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1/5/12 2:20 PM January 15, 2012 January www.revoptom.com ALSO INSIDE: The Increasing Value of OCT Imaging, p. 42 Seeing the Future with Contact Lenses, p. 26 Choroidal Melanoma is a Life Sentence, p. 48 Multiple Sclerosis and the Eye (Part 1), p. 77 1), Eye (Part and the Sclerosis Multiple Injections: The Third Method of Drug Administration, p. 32 Part 1 of 2 FC_RO1111.indd 1

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VOL. 149 NO. 1 ■ JANUARY 15, 2012

IN THE NEWS Drug Slows Metastasis

Nanoparticles called dendrimers offer a novel route into the retina for Of Uveal Melanoma age-related macular degeneration and retinitis pigmentosa treatments, A drug approved for epilepsy can also slow the spread of according to new research. Investiga- these deadly eye tumors. By Michael Hoster, Senior Editor tors at the Mayo Clinic, Wayne State University and Johns Hopkins Medicine type of drug that is com- ences and professor of biology and found that steroids attached to the monly used to treat molecular oncology at Washington dendrimers target the damage-causing Aepileptic seizures may slow University School of Medicine cells associated with neuroinﬂ am- or prevent uveal melanoma from in St. Louis. “When we look at mation, preserving vision and leaving metastasizing to other parts of aggressive melanoma cells under the rest of the eye unaffected. The the body, according to a study in the microscope after treatment results appear in the January issue of the October 28 online version of with HDAC inhibitors, they look Biomaterials. Clinical Cancer Research. more like normal cells and less like The researchers determined that tumor cells.” The FDA has launched a monitor- FDA-approved anti-epileptic drugs Treatment with HDAC inhibi- ing program to prevent outbreaks of known as histone deacetylase tors may allow patients with such toxic anterior segment syndrome (HDAC) inhibitors alter the way aggressive melanomas to live for (TASS)—a rare but potentially seri- that the aggressive form of uveal many years without any detectable

ous complication of cataract surgery. Photo: Mark T. Dunbar, O.D. metastasis, Dr. Harbour predicted. Working with the Centers for Dis- “Melanoma in general, and ease Control and Prevention and the uveal melanoma in particular, is American Academy of Ophthalmology, notoriously diffi cult to treat once the FDA has established a registry for it has metastasized and grown in a devices used in cataract surgery and a distant organ,” he added. “I sus- program for identifying and evaluating pect that the best role for HDAC suspected device contaminants. inhibitors will be to slow or prevent the growth of tumor cells Elderly patients who took the carot- that have spread out of the eye, enoid zeaxanthin showed improve- but cannot yet be detected. This ments in vision, according to results might lengthen the time between from the Zeaxanthin and Visual melanoma expresses its key genes. the original eye treatment and the Function Study, reported in the No- According to the researchers, appearance of detectable cancer in vember 2011 issue of Optometry. The uveal melanoma is very aggressive the liver and elsewhere.” study included 60 predominantly male and typically spreads from the eye In addition, HDAC inhibitors veterans who had mild-to-moderate to other bodily organs, such as the cause only relatively mild side AMD. They were randomized to receive liver. effects such as drowsiness, Dr. 8mg zeaxanthin, 8mg zeaxanthin plus “HDAC inhibitors appear to Harbour explained. 9mg lutein, or 9mg lutein for one year. reverse the aggressive molecular Clinical trials on patients with Researchers concluded that, indepen- signature that we had identifi ed metastatic uveal melanoma could dent of lutein, zeaxanthin contributed several years ago as a marker begin within the next six to 12 to improved vision in night driving, fi ne for metastatic death,” said lead months, he noted. detail and the disappearance of blind researcher J. William Harbour, Landreville S, Agapova OA, Matatall KA, et al. Histone spots. deacetylase inhibitors induce growth arrest and differentia- M.D., distinguished professor of tion in uveal melanoma. Clin Cancer Res. 2011 Oct 28. ophthalmology and visual sci- [Epub ahead of print]

4 REVIEW OF OPTOMETRY JANUARY 15, 2012

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RO1111_Keeler.indd 1 10/31/11 2:16 PM News Review

Myopia Treatments for Kids Come Up Short or Cause Side Effects urrent treatments to slow Photo: National Eye Institute–National Institutes of Health maceutical eye drops (ﬁ ve of these the progression of myopia were of anti-muscarinic medica- Cin children either don’t tions). work or cause problematic side ef- • One study investigated new fects, according to a recent review lenses designed to reduce periph- published by pediatric eye doctors eral hyperopic defocus (i.e., lenses and study methodologists. that help to focus peripheral vision The reviewers analyzed data as well as central vision). from 23 randomized controlled • One study evaluated both trials, which included a total of multifocal lenses and pharmaceuti- 4,696 participants. They consid- cal eye drops. ered a number of potential myopia The follow-up period was at treatments including bifocal glass- least one year for all studies. es, eye drops, intraocular pressure- Of all methods of myopia inhibition, anti- Of all the treatments, anti- lowering drugs and contact lenses: muscarinic drops work the best, but their muscarinic eye drops offered the • Two studies investigated un- use is limited and causes side effects. largest positive effects for slowing dercorrection of myopia. myopia progression, the authors • 12 studies investigated mul- soft contact lenses (BSCLs). found, but they caused either light tifocal spectacles (progressive • Two studies investigated sensitivity or blurred near vision. addition lenses [PALs] or bifocal rigid gas permeable contact lenses Also, these drops are not yet com- spectacles). (RGPCLs). mercially available, so their use is • One study investigated bifocal • Six studies investigated phar- limited and impractical. PALs and bifocal spectacles were found to yield a small Eyes in the Back of Its Head slowing of myopia progression. Biologists at Tufts University were able to make tadpoles grow eyes on their backs and RGPCLs were found to have no tails by genetically manipulating the membrane voltage of cells in frog embryos. evidence of effect on myopic eye This new mechanism could have great potential in the formation of complex organs for growth, while undercorrection transplantation and regenerative medicine applications. of myopia was found to increase Photo: Sherry Aw, Ph.D. and Michael Levin, myopia progression slightly. Lastly, “other methods of myopia control, such as the use of corneal reshaping contact lenses or bifocal soft contact lenses (BSCLs) with a distance center, are promising but currently no published randomized clinical trials exist,” the authors concluded. An overview of the report is available at: http://onlinelibrary. wiley.com/doi/10.1002/14651858. CD004916.pub3/pdf/abstract.

Walline JJ, Lindsley K, Vedula SS, et al. Interventions to slow progression of myopia in children. Cochrane Database Syst Rev. 2011 Dec 7;12:CD004916.

6 REVIEW OF OPTOMETRY JANUARY 15, 2012

004_RO0112_News.indd 6 1/5/12 2:14 PM RO0112_House Vision Source.indd 1 12/27/11 3:41 PM News Review

New Online Tool Calculates Risk of AMD Progression new, online risk assessment graphic, environmental, pheno- Their fi ndings appear in an model will help eye care typic and genetic covariates.”1 article published in the December Aproviders more easily iden- The fi nal model takes into ac- 2011 Archives of Ophthalmology. tify whether patients with AMD count these independent variables: In a related editorial, Ronald will experience disease progression age; smoking history; family histo- Klein, M.D., M.P.H., professor and/or visual compromise. ry of AMD (fi rst-degree member); in the department of ophthalmol- Michael Klein, M.D., and as- phenotype based on a modifi ed ogy and visual sciences at the sociates at the Casey Eye Insti- AREDS simple scale score; and University of Wisconsin School tute at the Oregon Health and genetic variants CFH Y402H and of Medicine and Public Health, Science University in Portland ARMS2 A69S. and associates commented on the used phenotypic, demographic, After testing the calculator’s clinical signifi cance of Dr. Michael environmental and genetic risk validity, the authors wrote, “the Klein’s predictive model.2 “Know- factors—in particular visual data model did well on performance ing the severity of the lesions of from 2,846 patients enrolled in measures, with very good dis- AMD that are already present, the Age-Related Eye Disease Study crimination and excellent calibra- coupled with knowledge of impor- (AREDS)—to design this risk as- tion and overall performance. tant lifestyle factors, gives most of sessment model.1 Successful external validation was the important information about The researchers evaluated longi- performed, and a risk assessment risk of progression.” tudinal data from AREDS partici- tool was designed for use with or The AMD Risk Assessment pants who had all levels of AMD, without the genetic component.” Calculator is available at: ranging from none to unilateral They conclude, “We believe our http://caseyamdcalc.ohsu.edu. advanced AMD. current model is of substantial val- 1. Klein ML, Francis PJ, Ferris FL 3rd, et al. Risk assessment model for development of advanced age-related macular de- With this information in hand, ue in assessing AMD risk, and we generation. Arch Ophthalmol. 2011 Dec;129(12):1543-50. they performed “a Cox propor- expect that future advances will 2. Klein R, Klein BE, Myers CE. Risk assessment models for late age-related macular degeneration. Arch Ophthalmol. tional hazards analysis with demo- further improve its accuracy.” 2011 Dec;129(12):1605-6. Sunshine Act Delayed—for Now roposed regulations from and teaching hospitals and to timeline is feasible. the Centers for Medicaid annually report those numbers The consequences of not report- Pand Medicare Services will to CMS. It also requires these ing are signifi cant, including civil postpone data collection under the manufacturers, as well as drug and fi nes and penalties from $1,000 federal Physician Payment Sun- device supplier group purchasing for a simple inaccuracy, up to $1 shine Act until later this year, after organizations, to annually report million for a knowing failure to the fi nal regulations have been is- physician ownership and invest- report. sued. The “physician” discussed in ment interests. The proposed regulations defi ne the ruling includes ophthalmolo- The proposed rule states that several key terms, describe the gists and optometrists, but does CMS is considering requiring reporting process and ask for not address opticians. manufacturers to start track- feedback on several key issues. Part of the 2010 health care ing payments 90 days after the Comments must be submitted by reform package, the Sunshine Act publication of the fi nal rule, with a February 17, 2012. requires drug, medical device and partial year report due on March To submit a comment, go to other manufacturers to collect 31, 2013. However, the agency is www.regulations.gov/#!document data on payments to physicians seeking comments on whether that Detail;D=CMS-2011-0191-0004.

8 REVIEW OF OPTOMETRY JANUARY 15, 2012

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RO0611_Vistakon Hydraclear.indd 1 5/18/11 3:02 PM News Review

Location and Temperature Are Risk Factors for Exfoliation Glaucoma eographic latitude and Pasquale, M.D., director of Mas- outside air temperature— sachusetts Eye and Ear. Gnot ethnicity—could Once the researchers realized be potential risk factors for the that ethnicity was not a signiﬁ cant development of exfoliation syn- risk factor for ES, they suggested drome (ES), according to a study that the disease might have an published in the January issue of environmental component. “Im- Ophthalmology. portantly, those with a lifetime Exfoliation syndrome is the residential history of living in the leading cause of secondary open- Exfoliation glaucoma. middle tier and south tier of the angle glaucoma, and may also United States was associated with contribute to cataract formation. family history of glaucoma were 47% and 75% reduced risks, In this study, researchers from more than twice as likely to de- respectively, compared with living the Massachusetts Eye and Ear velop ES. in the northern tier,” the authors Inﬁ rmary at Harvard Medical • Individuals of Scandinavian wrote. School examined the records of or Southern European descent are Another manuscript they 78,955 females enrolled in the not genetically predisposed to the recently published suggests that Nurses’ Health Study and 41,191 development of ES. lower ambient temperature inter- males enrolled in the Health • Iris color was not a risk factor acts with increased solar exposure Professionals Follow-up Study for for ES. to heighten the risk of ES. descriptive epidemiologic features “This large, prospective cohort More research needs to be done of ES. study demonstrates that there is to determine how these environ- The researchers determined a positive association between mental factors contribute to ES, that: latitude and ES risk that is robust they add. • Females were at a higher risk and not related to demographic Kang JH, Loomis S, Wiggs JL, et al. Demographic and geographic features of exfoliation glaucoma in 2 United for ES. features or other systemic covari- States-based prospective cohorts. Ophthalmology. 2012 • Individuals with a positive ates,” said study co-author Louis Jan;119(1):27-35. It’s Glaucoma Awareness Month anuary is the especially African your patients, including: perfect time to Americans over age • Prevent Blindness America’s Jraise awareness 40; people over age Glaucoma Learning Center: www. in your community 60, especially Mexi- preventblindness.org/glaucoma. about the prevalence can Americans; and • The Glaucoma Research of glaucoma and those with a family Foundation: www.glaucoma.org. the importance of history of the disease. • The Take on Glaucoma web- making eye health a Stress that early de- site: www.takeonglaucoma.com. priority—particular- tection and treatment • The National Eye Institute: ly while those New is the best way to www.nei.nih.gov/health/glaucoma. Year’s resolutions to take better prevent vision loss from this wide- • The Centers for Disease care of their health are still fresh. spread disease. There are a num- Control and Prevention’s Vision Encourage those at risk to get a ber of educational resources about Health Institute: www.cdc.gov/ comprehensive dilated eye exam, glaucoma that you can share with visionhealth.

10 REVIEW OF OPTOMETRY JANUARY 15, 2012

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Study: Perform Visual Fields Every Six Months wice-a-year visual ﬁ eld test- More speciﬁ cally, using mean

ing, compared to once-a- deviation as a criterion, 43.6% PRESIDENT & PUBLISHER year testing, leads to earlier (204 eyes) in the high-frequency RICHARD D. BAY T (610) 492-1020 •RBAY @JOBSON.COM detection of glaucoma progression data set progressed while 34.2% BUSINESS OFFICES for high-risk patients, especially (160 eyes) in the low-frequency 11 CAMPUS BLVD., SUITE 100 NEWTOWN SQUARE, PA 19073 using global trend analyses, ac- data set progressed. Alternatively, SUBSCRIPTION INQUIRIES cording to researchers at the Jules using pointwise linear regression 1-877-529-1746 (USA ONLY); Stein Eye Institute. as a criterion, 39.5% (185 eyes) in OUTSIDE USA, CALL (847) 763-9630 “This ﬁ nding the high-frequency SALES MANAGER, NORTHEAST, OHIO JAMES HENNE has signiﬁ cant im- data set and 35.7% (610) 492-1017 •JHENNE @JOBSON.COM plications for the (167 eyes) in the SALES MANAGER, SOUTHEAST, WEST MICHELE BARRETT care of patients low-frequency data (610) 492-1014 •MBARRETT @JOBSON.COM

with glaucoma,” set progressed. CONFERENCE DIRECTOR the authors wrote “The hazard ratios KIMBERLY MCCARTHY (610) 492-1045 •KMCCARTHY @JOBSON.COM in an article in the for progression CLASSIFIED ADVERTISING December issue of are large enough, 1-888-537-4858

Archives of Oph- especially for [mean DIRECTOR OF PUBLISHING OPERATIONS CASEY FOSTER thalmology. deviation] criteria, (610) 492-1007 •CFOSTER @JOBSON.COM Using data for the beneﬁ ts to be PRODUCTION MANAGER from the Advanced Glaucoma considered worth the extra time SCOTT TOBIN (610) 492-1011 •STOBIN @JOBSON.COM Intervention Study (AGIS), inves- and expense required for earlier SENIOR CIRCULATION MANAGER tigators gathered the visual ﬁ eld detection of glaucoma progres- ANTHONY GUADAGNINO examinations of 468 eyes (381 sion, at least in a subset of patients (212) 219-7870 •AGUADAGNINO @JOBSON.COM patients) with primary open-angle at higher risk of progression,” the SUBSCRIPTIONS $56 A YEAR, $88 (U.S.) IN CANADA, glaucoma, which was no longer researchers wrote. $209 (U.S.) IN ALL OTHER COUNTRIES.

controlled by maximum medical While three examinations per CIRCULATION PO BOX 2025 treatment. year have been recommended for SKOKIE, IL 60076 The researchers then created optimal detection of glaucoma TEL: (TOLL FREE) 1-877-529-1746 OUTSIDE USA: (847)763-9630 two data sets. The fi rst set, which progression, no evidence-based FAX: (847)763-9631 included twice-yearly AGIS fi eld data supports such a recommenda- test results, was labeled as the tion, the authors wrote. And, they high-frequency testing group. To add, only a minority of patients create the second data set to rep- have disease that progresses at a resent low-frequency fi eld testing, rate fast enough to justify thrice- the researchers deleted every other yearly testing. CHIEF OPERATING OFFICER test of the AGIS participants. Such a “testing strategy is cum- JEFF MACDONALD CEO, INFORMATION GROUP SERVICES The high-frequency group had a bersome and is not practical under MARC FERRARA median of 20 visual fi eld examina- most clinical circumstances,” they VICE PRESIDENT, HUMAN RESOURCES tions and the low-frequency group wrote. “Our data provide evidence LORRAINE ORLANDO had a median of 12. for the advantages of a more prac- VICE PRESIDENT, CREATIVE SERVICES & PRODUCTION “The high-frequency data set tical six-month schedule for visual MONICA TETTAMANZI ■ VICE PRESIDENT, CIRCULATION was more likely to detect progres- fi eld testing.” EMELDA BAREA sion with mean deviation or point- Nouri-Mahdavi K, Zarei R, Caprioli J. Infl uence of visual fi eld testing frequency on detection of glaucoma progression with wise linear regression criteria,” trend analyses. Arch Ophthalmol. 2011 Dec;129(12):1521- they found. 7.

12 REVIEW OF OPTOMETRY JANUARY 15, 2012

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RO0711_Nidek.indd 1 6/29/11 10:12 AM Contents Review of Optometry January 2012 26 Seeing the Future with Contact Lenses With advances in technology and improvements in materials, contact lenses aren’t just for vision correction anymore. By David L. Kading, O.D., and Katherine Shen, O.D. 32 Injections: The Third Method of Drug Administration Even if you don’t perform injections in your office, you should know the different types of injections in eye care, and how they’re performed. By James L. Fanelli, O.D. 42 The Increasing Value of OCT Imaging Ocular coherence tomography has become an all- around useful tool for glaucoma, retina and even anterior seg evaluation. Not every office needs one, but we certainly couldn’t do without ours. 56 By Kenny Bumgarner, O.D. Keep on Plugging Punctal plugs are an effective treatment option for many patients with dry eye syndrome. But, they also may be used in a variety of other ways to facilitate improved ocular health. By Walt Whitley, O.D., M.B.A.

OF OPTO EW ME VI T E R 64 R Y Earn 2 CE Credits: 48 The Impact of Autoimmune Disease Choroidal Melanoma is a Life Sentence Inflammatory autoimmune conditions can cause significant ocular A thorough knowledge of treatment options and surface disease and systemic complications. Here’s how to manage associated risks is crucial to ensure the best patients who present with Sjögren’s syndrome, rheumatoid arthritis and possible outcome with this dire condition. multiple sclerosis. By Andrew Morgenstern, O.D. By Sara Weidmayer, O.D.

REVIEW OF OPTOMETRY JANUARY 15, 2012 15

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★ ★ ★ ★ ★ ★ ★ ssion for 120 Years e Profes s Departments Serving th Review of Optometry January 2012

PRINTED IN U.S.A. 4 News Review FOUNDING EDITOR FREDERICK BOGER 20 Editor’s Page 1891-1913 Optometry’s Sharper Image EDITORIAL OFFICES 74 11 CAMPUS BLVD., SUITE 100 AMY HELLEM NEWTOWN SQUARE, PA 19073 EMAIL • [email protected] 22 Chairside WORLD WIDE WEB •WWW .REVOPTOM.COM I’m Shootin’ Blanks Here SUBSCRIPTION INQUIRIES 1-877-529-1746 MONTGOMERY VICKERS, O.D. CONTINUING EDUCATION INQUIRIES 1-800-825-4696 24 Coding Abstract EDITOR-IN-CHIEF •A MY HELLEM Happy(?) New Year! (610) 492-1006 •AHELLEM @JOBSON.COM JOHN RUMPAKIS, O.D., M.B.A. MANAGING EDITOR •JOHN MURPHY 72 Comanagement Q+A (610) 492-1021 •JMURPHY @JOBSON.COM Bust That Rust! SENIOR EDITOR/ASSOCIATE SPECIAL PROJECTS EDITOR PAUL C. AJAMIAN, O.D. 77 MICHAEL HOSTER (610) 492-1028 •MHOSTER @JOBSON.COM

74 Cornea + Contact Lens Q+A SENIOR EDITOR •C OLLEEN MULLARKEY On Thin Eyes (610) 492-1005 •CMULLARKEY @JOBSON.COM JOSEPH P. SHOVLIN, O.D. DIRECTOR ART/PRODUCTION •JOSEPH MORRIS 77 Review of Systems (610) 492-1027 •JMORRIS @JOBSON.COM Multiple Sclerosis and the Eye (Part 1) ART DIRECTOR •JARED ARAUJO CARLO J. PELINO, O.D. (610) 492-1032 •JARAUJO @JOBSON.COM JOSEPH J. PIZZIMENTI, O.D. GRAPHIC DESIGNER •A LICIA CAIRNS (610) 492-1029 •ACAIRNS @JOBSON.COM 81 Retina Quiz DIRECTOR OF CE ADMINISTRATION •R EGINA COMBS Patient Sees Better in the Dark (212) 274-7160 •RCOMBS @JOBSON.COM MARK T. DUNBAR, O.D. On The Web ›› SPECIAL PROJECTS •JANE COLE (610) 492-1043 •JCOLE @JOBSON.COM 85 Therapeutic Review Check out our Sowka Down Under, Part II EDITORIAL BOARD JOSEPH W. SOWKA, O.D. web exclusives and CHIEF CLINICAL EDITORS •R OBERT M. COLE, III, O.D. CHRISTINE W. SINDT, O.D. continuing education ASSOCIATE CLINICAL EDITOR •JOSEPH P. SHOVLIN, O.D. 88 Research Review DIRECTOR OPTOMETRIC PROGRAMS •A RTHUR EPSTEIN, O.D. A Look At MSI @ www.revoptom.com CLINICAL & EDUCATION CONFERENCE ADVISOR • DIANA L. SHECHTMAN, O.D. PAUL M. KARPECKI, O.D. CASE REPORTS COORDINATOR • THOMAS L. LEWIS, O.D., PH.D. PAUL M. KARPECKI, O.D. Digital Edition CLINICAL CODING EDITOR •JOHN RUMPAKIS, O.D., M.B.A. Left your Review of CONSULTING EDITOR •F RANK FONTANA , O.D. JAN BEITING 90 Product Review Optometry at the SENIOR CONTRIBUTING EDITOR • office? No problem! COLUMNISTS Get Review sent 92 Classifieds CHAIRSIDE •M ONTGOMERY VICKERS, O.D. to your desktop or COMANAGEMENT Q+A •P AUL C. AJAMIAN, O.D. mobile device! CORNEA & CONTACT LENS Q+A •JOSEPH P. SHOVLIN, O.D. 96 Meetings + Conferences Go to www.revoptom.com and DIAGNOSTIC QUIZ •A NDREW S. GURWOOD, O.D. RESEARCH REVIEW •P AUL M. KARPECKI, O.D.; click on the digimag link to get DIANA L. SHECHTMAN, O.D. 97 Advertisers Index your current issue. RETINA QUIZ •M ARK T. DUNBAR, O.D. REVIEW OF SYSTEMS •C ARLO J. PELINO, O.D.; Facebook and Twitter JOSEPH J. PIZZIMENTI, O.D. For daily updates, GLAUCOMA GRAND ROUNDS •JAMES L. FANELLI, O.D. 98 Diagnostic Quiz THERAPEUTIC REVIEW •JOSEPH W. SOWKA, O.D.; Right Between the Eyes “Like” us on Face- ALAN G. KABAT, O.D. ANDREW S. GURWOOD, O.D. book or “Follow” us PROFESSIONAL PUBLISHING GROUP on Twitter! JOBSON MEDICAL INFORMATION LLC •www.facebook.com/revoptom •http://twitter.com/#!/revoptom

16 REVIEW OF OPTOMETRY JANUARY 15, 2012

015_R0112_TOC.indd 16 1/5/12 2:32 PM RO1011_Allerganod.indd 1 8/18/11 1:53 PM Brief Summary of Prescribing Information

ATON Pharma, a Division of Valeant Pharmaceuticals North America LLC CONTRIBUTING EDITORS Madison, NJ 07940 PAUL C. AJAMIAN, O.D., ATLANTA Rx Only JEFFREY R. ANSHEL, O.D., CARLSBAD, CALIF. LACRISERT® (hydroxypropyl cellulose) OPHTHALMIC INSERT JILL AUTRY, O.D., R.PH., HOUSTON SHERRY J. BASS, O.D., NEW YORK DESCRIPTION MILE BRUJIC, O.D., BOWLING GREEN, OHIO LACRISERT® Ophthalmic Insert is a sterile, translucent, rod-shaped, water soluble, WALTER L. CHOATE, O.D., MADISON, TENN. ophthalmic insert made of hydroxypropyl cellulose, for administration into the ROBERT M. COLE, III, O.D., BRIDGETON, N.J. inferior cul-de-sac of the eye. ANTHONY S. DIECIDUE, O.D., STROUDSBURG, PA. Each LACRISERT is 5 mg of hydroxypropyl cellulose. LACRISERT contains no MARK T. DUNBAR, O.D., MIAMI preservatives or other ingredients. It is about 1.27 mm in diameter by about 3.5 mm S. BARRY EIDEN, O.D., DEERFIELD, ILL. long. LACRISERT is supplied in packages of 60 units, together with illustrated ARTHUR B. EPSTEIN, O.D., ROSLYN, N.Y. instructions and a special applicator for removing LACRISERT from the unit dose JAMES L. FANELLI, O.D., WILMINGTON, N.C. blister and inserting it into the eye. FRANK FONTANA, O.D., ST. LOUIS INDICATIONS AND USAGE GARY S. GERBER, O.D., HAWTHORNE, N.J. LACRISERT is indicated in patients with moderate to severe dry eye syndromes, ANDREW S. GURWOOD, O.D., PHILADELPHIA including keratoconjunctivitis sicca. LACRISERT is indicated especially in patients MILTON HOM, O.D., AZUSA, CALIF. who remain symptomatic after an adequate trial of therapy with artificial tear ALAN G. KABAT, O.D., FORT LAUDERDALE, FLA. solutions. LACRISERT is also indicated for patients with exposure keratitis, decreased PAUL M. KARPECKI, O.D., EDGEWOOD, KY. corneal sensitivity, and recurrent corneal erosions. JUDITH LEE, ATGLEN, PA. CONTRAINDICATIONS JEROME A. LEGERTON, O.D., M.B.A., SAN DIEGO LACRISERT is contraindicated in patients who are hypersensitive to hydroxypropyl THOMAS L. LEWIS, O.D., PH.D., PHILADELPHIA cellulose. DOMINICK MAINO, O.D., M.ED., CHICAGO WARNINGS JASON R. MILLER, O.D. M.B.A., POWELL, OHIO Instructions for inserting and removing LACRISERT should be carefully followed. PAMELA J. MILLER, O.D., J.D., HIGHLAND, CALIF. JOHN W. POTTER, O.D., M.A., DALLAS PRECAUTIONS CHRISTOPHER J. QUINN, O.D., ISELIN, N.J. General JOHN L. SCHACHET, O.D., ENGLEWOOD, COLO. If improperly placed, LACRISERT may result in corneal abrasion. JACK SCHAEFFER, O.D., BIRMINGHAM, ALA. Information for Patients CAROL SCHWARTZ, O.D., M.B.A., SAN JOSE DEL CABO, MEXICO Patients should be advised to follow the instructions for using LACRISERT which JEROME SHERMAN, O.D., NEW YORK accompany the package. JOSEPH P. SHOVLIN, O.D., SCRANTON, PA. Because this product may produce transient blurring of vision, patients should JOSEPH W. SOWKA, O.D., FORT LAUDERDALE, FLA. be instructed to exercise caution when operating hazardous machinery or driving LORETTA B. SZCZOTKA, O.D., M.S., CLEVELAND a motor vehicle. MONTGOMERY VICKERS, O.D., ST. ALBANS, W.VA. Drug Interactions KATHY C. WILLIAMS, O.D., SEATTLE Application of hydroxypropyl cellulose ophthalmic inserts to the eyes of unanesthetized rabbits immediately prior to or two hours before instilling pilocarpine, proparacaine EDITORIAL REVIEW BOARD HCl (0.5%), or phenylephrine (5%) did not markedly alter the magnitude and/or duration of the miotic, local corneal anesthetic, or mydriatic activity, respectively, EDWARD S. BENNETT, O.D., ST. LOUIS of these agents. Under various treatment schedules, the anti-inflammatory effect of MARC R. BLOOMENSTEIN, O.D., SCOTTSDALE, ARIZ. ocularly instilled dexamethasone (0.1%) in unanesthetized rabbits with primary uveitis CHRIS J. CAKANAC, O.D., MURRYSVILLE, PA. was not affected by the presence of hydroxypropyl cellulose inserts. JERRY CAVALLERANO, O.D., PH.D., BOSTON Carcinogenesis, Mutagenesis, Impairment of Fertility BRIAN CHOU, O.D., SAN DIEGO Feeding of hydroxypropyl cellulose to rats at levels up to 5% of their diet produced A. PAUL CHOUS, M.A., O.D., TACOMA, WASH. no gross or histopathologic changes or other deleterious effects. GLENN S. CORBIN, O.D., WYOMISSING, PA. Pediatric Use STEVEN FERRUCCI, O.D., SEPULVEDA, CALIF. Safety and effectiveness in pediatric patients have not been established. MURRAY FINGERET, O.D., HEWLETT, N.Y. IAN BEN GADDIE, O.D., LOUISVILLE, KY. Geriatric Use No overall differences in safety or effectiveness have been observed between elderly MATTHEW J. GARSTON, O.D., BOSTON and younger patients. ROBERT M. GROHE, O.D., HOMEWOOD, ILL. ANDREW S. GURWOOD, O.D., PHILADELPHIA ADVERSE REACTIONS NICKY HOLDEMAN, O.D., M.D., HOUSTON The following adverse reactions have been reported in patients treated with MILTON HOM, O.D., AZUSA, CALIF. LACRISERT, but were in most instances mild and transient: transient blurring WILLIAM L. JONES, O.D., ALBUQUERQUE, N.M. of vision, ocular discomfort or irritation, matting or stickiness of eyelashes, ALAN G. KABAT, O.D., FORT LAUDERDALE, FLA. photophobia, hypersensitivity, edema of the eyelids, and hyperemia. PAUL M. KARPECKI, O.D., EDGEWOOD, KY. DOSAGE AND ADMINISTRATION RON MELTON, O.D., CHARLOTTE, N.C. One LACRISERT ophthalmic insert in each eye once daily is usually sufficient to BRUCE MUCHNICK, O.D., PHILADELPHIA relieve the symptoms associated with moderate to severe dry eye syndromes. MARC MYERS, O.D., COATESVILLE, PA. Individual patients may require more flexibility in the use of LACRISERT; some CARLO J. PELINO, O.D., JENKINTOWN, PA. patients may require twice daily use for optimal results. JOSEPH PIZZIMENTI, O.D., FORT LAUDERDALE, FLA. Clinical experience with LACRISERT indicates that in some patients several WILLIAM B. POTTER, O.D., FREEHOLD, N.J. weeks may be required before satisfactory improvement of symptoms is achieved. JOHN RUMPAKIS, O.D., M.B.A., PORTLAND, ORE. Issued June 2007 MICHAEL C. RADOIU, O.D., STAUNTON, VA. LEO P. SEMES, O.D., BIRMINGHAM, ALA. Distributed by: DIANA L. SHECHTMAN, O.D., FORT LAUDERDALE, FLA. ATON Pharma, LEONID SKORIN, JR., O.D., D.O., ROCHESTER, MINN. a Division of Valeant Pharmaceuticals North America LLC JOSEPH W. SOWKA, O.D., FORT LAUDERDALE, FLA. Madison, NJ 07940 RANDALL THOMAS, O.D., CONCORD, N.C. Manufactured by: MERCK & Co., Inc. West Point, PA 19486 USA © 2011, ATON Pharma All rights reserved. LAC012-0211ROr

015_R0112_TOC.indd 18 1/5/12 2:32 PM In moderate to severe dry eye syndromes Only Dissatisfied Patients Need Apply

For patients seeking improvement in comfort and satisfaction:1

Continuous lubrication, starting day 1.2 Provides ongoing ocular surface protection, long term.3

s Results of a large multicenter registry study of over 400 patients showed significant reduction (p<0.05) in frequency and severity of dry eye symptoms after one month of therapy with LACRISERT®1 s 53% of patients felt that LACRISERT® provided incremental improvements to their existing therapy, including artificial tears1

Indications and Usage LACRISERT® is indicated in patients with moderate to severe Dry Eye syndromes, including keratoconjunctivitis sicca. LACRISERT® is indicated especially in patients who remain symptomatic after an adequate trial of therapy with artificial tear solutions. LACRISERT® is also indicated for patients with exposure keratitis, decreased corneal sensitivity, and recurrent corneal erosions.

