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Christmas Eye • 6 months use after opening It’s not what you think

Member-submitted case reports OCT for VMT by Rose Huang

Thygeson’s superficial punctate keratopathy by Anna Delmadoros

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From the Editors As the diverse range of topics covered in this issue of Pharma plainly shows, the practice of optometry is full of 02 12 surprises. Non-arteritic anterior Contact lenses: beyond ischemic optic 2020 Consider Rob Holloway's article on ‘Christmas Eye,’ proba- neuropathy Dr Lyndon Jones, Deborah bly one of the most unusual corneal conditions in the field Jue Wang, Dr Thanh Jones and Rebecca Jones of optometric health. A form of acute toxic keratitis that is Nguyen and Dr Kwang found primarily in Australia’s south east from November Meng Cham 14 to February, Christmas Eye, as Rob Holloway explains, is associated with pain that has reached ‘folkloric levels.’ FEATURED MEMBER 04 RESOURCE Another surprising article, by Debra Gleeson, traces the MEMBER CASE REPORT Reference guide: red eye increase in reported incidents of tattoo-related uveitis conditions (TAU) and may lead you to take a professional interest in OCT for VMT Optometry Australia your patients’ tattoos. It may also provide an opportunity Rose Huang to call upon your local tattoo parlour for a professional consultation. 16 06 Gut flora: why optometrist In this issue, we also commemorate a milestone with the Contact lens prescribing should be paying publication of the 20th annual contact lens prescribing trends: 20th annual attention trends survey results by Efron, Morgan and Woods. survey Julie Newport Professor Nathan Efron, Finally, this issue marks the first time that we have pub- Professor Philip B Morgan lished member-submitted case reports. In response to our 18 and Professor Craig A call for papers at the beginning of the year, Rose Huang Woods Revisiting presents an informative review of the use of OCT to diag- 'Christmas Eye' nose bilateral dynamic vitreomacular traction. And Anna Robert Holloway Delmadoros shares an illuminating case report on Thyge- 08 son’s superficial punctate keratopathy. CXO featured article: 22 The editors strongly believe that Pharma serves the mem- Low-dose brimonidine for TAU: Tattoo-associated bers of Optometry Australia best when it offers a place for relief of ocular redness: uveitis them to exchange ideas and to pursue learning opportuni- integrated analysis of ties at a pace conducive to their busy schedules. four clinical trials Debra Gleeson Dr Stacey L Ackerman, We invite all the members of Optometry Australia and Dr Gail L Torkildsen, Dr 26 the New Zealand Association of Optometry to submit Eugene McLaurin and their own case reports for consideration in 2020. Dr Jason L Vittow MEMBER RESOURCE PBS list of medicines Send a 200-word explanatory summary of your case prescribed by report to [email protected]. 10 optometrists MEMBER CASE REPORT Thygeson's superficial This issue of Pharma offers punctate keratopathy 6 (4T) CPD points. Anna Delmadoros

Editor JEFF MEGAHAN Cover 'Christmas Eye' by Lachlan Hessing. Pharma is distributed in Australia and New contributors expressly disclaim all [email protected] Photo by Vance A on Unsplash. Zealand. All references to pharmaceutical liability and responsibility to any person preparations in Pharma are applicable within in respect of, and for the consequences Clinical Editor KERRYN HART Optometry Australia ABN 17 004 622 431 Australia. of, anything done or omitted to be done in BOptom GCertOcTher MPH Level 1, 201 Clarendon Street Comments made in Pharma are of a general reliance wholly or partly on anything in this Teaching Scholar, Deakin University South Melbourne VIC 3205 publication. Ph 03 9668 8500 nature and intended for guidance only. Publications Manager JESSICA DONALD www.optometry.org.au Optometry Australia and the individual Copyright © 2019 2 DECEMBER 2019

Non-arteritic anterior ischemic optic neuropathy An atypical presentation

Jue Wang BOptom OcTher Bupa Optical, Victoria

Dr Thanh Nguyen MBBS PhD FRANZCO Centre for Eye Research Australia, University of Melbourne, Victoria

Dr Kwang Meng Cham PhD BOptom GCertUniTeach PGCertOcTher Figure 1. Note the inferior-temporal optic nerve pallor in the right eye (arrow). The left optic Department of Optometry and nerve was normal. Vision Sciences, The University of Melbourne, Victoria eye. Anterior slitlamp biomicroscopy negative NMO-IgG and MOG antibodies. evaluation was unremarkable. A dilated The vision in the right eye had fundus examination revealed right optic improved to 6/18 and the visual field disc pallor inferior-temporally while the defect showed mild improvement. Non-arteritic anterior ischemic optic left optic nerve appeared normal (Figure After considering the patient profile neuropathy (NAION) is the most 1). The maculae and retinal periphery and all clinical findings, the patient common type of acute optic neuropathy examination was normal in both eyes. was diagnosed with NAION. He in people over 50 years of age, and it was discharged from the neuro- affects every two to 10 individuals per The patient was urgently referred to a ophthalmologist and a 12-month review 100,000.1 Approximately 95 per cent medical retinal specialist for assessment with the optometrist was scheduled. of all ischemic optic neuropathy cases and evaluation of the possible optic are NAION.1 NAION results from an nerve neuropathy. Optical coherence The patient returned to the practice in ischemic damage of the anterior portion tomography (OCT) (Figure 2) showed March 2019. His vision in the right eye of the optic nerve head secondary to diffuse retinal nerve fibre layer thinning remained at 6/18 with stable optic nerve infarction of the short posterior ciliary in the right eye, with a right superior head appearance (Figure 3). The left artery, leading to axonal oedema and altitudinal visual field defect on eye remained normal. The patient was consequently painless vision loss.2 central 24-2 threshold testing. An MRI advised to seek prompt assessment and scan of the brain with angiography treatment if any form of vision loss or and venography demonstrated no visual disturbance is observed in either CASE REPORT intracranial or orbital space occupying eye. lesion, aneurysm or demyelination. A blood work-up did not detect any Discussion A 56-year-old male patient attended systemic infection or inflammation. the practice in October 2017 with a In this case report, the patient described two-week onset of blurry vision in his The patient was subsequently referred his vision loss as a ‘blur of the top half right eye. The patient described his to a neuro-ophthalmologist who of his vision,’ which is a typical way of vision as ‘only bottom-half visible.’ He performed antibody testing for myelin describing the symptoms of NAION.3 reported no flashes of light, floaters, or oligodendrocyte glycoprotein (MOG) Findings of a relative afferent pupillary any change in his physical or mental and neuromyelitis optica (NMO-IgG) defect and red cap desaturation, health status. He did not take regular to rule out autoimmune conditions. though non-specific, can indicate medications and was a non-smoker who On the basis of difficulty in confirming unilateral or bilateral asymmetric drunk alcohol occasionally. diagnosis retrospectively, a provisional optic neuropathy. NAION typically diagnosis of non-arteritic anterior causes (inferior) altitudinal and arcuate On examination, his vision was 6/24 ischemic optic neuropathy (NAION) visual field defects and does not lead in the right eye with no improvement was made and a follow-up in eight to dyschromatopsia due to sparing of with pinhole testing. The left eye weeks was scheduled. central nerve fibres.3,4 achieved 6/6. A right relative afferent pupillary defect was detected; red cap At the follow-up appointment, the Diffuse or sector optic disc oedema is testing showed desaturation in the same neuro-ophthalmologist confirmed observed during the acute phases of DECEMBER 2019 3

three months. The visual prognosis of NAION is mostly guarded, with studies reporting vision improvement by three lines in more than one-third of patients.3,7 The visual field defect is unlikely to show major improvement. The rate of recurrence in the same eye is less than five per cent,3 and the possibility of fellow eye involvement is approximately 15 per cent over five years.8 When the fellow eye develops NAION, the impact of vision and visual field loss cannot be predicted from the prognosis of the previously affected eye.9

NAION is a common sight-threatening disease with unknown pathophysiology. When a patient presents with atypical visual complaints, optometrists need to be proficient and proactive in conducting a targeted history, performing relevant entrance tests, and be aware of the life-threatening Figure 2. Diffuse retinal nerve fibre layer thinning in the right differentials. This case report has eye. The left eye appeared normal. illustrated the importance of multi- disciplinary collaborative assessment and management in providing best NAION, which is important for clinical hypotension, hypertension, diabetes, patient care and delivery. This patient diagnosis. Within the next two to three hypercholesterolemia, sleep apnoea and will require an ongoing 12-month months, optic atrophy occurs.3 In our smoking may increase the risk of optic review in the future due to significant case, the patient waited too long to seek nerve head hypoperfusion leading to risk to the fellow eye. help since early intervention using NAION.2,6 steroids or neuroprotective agents may 1. Johnson LN, Arnold AC. Incidence 5 of nonarteritic and arteritic anterior improve visual performance, and it also The most critically important ischemic optic neuropathy. Population- made the diagnosis challenging. differential diagnosis is arteritic anterior based study in the state of Missouri ischemic optic neuropathy secondary and Los Angeles County, California. J Neuroophthalmol 1994; 141: 38-44. The exact cause of the ischemic event to giant cell arteritis, which is life 2. Berry S, Lin WV, Sadaka A et al. in NAION remains unknown. Risk threatening as well as the significant Nonarteritic anterior ischemic factors include a small/’crowded disc’ risk of visual loss to the other eye. The optic neuropathy: cause, effect, and management. Eye Brain 2017; 9: 23–28. with small cup-to-disc ratio, which other main differential diagnosis is optic 3. Miller NR, Arnold AC. Current concepts has been referred as ‘structural disc at neuritis secondary to multiple sclerosis. in the diagnosis, pathogenesis and risk’ for NAION (the patient presented In these instances, a comprehensive management of nonarteritic anterior ischaemic optic neuropathy. Eye (Lond) here does not have the typical small systemic evaluation, including 2015; 29: 65–79. optic disc/disc at risk); optic disc neuroimaging, is essential to make an 4. Kerr NM, Chew SS, Danesh-Meyer HV. drusen which may disrupt blood accurate diagnosis. Non-arteritic anterior ischaemic optic 6 neuropathy: a review and update. J Clin flow causing ischemia; and other Neurosci 2009; 16: 994-1000. systemic conditions such as nocturnal NAION stabilises within two to 5. Cohen DN. Drusen of the optic disc and the development of field defects.Arch Ophthalmol 1971; 85: 224-226. 6. Hayreh SS, Zimmerman MB, Podhajsky P et al. Nonarteritic anterior ischemic optic neuropathy: role of nocturnal arterial hypotension. Arch Ophthalmol 1997; 115: 942–945. 7. Optic nerve decompression surgery for nonarteritic anterior ischemic optic neuropathy (NAION) is not effective and may be harmful. The Ischemic Optic Neuropathy Decompression Trial Research Group. JAMA 1995; 273: 625–632. 8. Newman NJ, Scherer R, Langenberg P et al. The fellow eye in NAION: report from the ischemic optic neuropathy decompression trial follow-up study. Am J Ophthalmol 2002; 134: 317-328. 9. Kupersmith MJ, Frohman L, Sanderson M et al. Aspirin reduces the incidence of second eye NAION: a retrospective study. J Neuroophthalmol 1997; 17: 250–253. Figure 3. Optic atrophy in the right eye. The left optic nerve remained normal. 4 DECEMBER 2019

OCT for VMT Ocular coherence tomography for management of vitreomacular traction

Rose Huang This original case report was submitted by fellow Optometry Australia BOptom BVisSc member Rose Huang in response to our nation-wide call for papers.

Malinda Halley Optometrist Dapto, NSW age-related macular degeneration Generally, there is minimal effect on (AMD) and diabetic clinically- visual acuity with most patients able significant macular oedema (CSME), to attain 6/6–6/12 vision, however in VMT may be exacerbated.5 certain cases central metamorphopsia may be observed on the Amsler Grid, A 66-year-old Caucasian female however this is more commonly With the introduction of optical presented complaining of discomfort associated with non-multifocal pattern coherence tomography (OCT) and and an intermittent bilateral central dystrophies.7 Therefore symptoms recent studies, we have been able scotoma blur with and without glasses. were not associated with underlying to better visualise and understand The symptoms had started months pattern dystrophy. the vitreomacular interface and ago, however had gradually worsened, therefore provide a better diagnosis, and consequently she was now having A symptom diary was administered management and prognosis for our difficulty with crocheting, knitting and so she could better identify the 1 patients. reading. nature of her problems. Upon review, she could confidently pinpoint that When the anterior vitreous pulls, it Examination through a dilated pupil accommodation and near-tasks were can cause asynchronous weakening revealed pattern macular dystrophy. the causative factors. She graded her in areas of attachments which may Otherwise posterior health was symptoms as severe and the only ultimately lead to anomalous posterior unremarkable. Pattern macular management which worked was rest vitreous detachments. These can often dystrophy presents as bilateral, breaks or sleep. result in vitreomacular traction (VMT) multiple, yellow vitelliform lesions and other vitreoretinal diseases. VMT and are autosomal dominant in nature. As her symptoms were elicited is characterised by the incomplete It typically presents between the ages by near-based work, an OCT was vitreous detachment and persistent of 40–60.6 performed prior to 30 minutes of 2 macular adherence. crocheting (Figures 1A, 2A, 3A and

Static anterior traction can result in foveal elevation or distortion, yet patients are often asymptomatic. It is the dynamic traction which is associated with ocular rotations and eye movements which ultimately lead to the most pronounced symptoms. These eye movements are often related to accommodation and downward head posture.3 A B It is interesting to note that the Figure 1. A: Right eye before near work. B: Right eye 30 minutes post near work. tractional effects are largely determined by the strength and size of the residual vitreoretinal adhesion, with a smaller diameter associated with higher tractional stress and consequently greater foveal involvement and retardation. Generally, a vitreofoveal adhesion ≤ 500 μm is more symptomatic and commonly associated with a microhole, lamellar hole and full- A B 4 thickness macular hole. In patients Figure 2. A: Left eye before near work. B: Left eye 30 minutes post near work. with concurrent diseases such as wet DECEMBER 2019 5

4A) and then repeated post crocheting A B (Figures 1B, 2B, 3B and 4B). Although the patient was told to crochet for 30 minutes, within 10–15 minutes she had largely given up.

