focal necrotizing retinitis.1 It is b. Cotton wool spot. 5. Which statement best character- caused by an intracellular parasite c. Active retinochoroiditis. izes her condition? Toxoplasma gondii.1 Cats are the d. Chorioretinal scar. a. Likely acquired. definitive hosts for Toxoplasma b. Likely congenital. gondii, and humans and other 2. What is the correct diagnosis for c. Reactivation. mammals act as intermediate hosts. the fundus lesion? d. Autoimmune. T. gondii exists in three forms, all a. Active syphilis. of which are able to infect its hosts. b. Toxocara canis. For answers, see page 106. Tachyzoites can infect almost all

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nucleated cells through a process of BID, and prednisolone 40mg PO active invasion. Tissue cysts, which QD. This is referred to as “triple- contain the bradyzoites, are the therapy.” Some uveitis specialists dormant form and primarily found will also give an intravitreal injec- in the brain and skeletal muscles. tion of dexamethasone 0.4mg/ Oocysts are produced during the clindamycin 1mg. This is considered sexual cycle that takes place in the quadruple therapy.4 intestine of acutely infected felines. In one study of 68 patients with The transmission occurs by many active toxoplasmosis, investigators routes, including ingestion of raw compared the standard triple-ther- or undercooked meat infected with Fig. 2. This fundus image shows our apy (34 patients) with local therapy tissue cysts, ingestion of food and patient three years after her initial with only an intravitreal injection water contaminated with oocysts, presentation. She was able to resolve on of clindamycin and dexametha- ingestion of eggs and milk con- her own without treatment. sone (34 patients) and found both taminated with tachyzoites, blood groups of patients did equally well. transfusion, organ transplantation because there is a high seropositiv- They concluded that this might be or transplacental transmission. ity in the general population. In an acceptable alternative to the clas- The most common form of trans- fact, more than 60 million people sic triple-drug treatment in ocular mission of the disease is mother in the United States may have been toxoplasmosis. to child, transplacentally. Mothers affected with the parasite, but those Advantages of intravitreal who are seropositive for toxoplas- who have been affected have few treatment include convenience, mosis show rates of transmission symptoms, if any.3 This is because improved systemic side effect pro- between 60% and 81%, often a healthy person’s immune system file, greater availability and fewer noticeable in the third trimester.2 usually keeps the parasite from follow-up visits and hematological Manifestations of congenital toxo- causing illness. A negative titer evaluations.5 plasmosis include: hydrocephalus, should give strong deliberation to Azithromycin has also emerged seizures, intracranial calcifications, alternate diagnosis.2 Blood work up as an alternative treatment for and retinochoroiditis. Pregnant was not performed on our patient toxoplasmosis. Research compar- mothers are cautioned to avoid con- because it was a pretty “classic” ing traditional triple therapy with tact or exposure to litter boxes. presentation. azithromycin shows no significant Toxoplasmosis is generally self- difference in results.6 Making the Call limiting in immunocompetent Our patient did not admit to The diagnosis toxoplasmosis is usu- patients and will resolve sponta- having any cats nor eating any ally made based on the clinical pre- neously in four to eight weeks. raw or undercooked pork, lamb or sentation. Serologic blood studies Treatment is reserved for lesions venison. She was observed with- such as the Toxoplasma ELISA can threatening or involving the macu- out treatment and spontaneously be performed to confirm the diag- lar or optic nerve or if there is a resolved on her own. ■

nosis. Detection of IgM antibody significant reduction in visual acu- 1. Yanhoff N, Duker J. Uveitis and Other Intraocular Inflam- titers are present within the first ity due to a severe vitritis. Other mations” Ophthalmology: Expert consult, 3rd edition. Mosby November 2008; 828-831. two weeks of infection and sug- indications for treatment include an 2. Chaudhry S, Gad N, Koren G. Toxoplasmosis and preg- gests a recently acquired infection. active lesion greater than one disc nancy. Can Fam Physician. 2014;60(4):334-6. 3. Gerstenblith A, Rabin M. The Wills Eye Manual: office and IgG antibodies means they were diameter in size and /or any immu- emergency room diagnosis and treatment of eye disease, 6th exposed to the infection some time nocompromised patient.1-2 Periph- edition. Philadelphia, Lippincott Williams & Wilkins 2012; 369-371. in their life time. The IgG antibod- eral lesions that do not affect visual 4. Kim S, Scott I, Brown G, et al. Interventions for toxoplasma retinochoroiditis: a report by the american academy of oph- ies are produced within two weeks acuity generally can be carefully thalmology. Ophthalmology, vol. 120, no. 2, pp. 371–378, and peak at two months and will be followed without treatment. 2013 5. Bosch-Driessen L, Verbraak F, Suttorp-Schulten M, et al. A present for life. prospective, randomized trial of pyrimethamine and azithro- Interestingly, a positive toxoplas- Treatment mycin vs pyrimethamine and sulfadiazine for the treatment of ocular toxoplasmosis. Am J Ophthalmol. 2002;134:34-40. mosis titer doesn’t always ensure The standard for treating active 6. Bosch-Driessen L, Verbraak F, Suttorp-Schulten M, et al. A that the diagnosis of a lesion in the toxoplasmosis patient is clindamy- prospective, randomized trial of pyrimethamine and azithro- mycin vs pyrimethamine and sulfadiazine for the treatment of eye is from toxoplasmosis. This is cin 30mg PO TID, Bactrim DS PO ocular toxoplasmosis. Am J Ophthalmol. 2002;134(1):34-40.

