REVIEW OF OPTOMETRY ■ New Column — Ocular Surface Review, The Evolution of Dry Eye, Page 79 VOL. 152 NO. 1 ■
January 15, 2015 www.reviewofoptometry.com JANUARY 15, 2015 ■ EARN 2 CE CREDITS Annual Pharmaceutical Issue GOING ANTIVIRAL:
ANNUAL PHARMACEUTICAL ISSUE ■ How to Bring HERPES to a HALT A review of the most commonly prescribed topical and oral antiviral medications
FOREIGN BODY REMOVAL ■ used to manage herpetic eye disease. PAGE 50
» ORAL MEDS: WHEN A DROP ISN’T ENOUGH, PAGE 38
» OFF LABEL, BUT ON TARGET, PAGE 46
NEURO
ALSO INSIDE: ■
ANTERIOR UVEITIS • NEW SERIES — ESSENTIAL PROCEDURES AT THE SLIT LAMP PART 1: FOREIGN BODY REMOVAL IN 12 STEPS, PAGE 22
• AN INTRO TO NEURO, PAGE 30
• PRACTICAL PEARLS FOR MANAGING ANTERIOR UVEITIS, PAGE 58
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VOL. 152 NO. 1 ■ JANUARY 15, 2015
IN THE NEWS High Blood Pressure is
All children aged 36 to 72 months should be have a vision screening Now a Glaucoma Risk annually (best practice) or at least once (acceptable minimum standard), A new study suggests that chronic hypertension does not according to the National Expert protect against elevated IOP. By Bill Kekevian, Senior Editor Panel to the National Center for Photo: James L. Fanelli, OD Children’s Vision and Eye Health. The nstead of viewing hypertension panel’s fi ndings appear in the January as beneficial in the fight against issue of Optometry & Vision Science. Iglaucoma, it should be identi- “A best practice for children who fail fied as a risk factor, an Australian vision screening includes documenta- research team suggests. tion of the referral to and subsequent That’s because, in older patients, comprehensive eye examination by an any benefit from high blood pres- optometrist or ophthalmologist,” the sure counteracting high intraocular panel advises. pressure is lost as damage to blood vessels—a consequence of hyper- About 93% of American adults spend tension—becomes more prevalent, Contrary to earlier theories, chronic high more than two hours per day using according to a study in the Decem- blood pressure adds a risk for glaucoma. digital devices—a length of time that ber issue of Investigative Ophthal- is increasing the prevalence of digital mology & Visual Science (IOVS).1 elevation in chronic hypertension. eyestrain, says The Vision Council in The idea that hypertension has “What this means is that having its “2015 Digital Eye Strain Report.” protective qualities against IOP high blood pressure for a longer Digital eyestrain has grown expo- elevation was supported by research time has compromised the eye’s nentially with the increase in use of conducted in the 1990s, which capacity to cope with high eye computers, smartphones, tablets and found systemic hypertension to be pressure. It seems that hyperten- other electronic devices. The report protective for younger patients, sion might damage the blood ves- attributes this trend primarily to factors but a risk factor in older patients.2 sels in the eye so that they can’t including screens with small text held Those authors proposed that compensate for changes in blood too close to the face, a reduced blink patients in the early stage of hyper- flow when eye pressure increases,” rate as a result of staring for prolonged tension are likely to benefit from says researcher Bang V. Bui, PhD, periods and poorly designed work- improved ocular perfusion pressure BSc(optom), of the University of spaces. and blood flow to the eye. Melbourne. Adults with computer-oriented In the recent experimental study The authors acknowledged that jobs are considered most at risk for in IOVS, researchers compared chronic hypertension in their exper- digital eyestrain, followed closely by the effect of normal blood pressure iment was limited to four weeks. those who use electronic devices for with one-hour (acute) and four- They speculated that, with longer recreational reading. Children are week (chronic) hypertension in lab periods of hypertension and thus also at risk for digital eyestrain and rats with elevated IOP. more severe vascular damage, the subsequent problems, with one in four The team found that rats with protective effect of high blood pres- spending more than three hours per chronic hypertension did not get sure might be further reduced. day using electronic devices. More than the same protection against elevated 1. He Z, Vingrys AJ, Armitage JA, et al. Chronic hypertension one in fi ve parents reported concern IOP. The researchers partially increases susceptibility to acute IOP challenge in rats. Invest about the impact of digital devices on associate the effect with a reduced Ophthalmol Vis Sci. 2014;55:7888-95. 2. Tielsch JM, Katz J, Sommer A, et al. Hypertension, perfusion their children’s eyes, the report found. capacity for ocular blood flow to pressure, and primary open-angle glaucoma. A population- autoregulate in response to IOP based assessment. Arch Ophthalmol. 1995;113:216-21.