In early stages, it is not unusual for the outer retina to appear intact. Figures 1B and 2B show moderate inner retinal layer distortion, however the outer retina is largely preserved.

The OCT scans show subtle changes in the macular thickness profile and foveal elevation following near work (Figures 3B and 4B). It can be argued Figure 3. A: Right eye macular thickness analysis before near work. B: Right eye macular thick- that there are already early changes in ness analysis after near work. the outer retina morphology, which increases the risk for a microhole, lamellar hole or macular hole. A B

Diagnosis The patient was diagnosed with bilateral dynamic VMT induced by accommodation.

The prevalence of VMT without the incidence of a macular hole has been estimated as approximately 22.5 cases per 100,000, with an incidence of 0.6/100 000 persons per year. The mean age of patients is estimated around 65–70 years, with a predominance of females.8 Figure 4. A: Left eye macular thickness analysis before near work. B: Left eye macular thick- Once a mydriatic has been instilled ness before after near work. for dilation, accommodation will be blocked and therefore symptoms cannot be detected. A 10-2 was thickness macular hole after a mean of incomplete posterior vitreoschisis performed, however as expected, follow-up of 11.4 ± 12.6 months. with vitreomacular traction syndrome and impending macular hole: a case results were within normal limits, as it report. Eur J Ophthalmol 2008; 18: 147- is difficult to induce symptoms in an The baseline OCT may predict 149. upright situation. There was, however, 3. Griffin D, Tadrus M, Jensen R et al. progression to a full-thickness macular Symptomatic dynamic vitreomacular distortion on the Amsler Grid in both hole, with patients presenting with traction induced by near-vision. Retin eyes. intraretinal cysts, clefts and foveal Cases Brief Rep 2016; 10: 214-216. 9 4. Spaide RF, Wong D, Fisher Y et al. detachment more likely to advance. In Correlation of vitreous attachment and these patients, the foveal detachment Management foveal deformation in early macular secondary to severe traction hole states. Am J Ophthalmol 2002; 133: As visual acuity was excellent, an 226–229. would cause a central scotoma and 5. Johnson M. Posterior vitreous initial conservative approach was unfortunately lead to a drop in visual detachment: evolution and chosen. Ultimately as the anterior acuity and therefore surgical options complications of its early stages. Am J Ophthalmol 2010; 149: 371-382 interface detaches from the site of the of intravitreal injections or vitrectomy 6. Marmor M, Byers B. Pattern dystrophy vitreofoveal attachment, symptoms may be the more viable option.10 of the pigment epithelium. Am J should resolve. Not surprisingly, Ophthalmol 1977; 84: 32-44. 7. Kellner U, Jandeck C, Kraus H et al. the patient returned six weeks later In conclusion, cases of transient blur Hereditary macular dystrophies. Der and requested to go ahead with the after near-work should be further Ophthalmologe 1998; 95: 597-601. vitrectomy and consequent cataract investigated for potential dynamic 8. Johnson M. Perifoveal vitreous detachment and its macular surgery. Post-operation, she was able vitreomacular traction syndrome. complications. Am J Ophthalmol 2006; to conduct near-based work again with 141: 792-793. ease. 1. Duker J, Kaiser P, Binder S et al. 9. Wu L, Zas M, Berrocal M et al. The international vitreomacular Anatomical and functional outcomes of traction study group classification of symptomatic idiopathic vitreomacula In a recent study, spontaneous vitreomacular adhesion, traction, and traction. Retina 2016; 1913–1918 resolution of VMT occurred in 21.4 per macular hole. Ophthalmology 2013; 120: 10. Bottós J, Elizalde J, Arevalo JF et al. 2611-2619. Vitreomacular traction syndrome. J cent of patients while 7.7 per cent of 2. Figus M, Carpineto P, Romagnoli M et al. Ophthalmic Vis Res 2012; 7:148–161. subjects developed a lamellar or full- Optical coherence tomography findings 6 DECEMBER 2019

Open access and online Contact lens www.optometry.org.au prescribing trends 2019 20th ANNUAL SURVEY Efron, Morgan and Woods report on Professor Emeritus Nathan Efron AC PhD DSc their 20th annual survey of Australian Institute of Health and Biomedical Innovation, and School of Optometry, contact lens prescribing habits QUT, Brisbane, Australia or extended wear) and care system. frequency of fitting contact lenses were Professor Philip B Morgan Practitioners were asked to return the afforded a higher weighting than those PhD photographed or scanned copies of the with a lower frequency of fits. questionnaire by email. Eurolens Research, the University The discussion below will concentrate of Manchester, Manchester, UK Completed questionnaires relating to primarily on data relating to new lens 502 contact lens fits were returned, fits, as opposed to refits. We believe that Professor Craig A Woods which provides a sound basis for a new fits are a more sensitive barometer PhD meaningful analysis. Each fitting was of current patterns and future trends, given an annualised weighting based whereas refits are more indicative of School of Medicine (Optometry), on the number of lenses fitted during previous fitting behaviours. Deakin University, Geelong, the survey period and the time taken to Australia complete the fits. This means that data In keeping with other markets around generated by practitioners with a higher the world,1 a majority of lenses (65

Materials Designs Replacements

The 20th annual survey of Australian

contact lens prescribing was conducted New fits during the first three months of 2019. The same format as in previous years was employed. An email was sent to all Low WC - 1% Sphere - 26% Daily - 63% members of Optometry Australia with Mid WC - 4% Toric - 26% Weekly to fortnightly - 8% a link to a questionnaire, and a request High WC - 15% Multifocal - 27% Monthly - 28% that this be downloaded, printed and Si-H - 79% Monovision - 4% Unplanned - 1% completed to provide details of the first Myopia control - 17% ten patients fitted with contact lenses after receipt of the questionnaire. The

survey was specifically designed to Refits be straightforward to complete while capturing key patient information.

Practitioners were asked general Low WC - 1% Sphere - 44% Daily - 52% questions about themselves. For each Mid WC - 6% Toric - 18% Weekly to fortnightly - 12% contact lens fitting, they were requested High WC - 14% Multifocal - 20% Monthly - 34% Si-H - 80% Monovision - 16% 3-6 monthly - 1% to complete the following details: date Myopia control - 2% of fitting, new fitting or refitting, age and sex of patient, lens material, lens design, frequency of replacement, Figure 1. Detailed results for soft contact lens prescribing in the 2019 Australian survey (Si-H: times per week of wear, modality (daily silicone hydrogel; WC: water content). DECEMBER 2019 7

per cent) were fitted to females. The average age of contact lens wearers at the time of fitting has increased over the past two decades, from 32 in 2000 to 37.0 ± 17.4 years this year. The age at fitting ranged from 1 to 89 years.

Soft lens materials and designs Soft lenses are still the main type of contact lens fitted, accounting for 90 per cent of new fits; soft lenses have represented the vast majority of contact lens fits since our survey began two decades ago.2

Figure 1 is a composite of pie charts detailing the key findings of the 2019 survey in relation to soft lenses. Figure 2. Proportion of all fits of various soft lens material types in Australia Silicone hydrogels are still the between 2000 and 2019 (Si-H: silicone hydrogel; WC: water content) dominant material, representing 79 and 80 per cent of materials prescribed as new fits and refits, respectively, with the balance comprising mainly of mid- and high-water content hydrogel materials.

The key categories of lens designs are spherical, toric, multifocal, monovision, coloured (tinted) and myopia control. Spherical and toric designs each represented 26 per cent of new fits (Figure 1).

Figure 2 shows trends in contact lens materials prescribed over the past two decades. It can be seen that there was a gradual increase in silicone hydrogel prescribing from 2000 to 2017, which has remained steady since then. The reason for the popularity of Figure 3. Proportion of all fits of soft lens lenses according to replacement this highly oxygen-permeable material frequency in Australia between 2000 and 2019 type is that it essentially eliminates hypoxic complications such as limbal and conjunctival redness, stromal oedema, corneal neovascularisation and Myopia control lenses incorporate per cent). Trends since 2000 in soft epithelial microcysts.3 special designs for arresting the rate of lens fitting according to replacement progression of myopia.4 This year saw a frequency are shown in Figure 3. Daily Multifocal designs (27 per cent of sudden surge of interest in prescribing disposable lenses now dominate the new fits) continue to be preferred to for myopia control, with such lenses Australian market, with the level of monovision (four per cent) for the representing 17 per cent of new fits. prescribing of this modality remaining correction of presbyopia. This trend, This sudden increase may be related to relatively constant at above 60 per cent which has been evident since the turn the recent introduction into Australia of since 2015. of the century, largely can be attributed the MiSight lens (CooperVision), which to improved multifocal lens designs. is specifically designed for myopia Extended wear lens fitting, almost The fact that almost one-third of control. As well, the considerable exclusively with silicone hydrogel soft lens fits are for the correction of discussion and debate in the literature, materials, has remained constant at presbyopia highlights the importance at conferences and in online forums under 10 per cent of all lens fits over of this growing demographic in modern has undoubtedly fuelled interest in this the past decade, and has dropped to a day contact lens practice. modality of lens correction. low point of five per cent of all lens fits in 2019. Coloured (tinted) lenses do not seem Soft lens replacement and wearing to be popular in Australia; in fact, no Multi-purpose solutions are now used modality coloured lens fits were recorded in our almost exclusively by those wearing 2019 survey. Virtually all soft lenses are replaced daily (63 per cent) or monthly (28 Continued page 8 8 DECEMBER 2019

as being at the forefront of contact CL trends 2019 lens prescribing, with Australian CLINICAL AND EXPERIMENTAL optometrists being ‘early adopters’ of From page 7 new technologies. As well, the rate of rigid lens prescribing is higher in reusable lenses, with this solution type Australia than world averages. representing 98 per cent of prescribed care regimens. The balance is peroxide Conclusions systems. The results of our 2019 survey confirm the ongoing high rate of Dr Stacey L Ackerman Australia versus the world prescribing of silicone hydrogel MD We conduct annual contact lens fitting materials and daily disposable Philadelphia Eye Associates, surveys in about 40 countries each lenses in Australia. The sudden Philadelphia, Pennsylvania, USA year.1 This provides an opportunity spike in prescribing of lenses for myopia control is perhaps the stand- to benchmark against international Dr Gail L Torkildsen out highlight of our 20th anniversary colleagues, and this year we compare MD contact lens prescribing in Australian report; it will be interesting to see if against world trends (the latter derived this very high rate of prescribing of Andover Eye Associates, from 2018 data1) (Figure 4). Seven key this lens type is sustained into the Andover, Massachusetts, USA categories of lens type are represented. future. The outer and inner rings display the Dr Eugene McLaurin Australian and world-wide fitting data,1 MD FACS respectively. 1. Morgan PB, Woods CA, Tranoudis Total Eye Care, P.A., IG et al. International contact lens Perhaps the greatest difference revealed prescribing in 2018. Contact Lens Memphis, Tennessee, USA Spectrum 2019; 34: 26-32. in Figure 4 is that daily disposable 2. Morgan PB, Efron N, Helland M et al. silicone hydrogel lenses – widely How does the UK market compare Dr Jason L Vittitow believed to be the most advanced with other countries? Optician 2001; PhD 221: 26-32. lens type in terms of eye health – are 3. Efron N. Contact Lens Complications. Clinical Affairs, Bausch + Lomb, prescribed at more than twice the rate 4th edition. Edinburgh: Elsevier, in Australia (35 per cent) compared 2019. Bridgewater, New Jersey, USA 4. Sankaridurg P. Contact lenses to slow with the rest of the world (17 per cent). progression of myopia. Clin Exp Australia has always been recognised Optom 2017; 100: 432-437.

Brimonidine is a drug that most optometrists would associate with 5% treatment for glaucoma due to its 10% action as an alpha 2 agonist. In Australia, it is available in both 3% 0.2 and 0.15% concentrations and 7% 7% 2% is branded as Alphagan. At these concentrations, brimonidine acts 10% to increase aqueous outflow and 13% Soft EW decrease aqueous production. In a 30% Reusable Si-H recent paper published in Clinical Outer ring Reusable hydrogel and Experimental Optometry authors Australia 2019 Ackerman, Torkildsen, McLaurin and DD Si-H Vittitow present an alternate use of Inner ring DD hydrogel World 2018 17% low-dose brimonidine: as a topical OK vasoconstrictor for the relief of ocular 47% Rigid (non OK) redness.

A red eye can be a result of a multitude 10% of causes including allergy, infection, 5% dry eye, contact-lens wear and exposure to environmental stimulants. 35% In clinical practice, in order to treat a red eye, the cause should first be identified so that management can be appropriately targeted. When ocular Figure 4. Percentage of all contact lenses prescribed in Australia (2019, outer ring) redness, with no identifiable cause, compared with the world (2018, inner ring). (EW: extended wear; Si-H: silicone hydrogel; becomes part of a person’s baseline DD: daily disposable; OK: orthokeratology). characteristics, over-the-counter DECEMBER 2019 9

Pharma and Optometry Australia’s official journal Clinical and Experimental Optometry (CXO) are collaborating to bring our readers up to date with some of the most interesting articles, reviews and original research available in the latest issues of CXO.