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Faculty

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

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

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Faculty

ASSISTANT PROFESSOR POSITIONS: PEDIATRICS &ƵůůͲƟŵĞŶŽŶͲƚĞŶƵƌĞƚƌĂĐŬĨĂĐƵůƚLJƉŽƐŝƟŽŶƐĨŽƌƚŚĞŚŝĐĂŐŽŽůůĞŐĞŽĨKƉƚŽŵĞƚƌLJ Z›ÝÖÊÄÝ®®½®ã®›Ý͗ĂŶĚŝĚĂƚĞƐĂƌĞĞdžƉĞĐƚĞĚƚŽďĞŚŝŐŚůLJŬŶŽǁůĞĚŐĞĂďůĞŝŶƚŚĞĮĞůĚŽĨƉĞĚŝĂƚƌŝĐŽƉƚŽŵĞƚƌLJĂŶĚĚĞǀĞůŽƉĂŶĚƚĞĂĐŚ ĐŽƵƌƐĞƐ ĂŶĚͬŽƌ ůĂďŽƌĂƚŽƌŝĞƐ ŝŶ ƚŚĞ ƐƵďũĞĐƚ ĂƌĞĂ͘ dŚĞ ƉƌŝŵĂƌLJ ĐĂƌĞ ĐĂŶĚŝĚĂƚĞ ŵƵƐƚ ĂůƐŽ ďĞ ĂďůĞ ƚŽ ƉƌŽǀŝĚĞ ĚŝƌĞĐƚ ƉĂƟĞŶƚ ĐĂƌĞ ĂŶĚ ĐůŝŶŝĐĂůŝŶƐƚƌƵĐƟŽŶƚŽƉƌŽĨĞƐƐŝŽŶĂůƐƚƵĚĞŶƚƐĂƐǁĞůůĂƐƌĞƐŝĚĞŶƚƐ͕ĂŶĚďĞŝŶǀŽůǀĞĚŝŶŝŶƚĞƌĚŝƐĐŝƉůŝŶĂƌLJƉƌĂĐƟĐĞǁŝƚŚŽƚŚĞƌĞĚƵĐĂƟŽŶĂů professionals. ĂŶĚŝĚĂƚĞƐŵƵƐƚďĞǁŝůůŝŶŐƚŽĂĐƟǀĞůLJƉĂƌƟĐŝƉĂƚĞŝŶĐƵƌƌŝĐƵůĂƌĂƐƐĞƐƐŵĞŶƚ͕ƉƌŽĨĞƐƐŝŽŶĂůĚĞǀĞůŽƉŵĞŶƚ͕ƐƚƵĚĞŶƚĐŽƵŶƐĞůŝŶŐĂŶĚƐĞƌǀŝĐĞĂĐƟǀŝƟĞƐǁŝƚŚŝŶƚŚĞ ĐŽůůĞŐĞ͕ƵŶŝǀĞƌƐŝƚLJĂŶĚƚŚĞƐĐŝĞŶƟĮĐĐŽŵŵƵŶŝƚLJ͘^ƵĐĐĞƐƐĨƵůĐĂŶĚŝĚĂƚĞƐĂƌĞĂůƐŽĞdžƉĞĐƚĞĚƚŽďĞŝŶǀŽůǀĞĚŝŶƌĞƐĞĂƌĐŚĂŶĚƐĐŚŽůĂƌůLJĂĐƟǀŝƟĞƐ͕ĂŶĚŚĂǀĞĂƐŝŶĐĞƌĞ ĐŽŵŵŝƚŵĞŶƚƚŽŽƉƚŽŵĞƚƌŝĐĞĚƵĐĂƟŽŶ͕ĐŽŵŵƵŶŝƚLJƐĞƌǀŝĐĞĂŶĚƉĂƟĞŶƚĐĂƌĞ͘WƌŝŵĂƌLJĚƵƟĞƐŝŶĐůƵĚĞ͕ďƵƚĂƌĞŶŽƚůŝŵŝƚĞĚƚŽ͗ a) Teaching b) Service • Developing and delivering lectures and/or • Helping to maintain and grow the state of • WĂƌƟĐŝƉĂƟŶŐ ŽŶ ŽůůĞŐĞ ĂŶĚ hŶŝǀĞƌƐŝƚLJ laboratories for related areas, as assigned; the art optometry program with a strong ĐŽŵŵŝƩĞĞƐ͕ĂƐĂƐƐŝŐŶĞĚ͖ • ŵďƌĂĐŝŶŐ ĂŶĚ ĞŶŚĂŶĐŝŶŐ ƚŚĞ ĚŝĚĂĐƟĐ interdisciplinary focus that meets the needs • WĂƌƟĐŝƉĂƟŶŐŝŶŽůůĞŐĞĂŶĚhŶŝǀĞƌƐŝƚLJƐĞƌǀŝĐĞ philosophies in the O.D. program; ŽĨƉĂƟĞŶƚƐŝŶƚŚĞƐƵƌƌŽƵŶĚŝŶŐĐŽŵŵƵŶŝƚLJ͖ŝƐ ĂĐƟǀŝƟĞƐ͘ • Maintaining and expanding the high quality ĞĸĐŝĞŶƚ͕ƉĂƟĞŶƚĨƌŝĞŶĚůLJ͕ĂŶĚĐŽƐƚͲĞīĞĐƟǀĞ͖ ĐůŝŶŝĐĂů ƉƌĂĐƟĐĞ ĞŶǀŝƌŽŶŵĞŶƚ ĨŽƌ ŽƉƚŽŵĞƚƌLJ • Working closely together with all optometry c) ^ĐŚŽůĂƌůLJĂĐƟǀŝƚLJ ƐƚƵĚĞŶƚƐŽŶƌŽƚĂƟŽŶ͖ and ophthalmology faculty to provide a ŶŐĂŐŝŶŐ ŝŶ ƌĞƐĞĂƌĐŚ ĂŶĚ ƐĐŚŽůĂƌůLJ ĂĐƟǀŝƚLJ͕ • WƌĞĐĞƉƟŶŐƐƚƵĚĞŶƚƐŽŶĐůŝŶŝĐĂůƌŽƚĂƟŽŶĂƚƚŚĞ complete range of eye and vision care ŝŶĐůƵĚŝŶŐƉƌĞƐĞŶƚĂƟŽŶƐĂƚƐĐŝĞŶƟĮĐŵĞĞƟŶŐƐ͕ DŝĚǁĞƐƚĞƌŶ hŶŝǀĞƌƐŝƚLJ LJĞ /ŶƐƟƚƵƚĞ ǁŚĞƌĞ services; ƌĞƐĞĂƌĐŚ͕ ĂŶĚ ƉƵďůŝĐĂƟŽŶ ŝŶ ƉĞĞƌ ƌĞǀŝĞǁĞĚ applicable; • WĂƌƟĐŝƉĂƟŶŐ ŝŶ ůĞĂĚĞƌƐŚŝƉ ƌŽůĞƐ ŝŶ ũŽƵƌŶĂůƐ ƐƵĸĐŝĞŶƚ ƚŽ ƋƵĂůŝĨLJ ĨŽƌ ĂĐĂĚĞŵŝĐ ƐƚĂƚĞ͕ ƌĞŐŝŽŶĂů͕ ĂŶĚ ŶĂƟŽŶĂů ŽƉƚŽŵĞƚƌLJ ĂĚǀĂŶĐĞŵĞŶƚŝŶĂŶŽŶͲƚĞŶƵƌĞƚƌĂĐŬƉŽƐŝƟŽŶ͘ ŽƌŐĂŶŝnjĂƟŽŶƐ͖