4 REVIEW OF OPTOMETRY JANUARY 15, 2015
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NJ ODs Seek to Retain Rx of Opioids ptometrists in New Jer- to prescribe drugs in the Schedule treat patients with ocular injuries sey are seeking to push III, IV and V categories. and serious eye infections with the Othrough a bill to reinstate The latest bill, S-2578/A-3922, proper medications,” he says. their privileges to prescribe hydro- does not expand ODs’ scope of The Medical Society of New Jer- codone, an opioid pain medica- practice but it would restore their sey (MSNJ) has taken the position tion. ability to prescribe hydrocodone, that it’s appropriate to restrict the Optometrists lost this privilege not other medications. The bill prescription of opioids in light of in October 2014, when the Drug argues that optometrists have for ongoing state efforts to prevent and Enforcement Administration (DEA) many years prescribed products treat chemical dependence on this rescheduled products containing containing hydrocodone without class of drugs. hydrocodone from Schedule III to incident. In a letter from MSNJ to the Schedule II, meaning that optom- NJSOP has been working col- members of the New Jersey Senate etrists are no longer authorized to laboratively with state legislators Commerce Committee, the society prescribe such products under state to address this change in schedule, cites that the legislature prudently law. Mr. Cooper says. The collaboration limited ODs’ prescription rights “This change affects the abil- seems to be making some in-roads when the original expanded scope ity of New Jersey optometrists to on the bill. In late December 2014, of practice bill was passed in 2004 provide the best possible care to S-2578 passed the Senate unani- because of the “high potential for patients with ocular injuries and mously. The NJSOP is working to abuse, which may lead to severe serious eye infections,” says How- have the Assembly version heard psychological or physical depen- ard Cooper, executive director of in committee when the legislature dence” on Schedule II dangerous the New Jersey Society of Opto- returns in January, Mr. Cooper substances. metric Physicians (NJSOP). adds. On the federal level, the Ameri- New Jersey optometrists had “Our interests are to ensure can Optometric Association says it obtained such prescription rights in that New Jersey optometrists pro- fought against the rescheduling of 2004, when their state legislature vide the best possible care to their hydrocodone drugs. passed a bill that would allow them patients and, when appropriate, But despite the best efforts of the AOA and other organizations, the DEA moved forward with the deci- Weight Loss Surgery Can Impact Eyes sion. Weight loss surgery can improve your waistline—but hurt your eyes, according to a Since hydrocodone’s move from recent study published in Obesity Surgery. a Schedule III to a Schedule II drug, People who have the procedure should take vitamin supplements to avoid ocular the AOA has worked with individ- complications, investigators advise. ual states to amend the law, accord- Bariatric surgery (such as gastric binding or gastric bypass) involves restriction or ing to the AOA. removal of some of the stomach, which limits the body’s ability to absorb key nutrients, Several other states—Alaska, resulting in vitamin defi ciencies.1 Arkansas, Arizona, California, This recent study specifi cally shows that patients who have undergone bariatric sur- Colorado, Georgia, Illinois, Ken- gery (especially “malabsorptive” procedures) may lack nutrients essential to ocular health, tucky, Michigan, Oklahoma and 2 including vitamins A, E, B1 (thiamine) and copper. These nutrients help with the normal Utah—have since enacted similar functioning of the eye and optic system. legislation authorizing optometrists Vitamin A defi ciency, in particular, is linked to eye-related complications developing licensed in those states to continue after bariatric surgery. prescribing pharmaceutical agents The researchers recommend that patients who have undergone bariatric surgery adopt containing hydrocodone as they did some form of supplement regimen. prior to federal rescheduling. 1. Shankar P, Boylan M, Sriram K. Micronutrient defi ciencies after bariatric surgery. Nutrition. 2010 Nov- Stay tuned as the New Jersey leg- Dec;26(11-12):1031-7. 2. Guerreiro RA, Ribeiro R. Ophthalmic complications of bariatric surgery. Obes Surg. 2015 Jan;25(1):167-73. islature takes up the bill again this month.