Low-dose brimonidine for relief of ocular redness: integrated analysis of four clinical trials redness, it was found to be significantly Summary and comment provided by Maria Markoulli lower to that of the vehicle alone at all PhD MOptom GradCertOcTher FBCLA FAAO post-instillation time-points and that Deputy Editor, Clinical and Experimental Optometry was the case both when the clinician assessed the ocular redness and when Senior Lecturer Postgraduate Research Coordinator the participants assessed their own School of Optometry and Vision Science, UNSW Sydney ocular redness.

Tachyphylaxis was not apparent and rebound redness was rare. Adverse vasoconstrictors or decongestants The authors of this study hypothesised events reported were low and included may be recommended in order to that, given its affinity forα 2 receptors a reduction in visual acuity in four per temporarily manage the appearance. which are expressed primarily in cent of cases on brimonidine and 4.3 veins, brimonidine would be less per cent of cases on the vehicle and Vasoconstriction is achieved with likely to result in rebound redness and conjunctival hyperaemia in 2.6 and drugs with alpha-adrenoceptor agonist tachyphylaxis. In the USA, a low-dose 2.9 per cent, respectively. There was activity (α-agonists) by binding to version (0.025%) of brimonidine has no difference in the reported comfort α-receptors on vascular smooth muscle. received approval for ocular redness by between the drops or between other This acts to induce vasoconstriction, the Food and Drugs Authority (FDA). measures. Analysis of plasma samples hence reducing the appearance of The authors of this study therefore set in the pharmacokinetic study showed ocular redness. A limitation of this out to report on the efficacy and safety concentrations of brimonidine were class of drugs is that their continued profile of low dose brimonidine for below the lower limit of detection at all use results in tachyphylaxis, or idiopathic ocular redness. time points. tolerance, so that rebound redness results, particularly when the treatment The authors collated the data of four The authors concluded from this work is discontinued. studies that included participants who that low-dose brimonidine reduces were prescribed low-dose brimonidine ocular redness without tachyphylaxis Vascular smooth muscle has two four times a day for 28 days (three over a 28-day instillation process, types of alpha-adrenoceptors: alpha1 studies) or a single dose followed by and with a low risk of both ocular (α1) and alpha2 (α2). While α1- four times a day for five days. The two and non-ocular adverse events. adrenoceptors are the predominant studies that explored the efficacy of Brimonidine 0.025% is currently not α-receptor located on vascular smooth brimonidine were randomised and available in Australian pharmacies. muscle, depending on the tissue and double-masked, with participants Until it is commercially available, most type of vessel, α2-adrenoceptors can randomised to the brimonidine or the ophthalmic compounding pharmacies also be found on smooth muscle. vehicle. The potential for tachyphylaxis in Australia make the 0.025% mixture. Different vasoconstrictors have differing was determined by evaluating the (See list of ophthalmic compounding affinity for each of these receptors. change from pre-instillation to five- pharmacists on page 28 of this issue). Phenylephrine, for example, is selective minutes post-instillation on day 15 for α1 receptors, while naphazoline compared to day 29 of the study. Safety Ackerman, Torkildsen, McLaurin et binds to both α1 and α2 receptors. was evaluated with plasma collections al. Low-dose brimonidine for relief of at various time points post-instillation ocular redness: integrated analysis of It is thought that tachyphylaxis relates in order to establish brimonidine four clinical trials. Clin Exp Optom to a reduction in the α1 receptor plasma concentrations. Safety was also 2019; 102: 131–139 response as a result of chronic exposure determined by monitoring visual acuity, to α1-agonists, with a subsequent the ocular surface, fundus, intraocular Clinical and Experimental Optometry rebound in redness due to loss of pressure and vital signs. Rebound is the official journal of Optometry vascular tone. Brimonidine is a redness was also measured as part of Australia, the New Zealand Association highly selective α2-receptor agonist, the safety assessment, as was comfort. of Optometrists, the Hong Kong Society meaning that it is not susceptible to of Professional Optometrists and the a reduction in α1 receptor response. When the investigators assessed ocular Singapore Optometric Association. 10 DECEMBER 2019

Thygeson's superficial punctate keratopathy

Anna Delmadoros This original case report was submitted by fellow Optometry Australia MOptom BOptom(Hons) member Anna Delmadoros in response to our nation-wide call for papers. Grad Cert Oc Ther

School of Optometry and Vision Science, UNSW Sydney in the literature.2,6 There is no cure for unlikely. TSPK. Management approach was conservative While TSPK is an uncommon condition, given the mild symptoms and Thygeson’s superficial punctuate it should be considered as a differential corticosteroids possibly contraindicated; keratitis (TSPK), first described in cases of chronic non-specific ocular existing drops were discontinued, by Phillips Thygeson in 1950,1 is discomfort and is therefore an important and non-preserved artificial tears a relatively uncommon, recurrent condition for eye-care practitioners were recommended every 1–2 hours and chronic non-infectious corneal to recognise and manage. A case is and ointment before bed; advice was condition that is typically bilateral presented where, after 11 months to return immediately if symptoms and asymmetric.1-5 It has no sex of misdiagnosis, the condition was worsened. Review at 24 hours revealed predilection and no age bias.2,6 The eventually diagnosed as TSPK and an unchanged appearance of the corneal prevalence of the condition is unknown successfully managed. lesions. and the underlying aetiology remains controversial.1-5 A 22-year-old Caucasian female first Significant improvement in symptoms presented to the clinic reporting an was reported at the follow-up visit three Diagnostic features of TSPK are 11-month history of recurrent episodes days later, although the patient reported multiple, mildly elevated, whitish/ of moderate-to-severe light sensitivity, some impracticalities in maintaining grey granular or stellate intraepithelial watery, stinging eyes and gritty 1–2 hourly dosing and an aversion to the opacities, occurring predominantly in sensation that lasted 5–7 days, occurring ointment. Acuities remained unchanged the central cornea, in the absence of approximately every 4–5 weeks. The and besides a reduction in the number of accompanying oedema or conjunctival ocular discomfort on the day was lesions, eyes continued to be white and involvement.1-4 Symptoms vary in degree subjectively graded as 3 out of 10, with quiet. The marked corneal improvement and include photophobia, foreign body reports of grade 8 discomfort in prior and absence of any dendritic lesions sensation and lacrimation.2 Visual acuity instances. She denied ocular redness, solidified the diagnosis and led to may be slightly reduced depending discharge and/or contact lens wear and management with preservative-free on the density and location of the medical history was unremarkable. ocular lubricants three times a day and opacities.2,3 to return for review at the next flare up. She reported consulting several eye- A hallmark feature of TSPK is the care practitioners, each with conflicting Three weeks later, the patient presented presence of active and quiescent phases, diagnoses. Various topical preparations with symptoms identical to previous which vary in duration and frequency.1-3 were prescribed including ocular occurrences, this time with acuity mildly Symptomatic exacerbations lasting lubricants, Chloramphenicol 0.5% and reduced to 6/6-2 in the right eye and weeks to months appear to be sporadic Aciclovir 3% w/w ointment, all with 6/6-1 in the left. There were numerous and the triggers unknown.1,2 During minimal alleviation of symptoms despite grouped corneal intraepithelial lesions, periods of remission (months to years), strict compliance. indistinguishable in appearance to the cornea is essentially void of any signs and the patient is completely Best corrected acuities were 6/6+2 asymptomatic.1,3 TSPK is a self-limiting in each eye. Both corneas exhibited condition that is reported to resolve multiple, scattered whitish-grey round/ spontaneously on average 3–7.5 years oval and stellate lesions (twelve in the after the first presentation,2-5 however right and seven in the left), confined course durations of up to 41 years have within the superficial epithelium (Figure been reported.3,5 1) that stained with sodium fluorescein (Figure 2). Some lesions were essentially Therapeutic intervention with low-dose flat and others minimally elevated. The topical corticosteroids is the mainstay eyes were otherwise white and quiet, of treatment during the active phases of and corneal sensitivity intact. the condition for symptomatic relief.2,6,7 A B Ocular lubricants, therapeutic soft A provisional diagnosis of TSPK was contact lenses (SCLs) and cyclosporin made, with herpes simplex keratitis Figure 1. TSPK corneal lesions. A: right eye. A (CsA) have also been recommended (HSK) still a differential, although B: left eye. DECEMBER 2019 11

non-preserved ocular lubricants with an ointment at bedtime.6 Otherwise the mainstay of treatment is a mild topical corticosteroid (FML 0.1%, Loteprednol or similar), although a more potent steroid such as fluorometholone acetate may be required in more severe cases, with minimal strength and dose to control symptoms.2,3,5,6 A gradual taper Figure 2. Fluorescein staining of corneal lesions. Figure A: fight eye. Figure B: left eye of the corticosteroid is essential to prevent recurrence, however, it can previous, with greater than twenty permanent faint sub-epithelial prove challenging given the variable lesions in each eye, worse in the right. opacities.6,8 presentation of TSPK, with some patients requiring a tapering schedule Active TSPK was diagnosed and patient TSPK is commonly confused with other over the course of weeks to months to commenced on fluorometholone (FML) conditions, and patients frequently avoid a recurrence.6 Other treatment 0.1% four times a day with continued report conflicting diagnoses from options such as therapeutic SCLs or use of 1–2 hourly non-preserved different practitioners and minimal topical CsA where available can be lubricating eye drops in between steroid success in treating their symptoms. considered, the latter indicated in dosing, at least 15 minutes either side Differential diagnoses and key recalcitrant cases or where topical of steroid use. There was a marked differential features are outlined in steroid treatment is contraindicated.2,10,11 improvement in symptoms at the 24- Table 1. hour follow-up visit. The risks of extended corticosteroid use Although there is no cure, therapeutic in an otherwise benign condition must Five days later, there was complete intervention is focused on symptomatic be considered, bearing in mind that resolution of symptoms with all except relief in the active phase of TSPK, as the TSPK can take many years to resolve.2,3,5 one corneal lesion remaining in the presenting symptoms can be debilitating Although low potency steroids have right eye. The corneas did not stain for some patients. less likelihood of side effects,9 there are with fluorescein; intraocular pressures still concerns associated with long term were 12 mmHg in each eye. FML Treatment varies depending on the case topical corticosteroid use, including 0.1% use was tapered and a two-week severity. Tolerable symptoms in mild steroid-induced glaucoma, cataracts and review advised. An essentially identical cases may be relieved by regular use of treatment protocol was implemented for Continued page 12 each of the subsequent flare ups. Differential Unilateral/bi- Lesion appearance, Vital staining Additional features The patient was unfortunately lost lateral associated features to follow-up due to a move overseas. Subsequent correspondence revealed Early herpes simplex Usually unilateral Fine/course SPK. Small + Fluorescein SPK coalesce to den- keratitis bullous epithelial Sodium dritic lesions. Heaped she was self-managing flare ups with vesicles. + Rose Bengal margins and terminal FML and ocular lubricants. Two bulbs. Reduced corneal years from onset, exacerbations were sensitivity reportedly milder, less frequent (every TSPK Typically bilateral Multiple, mildly ele- + Fluorescein Recurrent keratitis in a vated, whitish central Sodium white and quiet eye 3–4 months) and shorter in duration intraepithelial corneal (1–2 days). Despite the improvement, opacities the importance of regular ophthalmic Adenoviral keratopathy Bilateral Nummular sub-epitheli- - Swollen lymph nodes. reviews was stressed with regards to the al corneal opacities Follicles possible side effects of long-term topical Keratoconjunctivitis Usually bilateral Small, finer SPK +Fluorescein corticosteroid use; and the opportunity sicca (KCS) Sodium to discuss and consider alternate + Lissamine Green management therapies with an enhanced Sterile sub-epithelial Usually unilateral Usually peripheral - safety profile. infiltrates corneal distribution Microcystic epithelial Usually unilateral Small raised bullae. - Blurred vision, halos Discussion oedema Corneal oedema The clinical picture of TSPK is Acanthamoeba keratitis Mostly bilateral Raised subepithelial - History of CL wear. opacities Blurred vision. Symp- characterised by recurrent, bilateral toms disproportionate epithelial keratitis, with an essentially to signs. white and quiet eye in an otherwise Toxic epitheliopathy Usually bilateral Widespread superficial + Fluorescein Stinging, burning healthy patient. The keratitis is punctate epitheliopathy Sodium sensation. (SPE) Conjunctival injection. variable in its presentation and follows History multiple/chron- a relapsing course with remissions ic use of topical drugs/ and exacerbations over several years, CL and/or solution use until spontaneous resolution. There is Neurotrophic keratopa- Usually unilateral SPE + Fluorescein Red eye. generally an excellent long-term visual thy (mild/early) Sodium Blurred vision. No irritation/pain. outcome, although there have been reports of some patients developing Table 1. Differential diagnoses and key differential features 12 DECEMBER 2019

TSPK From page 11 Contact lenses: beyond 20/20

methods to slow or prevent myopia increased susceptibility to corneal Dr Lyndon Jones progression (and the ocular axial infections; there’s also speculation PhD DSc FCOptom FAAO elongation that accompanies it) are that corticosteroids may potentially extremely important if myopia-induced prolong the chronic nature of the Deborah Jones pathologies are to be avoided. Recent 2,3,5,6,8 disease. BSc FCOptom FAAO estimates suggest that slowing myopia progression by one dioptre should Those receiving topical corticosteroid Centre for Ocular Research and reduce the likelihood of a patient treatment should have their Education (CORE), School of developing myopic maculopathy by 40 intraocular pressures monitored Optometry & Vision Science, per cent.4 closely, especially if they are at risk of University of Waterloo, Ontario, a steroid response. Canada Several treatment paradigms for slowing myopia progression have been Finally, the chronic and recurrent Rebecca Jones evaluated in intervention studies, course of TSPK may lead patients BSc largely encompassing the use of to self-medicate, putting themselves either pharmacological means (most Michael G. DeGroote School of at higher risk for steroid related commonly through the use of the topical Medicine, McMaster University, ocular complications. It is therefore anti-muscarinic drug atropine) or Cairns Family Health imperative that all patients be acutely various optical interventions.5-13 These and Bioscience Research aware of the potential side effects of optical interventions include progressive Complex, Ontario, Canada topical steroid use and the importance addition spectacle lenses, bifocal of regular reviews. In addition, the spectacles, orthokeratology rigid contact practitioner should be astute in lenses and multifocal soft contact limiting the number of repeats when lenses.8,14-19 prescribing topical steroids. With The use of contact lenses continues to compliance, patients can be reassured grow, with an estimated 140 million To date, many of the contact lens that TSPK usually resolves without wearers globally. While the majority methods used remain ‘off-label,’ any long-term effects on vision. of wearers use contact lenses for the meaning that while studies would correction of refractive error, there is suggest that such technologies do indeed 1. Thygeson P. Superficial Punctate growing interest in their use for ‘non- appear to show a slowing of myopia Keratitis. JAMA 1950; 144: 1544-1549 2. Nagra PK, Rapuano CJ, Cohen EJ et standard’ concepts. As we approach the progression, regulatory approvals al. Thygeson’s superficial punctate magical year (for optics) of 2020, we for these products do not yet exist to keratitis. Ten years’ experience. ask: if we glimpse into the future, what Ophthalmol 2004; 111: 34-7 support the product being used in 3. Tabbara KF, Oster B, Dawson C et will the contact lenses of (say) 2035 look such a manner.20 One such example al. Thygeson’s superficial punctate like? What options will they provide is orthokeratology, which is approved keratitis. Ophthalmol 1981; 88: 75-7 to our patients that will differ from the 4. Darrel RW. Thygeson’s SPK: a natural for use in the reduction of refractive history and association with HLA-DK3. lenses of today?1 error, but not approved for slowing the Trans Am Ophthalmol Soc 1981; 79: progression of myopia, despite many 486-516 studies supporting this to be the case. 5. Tanzer DJ, Smith RE. Superficial Myopia control punctate keratitis of Thygeson’s: the longest course on record? Cornea 1999; Myopia is a significant public health However, as the interest in using contact 18: 729-730 6. Duszak RS. Diagnosis and management problem. In 2010 it was estimated that lenses for slowing myopia progression of Thygeson’s superficial punctate 28 per cent of the world’s population increases, more products will gain keratitis. Journal Am Optom Assoc was myopic, but it is predicted that regulatory approval for this indication, 2007; 78: 333-338 7. Bruce A, Loughnan M. Anterior eye by 2050, 50 per cent of the global resulting in this being a significant Disease and Therapeutics A-Z. Boston: population could be myopic.2 As growth area for contact lenses over Butterworth Heinemann, 2003 discussed in the September issue of the next decade. Two commercially 8. Chen LL, Young AL, Wong AK. In vivo confocal microscopy of Thygeson’s Pharma, the most rapid increase has available daily disposable soft lens superficial punctate keratitis.Clin Exp been in East Asian countries, where products that have gained regulatory Ophthalmol 2004; 32: 325-340 it has already reached epidemic approval for slowing the progression of 9. Jaanus SD, Cheetham JK, Lesher GA. Anti-inflammatory drugs. In: Bartlett proportions, affecting over 90 per cent myopia in various countries following JD, Jaanus SD, editors. Clinical of adults in some regions such as Korea, successful clinical trials are MiSight th Ocular Pharmacology, 4 ed. Boston: Taiwan and Singapore.3 Myopia is not 21 Butterworth, 2001. p 273-276 (CooperVision) and NaturalVue 10. Forstot SL, Binder PS. Treatment merely an inconvenience resulting in the Multifocal (Visioneering Technologies).22 of Thygeson’s superficial punctate patient requiring an optical correction. keratitis with soft contact lenses. Am J The myopic eye, particularly those Ophthalmol 1979; 88: 186-189 Drug delivery 11. Reinhard T, Sundmacher R. Topical with high myopia of > 6.00 D, has an cyclosporine A in Thygeson’s increased risk of developing ocular One of the biggest opportunities for the superficial punctate keratitis.Graefes Arch Clin Exp Ophthalmol 1999; 237: pathology that may lead to vision loss, development of ‘specialised’ contact 109-112 in particular retinal detachment and lenses relates to their use as drug myopic macular degeneration. Thus, delivery devices. A lens that would DECEMBER 2019 13

Open access and online Contact lenses: beyond 20/20 www.optometry.org.au

release therapeutically-relevant doses of a topical drug for five-to-seven days would likely find an immediate place in clinical practice and there is great interest in this concept among clinicians.23 The interest in this topic is evidenced by the fact that over 350 peer-reviewed publications have addressed this issue, with 25 per cent of them being published within the last five years. This is particularly relevant for diseases which require consistent dosing over many weeks or months, in which compliance with instilling drops becomes lower over time, for example in the management of glaucoma.24 Figure 1. The Sensimed Triggerfish continuous ocular monitoring system Several research groups around the globe are actively looking at developing such technologies. There are various methods 24-hour time period,40,41 and several virtual reality systems that offer great proposed to deliver ocular medications, groups have published work on the improvements over the current bulky, with many employing novel approaches development of materials that can head-mounted versions.50-54 based on nanotechnology.25 Recent monitor glucose levels within the publications on this topic include those tear film.42-44 Published work has also The future for contact lenses remains describing the extended release of anti- looked at using the tear film to monitor bright, with many new and exciting glaucoma medications,26 antibiotics,27-29 signs of cancer45,46 and contact lenses developments ahead. Contact lenses to antifungal agents,30,31 drugs to treat dry that could detect such small levels of control myopia progression are already eye and surface inflammation,32 drugs biomarkers within the tear film would here and the number of options will to slow the progression of myopia33 and be invaluable.47 Thus, the continued rapidly expand; in the near future, anti-inflammatory drugs.34,35 Contact expansion of interest in the development lenses to detect and treat ocular disease lenses have already been used in full- of such devices seems inevitable, as will be available and in the more scale clinical trials that release an anti- developments in miniaturisation of distant future, we are likely to see allergic agent (ketotifen).36 batteries and electrical components the availability of lenses with highly improves.48,49 sophisticated optics for unique optical Based upon the rapidly expanding applications. literature in this field and the level of Advanced optical designs interest, it appears to be just a matter Disclosure of time before such devices become The final area of interest relates to the commercially available. However, manufacture of lenses with novel optics. This manuscript was not specifically concerns relating to regulatory Spectacle-mounted head-up displays funded by any grant or contract. Over approvals, how to control the leaching of with the ability to access the internet, the past year, CORE has received drugs into the surrounding blister pack display websites and email, stream video research grants from Alcon, Allergan, solution and which practitioners are or take photographs have been under CooperVision, GLChemtech, Johnson & licensed to dispense such products will development for several years, with the Johnson Vision, Menicon, Novartis, PS likely delay their introduction for some most well-known being the Google Glass Therapy, Shire and Sightglass outside time while these issues are addressed. concept, launched in 2013. the submitted work. Lyndon Jones has received personal fees from Alcon, Other manufacturers have worked CooperVision, Johnson & Johnson Detection and monitoring of disease on various versions of these ‘smart Vision, Menicon, Novartis and Ophtecs The ability of contact lenses to monitor spectacle’ platforms and the outside the submitted work. Deborah ocular and systemic diseases such development of newer technologies Jones has received personal fees from as diabetes and glaucoma would have enabled companies to consider CooperVision. The authors report no appear to be something approaching incorporating this technology into a other conflicts of interest in this work. science fiction. However, there is contact lens platform. This concept growing interest in the use of wearable could be used to develop, for example, A complete list of references for this article sensors for many aspects of health a multifocal contact lens that changes is available on the Pharma page of the monitoring.37-39 There is already a power depending upon the distance at Optometry Australia website. Additionally, a commercially-available contact lens which the wearer is viewing an item of complete copy of the references is available device (Figure 1) that uses sophisticated interest, a magnifying contact lens for by contacting the editor at pharma@ strain-gauge technology to continuously people with low vision and even opens optometry.org.au. measure intraocular pressure over a up the potential for almost invisible Red eye conditions From the 2019 Optometry Australia Anterior Eye Clinical Practice Guide

Common symptoms Clinical presentations Risk factors Differential diagnoses Triggers for referral & appropriate timing Pharmacological management Review

Bacterial • Redness • Irregular focal lesion, may be Age • Sterile peripheral Same day/within 24 hours Topical ciprofloxacin or ofloxacin Daily until ulcer shows • Pain > 1 mm in size • 15-64 years (Trauma and infiltrate • Larger (> 2 mm), more central or improvement. Keratitis Q1h for 2 days then (if good response) • Photophobia • Epithelial defect Contact Lenses) • Marginal keratitis deeper lesions – risk of scarring and/ Loading dose: Weekly until complete QID until completely resolved. • Reduced vision • Discharge • > 60 years – Previous ocular • Fungal keratitis or perforation resolution. • Lid Swelling • Anterior chamber reaction – surgery • Herpes simplex • Consider referral for culture/corneal Considerations: • Mucopurulent cells & flare keratitis scrape to identify causative organism • Fluoroquinolones (ciprofloxacin and ofloxacin) cover External discharge • Lid swelling • Exposure • Non-responding cases: be aware both gram positive and gram negative pathogens Clinical discretion should be • “White spot on • Infiltrate • Contact lenses (e.g. keratopathy of bacterial resistance to antibiotic applied. Review schedule extended wear, poor hygiene, • Ciprofloxacin has enhanced activity towards gram eye” • Posterior synechiae • Neurotrophic treatment positive – may be preferred in hot climates in contact should be considered on a • Conjunctival injection inadequate disinfection, • Acanthamoeba • Consider non-bacterial causes case by case basis. Factors sharing of lenses, use of tap lens microbial keratitis keratitis • Ofloxacin in cooler climates for Staph species to consider include: water) • Shield ulcer • Trauma • Atropine – (prevent ciliary spasm) if significant pain • Severity of infection • Dellen and oral analgesia insufficient. • Risk of side effects • Previous ocular surgery • Phlyctenular Within 72 hours • Corticosteroids – limit scarring during healing • Reliability of patients to • Immunosuppression keratitis • Substance abuse • Cases that do not respond to initial • Steroid treatment should be introduced only after 2-3 comply with instructions treatment or slow/inadequate healing days of progressive improvement of the ulcer Internal • Tear-film deficiencies • Viral keratitis • Recurrent corneal erosion

Systemic conditions • Diabetes • Atopic dermatitis • Blepharoconjunctivitis • Gonococcal infection • Vitamin A deficiency

Herpes • Redness • Epithelial disease (dendritic • Long-term corticosteroid • Acanthamoeba Same day/within 24 hours Epithelial and Geographic 1-2 days until HSK is Simplex • Pain/Discomfort or geographic ulcers) inhalers keratitis • Stromal and endothelial involvement improving. • Photophobia • Stromal disease • Long-term corticosteroid • Herpes Zoster • Bilateral cases 3% Acyclovir* ointment - 5 times/day for 7 days then Keratitis 3 times/day for next 7 days. Weekly until complete • Reduced vision • Neurotrophic keratitis creams Ophthalmicus • Large geographic ulcers resolution. • Lid swelling • Endotheliitis • Asthmatic patients • Recurrent corneal (*Can be toxic to ocular surface. Cease 1-2 days after • Mild watery • Conjunctivitis (mild) • Cardiovascular disease erosion resolution and consider non-preserved lubricants to help with ocular surface toxicity) Clinical discretion should be discharge • Skin lesions • Immunosuppressed patients • Healing abrasion applied. • Reduced corneal • Anterior chamber reaction • Atopic patients Consider cycloplegic agent with anterior chamber Review schedule should sensitivity • Conjunctival injection • Multiple previous episodes reaction be considered on a case • Preauricular node Stromal Keratitis by case basis. Factors to Within a week Topical corticosteroids with oral prophylactic antivirals consider include: • Cases that do not respond to initial Considerations • Severity of infection treatment Topical steroids will worsen herpes simples keratitis HSK • Risk of side effects epithelial disease • Reliability of patients to Oral antivirals may be indicated in patients with many comply with instructions recurrences, e.g. • Valacyclovir 500mg 1xday • Acyclovir 400mg 2x/day Consider referral for medical opinion