Y烽®¥®‘ƒã®ÊÄÝ͗ĂŶĚŝĚĂƚĞƐŵƵƐƚƉŽƐƐĞƐƐĂŽĐƚŽƌŽĨKƉƚŽŵĞƚƌLJĚĞŐƌĞĞĨƌŽŵĂŶKͲĂĐĐƌĞĚŝƚĞĚŝŶƐƟƚƵƟŽŶ͕ŵƵƐƚŚĂǀĞĐŽŵƉůĞƚĞĚĂŶKͲĂĐĐƌĞĚŝƚĞĚ ƌĞƐŝĚĞŶĐLJ͕ĂŶĚŵƵƐƚďĞĞůŝŐŝďůĞĨŽƌĂŶŽƉƚŽŵĞƚƌŝĐƐƚĂƚĞůŝĐĞŶƐĞŝŶƚŚĞƐƚĂƚĞŝŶǁŚŝĐŚƚŚĞĐŽůůĞŐĞŝƐůŽĐĂƚĞĚ͘WƌŝŵĂƌLJĞLJĞĐĂƌĞĐůŝŶŝĐĂůĞdžƉĞƌƟƐĞŝƐĂůƐŽƌĞƋƵŝƌĞĚ͘ ^ĂůĂƌLJǁŝůůďĞĐŽŵŵĞƐƵƌĂƚĞǁŝƚŚƋƵĂůŝĮĐĂƟŽŶƐĂŶĚĞdžƉĞƌŝĞŶĐĞ ZĞǀŝĞǁŽĨĂƉƉůŝĐĂƟŽŶƐǁŝůůďĞŐŝŶŝŵŵĞĚŝĂƚĞůLJĂŶĚĐŽŶƟŶƵĞƵŶƟůƚŚĞƉŽƐŝƟŽŶŝƐĮůůĞĚ ÊÄパã®Ä¥ÊÙÃã®ÊÄ͗ŽŶƚĂĐƚŝŶĨŽƌŵĂƟŽŶ͗/ŶƚĞƌĞƐƚĞĚĂƉƉůŝĐĂŶƚƐƐŚŽƵůĚĂƉƉůLJŽŶůŝŶĞĂƚǁǁǁ͘ŵŝĚǁĞƐƚĞƌŶ͘ĞĚƵĂŶĚŝŶĐůƵĚĞ ĐƵƌƌŝĐƵůƵŵǀŝƚĂĞĂŶĚůĞƩĞƌŽĨŝŶƚĞƌĞƐƚƐƉĞĐŝĨLJŝŶŐƚŚĞƉŽƐŝƟŽŶĂŶĚĐŽůůĞŐĞƚŚĂƚŚĞͬƐŚĞǁŝƐŚĞƐƚŽďĞĐŽŶƐŝĚĞƌĞĚĨŽƌ͘/ŶƋƵŝƌŝĞƐŵĂLJďĞ ĚŝƌĞĐƚĞĚƚŽƌ͘DĞůŝƐƐĂ^ƵĐŬŽǁ͕ĞĂŶ͖DŝĚǁĞƐƚĞƌŶhŶŝǀĞƌƐŝƚLJ͗ŵƐƵĐŬŽΛŵŝĚǁĞƐƚĞƌŶ͘ĞĚƵ. DŝĚǁĞƐƚĞƌŶhŶŝǀĞƌƐŝƚLJŝƐĂŶƋƵĂůKƉƉŽƌƚƵŶŝƚLJͬĸƌŵĂƟǀĞĐƟŽŶĞŵƉůŽLJĞƌƚŚĂƚĚŽĞƐŶŽƚĚŝƐĐƌŝŵŝŶĂƚĞĂŐĂŝŶƐƚĂŶĞŵƉůŽLJĞĞŽƌĂƉƉůŝĐĂŶƚďĂƐĞĚƵƉŽŶƌĂĐĞ͕ ĐŽůŽƌ͕ƌĞůŝŐŝŽŶ͕ŐĞŶĚĞƌ͕ŶĂƟŽŶĂůŽƌŝŐŝŶ͕ĚŝƐĂďŝůŝƚLJ͕ŽƌǀĞƚĞƌĂŶƐƐƚĂƚƵƐ͕ŝŶĂĐĐŽƌĚǁŝƚŚϰϭ͘&͘Z͘ϲϬͲϭ͘ϰ;ĂͿ͕ϮϱϬ͘ϱ;ĂͿ͕ϯϬϬ͘ϱ;ĂͿĂŶĚϳϰϭ͘ϱ;ĂͿ͘