6 REVIEW OF OPTOMETRY JANUARY 15, 2015
004_ro0115_news.indd 6 1/9/15 9:48 AM RO0115_Allergan Lumigan.indd 1 12/18/14 11:15 AM ® At doses at least 41 times the maximum intended human exposure based on blood LUMIGAN 0.01% AUC levels, the gestation length was reduced in the dams, the incidence of dead fetuses, late resorptions, peri- and postnatal pup mortality was increased, and pup (bimatoprost ophthalmic solution) body weights were reduced. There are no adequate and well-controlled studies of LUMIGAN® (bimatoprost Brief Summary—Please see the LUMIGAN® 0.01% package insert for full ophthalmic solution) 0.01% administration in pregnant women. Because animal Prescribing Information. reproductive studies are not always predictive of human response LUMIGAN® 0.01% should be administered during pregnancy only if the potential benefit justifies the INDICATIONS AND USAGE potential risk to the fetus. LUMIGAN® (bimatoprost ophthalmic solution) 0.01% is indicated for the reduction Nursing Mothers: It is not known whether LUMIGAN® 0.01% is excreted in human of elevated intraocular pressure in patients with open angle glaucoma or milk, although in animal studies, bimatoprost has been shown to be excreted in ocular hypertension. breast milk. Because many drugs are excreted in human milk, caution should be CONTRAINDICATIONS exercised when LUMIGAN® 0.01% is administered to a nursing woman. None Pediatric Use: Use in pediatric patients below the age of 16 years is not recommended WARNINGS AND PRECAUTIONS because of potential safety concerns related to increased pigmentation following long-term chronic use. Pigmentation: Bimatoprost ophthalmic solution has been reported to cause changes to pigmented tissues. The most frequently reported changes have been increased Geriatric Use: No overall clinical differences in safety or effectiveness have been pigmentation of the iris, periorbital tissue (eyelid) and eyelashes. Pigmentation is observed between elderly and other adult patients. expected to increase as long as bimatoprost is administered. The pigmentation Hepatic Impairment: In patients with a history of liver disease or abnormal ALT, change is due to increased melanin content in the melanocytes rather than to AST and/or bilirubin at baseline, bimatoprost 0.03% had no adverse effect on liver an increase in the number of melanocytes. After discontinuation of bimatoprost, function over 48 months. pigmentation of the iris is likely to be permanent, while pigmentation of the periorbital OVERDOSAGE tissue and eyelash changes have been reported to be reversible in some patients. No information is available on overdosage in humans. If overdose with LUMIGAN® Patients who receive treatment should be informed of the possibility of increased (bimatoprost ophthalmic solution) 0.01% occurs, treatment should be symptomatic. pigmentation. The long term effects of increased pigmentation are not known. In oral (by gavage) mouse and rat studies, doses up to 100 mg/kg/day did not Iris color change may not be noticeable for several months to years. Typically, the produce any toxicity. This dose expressed as mg/m2 is at least 210 times higher than brown pigmentation around the pupil spreads concentrically towards the periphery the accidental dose of one bottle of LUMIGAN® 0.01% for a 10 kg child. of the iris and the entire iris or parts of the iris become more brownish. Neither nevi nor freckles of the iris appear to be affected by treatment. While treatment with NONCLINICAL TOXICOLOGY LUMIGAN® (bimatoprost ophthalmic solution) 0.01% can be continued in patients Carcinogenesis, Mutagenesis, Impairment of Fertility: Bimatoprost was not who develop noticeably increased iris pigmentation, these patients should be carcinogenic in either mice or rats when administered by oral gavage at doses examined regularly [see Patient Counseling Information (17.1)]]. of up to 2 mg/kg/day and 1 mg/kg/day respectively (at least 192 and 291 times Eyelash Changes: LUMIGAN® 0.01% may gradually change eyelashes and vellus the recommended human exposure based on blood AUC levels respectively) for hair in the treated eye. These changes include increased length, thickness, and 104 weeks. number of lashes. Eyelash changes are usually reversible upon discontinuation Bimatoprost was not mutagenic or clastogenic in the Ames test, in the mouse of treatment. lymphoma test, or in the in vivoo mouse micronucleus tests. Intraocular Inflammation: Prostaglandin analogs, including bimatoprost, have been Bimatoprost did not impair fertility in male or female rats up to doses of 0.6 mg/kg/day reported to cause intraocular inflammation. In addition, because these products may (at least 103 times the recommended human exposure based on blood AUC levels). exacerbate inflammation, caution should be used in