Acute Anterior • Redness • Circumlimbal flush • HLA-B27 positive • Glaucoma (acute Same day/within 24 hours Topical Steroids with good intraocular penetration: Review on first or second Uveitis • Pain • Anterior chamber reaction – • Rheumatoid conditions angle closure) • Severe cases e.g. significant posterior Predforte or Maxidex. day after commencing • Photophobia cells and flare • Inflammatory bowel • Fuchs synechiae, poor view of posterior pole, May require loading dose: treatment. • Reduced vision • Miotic pupil conditions Heterochromic atypical inflammation • Q1h waking hours (consider overnight based on • Copious watery • Keratic precipitate • Trauma iridocyclitis • Hypopyon severity) for 2 days, then (if improvement) Q2h for 2 Clinical discretion should be discharge • Hypopyon • Keratitis • Endophthalmitis • Bilateral days, then (if improving) applied. Review schedule • Abnormal IOP • Idiopathic • Posner-Schlossman • Posterior segment involvement • Qid for 1 week, then should be considered on a • Corneal oedema • Ulcerative colitis Syndrome • Recent surgery • Tid for 1 week, then case by case basis. Factors • Posterior synechia • Crohn’s disease • Lens induced uveitis • Presence of drainage bleb • Bid for 1 week, then to consider include: • Syphilis • Intraocular foreign • IOP > 30 mmHg • Qd for 1 week, then stop. • Behcet’s disease body • Severity of inflammation • Sarcoidosis Within 72 hours Monitor IOP while treating with topical steroids to identify • Risk of side effects • Tuberculosis • Cases that do not respond to initial steroid responders • Reliability of patients to • Multiple Sclerosis treatment comply with instructions • Refer to medical practitioners (GP, Atropine (bid – tid) until anterior chamber reaction under ophthalmologist) following 2nd control. episode

Anterior Eye tables from Anterior Eye CPG - working_v4.indd 2-3 20/09/2019 10:53:37 AM Red eye conditions From the 2019 Optometry Australia Anterior Eye Clinical Practice Guide

Common symptoms Clinical presentations Risk factors Differential diagnoses Triggers for referral & appropriate timing Pharmacological management Review

Bacterial • Redness • Irregular focal lesion, may be Age • Sterile peripheral Same day/within 24 hours Topical ciprofloxacin or ofloxacin Daily until ulcer shows • Pain > 1 mm in size • 15-64 years (Trauma and infiltrate • Larger (> 2 mm), more central or improvement. Keratitis Q1h for 2 days then (if good response) • Photophobia • Epithelial defect Contact Lenses) • Marginal keratitis deeper lesions – risk of scarring and/ Loading dose: Weekly until complete QID until completely resolved. • Reduced vision • Discharge • > 60 years – Previous ocular • Fungal keratitis or perforation resolution. • Lid Swelling • Anterior chamber reaction – surgery • Herpes simplex • Consider referral for culture/corneal Considerations: • Mucopurulent cells & flare keratitis scrape to identify causative organism • Fluoroquinolones (ciprofloxacin and ofloxacin) cover External discharge • Lid swelling • Exposure • Non-responding cases: be aware both gram positive and gram negative pathogens Clinical discretion should be • “White spot on • Infiltrate • Contact lenses (e.g. keratopathy of bacterial resistance to antibiotic applied. Review schedule extended wear, poor hygiene, • Ciprofloxacin has enhanced activity towards gram eye” • Posterior synechiae • Neurotrophic treatment positive – may be preferred in hot climates in contact should be considered on a • Conjunctival injection inadequate disinfection, • Acanthamoeba • Consider non-bacterial causes case by case basis. Factors sharing of lenses, use of tap lens microbial keratitis keratitis • Ofloxacin in cooler climates for Staph species to consider include: water) • Shield ulcer • Trauma • Atropine – (prevent ciliary spasm) if significant pain • Severity of infection • Dellen and oral analgesia insufficient. • Risk of side effects • Previous ocular surgery • Phlyctenular Within 72 hours • Corticosteroids – limit scarring during healing • Reliability of patients to • Immunosuppression keratitis • Substance abuse • Cases that do not respond to initial • Steroid treatment should be introduced only after 2-3 comply with instructions treatment or slow/inadequate healing days of progressive improvement of the ulcer Internal • Tear-film deficiencies • Viral keratitis • Recurrent corneal erosion

Systemic conditions • Diabetes • Atopic dermatitis • Blepharoconjunctivitis • Gonococcal infection • Vitamin A deficiency

Herpes • Redness • Epithelial disease (dendritic • Long-term corticosteroid • Acanthamoeba Same day/within 24 hours Epithelial and Geographic 1-2 days until HSK is Simplex • Pain/Discomfort or geographic ulcers) inhalers keratitis • Stromal and endothelial involvement improving. • Photophobia • Stromal disease • Long-term corticosteroid • Herpes Zoster • Bilateral cases 3% Acyclovir* ointment - 5 times/day for 7 days then Keratitis 3 times/day for next 7 days. Weekly until complete • Reduced vision • Neurotrophic keratitis creams Ophthalmicus • Large geographic ulcers resolution. • Lid swelling • Endotheliitis • Asthmatic patients • Recurrent corneal (*Can be toxic to ocular surface. Cease 1-2 days after • Mild watery • Conjunctivitis (mild) • Cardiovascular disease erosion resolution and consider non-preserved lubricants to help with ocular surface toxicity) Clinical discretion should be discharge • Skin lesions • Immunosuppressed patients • Healing abrasion applied. • Reduced corneal • Anterior chamber reaction • Atopic patients Consider cycloplegic agent with anterior chamber Review schedule should sensitivity • Conjunctival injection • Multiple previous episodes reaction be considered on a case • Preauricular node Stromal Keratitis by case basis. Factors to Within a week Topical corticosteroids with oral prophylactic antivirals consider include: • Cases that do not respond to initial Considerations • Severity of infection treatment Topical steroids will worsen herpes simples keratitis HSK • Risk of side effects epithelial disease • Reliability of patients to Oral antivirals may be indicated in patients with many comply with instructions recurrences, e.g. • Valacyclovir 500mg 1xday • Acyclovir 400mg 2x/day Consider referral for medical opinion

Acute Anterior • Redness • Circumlimbal flush • HLA-B27 positive • Glaucoma (acute Same day/within 24 hours Topical Steroids with good intraocular penetration: Review on first or second Uveitis • Pain • Anterior chamber reaction – • Rheumatoid conditions angle closure) • Severe cases e.g. significant posterior Predforte or Maxidex. day after commencing • Photophobia cells and flare • Inflammatory bowel • Fuchs synechiae, poor view of posterior pole, May require loading dose: treatment. • Reduced vision • Miotic pupil conditions Heterochromic atypical inflammation • Q1h waking hours (consider overnight based on • Copious watery • Keratic precipitate • Trauma iridocyclitis • Hypopyon severity) for 2 days, then (if improvement) Q2h for 2 Clinical discretion should be discharge • Hypopyon • Keratitis • Endophthalmitis • Bilateral days, then (if improving) applied. Review schedule • Abnormal IOP • Idiopathic • Posner-Schlossman • Posterior segment involvement • Qid for 1 week, then should be considered on a • Corneal oedema • Ulcerative colitis Syndrome • Recent surgery • Tid for 1 week, then case by case basis. Factors • Posterior synechia • Crohn’s disease • Lens induced uveitis • Presence of drainage bleb • Bid for 1 week, then to consider include: • Syphilis • Intraocular foreign • IOP > 30 mmHg • Qd for 1 week, then stop. • Behcet’s disease body • Severity of inflammation • Sarcoidosis Within 72 hours Monitor IOP while treating with topical steroids to identify • Risk of side effects • Tuberculosis • Cases that do not respond to initial steroid responders • Reliability of patients to • Multiple Sclerosis treatment comply with instructions • Refer to medical practitioners (GP, Atropine (bid – tid) until anterior chamber reaction under ophthalmologist) following 2nd control. episode

Anterior Eye tables from Anterior Eye CPG - working_v4.indd 2-3 20/09/2019 10:53:37 AM 16 DECEMBER 2019

Gut flora: why optometrists should be paying attention

Julie Newport B App Sc Opt (Hons) GradDip Oc Cert SFA

ICU Optometry, QLD

Our bodies are mostly microbes (micro-organisms such as bacteria, viruses or amoebae). For every human cell we have, there is at least one microbial cell in our microbiome.1 The microbiome is the collective genome of all micro-organisms living in us and on us, and although the number of 9 organisms in the average microbiome is In a healthy individual, the total is how Parkinson’s disease starts. approximately equal to our own cells, number and biodiversity of beneficial Neurones of the central nervous the number of their genes outnumbers bacteria in the gut help to stop any system can express inflammatory our own by many orders of magnitude.2 pathogenic organisms from becoming cytokines, such as IL-1 and TNF, too numerous. This is both through and it’s thought that these cytokines In the language of the ads, if our ‘good’ simply competing for food resources, play a role in inter-neuronal 9 bacteria are outgunned by too many and through more active competition. communication. ‘bad’ bacteria, our health can suffer. For example, some Bacteroides This imbalance is called dysbiosis,3 species kill off Candida albicans Either way, we have at least two and has been linked to many systemic by injecting the yeast cells with routes through which inflammation 7 conditions4 that are associated hydrogen peroxide. in the gut can lead to inflammation with eye disease, including type 1 and disease elsewhere, including the diabetes, type 2 diabetes, inflammatory However, in an individual whose eye. This is great news. It means that bowel diseases such as Crohn’s, and diversity or total population of not only can we help our dry eye cardiovascular disease. beneficial bacteria is limited, patients with traditional and topical dysbiosis results, causing the bad approaches, such as lubricating Most of the bacteria that call us home bacteria to take over. Pathogenic drops, steroids and oral omega-3s, it are beneficial to our health. They bacteria, such as Clostridium difficile also means that we can provide more produce essential amino acids, proteins and some species of E. coli, will information to help our patients to and vitamins, they help us to extract trigger inflammation in the lining help themselves. nutrients from our food,5 and they of the gut, which loosens the tight produce anti- inflammatory substances junctions between the cells of the 7 Implications for optometrists such as butyrate. Butyrate is a short- submucosa. Inflammatory mediators, chain fatty acid which protects against bacterial toxins and bacteria We don’t have to be experts on the bowel cancer, protects the lining of the themselves then have a direct route microbiome. Although we’re not gut and can down-regulate the vascular to the circulation and therefore the expert dieticians, it is within our endothelial growth factor (VEGF) rest of the body, and inflammation scope to provide lifestyle information gene.6 follows. In this way, dysbiosis can on reducing the risk of vision loss lead to inflammation of other tissues from macular degeneration. such as skin, lungs, joints and eyes. An appropriate step, as health care Another route for inflammation in professionals wanting the best the gut to reach other tissues is along outcomes for our patients, is to help the vagus nerve, part of the gut-brain steer them in the right direction. By axis.8 Material from the gut can giving them relevant information pass directly along this route to the and nudging them towards further brain, and researchers are now asking reading, as well as collaborating with serious questions as to whether this dieticians, we can potentially achieve DECEMBER 2019 17