Important Safety Information LACRISERT® is contraindicated in patients who are hypersensitive to hydroxypropyl cellulose. Instructions for inserting and removing LACRISERT® should be carefully followed. If improperly placed, LACRISERT® may result in corneal abrasion. Because LACRISERT® may cause transient blurred vision, patients should be instructed to exercise caution when driving or operating machinery. Patients should be cautioned against rubbing the eye(s) containing LACRISERT®.

The following adverse reactions have been reported, but were in most instances, mild and temporary: transient blurring of vision, ocular discomfort or irritation, matting or stickiness of eyelashes, photophobia, hypersensitivity, eyelid edema, and hyperemia.

Please see Brief Summary of Prescribing Information on the adjacent page.

* In most patients, one LACRISERT® placed into each eye once daily is effective in providing all-day symptom relief. Some patients may require twice-daily use for optimal results.

References: 1. Koffler BH, McDonald M, Nelinson D, Improved signs and symptoms and quality of life with dry eye syndrome: hydroxypropyl cellulose ophthalmic insert patient registry. Eye Contact Lens. 2010;3:170-176. Once a Day.* 2. LACRISERT [package insert] Madison, NJ: ATON Pharma, 2009. 3. Wander A, Koffler B. Extending the duration of tear film production: review and retrospective case series study of the hydroxypropyl cellulose Continuous Lubrication. ophthalmic insert. Ocul Surf. 2009;7(3e):154-162. Ongoing Protection.

RO0112_Aton Lacrisert.indd 1 12/22/11 12:51 PM Editor’s Page

Optometry’s Sharper Image If pointing a needle at my eye requires the skill of a surgeon, why isn’t there more outrage directed toward cosmetologists and tattoo artists who apply permanent makeup? By Amy Hellem, Editor-in-Chief

he use of injectable medi- optometrist’s experience is in pre- lated. According to the FDA’s web- cations is a touchy subject scribing topicals, optometrists are site: “FDA considers the inks used and the source of ongoing trained extensively on the use of a in intradermal tattoos, including dispute and deliberation. whole spectrum of pharmacologic permanent makeup, to be cosmetics Currently,T optometrists in 35 states agents—including systemic and and considers the pigments used in are permitted to administer drugs injectable medications. And, to be the inks to be color additives requir- via injection; yet many well-trained, fair, understanding absorption rates ing premarket approval under the prominent O.D.s opt not to do so. is not rocket science—particularly Federal Food, Drug, and Cosmetic Their reasons are varied and are of to trained doctors. So again, I ask, Act.”2 They go on, however, to say particular interest to many ophthal- what is everyone so afraid of? that they don’t traditionally exercise mologists who wish to retain sole Perhaps the reason why oph- their authority over tattoo inks or ownership of injectable territory. thalmologists so fiercely attack the pigments used in them, even While I would never criticize an optometry’s efforts to gain injection though they recognize the fact that optometrist for steering clear of privileges is because placing a needle “many pigments used in tattoo inks a procedure that he or she is not anywhere near the eye is dangerous are not approved for skin contact at comfortable performing, the hushed business. Certainly, states should all” and “some are industrial grade debate got me wondering what take a close look at your training colors that are suitable for printers’ everyone’s really so afraid of—is it before deciding whether you are ink or automobile paint.”2 the needle itself, or what’s inside that qualified to take a sharp object full I applaud the optometrist who sparks the quarrel and hesitation? of medicine or dye and inject it into knows his or her own limits and Much of what you would poten- a patient or consumer. That’s why I chooses not to go down the road of tially administer via injection is was so surprised when I went shop- gaining injection privileges. That’s already part of your frequently-used ping online for some less irritating not what I’m afraid of. I’m afraid armamentarium of pharmaceuti- eye makeup that wouldn’t leave me of the system, which obviously cal agents. But there are some key rubbing my itchy lids all day. During ignores the differences between points to remember when adminis- my quest, I stumbled upon several trained health care professionals and tering an injection. Several years ago, local businesses that will tattoo per- unlicensed tradesmen, and focuses James Fanelli, O.D., pointed out the manent eyeliner along my lash line instead on amplifying labels, rather following in a Review of Optometry for about $250. than considering the training that’s article:1 Excuse me? Apparently, the great behind them. “Injectable medications have one state of Pennsylvania has placed a very important and striking differ- higher educational value on its cos- ence compared with both topicals metology schools than on graduates and orals: The body absorbs inject- of the esteemed Salus University. ables faster than other routes of That’s right. Don’t inject that chala- Amy Hellem administration. Faster absorption zion with a steroid, but by all means, Editor-in-Chief

means that the desired action of the take a needle to my lid and pierce 1. Fanelli JL. The use of injections in primary care. Rev medication occurs more quickly, my skin while injecting me with Optom. 2002 Nov;139(11):70-81. 2. The U.S. Food & Drug Administration. Tattoos & Perma- but it also means that untoward side unregulated chemicals. nent Makeup. Available at: www.fda.gov/cosmetics/produc- effects also occur more rapidly.” Actually, I take that back, the tandingredientsafety/productinformation/ucm108530.htm While the lion’s share of an chemicals are—or should be—regu- (accessed January 4, 2012).

20 REVIEW OF OPTOMETRY JANUARY 15, 2012

020_ro0112_editorpg-FILM.indd 20 1/5/12 2:40 PM OCULUS Keratograph Tearﬁ lm Scan Software

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RO0112_Oculus.indd 1 12/27/11 11:21 AM Chair Side

I’m Shootin’ Blanks Here Staring at a blank page reminds me of all the times I’ve come up blank. Sometimes, patients still catch me off guard without a response. By Montgomery Vickers, O.D. he dreaded blank page! My Al instead of preparing for class. I not believe this—but I get stage editor has just reminded me knew he was right and I promised fright. So, I’ve simply convinced T that I need to send him my him that I would do all I could to myself that sheer terror is actually column for this month. I assured improve my attitude, my study physiologically identical to extreme him that I would do so and that efforts and my dart game as well. pleasure. This little tip may come this event would occur just about My dart game did in fact improve, in handy when you get tongue-tied any minute. Then, I stared at this and I did graduate from optometry taking an oral or practical board … blank page. school, which proves there is a examination as optometry evolves It reminds me of the many, many God. into its future. Here’s how to fill up moments in my life when I came Patients really find ways to that blank page that is your brain. up blank. We’ve all done that. The make you go blank. Even after 32 Examiner: “Describe the differen- first time I can recall “going blank” years, they continue to astound me. tial diagnosis of Posner-Schlossman was when I was in the ninth grade Generally, I’m astounded in a good syndrome and its relationship to and Miss Ollem said, “Just hand way, like when the 45-year-old Behçet’s disease.” me your research papers at the end grandmother told me she would You: “I just peed myself, so I of class today.” prefer that I not dilate her eyes must be thrilled.” Research paper? What research because she was pregnant. That You may not pass the test, but paper? I went blank. Perhaps I deserved some combination of awe you’ll think that you are filled with passed out. But when the room and joy and terror. I filled the blank joy. That’s nice, right? stopped spinning, my instincts with congratulations, grinning, Oh, I just noticed—I’ve filled kicked in and I immediately giggling and breaking into a cold this blank page! So here is my grasped the fact that one must sweat. column that I’ve been working on quickly and confidently fill any Then, what do we do when the diligently since last month’s col- blank page within reach. And—this patient announces something hor- umn, Mr. Editor. Gotta go now. is simple but critically important— rible … loss of a child … divorce … It’s darts night. ■ it really matters NOT how you fill cancer? Is there any possible way it. Just fill it! to fill that blank? Not with words, Before long, Miss Ollem read the and for a big mouth like me, that’s finest research paper ever written tough. So, I fill it with a touch. Just on one of the most important sub- a touch. jects of that time: The Beatles. Those of you who have seen me Another time that I went blank perform my optometric stand- was in optometry school. One of up comedy routine (complete the professors called me into his with optomet- office, sat me down and asked me ric musical what I planned to do when I left interludes) optometry school. I proudly stated: would “I will be an eye doctor!” He sighed and said, “No. Really.” OK, that left a blank I was more than a little hesitant to fill, because he knew for a fact that I had been playing darts with my buddy Big

22 REVIEW OF OPTOMETRY JANUARY 15, 2012

022_RO0112_chairside.indd 22 1/3/12 4:33 PM RO1211_Woodlyn.indd 1 11/11/11 11:05 AM Coding Abstract

Happy(?) New Year! Well, here we go again. A new year is just beginning, but we’re still dealing with problems from previous years. By John Rumpakis, O.D., M.B.A., Clinical Coding Editor was hoping that by the time Optometric Association, are I wrote this, there would be advocating their members to I some long-term clarity on urge Congress and the President Medicare’s Physician Payment to support doctors and patients Schedule for 2012 and beyond. by providing stability to the Unfortunately, there isn’t. Medicare physician payment Here is what we know so far… system. The threatened cut On December 23, all phy- must be corrected without any sicians—including optom- further delays and a bipartisan etrists—got a brief reprieve initiative to repeal the flawed from a 27% Medicare pay cut and disruptive SGR formula scheduled to go into effect on that is causing this crisis should January 1, because the U.S. be put in place. House of Representatives reached previous deadline was December The AOA is specifically request- an agreement with the Senate on a 31. The effective date for any par- ing doctors and students to sup- two-month extension of important ticipation status change during port the AOA’s direct advocacy policies. The Sustainable Growth the extension, however, remains efforts on Capitol Hill by con- Rate (SGR) cut to physicians January 1, and will be enforced for tacting their Senators and House servicing Medicare payments is the entire year. According to CMS, members through AOA’s Online not going to happen, at least for contractors will accept and process Legislative Action Center (http:// another month or so, because the any participation elections or with- app1.vocusgr.com/WebPublish/ current fee structure will remain drawals made during the extended Controller.aspx?SiteName= in place until the end of February enrollment period that are post- AOAGR&Definition=Issues& 2012. marked on or before February 14. Juris=US). A House-Senate conference committee convenes this month to The Good and The Bad More To Come work on a longer-term agreement. On January 1, the relative values 2012 should prove to be an inter- However, this will not happen (RVUs) for many codes commonly esting year with concerns about quickly because the House isn’t used by optometrists to report the E-prescribing penalties, PQRS scheduled to return to Washington physician services they provide incentives, audit concerns, new until January 17, while the Senate to Medicare patients were sched- CPT and ICD-9 codes just to name won’t return until January 23. The uled to increase. However, these a few. I look forward to keeping all goal is to extend all the expiring increases will not be realized on of you informed and engaged. ■ programs for a full year—except January 1 because of the 0% carry- Don’t forget to send your for the physician payment cut forward of the existing fee sched- questions and comments to reprieve, which is to be extended ule. CMS could not put into effect [email protected]. for two years until a better long- only the changes in RVUs without term solution can be found. incorporating the entire impact of Clinical Coding Committee Additionally, the Centers for the SGR formula, and that meant • John Rumpakis, O.D., M.B.A., Clinical Medicare & Medicaid Services taking the 27.4% cut as well. Coding Editor (CMS) have extended the annual The professional political orga- • Joe DeLoach, O.D. Medicare participation enrollment nizations, such as the American • Rebecca Wartman, O.D. period through February 14. The Medical Association and American

24 REVIEW OF OPTOMETRY JANUARY 15, 2012

024_RO0112_Coding.indd 24 1/3/12 4:34 PM RO0112_Akorn.indd 1 12/22/11 1:27 PM Contact Lenses Seeing the Future Contactwith Lenses With advances in technology and improvements in materials, contact lenses aren’t just for vision correction anymore. By David L. Kading, O.D., and Katherine Shen, O.D.

ore than 24 million Disease Monitoring lens prototype that utilizes LED Americans wear contact In recent years, several research- lights.3 Using sets of electrodes, it lenses—but we could see ers have been looking into whether runs tiny currents through the tear Mthat number skyrocket contact lenses could provide a fluid and measures them to detect even higher with the advent of noninvasive means of monitoring very small quantities of dissolved contact lenses that do more than blood glucose levels or intraocular sugar. Preliminary tests suggest offer vision correction.1 Imagine pressure that improves comfort that the sensors can accurately a day when you could use contact and convenience without sacrific- detect even very low glucose lev- lenses to monitor and deliver medi- ing accuracy. els.3 The design would also call for cation to your glaucoma patients, • Blood glucose. A professor at a portable device to be worn by or treat your allergy or dry eye the University of Western Ontario the patient that would wirelessly patients. Better yet, imagine if you has been developing a contact lens receive information from the con- were able to repair a damaged to measure glucose levels using tact lens, allowing the patient to cornea and restore vision noninva- tear film on the eye.2 The lens adjust their medication and diet as sively by using stem cells embed- contains nanoparticles that give it necessary.3 ded on a contact lens. a reddish hue when exposed to a • Intraocular pressure. In Sep- You won’t have to stretch certain concentration of glucose, tember 2011, Sensimed released your imagination too far because which would alert wearers to the very first commercial smart researchers are already develop- adjust their blood sugar.2 contact lens that records changes ing unique contact lens designs The lenses have been success- in corneal curvature secondary to that could achieve those aims and fully tested in the lab using arti- intraocular pressure fluctuation.3 more. In a few years, you might ficial tears, but there’s still much The Triggerfish lens (figure 1) even find yourself fitting contact work to be done—including devel- transmits wireless measurements lenses on patients with perfectly oping a portable reader to provide at regular intervals to a portable healthy vision who aren’t in need specific measurements and an recording device worn by the of any correction, but rather are understanding of the connection patient.3 The disposable lenses are looking for convenience. As tech- between glucose levels in tears and designed to be worn just once for nological advancements continue in the blood.2 24 hours. Patients wear them once to revolutionize the contact lens A Seattle researcher took a or twice a year for one day so that industry, these visions will soon slightly different approach to dia- providers can measure diurnal become realities. betes detection, creating a contact pressure (figure 2).3

26 REVIEW OF OPTOMETRY JANUARY 15, 2012

026_ro0112_f1.indd 26 1/5/12 1:36 PM 1, 2. Sensimed’s Triggerfish lens features highly sensitive platinum strain gauges that record changes in corneal curvature that correspond directly with intraocular pressure.

This information allows doctors to schedule medication more appropriately for better IOP control. In November 2011, the company completed its first U.S. clinical study, and recruitment for a second currently is underway.4,5 Drug Delivery In addition to looking for a more effective means of monitoring, the eye care industry has long been seeking techniques to opti- mize drug delivery for the treatment of chronic eye diseases, such instilling drops because of the way effects. 6 as cataracts, glaucoma and age- the bottles are designed. In these For years, researchers have been related macular degeneration. Top- cases, the medicine often flows particularly interested in using ical eye drops are one of the most away from the eye, draining into contact lenses as a delivery vehicle frequently used treatments, but the nasal cavity and then entering for various classes of ophthal- they can be cumbersome and inef- the bloodstream, which can lead mic drugs. With advances in lens ficient. Some users have difficulty to drug waste and unwanted side design and the availability of new

REVIEW OF OPTOMETRY JANUARY 15, 2012 27

026_ro0112_f1.indd 27 1/5/12 1:36 PM Contact Lenses

Photo: Nick Di Girolamo Ph.D. Stem Cell-Coated Lenses Taking a step into uncharted territory, scientists in Australia have been looking into the possibility of using a contact lens to restore vision in patients with blindness caused by corneal damage. Researchers at the University of New South Wales infused a contact lens with a patient’s own stem cells (figure 3)––an idea that came about from the observation that stem cells from the cornea stick to contact lenses.9 They took three subjects who were blind in one eye, then obtained stem cells from their healthy eyes and cultured them in extended wear contact lenses for 10 days. Next, they cleaned the surfaces of the 3. Stem cells, such as these, have been cultured on a common therapeutic contact patients’ corneas and inserted the lens in order to repair corneal damage. contact lenses. Within 10 to 14 days, the stem polymers, it’s becoming a more lenses in the past is how to ensure cells began to recolonize and repair realistic option.6 One new tech- that sufficient oxygen gets through the cornea.9 Two of the three nique involves mixing the medica- to the eye. Otherwise, neovascular patients went from being legally tion with a pre-polymer liquid, and blood vessel growth can occur. blind to being able to read some then polymerizing the combination With its interconnected channels, of the eye chart. The third patient to create a transparent contact lens the nanostructure of the new lenses actually regained enough sight to coating.7 This new approach has allows gases, salts and nutrients pass a driving exam. Researchers shown great promise in contact to travel easily across the contact are still monitoring the stability of lens drug delivery devices, but its lens barrier.7 After testing the the treatment, but the early results effect depends on the drug’s solu- nano-engineered lenses to release seem promising. The simplicity bility. a water-soluble glaucoma medica- and low cost of the technique also If the drug is water-soluble, it tion and a water-insoluble anti- means that it could be utilized in will be trapped within a network biotic onto the cornea, a research poorer countries. If the stem cell of tiny, interconnected, water- team was able to sustain controlled corneal method shows additional filled channels in the material. If drug release over a few hours and potential, the procedure could the drug is water-insoluble, it will even a few days.7 open doors in the future so that be trapped within nano-spaces in Ideally, these drug-eluting con- patients with compromised ocular the polymer matrix, and slowly tact lenses eventually would be structures may not have to wait for filter out into the channels.7 Upon available in daily, two-week and a donor. contact with fluid on the eyeball, monthly lenses so that patients these channels will open, releas- could receive effective, controlled Photochromatic CLs ing the drug. By varying the water doses of medication while main- Patients even may be able to content, the channel size can be taining vision correction. Using avoid eye damage before it hap- adjusted, and the rate at which the a model of drug delivery like this pens by using contact lenses with drug is dispensed onto the eye can could increase treatment compli- UV protection. Long-term expo- be controlled.8 ance and stabilization of many sure to UV radiation can lead to One major obstacle eye care ocular diseases that our patients cataracts, skin cancers around the professionals have faced with such encounter. eyelids, and other eye disorders.

28 REVIEW OF OPTOMETRY JANUARY 15, 2012

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RO1010_Lombart.indd 1 9/29/10 11:52 AM Contact Lenses

Adapting the flexibility of UV protection into contact lenses by adding a photochromic effect could benefit many patients who find

sunglasses to be a nuisance. Photo: Babak Parviz, Ph.D., M.S. (Many contacts already have UV protection in them.) Conventional light- responsive sunglasses (such as Transitions) are coated with millions of molecules of photochromic dyes, which are transparent when out of the sun.10 These molecules change shape when exposed to sun- light, which allows them to absorb the UV radiation, trig- gering a response that dark- ens the lens. When UV light disappears, the molecules return to their original shape 4. Placed on the eye of a live rabbit, this contact lens display is powered by a dipole antenna, and transparent appearance. showing bright emission from the on-lens pixel. Attempts have been made to design similar light-responsive of contact lenses is the addition of cuits, and miniature antennas.11 contact lenses; however, the strug- augmented reality on top of our They tested a single-pixel, wire- gle of applying a dye coating uni- regular vision, which combines less contact lens display on live, formly along the surface of the lens real and virtual surroundings to anesthetized rabbits and found no has proven difficult. Researchers at create an “integrated world.” adverse effects (figure 4).11 Lead the Institute for Bioengineering and Containing hundreds of LEDs, researcher Babak Parviz, Ph.D., Nanotechnology in Singapore have these lenses would form images M.S., suggests that even a lens with managed to overcome this hurdle in front of the eye that integrate a single pixel could aid individu- and successfully develop photo- words, photographs and diagrams als with hearing impairments.12 chromic contact lenses that darken so that wearers can navigate their Furthermore, with the addition when exposed to UV light and surroundings and view display- of color and increased resolution, return to normal in its absence.10 able information through their he believes it could translate into They contain an intricate net- contact lenses—much like Arnold speech captions, visual cues and work of nano-sized tunnels that can Schwarzenegger’s character in displayed texts.12 be filled with dyes and transition “The Terminator” movies and, in 10 to 20 seconds—faster than more recently, as seen in “Mission: Challenges light-sensitive sunglasses on the Impossible Ghost Protocol.” Advances in contact lens tech- market today, according to prelimi- While it may seem like science nology take considerable time. For nary studies the researchers have fiction, such bionic technology is a new refractive error lens to reach conducted.10 The team is currently much closer to becoming a reality the market, it must go through a working to make the lenses com- than you might think. Researchers stringent research and develop- mercially available. at the University of Washington ment process in addition to rigor- have created semi-transparent con- ous studies and trials. This process Electronic Viewing tact lenses with built-in electronics, will be even more significant for One of the most exciting uses control and communication cir- lenses geared toward applications

30 REVIEW OF OPTOMETRY JANUARY 15, 2012

026_ro0112_f1.indd 30 1/5/12 1:36 PM beyond vision correction. health. 4. Medeiros F. SENSIMED Triggerfish safety and tolerability. In: ClinicalTrials.gov [Internet]. Bethesda, MD: National Library Variables, such as lens tempera- If we look at our current patient of Medicine. 2011. NLM Identifier: NCT01319617. Available ture, oxygen/water content and base, we can readily see how con- at: http://clinicaltrials.gov/ct2/show/NCT01319617 (accessed December 28, 2011). duration of wear time, should be tact lenses change lives daily––from 5. Liu JHK. Efficacy of 24-hour intraocular pressure fluctuation considered for the safety of the the patient who has keratoconus to recording with the SENSIMED Triggerfish contact lens sensor. In: ClinicalTrials.gov [Internet]. Bethesda, MD: National Library patient. It will take additional the child who plays sports. They are of Medicine. 2011. NLM Identifier: NCT01390779. Available efforts, including further scientific integral to improving vision and, in at: http://clinicaltrials.gov/ct2/show/NCT01390779 (accessed December 28, 2011). research, testing and development, many cases, quality of life. ■ 6. Singh K, Nair AB, Kumar A, Kumria R. Novel approaches in to ensure that they meet the same Dr. Kading owns Specialty Eyec- formulation and drug delivery using contact lenses. J Bas Clin Pharm. 2011 May;2(2):87-101. health and safety standards as cur- are Group, a Seattle-based practice 7. Young E. Drug-delivering contact lenses revealed. New rent lenses. with multiple locations. His empha- Scientist. October 29, 2004. Available at: www.newscientist. com/article/dn6597-drugdelivering-contact-lenses-revealed. sis is on specialty contact lenses html (accessed December 28, 2011). As eye care providers, such and new technologies. Dr. Shen is 8. Gulsen D, Chauhan A. Ophthalmic drug delivery through contact lenses. Invest Opthalmol Vis Sci. July 2004; advances could bolster our practices an associate at Specialty Eyecare 45(7):2342-7. and improve our reach by increas- Group where she specializes in 9. Di Girolamo N, Bosch M, Zamora K, et al. A contact lens- based technique for expansion and transplantation of autolo- ing the market for contact lens pediatrics, binocular vision and gous epithelial progenitors for ocular surface reconstruction. wearers. As these changes come ocular pathology. Transplantation. 2009 May 27;87(10):1571-8. 10. Chu J. Contact lenses that respond to light. Technology about, it’s crucial that we maintain Review. 2009 November 10. Available at: www.technologyre- our stance that any contact lens is 1. University of Michigan Kellogg Eye Center. Contact Lenses. view.com/biomedicine/23922 (accessed December 28, 2011). Available at: www.kellogg.umich.edu/patientcare/conditions/ 11. Lingley AR, Ali M, Liao Y, et al. A single-pixel wireless a medical device that needs to be contact.lenses.html. (accessed December 28, 2011). contact lens display. J Micromech Microeng. 2011;21(12):1-8. fitted by a trained eye care profes- 2. Collier R. Rosy outlook for people with diabetes. CMAJ. 12. Parviz BA. Augmented reality in a contact lens. IEEE 2010 March 23;182(5):E235-6. Spectrum. Available at: http://spectrum.ieee.org/biomedi- sional to ensure the highest level 3. Graham-Rowe D. Smart contact lenses for health and head- cal/bionics/augmented-reality-in-a-contact-lens (accessed of safety for patients and their eye up displays. New Scientist. 2011 January 10; 2794:18-9. December 27, 2011).

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REVIEW OF OPTOMETRY JANUARY 15, 2012 31

026_ro0112_f1.indd 31 1/5/12 1:37 PM Therapeutics Injection: The Third Method of Drug Administration Even iiff you ddon’t’ performf ijinjections i iin your office,ffi you shouldh ld kknow theh ddifferentiff types of injections in eye care, and how they’re performed. By James L. Fanelli, O.D.

ith dramatic changes in tion, inhalation and transdermal the treatment. However, when the delivery of health administration. utilizing injectable medications care and the advent of This article focuses on our third for managing eye conditions, the Wnewer diagnostic and most common route of administra- onus of proper administration of treatment modalities, optometrists tion of medications used to treat the injectable medications falls are in a unique position to deliver conditions of the eye and adnexa: squarely on the shoulders of the care to an organ system that truly injections. provider. As such, any eye care has system-wide implications. Not provider who utilizes injectable only can the treatment we render Reasons for Injections medications must be trained in the to an eye have systemic ramifica- Just as in the use of oral and proper administrative techniques tions, so too can systemic prob- topical medications, injectable involved. lems manifest in the eye. medications can be divided into In addition, the provider obvi- A large number of ophthalmic those that are used for diagnostic ously must be familiar with the conditions can be treated with purposes and those that are used medications themselves—including topical and oral pharmaceuti- for therapeutic purposes. And, of dosages, indications, contraindica- cal agents. But we need to keep those injectable medications used tions, side effects and expected in mind that when we discuss for therapeutic purposes, they can outcomes—as well as manage “topical” and “oral,” we are not be further divided into primary complications that result from so much discussing medications treatment therapies and adjunctive their administration. directly but rather we are describ- treatment therapies. (See “Uses of So, it is absolutely imperative ing routes by which medication Eye Care Injections,” page 36.) that eye care providers who uti- can be delivered. In fact, several When using oral and topical lize injections are trained in the medications, such as steroids for medications, the onus of proper actual techniques of injectable example, can be delivered in a medication administration usu- administration because there are variety of ways. We are familiar ally falls on the shoulders of many types of injections germane with topical and oral steroid uses, the patients, and we as eye care to eye care. Furthermore, state but many of those same steroids providers often give too little licensing laws must be adhered to can be delivered by way of injec- thought to the actual delivery of when prescribing any medications.

32 REVIEW OF OPTOMETRY JANUARY 15, 2012

032_ro0112_f2.indd 32 1/5/12 9:47 AM (See “Authority of Optometrists to ocular manifestations, such as Administer Drugs Via Injection,” gonococcal infections, in which the page 34.) typical treatment consists of an IM injection of Rocephin (ceftriaxone, Types of Injections Roche).1-3 Locations for place- The types of injections used for ment of these IM injections are the conditions of the eye and adnexa deltoids and quadriceps femoris include intramuscular, intradermal, muscles, and the hip.3 subcutaneous, subconjunctival and Sometimes, IM injections are sub-Tenon’s, intravitreal, intrave- used to treat contact dermatitis nous and intracameral injections. reactions of the eye and adnexa, as Botox is used not only for cosmetic pur- Let’s look at each in turn. in cases of poison ivy, for example. poses but also for therapeutic purposes, Nowadays, one of the more such as hemifacial spasm (pictured Intramuscular Injections common types of facial injections here), blepharospasm and migraine When we think of intramuscular is also technically an intramuscular headaches. (IM) injections, we tend to think injection. These injections are most of significant volumes of medica- often utilized by dermatologists in paralysis of the striated muscle tion delivered through large, long and plastic surgeons for cosmetic supplied by that neuromuscular needles into the muscles of the purposes.4-6 Botox Cosmetic (ona- junction (NMJ). extremities. But this type of IM botulinumtoxin A, Allergan) for Ideally, Botox is administered injection has relatively limited use the reduction of glabellar lines directly into the desired muscle, in eye care. and facial wrinkles falls into this making it an IM injection. How- Often, IM injections in the set- category. Botulinum toxin inter- ever, Botox is often administered ting of eye care are used to treat rupts the normal neuromuscular as a subcutaneous facial injection systemic infections that have junction transmission, resulting in the tissue overlying the target Photo: CDC/Gabrielle Benenson

A general example of intradermal injection: Placement of this injection involves inserting the needle bevel slowly at a 5° to 15° angle. The needle bevel is advanced through the epidermis, just under the skin surface, so that the entire bevel is covered.