patients with active intraocular PATIENT COUNSELING INFORMATION inflammation (e.g., uveitis). Potential for Pigmentation: Advise patients about the potential for increased brown Macular Edema: Macular edema, including cystoid macular edema, has been ® pigmentation of the iris, which may be permanent. Also inform patients about the reported during treatment with bimatoprost ophthalmic solution. LUMIGAN 0.01% possibility of eyelid skin darkening, which may be reversible after discontinuation of should be used with caution in aphakic patients, in pseudophakic patients with a LUMIGAN® (bimatoprost ophthalmic solution) 0.01%. torn posterior lens capsule, or in patients with known risk factors for macular edema. Potential for Eyelash Changes: Inform patients of the possibility of eyelash and Bacterial Keratitis: There have been reports of bacterial keratitis associated with vellus hair changes in the treated eye during treatment with LUMIGAN® 0.01%. the use of multiple-dose containers of topical ophthalmic products. These containers These changes may result in a disparity between eyes in length, thickness, had been inadvertently contaminated by patients who, in most cases, had a pigmentation, number of eyelashes or vellus hairs, and/or direction of eyelash concurrent corneal disease or a disruption of the ocular epithelial surface [see Patient growth. Eyelash changes are usually reversible upon discontinuation of treatment. Counseling Information (17.3)]]. Handling the Container: Instruct patients to avoid allowing the tip of the dispensing Use with Contact Lenses: Contact lenses should be removed prior to instillation of ® container to contact the eye, surrounding structures, fingers, or any other surface in LUMIGAN 0.01% and may be reinserted 15 minutes following its administration. order to avoid contamination of the solution by common bacteria known to cause ADVERSE REACTIONS ocular infections. Serious damage to the eye and subsequent loss of vision may Clinical Studies Experience: Because clinical studies are conducted under widely result from using contaminated solutions. varying conditions, adverse reaction rates observed in the clinical studies of a drug When to Seek Physician Advice: Advise patients that if they develop an intercurrent cannot be directly compared to rates in the clinical studies of another drug and may ocular condition (e.g., trauma or infection), have ocular surgery, or develop any ocular not reflect the rates observed in practice. reactions, particularly conjunctivitis and eyelid reactions, they should immediately In a 12-month clinical study with bimatoprost ophthalmic solutions 0.01%, the most seek their physician’s advice concerning the continued use of LUMIGAN® 0.01%. common adverse reaction was conjunctival hyperemia (31%). Approximately 1.6% Use with Contact Lenses: Advise patients that LUMIGAN® 0.01% contains of patients discontinued therapy due to conjunctival hyperemia. Other adverse drug benzalkonium chloride, which may be absorbed by soft contact lenses. Contact reactions (reported in 1 to 4% of patients) with LUMIGAN® 0.01% in this study lenses should be removed prior to instillation of LUMIGAN® 0.01% and may be included conjunctival edema, conjunctival hemorrhage, eye irritation, eye pain, eye reinserted 15 minutes following its administration. pruritus, erythema of eyelid, eyelids pruritus, growth of eyelashes, hypertrichosis, Use with Other Ophthalmic Drugs: Advise patients that if more than one topical instillation site irritation, punctate keratitis, skin hyperpigmentation, vision blurred, ophthalmic drug is being used, the drugs should be administered at least five (5) and visual acuity reduced. minutes between applications. Postmarketing Experience: The following reaction has been identified during postmarketing use of LUMIGAN® 0.01% in clinical practice. Because it was reported © 2014 Allergan, Inc., Irvine, CA 92612 voluntarily from a population of unknown size, estimates of frequency cannot be ® marks owned by Allergan, Inc. made. The reaction, which has been chosen for inclusion due to either its seriousness, Patented. See: www.allergan.com/products/patent_notices frequency of reporting, possible causal connection to LUMIGAN® 0.01%, or a Made in the U.S.A. combination of these factors, includes headache. APC87BO14 based on 71807US14. Rx only In postmarketing use with prostaglandin analogs, periorbital and lid changes including deepening of the eyelid sulcus have been observed. USE IN SPECIFIC POPULATIONS Pregnancy: Pregnancy Category C Teratogenic effects: In embryo/fetal developmental studies in pregnant mice and rats, abortion was observed at oral doses of bimatoprost which achieved at least 33 or 97 times, respectively, the maximum intended human exposure based on blood AUC levels.