better results for many of our more antibiotics will annihilate many of our 1. Sender R, Fuchs S, Milo R. Revised challenging dry-eye patients. healthy species.17 In the dry eye arena, Estimates for the Number of Human and Bacteria Cells in the Body. PLoS Biol this might make us think twice before 2016; 14: e1002533. referring a patient for doxycycline 2. Lin P. The Role of the intestinal Supplements microbiome in ocular inflammatory therapy. It also might explain why disease. Curr Opin Ophthalmol 2018; 29: A simple way to help rebalance a many patients taking doxycycline will 261-255. dysbiotic large intestine is to take suffer side effects such as nausea, and 3. Petersen C, Round J. Defining dysbiosis 10 18 and its influence on host immunity and probiotics. A probiotic supplement thrush, caused by Candida albicans. disease. Cell Microbiol 2014; 16: 1024- typically contains billions of bacteria 1033. from the species known to be beneficial Another step, for those who are 4. Carding S, Verbeke K, Vipond DT et al. Dysbiosis of the gut microbiota in to our overall health. These are readily particularly interested, is to advise disease. Microb Ecol Health Dis 2015; available in powder or capsule form, patients they can now have their 26: 26191. as well as in food products such as intestinal microbiome genetically 5. Lloyd-Price J, Galeb A-A, Huttenhower C. The healthy human microbiome. various yoghurts and drinks. sequenced. Professor Ian Frazer and Genome Med 2016; 8: 51. the University of Queensland have 6. Canani RB, Di Costanzo M, Leone L. The launched a company (www.microba. epigenetic effects of butyrate: potential Diet therapeutic implications for clinical com) which offers this service, practice. Clin Epigenetics 2012; 4: 4 Other lifestyle changes are also including bespoke dietary and lifestyle 7. Mosley M. The Clever Guts Diet. Sydney: potentially beneficial to a healthy advice. Simon & Schuster Australia; 2017. 8. Carabotti M, Scirocco A, Maselli MA, microbiome. These include a healthy et al. The gut-brain axis: interactions diet, resplendent in brightly-coloured between enteric microbiota, central Dry eye vegetables, particularly those that and enteric nervous systems. Ann 11 Gastroenterol 2015; 28: 203–209 contain polyphenols. Among Perhaps when patients complain of 9. Mulak A, Bonaz B. Brain-gut-microbiota other things, polyphenols nourish dry eyes, we could gain some insights axis in Parkinson’s disease. World J 12 Gastroenterol 2015; 21: 10609–10620 Akkermansia bacteria, one of the into whether their condition might be 10. De Oliveira GLV, Leite AZ, Higuchi BS good guys. Akkermansia have the more internally driven before making et al. Intestinal dysbiosis and probiotic attention of the research community exclusively topical recommendations. applications in autoimmune diseases. Immunology 2017; 152: 1-12 because they seem to play a role For example, if a patient complains of 11. Duda-Chodak A, Tarko T, Satora P et in battling insulin resistance and frequent dryness, we could simply ask al. Interaction of dietary compounds, obesity,12 and are associated with better if they also suffer from problems with especially polyphenols, with the 13 intestinal microbiota: a review Eur J control of blood glucose after a meal. their lungs, joints or skin, or whether Nutr 2015; 54: 325–341 they have gastrointestinal problems. 12. Roopchand DE, Carmody RN, Kuhn P et You’ll also find polyphenols in coffee, This could at least open the door to al: Dietary polyphenols promote growth of the gut bacterium Akkermansia tea, red wine, dark chocolate, dried discussion as to how best to manage muciniphila and attenuate high-fat diet- herbs, olives and oily fish.14 the condition in the longer term, rather induced metabolic syndrome. Diabetes than potentially just ‘window-dressing’ 2015; 64: 2847-2858. 13. Utzschneider KM, Kratz M, Damman by concentrating only on the ocular Exercise CJ et al. Mechanisms linking the gut surface. microbiome and glucose metabolism. Exercise has been linked to a greater J Clin Endocrinol Metab 2016; 101: 1445–1454. diversity of healthy species in the Dry-eye care is the tip of the iceberg 14. Scalbert A, Johnson IT, Saltmarsh M microbiome.15 So has exposure to the when considering how we, as et al. Polyphenols: antioxidants and great outdoors,7 whether it’s getting out optometrists, can steer patients in the beyond. Am J Clin Nutr 2005; 81: 215S–217S. and about or simply opening a window direction of better eye health through 15. Clarke SF, Murphy EF, O’Sullivan O to your home or office. Similarly, better gut health. There are now clear et al. Exercise and associated dietary people who expose themselves to dirt links between gut inflammation and extremes impact on gut microbial 19,20 diversity. Gut 2014; 63: 1913-1920. in their garden are increasing their uveitis, between gut inflammation 16. Dollé L, de La Serre CB, van Grunsven exposure to (mostly) good bacteria.7 and retinal inflammation,20,21(for LA. Are dietary emulsifiers making us fat? J Hepatol 2015; 63: 1045–1048 example in Crohn’s patients) and 17. Francino MP. Antibiotics and the between gut inflammation and human gut microbiome: dysbioses and The list goes on ARMD.20, 21 accumulation of resistances. Front Microbiol 2015; 6: 1543. Maintaining regular sleep patterns and 18. NPS Medicinewise [Internet]. Surry reducing cortisol levels by reducing Hills, NSW: NPS MedicineWise; 2019. Systemic conditions stress, where possible, are good for a APO-Doxycycline Tablets [cited 2019 7 Aug 28]. Available at: https://www. healthy, diverse microbiome. Fasting Finally, many of our patients are nps.org.au/medicine-finder/apo- from time to time allows Akkermansia affected by systemic conditions, such doxycycline-tablets bacteria access to one of their favourite as diabetes and hypertension, which 19. Horai R, Zárate-Bladés CR, Dillenburg- Pilla P et al. Microbiota-dependent foods – the mucus lining of our large not only have the potential to affect activation of an autoreactive t cell intestine.7 The sugars found in fast vision adversely, but which may often receptor provokes autoimmunity in foods and alcohol will (unfortunately) be better controlled through attention an immunologically privileged site. 7 Immunity 2015; 43: 343-353. mostly feed the pathogens, so red wine to the intestinal microbiome. Even 20. Rowan S, Taylor A. The Role of in moderation is the recommendation. just a gentle nudge from us, in the Microbiota in Retinal Disease in: Ash Fast food also contains emulsifiers, direction of a Google search—linking J, Anderson R, LaVail M, et al. Retinal Degenerative Diseases. Cham: Springer; which alter microbiome diversity in dysbiosis to their disease—might 2018. p. 429-435 ways that promote inflammation.16 make the world of difference to their 21. Scholz R, Langmann T. Gut flora connects obesity with pathological overall health and the protection of angiogenesis in the eye. EMBO Mol Med Inappropriate use of systemic their sight. 2016; 8:1361-1363 18 DECEMBER 2019

Revisiting ‘Christmas Eye’ 'Tis the season for acute toxic keratopathy

Robert Holloway BScOptom

Holloway Vision, Wangaratta VIC

In 2008, I wrote a case study for this publication regarding the condition of ‘Christmas Eye.’ Eleven years later, I have been asked to update our Figure 1. Orthoperus releases a blistering agent when crushed. understanding and management of this peculiar seasonal condition.

etc.) the previous afternoon or evening. the victims, shake their heads with The condition sympathy when they hear of a friend or ‘Christmas Eye’ is an acute toxic Prior to the use of the bandage contact colleague who has been affected. keratitis that occurs during the lenses, the effects of Christmas Eye hot, dry summer months in south were debilitating in the short term. The One of our patients has been affected eastern Australia. It has also been patient was unable to work and suffered three times in ten years. referred to as Albury-Wodonga extreme pain until the cornea had syndrome, harvester’s eye or seasonal recovered. Typically, up to a week of Pederin and Orthoperus corneal ulcer.1 Typically, we expect employment or useful activity was lost. presentations from mid-November For many years, the cause of the until late February. The cases often The level of pain associated with condition has been frustrated by a occur in clusters and the patient Christmas Eye has achieved folkloric lack of physical evidence. But further history consistently involves some status. The hardy farming types, research has supplied the reason for outdoor activity (gardening, mowing, who make up a sizeable portion of this lack of evidence. The causative

Figure 2. Typical NaFL corneal staining Figure 3. Subject 1 LE white light Figure 4. Subject 1 LE cobalt blue/Wrattan associated with Christmas Eye filter DECEMBER 2019 19

agent is thought to be a small beetle of the genus Orthoperus.2

Orthoperus is a genus of minute hooded beetles in the family Corylophidae. Their size is of the order 0.5–0.7mm (Figure 1). Orthoperus are known to carry the compound Pederin3 in their haemolymph which is released when the insect is crushed on the skin or eye. Pederin is a powerful inhibitor of protein biosynthesis and mitosis and is a known vesicant (blistering agent). With these properties, it is unsurprising that it has such a dramatic effect on the corneal epithelium. Figure 5. Geographic distribution of Christmas Eye

Signs and symptoms Patients will often present in the early occasional cases being reported in be readily identified. Herpes has a hours of the morning at the local western Victoria, Gippsland and central more gradual build-up of discomfort Emergency Department suffering NSW. Statistically however, the vast over a day or so. Christmas Eye extreme pain. majority of cases occur in north east generally wakes a person in the early Victoria and southern NSW (Figure 5). hours of the morning with increasing Clinical signs eye pain that continues to build despite the patient’s best efforts to reduce the Differential diagnosis • Mottled corneal epithelium aggravation. disturbance progressing to Conditions with potentially similar extensive full thickness epithelial presentations include: Corneal observation with fluorescein loss involving up to 90 per cent of will provide further information to the cornea (Figure 2). • Herpes keratitis assist with the diagnosis. • Corneal oedema increasing • Corneal abrasion corneal thickness up to 30 per cent Herpes will commonly present with • Infectious corneal ulcer with accompanying endothelial its tell-tale linear and lobular staining, wrinkling Taking a careful history, paying quite different to the lesions found in particular attention to the timeline of • Extensive bulbar conjunctival Christmas Eye. The epithelium in the pain and discomfort, will generally injection surrounding area with Christmas Eye is provide the diagnosis. Biomicroscopy often disrupted and can be dislodged • Bulbar conjunctival chaemosis and will show the extent of corneal with ease. This is quite different oedema damage, the integrity of the remaining to the other differentials where the • Mild anterior chamber reaction epithelium and provide a confirmation surrounding tissue is still intact and with cells and flare of the diagnosis. looks ‘normal.’ • Moderate lid and periorbital oedema An essential fact in determining your differential diagnosis is the time of Management • Decreased vision (6/15 to 6/24) year. Christmas Eye only seems to (Figures 3 and 4) The management of Christmas Eye occur between late October and early is quite straight-forward once the March. A clinical presentation outside Clinical symptoms: PAIN diagnosis has been made. of this time of year makes the diagnosis The pain level is extreme with a pain extremely unlikely. It is well known that the corneal score of 8-9/10 and, in the early stages, epithelium heals rapidly and that is often disproportionate to the degree The higher the pain level, the more pain levels diminish as the epithelium of corneal disruption. likely the Christmas Eye presentation. recovers. The control and reduction Patients will often arrive cradling their of pain is the key tenant of the • Excessive lacrimation head with their hand cupped over management strategy. • Marked photosensitivity the affected eye. They are miserable • Headache and have often attended following an In 2008, treatment involved the fitting initial presentation at the local hospital of a bandage silicone hydrogel contact • Nausea emergency department. lens and intensive use of a topical Geographic distribution nonsteroidal anti-inflammatory such as Details regarding the timeframe of the diclofenac sodium (Voltaren). Traditionally, ‘Christmas Eye’ in pain onset will also give key clues as to Australia was thought to be limited the diagnosis. to north east Victoria and southern NSW. Further enquiries have shown A corneal abrasion will cause instant it is distributed further afield with pain and the offending object can often Continued page 20 20 DECEMBER 2019

Figure 6. Marked localised corneal swelling

Figure 7. Localised corneal thinning Figure 8. Corneal scarring

Prescribe Visual acuity and corneal structure Christmas Eye return to pre-incident levels and there • Chloramphenicol eye drops, four From page 19 are no residual signs of corneal insult. times a day • Oral non-steroidal anti- Over twenty years, I have dealt with In 2019, our management has been inflammatory medication, for hundreds of cases of Christmas Eye modified but the key principle of pain example: Nurofen or Voltaren – without any problems using the regime relief has remained. My current regime maximum daily dose outlined in 2008. However, two years is as follows: ago, for the first time, we experienced a When the corneal epithelium has cluster of adverse events involving the healed cornea. At initial presentation • Remove bandage silicone hydrogel • Topical anaesthesia to alleviate pain contact lens Sub-epithelial corneal haze and allow examination of the eye • Stop antibiotics • Photo document the extent of Looking similar to pronounced epithelial loss • Stop oral pain relief sub-epithelial haze seen in surface photorefractive keratectomy (PRK) • Record corneal thickness (anterior • Commence non-preserved refractive surgery, the haze was present OCT) lubricants (AFT Hyloforte) four times daily for two weeks in the anterior stroma and contributed • Insert bandage silicone hydrogel to a slight reduction in acuity and • Review in two weeks and then contact lens (B&L Ultra) increased glare. This gradually discharge • Review every two to three days until resolved over 12 months with a corneal epithelium is healed Adverse events slow return to the original corneal topography and thickness. • Provide patient with after-hours The vast majority of patients will heal contact number perfectly without any adverse effects. Continued page 22

Figure 9. Child’s cornea completely stained with NaFL Figure 10. Cornea and aqueous humour stained with NaFL DON’T LOSE SIGHT OF WHAT’S IMPORTANT

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18 is unknown. Last summer (2018– Christmas Eye 19) I experienced no complications. TAU: Tattoo-associated uveitis From page 20 It may be the causative agent was slightly different, creating a greater inflammatory response or that these Cutanteous reactions and ocular problems Localised corneal thinning individuals happened to be more I have seen three cases where there susceptible to corneal damage from has been a localised area of stromal inflammation. thinning. The corneal response appears Debra Gleeson as expected until the four-day mark The events have led me to remove Assoc Dip Orth where marked corneal inflammation the topical NSAIDS from the and oedema seems to remain. As it management plan. There have been Senior Orthoptist/Orthoptic subsides, the stroma appears to thin literature reports of corneal damage Glaucoma Lead Royal Victorian Eye and the corneal topography changes to related to topical NSAID use.4 I am and Ear Hospital, Melbourne show an area of depression. There is unsure why this would become an associated vision disruption due to the issue in one particular year and it altered topography. may be completely unrelated.

Detailed anterior OCT scans confirm These events appear to be individual As a cosmetic and decorative body art, the stromal thickness loss as the reactions to the extreme corneal tattooing has dramatically increased epithelium regrows with normal inflammation that occurs with particularly among young adults. A thickness. Christmas Eye. They are a cautionary survey of 1,013 Australians by market reminder that unusual events can researcher McCrindle in April 20181 Visual recovery from this is very slow occur when treating eye conditions. showed that the number of people and can be incomplete. OCT scans getting tattooed had hit a record high and topography over the past three with one in five people having one or Imaging years show both a localised thickening more tattoos. of the overlying epithelium and an The development of imaging systems improvement in the corneal regularity. such as topography, anterior OCT The majority have more than one tattoo and digital photography allows the (61 per cent) and around 14 per cent practitioner to capture some of very have six or more. Fifty-one per cent Dense corneal scarring strange images that can be associated had obtained their first tattoo between Unfortunately, I have one patient who with Christmas Eye. This technology the ages of 18 and 25, and thirty-six per experienced the development of a disc- allows us to monitor the effects on cent at 26 or older. Australian women shape intrastromal corneal scar. His the eye as never before (Figures 9 with tattoos (20 per cent) outnumber incident history was identical until the and 10). men (19 per cent). day-five mark, when he developed a disc shaped sub-epithelial lesion with Given these figures, we need to Conclusion marked corneal thickening. His corneal be aware of a possible increase in epithelium was nearly fully healed Christmas Eye can be a confronting presentations of tattoo-associated (Figure 6). condition for those who are unaware uveitis (TAU). of its signs and symptoms. Any Over the next six months the cornea condition that causes extreme pain involved proceeded to flatten and thin. is stressful for both the practitioner CASE REPORT The density of the corneal scarring and particularly the patient. Care, also reduced. The original size of the reassurance and pain control are scar is indicated by the white outline the keys in managing this unusual A 25-year-old male presented to the in Figure 8. At its peak, the corneal condition. emergency department in 2017 with thickness through the lesion was decreased visual acuity, intermittent 721microns. Four weeks later, the 1. Howsam G. The Albury – Wodonga redness and a feeling of ‘pressure’ in syndrome. A tale of two cities. Aust thickness had reduced to 489 microns NZ J Ophthalmol 1995; 23: 135–137 both eyes (OU). These symptoms had (Figures 7 and 8). 2. Farrow R. Insects of South-Eastern been intermittent for approximately Australia: An Ecological and one year. Behavioural Guide. Clayton South: A year later, the lesion is still present CSIRO Publishing, 2016. but less dense. The topography and 3. Mullen G, Durden L, editors. Medical The patient’s medical history was and Veterinary Entomology, 2nd ed unremarkable; he denied any past corneal thickness changes have London: Academic Press, 2019. stabilised. Fortunately, the lesion was 4. Lin JC, Rapuano CJ, Laibson PR et ocular history but was diagnosed with off axis and is now only causing slight al. Corneal melting associated with allergic conjunctivitis in 2015. Old use of topical nonsteroidal anti- keratic precipitates (KP) OU were also blur and mild flare at night while inflammatory drugs after ocular driving. surgery. Arch Ophth 2000; 118: noted at this time, indicating previous 1129–1132 inflammation. His vision was 6/36 OU with no pinhole improvement. Bilateral Discussion anterior uveitis and posterior synechiae Why there was a cluster of these were noted, intraocular pressures (IOP) adverse events in the summer of 2017– were RE 9 mmHg and LE 10 mmHg. DECEMBER 2019 23

(LE > RE) had recurred. Bilateral posterior synechiae and a left iris TAU: Tattoo-associated uveitis nodule were noted. The retina could not be visualised. Due to severe eye- threatening uveitis, he was given a left Cutanteous reactions and ocular problems orbital floor injection and was advised to reduce his PNL by half and continue with PF hourly OU.