REVIEW OF OPTOMETRY JANUARY 15, 2012 33

032_ro0112_f2.indd 33 1/5/12 9:48 AM Therapeutics

Authority of Optometrists to Administer Drugs Via Injection

STATE: USE OF INJECTABLE DRUGS FOR DIAGNOSTIC AND USE OF INJECTABLE DRUGS CURRENTLY LIMITED TO TREATMENT PURPOSES 1 TREATMENT OF ANAPHYLAXIS ONLY [including the treatment of anaphylaxis] ALASKA YES ALABAMA YES ARIZONA YES ARKANSAS YES CALIFORNIA YES COLORADO YES CONNECTICUT YES D.C. YES HAWAII YES IDAHO YES ILLINOIS YES IOWA YES KENTUCKY YES LOUISIANA YES MAINE YES MARYLAND YES MINNESOTA YES MISSISSIPPI YES MONTANA YES NEW HAMPSHIRE YES NEW JERSEY YES NEW MEXICO YES NORTH CAROLINA YES NORTH DAKOTA YES OHIO YES OKLAHOMA YES OREGON YES TENNESSEE YES TEXAS YES UTAH YES VERMONT YES VIRGINIA YES WASHINGTON YES WEST VIRGINIA YES WISCONSIN YES

¹ The authority to administer injectable drugs for diagnostic and treatment purposes may be limited by the state optometry act or regulations.

Source: American Optometric Association State Government Relations Center

34 REVIEW OF OPTOMETRY JANUARY 15, 2012

032_ro0112_f2.indd 34 1/5/12 9:48 AM muscle, and diffusion of the neurotoxin into the underlying muscle produces the desired effect. While Botox is often considered a cosmetic treatment, there are indications where Botox is used for therapeutic purposes, such as blepharospasm, hemifacial spasms, extraocular muscle disturbances and, most recently, migraine Subcutaneous injections are used to anesthetize the eyelids for repair of lacerations, headaches.5,7 While the actual biopsy of lesions, removal of foreign bodies of the lid, electroepilation, chalazia mechanism of headache reduction removal and thermal punctal cautery. is unknown, botulinum toxin is believed to block nocioceptive neu- as those that occur when purified mally vascularized. It is not tightly ropeptides, which are released in protein derivative (PPD) testing is adherent to the over- and underly- situations of chronic type pain. used to determine an individual’s ing tissues and, as such, can hold exposure to tuberculin. larger volumes of medications. Intradermal Injections Injectable anesthetics are admin- This type of injection has limited Subcutaneous Injections istered subcutaneously in the use in eye care. Because intrader- The subcutaneous tissue lies periocular tissues. These may be mal tissue is poorly vascularized, it beneath the dermis and above the delivered as a local type of injec- is a good site for observing local- muscle tissue. It consists of con- tion (targeting a specific area, such ized immune-type reactions, such nective tissue and fat, and is mini- as the temporal aspect of a lid),

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REVIEW OF OPTOMETRY JANUARY 15, 2012 35

032_ro0112_f2.indd 35 1/5/12 9:49 AM Therapeutics

rather dense, and inserting a fine needle into tissue of this density is difficult. However, as chalazia develop, they invariably enlarge in the x-, y- and z-axes. Some chalazia may

Photo: Thomas J. Stokkermans, O.D., Ph.D. “point” internally more than externally, and some When considering an injectable steroid vice versa.8 With either for an eyelid “stye,” make sure that the presentation, the most condition is in fact a chalazion and not appropriate location for something else. the administration of the A chalazion may “point” externally more than injectable steroid is still internally (or vice versa). Regardless, the steroid is eyelid, because of its the subcutaneous space. injected into the subcutaneous space. physical characteristics On the conjunctival side of (ability to hold larger the lid, the tarsal conjunctiva is or as a more regional, nerve block volumes of medications) tightly adherent to the underlying injection, targeting a larger area. and its close proximity to the tar- tarsal plate, and as such, there is These are used primarily for anes- sal plate, make it an ideal tissue very little subconjunctival space. thesia of the upper and/or lower reservoir for steroids to treat cha- Attempting to administer an inject- eyelids during repair of lacerations, lazia. Chalazia are inflammatory able steroid into this space is dif- biopsy of lesions, removal of for- processes of the meibomian glands. ficult at best. eign bodies of the lid, electroepila- They may begin spontaneously due While chalazia vary in size, tion, chalazia removal and thermal to localized irritation, but most duration and firmness, steroid punctal cautery. often develop following an infec- injections generally work very The subcutaneous tissue of the tious process. well if two conditions are met: the Steroids are useful appropriate amount and concen- in the management tration of steroid is used, and the Uses of Eye Care Injections of chalazia, but they chalazion is of recent origin (gener- Diagnostic Injections are contraindicated in ally less than four to six months) • IV fluorescein angiography active infectious eyelid and so is still relatively soft. As a • IV indocyanine green angiography processes. Therefore, chalazion becomes more compact • IV Tensilon testing for myasthenia gravis when considering an over time and more granulation • Intradermal TB testing injectable steroid for tissue develops inside the affected the treatment of an meibomian gland, it becomes Primary Therapeutic Injections eyelid “stye,” make more dense. These respond more • IM antibiotics for gonorrhea sure that the condition slowly to steroid injections, and • Translesional steroids for chalazia is in fact a chalazion may require a second injection. • Subcutaneous anesthetics for the periocular region and not something else. Older chalazia––especially if they • IM/subcutaneous botulinum toxin From an anatomical have been present for longer than • Intravitreal injections for AMD perspective, chalazia six months––may not respond to • Intravitreal injections for macular edema develop within the steroids and must be incised and • SC, IM or IV epinephrine for anaphylaxis meibomian gland. drained or excised. Meibomian glands The most effective steroid for Secondary and Adjunctive Injections are located within the the treatment of chalazia is Kena- • Subconjunctival steroids for uveitis tarsal plate. The tarsal log-40 (Bristol-Myers Squibb), • Sub-Tenon’s injections of steroids for uveitis, pars plate consists of loose which is triamcinolone acetonide planitis, posterior pole inflammations connective tissue, and in a 40mg/cc concentration. Kena- • Intravitreal injections for AMD and macular edema is cartilaginous in log-40 is a thick, viscous, white nature. As such, it is suspension, and is not quickly

36 REVIEW OF OPTOMETRY JANUARY 15, 2012

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RO0112_Optos.indd 1 12/22/11 1:11 PM Therapeutics

absorbed into the systemic circula- Sub-Tenon’s injections tion. It is ideal for the treatment of The indications for these types chalazia for this and several other of injections often overlap; while reasons. While the eyelid subcuta- the techniques for administer- neous space can hold a (relatively) ing these injections are similar in larger volume of injectable medi- approach, they are fundamentally cations, what is administered in different. this area should be not excessively As the names indicate, the voluminous. Depending on the size injected medication ultimately is and duration of the chalazion, any- Uveitis, such as this inflammatory cho- delivered to either the subcon- where between 0.2cc to 1.0cc of rioretinitis, may require steroid injection junctival space or the sub-Tenon’s Kenalog-40 is used. administered to the sub-Tenon space or space. Access to the subconjunc- Because it is a viscous suspen- intravitreally. tival space is easier than the sub- sion that is slowly absorbed, the Tenon’s space. Also, given that bolus of medication tends to sit these situations, there still is not the subconjunctival space is more in the subcutaneous space for an much physical space inside the anterior that the sub-Tenon’s extended period of time, and grad- meibomian gland to deposit much space, subconjunctival injections ually works to reduce the chronic steroid. So, it is not critical that the have a more pronounced effect in inflammatory response that is the injection be made intralesionally; the anterior segment, while sub- basis of the chalazion’s recalci- paralesional injections work just Tenon’s injections have more of an trance. As such, it is quite normal as well. effect on the posterior segment.8,9 to be able to visualize the triamcin- From a safety perspective, In some situations, administering olone remaining under the dermis when eyelid steroid injections are a subconjunctival injection of lido- and epidermis of the lid for several made, it is important to keep the caine prepares the tissue for a sub- weeks. This effect can remain vis- needle tip moving, and not remain sequent sub-Tenon’s injection.9 ible for several weeks and happens stationary in one space. So, it is Both types of injections are primarily because of the density possible that one injection of the used primarily for the treatment of the steroid itself, as well as the steroid, made in a translesional of inflammation. Chronic, recal- translucence of the thin eyelid skin. approach, can encompass both an citrant anterior uveitis can often Sometimes, this residual steroid intralesional and a paralesional be supplementally managed with is misdiagnosed as a side effect of injection. a subconjunctival injection of injectable triamcinolone: depig- Subconjunctival and steroid.8,9 It is important to note mentation of the that when consider- skin. In any case, ing a subconjunctival the patient should injection of a steroid be forewarned and to facilitate control educated about of recalcitrant uveitis, this possibility. the patient must first Some chalazia, demonstrate poor or especially those in minimal response to the initial stages, aggressive topical ther- are very soft, apy. In other words, and the affected subconjunctival steroid meibomian gland injections should not is not fully dis- be used unless aggres- tended. This sive topical therapy situation lends with cycloplegics and itself to a direct topical steroids fail to intralesional injec- control the anterior tion of the steroid. A prime example of intravenous (IV) administration in eye care: fluorescein segment inflammation. However, even in angiography. Also, subconjunctival

38 REVIEW OF OPTOMETRY JANUARY 15, 2012

032_ro0112_f2.indd 38 1/5/12 9:49 AM Two common tools for injection: a 3cc syringe with a 1.5” 23-gauge needle (left) and a 1cc syringe with 3/8” 30-gauge needle (right).

Common Supplies Needed for Injections • Syringes, usually 1cc to 3cc • Needles, usually 27ga to 30ga 3/8” to 5/8” for periocular, 23ga 1.5” for extremity IM (insulin or TB syringes work well for periocular injections) • Alcohol wipes A 23-gauge butterfly setup, as used in • Adhesive bandages the intravenous (IV) administration of • Sterile swabs fluorescein. • Topical anesthetics • Topical antibiotic drops and ointments steroid injections are not to be • Medication ampules or vials used in lieu of topical therapy, but • Forceps used as adjunctive therapy along • Lid speculum with the topical medications. Sub- Last but not least: Informed consent document Tenon’s injections are used to treat inflammations of the posterior increased fluid accumulation in fewer systemic side effects than if segment, although with the advent the subretinal space and/or in the given by other routes of admin- of safer delivery systems and medi- intraretinal spaces. There are a istration. Lucentis (ranibizumab, cations, intravitreal injections are variety of forms of wet AMD, but Genentech) and off-label Avastin also frequently used. all are predicated upon the break- (bevacizumab, Genentech) are down of the blood retinal barrier prime examples of anti-VEGF Intravitreal Injections and the development of new blood medications that are administered While these injections are vessels originating in the choroid. by intravitreal injection. not used by many optometrists, Anti-VEGF therapy targets certain Steroids such as Kenalog are retinologists use them regularly in growth factors that are respon- also administered intravitreally, modern practice. Intravitreal injec- sible for the genesis of neovascular although for different reasons. tions are used to treat posterior membranes, which are susceptible Macular edema—whether from segment disorders––mainly those to leakage and hemorrhage; this is diabetic maculopathy, vein occlu- of the macula. Given that the vit- the basis of vision loss in patients sions or other non-angiogenic reous is avascular, absorption of with angiogenic AMD. diseases where fluid accumulates intravitreously administered drugs When administered into the in the central macula and threat- is usually slow. vitreous cavity, anti-VEGF agents ens vision—has been found to Angiogenic age-related macular are in close proximity to the neo- respond to intravitreal Kenalog degeneration is characterized by vascular membranes, and produce (IVK) administration. Though

REVIEW OF OPTOMETRY JANUARY 15, 2012 39

032_ro0112_f2.indd 39 1/5/12 9:49 AM Therapeutics

other treatments are often used in conjunction with BRIEF SUMMARY OF PRESCRIBING INFORMATION IVK therapy (focal laser, for example), IVK remains INDICATIONS AND USAGE PATADAY™ solution is a mast cell stabilizer indicated for the a viable treatment option for many cases of macular treatment of ocular itching associated with allergic conjunctivitis. degeneration. DOSAGE AND ADMINISTRATION The recommended dose is one drop in each affected eye once a day. Intravenous Injections DOSAGE FORMS AND STRENGTHS Ophthalmic solution 0.2%: each ml contains 2.22 mg of olopatadine Intravenous (IV) injections are usually used only in hydrochloride. diagnostic procedures in the context of ophthalmic CONTRAINDICATIONS care. Fluorescein angiography, indocyanine green None. angiography and, less frequently, Tensilon (edropho- WARNINGS AND PRECAUTIONS For topical ocular use only: not for injection or oral use. nium, Valeant Pharm.) testing are all performed with Contamination of Tip and Solution: As with any eye drop, to prevent contaminating the dropper tip and solution, care should be IV-administered drugs. taken not to touch the eyelids or surrounding areas with the dropper Both the advantage and disadvantage to IV injec- tip of the bottle. Keep bottle tightly closed when not in use. Contact Lens Use: Patients should be advised not to wear a contact tions lies in the almost instant absorption of the drug lens if their eye is red. PATADAY™ (olopatadine hydrochloride ophthalmic solution) 0.2% should not be used to treat contact into the vascular system. Desired effects, such as being lens related irritation. The preservative in PATADAY™ solution, benzalkonium chloride, may be absorbed by soft contact lenses. able to evaluate fluorescein flow through the eye, Patients who wear soft contact lenses and whose eyes are not happen quickly. But, unwanted side effects also occur red, should be instructed to wait at least ten minutes after instilling PATADAY™ (olopatadine hydrochloride ophthalmic solution) 0.2% quickly and more noticeably when drugs are adminis- before they insert their contact lenses. tered via the IV route. ADVERSE REACTIONS Symptoms similar to cold syndrome and pharyngitis were reported at an incidence of approximately 10%. The following ocular adverse experiences were reported in 5% or less of patients: blurred Intracameral Injections vision, burning or stinging, conjunctivitis, dry eye, foreign body sensation, hyperemia, hypersensitivity, keratitis, lid edema, pain These injections are usually reserved for operation and ocular pruritus. The following non-ocular adverse experiences were reported in 5% or less of patients: asthenia, back pain, flu room procedures during intraocular surgery. These syndrome, headache, increased cough, infection, nausea, rhinitis, would not be used in day-to-day clinical eye care. sinusitis and taste perversion. Some of these events were similar to the underlying disease being studied. USE IN SPECIFIC POPULATIONS The injectable route of administration is simply an Pregnancy: Teratogenic effects: Pregnancy Category C. Olopatadine was found not to be teratogenic in rats and rabbits. alternative way to deliver medicine to the body. Inject- However, rats treated at 600 mg/kg/day, or 150,000 times the MROHD and rabbits treated at 400 mg/kg/day, or approximately able medications can be used as primary therapies and 100,000 times the MROHD, during organogenesis showed a decrease in live fetuses. In addition, rats treated with 600 mg/ as adjunctive therapies. Being familiar with their indi- kg/day of olopatadine during organogenesis showed a decrease in fetal weight. Further, rats treated with 600 mg/kg/day of cations and uses is imperative in current optometric olopatadine during late gestation through the lactation period practice. ■ showed a decrease in neonatal survival and body weight. There are, however, no adequate and well-controlled studies in pregnant Dr. Fanelli is in private practice in Wilmington, women. Because animal studies are not always predictive of human responses, this drug should be used in pregnant women only if N.C., writes Review of Optometry’s “Glaucoma the potential benefit to the mother justifies the potential risk to the embryo or fetus. Grand Rounds” column, and lectures on glaucoma Nursing Mothers: Olopatadine has been identified in the milk and other clinical topics. of nursing rats following oral administration. It is not known whether topical ocular administration could result in sufficient systemic absorption to produce detectable quantities in the human 1. Ison CA, Alexander S. Antimicrobial resistance in Neisseria gonorrhoeae in the UK: surveil- breast milk. Nevertheless, caution should be exercised when PATADAY™ (olopatadine hydrochloride ophthalmic solution) 0.2% is lance and management. Expert Rev Anti Infect Ther. 2011 Oct;9(10):867-76. administered to a nursing mother. 2. Carannante A, Prignano G, Cusini M, et al. Cefixime and ceftriaxone susceptibility of Pediatric Use: Safety and effectiveness in pediatric patients below Neisseria gonorrhoeae in Italy from 2006 to 2010. Clin Microbiol Infect. 2011 Jun 28. doi: the age of 2 years have not been established. 10.1111/j.1469-0691.2011.03619.x. [Epub ahead of print] Geriatric Use: No overall differences in safety and effectiveness 3. Roy FH, Fraunfelder FW, Fraunfelder FT. Roy and Fraunfelder’s Current Ocular Therapy. 6th have been observed between elderly and younger patients. ed. Philadelphia: Saunders/Elsevier; 2008:32-33. NONCLINICAL TOXICOLOGY 4. Darlington AB. The Botox phenomenon. Plast Surg Nurs. 2010 Jan-Mar;30(1):22-6. 5. Matarasso A, Shafer D. Botulinum neurotoxin type A-ABO (Dysport): clinical indications and Olopatadine administered orally was not carcinogenic in mice and rats in doses up to 500 mg/kg/day and 200 mg/kg/day, respectively. practice guide. Aesthet Surg J. 2009 Nov;29(6 Suppl):S72-9 Based on a 40 μL drop size and a 50 kg person, these doses were 6. Braccini F, Dohan Ehrenfest DM. Advantages of combined therapies in cosmetic medicine approximately 150,000 and 50,000 times higher than the maximum for the treatment of face aging: botulinum toxin, fillers and mesotherapy. Rev Laryngol Otol recommended ocular human dose (MROHD). No mutagenic Rhinol (Bord). 2010;131(2):89-95. potential was observed when olopatadine was tested in an in vitro bacterial reverse mutation (Ames) test, an in vitro mammalian 7. Blumenfeld A, Silberstein SD, Dodick DW, et al. Method of injection of onabotulinumtoxinA chromosome aberration assay or an in vivo mouse micronucleus for chronic migraine: a safe, well-tolerated, and effective treatment paradigm based on the test. Olopatadine administered to male and female rats at oral PREEMPT clinical program. Headache. 2010 Oct;50(9):1406-18. doses of approximately 100,000 times MROHD level resulted in a 8. Kanski JJ, Bowling B. Clinical Ophthalmology: A Systematic Approach. 7th ed. Philadelphia: slight decrease in the fertility index and reduced implantation rate; no effects on reproductive function were observed at doses of Saunders/Elsevier; 2011:411-12. approximately 15,000 times the MROHD level. 9. Ehlers JP, Chirag PS, Gregory LF, et al. The Wills Eye Manual: Office and Emergency Room U.S. Patents Nos. 5,641,805; 6,995,186; 7,402,609 Diagnosis and Treatment of Eye Disease. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2008:422.

032_ro0112_f2.indd 40 1/5/12 9:50 AM 1

Zero-itch Starts Here

Prescribe the Number One prescription allergy eye drop to Start and Finish the day with Zero-itch.1,2

J Start: As soon as 3 minutes following allergen challenge, 60% of patients achieved Zero-itch*†

J Finish: At 16 hours, 60% of patients had Zero-itch*‡

INDICATION AND DOSING PATADAY ™ Solution is a mast cell stabilizer indicated for the treatment of ocular itching associated with allergic conjunctivitis. The recommended dose is one drop in each affected eye once a day.

IMPORTANT SAFETY INFORMATION PATADAY™ Solution is for topical ocular use only. It is not for injection or oral use. To prevent contaminating the dropper tip and solution, care should be taken not to touch the eyelids or surrounding areas with the dropper tip of the bottle. Keep the bottle tightly closed when not in use. PATADAY™ Solution should not be used to treat contact lens-related irritation. The preservative in PATADAY™ Solution, benzalkonium chloride, may be absorbed by soft contact lenses. Patients who wear soft contact lenses should be instructed to wait at least ten minutes after instilling PATADAY™ Solution before they insert their contact lenses. Symptoms similar to cold syndrome and pharyngitis were reported at an incidence of approximately 10%. For additional information about PATADAY™ Solution, please refer to the brief summary of prescribing information on the following page.

* Post-hoc analysis of combined data from two studies using a contralateral conjunctival allergen challenge (CAC). Based on a scale of itching scores of 0-4, with 0 as no itching and 4 as severe itching. Ocular itching was evaluated 3 minutes after allergen challenge at onset and at 16 hours. †(N=85; 95% CI=48.8, 70.5) ‡(N=82; 95% CI=48.3, 70.4) References: 1. IMS Health, IMS National Prescription Audit™, August 2010 to February 2011, USC 61500 OPHTH ANTI-ALLERGY. 2. Data on ﬁ le.

RO0112_Alcon Pataday.indd 1 12/16/11 11:13 AM Diagnostic Technology

The Increasing Value of OCT Imaging

Ocular coherence tomography has become an all-around useful tool for glaucoma, retina and even anterior seg evaluation. Not every office needs one, but we certainly couldn’t do without ours. By Kenny Bumgarner, O.D.

oday’s optometrists are adjunctive asset for optimal patient increasing their utilization care. of non-invasive technologies Tto aid in the observation of Clinical Uses for OCT retinal tissues. OCT affords us a highly quan- Ocular coherence tomography tifiable, accurate and repeatable (OCT) facilitates evaluation, moni- technology that is best utilized in toring and follow-up for glaucoma conjunction with other available and macular pathologies. In addi- subjective and objective technolo- tion, OCT can be beneficial in OCT may have already supplanted the gies. We can utilize OCT for many numerous retinal manifestations to ‘gold standard’ fluorescein angiography types of posterior polar evaluations, establish tissue thickening or thin- for detecting some retinal etiologies, such as optic nerve abnormalities, ning when compared to the normal such as cystoid macular edema. glaucoma progression, macular and population database. retinal pathologies. While fluorescein angiography allowed for increased efficacy of Resolution of this technology in has been the “gold standard” referrals and continued in-office the last several years has gone from of evaluation and management management of patients. In this approximately 10µm microns to of macular and retinal patholo- regard, the wider use of OCT may 4µm. This instrument is essentially gies, OCT has augmented or even have a beneficial impact for the able to measure within the accuracy replaced angiography in particular patient, as well as the doctor. of two-thirds the width of one red cases. Cystoid macular edema, cen- This article examines the OCT’s blood cell. (Practically speaking, tral serous retinopathy and diabetic revolutionary technology, address- we are able to examine living tissue maculopathy are only a few of the ing benefits from a clinical view, in that is 0.25mm thick, containing 10 macular pathologies where OCT addition to an investment stand- layers of highly specialized, nearly proves to be extremely beneficial.1 point. It also discusses professional transparent cells. It shows us a liv- Since the introduction of the opinions, clinical diagnoses, man- ing histology slide of the sensory OCT, optometrists have rewritten agement and follow-up modalities retina and retinal pigment epithe- our optometric algorithms in the that suggest the OCT is not only lium.) diagnosis, management and follow- important in primary care optom- Scanned information is then up of patients. This technology has etry, but becoming a valuable compared to “normal population”

42 REVIEW OF OPTOMETRY JANUARY 15, 2012

042_ro0112_f3.indd 42 1/5/12 1:58 PM data in a way that is repeatable and highly accurate, with a high degree of sensitivity and specific- ity. Scanning devices allow us to pinpoint the exact layer damaged in glaucoma, optic nerve and macular processes. Let’s look at each of these appli- This patient’s visual field (left) corre- cations individually: lates with his OCT TSNIT graph, which • Glaucoma. There is no ques- corroborates the findings of nerve fiber tion that nerve fiber loss and thinning. structural damage appear much earlier in the disease process than functional subjective visual field defects.2 OCT technology facilitates our ability to more accurately confirm or dismiss a diagnosis of glaucoma at an earlier stage of development. This fact promotes earlier intervention long before However, this patient’s visual field (left) 40% of the nerve fiber loss mani- does not agree with her OCT TSNIT graph, fests (which is necessary for subjec- which suggests early nerve fiber thin- tive visual field depressions to be ning not yet apparent with perimetry. recorded).2 When combining scanning technologies with other clinical information, such as pachymetry, example would be in progressive data, interventional therapy may be serial intraocular pressures, visual thinning in the optic atrophies by initiated much earlier when includ- fields, stereophotography and serial analysis. ing OCT findings with visual fields. finally clinical experience. In short, RNFL analysis can be helpful in However, OCT is not a stand- you would rarely start therapy assessing nerve head thickening in alone test for glaucoma evaluation based only on OCT thinning, but a patient with suspected pseudo- and management. It should be consideration of RNFL is a valu- tumor cerebri (PTC). I have found viewed as a critical piece of infor- able contribution to the decision- it especially helpful in follow-up mation in the decision-making making process. monitoring of disc changes once process. A good example is when Looking forward, the most treatment has begun for PTC.4 This the retinal nerve fiber layer (RNFL) powerful use of this technology in management, in conjunction with shows superior and/or inferior thin- glaucoma will take place when we other ocular, physical and neuro- ning that is suspicious for glaucoma can “marry” OCT structural analy- logical examinations, can be helpful while the visual fields remain nor- sis with functional testing of visual in assessing the patient’s treatment mal. OCT allows an added point field analysis. (Several companies progress. of reference in following a patient are now working on producing • Macular abnormalities. OCT from normal to glaucoma suspect, this combined testing technology.) analysis of the macula includes a and finally to glaucoma patient. Although this information is not range of disorders, such as: The valuable OCT data should diagnostic, it does provide relevant —Macular degeneration/choroi- be clinically confirmed by the structural analysis to verify stability dal neovascular membrane. Scan- examination findings, including the vs. progression. ning technology is important for “multifactorial glaucoma risk pie.” • Optic nerve abnormalities. In initial substantiation of macular This analysis includes history, age, addition to glaucoma, OCT can be thickening when combined with race, family history, longevity and used in contributing information clinical findings of deep and super- general health information. Clinical in the areas of optic nerve drusen, ficial retinal hemorrhages, deep testing to be added to the decision- optic pits, optic atrophy disorders and superficial exudate, fluorescein making process includes important and optic nerve edema.3 Another angiography, as well as subjective

REVIEW OF OPTOMETRY JANUARY 15, 2012 43

042_ro0112_f3.indd 43 1/5/12 1:59 PM Diagnostic Technology

symptoms of metamorphop- can be seen initially. In long-term sia. OCT can show structural follow-up, thinning of the affected thickening and distortion of macular and adjacent retina will the macular anatomy. In addi- be noted in many post-arterial tion, its usefulness has been occlusive cases. OCT is useful in documented to follow the suc- initial evaluation of macular thick- cess or failure of anti-VEGF ening as it relates to other clinical therapies; it allows us serial objective and subjective findings. review post-injection to struc- This becomes helpful in deciding This series of OCT images, from different turally document the reduction when to refer to the retinal special- patients, demonstrates the development of of macular thickening.5 This ist (not to mention concurrently a macular hole, starting here with epiretinal becomes a valuable tool in orchestrating multidisciplinary membrane with subsequent macular thickening. guiding therapy and follow-up management of underlying systemic decisions for re-injection vs. disease). Finally, as with the macu- monitoring. lar edemas, OCT can be useful —Vitreomacular traction in post-treatment monitoring for syndromes. Scanning technol- improvement, stability or exacerba- ogy is valuable in the verification of the macular anatomy. tion and diagnosis of these • Anterior segment evaluation. syndromes as they progress OCT scanning devices, although from preretinal fibrosis, clas- not necessarily diagnostic, can be sic vitreomacular traction helpful in evaluating anterior seg- syndrome and, finally, differ- ment disorders, such as narrow entiation of early macular hole angles, anterior chamber or iris An impending macular hole secondary to vitreo- formation to complete macular abnormalities when combined with macular traction. hole formation. As with other additional clinical testing, such as disorders, this information gonioscopy, ultrasound and other provides structural evidence clinical apparatus. of deviation from normal In terms of iris thickening dis- macular anatomy in its vari- orders, including iris cysts and ous forms. melanomas, OCT helps us to more —Macular edema. OCT has critically differentiate between solid become a valuable instrument vs. cystic defects. in the evaluation of macular distortion, whether from dia- OCT for Communication betic, cystoid, central serous OCT is becoming an invaluable or other disorders. It also tool not only for clinical diagnosis An early macular hole. has become valuable for the but also for patient education, doc- retinologist, as well as the co- tor-to-doctor communication and managing optometrist, in post- comanagement. treatment patients to monitor Consider these uses: for resolution, exacerbation or • Cataract surgical referrals. In stability of macular integrity. special instances, OCT provides —Retinal arteriovenous potential contributory information occlusive diseases. OCT is in patients with reduced visual acu- used to monitor central retinal ity that is not clearly defined by venous and branch occlusions other techniques. It can offer infor- as they approach the macula. mation when there is question as to In addition, arteriolar occlu- degree of, for example, cataract vs. A macular hole with overlying posterior vitreous sive disease with secondary retinal effect on visual acuity. This detachment. macular and retinal edema is helpful in macular degeneration,

44 REVIEW OF OPTOMETRY JANUARY 15, 2012

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RP1111_FCI.indd 1 10/11/11 2:01 PM Diagnostic Technology

Estimated Return on Investment is not used in an Example: ZEISS CIRRUS HD OCT models 4000 and 400 illustrative man- ner. The ability to Patients per day actually show the ESTIMATED REIMBURSEMENT 2 3456 patient normal vs. CPT 92133 / 92134, $44 per patient (nat’l avg) $44 $44 $44 $44 $44 abnormal tissue MONTHLY reimbursement (20 days) $1,760 $2,640 $3,520 $4,400 $52,800 is highly educa- ANNUAL Reimbursement (240 days) $21,120 $31,680 $42,240 $52,800 $63,360 tional. This gives 5 YEAR PROJECTION $105,600 $158,400 $211,200 $264,000 $316,800 the patient a better understanding of his or her disease CIRRUS 4000 CIRRUS 400 process and/or rea- MONTHLY BREAK EVEN Patients Patients son we are refer- Number of patients needed to make monthly ring for further 25 21 payment evaluation. It also Lease payment divided by CPT 92133 / 92134 ($44) provides patients Does not include 92132, which may increase reimbursement to approx $80 / patient with a clear understanding of why SALES PRICE CIRRUS 4000 CIRRUS 400 we are monitoring their retinal tissue. $73,950 $63,950 This is a valuable asset in instilling patient confidence ESTIMATED TAX CONSIDERATIONS and allowing the IRS Section 179 Accelerated Depreciation patient to “actu- NET PRICE AFTER TAX CONSIDERATIONS $34,418 $29,218 ally see what is wrong.” Source: Carl Zeiss Meditec USA Both my patients THE ABOVE INFORMATION IS NOT LEGAL OR TAX ADVICE. Please verify reimbursement with your local medicare carrier and verify your tax implications and I have found with your CPA/tax advisor the OCT images intuitive and retinal macular fibrosis or any case nication with secondary or tertiary easy to understand. And, patients of suspected macular abnormality. care providers in the event they are require very little training to see Although mere thickness readings concerned that macular abnormali- how their “abnormal scan” differs cannot guarantee acuity assessment, ties may affect the visual acuity out- from the normal. these findings can help the practi- comes post-cataract surgery. In the •Teleophthalmology . The OCT tioner more accurately predict post- same way, it can be helpful in cer- provides an excellent opportunity surgical cataract outcomes. tain refractive surgical candidates. for us to communicate with other In addition, OCT can be useful In short, OCT should be used in secondary and tertiary ophthalmic for visualizing macular structural a case of “reasonable suspicion of physicians “over the airwaves.” abnormalities that are not clearly abnormality” when we are unsure This often results in a more effec- seen through a dense cataract. This of the total visual acuity due to tive referral as well as saving the may include subtle macular edema cataract, or a combination of cata- patient time and money monitoring from diabetes, small focal venous ract and macular abnormality. This certain retinal disorders “in-house.” occlusive disorders, preretinal fibro- technology allows the primary care A simple phone call along with sis or more subtle early macular practitioner a better and higher an e-mail of the OCT allows us a hole formation. Although this can- degree of competency and referral. “telecommunicative consultation” not be used as a routine test when •Patient education. On a per- to facilitate clinical decision-making considering cataract referral, it can sonal note, there isn’t a day that between the primary and secondary be valuable information in commu- goes by in our office that OCT care providers.