RO0115_Allergan Lumigan PI.indd 1 12/18/14 11:18 AM News Review
Most Ocular Vitamins Don’t Match AREDS BUSINESS OFFICES f 11 top-selling ocular vita- al vitamins, minerals and herbal 11 CAMPUS BLVD., SUITE 100 NEWTOWN SQUARE, PA 19073 mins, seven don’t contain extracts not part of the AREDS or the ingredient dosages AREDS2 formulas. CEO, INFORMATION SERVICES GROUP O MARC FERRARA identical to the formulas identified In addition, all 11 of the prod- (212) 274-7062 • [email protected]
by the Age-Related Eye Disease ucts’ promotional materials con- PUBLISHER Study (AREDS) or AREDS2, ac- tained claims that the supplements JAMES HENNE (610) 492-1017 • [email protected] cording to a study published online “support,” “protect,” “help” or REGIONAL SALES MANAGER in Ophthalmology. “promote” vision and eye health; MICHELE BARRETT The study also found that claims however, none had language stating (610) 492-1014 • [email protected]
made in the promotional materials that nutritional supplements have REGIONAL SALES MANAGER of all of the products lack scientific been proven effective only in people MICHAEL HOSTER (610) 492-1028 • [email protected] evidence. with specific stages of AMD. VICE PRESIDENT, OPERATIONS In their analysis, the research- The supplements’ promotional CASEY FOSTER ers identified the five top-selling materials also lacked another (610) 492-1007 • [email protected]
brands of ocular nutritional supple- important message: “At this time, VICE PRESIDENT, CLINICAL CONTENT ments (during June 2011 to June nutritional supplements have yet PAUL M. KARPECKI, OD, FAAO [email protected] 2012) and compared the brands’ to be proven clinically effective in PRODUCTION MANAGER 11 products to the exact AREDS preventing the onset of eye diseases SCOTT TOBIN and AREDS2 formulas. They found such as cataracts and AMD,” Dr. (610) 492-1011 • [email protected]
that all of the products did contain Yong says. SENIOR CIRCULATION MANAGER the ingredients from the AREDS or Results of the study’s product HAMILTON MAHER (212) 219-7870 • [email protected] AREDS2 formulas, but only four of analysis can be found at: www.aao. CLASSIFIED ADVERTISING the products had doses equivalent org/newsroom/release/upload/Table- (888) 498-1460 to AREDS or AREDS2 ingredients. 1-OcularNutritionalSupplements- SUBSCRIPTIONS Another four of the products con- InPress.pdf. $56 A YEAR, $88 (US) IN CANADA, $209 (US) IN ALL OTHER COUNTRIES. tained lower doses of all the AREDS Yong JJ, Scott IU, Greenberg PB. Ocular nutritional supple- ments: Are their ingredients and manufacturers’ claims SUBSCRIPTION INQUIRIES or AREDS2 ingredients. Also, four evidence-based? Ophthalmology. 2014 Nov 20. [Epub ahead (877) 529-1746 (US ONLY); of print] of the products included addition- OUTSIDE US, CALL (847) 763-9630
CIRCULATION Doctor, how long has it been since you had a complete eye exam? PO BOX 2025 SKOKIE, IL 60076 TEL: (TOLL FREE) 1-877-529-1746 Nearly one-third (30%) of ODs OUTSIDE US: (847)763-9630 ≥10 years 6 to 9 years haven’t had a complete eye exam FAX: (847)763-9631 2 years in three years or more, according 5% 6% to our recent Diagnostic Technol- 3 to 5 years ogy Survey. CEO, INFORMATION SERVICES GROUP 35% MARC FERRARA 19% Still, that’s better than what SENIOR VICE PRESIDENT, OPERATIONS ODs said in our survey in 2012, in JEFF LEVITZ which 34% reported that it’d been 35% SENIOR VICE PRESIDENT, HUMAN RESOURCES longer than three years since their LORRAINE ORLANDO last exam. VICE PRESIDENT, CREATIVE SERVICES & PRODUCTION The good news is that 70% of MONICA TETTAMANZI n = 262 ≤1 year ODs have had an eye exam in the VICE PRESIDENT, CIRCULATION past two years. EMELDA BAREA Source: Review of Optometry’s 2014 Diagnostic Technology Survey
REVIEW OF OPTOMETRY JANUARY 15, 2015 9
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RO0115_Icare.indd 1 1/2/15 11:02 AM Contents Review of Optometry January 2015