ASSISTANT PROFESSOR POSITIONS: PRIMARY CARE/OPTOMETRIC THEORY AND METHODS &ƵůůͲƟŵĞŶŽŶͲƚĞŶƵƌĞƚƌĂĐŬĨĂĐƵůƚLJƉŽƐŝƟŽŶƐĨŽƌƚŚĞŚŝĐĂŐŽŽůůĞŐĞŽĨKƉƚŽŵĞƚƌLJ Z›ÝÖÊÄÝ®®½®ã®›Ý͗ĂŶĚŝĚĂƚĞƐĂƌĞĞdžƉĞĐƚĞĚƚŽďĞŚŝŐŚůLJŬŶŽǁůĞĚŐĞĂďůĞŝŶƚŚĞĮĞůĚŽĨƉƌŝŵĂƌLJĐĂƌĞŽƉƚŽŵĞƚƌLJĂŶĚŽƉƚŽŵĞƚƌŝĐƚŚĞŝƌŽLJ ĂŶĚŵĞƚŚŽĚƐĂŶĚĚĞǀĞůŽƉĂŶĚƚĞĂĐŚĐŽƵƌƐĞƐĂŶĚͬŽƌůĂďŽƌĂƚŽƌŝĞƐŝŶƚŚĞƐƵďũĞĐƚĂƌĞĂ͘dŚĞƉƌŝŵĂƌLJĐĂƌĞĐĂŶĚŝĚĂƚĞŵƵƐƚĂůƐŽďĞĂďůĞ ƚŽƉƌŽǀŝĚĞĚŝƌĞĐƚƉĂƟĞŶƚĐĂƌĞĂŶĚĐůŝŶŝĐĂůŝŶƐƚƌƵĐƟŽŶƚŽƉƌŽĨĞƐƐŝŽŶĂůƐƚƵĚĞŶƚƐĂƐǁĞůůĂƐƌĞƐŝĚĞŶƚƐ͕ĂŶĚďĞŝŶǀŽůǀĞĚŝŶŝŶƚĞƌĚŝƐĐŝƉůŝŶĂƌLJ ƉƌĂĐƟĐĞǁŝƚŚŽƚŚĞƌĞĚƵĐĂƟŽŶĂůƉƌŽĨĞƐƐŝŽŶĂůƐ͘ ĂŶĚŝĚĂƚĞƐŵƵƐƚďĞǁŝůůŝŶŐƚŽĂĐƟǀĞůLJƉĂƌƟĐŝƉĂƚĞŝŶĐƵƌƌŝĐƵůĂƌĂƐƐĞƐƐŵĞŶƚ͕ƉƌŽĨĞƐƐŝŽŶĂůĚĞǀĞůŽƉŵĞŶƚ͕ƐƚƵĚĞŶƚĐŽƵŶƐĞůŝŶŐĂŶĚƐĞƌǀŝĐĞĂĐƟǀŝƟĞƐǁŝƚŚŝŶƚŚĞ ĐŽůůĞŐĞ͕ƵŶŝǀĞƌƐŝƚLJĂŶĚƚŚĞƐĐŝĞŶƟĮĐĐŽŵŵƵŶŝƚLJ͘^ƵĐĐĞƐƐĨƵůĐĂŶĚŝĚĂƚĞƐĂƌĞĂůƐŽĞdžƉĞĐƚĞĚƚŽďĞŝŶǀŽůǀĞĚŝŶƌĞƐĞĂƌĐŚĂŶĚƐĐŚŽůĂƌůLJĂĐƟǀŝƟĞƐ͕ĂŶĚŚĂǀĞĂƐŝŶĐĞƌĞ ĐŽŵŵŝƚŵĞŶƚƚŽŽƉƚŽŵĞƚƌŝĐĞĚƵĐĂƟŽŶ͕ĐŽŵŵƵŶŝƚLJƐĞƌǀŝĐĞĂŶĚƉĂƟĞŶƚĐĂƌĞ͘WƌŝŵĂƌLJĚƵƟĞƐŝŶĐůƵĚĞ͕ďƵƚĂƌĞŶŽƚůŝŵŝƚĞĚƚŽ͗ a) dĞĂĐŚŝŶŐ b) ^ĞƌǀŝĐĞ • ĞǀĞůŽƉŝŶŐ ĂŶĚ ĚĞůŝǀĞƌŝŶŐ ůĞĐƚƵƌĞƐ ĂŶĚͬŽƌ • ,ĞůƉŝŶŐ ƚŽ ŵĂŝŶƚĂŝŶ ĂŶĚ ŐƌŽǁ ƚŚĞ ƐƚĂƚĞ ŽĨ • WĂƌƟĐŝƉĂƟŶŐ ŽŶ ŽůůĞŐĞ ĂŶĚ hŶŝǀĞƌƐŝƚLJ ůĂďŽƌĂƚŽƌŝĞƐĨŽƌƌĞůĂƚĞĚĂƌĞĂƐ͕ĂƐĂƐƐŝŐŶĞĚ͖ ƚŚĞ Ăƌƚ ŽƉƚŽŵĞƚƌLJ ƉƌŽŐƌĂŵ ǁŝƚŚ Ă ƐƚƌŽŶŐ ĐŽŵŵŝƩĞĞƐ͕ĂƐĂƐƐŝŐŶĞĚ͖ • ŵďƌĂĐŝŶŐ ĂŶĚ ĞŶŚĂŶĐŝŶŐ ƚŚĞ ĚŝĚĂĐƟĐ ŝŶƚĞƌĚŝƐĐŝƉůŝŶĂƌLJĨŽĐƵƐƚŚĂƚŵĞĞƚƐƚŚĞŶĞĞĚƐ • WĂƌƟĐŝƉĂƟŶŐŝŶŽůůĞŐĞĂŶĚhŶŝǀĞƌƐŝƚLJƐĞƌǀŝĐĞ ƉŚŝůŽƐŽƉŚŝĞƐŝŶƚŚĞK͘͘ƉƌŽŐƌĂŵ͖ ŽĨƉĂƟĞŶƚƐŝŶƚŚĞƐƵƌƌŽƵŶĚŝŶŐĐŽŵŵƵŶŝƚLJ͖ŝƐ ĂĐƟǀŝƟĞƐ͘ • DĂŝŶƚĂŝŶŝŶŐ ĂŶĚ ĞdžƉĂŶĚŝŶŐ ƚŚĞ ŚŝŐŚ ƋƵĂůŝƚLJ ĞĸĐŝĞŶƚ͕ƉĂƟĞŶƚĨƌŝĞŶĚůLJ͕ĂŶĚĐŽƐƚͲĞīĞĐƟǀĞ͖ ĐůŝŶŝĐĂů ƉƌĂĐƟĐĞ ĞŶǀŝƌŽŶŵĞŶƚ ĨŽƌ ŽƉƚŽŵĞƚƌLJ • tŽƌŬŝŶŐĐůŽƐĞůLJƚŽŐĞƚŚĞƌǁŝƚŚĂůůŽƉƚŽŵĞƚƌLJ c) ^ĐŚŽůĂƌůLJĂĐƟǀŝƚLJ ƐƚƵĚĞŶƚƐŽŶƌŽƚĂƟŽŶ͖ ĂŶĚ ŽƉŚƚŚĂůŵŽůŽŐLJ ĨĂĐƵůƚLJ ƚŽ ƉƌŽǀŝĚĞ Ă ŶŐĂŐŝŶŐ ŝŶ ƌĞƐĞĂƌĐŚ ĂŶĚ ƐĐŚŽůĂƌůLJ ĂĐƟǀŝƚLJ͕ • WƌĞĐĞƉƟŶŐƐƚƵĚĞŶƚƐŽŶĐůŝŶŝĐĂůƌŽƚĂƟŽŶĂƚƚŚĞ ĐŽŵƉůĞƚĞ ƌĂŶŐĞ ŽĨ ĞLJĞ ĂŶĚ ǀŝƐŝŽŶ ĐĂƌĞ ŝŶĐůƵĚŝŶŐƉƌĞƐĞŶƚĂƟŽŶƐĂƚƐĐŝĞŶƟĮĐŵĞĞƟŶŐƐ͕ DŝĚǁĞƐƚĞƌŶ hŶŝǀĞƌƐŝƚLJ LJĞ /ŶƐƟƚƵƚĞ ǁŚĞƌĞ ƐĞƌǀŝĐĞƐ͖ ƌĞƐĞĂƌĐŚ͕ ĂŶĚ ƉƵďůŝĐĂƟŽŶ ŝŶ ƉĞĞƌ ƌĞǀŝĞǁĞĚ ĂƉƉůŝĐĂďůĞ͖ • WĂƌƟĐŝƉĂƟŶŐ ŝŶ ůĞĂĚĞƌƐŚŝƉ ƌŽůĞƐ ŝŶ ũŽƵƌŶĂůƐ ƐƵĸĐŝĞŶƚ ƚŽ ƋƵĂůŝĨLJ ĨŽƌ ĂĐĂĚĞŵŝĐ ƐƚĂƚĞ͕ ƌĞŐŝŽŶĂů͕ ĂŶĚ ŶĂƟŽŶĂů ŽƉƚŽŵĞƚƌLJ ĂĚǀĂŶĐĞŵĞŶƚŝŶĂŶŽŶͲƚĞŶƵƌĞƚƌĂĐŬƉŽƐŝƟŽŶ͘ ŽƌŐĂŶŝnjĂƟŽŶƐ͖