At his next visit he complained that his tattoos were feeling ‘lumpy’ again. Control of his ocular inflammation was difficult, exacerbated by his poor attendance and treatment compliance, so he was commenced on a weekly dose of both immunosuppressant drug methotrexate (MTX) and folic acid. He was to continue with 5 mg PNL and PF four times each day. Monthly blood tests were initiated to monitor for dosage and side effects of the MTX.

Improvement was noted in his vision and ocular inflammation, however, a right IOP of 32 mm Hg was noted (left 12 mm Hg). His topical and systemic medications were reduced by half and he was sent to the Glaucoma Unit due to development of right ocular hypertension (OHT) caused by iris Figure 1. Posterior synechiae (adhesion of the iris to the capsule of the lens) due to inflamma- bombe (synechial closure R > L). He tion. underwent a right Yag laser peripheral iridotomy and his IOP was noted to be 8 mmHg after this. His cup-to-disc He was diagnosed with bilateral with tropicamide. Vision and IOP ratios were 0.2 OU and his visual field acute anterior uveitis (AAU) and remained stable and further weaning of tests were essentially normal. cystoid macular oedema (CMO), and PNL was suggested. commenced on topical medications: When last seen, his vision was 6/9 OU; prednefrin forte (PF) hourly, and He missed his next review, and on both eyes were quiescent and there was atropine twice daily in both eyes for presentation seven weeks later there minimal CMO. IOPs were RE 8 mmHg pain management and to reduce further was a recurrence of bilateral uveitis and LE 8 mmHg. He had been weaned posterior synechiae formation. (2+ cells, SUN grading), disc swelling off the PF but was to continue with and left CMO. Compliance was stressed the immunosuppressant drug MTX Blood tests were taken to rule out but it was thought that a left orbital to curtail the cutaneous reaction and sarcoidosis, syphilis, HLA-B27 floor injection of triamcinolone may be reduce the risk of recurrent uveitis. positivity and various infectious and needed in the future. inflammatory aetiologies (repeated throughout his follow-up). Having missed an appointment, he was Discussion reviewed five weeks later. He had lost There have been an increasing number On review 10 days later, it has been his prescription and had only instilled of cases in literature2 of TAU since noted that compliance had been poor topical medications on a few occasions. Rorsman et al.3 described three cases with the topical medications. His His left CMO had reduced, and an with light blue tattoo granuloma and vision had deteriorated further (6/60 indurated red, raised left tricep tattoo anterior uveitis with no features of OU), the uveitis persisted (+2 cells) was noted. systemic disease in 1969. In 2014 and his optic nerves were swollen and Ostheimer et al.4 submitted the largest hyperaemic. In retrospect, he felt that his ocular study which followed seven patients problems commenced around the with various sequelae of uveitis with He was commenced on systemic time that he got the tattoo. In light of simultaneous tattoo induration over 20 prednisolone (PNL) 50 mg daily. previous negative investigations and months. With improved compliance of all the presence of inflamed tattoos, a medications, his vision improved to diagnosis of tattoo-associated uveitis TAU presents with bilateral recurrent/ 6/9 OU due to decreased CMO and (TAU) with CMO OU was made. chronic uveitis, though in one case inflammation. Intraocular pressures the second eye became involved (IOP) were RE 19mmHg and LE 16 mm He was lost to follow-up for almost five one month later.5 Cases cited have Hg. He was advised to reduce his PNL months after which bilateral recurrent to 37.5 mg and atropine was replaced anterior uveitis (3+ cells) and CMO Continued page 24 24 DECEMBER 2019

Tattoo uveitis From page 23 ranged from having anterior uveitis (predominately non-granulomatous) to chronic pan uveitis and hypopyon.

Tattoo swelling has been said to precede uveitis for a week on recurrent episodes.6

The time frame of onset can occur from at least six months after tattoo placement and up to 13 years which possibly presents a specific Figure 2. Induration (cutaneous reaction) of a black chest tattoo. granulomatous-delayed allergic response to ink containing metal compounds.7 Obtaining a number of tattoos over a short period of time excision of the affected tattoo, ocular blurred vision. possibly increases the toxic load.4 symptoms completely resolved without 4 Most had extensive tattoos and were medication, an option not possible Immediate treatment may reduce predominately male. where large areas are affected. the severity and sequelae of uveitis which may require laser, surgery and The majority of cases have been The inflammatory response can be medications with possible serious side in the USA and many of the inks difficult to control and many patients effects. used were industrial grade colours have suffered potentially vision- suitable for printers and automobile threatening ocular complications such The author would like to acknowledge ink. The induration appeared in as seclusio pupillae, iris bombe, OHT Dr Catrin Bertalot (Medical Retinal more extensively tattooed areas that (often refractory), uveitic glaucoma, Fellow, RVEEH) for her advice and contained or consisted entirely of black pupillary membranes, severe CMO, Matthew Ayres (Medical Photographer, ink. The black ink possibly contained elevated and hyperaemic optic nerves RVEEH) for the photographic images. toxic, mutagenic or carcinogenic with papillomacular exudates and retinal detachment.4 1. McCrindle [Internet]. Tattoos in compounds.4 Two articles cite skin Australia: Perceptions, trends and reaction to light blue3 and red8 ink. regrets. c.2016 [Cited 2019 Sep 16] As shown, in addition to topical, Available from: http://mccrindle.com. periocular and systemic steroids, au/insights/blog/tattoos In Australia, state and territory 2. Mansour AM. Tattoo-associated uveitis. authorities are responsible for systemic immunosuppressants may be Am J Ophthalmol 2015; 159: 408-409 3. Rorsman H, Brehmer-Andersson E, regulating the safety of tattoo inks required. Reactivation is common on tapering steroids. Regular ophthalmic Dahlquist I et al. Tattoo granuloma including product labelling and uveitis. Lancet 1969; 294: 27-28 restrictions on their use in tattooing. review and blood tests to watch for 4. Ostheimer TA, Burkholder BM, Leung serious side effects are required. Raised TG et al. Tattoo-associated uveitis. Am J Chemicals used in tattoo and Ophthalmol 2014; 158: 637-643 permanent makeup (PMU) inks are IOP due to uveitic mechanisms and/or 5. McElvanney AM, Sherrif SM. Uveitis classified as industrial chemicals in topical steroid use may require topical and skin tattoos. Eye (Lond) 1994; 8: 9 glaucoma drops. Traditional glaucoma 602-603 Australia. These regulations may not 6. Mansour AM, Chan CC. Recurrent be adhered to, particularly if used surgery can have poor outcomes in uveitis preceded by swelling of skin outside of a registered tattoo parlour or inflamed eyes. Drainage tubes have tattoo. Am J Ophthalmol 1991; 111: 515- been required due to refractory OHT or 516 in a country without a regulatory body. 7. Jacobs J, Van Calster J.Skin tattoos secondary glaucoma. and the development of uveitis. Acta The cutaneous reactions of erythema, Ophthalmologica 2013: 650-652 The following questions need to be 8. Barbarasi Z, Kiss E, Balaton G et al. pruritis, indurated papules or nodules Cutaneous granuloma and uveitis can occur on the border or within asked of anybody presenting with caused by a tattoo. Wien Klin the tattoo area (Figure 2). Similar uveitis: do you have tattoos and if so, Wochenschr 2008; 120: 18 are they inflamed, red or lumpy? Those 9. Australian Government Department of cutaneous reactions may arise in Health [Internet]. Characterisation of patients with sarcoidosis (33 per cent), presenting with old KPs need to be tattoo inks used in Australia. c.2018 as can granulomatous uveitis (80 per asked in regard to tattoos and previous [Cited 2018 May 15]. Available from: ocular/cutaneous reactions. https://www.nicnas.gov.au/chemical- cent).9 There have been a number information/Topics-of-interest2/ of cases where TAU has been the subjects/tattoo-inks-used-in-Australia/ Characterisation-of-tattoo-inks-used-in- presenting feature of sarcoidosis. It Tattoo parlours should make their customers aware of cutaneous reactions Australia has been postulated that sarcoidosis 10. Pandya VB, Hooper CY, Merani R et al. may be diagnosed in these cases in which may be a precursor to ocular Tattoo-associated uveitis with choroidal 10 problems and that an urgent eye check granuloma: a rare presentation of the long term or that this entity is systemic sarcoidosis. Retin Cases Brief perhaps a subset of sarcoidosis.7 It was is required with symptoms such as Rep 2017; 11: 272-276 noted that when there was complete ocular pain, photophobia, redness and Envisioning the future with Novartis

ovartis is reimagining the treatment and This undertreatment is largely driven by: Nprevention of visual impairment and blindness. • 1 in 4 people with AMD undiagnosed9 By working to push the boundaries of medicine • 1 in 3 people discontinuing anti-VEGF treatment in the first year8 and technology, we aim to develop life-changing gene therapies, next-generation pharmaceuticals, and transformative technologies for diseases and conditions spanning every area of eye disease, from At Novartis, we’re working to the front to the back of the eye. eliminate wet AMD-related

In Australia, Novartis offers one of the industry’s largest vision impairment and blindness and most diverse ophthalmology pharmaceuticals portfolios,2 and is the industry’s largest investor in clinical trials across Australia:3 Novartis has partnered with Macular Disease Foundation 14 ophthalmology trials sponsored in the Australia to launch See What’s Next, a public awareness last 3 years alone4 campaign to support patients with wet AMD.1 Over the past few weeks, we’ve been running an awareness 100,000 blind or vision-impaired Australians’ and education campaign to encourage people at risk of lives touched by Novartis in 2017–184 AMD to see their optometrist for an eye exam.

Together, we can help improve diagnosis of AMD and Proud hosts of the Australian annual ensure patients receive the care they need to maintain Future Directions in Ophthalmology their vision. symposium since 2014

Envisioning improved diagnosis If you’d like to order free materials to help increase for people with wet AMD awareness of wet AMD in your practice, scan the Anti-VEGF injections have revolutionised the treatment QR code or visit medhub.com.au/see-whats-next of wet (neovascular) age-related macular degeneration (AMD).5 Australian wet AMD patients treated with anti- VEGF maintain their starting level of vision for an average of 6 years.6

However, there’s still more to do. More than 1 in 2 patients 1 with wet AMD did not receive anti-VEGF treatment in 2017, putting them at serious risk of losing their vision.7,8

Macular Disease Foundation Australia (MDFA) and Novartis Pharmaceuticals Pty Ltd are working together on the common goal to raise awareness of age-related macular degeneration in the community. See What’s Next is an awareness campaign developed by Novartis. By supporting this campaign MDFA is not endorsing any specific treatment or therapy. Abbreviations: AMD: age-related macular degeneration; VEGF: vascular endothelial growth factor. References: 1. Optometry Australia. 2019 Clinical Practice Guide for the diagnosis, treatment and management of Age-Related Macular Degeneration. 2. Novartis data on file. IMS ophthalmology market sales, May 2019. 3. Austrade. Clinical Trials Capability Report 2018. 4. Novartis data on file. 5. Al-Zamil W, Yassin S. Recent developments in age-related macular degeneration: a review. Clin Interv Aging 2017;12:1313–30. 6. Gillies M et al. Long-term outcomes of treatment of neovascular age-related macular degeneration: data from an observational study. Ophthalmology 2015;122:1837–45. 7. Macular Disease Foundation Australia. Macular degeneration research update. Dec 2017. 8. Drug Utilisation Sub-Committee (DUSC). Ranibizumab and aflibercept: analysis of use for AMD, DMO, BRVO and CRVO. May 2018. 9. Neely DC et al. Prevalence of Undiagnosed Age-Related Macular Degeneration in Primary Eye Care. JAMA Ophthalmol 2017;135:570–75. Novartis Pharmaceuticals Australia Pty Limited ABN 18 004 244 160. 54 Waterloo Road, Macquarie Park NSW 2113. Ph (02) 9805 3555. September 2019. AU-10075 NOBR17308WP. Ward6.