46 REVIEW OF OPTOMETRY JANUARY 15, 2012

042_ro0112_f3.indd 46 1/5/12 1:59 PM Management and Follow-up can only be maximized if we become familiar with the Management of numerous posterior segment dis- strengths and weaknesses of the equipment. Learning orders with the aid of serial OCT is becoming more and experience, with a keen eye on the literature, can important in daily practice. With our present technol- allow us to maximize utilization of scanning devices to ogy, follow-up of macular thickening from tractional enhance our ability to provide quality eye care to our or edematous disorders can be precisely measured to community. ■ within microns. In addition to macular and retinal Dr. Bumgarner is in a primary care group practice evaluation, no one can argue the benefit of OCT in the in Pinehurst, N.C. He has no financial relationships to management and predictive value in glaucoma evalua- disclose. He thanks Andrew Apple and Nicole Piatt, tion, both in-office and for referral to secondary glau- fourth year optometry students at Pennsylvania College coma specialties. of Optometry at Salus University, for their assistance Comanagement is becoming a big issue in follow- with this article. ing the post-treatment macular degeneration patient 1. Ouyang Y, Keane PA, Sadda SR, Walsh AC. Detection of cystoid macular edema with three- who has had anti-VEGF, intraocular steroid injections, dimensional optical coherence tomography versus fluorescein angiography. Invest Ophthalmol photodynamic therapeutics, or a combination of any of Vis Sci. 2010 Oct;51(10):5213-8. 2. Quigley HA, Addicks EM, Green WR. Optic nerve damage in human glaucoma. III. Quantita- these. This gives the retinal specialist and the practicing tive correlation of nerve fiber loss and visual field defect in glaucoma, ischemic neuropathy, optometrist the confidence in each other to comanage papilledema, and toxic neuropathy. Arch Ophthalmol. 1982 Jan;100(1):135-46. 3. Johnson LN, Diehl ML, Hamm CW, et al. Differentiating optic disc edema from optic nerve these patients. In particular, it gives the ophthalmolo- head drusen on optical coherence tomography. Arch Ophthalmol. 2009 Jan;127(1):45-9. gist the assurance that subtle edemas and retinal thick- 4. Rebolleda G, Muñoz-Negrete FJ. Follow-up of mild papilledema in idiopathic intracra- nial hypertension with optical coherence tomography. Invest Ophthalmol Vis Sci. 2009 ening, as well as other retinal fluctuations, can be more Nov;50(11):5197-200. precisely monitored in the primary care office. 5. Lalwani GA, Rosenfeld PJ, Fung AE, et al. A variable-dosing regimen with intravitreal ranibizumab for neovascular age-related macular degeneration: year 2 of the PrONTO Study. Am J Because many of our retinal specialists are over- Ophthalmol. 2009 Jul;148(1):43-58.e1. worked, they welcome the opportunity to send the patient back to the referring physician’s office. The patient benefits because he is back with “the doctor I know and trust.” The cost to the health care system is arguably lower in primary vs. secondary and tertiary office settings. In addition, the patient benefits in less travel time and less wait time. Importantly, the average O.D. spends more “one-on-one” time with the patient. Return on Investment Even with a reduction in office reimbursements, the familiar argument that OCT is not a revenue producer Allergan is unfounded. Our office performs more than 120 OCT With a 60 year heritage in discovering scans a month. True, reimbursements for OCT itself and developing therapeutic agents to have gone down; yet, the added financial enhancement help protect and preserve vision, eye comes not only in OCT coding, but also in the charges care professionals and patients rely on for office visits and verification of acuities, which often requires refractions (an additional charge). This makes Allergan products to treat a variety of OCT an excellent revenue producer in the office. (See eye conditions. We are a leader in this “Estimated Return on Investment,” page 46.) area and are one of the fastest-growing eye care companies worldwide. Since the advent of scanning technologies in the 1980s, OCT has become more affordable and, more importantly, more valuable in patient care. The impact APC63RP10 of this technology will make it one of the most important clinical tools available in our decade, and will only 800-433-8871 get better as technology and integration with other test- www.allerganoptometry.com ing modalities improves. The value of OCT, as with any testing technology,

REVIEW OF OPTOMETRY JANUARY 15, 2012 47

042_ro0112_f3.indd 47 1/5/12 1:59 PM Case Report

Choroidal Melanoma Life Sentenceis a A thorough knowledge of treatment options and associated risks is crucial to ensure the best possible outcome with this dire condition. By Sara Weidmayer, O.D.

65-year-old white male inmate presented at a state correctional facility’s eye Aclinic with a complaint of “bugs” in the vision of his left eye. This had been happening for about three weeks; he denied photopsia. The patient’s systemic history was significant for hypertension, heart problems (having had two valve replacements) and type 2 diabetes that was controlled with oral medications. His ocular history was significant for “long-standing” blindness of his right eye. Upon further questioning about this long-standing blindness, we learned that, 15 years earlier, the patient had seen a retinal spe- 1. A fundus photograph of our patient’s right eye. cialist, who told him he had a “freckle” in his eye. He reported Diagnostic Data O.S. and were both round and that he had lost his vision in the Upon examination, the patient’s reactive, with a 3+ afferent defect right eye about 10 years ago, but visual acuity was light perception O.D. Anterior segment evalua- hadn’t seen a specialist since that only O.D., and 20/25 O.S. Pupils tion was remarkable for nuclear visit 15 years ago. measured 4mm O.D. and 3mm sclerotic cataracts. We performed

48 REVIEW OF OPTOMETRY JANUARY 15, 2012

048_ro0112_f4.indd 48 1/5/12 9:54 AM a dilated fundus examination, oculoplastics specialist that day groups.1,3,4 They occur mostly in and found that the patient’s chief to discuss treatment. Diagnostic light-skinned persons with blue or complaint was due to a posterior testing results from the retinal green irides, and are rarely found vitreous detachment O.S., which specialist and ocuplastics special- in blacks or Asians.1,4 caused dense, central vitreous syn- ist were not available to us in the Patients with choroidal mela- eresis. We found no retinal breaks patient’s record. An abdominal nomas are often asymptomatic, or anything else of clinical signifi- CT scan with contrast and a chest but may present with decreased cance in that eye. X-ray were also ordered. vision, visual field defects, floaters, Dilated fundus examination The patient and oculoplastics photopsias or, in rare instances, of his right eye revealed a large elevated lesion, approximately 12 Choroidal melanomas often display an abrupt elevation disc diameters in size, extending from—and including—the tempo- from the choroid, subretinal fluid, orange pigmentation ral optic disc, past the temporal macula and beyond the superior over the lesion’s surface and growth over time. arcade. It was gray-white in color with what appeared to be some fluid content in the inferior-nasal specialist decided on treatment pain.4,5 If pain does occur, it is aspect (figure 1). with enucleation, and the patient usually a result of secondary glau- was scheduled for surgery the fol- coma or tumor necrosis; choroidal Diagnosis lowing week. The enucleation was melanomas also can cause pain by We made a provisional diagno- successful; however, the patient impinging on underlying posterior sis of choroidal melanoma with unfortunately experienced diffi- ciliary nerves, but this seldom serous retinal detachment, and culty with the anesthesia and died occurs.3,5 documented it with fundus photos. two days after the enucleation. These lesions usually are ele- The abdominal CT and chest vated and may appear mottled, Treatment and Follow-Up X-rays had not yet been com- dark brown, dull-gray, gray-green We referred the patient to the pleted. or yellow (amelanotic).4-6 They facility’s staff ophthalmologist for may assume a mushroom or dome further evaluation and treatment. Discussion shape with congested blood vessels About two weeks later, the oph- Choroidal melanomas are rela- within the tumor—this configura- thalmologist saw him and took a tively rare, with an incidence of tion represents the 20% of choroi- fluorescein angiogram as well as approximately five to six cases dal melanomas that erupt through an A- and B-scan ultrasound. The per one million people, which Bruch’s membrane and the retinal interpretation reports for these equates to about 1,400 cases in the pigment epithelium (RPE).1,4,5 procedures were fairly rudimen- United States each year.1,2 They Choroidal melanomas often dis- tary; they stated that the A- and are found mostly in adults (with play an abrupt elevation from the B-scans revealed a “solid mass,” the peak around age 55), generally choroid, subretinal fluid, orange and the fluorescein showed that are not familial, and show a slight pigmentation over the lesion’s the mass was filled with dye early male predilection for most age surface and growth over time.4 and then slowly disappeared. After these studies, the ophthal- Malignant Transformation mologist posed differentials of Risk factors for malignant transformation of choroidal nevi include:4 malignant melanoma or disciform • Thickness > 2mm. macular degeneration. He referred • Subretinal fluid. the patient to a retinal specialist, • Presence of symptoms. who saw him just days after his • Prominent orange pigment overlying the lesion. ophthalmology consultation. • Location < 3mm from the optic disc. The retinal specialist immediately diagnosed a choroidal mela- *If two or more factors are present, the lesion is likely a choroidal melanoma. noma and sent the patient to an

REVIEW OF OPTOMETRY JANUARY 15, 2012 49

048_ro0112_f4.indd 49 1/5/12 9:54 AM Case Report

Subretinal fluid with resultant mation if followed for underlying serous retinal detach- 10 years; the estimated ment results from RPE breakdown. annual rate of malignant These serous detachments often transformation is one in shift, and may appear to contain 8,845.6,9 blood if the tumor has traversed There are multiple Bruch’s membrane.5 known risk factors for Overlying orange pigmenta- such transformation (see tion is lipofuscin; this pigment is “Malignant Transforma- composed of proteins, lipids and tion,” page 49).4,8 The small chromophores, and it accu- most important appears mulates in the RPE as a result of to be initial nevus thick- cell degeneration and incomplete ness of greater than digestion of the photoreceptor 2mm, but a large base outer segments.6,7 Lipofuscin is not diameter (greater than specific to melanomas; it may also 7mm) also suggests be associated with choroidal nevi premalignancy of the or other benign choroidal tumors. nevus.8,9 The absence of However, lipofuscin is much more drusen is a good prog- commonly seen with melanomas nostic indicator.7 than with benign counterparts.5 Whereas choroidal Other possible signs associ- melanomas tend to grow ated with choroidal melanomas relatively rapidly, cho- 2. Choroidal nevus with overlying drusen. include vitreous hemorrhages or roidal nevi may enlarge pigmented vitreous cells, drusen on slowly over a period of several from a primary malignancy else- the surface of the tumor, choroidal years, not necessarily indicating where in the body. Thus, they are neovascular membranes, or even malignant transformation. Such not primary tumors like choroidal proptosis if the tumor invades the non-malignant growth is more melanoma—most often, they are orbit.4 common in younger patients metastases from breast or lung and tends to stabilize with age.11 cancer. These lesions usually Differential Diagnoses Thus, slow growth of choroidal appear dome-shaped and creamy- There are a plethora of differ- nevi is not invariably a sign of yellow in color, and often induce ential diagnoses for melanotic and malignancy, especially in younger retinal detachments. Choroidal amelanotic choroidal melanomas, patients without other risk fac- metastases are often bilateral or which vary on the prognostic con- tors.11 multifocal and do not appear tinuum of severity. Interestingly, pigmented choroi- mushroom-shaped, unlike amelo- • Choroidal nevi are a major dal lesions with none of the above natic melanomas.1 differential. They are common, risk factors have a 3% chance of • Congenital hypertrophy of the benign melanocytic tumors and growth in five years; such lesions RPE presents as single or multifo- are found in approximately 2% are usually choroidal nevi.9 Pres- cal, darkly-pigmented, flat lesions, to 6.5% of the white popula- ence of one of the above factors often with hypopigmented lacunae. tion.8-10 Nevi usually are slate-gray carries a 38% chance of growth, They are benign, usually do not and relatively flat (less than 2mm and more than a 50% chance of change with time, and require no thickness), although there is sig- growth exists if two or more risk treatment.1 nificant size overlap between small factors are present.9 The relative The resultant serous retinal melanomas and larger nevi.8,9 Like risk of growth climbs from 1.9 detachment and retinal elevation choroidal melanomas, they also times to 27.1 times for the pres- secondary to exudative age-related may show overlying drusen or ence of one vs. all five risk factors.9 macular degeneration (AMD) lipofuscin (figure 2). Statistically, • Choroidal metastasis refers poses another differential for cho- of every 500 choroidal nevi, one to a tumor that has spread to the roidal melanoma. AMD may show will undergo malignant transfor- choroid via hematogenous routes subretinal hemorrhaging, lipid or

50 REVIEW OF OPTOMETRY JANUARY 15, 2012

048_ro0112_f4.indd 50 1/5/12 9:54 AM The First Breakthrough in Subjective Refraction in 80 Years

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RO1211_Vmax.indd 1 11/21/11 2:48 PM Case Report

turbid exudation, dirty-gray or of mature bone tissue. They may cross-sectional shape typically is yellow macular edema, choroidal allow choroidal neovascularization bi-convex, but may appear mush- folds, pigment epithelial detach- and subretinal bleeding to develop. room-like. Choroidal excavation ments or disciform scarring.1 Very characteristic features make and orbital shadowing may also be Fluorescein angiography aids in them easy to differentiate from seen.1,5 differentiating between these con- choroidal melanomas using ultra- Fluorescein angiography typi- ditions. sonography or CT scan.1 cally shows hyperfluorescence of • Melanocytomas are darkly • Additional differentials for the tumor’s vessels and diffuse late pigmented and found on or around amelonotic or melanotic choroi- staining.1 However, the fluorescein the optic disc (figure 3). Unlike dal melanomas include choroidal pattern depends on the tumor’s melanomas, they are congenital detachment, lymphoma, metastatic size, shape, pigmentation, integ- and often occur in individuals with carcinoma, subretinal or sub-RPE rity of the RPE and whether there dark pigments. They usually are hematoma, localized suprachoroi- is a corresponding serous retinal inactive, but may grow and rarely dal hematoma, nodular posterior detachment, among other vari- develop into melanomas.1 scleritis, reactive hyperplasia of ables.5 Fluorescein angiography • Choroidal hemangiomas are RPE or massive gliosis of the does not yield pathognomonic benign dilations of choroidal blood retina.4,5 signs of choroidal melanoma.3 vessels and are often associated In this particular patient, cho- with Sturge-Weber syndrome. Additional Testing roidal melanoma was diagnosed They appear elevated and are Various instruments may assist based on fundoscopic examina- red-orange in color. Like choroi- in the diagnosis of choroidal mela- tion, A- and B-scan ultrasounds, dal melanomas, they may induce nomas. and fluorescein angiography (with- serous retinal detachments.1 A- and B-scan ultrasonography out biopsy). • Choroidal osteomas are not only aids in diagnosis, but also This patient’s clinical presen- yellow-orange placoid masses. may provide more accurate mea- tation alone was highly sugges- Interestingly, they are composed surements of the tumor. A-scan tive––basically unequivocally––of usually reveals choroidal melanoma. He possessed low internal four of the five aforementioned reflectivity risk factors for malignancy: thick- within the ness > 2mm, subretinal fluid, tumor; oscilla- symptoms/visual loss, and a location in height tion < 3mm from the optic disc. of the echoes Though the dimensions of the within the melanotic lesion based on ultraso- lesion may cor- nography are not available, it was respond with clearly thickened more than 2mm the patient’s and had a basal diameter larger pulse, which than 7mm (the widely accepted indicates the upper limits of benign nevi).8,12 presence of Additionally, the mass exhibited intralesional blatantly invasive features, such vascularity.1,5 as encroachment onto the optic B-scan shows disc.8,12 a solid mass with an acous- Management and Prognosis tically bright When a suspicious ocular mass anterior aspect is found, it is important to ask the with internal patient whether they have had any 3. Melanocytoma are darkly pigmented and found on or around and basal ocular surgery or trauma; a history the optic disc. darkness; the of cancer; or any systemic symp-

52 REVIEW OF OPTOMETRY JANUARY 15, 2012

048_ro0112_f4.indd 52 1/5/12 9:54 AM INCREASE PATIENT COMPLIANCE

5FBST"HBJO®):%3"5&ªJTUIFPOMZQSFTDSJQUJPO OVUSJUJPOBMTVQQMFNFOUTQFDJBMMZGPSNVMBUFEGPS UIFEJFUBSZNBOBHFNFOUPG t %SZ&ZF4ZOESPNF t #MFQIBSJUJT t .FJCPNJBO(MBOE%ZTGVODUJPO

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DESCRIPTION: Tears Again® HYDRATE™ is a Medical Foood specially formulated for the Dietary Management of Dry Eye Syndrome, PRECAUTIONS: Keep out of the reach of children. Inn casec of emergency contact a Poison Control Center Immediately. Avoid takinng at the Blepharitis, and Meibomian Gland Dysfunction. Tears Agaiin® HYDRATE™ is intended to be used under the supervision of a physician. Tears same time with other medications and/or supplements. Again® HYDRATE™ is formulated to contain the omega-a-3 fatty acid, Flaxseed Oil, but has also included Evening Primrose Oil (EPO), a Pregnancy Category C: It is not known whether this Mediccal Food can cause fetal harm when administered to a pregnant woman or affect substance having exceptionally high content of the evenn rarer essential fatty acid, gamma linolenic acid (Omega-6) as well as Bilberry Extract reproduction. (BBE). The clinically supported tear speci¿c ingrediennts in Tears Again® HYDRATE™ are microencapsulated through a unique proprietary Pediatric Use: Safety and effectiveness in children have not beebe n established. liposome process to enhance absorption. This deliverry system, termed Hypersorb®, eliminates digestive problems commonly associated with EFAs and is especially suited for the oral delivery of ingredients with poor bioavailability. ADVERSE REACTIONS: Other than the possibility for allergicc reaction in susceptible individuals, no serious side effects are associaated with consumption of normal; amounts. Flaxseed Oil increases ststool bulk and frequency of defecation, it is not recommended for those wiw th CONTAINS: Flaxseed Oil 1000 mg, Evening Primroose Oil 500 mg, Bilberry Extract 40 mg bowel obstruction, irritable bowel syndrome or diverticular diseasse. Stop taking immediately and talk to your doctor if you have any of tthe following side effects: Breathing problems or tightness in your throoaat or chest, chest pain, skin hives, rash, or itchy or swollen skin, headachhe, Flaxseed Oil is derived from the seeds of the Àax plp ant and is one of the richest sources of the Omega-3 fatty acid, Alpha-/inoleic Acid (A/A). GI upset, nausea. Recent reports have linked dietary Flaxseed Oil to increased comfort when used to manage Dry Eye Syndrome.1 Essential Fatty acids such as Flaxseed Oil work throughout the body to proteect cell membranes. Omega-3 Fatty Acids (Flaxseed Oil) have a competitive inhibitory effect DOSAGE: Take 4 soft gels daily. May be taken directly or during meeals or snacks. Avoid taking at the same time with other medications annd/ on the arachidonic acid (omega-6 derivative) inÀammatory cascade and a modular effect on immune cells.2,3 Flaxseed Oil also improves or supplements. meibomian gland secretion by increasing its Àuidiity, thereby µunplugging¶ the gland ori¿ces. A recent study demonstrated that increased intake of Omega-3 fatty acids improved the pro¿le of the polar lipid fraction of meibomian secretions in patients with Dry Eye Syndrome. By enhancing HOW SUPPLIED: Tears Again® HYDRATE™ is supplied as 120 Softt Gels in a caramel color. the lipid fraction of the tear ¿lm, evaporative loss wwill decrease.4 Chronic blepharitis has associated meibum abnormalities that explain defects in the tear lipid layer that may result in a frankly unnstable tear ¿lm and that explain the frequently associated evaporative dry eye.5 STORAGE:Store at a controlled room temperature, 15 –30 degree Celsius (59-86 degree Fahrenheit) Keep container tightly closed.

Evening Primrose Oil is an Omega-6 gamma linolelenic acid (G/A) that is a downstream metabolite of Omega-6 linoleic acid. This compound REFERENCES: is a necessary component in the downstream metaabolism of Omega-6 fatty acid to the series one anti-inÀammatory prostaglandins (PGE1s), 1. Ambrioso RJ, Stelzner SK, Boerner CF, Honan PR, McIntyre DJDJ. Nutrition and Dry Eye: The Role of Lipids. Review of Refractive Surgeery, which are associated with healthy mucosal tissue anda tear ¿lm. The human body cannot metaboli]e Omega-3 fatty acids to these speci¿cs August 2002; 29-32. anti-inÀammatory prostaglandins.6 Omega-6 fatty acacids that are successfully metaboli]ed or those that have the metabolic advantage of 2. Calder PC. N-3 polyunsaturated fatty acids and immune cell function. Adv Enzyme Regul. 1997; 37:197-237. containing G/A reduce inÀammation after further metataboli]ing to dihomo-gamma-linolenic acid (DG/A), which also blocks, when appropriate, 3. Calder PC. Omega-3 polyunsaturated fatty acids, inÀammatoory and immunity. :orld Rev Nutr. Diet 2001; 88:109-116. the pro-inÀammatory arachidonic acid conversion. Theey also enhance the delta-6 and delta-5 desaturase en]ymatic conversion of Omega-3 4. Sullivan BD, Cermak JM, Sullivan RM, Papas AS, Evans JE,E, Dana MR, Sullivan DA. Correlations between nutrient intake and the polarr lipid alphalinolenic- acid to EPADHA and the series 3 anti-i-inÀammatory prostaglandins.7 The body requires all of the essential fatty acids for pro¿les of meibomian gland secretions in women with SMogrenen¶s Syndrome. Adv Exp Med Biol 2002; in press. optimal health. They are particularly important for the patitiente that has Dry Eye Syndrome because PGE1s from Omega-6 (EPO) interrupt the 5. McCulley JP, Shine :E. Eyelid disorders: the meibomian gland, blepharitis, and contact lenses. Eye Contact Lens. 2003 Jan; 29(1 Suppl) inÀammatory loop associated with chronic Dry Eye Syndromome. :S93-5; discussion S115-8, S192-4. 6. Furse RK, Rossetti RG, =urier RB. Gamma linolenic acia d, an unsaturated fatty acid with anti-inÀammatory properties, blocks amplili¿cation Bilberry Extract is a botanical source of an important bioÀavanooid for eye health. BioÀavanoids are water-soluble plant-based antioxidants that of IL-1 beta production by human monocytes. J Immunonol 2001 Jul 1; 167 (1); 490-6. have additional bene¿cial effects on eye health. The eyes are supplied with oxygen and nutrients through minute capillaries bioÀavonoids 7. Barabino S, Rolando M, Camicione P, et al. Systememic linolenic and gamma linolenic acid therapy in dry eye syndrome with an inÀaammatory may increase the integrity of these blood vessels, enhancing theirr function. Research has also demonstrated improvements in patients with component. Cornea 2003 Mar; 22(2); 97-101 retinopathy by supporting blood vessels of the eyes and thereby reduucingci exudations (Àuid seeping through blood vessels).

RX only OTHER INGREDIENTS: SafÀower Oil, /ecithin (Precept 120), d-alpha Tococopherp yl Acetate, Gelatin, Glycerin, Puri¿ed :ater, Caramel Powder. Based on package insert.

CONTRAINDICATIONS: Should not be used by the patient without physician supervervision, or in those persons showing hypersensitivity to any Distributed by OCuSOFT INC. component of this preparation. Avoid taking at the same time with other medications and/an or supplements. Pregnant women should not take P.O. Box 429 Richmond TXX 777406 USA Evening Primrose Oil due to increased risk of pregnancy complications. Evening Primrose Oil maym lower the sei]ure threshold and precipitate 800-233-5469 sei]ures in patients taking phenothia]ines. www.tearsagainhynhydradrate.com MADE INN USA WWARNINGS: Before taking, tell your doctor if you are pregnant or breastfeeding. Flaxseed Oil may cause ileus (inttestinal blockage).) Flaxsaxseed Oill maym cause a thyroid problem. Flaxseed Oil and Evening Primrose Oil reduce blood vessel platelet aggregation. If already taking aspirin or U.S. Patent 6610322 B1 blood thinners consult your physician ± you may need to have your clotting time checked. Evening Primrose Oil may lower the sei]ure threshold * HyperSorb® is a registered trademark of Biozone Labs, Inc. © 2011 OCuSOFT, Inc.c., Rosenberg, TX 77471 and prececipitate sei]ures in patients taking phenothia]ines. © 2011 OCuSOFT, Inc. Richmond,TX 77406

RO0112_Ocusoft Hydrate.indd 1 12/21/11 3:39 PM Case Report

toms of cancer, such as anorexia, nomas are treated with locally include local resection, photody- weight loss, general fatigue, destructive therapies, such as ther- namic therapy or cryotherapy.4,5 malaise or illness. While 98% of motherapy, radiotherapy or irradi- Often, multiple treatments are patients with choroidal melanomas ation.12 Various types of radiation used as part of a combination do not have metastatic disease may be used as treatment.4,5 The approach. detectable at the time of diagno- most common is plaque brachy- Sadly, the prognosis for patients sis, metastasis must be ruled out.5 therapy, which utilizes a radioac- with choroidal melanoma often is This would most appropriately be tive plaque that is sutured on the poor. Despite treatment, 30% to handled by an ocular oncologist, surface of the globe exterior to the 50% of patients eventually develop so such a referral should be made. tumor. metastatic disease; this occurs Tests include a complete blood This is more commonly preferentially to the liver, but also count, liver enzymes, abdominal attempted with smaller tumors to lung, bone, skin, lymph nodes CT, MRI or ultrasound, and a that are 3 disc diameters or more or central nervous system.3,11,14 chest X-ray.4,5 Several treatment away from the disc and fovea. The same proportion of patients will die within 10 years from diag- A few factors to consider are tumor size and nosis, usually due to metastatic location, metastasis status, the visual status of spread.3,11 Once metastasized, fatality is both the affected and unaffected eyes, and the almost certain.11 The highest incidence of metastatic detection is patient’s age and overall health. within a year from choroidal melanoma diagnosis, though it may options are available for choroi- Approximately 10% to 15% of not occur until years later. Several dal melanomas, but many have patients treated in this way expe- factors correlate with increased high risks involved; therefore, the rience local tumor relapse after mortality rate, including larger treating practitioner must care- treatment. Post-treatment, the melanoma size, anterior location, fully weigh many variables when patient’s vision usually remains the extrascleral extension, growth selecting the appropriate treat- same as it was before treatment, through Bruch’s membrane, optic ment modality for each particular but there is a chance that it may nerve extension, lack of pigmenta- patient. A few factors to consider improve. However, vision may be tion, and aggressive cell type and/ are tumor size and location, metas- subsequently reduced due to sec- or mitotic activity.3 tasis status, the visual status of ondary effects, such as radiation both the affected and unaffected retinopathy, optic papillopathy, It is apparent that this patient eyes, and the patient’s age and cataracts or neovascular glaucoma. did not receive adequate care at overall health.5 Depending on Photocoagulation may be his first appointment with the these factors, observation may be attempted for small tumors (< optometry clinic; however, despite a viable management plan if the 3mm thickness, < 7mm basal appropriate referrals following his patient has serious concurrent diameter).4,5 Like photocoagula- second appointment, the chances medical issues, but generally is not tion for any other reason, a per- of a successful outcome were advised. manent scotoma will result in the reduced markedly. One very aggressive treatment is photocoagulated areas. Other Though a delay in referral of enucleation, but it comes with sig- laser treatments can also be used, a few months may not have significant risks. Half of the patients including transpupillary thermo- nificantly altered outcomes in this who are treated with enucleation therapy, which utilizes a low- case, this situation emphasizes the eventually die of metastatic mela- power, long-duration infrared importance of thorough case his- noma. This invasive treatment laser.5,12 This technique may be tory and effective doctor-patient option is more often discussed if used in conjunction with plaque communication. It also highlights the affected eye is blind, painful, radiotherapy, but has not shown the importance of appropriate shows optic disc involvement, or if a significant improvement in local referrals and additional work-ups, the tumor is very large.5 tumor control.13 regardless of the “long-standing” Most small choroidal mela- Other, less common treatments nature of a condition.