Y烽®¥®‘ƒã®ÊÄÝ͗ĂŶĚŝĚĂƚĞƐŵƵƐƚƉŽƐƐĞƐƐĂŽĐƚŽƌŽĨKƉƚŽŵĞƚƌLJĚĞŐƌĞĞĨƌŽŵĂŶKͲĂĐĐƌĞĚŝƚĞĚŝŶƐƟƚƵƟŽŶ͕ŵƵƐƚŚĂǀĞĐŽŵƉůĞƚĞĚĂŶKͲĂĐĐƌĞĚŝƚĞĚ ƌĞƐŝĚĞŶĐLJ͕ĂŶĚŵƵƐƚďĞĞůŝŐŝďůĞĨŽƌĂŶŽƉƚŽŵĞƚƌŝĐƐƚĂƚĞůŝĐĞŶƐĞŝŶƚŚĞƐƚĂƚĞŝŶǁŚŝĐŚƚŚĞĐŽůůĞŐĞŝƐůŽĐĂƚĞĚ͘WƌŝŵĂƌLJĞLJĞĐĂƌĞĐůŝŶŝĐĂůĞdžƉĞƌƟƐĞŝƐĂůƐŽƌĞƋƵŝƌĞĚ͘ ^ĂůĂƌLJǁŝůůďĞĐŽŵŵĞƐƵƌĂƚĞǁŝƚŚƋƵĂůŝĮĐĂƟŽŶƐĂŶĚĞdžƉĞƌŝĞŶĐĞ ZĞǀŝĞǁŽĨĂƉƉůŝĐĂƟŽŶƐǁŝůůďĞŐŝŶŝŵŵĞĚŝĂƚĞůLJĂŶĚĐŽŶƟŶƵĞƵŶƟůƚŚĞƉŽƐŝƟŽŶŝƐĮůůĞĚ ÊÄパã®Ä¥ÊÙÃã®ÊÄ͗ŽŶƚĂĐƚŝŶĨŽƌŵĂƟŽŶ͗/ŶƚĞƌĞƐƚĞĚĂƉƉůŝĐĂŶƚƐƐŚŽƵůĚĂƉƉůLJŽŶůŝŶĞĂƚǁǁǁ͘ŵŝĚǁĞƐƚĞƌŶ͘ĞĚƵĂŶĚŝŶĐůƵĚĞ ĐƵƌƌŝĐƵůƵŵǀŝƚĂĞĂŶĚůĞƩĞƌŽĨŝŶƚĞƌĞƐƚƐƉĞĐŝĨLJŝŶŐƚŚĞƉŽƐŝƟŽŶĂŶĚĐŽůůĞŐĞƚŚĂƚŚĞͬƐŚĞǁŝƐŚĞƐƚŽďĞĐŽŶƐŝĚĞƌĞĚĨŽƌ͘/ŶƋƵŝƌŝĞƐŵĂLJďĞ ĚŝƌĞĐƚĞĚƚŽƌ͘DĞůŝƐƐĂ^ƵĐŬŽǁ͕ĞĂŶ͖DŝĚǁĞƐƚĞƌŶhŶŝǀĞƌƐŝƚLJ͗ŵƐƵĐŬŽΛŵŝĚǁĞƐƚĞƌŶ͘ĞĚƵ͘ DŝĚǁĞƐƚĞƌŶhŶŝǀĞƌƐŝƚLJŝƐĂŶƋƵĂůKƉƉŽƌƚƵŶŝƚLJͬĸƌŵĂƟǀĞĐƟŽŶĞŵƉůŽLJĞƌƚŚĂƚĚŽĞƐŶŽƚĚŝƐĐƌŝŵŝŶĂƚĞĂŐĂŝŶƐƚĂŶĞŵƉůŽLJĞĞŽƌĂƉƉůŝĐĂŶƚďĂƐĞĚƵƉŽŶƌĂĐĞ͕ ĐŽůŽƌ͕ƌĞůŝŐŝŽŶ͕ŐĞŶĚĞƌ͕ŶĂƟŽŶĂůŽƌŝŐŝŶ͕ĚŝƐĂďŝůŝƚLJ͕ŽƌǀĞƚĞƌĂŶƐƐƚĂƚƵƐ͕ŝŶĂĐĐŽƌĚǁŝƚŚϰϭ͘&͘Z͘ϲϬͲϭ͘ϰ;ĂͿ͕ϮϱϬ͘ϱ;ĂͿ͕ϯϬϬ͘ϱ;ĂͿĂŶĚϳϰϭ͘ϱ;ĂͿ͘