NOBR17308W Ophth Joiurnal FPC 297x210 v1a FA.indd 1 30/9/19 4:04 pm PBS list of medicines prescribed by optometrists Revised November 2019 Note: To satisfy PBS criteria for combination antiglaucoma agent, patient must have been inadequately controlled with monotherapy

Product Max qty Repeats

ANTI-GLAUCOMA PREPARATIONS

Betaxolol eye-drops, solution, 5 mg (as hydrochloride)/mL, (0.5%), 5 mL Betoptic, BetoQuin 1 5

Bimatoprost eye-drops 300 mcg/mL (0.03%), 3 mL Lumigan, Bimatoprost Sandoz, Bimtop, APO-Bimatoprost 1 5

Bimatoprost eye-drops 300 mcg/mL (0.03%) 30 x 0.4 mL unit doses Lumigan PF* 1 5

Bimatoprost with timolol eye-drops containing bimatoprost 300 mcg/mL (0.03%) Ganfort 0.3/5 1 5 with timolol 5 mg (as maleate)/mL (0.5%), 3 mL

Bimatoprost with timolol eye-drops containing bimatoprost 300 mcg/mL (0.03%) Ganfort PF 0.3/5* 1 5 with timolol 5 mg (as maleate)/mL (0.5%), 30 x 0.4 mL unit doses

Brimonidine tartrate eye-drops 1.5 mg/mL (0.15%), 5 mL Alphagan P 1.5 1 5

Brimonidine tartrate eye-drops 2.0 mg/mL (0.2%), 5 mL Alphagan, Enidin 1 5

Brimonidine with timolol eye-drops containing brimonidine tartrate Combigan 1 5 2 mg/mL (0.2%) with timolol 5 mg (as maleate)/mL (0.5%), 5 mL

Brinzolamide eye-drops 10 mg/mL (1%), 5 mL Azopt, BrinzoQuin 1 5

Brinzolamide 10 mg/mL (1%) eye-drops containing brimonidine tartrate 2 mg/mL (0.2%), 5 mL Simbrinza 1 5

Brinzolamide with timolol eye-drops containing brinzolamide Azarga 1 5 10 mg/mL (1%) with timolol 5 mg (as maleate)/mL (0.5%) 5 mL

Dorzolamide eye-drops 20 mg (as hydrochloride)/mL (2%), 5 mL Trusopt, Trusamide, APO-Dorzalamide 1 5

Dorzolamide with timolol eye-drops containing dorzolamide 20 mg Cosopt, Cosdor, Dorzolamide/ 1 5 (as hydrochloride)/mL (2%) with timolol 5 mg (as maleate)/mL (0.5%), 5 mL Timolol 20/5 (AN, APO)

Latanoprost eye-drops 50 mcg/mL (0.005%), 2.5 mL Lanpro, Latanoprost (APO, Actavis, Sandoz), Xalaprost, Xalatan 1 5

Latanoprost with timolol eye-drops containing latanoprost 50 mcg/mL (0.005%) Xalacom, Xalamol 50/5, Lantim, with timolol 5 mg (as maleate)/mL (0.5%), 2.5 mL Latanaprost/Timolol (AN, APO, Sandoz) 1 5

Pilocarpine eye-drops containing pilocarpine hydrochloride 10 mg/mL (1%), 15 mL Isopto Carpine 1 5

Pilocarpine eye-drops containing pilocarpine hydrochloride 20 mg/mL (2%), 15 mL Isopto Carpine 1 5

Pilocarpine eye-drops containing pilocarpine hydrochloride 40 mg/mL (4%), 15 mL Isopto Carpine 1 5

Tafluprost eye-drops 15 mcg/ml (0.0015%) 30 x 0.3mL unit doses Saflutan* 1 5

Timolol eye-drops 5 mg (as maleate)/mL (0.5%), 5 mL Timoptol 1 5

Timolol eye-drops (gellan gum solution) 5 mg (as maleate)/mL (0.5%), 2.5 mL Timoptol XE 1 5

Travoprost eye-drops 40 mcg/mL (0.004%), 2.5 mL Travatan 1 5

Travoprost with timolol eye-drops containing travoprost 40 mcg/mL (0.004%) with Duotrav 1 5 timolol 5 mg (as maleate)/mL (0.5%), 2.5 mL

* Unit doses

Product Restriction Max qty Repeats

ANTI-VIRAL EYE PREPARATIONS Aciclovir eye ointment 30 mg/g (3%), 4.5 g AciVision Restricted: Herpes simplex keratitis 1 0 PBS list of medicines prescribed by optometrists Revised November 2019

Product Restriction Max qty Repeats

ANTIBIOTICS

Chloramphenicol eye-drops 5 mg/mL (0.5%), 10 mL Chlorsig Restricted: For treatment of patients identifying as Aboriginal or Torres Strait Islander 1 2

Ciprofloxacin† eye-drops 3 mg /mL (0.3%), 5 mL CiloQuin, Ciloxan Authority required: bacterial keratitis 2 0

Framycetin sulfate eye-drops 5 mg/mL (0.5%), 8 mL Soframycin 1 2

Gentamicin eye-drops 3 mg/mL (0.3%), 5 mL Genoptic Restricted: Suspected pseudomonal eye infection 1 2

Ofloxacin† eye-drops 3 mg/mL (0.3%), 5 mL Ocuflox Authority required: bacterial keratitis 2 0

Tobramycin eye-drops 3 mg/mL (0.3%), 5 mL Tobrex Restricted: Suspected pseudomonal eye infection 1 2

Tobramycin eye ointment 3 mg/g (0.3%), 3.5 g Tobrex Restricted: Suspected pseudomonal eye infection 1 0

†NOTE: must be in consultation with an ophthalmologist

ANTI-INFLAMMATORY AGENTS

Dexamethasone eye-drops 1 mg /mL (0.1%), 5 mL Maxidex 1 0

Fluorometholone eye-drops 1 mg/mL (0.1%), 5 mL FML Liquifilm 1 0

Fluorometholone acetate eye-drops 1 mg/mL (0.1%), 5 mL Flarex 1 0

Hydrocortisone acetate eye ointment 10 mg/g (1%), 5 g Hycor 1 0

Prednisolone acetate with phenylephrine hydrochloride eye-drops 10 mg-1.2 mg/mL (1%-0.12%), 10 mL Prednefrin Forte Restriction: Uveitis 1 0

TEAR SUPPLEMENTS Restricted: Severe dry eye including Sjögren’s syndrome

Carbomer 980 eye gel 2 mg/g (0.2%), 10 g Optifresh eye gel As above 1 5

PAA As above 1 5

Viscotears As above 1 5

Carmellose sodium eye-drops 5mg/mL (0.5%) Optive As above 1 3 with glycerol 9 mg/mL (0.9%), 15ml

Carmellose sodium eye-drops 10 mg/mL (1%), 15 mL Refresh Liquigel As above 1 5

Carmellose sodium eye-drops 5 mg/mL (0.5%), 15 ml Refresh Tears plus As above 1 5

Hypromellose eye-drops 3 mg/mL (0.3%), 15 mL In a Wink As above 1 5 (contains sodium perborate) Genteal

Hypromellose eye-drops 5 mg/mL (0.5%), 15 mL Methopt As above 1 5

Hypromellose 3 mg/mL (0.3%) with carbomer 980 HPMC PAA As above 1 5 2 mg/g (0.2%) ocular lubricating gel, 10 g Genteal Gel

Hypromellose 3 mg/mL (0.3%) with dextran eye-drops Poly-Tears, 1 mg/mL (0.1%), 15 mL Tears Naturale As above 1 5

Polyethylene glycol 400 mg/mL (0.4%) with propylene glycol 3 mg/mL (0.3%) eye-drops, 15 mL Systane As above 1 5

Polyvinyl alcohol eye-drops 14 mg/mL (1.4%), 15 mL PVA Tears, Liquifilm Tears As above 1 5 PBS list of medicines prescribed by optometrists Revised November 2019

Product Restriction Max qty Repeats

UNPRESERVED TEAR SUPPLEMENTS** Authority required: streamlined Carbomer 974 ocular lubricating gel 3 mg/g (0.3%), Poly Gel Severe dry eye syndrome in 3 5 single dose units 0.5 g x 30 patients sensitive to preservatives in multi-dose eye-drops Carbomer 980 eye gel 2 mg/g (0.2%), Viscotears Gel PF As above 3 5 single dose units 0.6 mL x 30 Carmellose sodium eye-drops 5 mg/mL (0.5%), Cellufresh As above 3 5 single dose units 0.4 mL x 30 Optifresh Tears Carmellose sodium eye-drops 10 mg/mL (1%) , Celluvisc As above 3 5 single dose units 0.4 mL x 30 Optifresh Plus Hypromellose 3 mg/ mL (0.3%) with dextran eye-drops 1 mg/mL (0.1%), single dose units 0.4 mL x 28 Bion Tears As above 3 5 Perfluorohexyloctane eye-drops (100%), 3mL NovaTears As above 1 5 Polyethylene glycol 400, 4 mg/mL (0.4%) with propylene glycol 3 mg/mL (0.3%) eye-drops, single dose units 0.8 mL x 28 Systane As above 2 5 Sodium Hyaluronate sodium hyaluronate eye-drops 1 mg/mL (0.1%), 10 mL Hylo-Fresh As above 1 5 Sodium Hyaluronate sodium hyaluronate eye-drops 2 mg/mL (0.2%), 10 mL Hylo-Forte As above 1 5 Soy Lecithin 1% + tocopherol 0.002% + vitamin A palmitate 0.025% eye spray, 100 actuations Tears again As above 2 5 **Optometrists have two Streamlined Authority Codes for unpreserved tear supplements: 4105 Hylo-Fresh and Hylo-Forte, and 6172 all other unit-dose ocular lubricants

TOPICAL OCULAR LUBRICANT OINTMENTS Paraffin 1 g/g compound eye ointment 3.5 g Polyvisc 2 5 Paraffin 1 g/g pack containing 2 tubes Polyvisc (2 pack), Ircal (2 pack), eye ointment 3.5 g Refresh Night Time (2 pack) 1 5 Paraffin VitA-POS paraffin + retinol palmitate 138 mcg/g (0.0138%) (equivalent to 250 units/g vitamin A) eye ointment, 5 g 2 5

Ophthalmic compounding pharmacists This list is intended to assist the members of Optometry Australia and is not an endorsement of any of the pharmacists listed below. If you know a certified ophthalmic compounding pharmacist, please email us at [email protected] and we will add it to future published lists.

NEW SOUTH WALES Green Dispensary PharmacySmart Compounding CustomCare Compounding Pharmacy St Peters, SA East Melbourne, VIC Dural, NSW Tel: (08) 8363 7322 Tel: (03) 9416 1223 Email: [email protected] Tel: (02) 9651 3547 Email: [email protected] www.greendispensary.com.au Email: [email protected] www.pharmacysmart.com.au www.customcarepharmacy.com.au Infinity Custom Pharmaceuticals PharmacySmart Compounding 127 Glynburn Road, Glynde SA 5070 Stenlake Compounding Chemist Pascoe Vale South, VIC Tel (08) 7132 0676 Tel: (03) 8679 6776 Bondi Junction, NSW Email: [email protected] Tel: (02) 9387 3205 www.pharmacysmart.com.au Email: [email protected] VICTORIA www.stenlake.com.au Slade Pharmacy Como Compounding Pharmacists Richmond, VIC South Yarra, Melbourne Tel: (03) 8420 0700 QUEENSLAND Tel: (03) 9079 1999 Email: [email protected] Email: [email protected] Your Solution Compounding Pharmacy www.sladepharmacy.com.au www.comocompounding.com.au Brendale, QLD Tel: 1300 900 939 CustomCare Compounding Pharmacy Your Solution Compounding Pharmacy Email: [email protected] Malvern East, VIC Hawthorn, VIC www.yoursolutioncompounding.com.au Tel: (03) 9509 2157 Tel: 1300 900 939 Email: [email protected] Email: [email protected] SOUTH AUSTRALIA www.customcarepharmacy.com.au www.yoursolutioncompounding.com.au CustomCare Compounding Pharmacy PharmacySmart Compounding Lockleys, SA WESTERN AUSTRALIA Balwyn, VIC Tel: (08) 8443 5639 Tel: (03) 9857 3679 Oxford Compounding Email: [email protected] Email: [email protected] 73 Angove St North Perth www.customcarepharmacy.com.au www.pharmacysmart.com.au 08 9225 9400 Business Insurance – What is it? Business Insurance – When do I need it?

Property Damage  If you OWN or LEASE a  commercial Property Business Interruption  If you have CONTENTS or STOCK  Crime / Theft  If you could not maintain normal Glass  business operation if you were to  General Property  suffer a major loss at your business If you are RESPONSIBLE to insure Money   LEASED equipment Electronic Data  If you have staff who visit Machinery Breakdown  worksites with expensive  equipment For severe or For mild or chronic dry eye moderate dry eye The systematic approach to eye lubrication for Preservative-free and phosphate-free At least 300 measured drops per pack, or 150 treatments (both eyes) Can be used for 6 months after opening Delivered through the unique COMOD® Dry Eyes Compatible with contact lenses multi-dose application system

STREAMLINED AUTHORITY CODE 4105

PBS Information: Authority Required (STREAMLINED): Severe dry eye syndrome in patients who are sensitive to preservatives in multi-dose eye drops.

HYLO®-FRESH, HYLO-FORTE® and COMOD® are registered trademarks of URSAPHARM. AFT Pharmaceuticals Pty Ltd, Sydney. ABN 29105636413.

Available from:

www.aftpharm.com

p: 1800 814 963

w: goodoptical.com.au 28082PM