54 REVIEW OF OPTOMETRY JANUARY 15, 2012

048_ro0112_f4.indd 54 1/5/12 9:54 AM While the prognosis for patients with choroidal melanoma may seem bleak, eye care professionals must institute appropriate treatment as soon as they discover such a lesion to improve the patient’s chances of having positive secondary outcomes, including preserva- tion of vision. ■

Dr. Weidmayer practices with a group of optometrists at Eye Cen- ter of Lenawee, P.C., in Adrian and Brooklyn, Mich.

1. Spaide RF. Diseases of the Retina and Vitreous. 1st ed. Philadelphia: W.B. Saunders; 1999:262-65. 2. Margo CE. The collaborative ocular melanoma study: an overview. Cancer Control. 2004 Sep-Oct;11(5):304-9. 3. Garcia-Valenzuela E, Pons ME, Puklin JE, Davidson CA. Choroidal Melanoma EMedicine Ophthalmology. Medscape Reference. June 24, 2009. http://emedicine.medscape.com/ article/1190564-overview. Accessed August 17, 2010. 4. Choroidal nevus and malignant melanoma of the choroid. In: Ehlers JP, Shah CP (eds). The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2008:330-3. 5. Augsburger JJ, Damato BE, Bornfeld N. Uveal Melanoma. In: Yanoff M, Duker JS, eds. Ophthalmology. 1st ed. London: Mosby;1999:1052-63. 6. Jones WL. Ophthalmoscopy. In: Terry JE (ed). Ocular Dis- ease: Detection, Diagnosis, and Treatment. 1st ed. Boston: Butterworth Publishers; 1984:155-57. 7. Materin MA, Raducu R, Bianciotto C, Shields CL. Fundus autofluorescence and optical coherence tomography findings in choroidal melanocytic lesions. Middle East Afr J Ophthal- mol. 2010 Jul;17(3): 201-6. 8. Augsburger JJ, Correa ZM, Trichopoulos N, Shaikh A. Size overlap between benign melanocytic choroidal nevi and choroidal malignant melanomas. Invest Ophthalmol Vis Sci. 2008 Jul;49(7):2823-8. 9. Kaiserman I, Kaiserman N, Pe’er J. Long term ultrasonic follow up of choroidal naevi and their transformation to melanomas. Br J Ophthalmol. 2006 Aug;90(8):994-8. 10. Mashayekhi A, Siu S, Shields CL, Shields JA. Slow enlargement of choroidal nevi: a long-term follow-up study. Ophthalmology. 2011 Feb;118(2):382-8. 11. Onken MD, Worley LA, Tuscan MD, Harbour JW. An accurate, clinically feasible multi-gene expression assay for predicting metastasis in uveal melanoma. J Mol Diagn. 2010 July;12(4):461-8. 12. Augsburger JJ, Correa ZM, Schneider S, et al. Diagnostic transvitreal fine-needle aspiration biopsy of small melanocytic choroidal tumors in nevus versus melanoma category. Trans Am Ophthalmol Soc. (2002);100:225-34. 13. Sagoo MS, Shields CL, Mashayekhi A, et al. Plaque radiotherapy for juxtapapillary choroidal melanoma: tumor control in 650 consecutive cases. Ophthalmology 2011 Feb;118(2):402-7. 14. Finger PT, Kurli M, Reddy S, et al. Whole body PET/CT for initial staging of choroidal melanoma. Br J Ophthalmol. 2005 Oct;89(10):1270-74.

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048_ro0112_f4.indd 55 1/5/12 9:54 AM Dry Eye

13th Annual Dry Eye Report Keep On Plugging Punctal plugs are an effective treatment option for many patients with dry eye syndrome. But, they also may be used in a variety of other ways to facilitate improved ocular health. By Walt Whitley, O.D., M.B.A. hen we hear about This multifactorial disease of the even more patients present with punctal plugs, the first tears and ocular surface results dry eye symptoms. thing that comes to from insufficient tear produc- There are two subcategories of mind is dry eye treat- tion, excessive tear evaporation DES: aqueous-deficient and evap- W 2,3 ment. Although frequently used or abnormal tear composition. orative. Aqueous-deficient causes for this purpose, there are several DES causes symptoms of burning, include Sjögren’s syndrome, other conditions in which punctal itching, redness, photophobia and lacrimal gland insufficiency, lac- occlusion can be implemented reduced visual acuity.2,4,5 rimal duct obstruction and reflex into your treatment plan. Indeed, Multiple studies have shown hyposecretion.2 Evaporative punctal and canalicular occlusion that nearly five million Americans mechanisms include meibomian may enhance the effects of topical age 50 or older are affected sig- gland dysfunction, eyelid aperture medications, help catalyze postop- nificantly by DES.6 Additionally, disorders, lid-globe incongruity, erative healing and improve con- millions more Americans experi- blink disorders and ocular surface tact lens wear. ence varying, less severe symp- irregularites.2 Here, I’ll review how punctal toms of DES. Irrespective of the subcategory, occlusion may be used to treat not There are many underlying risk DES produces tear hyperosmolar- only dry eye syndrome (DES) but factors for dry eye, including age, ity and/or ocular surface inflam- other ocular surface conditions. female gender, systemic diseases, mation. Tear hyperosmolarity can Also, I’ll discuss several non-tradi- medications, environmental con- be caused by either low aqueous tional uses for occlusion that may siderations, contact lens wear and flow of excessive tear film or greatly enhance your patient’s refractive eye surgeries.7 The Bea- excessive tear film evaporation–– overall ocular health and comfort. ver Dam Eye Study showed that both of which can damage the age was the biggest contributory ocular surface by causing an epi- The Traditional Use for factor to dry eye syndrome.7 And, thelial inflammatory response.2,8 Occlusion because a large percentage of Proper diagnostic testing for The most common indication Americans are now more than 50 DES often helps guide treatment for punctal occlusion is DES.1 years of age, we can expect to see decisions. Diagnostic screening

56 REVIEW OF OPTOMETRY JANUARY 15, 2012

056_ro0112_f5_final.indd 56 1/5/12 1:41 PM assesses tear film stability, tear Types of Occlusion production and flow, and ocular Punctal occlusion may be performed in a variety of ways: surface stability. Typical tests for • Temporary occlusion with collagen plugs may help identify patients who likely would DES include tear film break-up benefit from permanent occlusion, or may be an ideal option for individuals who are appre- time, Schirmer testing, corneal hensive about more permanent treatment options. Collagen plugs typically dissolve within topography, impression cytology, four to seven days. and rose bengal, lissamine green • Semi-permanent occlusion with punctal plugs are comprised of silicone or thermal or fluorescein dye testing.2 Addi- labile acrylic polymers, and may last for several months. tionally, tear film osmolarity test- • Permanent occlusion can be achieved with the use of silicone plugs and thermal or ing (i.e., TearLab) has been used laser cautery. While silicone plugs do not dissolve, it is important to note that they may to identify dry eye patients. extrude or migrate out of the puncta over time. No matter which testing you perform, the first step to effective DES management is to determine moderate to severe symptoms, Although many practitioners whether the patient has ocular tear film signs, mild corneal punc- have been able to effectively treat surface inflammation. If so, you tate staining, conjunctival staining DES with various medications, should consider the use of anti- and visual signs. Recommended such as topical cyclosporine, inflammatory therapies, such as treatment includes preservative- punctal occlusion is often a for- cyclosporine and omega-3 fatty free artificial tears, gels, oint- gotten adjunct tool. acids supplementation, to opti- ments, nutritional supplements, One reason for this potential mize ocular surface health before cyclosporine A and topical corti- oversight may be related to the recommending punctal occlusion. costeroids. (Most patients present current FDA labeling of Restasis Sometimes, a short course of to our offices when they reach (cyclosporine, Allergan), which topical steroids––used simulta- Level 2 signs and symptoms.) indicates that increased tear pro- neously with the initiation of • Severity Level 3 includes duction was not documented in cyclosporine––will help reduce severe symptoms, marked corneal patients who were taking topical the sting, allow for rapid symp- superficial punctate keratitis, anti-inflammatory drugs or using tomatic relief, and/or facilitate the central corneal staining and fila- punctal plugs.10 This, however, long-term success of cyclosporine mentary keratitis. Recommended does not mean that these patients dosing. Implementing this strat- treatment includes all Level 2 did not experience tear produc- egy to first identify patients with options as well as tetracyclines tion. inflammation prevents the poten- and punctal plugs. Because patients with punctal tial accumulation of inflamed • Severity Level 4 includes plugs already have increased tear tears after punctal occlusion, severe symptoms, such as sig- volume due to mechanical block- which may exacerbate the ocular nificant corneal staining, corneal age––and those on anti-inflam- surface disease. erosion and conjunctival scarring. matory agents show decreased The Dry Eye Workshop Recommended treatment includes inflammation associated with (DEWS) and the International systemic anti-inflammatory ther- many of the symptoms of dry Task Force (ITF) Delphi Panel apy, oral cyclosporine, moisture eye––it was more difficult to doc- on Dry Eye outlined the primary goggles, acetylcysteine and punc- ument statistical improvement in signs and symptoms that could be tal cautery.2,9 these patient groups.10 used to determine DES severity.9 Again, many patients who suf- In 2007, Calvin Roberts, M.D., More specifically, the ITF created fer from DES have found success and associates noted a synergistic a four-tier, step-wise approach to with topical artificial tears and effect with punctal occlusion and DES grading and management:3,9 anti-inflammatories as well as topical cyclosporine use.11 They • Severity Level 1 includes mild omega-3 fatty acid supplementa- concluded that, “while topical to moderate signs and no symp- tion. Whether using medications cyclosporine is being used more toms. Recommended treatment short- or long-term, ocular surface and more for the treatment of includes patient education and diseases are chronic, co-morbid moderate dry eye, our study artificial tears. conditions that wax and wane results indicate clinicians should • Severity Level 2 includes over time. not abandon punctal plugs nor

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Importance of Patient Education and Punctal Occlusion patient will be ready to wear con- Be sure to communicate these points to your patients when considering occlusion: tact lenses comfortably. Addition- • Punctal occlusion is a safe, quick, reversible and widely performed procedure. ally, making patients comfortable • Punctal plugs help alleviate symptoms of dry eye, but do not cure the disease. and happy will keep them in their • Punctal plugs will help increase the contact time of your drops. lenses longer and may prevent • Punctal plugs will not interfere with tear production. them from seeking refractive sur- • Collagen plugs are temporary and are often used for diagnostic purposes. gical options. • Permanent silicone plugs do not dissolve and can be removed if complications arise. • Acute ocular conditions. As primary eye care providers, we often encounter patients who consider punctal plugs and cyclo- as ocular surface disease.11,12 present with various acute con- sporine mutually exclusive.”11 • Contact lenses. Patient dis- ditions. Although the signs and comfort is the leading reason symptoms may vary, patients Non-traditional Uses for for contact lens dropout. When often come to us for our expert Occlusion compounded with poor lens care medical opinion. According to the ITF, punctal compliance, discomfort can make Depending on the presentation, occlusion is recommended for successful management of the appropriate treatment options dry eye patients at Severity Level contact lens wearer almost impos- may include topical lubricants, 3.2 However, punctal plugs can sible. antibiotics, steroids and combina- be used to treat conditions other Multiple factors can help facili- tion medications. According to our than dry eye that may disrupt nor- tate an optimal contact lens wear corneal specialist, John Sheppard, mal tear volume and balance. experience, including good ocu- M.D., temporary punctal occlu- • Compliance issues. Punctal lar and systemic health, proper sion increases the contact time of plugs may play an indirect role lens care, satisfactory compli- topical medications, which allows in addressing patient non-com- ance, and the type of contact the drugs to penetrate into ocular pliance. Factors that influence lens material. Once lens wear is surface tissues and render their patient compliance include: cost optimized, contact lens rewetting desired effect with greater efficacy. of medication, dosing schedule, drops and punctal occlusion are Common conditions in which inability to take drops/meds, for- viable options to address comfort punctal occlusion may yield some getfulness, poor understanding throughout the day and increase benefit include corneal infiltrates, of the condition and insufficient tear volume. One study indicated corneal abrasions, recurrent cor- trust in their doctors. No matter that patients with punctal plugs neal erosions, filamentary keratitis, the reason, poor compliance and experienced a 34.6% increase in superior limbic keratitis, trachoma adherence to our recommenda- contact lens comfort within three and neurotrophic keratopathy. tions can have a significant impact weeks of occlusion.13 A recent example in our clinic on final outcome. The best way to maximize con- was a 32-year-old white male Simpler, less frequent dosing tact lens success is to evaluate the who was referred for a bacterial results in better compliance in a ocular surface prior to the initial corneal ulcer secondary to contact variety of therapeutic classes.12 fit. If patients show any signs lens wear. He presented with pain Additionally, plugs are not or symptoms of ocular surface O.S., mild mucous discharge and dependent on patient adherence disease, treat it accordingly. If light sensitivity. Clinical find- or dexterity for therapeutic effi- patients present with any signs of ings included 1+ lid edema, 3+ cacy. In fact, punctal plugs may conjunctival or corneal staining, conjunctival injection, 3.0mm help eliminate compliance issues topical therapy and punctal occlu- mid-peripheral corneal ulcer at 5 by reducing the need for consis- sion may be indicated. o’clock and 1+ anterior chamber tent artificial tear instillation.11 You may need to consider cells. We performed cultures to Furthermore, punctal occlusion both the lens material and wear determine the causative pathogen. increases the residence time of schedule for your patients, and We prescribed homatropine 5% topical therapeutic agents that transition them into daily wear t.i.d. O.S., moxifloxacin 0.3% may be prescribed to address lenses with low water content, if q1h (throughout the night) O.S., other co-morbid conditions, such necessary. Once improved, the a 0.4mm temporary collagen plug

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056_ro0112_f5_final.indd 58 1/5/12 1:42 PM RP0311_Allergan Restasis.indd 1 2/16/11 1:41 PM RESTASIS® (cyclosporine ophthalmic emulsion) 0.05% Sterile, Preservative-Free INDICATIONS AND USAGE RESTASIS® ophthalmic emulsion is indicated to increase tear production in patients whose tear production is presumed to be suppressed due to ocular inflammation associated with keratoconjunctivitis sicca. Increased tear Dry Eye production was not seen in patients currently taking topical anti-inflammatory drugs or using punctal plugs. CONTRAINDICATIONS RESTASIS® is contraindicated in patients with active ocular infections and in patients with known or suspected hypersensitivity to any of the ingredients in the formulation. Complications of Occlusion WARNING With the exception of thermal/laser cauterization, punctal occlu- RESTASIS® ophthalmic emulsion has not been studied in patients with a history of herpes keratitis. PRECAUTIONS sion is a reversible procedure that is widely used within eye General: For ophthalmic use only. care. Regarding most types of plugs, the safety profile is very Information for Patients The emulsion from one individual single-use vial is to be used immediately after opening for administration to one high; epiphora, conjunctival irritation and extrusion typically are or both eyes, and the remaining contents should be discarded immediately after administration. the most common––yet infrequent––complications. Other rare Do not allow the tip of the vial to touch the eye or any surface, as this may contaminate the emulsion. complications include canaliculitis and dacryocystitis, which are RESTASIS® should not be administered while wearing contact lenses. Patients with decreased tear produc tion typically should not wear contact lenses. If contact lenses are worn, they should be removed prior to caused by common bacterial pathogens, such as Actinomyces the administration of the emulsion. Lenses may be reinserted 15 minutes following administration of RESTASIS® israelii, staphylococci, streptococci and diphtheroids. In the event ophthalmic emulsion. of complications, patients may require plug removal as well as Carcinogenesis, Mutagenesis, and Impairment of Fertility Systemic carcinogenicity studies were carried out in male and female mice and rats. In the 78-week oral therapeutic treatment anti-inflammatories and antibiotics. Rarely, (diet) mouse study, at doses of 1, 4, and 16 mg/kg/day, evidence of a statistically significant trend was found for lymphocytic lymphomas in females, and the incidence of hepatocellular carcinomas in mid-dose males surgical removal of plugs is indicated. significantly exceeded the control value. In the 24-month oral (diet) rat study, conducted at 0.5, 2, and 8 mg/kg/day, pancreatic islet cell adenomas significantly exceeded the control rate in the low dose level. The hepatocellular carcinomas and pancreatic islet cell adenomas were not dose related. The low doses in mice and rats are approximately 1000 and 500 times O.S. (lower puncta) and had him return the follow- greater, respectively, than the daily human dose of one drop (28 μL) of 0.05% RESTASIS® BID into each eye of a 60 kg person (0.001 mg/kg/day), assuming that the entire dose is absorbed. ing day. Upon examination, the infection improved Cyclosporine has not been found mutagenic/genotoxic in the Ames Test, the V79-HGPRT Test, the with resolution of the cellular reaction and the med- micronu cleus test in mice and Chinese hamsters, the chromosome-aberration tests in Chinese hamster bone- ications were continued for the following week until marrow, the mouse dominant lethal assay, and the DNA-repair test in sperm from treated mice. A study analyzing sister chromatid exchange (SCE) induction by cyclosporine using human lymphocytes in vitro gave indication of a complete resolution. Although the condition could positive effect (i.e., induction of SCE). have improved without occlusion, the punctal plugs No impairment in fertility was demonstrated in studies in male and female rats receiving oral doses of cyclosporine up to 15 mg/kg/day (approximately 15,000 times the human daily dose of 0.001 mg/kg/day) for 9 weeks (male) helped increase the contact time of the medications. and 2 weeks (female) prior to mating. • Glaucoma. Similar to topical treatment of ocu- Pregnancy-Teratogenic Effects Pregnancy category C. lar surface disease, punctal occlusion may benefit Teratogenic Effects: No evidence of teratogenicity was observed in rats or rabbits receiving oral doses of glaucoma patients by increasing the penetration and cyclosporine up to 300 mg/kg/day during organogenesis. These doses in rats and rabbits are approximately efficacy of IOP-lowering medications. Additionally, 300,000 times greater than the daily human dose of one drop (28 μL) 0.05% RESTASIS® BID into each eye of a 60 kg person (0.001 mg/kg/day), assuming that the entire dose is absorbed. occlusion may decrease systemic absorption of glau- Non-Teratogenic Effects: Adverse effects were seen in reproduction studies in rats and rabbits only at dose levels coma medications, such as beta blockers, and there- toxic to dams. At toxic doses (rats at 30 mg/kg/day and rabbits at 100 mg/kg/day), cyclosporine oral solution, USP, was embryo- and fetotoxic as indicated by increased pre- and postnatal mortality and reduced fetal weight fore reduce unwanted side effects. One study group together with related skeletal retardations. These doses are 30,000 and 100,000 times greater, respectively found that nasolacrimal duct occlusion reduces the than the daily human dose of one-drop (28 μL) of 0.05% RESTASIS® BID into each eye of a 60 kg person 14 (0.001 mg/kg/day), assuming that the entire dose is absorbed. No evidence of embryofetal toxicity was observed amount of systemic absorption by up to 60%. in rats or rabbits receiving cyclosporine at oral doses up to 17 mg/kg/day or 30 mg/kg/day, respectively, during Nonetheless, clinical studies have found conflicting organogenesis. These doses in rats and rabbits are approximately 17,000 and 30,000 times greater, respectively, than the daily human dose. results regarding the statistical significance of punc- Offspring of rats receiving a 45 mg/kg/day oral dose of cyclosporine from Day 15 of pregnancy until Day 21 post tal occlusion for glaucoma therapy.15,16 partum, a maternally toxic level, exhibited an increase in postnatal mortality; this dose is 45,000 times greater than the daily human topical dose, 0.001 mg/kg/day, assuming that the entire dose is absorbed. No adverse events • Prevention of herpes simplex keratitis (HSK) were observed at oral doses up to 15 mg/kg/day (15,000 times greater than the daily human dose). reactivation. Herpes simplex virus (HSV) is the There are no adequate and well-controlled studies of RESTASIS® in pregnant women. RESTASIS® should be most common cause of corneal blindness second- administered to a pregnant woman only if clearly needed. Nursing Mothers ary to infection in the United States and developed Cyclosporine is known to be excreted in human milk following systemic administration but excretion in human countries.17 The recurrence rate of ocular HSV milk after topical treatment has not been investigated. Although blood concentrations are undetectable after topical administration of RESTASIS® ophthalmic emulsion, caution should be exercised when RESTASIS® is within two years ranges from 23% to 33%, and administered to a nursing woman. about 20% to 25% of those with ocular HSV infec- Pediatric Use tions develop T-cell mediated stromal HSK. In addi- The safety and efficacy of RESTASIS® ophthalmic emulsion have not been established in pediatric patients below the age of 16. tion to stromal inflammation, HSK patients often Geriatric Use exhibit decreased tear production and dry eyes.18,19 No overall difference in safety or effectiveness has been observed between elderly and younger patients. ADVERSE REACTIONS Thermal cautery could facilitate therapy simply The most common adverse event following the use of RESTASIS® was ocular burning (17%). by enhancing the effectiveness of topically applied Other events reported in 1% to 5% of patients included conjunctival hyperemia, discharge, epiphora, eye pain, foreign body sensation, pruritus, stinging, and visual disturbance (most often blurring). drugs. Both thermal cautery and cyclosporine dis- Rx Only courage HSV reactivation by targeting dry eye, improving tear film quality and decreasing ocular 20 Based on package insert 71876US14B Revised February 2010 surface irritation. ©2010 Allergan, Inc. Interestingly, Dr. Sheppard suggested that punc- Irvine, CA 92612, U.S.A. ® marks owned by Allergan, Inc. APC66CG11 tal occlusion––in conjunction with topical cyclospo- U.S. Patent 5,474,979 Made in the U.S.A.

60 REVIEW OF OPTOMETRY JANUARY 15, 2012

056_ro0112_f5_final.indd 60 1/5/12 1:42 PM rine––might reduce the frequency their ocular surface with artificial individuals. and duration of HSV recurrences tears, anti-inflammatories, nutri- Additionally, punctal occlu- and consequently minimize the ceuticals and/or punctal occlusion sion promotes wound healing and risk of serious ocular damage.20 before surgery, we can ensure better visual acuity after certain This may be a more agreeable a more favorable postoperative refractive procedures, such as option for patients who are wary outcome. Although punctal plugs LASEK. One study documented a about the permanence of cauter- cannot address all preoperative lower fluorescein staining score, ization. ocular surface concerns, occlu- a better uncorrected distance acu- • Refractive surgery. Optom- sion can help address tear volume ity, and a lower incidence of haze etrists play an integral role in the levels. in LASEK patients who received peri-operative care of refractive The incidence of dry eye after punctal plugs.22 surgery patients. Whether patients cataract surgery may be as high as are undergoing cataract surgery 87%.21 Both cataract surgery and Future Developments in with premium IOL implantation, laser vision correction transects Punctal Occlusion laser vision correction, or any the corneal nerves, causing dein- Currently, punctal plug delivery other ocular surgical procedure nervation that typically persists systems are being developed that (pterygium removal, glaucoma for one to three months following can distribute a sustained time- surgery, etc.), an ocular surface the procedure. release dose of glaucoma medica- evaluation is an essential aspect of This may produce a neuro- tion over a three-month period.23 the preoperative evaluation. trophic cornea, as well as yield The Punctal Plug Delivery System Prior to any ocular surgery, our clinical signs of epitheliopathy (QLT Inc.) is designed to provide role is to prepare the ocular sur- with little to no symptoms other a consistent dose of prostaglandin face in order to maximize patient than decreased visual acuity. analog in glaucoma patients. outcomes as well as minimize Other consequences of postopera- The initial results of the tech- the risk for surgical complica- tive dry eye include ocular dis- nology’s phase II clinical study tions. Pre-existing ocular surface comfort, decreased or fluctuating revealed that 60% of subjects disease, such as DES, can have a vision and refractive regression. experienced an IOP reduction of tremendously negative impact on Whenever patients present with 5mm Hg or greater at four-week the accuracy of the preoperative decreased vision following refrac- follow-up.23 Even more impres- measurements and overall patient tive surgery, aggressive ocular sive, the Punctal Plug Delivery comfort throughout the proce- surface treatment may determine System’s four-week retention rate dure. whether patients need additional was 95%.23 Clearly, such a device If we can identify these dry eye surgery. Punctal occlusion may be could markedly reduce compli- patients and aggressively treat a viable alternative for these ance issues for glaucoma patients.

Proper fit of the Odyssey Parasol Plug (left). Pyogenic granuloma formation following punctal plug insertion (right).

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Optometry plays an integral 3. Hardten D. Managing dry eye. Ophthalmol Management. Improving the therapeutic index of topically applied ocular 2008 Aug. drugs. Arch Ophthalmol. 1984 Apr;102(4):551-3. role in the treatment and manage- 4. Perry HD. Dry Eye Disease: Pathophysiology, Classifica- 15. Opitz DL, Tung S, Jang US, Park JJ. Silicone punctal ment of many ocular surface con- tion, and Diagnosis. Am J Manag Care. 2008 Apr;14(3 plugs as an adjunctive therapy for open-angle glau- Suppl):S79-87. coma and ocular hypertension. Clin Exp Optom. 2011 ditions. Today, we have several 5. Wester S. Punctum plugs: highly engineered treat- Sep;94(5):438-42. treatment options to address not ment for dry eye. Available at: www.ophthalmologyweb. 16. Bartlett JD, Boan K, Corliss D, Gaddie IB. Efficacy of com/Tech-Spotlights/26480-Punctum-Plugs-Highly- silicone punctal plugs as adjuncts to topical pharmacother- only DES, but also many other Engineered-Treatment-for-Dry-Eye (accessed December apy of glaucoma-a pilot study. Punctal Plugs in Glaucoma conditions that could be improved 20, 2011). Study Group. J Am Optom Assoc. 1996 Nov;67(11):664-8. 6. Moss SE, Klein R, Klein BE. Prevalence of and risk 17. Judge A, Assil K. E-Medicine. Herpes simplex. Avail- by increased tear volume and factors for dry eye syndrome. Arch Ophthalmol. 2000 able at: www.emedicine.com/oph/topic256.htm (accessed medication efficacy. Sep;118(9):1264-8. November 13, 2011). 7. Moss SE, Klein R, Klein BE. Incidence of dry eye in an 18. Doymaz MZ, Rouse BT. Herpetic stromal keratitis: an Although punctal plugs chiefly older population. Arch Ophthalmol. 2004 Mar;122(3):369- immunopathologic disease mediated by CD4+ T lympho- have been used to treat dry eye 73. cytes. Invest Ophthalmol Vis Sci. 1992 Jun;33(7):2165-73. 8. Suzuki M, Massingale M, Ye F, et al. Tear osmolarity as 19. Keijser S, van Best JA, Van der Lelij A, Jager MJ. conditions, practitioners now can a biomarker for dry eye disease severity. Invest Ophthalmol Reflex and steady state tears in patients with latent stro- consider other potential therapeu- Vis Sci. 2010 Sep;51(9):4557-61. mal herpetic keratitis. Invest Ophthalmol Vis Sci. 2002 9. Behrens A, Doyle JJ, Stern L, et al. Dysfunctional tear Jan;43(1):87-91. tic benefits. ■ syndrome: a delphi approach to treatment recommenda- 20. Sheppard JD, Wertheimer ML, Scoper SV. Modalities Dr. Whitley is the director of tions. Cornea. 2006 Sep;25(8):900-7. to decrease stromal herpes simplex keratitis reactivation 10. Data on file, Allergan. rates. Arch Ophthalmol. 2009 Jul;127(7):852-6. optometric services at Virginia 11. Roberts CW, Carniglia PE, Brazzo BG. Comparison of 21. Kojima T, Watabe T, Nakamura T, et al. Effects of Eye Consultants in Norfolk, Va. topical cyclosporine, punctal occlusion, and a combination preoperative punctal plug treatment on visual function and for the treatment of dry eye. Cornea. 2007 Aug;26(7):805-9. wound healing in laser epithelial keratomileusis. J Refract 12. Claxton AJ, Cramer J, Pierce C. A systematic review of Surg. 2011 Dec;27(12):894-8. 1. Baxter SA, Laibson PR. Punctal plugs in the management the associations between dose regimens and medication 22. Albietz JM, Lenton LM, McLennan SG. Chronic dry eye of dry eyes. Ocular Surface. 2004 Oct;2(4):255-65. compliance. Clin Ther. 2001 Aug;23(8):1296-310. and regression after laser in situ keratomileusis for myopia. 2. McDonald M, D’Aversa G, Perry HD, et al. Hydroxy- 13. Giovagnoli D, Graham SJ. Inferior punctal occlusion J Cataract Refract Surg. 2004 Mar;30(3):675-84. propyl cellulose ophthalmic inserts (lacrisert) reduce the with removable silicone punctal plugs in the treatment 23. QLT Announces Encouraging Phase II Data from CORE signs and symptoms of dry eye syndrome and improve of dry-eye related contact lens discomfort. J Am Optom Study Drug Delivery System. Available at: www.qltinc. patient quality of life. Trans Am Ophthalmol Soc. 2009 Assoc. 1992 Jul;63(7):481-5. com/newsCenter/2011/110829.htm (accessed December Dec;107:214-21. 14. Zimmerman TJ, Kooner KS, Kandarakis AS, Ziegler SP. 20, 2011). Get Hired Now!

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13th Annual Dry Eye Report The Impact of Autoimmune Disease Inflammatory autoimmune conditions can cause significant ocular surface disease and systemic complications. Here’s how to manage patients who present with Sjögren’s syndrome, rheumatoid arthritis and multiple sclerosis. By Andrew Morgenstern, O.D.