Essential Procedures at the Slit Lamp: Foreign Body 22 Removal in 12 Steps Need to remove a foreign body and rust ring? We’ll show you how it’s done. Here’s the first in a new, six-part, print-and- video instructional series. By Joseph Shetler, OD, and Nathan Lighthizer, OD
Annual Pharmaceutical Issue
38 When a Drop Isn’t Enough Oral antibiotics and analgesics often are clinically necessary when treating certain ocular conditions. Here’s a rundown of our favorite systemic agents. By Carl H. Spear, OD, MBA, and Mark Obenchain, OD 30 An Intro to Neuro Neuro-ophthalmic disorders can be intimidating—but you can diagnose and manage many of them. Here’s a simple guide for these serious presentations. 46 Off Label, But on Target By Michael Trottini, OD, and Michael DelGiodice, OD Using drugs off label is not only permissible, it’s often standard of care. Get to know the following non-FDA approved indications (if you don’t know them already). By John Murphy, Executive Editor
Earn 2 CE Credits: Going Antiviral: How to 50 Bring Herpes to a Halt Practical Pearls for A review of the most commonly prescribed topical and oral 58 antiviral medications used to manage herpetic eye disease. Managing Anterior Uveitis By Michael J. Lyons, OD When diagnosing uveitis, let the history and signs guide your treatment plan. By Kyle D. Dohm, OD
REVIEW OF OPTOMETRY JANUARY 15, 2015 11
011_ro0115_toc.indd 11 1/9/15 1:05 PM Departments On The Web ›› Review of Optometry January 2015 and more 4 News Review Check out our multimedia and continuing education online at: 16 Outlook 20 www.reviewofoptometry.com Optometry, We’ve Got You Covered JACK PERSICO Digital Edition Left your copy of 18 Chairside Review of Optometry at This Column Can Rent a Car! the office? No problem! MONTGOMERY VICKERS, OD Access Review on your computer or mobile device! 20 Clinical Quandaries Go to www.reviewofoptometry. This Eye is Choking com and click on the digimag link PAUL C. AJAMIAN, OD for the current issue. 65 Coding Connection Facebook and Twitter New Year, New Connections For daily updates, “Like” JOHN RUMPAKIS, OD, MBA our page on Facebook or 67 “Follow” us on Twitter! 67 Cornea + Contact Lens Q+A Gas it up • www.facebook.com/revoptom • http://twitter.com/#!/revoptom JOSEPH P. SHOVLIN, OD
68 Review of Systems Look for augmented content and Tiny Viruses, Major Diseases special offers from Review and CARLO J. PELINO, OD our advertisers. Specified pages JOSEPH J. PIZZIMENTI, OD work in conjunction with your smartphone or other mobile 72 Retina Quiz device to enhance the experience. Two Decades of Poor Vision With Layar, interactive content MARK T. DUNBAR, OD leaps off the page! 74 Therapeutic Review 72 Don’t Delay Optic Neuritis Dx JOSEPH W. SOWKA, OD ALAN G. KABAT, OD Step1: Download the free Layar 79 Ocular Surface Review app for iPhone or Android. The Evolution of Dry Eye PAUL M. KARPECKI, OD 82 Surgical Minute Conquering Cataracts Step 2: Look for pages with the DEREK N. CUNNINGHAM, OD Layar Logo. INTERACTIVE PRINT WALTER O. WHITLEY, OD, MBA 84 Product Review 85 Meetings + Conferences 82 Step 3: Open the Layar app, hold the phone above the page 85 Advertisers Index and tap to scan it. Hold the phone above the page to view 86 Classifieds the interactive content. 90 Diagnostic Quiz The first 150 app downloads and completed Her Vision is on the Bubble forms will be entered into a drawing for a ANDREW S. GURWOOD, OD complimentary registration to one of Review’s 14-hour CE meetings, valued at $495. Stock Images: ©iStock.com/JobsonHealthcare
12 REVIEW OF OPTOMETRY JANUARY 15, 2015
011_ro0115_toc.indd 12 1/9/15 1:06 PM LOTEMAX® GEL–UNIQUE FORMULATION DESIGNED TO CONTROL INFLAMMATION