104 REVIEW OF OPTOMETRY NOVEMBER 15, 2018

ROPT1118.indd 104 11/8/18 5:59 PM Meetings + Conferences Advertisers Index

Akorn Consumer Health .....89 Lacrimedics, Inc ...... 17 Phone ...... (800) 579-8327 Phone ...... (800) 367-8327 November 2018 www.akornconsumerhealth.com Fax ...... (253) 964-2699 ...... [email protected] ■ 28-Dec. 2. Art & Science of Optometric Care—A Behavioral Akorn Pharmaceuticals 23, 59 ...... www.lacrimedics.com Perspective. OEP National Education Center, Timonium, MD. Phone ...... (800) 932-5676 Hosted by: Optometric Extension Center. Key faculty: Paul www.akorn.com Lacrivera ...... 51 Phone ...... (855) 857-0518 Harris. CE hours: 35. For more information, email Karen Ruder Alcon Laboratories ...... 5, 6 ...... www.lacrivera.com at [email protected], call (410) 561-3791 or go to ...... 85, 108 www.oep.org. Phone ...... (800) 451-3937 Lombart Instruments ...... 49 Fax ...... (817) 551-4352 Phone ...... (800) 446-8092 ■ 30-Dec. 1. Retina Update 2018. Fairmont Scottsdale Fax ...... (757) 855-1232 Princess, Scottsdale, AZ. Hosted by: Review of Optometry Allergan, Inc...... 35 and the Optometric Retina Society. Key faculty: Mohammad Phone ...... (800) 347-4500 Menicon ...... 7 Rafieetary, Steve Ferrucci, Mark Barakat, Jeff Gerson, Leo Phone ...... (800) MENICON Bausch + Lomb ...... 12, 53, 61 ...... [email protected] Semes, Brad Sutton. CE hours: 11. For more information, email ...... 79, 107 ...... www.meniconamerica.com Lois DiDomenico at [email protected] or go to Phone ...... (800) 323-0000 www.reviewsce.com/orsretupdate2018. Fax ...... (813) 975-7762 Natural Ophthalmics, Inc. ...65 Phone ...... (877) 220-9710 ■ 30-Dec. 1. Fourth Annual Tulsa Winter Weekend. Bruder Ophthalmic Products ...... [email protected] Renaissance Tulsa Hotel & Convention Center, Tulsa, OK...... 25 ...... www.NaturalEyeDrops.com Hosted by: Oklahoma College of Optometry. CE hours: 9. For Phone ...... (888) 827-8337 [email protected] NuSight Medical Operations more information, email Callie McAtee at [email protected], ...... 39, 41 call (918) 316-3602 or go to optometry.nsuok.edu/continuinge- Dry Eye Institute ...... 16 Phone ...... (833) 468-5437 ducation. Phone ...... (910) 447-2020 www.NuSightMedical.com ...... www.dryeyeinstitute.com Optos North America ...... 83 December 2018 Eye Designs ...... 29 Phone ..... (877) 455-8855 x 100 ■ 2. Clinical Topics in Optometry. Marshall B. Ketchum Phone ...... (800) 346-8890 Fax ...... (508) 486-9310 University, Fullerton, CA. Hosted by: Southern California Fax ...... (610) 489-1414 Quidel ...... 55 College of Optometry. CE hours: 8. For more information, email Eyevance Pharmaceuticals 27 Phone ...... (800) 874-1517 Antoinette Smith at [email protected] or go to Phone ...... (817) 677-6120 [email protected] www.ketchum.edu/ce...... eyevance.com ...... www.quidel.com ■ 2-3. 35th Annual Cornea, Contact Lens & Contemporary Focus Laboratories, Inc...... 21 Reichert Technologies ...... 2-3 Vision Care Symposium. Westin Memorial City, Houston, TX. Phone ...... (866) 752-6006 Phone ...... (888) 849-8955 Hosted by: University of Houston College of Optometry. Key Fax ...... (501) 753-6021 Fax ...... (716) 686-4545 ...... www.focuslaboratories.com ...... www.reichert.com faculty: Jan Bergmanson. CE hours: 16. For more information, email [email protected] or go to ce.opt.uh.edu. Imprimis Pharmaceuticals, Inc. S4OPTIK ...... 43, 45, 47 ■ 8-9. Orlando Super Weekend. Nova Southeastern ...... 15 Phone ...... (888) 224-6012 University—Orlando Campus, Orlando, FL. Hosted by: Nova Phone ...... (858) 704-4040 Fax ...... (858) 345-1745 Southeastern University College of Optometry. Key faculty: Mile ...... www.imprimispharma.com Shire Ophthalmics ...... 31, 32 Brujic, Leo Semes, Marco Gonzalez. CE hours: 8. For more ...... www.shire.com information, email Vanessa McDonald at [email protected] or Kala Pharmaceuticals ...... 9 Phone ...... (781) 996-5252 TelScreen ...... 63 go to optometry.nova.edu/ce/index.html. Fax ...... (781) 642-0399 ...... www.TelScreen.com ■ 14-15. West Coast Optometric Glaucoma Symposium...... [email protected] ...... [email protected] Monarch Beach Resort, Dana Point, CA. Hosted by: Review ...... www.kalarx.com Vital Tears ...... 57 of Optometry. Key faculty: Murray Fingeret, Robert Weinreb, Katena ...... 11, 81 Phone ...... (800) 360-9592 Andrew Camp, Ben Gaddie, Alex Huang, Richard Maddonna. Phone ...... (800) 225-1195 Fax ...... (816) 255-1395 CE hours: 8. For more information, email Vanessa McDonald at ...... www.katena.com ...... [email protected] ...... www.vitaltears.org [email protected] or go to optometry.nova.edu/ce/index.html. Keeler Instruments ...... 19 Phone ...... (800) 523-5620 X-Cel Speciality Contacts ...75 To list your meeting, please send the details to: Fax ...... (610) 353-7814 Phone ...... (877) 336-2482 Mark De Leon, Associate Editor www.xcelspecialitycontacts.com Email: [email protected] This advertiser index is published as a convenience and not as part of the advertising contract. Phone: (610) 492-1021 Every care will be taken to index correctly. No allowance will be made for errors due to spelling, incorrect page number or failure to insert.