IM KARDASHIAN! Now, attack, diabetes, high blood pres- tantly chronic inflammation, is a I have your attention. Evi- sure, obesity and depression. fundamental issue for nearly all dently, you can’t even read We know that inflammation is a bodily systems as well as individu- Kan eye care article today primary contributor to many com- al anatomical components. without seeing her name. So, what mon ocular conditions, including And, for optometrists, it is on earth does Kim Kardashian ocular surface disease, age-related essential to know that a host of have to do with optometry? Well, macular degeneration and uve- inflammatory autoimmune condi- the A-list socialite released a state- itis. This explains why topical tions can have adverse effects on ment in July 2011 indicating that corticosteroids and other potent one or many components of the she has the autoimmune disease anti-inflammatory drugs are now eye. psoriasis. mainstay therapeutic options for Here, we’ll explore how three of She, like many others, has a such conditions that we once the most common inflammatory 30% chance of developing psori- treated very passively. autoimmune processes––Sjögren’s atic arthritis and other advanced Clearly, eye care is not the only syndrome, rheumatoid arthritis inflammatory conditions that branch of medicine to confront (RA) and multiple sclerosis (MS)–– could contribute to significant dry problems with inflammation. impact both ocular and systemic eye as well as heart disease, heart Inflammation, and more impor- health. Additionally, we’ll discuss

Release Date: January 2012 Faculty/Editorial Board: Andrew Morgenstern, O.D. Expiration Date: January 1, 2015 Credit Statement: COPE approval for 2 hours of CE credit is pending Goal Statement: Inflammation is a primary contributor to many for this course. Check with your local state licensing board to see if common ocular conditions, including ocular surface disease, age- this counts toward your CE requirement for relicensure. related macular degeneration and uveitis. Here, we’ll explore how Joint-Sponsorship Statement: This continuing education course is three of the most common inflammatory autoimmune processes–– joint-sponsored by the Pennsylvania College of Optometry. Sjögren’s syndrome, rheumatoid arthritis (RA) and multiple sclerosis Disclosure Statement: Dr. Morgenstern has no relationships to (MS)––impact both ocular and systemic health. disclose.

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064_ro0112_F6_osc_final.indd 64 1/5/12 2:01 PM a variety of diagnostic and management strategies for each condition. Sjögren’s Syndrome In August 2011, tennis superstar Venus Williams pulled out of the U.S. Open, citing fatigue and other issues associated with Sjögren’s syndrome. She said, “I have been recently diagnosed with Sjögren’s syndrome, an autoimmune disease which is an ongoing medical condition that affects my energy level and causes fatigue and joint pain.”1 Ms. Williams is not alone. More than one million Americans have the disease––90% of whom are women.2 The sicca complex of Sjögren’s syndrome presents with a hallmark triad of xerostomia (dry mouth), xerophthalmia (dry eye) and arthritis. These hallmark clinical signs of Sjögren’s syndrome are caused by an overproduction of B-lymphocytes (antibodies).3 The onslaught of B-lymphocytes clogs and destroys exocrine glands. In fact, some Sjögren’s patients even have trouble perspiring because of obstructed sweat glands. The most common findings associated with Sjögren’s syndrome include:4 • Extremely dry eyes. This includes a gritty or sandy sensation; burning; and redness. • Excessive dry mouth and throat. Patients often experience difficulty chewing and swallowing; Image courtesy of the Sjögren’s Syndrome Foundation (www.sjogrens.org). a decreased sense of taste; difficulty speaking; an increased incidence in both muscles and joints. of the lungs, kidneys, liver or pan- of cavities and other periodontal Sjögren’s patients also may creas; and cancer of the lymphatic disease; and a dry cough or linger- experience other less common tissue (occurs in up to 5.8% of ing hoarseness. Additionally, indi- symptoms, such as irritation of patients with the disease).5 viduals with Sjögren’s syndrome the nerves in the arms, hands, There are two forms of Sjögren’s may exhibit enlarged or infected legs or feet (neuropathy); thyroid syndrome––primary and second- parotid glands, which are located gland abnormalities; skin rashes; ary. Primary Sjögren’s syndrome at the angle of the jawbone. memory loss or confusion; feeling is not associated with any other • Persistent fatigue. This of numbness or tingling; gastro- illness. The chief clinical finding includes lingering aches and pains intestinal problems; inflammation of primary Sjögren’s syndrome

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Lip Biopsy in Detail Management of Sjögren’s Sjögren’s syndrome is characterized by chronic inflammation of the glands that produce saliva Syndrome and tears. An effective way to confirm a diagnosis of Sjögren’s syndrome is to biopsy these Your patients likely will benefit glands to determine whether inflammation is present.24 If inflammation is noted, the clinician from a frank discussion about the may also determine the type and severity of the underlying condition. nature of treating a chronic condi- The minor salivary glands located just under the inner surface of the lip are the most tion. One of my favorite lines to accessible of these glands. (These are the “cobblestones” that you can feel when you rub your tell a patient at the first visit: “We tongue along the inner surface of your lower lip.) In performing a lip biopsy, the surgeon typi- are going to become long-term cally makes a shallow, half-inch incision on either side of the inner lip, after numbing the area friends. I don’t have a magic pill with a local anesthetic. Approximately five to seven glands are removed with sterile tweezers. to cure you today, and if I can Then, the incision is closed with resorbable sutures. The patient may report soreness of the lip resolve 85% of your problems, we for a few days afterward. Approximately 1% to 2% of individuals will notice localized numb- are all going to be happy in the ness for two to three months following surgery.25 end.” Be sure to set your patient The lip biopsy has to be evaluated for the presence of a lesion by a pathologist with special expectations accordingly. training. The offending lesion associated with Sjögren’s syndrome is termed “focal lymphocyt- Long-term Restasis (cyclo- ic sialadenitis,” and is characterized by one or more tightly aggregated lymphocytes that are sporine, Allergan) use likely will located adjacent to normal gland tissue, surrounding a duct in a 4mm2 area of gland tissue. become a part of the treatment The lip biopsy may reveal the presence of other types of glandular inflammation and/or point regimen. Also, consider a short- to alternative diagnoses, such as sarcoidosis or lymphoma. term course of corticosteroids to It is worth noting that optometrists cannot perform lip biopsies. Instead, it is best to refer treat significant ocular surface the patient to an oral surgeon or an otolaryngologist. disease and tear dysfunction. According to corneal specialist Stephen Pflugfelder, M.D., is ocular dryness. This may be er autoimmune disease such as “Patients treated with steroid confirmed with several diagnostic RA, systemic lupus erythematosus eye drops often have a rapid examinations, including phenol (SLE) or vasculitis. The condi- improvement in ocular irritation red thread testing, lissamine green tion generally is diagnosed when symptoms and severity of corneal- staining, Schirmer testing, tear film someone with an established, epithelial disease. Steroids can break-up time, corneal topography underlying autoimmune disease jumpstart therapy when they are or photokeratoscopy, and tear film experiences extreme dryness of combined with other therapies, osmolarity testing. the eyes and mouth. Fortunately such as topical cyclosporine or Additional laboratory tests may for the patient, a diagnosis rarely oral omega-3 essential fatty acid also indicate that dry eyes and requires a lip biopsy. supplements that require weeks to mouth are caused by associated When attempting to make a show improvement.”6 Dr. Pflug- autoimmune mechanisms. Some positive diagnosis of Sjögren’s felder notes that he typically uses examples include testing for the syndrome in our office, we typi- corticosteroids (e.g., Lotemax presence of autoantibodies in the cally refer the patient to a rheu- [loteprednol, Bausch + Lomb]) for blood, known as anti-Ro/SSA or matologist for several reasons. approximately four weeks, while anti-La/SSB. First, rheumatologists are familiar watching for steroid-related com- In challenging cases, inner and comfortable with ordering plications.6 lip biopsy may be performed to the required blood testing for According to ocular surface confirm the diagnosis of primary Sjögren’s screening. Also, if the research pioneer, Scheffer Tseng, Sjögren’s syndrome (see “Lip rheumatologist confirms a posi- M.D., one of the unique identify- Biopsy in Detail,” above). The tive diagnosis, the patient likely ing features of Sjögren’s syndrome biopsy may reveal that inflam- will exhibit additional associated is decreased reflex tearing.7 As a mation is damaging the salivary symptoms that require manage- result, if you notice a decrease in glands. Some patients, however, ment. Finally, a strong relation- reflex tearing, punctal occlusion have described the lip biopsy as ship with a rheumatologist can be in combination with supplemental a painful procedure that yields a extremely beneficial, because they artificial tears may be warranted. slow recovery time. can refer RA, SLE and sarcoidosis In addition, you may consider Secondary Sjögren’s syndrome patients to you for dry eye consul- prescribing one or more medica- develops in the presence of anoth- tations. tions to treat Sjögren’s-associated

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064_ro0112_F6_osc_final.indd 66 1/5/12 2:01 PM dry mouth. One common thera- Management of RA Oral and Biologic DMARDs peutic option is Evoxac (cevime- Management includes systemic Commonly used oral DMARDs: line, Daiichi Sankyo). Exovac is a suppression of the autoimmune • Hydroxychloroquine cholinergic agonist that binds to reaction. Unfortunately, however, • Chloroquine muscarinic receptors. In sufficient the indicated oral medications • Leflunomide dosages, muscarinic agonists can often yield several side effects, • Methotrexate increase saliva and sweat secretion including dry eye and decreased • Sulfasalazine from exocrine glands, as well as aqueous production. These side enhance smooth muscle tone in the effects, in combination with the Less commonly used oral DMARDs: gastrointestinal and urinary tracts. underlying ocular inflammatory • Azathioprine Typically, Evoxac is taken three effects of RA, often cause moder- • Cyclophosphamide times a day by mouth. It is contra- ate to severe ocular surface dis- • Cyclosporine indicated in patients with uncon- ease. Common ocular treatment • Gold salts trolled asthma, those with a known includes artificial tears, corticoste- • Minocycline hypersensitivity to cevimeline, roids, cyclosporine and nutritional • Penicillamine and in instances when miosis is supplements. undesirable, (e.g., in patients with Disease-modifying antirheumat- Biologic DMARDs: acute iritis or narrow-angle closure ic drugs (DMARDs) frequently are • Abatacept glaucoma). Common side effects of prescribed to RA patients to slow • Adalimumab Evoxac use include excess sweat- or sometimes prevent joint inflam- • Anakinra ing, nausea and diarrhea.8 mation and destruction.12 Initiat- • Etanercept Ultimately, however, I have lim- ing early treatment with DMARDs • Infliximab ited experience with the treatment can reduce the severity of the • Rituximab of dry mouth and would prefer to disease. These medicines are most • Tocilizumab comanage such cases with a rheu- effective when used long-term. matologist. DMARDs can be divided into two general categories: oral and • Low white blood cells counts. Rheumatoid Arthritis biologic (see, “Oral and Biologic • Blood or protein in the urine. RA is a systemic collagen vas- DMARDs,” right). Oral DMARDs • Liver and/or lung damage. cular inflammatory disease that interfere with the formation or • Bone marrow toxicity. has a significant impact on ocular function of immune cells that • Skin rashes, nausea and hair surface health. In addition to dry cause joint inflammation. Biologic loss. eye, inflammation secondary to DMARDs are administrated via In addition to these systemic RA can cause episcleritis, uveitis intramuscular injection, and act side effects, patients on DMARD and scleritis. in several different ways to affect therapy may experience a vari- Nearly 1.3 million Americans immune cell function. ety of ocular side effects. These have RA. The majority of these Keep in mind that DMARDs include:14 individuals are 65 years of age or are very potent drugs. Any patient • “Bull’s eye” maculopathy, older.9 And, according to a 2010 who is taking either oral or biolog- which can cause a reduction in report from the Centers for Dis- ic DMARDs for RA must be fol- best-corrected visual acuity and ease Control and Prevention, by lowed closely by a rheumatologist. impaired central vision. the year 2030, 65 million Ameri- Additionally, the patient should • Retinal pigment epithelium cans age 18 and older will have undergo frequent blood tests and damage. diagnosable arthritis.9 urinalysis to monitor for poten- • Loss of color sensitivity and Research has shown that lym- tially negative effects on the bone central vision loss. phocyte infiltration of the lacrimal marrow, kidneys and liver. Before initiating DMARD thera- glands is the primary cause of As is the case with any drug py, patients should undergo a base- associated dry eye.10,11 It is inter- class, patients who use DMARDs line retinal evaluation, including an esting to note that about 90% of may experience several side effects. optical coherence tomography scan. the RA patients who present to Some of the most common system- Then, after beginning therapy, re- my office with ocular dryness are ic side effects caused by either oral evaluate the patient’s retinae every women over the age of 60.8 or biologic DMARDs include:13 six to 12 months for changes.

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American-European Consensus Criteria for Sjögren’s Syndrome26 comfort, many of my patients In order to make a diagnosis of Sjögren’s syndrome, the following criteria must be met: seemingly have avoided the onset 1. Ocular Symptoms (at least one) of recurrent uveitis. • Symptoms of dry eye that persist for at least three months. • A foreign body sensation in the eyes. Multiple Sclerosis • Use of artificial tears three or more times per day. The relationship between MS 2. Oral Symptoms (at least one) and ocular surface disease is very • Symptoms of dry mouth that persist for at least three months. interesting. In MS patients, associ- • Recurrent or persistently swollen salivary glands. ated ocular surface disease may be • Need for liquids to swallow dry foods. triggered by the underlying condi- 3. Ocular Signs (at least one) tion itself or may occur secondary • Abnormal Schirmer’s test (without anesthesia; ≤5mm/5 min). to neural interruption.17 • Positive vital dye staining of the eye surface. MS causes the myelin sheath 4. Histopathology around some of the most impor- • Lip biopsy that shows focal lymphocytic sialadenitis (focus score ≥1 per 4mm2) tant neurologic components to 5. Oral Signs (at least one) become inflamed. Myelin is a criti- • Unstimulated whole salivary flow (≤1.5mL in 15 minutes). cal component in the conduction • Abnormal parotid sialography. of electrical impulses for proper • Abnormal salivary scintigraphy. nerve function. When inhibited, 6. Autoantibodies (at least one) sensory impulses are not conduct- • Anti-Ro/SSA or anti-La/SSB, or both. ed properly and can result in poor motor control. Also, the motor For a primary Sjögren’s syndrome diagnosis: response itself can be interrupted • Any four of the six criteria; must include criteria from either category 4 or category 6. by poor signaling/conduction to • Any three of the four objective criteria (categories 3, 4, 5, 6). the end target. For a secondary Sjögren’s syndrome diagnosis: For eye care providers, it is • In patients with another well-defined major connective tissue disease, the presence of important to know that MS one ocular or oral symptom, in addition to two of the three objective criteria for categories 3, 4 patients can develop severe ocu- or 5, is indicative of secondary Sjögren’s syndrome. lar surface disease from insufficient tear production (which Exclusion Criteria is a motor response to a dry eye • Past head and neck radiation treatment. stimulus), failure to recognize • Hepatitis C infection. dryness (corneal sensory issues), • Acquired immunodeficiency syndrome (AIDS). lagophthalmos (the lid failing to • Pre-existing lymphoma. close properly due to muscle limi- • Sarcoidosis. tations) and an increased risk for • Graft vs. host disease. uveitis.18-20 • Current use of anticholinergic drugs. Management of MS If your MS patients experience Other medications, such as course of Restatis. Because these insufficient tear production, punc- NSAIDs and corticosteroids, often patients have chronic inflamma- tal occlusion may be a suitable are used to treat the symptoms of tory disease, the long-term use of treatment option. In most cases, RA––not the primary autoimmune steroids is not advised because of punctal occlusion should be com- condition.15 Therefore, in cases of the potential for IOP increase and bined with artificial tears, omega- dry eye secondary to RA, it is very cataract development.16 3 fatty acid supplementation, useful to include a corticosteroid From clinical experience, there artificial tear gel at bedtime, and in the treatment regimen to maxi- is great benefit to long-term sometimes topical cyclosporine. mize patient relief. Restasis use in most patients who For MS patients with lagoph- In non-uveitic dry eye secondary experience dry eye secondary to an thalmos, you may wish to recom- to RA, consider Lotemax q.i.d. for autoimmune condition. In addi- mend the addition of a humidifier one month as well as a long-term tion to improved ocular surface to the room that they sleep in.

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064_ro0112_F6_osc_final.indd 68 1/5/12 2:01 PM Also, be sure to consider the use be monitored and managed for Sep;16(5):287-97. 5. Tonami H, Matoba M, Kuginuki Y, et al. Clinical and imaging of dry eye goggles, Lacriserts life. Unfortunately, because of the findings of lymphoma in patients with Sjögren syndrome. J Com- (hydroxypropyl cellulose ophthal- progressive nature of MS, a par- put Assist Tomogr. 2003 Jul-Aug;27(4):517-24. 6. Asbell PA, Tu E, Jeng BH, et al. Dry eye and the ocular surface. mic insert, Aton Pharma) and lid ticular treatment may be effective OSN SuperSite. Available at: www.osnsupersite.com/edulab/ scrubs. one day, but not two years later. (accessed December 30, 2011). 7. Pflugfelder SC, Tseng SC, Sanabria O, et al. Evaluation of sub- Remember, many MS patients jective assessments and objective diagnostic tests for diagnosing may have experienced a previous Ocular surface disease second- tear-film disorders known to cause ocular irritation. Cornea. 1998 Jan;17(1):38-56. episode of optic neuritis. If so, ary to inflammatory autoimmune 8. Petrone D, Condemi JJ, Fife R, et al. A double-blind, ran- their best-corrected visual acuity disease is very common. When a domized, placebo-controlled study of cevimeline in Sjögren’s syndrome patients with xerostomia and keratoconjunctivitis sicca. may be unsatisfactory. So, creating patient presents to your practice Arthritis Rheum. 2002 Mar;46(3):748-54. a healthy ocular surface is para- with a prior diagnosis of Sjögren’s 9. Cheng YJ, Hootman JM, Murphy LB, et al. Centers for Disease Control and Prevention: Morbidity and Mortality Weekly Report. mount for achieving the highest syndrome, RA or MS, you should Prevalence of doctor-diagnosed arthritis and arthritis-attributable possible vision quality. consider the likelihood of con- activity limitation: United States, 2007-2009. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm5939a1.htm?s_ Additionally, some MS patients comitant ocular surface disease cid=mm5939a1_w (accessed December 30, 2011). have mobility issues that physi- until proven otherwise. In fact, 10. Karonitsch T, Dalwigk K, Steiner CW, et al. Interferon (IFN) signals and monocytic sensitization of the IFN signaling pathway cally restrict their ability to use the probability that a patient with in peripheral blood of rheumatoid arthritis patients. Arthritis drops, gels and lid scrubs effective- autoimmune disease will present Rheum. 2011 Sep 27. doi: 10.1002/art.33347. [Epub ahead of print] ly. So, this potential complication with at least one or more signs or 11. Patel SJ, Lundy DC. Ocular manifestations of autoimmune must be actively addressed and symptoms of ocular surface dis- disease. Am Fam Physician. 2002 Sep 15;66(6):991-8. 12. Agarwal SK. Biologic agents in rheumatoid arthritis: an considered when prescribing an ease is extremely high. update for managed care professionals. J Manag Care Pharm. appropriate treatment regimen. However, by knowing how to 2011 Nov-Dec;17(9 Suppl B):S14-8. 13. Felson DT, Anderson JJ, Meenan RF. The compara- Generally speaking, excessive effectively treat the associated ocu- tive efficacy and toxicity of second-line drugs in rheumatoid mobility restrictions secondary to lar manifestations of various auto- arthritis. Results of two metaanalyses. Arthritis Rheum. 1990 Oct;33(10):1449-61. MS also may result in decreased immune processes, you can ensure 14. Aylward JM. Hydroxychloroquine and chloroquine: assess- ocular surface hygiene. Physically that your patients experience the ing the risk of retinal toxicity. J Am Optom Assoc. 1993 Nov;64(11):787-97. restricted patients have a higher best vision and ocular health pos- 15. Kawai VK, Grijalva CG, Arbogast PG, et al. Changes in incidence of anterior and posterior sible. ■ cotherapies after initiation of disease-modifying antirheumatic drug therapy in patients with rheumatoid arthritis. Arthritis Care 21,22 blepharitis. Dr. Morgenstern is an optom- Res (Hoboken). 2011 Oct;63(10):1415-24. Treatment of blepharitis, as etrist with Washington Eye Phy- 16. Rajpal RK, Digby D, D’Aversa G, et al. Intraocular pressure elevations with loteprednol etabonate: a retrospective chart outlined by the International sicians and Surgeons in Chevy review. J Ocul Pharmacol Ther. 2011 Jun;27(3):305-8. Workshop on Meibomian Gland Chase, Md. He is also the vice 17. Lewandowska-Furmanik M, Pozarowska D, Matysik-Wo niak A, Katski W. Uveitis in patients with multiple sclerosis. Klin Dysfunction, is essential to opti- president of the Maryland Opto- Oczna. 2011;113(1-3):25-7. mal vision and overall ocular metric Association, Secretary 18. Prasad S, Galetta SL. Eye movement abnormalities in multiple sclerosis. Neurol Clin. 2010 Aug;28(3):641-55. 22 health. of the Optometric Council on 19. Jung SM, Lee BG, Joh GY, et al. Primary Sjögren’s syndrome Systemic treatment of MS Refractive Technology (OCRT) manifested as multiple sclerosis and cutaneous erythematous lesions: a case report. J Korean Med Sci. 2000 Feb;15(1):115-8. includes the use of Betaseron and a founding member of the 20. Lewandowska-Furmanik M, Pozarowska D, Matysik-Wo niak (interferon beta-1b, Bayer Health- American Optometric Association, A, Katski W. Uveitis in patients with multiple sclerosis. Klin Oczna. 2011;113(1-3):25-7. Care Pharmaceuticals) and Avon- New Technology Workgroup. Dr. 21. Prokesova V, Kriz S, Berg L, Halvorsen I. Ophthalmologic ex (interferon beta-1a, Biogen Morgenstern has no direct finan- examination of the mentally retarded at a central institution. Tidsskr Nor Laegeforen. 1990 May 20;110(13):1659-62. Idec.) to either reduce or eliminate cial interest in any of the products 22. Geerling G, Tauber J, Baudouin C, et al. The international inflammatory flareups.23 mentioned. workshop on meibomian gland dysfunction: report of the sub- committee on management and treatment of meibomian gland The fundamental treatment goal dysfunction. Invest Ophthalmol Vis Sci. 2011 Mar 30;52(4):2050- for MS is not to eradicate the dis- 1. Clarke L. Venus Williams withdraws from U.S. Open, cites 64. illness. Washington Post. August 31, 2011. Available at: www. 23. Tur C, Montalban X, Tintoré M, et al. Interferon beta-1b for ease, but curtail its progression. washingtonpost.com/sports/tennis/venus-williams-withdraws- the treatment of primary progressive multiple sclerosis: five-year By minimizing the frequency and from-us-open-cites-illness/2011/08/31/gIQAm1DbsJ_story.html clinical trial follow-up. Arch Neurol. 2011 Nov;68(11):1421-7. (accessed December 30, 2011). 24. Bamba R, Sweiss NJ, Langerman AJ, et al. The minor salivary severity of associated flareups, the 2. Helmick CG, Felson DT, Lawrence RC, et al. Estimates of the gland biopsy as a diagnostic tool for Sjogren syndrome. Laryngo- patient has a reduced likelihood prevalence of arthritis and other rheumatic conditions in the scope. 2009 Oct;119(10):1922-6. United States. Part I. Arthritis Rheum. 2008 Jan;58(1):15-25. 25. Johns Hopkins Medicine: Sjogren’s Syndrome Center. Labial of progressive mobility changes, 3. Varin MM, Guerrier T, Devauchelle-Pensec V, et al. In Gland (Lip) Biopsy. Available at: www.hopkinssjogrens.org/ vision loss and associated ocular Sjögren’s syndrome, B lymphocytes induce epithelial cells of disease-information/diagnosis-sjogrens-syndrome/labial-gland- salivary glands into apoptosis through protein kinase C delta lip-biopsy/ (accessed December 30, 2011). surface disease. activation. Autoimmun Rev. 2011 Oct 7. [Epub ahead of print] 26. Vitali C, Bombardieri S, Jonsson R, et al. Classification Remember, individuals with MS 4. Birnbaum J. Peripheral nervous system manifestations of criteria for Sjögren’s syndrome: a revised version of the European Sjögren syndrome: clinical patterns, diagnostic paradigms, criteria proposed by the American-European Consensus Group. have a chronic condition that must etiopathogenesis, and therapeutic strategies. Neurologist. 2010 Ann Rheum Dis. 2002 Jun;61(6):554-8.

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OSC QUIZ

ou can obtain transcript-qual- 4. Which symptom is NOT part of the hall- d. Decreased reflex tearing. ity continuing education credit mark triad of Sjögren’s syndrome? Ythrough the Optometric Study a. Arthritis. 10. What drug is often used to treat dry Center. Com plete the test form (page b. Dry eyes. mouth in patients with Sjögren’s syn- 71), and return it with the $35 fee to: c. Dry skin. drome? Optometric CE, P.O. Box 488, Canal Street d. Dry mouth. a. Hydroxychloroquine. Station, New York, NY 10013. To be eli- b. Methotrexate. gible, please return the card within one 5. The overproduction of B-lymphocytes is c. Azathioprine. year of publication. thought to destroy which glands? d. Cevimeline. You can also access the test form and a. Meibomian. submit your answers and payment via b. Krause’s. 11. By the year 2030, approximately how credit card at Review of Optometry Online, c. Wolfring’s. many Americans over age 18 will have a www.revoptom.com. d. Exocrine. diagnosable form of arthritis? You must achieve a score of 70 or a. 1.3 million. higher to receive credit. Allow eight to 10 6. All are forms of dry eye testing and b. 6.5 million. weeks for processing. For each Optomet- evaluation EXCEPT: c. 13 million. ric Study Center course you pass, you a. Tear film osmolarity. d. 65 million. earn 2 hours of transcript-quality credit from Pennsyl vania College of Optometry b. Ocular Response Analyzer (ORA). and double credit toward the AOA Optom- c. Corneal topography. 12. Common ocular treatments for inflam- et ric Recog nition Award—Cate gory 1. d. Tear film break-up time. mation and dry eye associated with rheu- Please check with your state licens- matoid arthritis include all of the following ing board to see if this approval counts 7. A biopsy of what anatomical component EXCEPT: toward your CE requirement for relicen- is an effective way to confirm a diagnosis a. Artificial tears. sure. of Sjögren’s syndrome? b. Biologic DMARDs. a. Conjunctiva. c. Corticosteroids. 1. Which condition is NOT associated with b. Meibomian glands. d. Cyclosporine. advanced inflammatory conditions? c. Inner lip. a. High blood pressure. d. Lacrimal glands. 13. What are the two primary categories b. Obesity. of DMARDs? c. Dry eyes 8. According to Stephen Pflugfelder, M.D., a. Anti-malarial and biological. d. Epstein-Barr virus. which drug should be used for four weeks b. Biological and anti-arthritic. to treat dry eye in patients with Sjögren’s c. Anti-arthritic and oral. 2. What major medication class is often syndrome? d. Oral and biological. used to treat ocular inflammation? a. Lotemax (loteprednol, Bausch + Lomb). a. Topical fluoroquinolones. b. Zirgan (ganciclovir, Bausch + Lomb). 14. How are biologic DMARDs adminis- b. Topical corticosteroids. c. Nevanac (nepafenac, Alcon). tered? c. Anti-malarials. d. Lastacaft (alcaftadine, Allergan). a. Intramuscular injection. d. Disease modifying antirheumatic drugs b. Intranasal spray. (DMARDs). 9. According to Scheffer Tseng, M.D., what c. Topical eye drop. is a unique identifying feature of Sjögren’s d. Orally. 3. What percentage of Americans with syndrome? Sjögren’s syndrome are women? a. Lagophthalmos that is greater in the 15. What clinical finding is NOT a common a. 60%. dominant eye. ocular side effect of DMARD use? b. 70%. b. Posterior blepharitis without anterior a. Bull’s eye maculopathy. c. 80%. blepharitis. b. Cataract formation. d. 90%. c. Increase in ptosis of the unaffected eye. c. Retinal pigment epithelium damage.

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064_ro0112_F6_osc_final.indd 70 1/5/12 2:02 PM Examination Answer Sheet Valid for credit through January 1, 2015 This exam can be taken online at www.revoptom.com. Upon passing the exam, you can view your results immediately. You can also view your test history at any time from the website.

The Impact of Autoimmune Disease OSC QUIZ d. Loss of color sensitivity. Directions: Select one answer for each question in the exam and completely darken the appropriate circle. A minimum score of 70% is required to earn credit.

16. All are clinical explanations as to why Mail to: Jobson - Optometric CE, PO Box 488, Canal Street Station, New York, NY 10013 a multiple sclerosis (MS) patient may Payment: Remit $35 with this exam. Make check payable to Jobson Medical Information LLC. develop dry eye EXCEPT: COPE approval for 2 hours of CE credit is pending for this course. This course is joint-sponsored by the Pennsylvania College of Optometry a. Insufficient tear production. There is an eight-to-ten week processing time for this exam. b. Corneal sensory issues. A B C D c. Lagophthalmos. 1. 1 = Excellent 2 = Very Good 3 = Good 4 = Fair 5 = Poor 2. A B C D Rate the effectiveness of how well the activity: d. Epiphora. 3. A B C D 4. A B C D 21. Met the goal statement: 1 2 3 4 5 17. If insufficient tear production is an 5. A B C D 22. Related to your practice needs: 1 2 3 4 5 6. A B C D 23. Will help you improve patient care: 1 2 3 4 5 underlying cause of dry eye in an MS 7. A B C D 24. Avoided commercial bias/influence: 1 2 3 4 5 patient, what is a potential first-line treat- 8. A B C D 25. How would you rate the overall ment? 9. A B C D quality of the material presented? 1 2 3 4 5 10. A B C D 26. Your knowledge of the subject was increased: a. Corticosteroids. 11. A B C D Greatly Somewhat Little b. Punctal occlusion. 12. A B C D 27. The difficulty of the course was: c. Punctal cautery. 13. A B C D Complex Appropriate Basic A B C D d. Autologous serum. 14. How long did it take to complete this course? 15. A B C D 16. A B C D Comments on this course: 18. Physically restricted patients often 17. A B C D have a higher incidence of what ocular 18. A B C D 19. A B C D Suggested topics for future CE articles: condition? 20. A B C D a. Anterior and posterior blepharitis. b. Corneal infiltrates. Please retain a copy for your records. Please print clearly. c. Glaucoma. You must choose and complete one of the following three identifier types: d. Cataracts. 1 SS # - -

Last 4 digits of your SS # and date of birth State Code and License #: (Example: NY12345678) 19. According to the American-European 2 - 3 Consensus Criteria for Sjögren’s

Syndrome, which condition is NOT includ- First Name

ed in the exclusion criteria for a diagnosis Last Name of secondary Sjögren’s syndrome? E-Mail a. AIDS. The following is your: Home Address Business Address b. Pre-existing lymphoma. c. Systemic lupus erythematosus. Business Name d. Sarcoidosis. Address City State

20. Which agent is NOT an oral DMARD? ZIP

a. Methotrexate. Telephone # - -

b. Azathioprine. Fax # - - c. Rituximab. By submitting this answer sheet, I certify that I have read the lesson in its entirety and completed the self- d. Gold salts. assessment exam personally based on the material presented. I have not obtained the answers to this exam by any fraudulent or improper means.