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Indications and Usage ILOTEMAX® !7A/1=@B71=AB3@=727<271/B324=@B63B@3/B;3=AB=>3@/B7D3 I/1B3@7/:7<431B7= Please see brief summary of full prescribing information on adjacent page. References: 1.!$(", !%@3A1@707<5 <4=@;/B7=<'3>B3;03@ 2. =<5&!37B@7BH"'7=C"3@;3B&@0( !=B3>@32<=: 3B/0==AB=>3@/B7D3>/7</<27 K TM/@3B@/23;/@9A=4/CA16!=;0 <1=@>=@/B32=@7BA/4M:7/B3A L /CA16!=;0 <1=@>=@/B32 )' ! , - . DISCOVER THE POWER OF GEL RP1113_BL Lotemax.indd 1 10/17/13 11:24 AM USE IN SPECIFIC POPULATIONS Pregnancy Teratogenic Effects: Pregnancy Category C. Loteprednol etabonate has been shown to be embryotoxic (delayed ossification) and teratogenic (increased incidence of meningocele, abnormal left common carotid artery, and limb flexures) when administered orally to rabbits during organogenesis at a dose of 3 mg/kg/day (35 times the maximum daily clinical dose), a dose which caused no maternal toxicity. The no-observed-effect-level (NOEL) for these effects was 0.5 mg/kg/day Brief Summary: Based on full prescribing information. (6 times the maximum daily clinical dose). Oral treatment of rats during organogenesis resulted in teratogenicity (absent innominate artery at ≥5 mg/ To report SUSPECTED ADVERSE REACTIONS, contact Bausch & Lomb at kg/day doses, and cleft palate and umbilical hernia at ≥50 mg/kg/day) and 1-800-323-0000 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch embryotoxicity (increased post-implantation losses at 100 mg/kg/day and decreased fetal body weight and skeletal ossification with ≥50 mg/kg/day). INDICATIONS AND USAGE Treatment of rats with 0.5 mg/kg/day (6 times the maximum clinical dose) during organogenesis did not result in any reproductive toxicity. Loteprednol LOTEMAX is a corticosteroid indicated for the treatment of post-operative etabonate was maternally toxic (significantly reduced body weight gain during inflammation and pain following ocular surgery. treatment) when administered to pregnant rats during organogenesis at doses DOSAGE AND ADMINISTRATION of ≥5 mg/kg/day. Invert closed bottle and shake once to fill tip before instilling drops. Oral exposure of female rats to 50 mg/kg/day of loteprednol etabonate from Apply one to two drops of LOTEMAX into the conjunctival sac of the affected the start of the fetal period through the end of lactation, a maternally toxic eye four times daily beginning the day after surgery and continuing treatment regimen (significantly decreased body weight gain), gave rise to throughout the first 2 weeks of the post-operative period. decreased growth and survival, and retarded development in the offspring CONTRAINDICATIONS during lactation; the NOEL for these effects was 5 mg/kg/day. Loteprednol LOTEMAX, as with other ophthalmic corticosteroids, is contraindicated in etabonate had no effect on the duration of gestation or parturition when most viral diseases of the cornea and conjunctiva including epithelial herpes administered orally to pregnant rats at doses up to 50 mg/kg/day during the simplex keratitis (dendritic keratitis), vaccinia, and varicella, and also in fetal period. mycobacterial infection of the eye and fungal diseases of ocular structures. There are no adequate and well controlled studies in pregnant women. WARNINGS AND PRECAUTIONS LOTEMAX should be used during pregnancy only if the potential benefit Intraocular Pressure (IOP) Increase justifies the potential risk to the fetus. Prolonged use of corticosteroids may result in glaucoma with damage to the Nursing Mothers optic nerve, defects in visual acuity and fields of vision. Steroids should be It is not known whether topical ophthalmic administration of corticosteroids used with caution in the presence of glaucoma. If this product is used for 10 could result in sufficient systemic absorption to produce detectable quantities days or longer, intraocular pressure should be monitored. in human milk. Systemic steroids appear in human milk and could suppress Cataracts growth, interfere with endogenous corticosteroid production, or cause other untoward effects. Caution should be exercised when LOTEMAX is administered Use of corticosteroids may result in posterior subcapsular cataract formation. to a nursing woman. Delayed Healing Pediatric Use The use of