REVIEW OF OPTOMETRY NOVEMBER 15, 2018 105

1105_ro1118_m&c.indd05_ro1118_m&c.indd 105105 111/16/181/16/18 10:1310:13 AMAM Diagnostic Quiz

Not Fade Away By Andrew S. Gurwood, OD

History A 45-year-old male presented to the office with an unsettling complaint; “My right eye is going blind!” He explained that his vision seemed to be gradually changing for the worse over the last couple of days. He reported the left eye was unaffected, and claimed to experi- ence no eye pain, redness, flashes, floaters or photophobia. His systemic history was com- Can these fundus images of the patient’s right (at left) and left eye uncover the cause plicated, with hypertension for 15 of our 45-year-old patient’s reported gradual vision loss? years and kidney and liver cancer diagnosed two years earlier, with Diagnostic Data Hg OU. The pertinent clinical chemotherapy treatments ongoing. Best-corrected entering visual acu- observation is demonstrated in the He also had a pituitary adenoma ity was 20/40 OD and 20/20 OS, photographs. resection six years earlier. His respectively, with no improvement medications included prednisone upon pinhole. Pupils were equal Your Diagnosis 5mg QD PO, Lovenox (enoxapa- and responsive to light with no evi- Does the case presented require rin sodium, Sanofi) and prochlo- dence of afferent defect. Confronta- any additional tests, history or perazine 10mg QD PO. He had tion visual fields were full with mild information? What steps would discontinued his hypertensive med- distortion of the central face in the you take to manage this patient? ication, claiming that without it he right eye. Based on the information pro- was still adequately controlled. His color vision and motilities vided, what would be your diag- He did, however, volunteer that were normal. The anterior segment nosis? What is the patient’s most his wife was filing for divorce, was normal, with Goldmann intra- likely prognosis? To find out, visit which was adding to his stress. ocular pressures measuring 14mm www.reviewofoptometry.com. ■

Retina Quiz Answers (from page 99): 1) c; 2) c; 3) d; 4) a; 5) c.

Next Month in the Mag • Surgery and the Ocular Surface: Pretreating Patients to Review of Optometry presents its Annual Surgery Report. Improve Outcomes Topics include: • Screening for, and preventing, post-LASIK ectasia • Adding Minor Procedures in the Optometric Office • Clinical Optics of Intraocular Lenses

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