Signature Date

Lesson 108036 RO-PCO-0112

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064_ro0112_F6_osc_final.indd 71 1/5/12 2:02 PM Comanagement Q+A

Bust That Rust! You can remove foreign bodies and rust rings, even those located centrally—if you do it properly and use the right tools. By Paul C. Ajamian, O.D. A patient presented to my 4. Make sure it’s all gone. With Q office five days after getting a any FB, make sure to evert the piece of metal in his eye. The upper and lower lids. We occa- foreign body was central and seemed sionally see what’s described as an deep, so I referred the patient out. “infectious ulcer,” which is really a Was that the right move? FB abrasion caused by an embed- There are several reasons ded lash or hidden foreign body in A why the O.D. might refer the upper or lower lid. out a patient with a foreign 4. Prevent infection and pain. body (FB). But, usually these Corneal foreign body with rust ring. We no longer patch eyes, even are also the same reasons why we those with large FBs or abrasions. should seize the opportunity to prompt you to refer the patient. So, to prevent infection of the open remove the foreign body ourselves: Some doctors advocate allow- epithelial defect, prescribe a short • The foreign body is central and ing rust to remain for a few days course (up to seven days) of a topi- might leave a scar. If the FB is going to allow it to “rise to the surface” cal antibiotic. To take the edge off to leave a scar, it’s going to leave a or “soften up.” I disagree. The lon- the pain, prescribe a topical NSAID. scar no matter who removes it. So ger rust remains in the cornea, the For patients in severe pain, be pre- the sooner you get it out, the better. more likely it will cause an immune pared to prescribe an oral narcotic • The patient is in pain. If so, response. We’ve actually seen an analgesic. Copious artificial tears that’s a good reason to remove it immune ring that formed around a also help with comfort and healing. right away so that the cause of the FB and started to thin the cornea. 5. Be on call. Be available after pain will be eliminated. So, no matter what the foreign body hours for these patients. Give them • The foreign body appears deep. is, including rust, just get it out. your cellphone number or some Many FBs that appear deep are no 3. Use the proper tools. You’ll way to reach you directly if there’s deeper than the epithelium or ante- need a pair of jeweler’s forceps, a a problem. Telling patients to go to rior stroma. But even if it’s in the foreign body spud (like a golf club an emergency room after hours is a deep stroma, you can usually take spud) and an Alger brush. recipe for disaster—and a lawsuit. the FB out yourself, as long as you Focus your attention first on 6. Follow up in 24 hours. Have do it properly. Here’s how to do it: removing the object (using the the patient come back the next day 1. Anesthetize the eye. Use pro- spud), and worry about the rust so you can check the eye’s condi- paracaine or, if the patient is very after the FB is out. (You don’t want tion. Also, use this as an opportu- sensitive or the FB is at the limbus, to start with the Alger brush and nity to educate the patient about the consider using Akten (lidocaine turn one piece of metal into a mil- importance of protective eyewear. 3.5%, Akorn Inc.), an ophthalmic lion fragments, when you could Also, don’t forget to document gel that provides deeper anesthesia. have taken it out in one piece.) everything in the patient’s chart— 2. Identify the foreign body. If there is rust left behind, noth- what you did, what instructions you While a lot of the FBs we see are ing gets it out better than an Alger provided, and any precautions you metallic, don’t assume this one brush. Place the instrument right gave for the future. Last but not is. But, even if it is an unusual on the edge of the crater and apply least, if you have any suspicion that object—such as bugs’ wings, spat- pressure to clean out the area. the FB caused a penetrating injury, ters of latex paint, droplets of Super Don’t worry; if you push too hard perform gonioscopy and dilation. If Glue, or just an unidentified for- or too deep, the drill motor will it does appear to have penetrated, eign body—that in itself shouldn’t stop on its own. get an X-ray of the eye. ■

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072_RO0112_cmqa_final.indd 72 1/5/12 2:50 PM RO0112_House Seco.indd 1 12/28/11 10:58 AM Cornea+Contact Lens Q+A

On Thin Eyes While CXL complications are rare, operating on a cornea that’s too thin can result in some unexpected—and unwanted—snags. Edited by Joseph P. Shovlin, O.D. I just had a patient who had tear replacement Q bilateral corneal collagen therapy, topi- cross-linking (CXL) for post- cal cyclosporine LASIK ectasia. In one eye, she devel- drops and topical oped corneal edema and a somewhat antibiotics, as nec- Photo: Peter Hersh, M.D. significant hypopyon immediately fol- essary to address lowing her procedure. What may have ocular surface caused this? Is there anything we can disease preop- do to avoid it in the future? eratively. But, he warns against Your first step should be treating patients A to rule out the possibility with pre-existing of infection. “While infec- herpetic keratitis tion is a rare complication of CXL, because of the risk there have been a few reported of precipitating cases of post-CXL infection in the recurrent infec- Typically, a fine corneal haze is seen after cross-linking. Over literature,” says Peter Hersh, M.D., tion. time, this dust-like haze evolves into a demarcation line, and director of the Cornea and Laser In the early subsequently resolves. Eye Institute–Hersh Vision Group postoperative in Teaneck, N.J. “Most are bacte- period with epithelial removal, the and subsequently resolves.2 In rare rial in origin, although herpes sim- patient should be followed carefully cases, a focal, deep, scar-like haze plex keratitis and Acanthamoeba until complete re-epithelialization. has been described. Risk factors for have been reported.” Typically, prophylactic antibiotics such a focal scar remain unclear, Post-CXL infection is likely a (usually a broad-spectrum fluoro- but may include pre-existing cor- result of the decreased epithelial quinolone) are used until the epi- neal opacities. barrier to microbial infiltration dur- thelium has healed completely. Corneal edema itself is a risk of ing the healing process after CXL “To help avoid infection, the CXL. “If the cornea is too thin, the rather than during the procedure contact lens should be removed as interaction of riboflavin and the itself because CXL kills bacteria soon as any epithelial defect from ultraviolet light potentially may and fungi in addition to damaging the CXL procedure is healed,” damage the corneal endothelium keratocytes.1 In some cases, a ban- Dr. Hersh says. “If any infiltrate, leading to corneal swelling,” Dr. dage contact lens that is used post- edema or hypoyon is noted, cul- Hersh says. “Treatment of eyes operatively may contribute, tures should be taken as indicated with appropriate corneal thickness, Dr. Hersh says. and early treatment with broad- intraoperative stromal swelling and A number of interventions may spectrum antibiotics instituted.” proper riboflavin diffusion timing help to avoid infections after CXL. Outside the setting of microbial should help avoid such complica- First, you should perform a thor- infection, severe inflammation tions.” ■ ough preoperative examination to with hypopyon and corneal edema 1. Koller T, Mrochen M, Seiler T. Complication and failure look for any ocular surface disease would be quite rare after CXL, Dr. rates after corneal crosslinking. J Cataract Refract Surg. 2009 and treat any instances of dry eye Hersh says. Typically, a fine cor- Aug; 35(8):1358-62. 2. Greenstein SA, Fry KL, Bhatt J, Hersh PS. Natural history or blepharitis. neal haze is seen after cross-linking. of corneal haze after collagen crosslinking for keratoconus Dr. Hersh recommends the use Over time, this dust-like haze and corneal ectasia: Scheimpflug and biomicroscopic analy- of warm compresses, lid hygiene, evolves into a demarcation line, sis. J Cat Refract Surg. 2010 Dec;35(12):2105-14.

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074_ro0112_clqa.indd 74 1/5/12 2:04 PM 1•DAY ACUVUE® MOIST® Brand Contact Lenses with LACREON™ Technology

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Reference: 1. Data on ﬁ le. Johnson & Johnson Vision Care, Inc. 2009. ACUVUE® Brand Contact Lenses are indicated for vision correction. As with any contact lens, eye problems, including corneal ulcers, can develop. Some wearers may experience mild irritation, itching or discomfort. Lenses should not be prescribed if patients have any eye infection, or experience eye discomfort, excessive tearing, vision changes, redness or other eye problems. Consult the package insert for complete information. Complete information is also available from VISTAKON®, Division of Johnson & Johnson Vision Care, Inc., by calling 1-800-843-2020 or by visiting jnjvisioncare.com. ACUVUE®, 1•DAY ACUVUE® MOIST®, LACREON™, INNOVATION FOR HEALTHY VISION™, and VISTAKON® are trademarks of Johnson & Johnson Vision Care, Inc. All third party products are trademarks of their respective companies. © Johnson & Johnson Vision Care, Inc. 2011. May 2011 INNOVATION FOR HEALTHY VISION™

RO0611_Vistakon Moist.indd 1 5/18/11 3:10 PM 000_ro0112RO3mtgs.indd 49 12/21/11 3:38 PM Review of Systems

MS and the Eye (Part 1) In any patient with unexplained neurologic deficits, consider disease that damages the myelin sheath. By Carlo J. Pelino, O.D., and Joseph J. Pizzimenti, O.D.

demyelinating disease is any condition that results Ain damage to the myelin sheath that surrounds nerve fibers in the brain and spinal cord. When the myelin sheath is damaged, nerve impulses slow or even stop, causing neurological problems. Demyelinating diseases may result in vision or hearing loss, headache, seizures, muscle spasms and weakness, loss of coordina- tion, paralysis and loss of sensation. In the first part of this two-part column, we present an overview of demyelinating disease, with a focus on multiple sclerosis (MS)—the most common demyelinating disorder. Myelin Basics Myelin is a collection of lipid fats and proteins that covers the long extensions of axons. It con- siderably increases the speed that the action potentials move down the axons. At rest (resting potential), the neuron and the surrounding space act as a “capacitor” storing current, which is released Notice the multiple ring and ovoid lesions in the periventricular and deep white matter during the action potential.1 in this patient with MS. Myelin is in both the central nervous system (CNS) and the Patient symptoms may reflect defi- times follows a viral infection or peripheral nervous system (PNS). cits in any part of the nervous sys- viral vaccination. Demyelination In the PNS, Schwann cells produce tem. The most commonly affected may also occur secondary to an and maintain the myelin; whereas areas in the CNS are the brain, infectious, ischemic, metabolic or glial cells called oligodendrocytes spinal cord and optic nerves.3,4 hereditary disorder.4 produce and maintain the myelin In primary demyelinating dis- MS is a chronic, recurrent dis- in the CNS.2,3 orders, the cause is unknown, but ease characterized by disseminated Disorders that affect myelin an autoimmune mechanism is sus- patches of demyelination in the interrupt nerve transmission. pected because the disorder some- brain and spinal cord (figure 1).

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But, there are also a number of time and space”—that is, they on the development of MS, with other primary demyelinating dis- occur months or years apart and scientists having identified a num- orders of the CNS (see “Non-MS affect different anatomical loca- ber of MS susceptibility genes.1 Primary Demyelinating Disease of tions. As an example, a patient Whites are at higher risk than the CNS,” below).4,5 may present with paresthesias of Asians and people of African the hand that resolve, followed a descent, even when residing in A Demyelinating Myelopathy few months later by optic neuritis. a similar environment. Genetic MS affects approximately MS is a clinical diagnosis sup- heterogeneity may also be present 350,000 Americans and 2.5 ported by laboratory studies and in MS, meaning that there are dif- million people worldwide. The neuroimaging findings.4,5 ferent causative genes in different prevalence of MS in the United individuals.1,3 The risk of develop- States ranges from 6 to 177 per What Causes MS? ing MS is approximately 20 times 100,000.1 In Western societies, A proposed explanation for the greater in first-degree relatives of MS is second only to trauma as latitude effect on MS is the possi- patients with the disease.3 the leading cause of neurologic ble protective power of sun expo- Although the precise etiology of disability beginning in early to sure. Ultraviolet radiation from MS remains unknown, multiple middle adulthood. the sun is an important source factors appear to contribute. It is The number of cases of MS of vitamin D, and low levels of thought that the immune system appears to have steadily risen over vitamin D are common at high attacks the myelin sheath or the the past century, and this increase latitudes, particularly in winter cells that produce and maintain has occurred primarily in women.1 months. Prospective studies have it. This causes inflammation and The disease is three times more shown that vitamin D deficiency injury to the sheath––and ulti- common in women than in men, is associated with increased MS mately to the nerve fibers that it with onset occurring between risk, which could be explained by surrounds––and may result in mul- ages 20 and 40.1,2 Approximately the immunoregulatory effects of tiple areas of scarring (sclerosis).4,5 10% of cases begin before age 18; vitamin D.1,3 however, the disease is relatively MS also correlates with high We wish all our readers the best uncommon in children under 10. socioeconomic status, which may of systemic and ocular health in Geographically, the prevalence reflect better sanitation and thus 2012! Keep an eye out for our rates of MS increase at higher delayed initial exposure to infec- next column in March, when we’ll latitudes. tious agents. Some reports impli- discuss how to classify, diagnose Inflammation, demyelination cate specific infectious agents, and manage MS. ■ and gliosis occur in patients with such as human herpes virus type To read more about MS, see also MS. The course can be relapsing- 6 or Chlamydophila pneumoniae; “The Impact of Autoimmune Dis- remitting or progressive. Symp- although, in general, the available ease,” page 64. tomatic episodes consistent with reports have been inconsistent. A MS are typically “separated in number of epidemiologic and lab- 1. Hauser SL, Goodin DS. Multiple sclerosis and other demyelinating diseases. In: Hauser SL, Josephson SA. Harri- oratory studies suggest son’s Neurology in Clinical Medicine. 2nd edition. New York: that an Epstein-Barr McGraw-Hill; 2010:435-50. Non-MS Primary Demyelinating Diseases infection rarely may 2. Motor deficits. In: Simon RP, Greenberg DA, Aminoff MJ. Clinical Neurology. 7th ed. New York: McGraw-Hill; of the CNS Systems play a role in MS. The 2009:152-202. • Optic neuritis: inflammation of the optic nerve in one or virus may precipitate 3. The M.D. Association. Selected systemic conditions with both eyes an autoimmune process neuro-ophthalmic signs. In: American Academy of Ophthal- mology. Basic and clinical science course, section 5: neuro- • Neuromyelitis optica (Devic’s disease): inflammation of the that attacks myelin. At ophthalmology. 2006-2007: 317-68. optic nerve and spinal cord this time, however, a 4. Introduction, organization, and cellular components. In: • Acute transverse myelitis: inflammation of the spinal cord causal role for Eptstein- Young PA, Young PH, Tolbert DL. Basic clinical neurosci- ence. 2nd ed. Philadelphia: Wolters Kluwer/Lippincott Wil- • Acute disseminated encephalomyelitis: inflammation of Barr virus or any spe- liams & Wilkins; 2008:1-14. the brain and spinal cord cific infectious agent 5. McDonald WI, Compston A, Edan G, et al. Recommended • Adrenoleukodystrophy and adrenomyeloneuropathy: rare, remains uncertain.1,3 diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the diagnosis of multiple sclerosis. inherited metabolic disorders Some evidence points Ann Neurol. 2001Jul;50(1):121-7. to a genetic influence

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077_ro0112_ros.indd 78 1/5/12 2:07 PM STEP-BY-STEP PRESENTATIONS • HANDS-ON WORKSHOPS THE HOW TO MEETING Manchester Grand Hyatt San Diego February 24-26, 2012 Chair: Jerome A. Legerton OD, MS, MBA, FAAO

Faculty: Christine Sindt, OD, FAAO, Barry Eiden, OD, FAAO, Muriel Schornack, OD, FAAO, The Symposium is designed to train and engender confidence to initiate and advance a wide range of specialty lens prescribing and case management. Dianne Anderson, OD, FAAO, 20 one hour COPE approval pending, step by step presentations. Select from Robert Gordon, OD, FAAO, 10 hours of basic lectures and 10 hours of advanced lectures and 33 hours of Michael Lipson, OD, FAAO, live patient hands-on industry sponsored non-COPE workshops. Thomas Quinn, OD, MS, FAAO, SPECIAL OFFER: ONE FREE ANCILLARY PERSONNEL WITH Edward Boshnick, OD, FAAO, ONE PAID DOCTOR OF OPTOMETRY Greg DeNaeyer, OD, FAAO, Ancillary personnel are invited to assist you in developing a cost eff ective offi ce Jeff Walline, OD, PhD, FAAO, system for your specialty contact lens services. Cary Herzberg, OD, FOAA Visit www.specialtycontactlens.org to redeem Nick Despotidis, OD, FAAO, FCOVD ACCESS CODE: freeancillary PLATINUM LEVEL SPONSORS:

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Reference: 1. Data on ﬁ le. Johnson & Johnson Vision Care, Inc. 2008. ACUVUE® Brand Contact Lenses are indicated for vision correction. As with any contact lens, eye problems, including corneal ulcers, can develop. Some wearers may experience mild irritation, itching or discomfort. Lenses should not be prescribed if patients have any eye infection, or experience eye discomfort, excessive tearing, vision changes, redness or other eye problems. Consult the package insert for complete information. Complete information is also available from VISTAKON®, Division of Johnson & Johnson Vision Care, Inc., by calling 1-800-843-2020 or by visiting jnjvisioncare.com. ACUVUE®, ACUVUE® OASYS®, BLINK STABILIZED™, HYDRACLEAR®, INNOVATION FOR HEALTHY VISION™, and VISTAKON® are trademarks of Johnson & Johnson Vision Care, Inc. © Johnson & Johnson Vision Care, Inc. 2011. May 2011 INNOVATIONINNOVATION FORFOR HHEALTHYEALTHY VVISION™ISIONN™

RO0611_Vistakon Astig.indd 1 5/18/11 2:57 PM Retina Quiz

Patient Sees Better in the Dark This young patient presented with a 10-year history of extremely poor visual acuity and photophobia. By Mark T. Dunbar, O.D.

20-year-old Hispanic male the maculae appeared healthy with SD-OCT? presented with a chief com- a foveal light reflex O.U. We took a. Normal. Aplaint of slow, painless, pro- fundus photographs (figures 1 and b. Abnormally thick choroid. gressive vision loss at distance and 2) and performed a spectral-domain c. Loss of the photoreceptor near. The patient reported that he optical coherence tomography (SD- integrity line (PIL). had difficulty with his vision since OCT) scan (figures 3 and 4). d. Occult choroidal neovascular- he was 10 years of age. His only ization (CNV). other symptom was photophobia. Take the Retina Quiz His medical and family ocular his- 1. What simple, in-office test 4. What is the most likely diag- tories were unremarkable. would provide the most useful nosis? On examination, his best-correct- information about our patient? a. Cone dystrophy. ed visual acuity measured 20/200 a. Applanation tonometry. b. Stargardt’s macular dystrophy O.U. at distance and near. Con- b. Amsler grid. (SMD). frontation visual fields were full c. Color vision testing. c. Malingering. to finger counting O.U. His pupils d. Manifest refraction. d. Functional vision loss. were equally round and reactive to light, with no afferent defect. Extra- 2. What additional testing is For answers, go to page 98. ocular motility testing was normal. necessary to help confirm the diag- His anterior segment examination nosis? Discussion was unremarkable. a. Electroretinogram (ERG). The dilated fundus exam of our The dilated fundus examination b. Electrooculography (EOG). patient showed essentially normal revealed clear vitreous and rela- c. Fluorescein angiography (FA). optic nerves and what appeared to tively large optic nerves with mod- d. Visual fields. be healthy maculae. There was no erate-sized cups O.U. The retinal evident macular edema or any other vessels were of normal caliber, and 3. How would you interpret the overt macular pathology. In fact,

1, 2. Fundus photographs of our patient (O.D. left, O.S. right). What clinical finding do you notice?

REVIEW OF OPTOMETRY JANUARY 15, 2012 81

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to be progressive reduced rod response that was in nature and is consistent with an acquired cone acquired later in dystrophy. life––unlike other The SD-OCT scan is quite inter- congenital photore- esting. At first glance, it appears ceptor conditions, normal. However, on careful such as achroma- inspection, you can see that the topsia, in which the PIL is absent in the fovea, which patient experiences suggests that a process is affecting poor vision from the photoreceptors. The PIL can be birth; nystagmus, seen as a highly reflective line that an aversion to light is located just above the retinal pig- (referred to as hem- ment epithelium. It is present out- eralopia); and vary- side the macula; but, as you follow ing degrees of color it temporal to nasal through the 3, 4. The SD-OCT scan of both maculae (O.D. top, O.S. bottom). vision loss.1,2 macula, you can see that it disap- There are several pears on each side. a foveal light reflex was present in hereditary patterns of acquired There are a number of heredi- each eye. cone dystrophy––all of which result tary patterns for cone dystrophy, So, what was wrong with our in early loss of color vision as well including autosomal dominant, patient? Did he have some form as a progressive decline in visual autosomal recessive and X-linked. of functional vision loss, or was acuity (to the level of 20/200 to Some patients with the X-linked our patient a malingerer who was 20/400).1 form may exhibit a golden, tapetal- seeking some financial gain? Our In most cases, vision loss begins like sheen that disappears on dark answer was embedded in the case during the teenage years; however, adaptation. But, because most cone history. initial symptoms may present even dystrophies occur sporadically, One of his primary complaints as late as the seventh decade of life. many researchers believe that the was photosensitivity. More spe- Interestingly, our patient was first majority of cases are autosomal cifically, he noted that, even on a seen at age 15, and at that time his recessive.1 Our patient’s family his- cloudy day, he was bothered by best-corrected acuity was 20/60 tory was negative for cone dystro- light. In addition, he believed that O.U. Over the ensuing five years, phy, so it is likely that his condition he didn’t see as well in normal his vision slowly dropped to the was indeed autosomal recessive in lighting conditions and that his 20/200 level. nature. vision was actually better at night The primary difficulty in mak- or when the lighting was dimmer. ing the diagnosis is that, in many We referred our patient to the The final clue (which I intentionally instances, the retinal exam can low vision service for evaluation omitted from the patient’s history be completely normal. Bull’s-eye and educated him about helpful above) was color blindness. In fact, maculopathy and temporal disc programs that were offered by the patient missed all 15 plates pallor has been reported.1,2 In our Florida’s Division for Blind Ser- O.U. on Ishihara color vision test- patient, the retinal exam appeared vices. Additionally, we completed ing. normal––although you could the necessary forms that declared At this point, all the clues sug- almost convince yourself that there him legally blind, which will grant gested that the patient had a cone may had been temporal optic nerve him access to special assistance pro- dystrophy––although SMD was still pallor. grams. ■ a potential differential diagnosis. The wide variety of clinical 1. Sunness JS, Carr RE. Retinal Degenerations and Dystro- However, FA testing did not show presentations illustrates why elec- phies. In: Ryan SJ. Retina, vol. I: Medical retina. 4th edition. St. the classic, quiet choroid that is trophysiology is so important in Louis: Mosby; 2006:509-18. 2. Michaelides M, Holder GE, More AT. Inherited Retinal Dys- associated with SMD. confirming the diagnosis. We per- trophies. In: Pediatric Ophthalmology and Strabismus. Taylor Cone dystrophy is considered to formed ERG on our patient, which D, Greig S (eds). Section 4: Systematic Pediatric Ophthalmol- ogy, Chapter 52. 3rd edition. London: Elsevier Saunders; be an acquired disorder that affects revealed significantly reduced and 2005:531-57. the cone photoreceptors. It tends prolonged cone response and mildly

82 REVIEW OF OPTOMETRY JANUARY 15, 2012

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RO0112_House VC.indd 1 1/3/12 9:49 AM Therapeutic Review

Sowka Down Under, Part II Resistance is futile… But, it happens anyway. By Joseph W. Sowka, O.D. his past fall, I had the oppor- for ophthalmic resistance. And, tunity to lecture again at the although the rise in resistant ocular TTasmania Lifestyle Congress bacteria is apparently linked to the in Hobart, Tasmania, Australia. I increase in resistant systemic patho- enjoy lecturing abroad because it gens, recent evidence has identified gives me the opportunity to meet the emergence of resistant bacteria colleagues the world over and to in the eye to prior topical antibi- see how optometry is practiced else- otic therapy.6 In any case, either of where. these postulations contributes to From a therapeutic perspective, the emergence of resistance among optometrists in both Australia and The author making friends with some of ocular pathogens. (To that end, New Zealand are very sophisticated the locals. besifloxacin is one of the latest and keep abreast of the literature fluoroquinolones that has no sys- when delivering care to their not seem to be suffering. Interest- temic counterpart. It was developed patients. Our therapeutic options in ingly, there are low resistance rates exclusively for ophthalmic use with the U.S. are very similar. In fact, we of Pseudomonas aeruginosa and the hope that it will decrease the use the same glaucoma medications. Staphylococcus aureus to ciproflox- development of resistant microbes But, there is one area where I see a acin in Australia.1 You have to won- because of no systemic use.) major difference: topical antibiotics. der how clinicians Down Under can A recent surveillance study saw In the U.S., we have a plethora of be so successful, yet we in America that a large proportion of S. aureus later-generation fluoroquinolones, seem to have significant issues with and coagulase-negative staphylo- such as moxifloxacin, gatifloxa- resistance and consistently need to cocci isolates were resistant to oxa- cin, levofloxacin and besifloxacin. develop new drugs to combat these cillin/methicillin, azithromycin and However, these medications are heartier microbes. fluoroquinolones.7 Another study not available in Australia––and it indicated that methicillin-resistant is unclear if they ever will be. In Emerging Resistance staphylococci were more likely to be Australia, the only fluoroquinolones Antibiotic resistance among ocu- resistant to fluoroquinolones, ami- available are ofloxacin and cipro- lar pathogens seems to be increasing noglycosides and macrolides.8 floxacin, and these medications in correlation with the prevalence There are two schools of thought typically are reserved for cases of of resistant bacteria associated with regarding antibiotic choice and the bacterial keratitis.1 Of course, these systemic infections. In other words, development of resistance. fluoroquinolones are still available systemic treatment of bacterial infec- • High risk. This concept involves as generics in the U.S., but are not tions seems to be promoting the using the most potent antibiot- often used because of the availability development of organisms that are ics only in high-risk cases, such as of newer alternatives as well as con- heartier and more resistant to antibacterial keratitis. In most countries cerns of bacterial resistance.2,3 microbial therapy.6 So, when one of outside the U.S., topical fluoroqui- Bacterial keratitis is as common these heartier organisms infects the nolones––particularly those recently in Australia as in the U.S., with con- conjunctiva or cornea, there may be approved by the European Medi- tact lens wear and ocular surgery fewer therapeutic options. cines Agency, including levofloxacin as precipitating events.4,5 Despite We have always looked upon and moxifloxacin––rarely are used. the absence of the later-generation heavy systemic use of antibiotics The strategy of using topical fluoro- fluoroquinolones, Australian eye as well as antibiotic treatment of quinolones as a last resort reflects a care providers and their patients do livestock feed as primary culprits belief that the agents may enhance

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the development of resistance, typically restrict their use of the two use? Doesn’t seem so. How do I jeopardizing future availability of available fluoroquinolones to cases know? Because, in Australia, topi- antibacterial treatment for ocular of bacterial keratitis, what do they cal chloramphenicol is sold over the infections.9 use for other conditions? counter without a prescription! ■ • High concentration. The other Dr. Sowka has no direct financial school of thought suggests that the Chloramphenicol Revisited interests in any of the products men- use of topical fluoroquinolones, In the January 2008 column, I tioned. which results in antibacterial con- discussed the widespread use of 1. Willcox MD. Review of resistance of ocular isolates of Pseu- centrations at the ocular surface topical chloramphenicol in New domonas aeruginosa and staphylococci from keratitis to cipro- that can significantly exceed mutant Zealand. In Australia, as in New floxacin, gentamicin and cephalosporins. Clin Exp Optom. 2011 Mar;94(2):161-8. prevention concentrations (approxi- Zealand, topical chloramphenicol 2. Alexandrakis G, Alfonso EC, Miller D. Shifting trends in bacterial mately 10 times the minimum is the most widely used ophthalmic keratitis in south Florida and emerging resistance to fluoroquinolones. Ophthalmology. 2000 Aug;107(8):1497-502. inhibitory concentration), should antibiotic. Moreover, it is used 3. McDonald M, Blondeau JM. Emerging antibiotic resistance be preferentially used in order to extensively throughout the world in ocular infections and the role of fluoroquinolones. J Cataract Refract Surg. 2010 Sep;36(9):1588-98. prevent the development of resis- (except in the U.S.) for the treat- 4. Stapleton F, Keay L, Edwards K, et al. The incidence of contact tance. In the case of later-generation ment of acute bacterial infections lens-related microbial keratitis in Australia. Ophthalmology. 2008 Oct;115(10):1655-62. fluoroquinolones such as topical and corneal trauma. Also, due to its 5. Green M, Apel A, Stapleton F. A longitudinal study of trends in moxifloxacin, a dual-step mutation excellent ocular penetration, chlor- keratitis in Australia. Cornea. 2008 Jan;27(1):33-9. 6. Sharma S. Antibiotic resistance in ocular bacterial pathogens. is required for resistance to emerge. amphenicol is very popular in surgi- Indian J Med Microbiol. 2011 Jul-Sep;29(3):218-22. Moxifloxacin restricts the selection cal prophylaxis. 7. Bradley JS, Jackson MA; Committee on Infectious Diseases; American Academy of Pediatrics. The use of systemic and topical of resistant mutants, meaning that Chloramphenicol has a broad fluoroquinolones. Pediatrics. 2011 Oct;128(4):e1034-45. emergence of resistance is unlikely.9 spectrum of both gram-positive and 8. Haas W, Pillar CM, Torres M, et al. Monitoring antibiotic resistance in ocular microorganisms: results from the Antibiotic It is not clear which strategy is gram-negative antibacterial activity, Resistance Monitoring in Ocular micRorganisms (ARMOR) 2009 most appropriate. Despite the avail- and it is effective against anaerobic surveillance study. Am J Ophthalmol. 2011 Oct;152(4):567-74. 9. Benitez-Del-Castillo J, Verboven Y, Stroman D, Kodjikian L. ability of just two fluoroquinolones organisms, Mycoplasma, Rickettsia The role of topical moxifloxacin, a new antibacterial in Europe, in Australia, resistance rates are and Chlamydia. Especially note- in the treatment of bacterial conjunctivitis. Clin Drug Investig. 2011;31(8):543-57. quite low. A study from New South worthy is its low rate of clinical 10. Schubert TL, Hume EB, Willcox MD. Staphylococcus aureus Wales, Australia, indicated that ocu- and microbiologic resistance as well ocular isolates from symptomatic adverse events: antibiotic resistance and similarity of bacteria causing adverse events. Clin Exp lar infections––both conjunctivitis as its ability to conquer organisms Optom. 2008 Mar;91(2):148-55. and keratitis––involving S. aureus in that are resistant to more common 11. Leibovitch I, Lai TF, Senarath L, et al. Infectious keratitis in 13-16 South Australia: emerging resistance to cephazolin. Eur J Ophthal- the U.S. exhibited greater resistance antibiotics. Chloramphenicol’s mol. 2005 Jan-Feb;15(1):23-6. to antibiotics than those in Austra- efficacy against ocular methicillin- 12. Ly CN, Pham JN, Badenoch PR, et al. Bacteria commonly 10 isolated from keratitis specimens retain antibiotic susceptibility to lia. Additionally, the researchers resistant Staphylococcus aureus fluoroquinolones and gentamicin plus cephalothin. Clin Experiment noted that isolates from corneal (MRSA) infections has also been Ophthalmol. 2006 Jan-Feb;34(1):44-50. 13. McGhee CN, Anastas CN. Widespread ocular use of topical infections were more resistant to documented in several investigative chloramphenicol: is there justifiable concern regarding idiosyn- antibiotics than those from conjunc- reports.17-20 cratic aplastic anaemia? Br J Ophthalmol 1996 Feb;80(2):182-4. 14. Egger SF, Ruckhofer J, Alzner E, et al. In vitro susceptibilities to tival infections, with isolates from To date, there have been 23 cases topical antibiotics of bacteria isolated from the surface of clinically the U.S. demonstrating the greatest of aplastic anemia (the majority symptomatic eyes. Ophthalmic Res 2001 Mar-Apr;33(2):117-20. 10 15. Altaie R, Fahy GT, Cormican M. Failure of Listeria monocy- resistance levels. were not fatal) reported in the U.S. togenes keratitis to respond to topical ofloxacin. Cornea 2006 Nonetheless, there have been that possibly were associated with Aug;25(7):849-50. 13 16. Cimolai N. Ocular Methicillin-resistant Staphylococcus aureus some issues with bacterial resistance the use of topical chloramphenicol. Infections in a Newborn Intensive Care Cohort. Am J Ophthalmol in Australia. For example, there is This purported association with 2006 Jul;142(1):183-4. 17. Fukuda M, Ohashi H, Matsumoto C, et al. Methicillin-resistant an emerging resistance to cefazolin, aplastic anemia has curtailed use of Staphylococcus aureus and methicillin-resistant coagulase- which commonly is used as a first- the drug in the U.S. negative Staphylococcus ocular surface infection efficacy of chloramphenicol eye drops. Cornea. 2002 Oct;21(7 Suppl):S86-9. line antibiotic for gram-positive 18. Walvick MD, Amato M. Ophthalmic methicillin-resistant Staph- cocci.11 However, most micro- We have long shied away from ylococcus aureus infections: sensitivity and resistance profiles of 234 isolates. J Community Health. 2011 Dec;36(6):1024-6. organisms isolated from patients topical chloramphenicol due to its 19. Elsahn AF, Yildiz EH, Jungkind DL, et al. In vitro susceptibil- with bacterial keratitis in Australia perceived threat to patient health ity patterns of methicillin-resistant Staphylococcus aureus and coagulase-negative Staphylococcus corneal isolates to antibiotics. showed susceptibility to ciprofloxa- and risk of death. But, are Austra- Cornea. 2010 Oct;29(10):1131-5. cin and aminoglycosides.12 lian optometrists and ophthalmolo- 20. Lam RF, Lai JS, Ng JS, et al. Topical chloramphenicol for eye So, if clinicians in Australia gists worried about chloramphenicol infections. Hong Kong Med J 2002 Feb;8(1):44-7.

86 REVIEW OF OPTOMETRY JANUARY 15, 2012

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RO0112_House MBA.indd 1 12/22/11 12:59 PM Research Review

A Look At MSI Multispectral imaging may help eye care providers diagnose retinal conditions earlier than conventional fundoscopy. Edited by Diana L. Shechtman, O.D., and Paul M. Karpecki, O.D. ultispectral imaging (MSI) camera design was hampered by process as a means of demonstrating is an emerging diagnostic the use of filters and a bandwidth oxygen saturation through morpho- Mtechnology that permits that was too wide, which resulted in logical angiography.3 the clinician to dissect and visualize diminished contrast and poor spec- the retina in spectral slices, from the tral separation. MSI in Clinical Practice inner limiting membrane all the way Current, commercially avail- Today, MSI takes digital imaging to the choroid. able MSI devices, such as the RHA to a new diagnostic level by yielding Most importantly, however, MSI instrument (Annidis Health Sys- an enhanced view of the anatomical may help clinicians detect and evalu- tems), use multiple monochromatic fundus layers. Separation of anatom- ate several sight-threatening retinal LED-sourced wavelengths––ranging ical layers allows pathology-specific and choroidal diseases, including from 550nm to 780nm––to illustrate ophthalmoscopy and progressive diabetic macular edema, retinal the individual anatomic components views through the entire retina–– pigment epithelium atrophy, vitreo- of the retina. Generally, shorter from the internal limiting membrane macular traction syndrome and wet wavelengths are used to reflect to the choroid. age-related macular degeneration. anterior retinal features and lon- MSI is capable of creating a series Here, we’ll examine how MSI ger wavelengths are used to reflect of monochromatic, en face fundus technology can help eye care provid- deeper retinal features, including the spectral slices for added diagnostic ers effectively diagnose and manage choroid. insight. And, because conventional retinal pathology. RHA also has additional after- fundus photography is limited to image processing that highlights parameters of the visible spectrum, Multispectral Overview oxygenated and deoxygenated it is less sensitive than MSI in detect- The concept of MSI was first hemoglobin, which may yield rep- ing features that are reflected in the described in 1977, when a research resentation of metabolic activity longer range of the spectrum such as team combined a modified fundus (figure 1).3 This may allow the eye deep retinal layers and the choroidal camera with various interference care practitioner to accent the retinal structures. filters to enhance the appearance of structures associated with arterial Furthermore, MSI may help a anatomical and pathological retinal and venous blood by non-invasive managing clinician make a more features.1,2 However, this modified means. One study described this informed diagnosis. The device aids in: • Localization of retinal morphological abnormalities. • Interpretation of disease, based upon affected layer. • Enhanced viewing of obscure, subtle or overlapping pathological structures. • Enhanced viewing of deep retinal structures.

Preventative eye care is predicated on early detection, and being able to 1. Oxy/deoxy map of a patient with myopic degeneration. Note the visualization of the identify risk factors and preliminary choriocapillaris in the magnified image (right). clinical signs is essential. MSI affords

88 REVIEW OF OPTOMETRY JANUARY 15, 2012

088_ro0112_rr_final.indd 88 1/5/12 10:00 AM eye care providers the means to Case Report: MSI Helps Confirm Diagnosis of VMTS understand the anatomical aspects of A 54-year-old white male specific pathologies, as well as per- presented with signs of form further examination of vascular small-caliber drusen in tissues, fluids and metabolic mark- his left eye that were evi- ers of retinal health and integrity. dent with fundus imaging. Ultimately, with increased use, MSI Interestingly, his visual will help facilitate earlier and more acuity measured 20/20 O.U. accurate detection of many sight- In addition to fundoscopy, threatening retinal conditions. ■ we performed multispectral Fundus (left) and MSI shorter wavelength (right) Thanks to Richard Maharaj, imaging (MSI) and spectral- images of our patient’s left eye reveal surface traction O.D., B.Sc., of Hamilton, Ontario, domain optical coherence secondary to VMTS. Note the enhanced anatomical for contributing this column. Dr. tomography (SD-OCT). detail on MSI shorter wavelength. Maharaj sits on the U.S. optometric Both MSI and SD-OCT advisory board for Annidis Health indicated the presence of vitreomacular traction syndrome (VMTS). MSI shorter wavelength Systems, Inc. effectively captured the topographical striations associated with the VMTS. Also, MSI further identified an atrophic area associated with the decomposition of melanin in the retinal pig- 1. Delori FC, Gragoudas ES, Francisco R, Pruett RC. Monochro- ment epithelium (RPE). On SD-OCT, we saw that the photoreceptor integrity line was intact, matic ophthalmoscopy and fundus photography. The normal fundus. Arch Ophthalmol. 1977 May;95(5):861-8. which was why this patient––with significant RPE atrophy––remained asymptomatic. 2. Ducrey NM, Delori FC, Gragoudas ES. Monochromatic We recommended oral carotenoid supplements as well as an AREDS-equivalent multi- ophthalmoscopy and fundus photography. II. The pathological fundus. Arch Ophthalmol. 1979 Feb;97(2):288-93. vitamin. Additionally, we prescribed 1,000 IU vitamin D daily to address the inflammatory 3. Arimoto H, Furukawa H. Retinal blood oxygen saturation map- nature of the pathology. ping by multispectral imaging and morphological angiography. Conf Proc IEEE Eng Med Biol Soc. 2007;2007:1627-30.

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REVIEW OF OPTOMETRY JANUARY 15, 2012 89

088_ro0112_rr_final.indd 89 1/5/12 10:00 AM Product Review

Contact Lenses Specialty Line ABB Concise received FDA clearance to produce an entire line of specialty contact lenses in silicone hydrogel 60Dk, 74% H2O Definitive material. This includes indications for use in toric, multifocal, multifocal toric and irregular cornea lenses as well as the KeraSoft IC Lens manufactured under the Bausch + Lomb license and offered exclusively in the Defini- two options—VirtualFitLive and VirtualFitPhoto. tive material. ABB plans to launch the new product VirtualFitLive is the live webcam option that proj- line in the first quarter of 2012. ects a live image of the user’s face; then the system superimposes sunglasses onto the image. If the user Website Enhancement turns their face, the glasses move with them. Virtual- VirtualTryOn FitPhoto lets users upload photos of their face, either Polarized sunglass maker Maui Jim has added Vir- by snapping photos through their computer’s web- tualTryOn to its website. The new system provides cam or by uploading a photo from their files. The enhanced information about each sunglass style chosen sunglasses will appear on the photo, and can and allows customers to see themselves in a pair of be saved or shared with friends on Facebook. To try glasses and then post the images to Facebook. It has it out, visit www.mauijim.com/tryonlive.html.

Frames

Aspex Grilamid TR90 The Aspex Grilamid TR90 was developed with ther- moplastic polyamide, a new, advanced polymer developed exclusively for Aspex that is 20% lighter than other plastics. Frames using TR90 are now available in all Aspex brand lines, including EasyClip, Manhattan Design Studio and Takumi Magnetic Eyewear. In addition to being flexible, durable and lightweight, frames made from TR90 are temperature resistant, the company says. TR90 frames are also non-allergenic and block damaging UV exposure. For more information, visit www.aspexeyewear.com.

Carrera Champion Sunglasses Worn by Gym Class Heroes lead singer Travie McCoy, Carrerra’s Champion sunglasses appeared in the band’s latest music video “Ass Back Home.” Sleeping on buses and in hotel rooms in different cities every night, the documentary-style video showcases the hard, taxing lifestyle of an artist while on tour. The Carerra “Champion” sunglass model is inspired by the original design first intro- duced in the early 1980s and produced in Safilo Group’s Optyl, a lightweight, hypoallergenic material. Visit carreraworld.com.

90 REVIEW OF OPTOMETRY JANUARY 15, 2012

090_ro0112_products.indd 90 1/5/12 2:08 PM Frames

Costa Double Haul Serious anglers will appreciate Costa’s signature vent system in Double Haul’s frame front to alleviate lens fog in extreme weather conditions, as well as full-eye coverage to allow full range of vision while on the water. Double Haul features a large fitting frame with Hydrolite no-slip nose pads, sturdy integral hinges and durable co-injected molded temples for a comfortable fit. The new style is available in tortoise, black and the new translucent crystal frame colors. Anglers can customize Double Haul in Costa’s patented 580 lenses in either glass or polycarbonate (580P). The new style will retail from $179 to $249 depending on lens customization, and will be available at www.costadelmar.com and at authorized Costa retail outlets.

Karl Lagerfeld Eyewear Collection KL747S Marchon debuted the Karl Lagerfeld Fall/Winter collection for men and women this season. Shapes from the women’s sunwear collection are vintage-inspired and amplified by use of colors—dark hues that graduate to light and then are infused with a contrasting color burst or rich tortoise shells and horns. The men’s collection showcases retro shapes with modern color gradients and the K temple exempli- fies skilled craftsmanship. The collection features ophthalmic and sunwear styles, including: • K747S. A thin, polished metal bar is inlayed at the temples, beginning at the end pieces and continuing to the mid temples, punctuated by the “KL” logo. Lagerfeld enhances the depth of design by setting the inlayed metal against color gradients, specifically a purple/vio- let gradient and grey/orange gradient to enhance the cat eye shape. • KL748S. This sister style to the KL747S is a modified butterfly, evident on the slightly waved brows crafted from rich zyl. Thin, polished metal beginning at end pieces and continuing down the temples toward the “KL” logo is prevalent set KL748S against black, Havana, light tortoise and sand colorations. ■

REVIEW OF OPTOMETRY JANUARY 15, 2012 91

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Continuing Medical Education Professional Opportunities

American Academy of Optometry New Jersey Chapter 10th Annual Educational Conference April 25-29, 2012 Myrtle Beach, South Carolina Hilton Embassy Suites at Kingston Plantation The Wilmer Eye Institute at Johns Hopkins is seeking an Bruce Onofrey, O.D., RPh, F.A.A.O. 16 HOURS optometrist or ophthalmologist specializing in low vision rehabili- Steven Ferucci, O.D., F.A.A.O. COPE CE tation (LVR) to join our team of doctors, therapists and researchers. This low vision specialist will provide clinical LVR Registration: $475.00 care at our academic medical center, satellite location(s), and will contribute to the educational and academic mission of the group. One, Two or Three Bedroom Suites Accommodations Include a Daily Breakfast Buffet The successful applicant will be appointed to the full-time faculty and Evening Cocktail Reception of the Johns Hopkins University School of Medicine and to the full- time active staff of the Johns Hopkins Hospital. LVR residency or PACK YOUR CLUBS! fellowship training is preferred, but not required. Candidates must Golf details to follow. be eligible for a Maryland license and pass a criminal back- For Accommodation and Additional Information, contact: ground check. Dennis H. Lyons, OD, F.A.A.O. Inquiries, curriculum vitae and bibliography should be directed to: Phone: (732) 920-0110 E-Mail: [email protected] Search Committee-Low Vision Specialist: [email protected]

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REVIEW OF OPTOMETRY JANUARY 15, 2012 95

ROPT0112.indd 95 12/27/11 6:23 PM Meetings + Conferences

January 2012 Optometric Association. CE hours: 13. E-mail sweingartner@ rmsmanagement.com or call (406) 443-1160. For more informa- ■ 21-23. Southwest Congress of Optometry. Hotel Valencia tion, visit www.mteyes.com. Riverwalk, San Antonio. Hosted by: the Optometric Extension ■ 4-9. 26th Annual Eye Ski Conference. The Lodge at Mountain Program Foundation. CE hours: 15. Contact Denise Smith, O.D., Village, Park City, Utah. CE hours: 20. Contact Tim Kime, O.D., at (512) 329-8900 or [email protected]. For more informa- Meeting Director, at [email protected]. For more tion, visit www.oepf.org. information, visit www.eyeskiutah.com. ■ 22-28. 2012 Island Eyes Conference. Hilton Waikoloa Resort, ■ 11-12. 75th Great Lakes Optometric Congress. Chicago/ Waikoloa, Hawaii. Hosted by: Pacific University College of Northbrook Hilton, Northbrook, Ill. Hosted by: The Optometric Optometry. CE hours: 25. Contact Jeanne Oliver at (503) 352- Extension Program Foundation. CE hours: 13. Contact John 2740 or [email protected]. For more information, visit www. Loesch, O.D., at [email protected]. For more information, pacificu.edu/optometry/ce. visit www.oepf.org. ■ 27-29. 2nd Annual Final Eyes CE Event. Baptist Medical ■ 22-25. International Vision Expo & Conference East 2012. Center in the duPont Auditorium, Jacksonville, Fla. CE hours: 16. Jacob K. Javits Convention Center, New York, N.Y. For more Contact Valerie Fernandez, CME Coordinator, at (904) 202-2080 information, visit www.visionexpoeast.com. or [email protected]. For more information, visit ■ 30-31. 25th Anniversary of the Cogan Ophthalmic History FinalEyesCE.com. Society. National Library of Medicine, Bethesda, Md. Contact ■ 28. Snow School 2012. Great Wolf Lodge, Scotrun, Pa. Hosted George Bohigian, M.D., president, at [email protected] or visit by: The New Jersey Society of Optometric Physicians. CE hours: www.cogansociety.org for more information. 6. Call (609) 323-4012 or visit www.njsop.org. ■ 31-April 1. 6th Annual Conference on Comprehensive Eye February 2012 Care. Sheraton Hotel (formerly Crowne Plaza), Niagra Falls, N.Y. Hosted by: PSS EyeCare. CE hours: 16. Call (203) 415-3087 or ■ 17-19. 51st Annual Heart of America Contact Lens Society e-mail [email protected]. For more information, visit Contact Lens and Primary Care Congress. Hyatt Regency-Crown www.psseyecare.com. Center, Kansas City, Mo. Hosted by: Heart of America Contact Lens Society. CE hours: 57. Contact Dr. Steve Smith at (918) 341- April 2012 8211 or [email protected]. For more information, visit www. ■ 11-12. 2012 WOA Spring Seminar. Country Springs hoacls.org. Hotel, Waukesha, Wis. Hosted by: The Wisconsin Optometric ■ 18-22. Ski Vision 2012. Viceroy Snowmass Luxury Mountain Association. For more information, call (800) 678-5357 or visit Resort, Snowmass Village, Colo. CE hours: 23. Contact (888) www.woa-eyes.org. SKI-2530 or [email protected]. For more information, visit ■ 12-14. OptoWest 2012. Renaissance Esmeralda Resort and http://SkiVision.com. Spa, Indian Wells, Calif. For more information, call (800) 877-5738 ■ 19-26. Retinal and Optic Nerve Diseases: In-Depth or e-mail [email protected]. Visit www.optowest.com. Discussions. Royal Caribbean Cruise Line leaving from Ft. ■ 13-14. OAOP Annual Spring Congress. Embassy Suites & Lauderdale for Eastern Caribbean Cruise. Presented by: William Conference Center, Norman, Okla. Hosted by: the Oklahoma L. Jones, O.D. CE hours: 12. Call (800) 436-1028 or e-mail info@ Association of Optometric Physicians. CE hours: 21. For more drtravelinc.com. For more information, visit www.drtravel.com/ information, visit www.oaop.org. optometristsSeminars.html. ■ 14-15. 4th Annual Symposium on Ocular Disease. Crowne ■ 24-26. Annual AOS Meeting and CE Conference. Westin Plaza Hotel, Tyson’s Corner, Va. Hosted by: PSS EyeCare. CE Kierland Resort and Spa, Scottsdale, Ariz. Hosted by: The hours: 16. Call (203) 415-3087 or e-mail education@psseyecare. American Optometric Society. COPE CE hours: 14. For details com. For more information, visit www.psseyecare.com. and registration, visit www.optometricsociety.org. ■ 20-21. ■ 29-March 4. SECO 2012. Building A, Georgia World Educational Meeting 2012. Mission Inn, Howey-in- Congress Center, Atlanta. Hosted by: SECO International, LLC. the-Hills, Fla. Hosted by: the Florida Chapter of the American CE hours: 300+. Call (770) 452-0600 or e-mail registration@ Academy of Optometry. CE hours: 10. For more information, secostaff.com. For more information, visit www.seco2012.com. contact Arthur T. Young, O.D., at [email protected] or (239) 542-4627. March 2012 ■ 20-22. WFOA 2012 Spring Seminar. Sandestin Hilton Beach ■ 1-3. Big Sky Ski Conference. Huntley Lodge, Big Sky Resort, Destin, Fla. Hosted by: the West Florida Optometric Conference Center, Big Sky, Mont. Hosted by: The Montana Association. CE hours: 18. For more information, contact Tom

96 REVIEW OF OPTOMETRY JANUARY 15, 2012

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Streeter at (850) 279-4361 or [email protected]. Visit http:// Accutome, Inc...... 11 Nidek ...... 14 wfoameeting.com. Phone ...... (800) 979-2020 Phone ...... (800) 223-9044 ■ 21-22. 20th Annual Suncoast Educational Seminar. Hyatt Fax ...... (610) 889-3233 Fax ...... (510) 226-5750 Regency Clearwater Beach Resort & Spa, Clearwater Beach, Fla. Hosted by: The Pinellas Optometric Association. For more Advanced Vision Research/ Oculus, Inc...... 21 information, contact Dr. Bruce Cochran at (727) 446-8186. Akorn Pharmaceutical Phone ...... (888) 284-8004 ■ 25-29. 10th Annual New Jersey Chapter—American Company ...... 25 Fax ...... (425) 867-1881 Academy of Optometry. Kingston Plantation, Myrtle Beach, S.C. Phone ...... (800) 932-5676 CE hours: 16. For more information, contact Dennis H. Lyons, Fax ...... (800) 943-3694 Ocusoft ...... 31, 53 O.D., at (732) 920-0110 or [email protected]. Phone ...... (800) 233-5469 Alcon Laboratories ...... 40 Fax ...... (281) 232-6015 May 2012 ...... 41, 100 ■ 3-5. MWCO Annual Congress. Caesar’s Palace, Las Vegas. Phone ...... (800) 451-3937 Odyssey Medical ...... 55 Hosted by: Mountain West Council of Optometrists. Contact Fax ...... (817) 551-4352 Phone ...... (888) 905-7770 Tracy Abel, CMP, at (888) 376-6926 or [email protected]. Fax ...... (901) 382-2712 For more information, visit www.mwco.org. Allergan, Inc...... 17, 59, 60 ■ 18-20. Nova Southeastern University’s 16th Annual Clinical Phone ...... (800) 347-4500 Optos North America ...... 37 Eye Care Conference & Alumni Reunion. NSU College of Phone .... (877) 455-8855 x 100 Optometry. CE hours: TBD. Contact Vanessa McDonald, Amcon Laboratories, Inc. ..63 Fax ...... (508) 486-9310 MS, Manager of Continuing Education, at (954) 262-4224 or Phone ...... (800) 255-6161 [email protected]. For more information, visit http://optometry. Fax ...... (800) 397-0013 Rhein Medical ...... 13 nova.edu/ce...... www.amconlabs.com Phone ...... (800) 637-4346 Fax ...... (727) 341-8123 June 2012 Aton Pharma, Inc...... 18, 19 ® ■ 10-24. Majestic China 2012. Hosted by: iTravelCE, LLC. CE Phone ...... (609) 671-9010 Vision Source ...... 7 hours: 20. Contact Dr. Bridgitte Shen Lee, at (832) 390-1393 or Fax ...... (609) 671-9046 Phone ...... (281) 312-1111 [email protected]. For more info, visit www.itravelce.com. Fax ...... (281) 312-1153 ■ 21-24. Maui 2012. Wailea Beach Marriott Resort & Spa, Fashion Optical Displays ...... www.visionsource.com Maui, Hawaii. Contact Lois DiDomenico at ReviewMeetings@ ...... 35 Jobson.com or (866) 658-1772. For more information, visit Phone ...... (800) 824-4106 Vistakon ...... 9, 75, 80 www.revoptom.com/conferences. Fax ...... (530) 877-2013 Phone ...... (800) 874-5278 Fax ...... (904) 443-1252 July 2012 FCI Ophthalmics ...... 45 ■ 19-22. Caribbean 2012. Ritz Carlton, San Juan, Puerto Rico. Phone ...... (800) 932-4202 Vmax Vision, Inc...... 51 Contact Lois DiDomenico at [email protected] or Phone ...... (888) 413-7038 (866) 658-1772. For more information, visit www.revoptom.com/ Keeler Instruments ...5, 83, 99 [email protected] conferences. Phone ...... (800) 523-5620 www.VmaxVision.com Fax ...... (610) 353-7814 August 2012 Woodlyn ...... 23 ■ 3-5. Educational Retreat 2012. South Seas Island Resort, Lombart Instruments ...... 29 Phone ...... (847) 952-8330 Sanibel, Fla. Hosted by: Southwest Florida Optometric Phone ...... (800) 446-8092 Fax ...... (847) 952-0045 Association Inc. CE hours: 12. Contact Brad Middaugh, O.D., Fax ...... (757) 855-1232 at (239) 481-7799 or [email protected]. For more information, visit www.swfoa.com. Marchon ...... 2-3 Phone ...... (800) 645-1300 To list your meeting, contact: Fax ...... (800) 544-1334 Colleen Mullarkey E-mail: [email protected] This advertiser index is published as a convenience and not as part of the advertising contract. Every Senior Editor Phone: (610) 492-1005 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 JANUARY 15, 2012 97

096_ro0112_m&c.indd 97 1/9/12 4:25 PM Diagnostic Quiz

Right Between the Eyes By Andrew S. Gurwood, O.D.

History A 35-year-old black female presented following an emergency room visit for a chief complaint of pain around both eyes. The patient was in considerable distress, but did not report altered vision. She had no known ocular history and reported no allergies to medications. Diagnostic Data Her best-uncorrected visual acuity was 20/20 O.U. at distance and near. External examination was normal, and there was no evidence Our patient presented with pain around both eyes. What is your diagnosis? of afferent pupillary defect. The anterior segments of both Your Diagnosis prognosis? eyes were normal underneath the How would you approach this To find out, visit www.revop- swollen adnexa. Intraocular pres- case? Does this patient require tom.com. Click on the cover icon sure measured 19mm Hg O.U. any additional tests? What is your for this month’s issue, and then The dilated fundus findings were diagnosis? How would you man- click “Diagnostic Quiz” under the normal. age this patient? What’s the likely table of contents. ■

Retina Quiz Answers (from page 81): 1) c; 2) a; 3) c; 4) a.

Next Month in the Mag And... Our February issue covers the latest research in pharmaceuticals. • Don’t miss our annual Ophthalmic Product Guide. Topics include: • Optometric Study Center: Topical and Oral Prescribing for Feedback Pain Management (earn 2 CE credits) Review of Optometry welcomes questions and comments. E-mail •Cost vs. Efficacy of Generic and Substitution Pharmaceuticals Amy Hellem, editor-in-chief, [email protected], with “Letter to Also in February: the Editor” as the subject line. •Are SiHi Lenses Living up to Their Promise? Or, write to Review of Optometry, 11 Campus Blvd., Suite 100, • Pseudoexfoliative Glaucoma Management Newtown Square, PA 19073. •Special Diagnostic Equipment for a Pediatric Population • Counseling, Educating and Managing the New Presbyope

REVIEW OF OPTOMETRY (ISSN 0147-7633) IS PUBLISHED MONTHLY, 12 TIMES A YEAR BY JOBSON PUBLISHING LLC., 100 AVENUE OF THE AMERICAS, NEW YORK, NY 10013- 1678. JOBSON PUBLISHING LLC, A WHOLLY-OWNED SUBSIDIARY OF JOBSON MEDICAL INFORMATION, LLC. PERIODICALS POSTAGE PAID AT NEW YORK, NY AND ADDITIONAL MAILING OFFICES. POSTMASTER: SEND ADDRESS CHANGES TO REVIEW OF OPTOMETRY, PO BOX 2025, SKOKIE, IL 60076. SUBSCRIPTION PRICES: US: ONE YEAR $56; TWO YEARS $97, CANADA: ONE YEAR $88, TWO YEARS $160, INT’L: ONE YEAR $209, TWO YEARS $299. FOR SUBSCRIPTION INFORMATION CALL TOLL-FREE (877) 529-1746 (USA ONLY); OUTSIDE USA, CALL (847) 763-9630 OR FAX (847) 763-9631. PUBLICATIONS MAIL AGREEMENT NO: 40612608. CANADA RETURNS TO BE SENT TO BLEUCHIP INTERNATIONAL, P.O. BOX 25542, LONDON, ON N6C 6B2.

98 REVIEW OF OPTOMETRY JANUARY 15, 2012

098_ro0112_dq_final.indd 98 1/5/12 10:03 AM Has the rising cost of tonometry raised YOUR pressure?

Lowest Price No Consumables Easiest to Use Smallest Footprint

Dr. Scott, Keeler is right. Our other tonometer is costing us a fortune each year. Then purchase the tonometer that PAYS YOU BACK every time you use it. Ex. Consumables: $1.00 Per Eye, 3XOVDLULQWHOOL3XIIGHOLYHUVIDVWDFFXUDWHUHVXOWVZLWKRXW Patients Per Week: 35 x 50 weeks LQFXUULQJGDLO\FRQVXPDEOHVFRVWV:LWKRXUH[FOXVLYHOHG WHFKQRORJ\WKHFRVWRI\RXULQYHVWPHQWZLWK.HHOHUZLOO Cost Per Year = $3,500 on avg. QHYHULQFUHDVH\RXUSUHVVXUH1RFRQVXPDEOHVUHTXLUHG New Pressure Reducing Price Just in Consumables! $3,495.00 We should get a Keeler!

.HHOHU,QVWUXPHQWV,QF3DUNZD\%URRPDOO3$7HO )D[ HPDLONHHOHU#NHHOHUXVDFRP

RO0811_Keeler Intell.indd 1 7/26/11 10:25 AM Now there’s a better way to give today’s contact lens wearers comfort and moisture from morning to night.1†

Reference: 1. Lemp, J., Garafolo, R., Napier, L., Stein, J., Lally, J. Clinical Assessment of an Investigational Multi-Purpose Disinfecting Solution. Poster presented at: AOA, June 18, 2011; Salt Lake City, UT. © 2011 Novartis 9/11 OPM12007JAD † Better than a fishbowl

RO0112_Alcon Opti.indd 1 12/27/11 10:30 AM