steroids after cataract surgery may delay healing and increase the Safety and effectiveness in pediatric patients have not been established. incidence of bleb formation. In those diseases causing thinning of the cornea or sclera, perforations have been known to occur with the use of topical Geriatric Use steroids. The initial prescription and renewal of the medication order should No overall differences in safety and effectiveness have been observed be made by a physician only after examination of the patient with the aid between elderly and younger patients. of magnification such as slit lamp biomicroscopy and, where appropriate, NONCLINICAL TOXICOLOGY fluorescein staining. Carcinogenesis, Mutagenesis, Impairment Of Fertility Bacterial Infections Long-term animal studies have not been conducted to evaluate the Prolonged use of corticosteroids may suppress the host response and carcinogenic potential of loteprednol etabonate. Loteprednol etabonate was thus increase the hazard of secondary ocular infections. In acute purulent not genotoxic in vitro in the Ames test, the mouse lymphoma tk assay, or in conditions of the eye, steroids may mask infection or enhance existing a chromosome aberration test in human lymphocytes, or in vivo in the single infection. dose mouse micronucleus assay. Treatment of male and female rats with up to Viral Infections 50 mg/kg/day and 25 mg/kg/day of loteprednol etabonate, respectively, (600 Employment of a corticosteroid medication in the treatment of patients with and 300 times the maximum clinical dose, respectively) prior to and during a history of herpes simplex requires great caution. Use of ocular steroids may mating did not impair fertility in either gender. prolong the course and may exacerbate the severity of many viral infections PATIENT COUNSELING INFORMATION of the eye (including herpes simplex). Administration Fungal Infections Invert closed bottle and shake once to fill tip before instilling drops. Fungal infections of the cornea are particularly prone to develop coincidentally Risk of Contamination with long-term local steroid application. Fungus invasion must be considered Patients should be advised not to allow the dropper tip to touch any surface, in any persistent corneal ulceration where a steroid has been used or is in as this may contaminate the gel. use. Fungal cultures should be taken when appropriate. Contact Lens Wear Contact Lens Wear Patients should be advised not to wear contact lenses when using LOTEMAX. Patients should not wear contact lenses during their course of therapy with Risk of Secondary Infection LOTEMAX. If pain develops, redness, itching or inflammation becomes aggravated, the ADVERSE REACTIONS patient should be advised to consult a physician. Adverse reactions associated with ophthalmic steroids include elevated FOR MORE DETAILED INFORMATION, PLEASE READ THE PRESCRIBING intraocular pressure, which may be associated with infrequent optic nerve INFORMATION. damage, visual acuity and field defects, posterior subcapsular cataract formation, delayed wound healing and secondary ocular infection from Bausch & Lomb Incorporated pathogens including herpes simplex, and perforation of the globe where there Tampa, Florida 33637 USA is thinning of the cornea or sclera. US Patent No. 5,800,807 ©Bausch & Lomb Incorporated The most common adverse drug reactions reported were anterior chamber inflammation (5%), eye pain (2%), and foreign body sensation (2%). ®/™ are trademarks of Bausch & Lomb Incorporated or its affiliates. 9303400 RRP1113_BLP1113_BL LotemaxLotemax PI.inddPI.indd 1 110/16/130/16/13 9:529:52 AMAM CONTRIBUTING EDITORS CHRIS J. CAKANAC, OD, MURRYSVILLE, PA. JERRY CAVALLERANO, OD, PHD, BOSTON PAUL C. AJAMIAN, OD, ATLANTA WALTER L. CHOATE, OD, MADISON, TENN. AARON BRONNER, OD, KENNEWICK, WASH. BRIAN CHOU, OD, SAN DIEGO MILE BRUJIC, OD, BOWLING GREEN, OHIO A. PAUL CHOUS, MA, OD, TACOMA, WASH. DEREK N. CUNNINGHAM, OD, AUSTIN, TEXAS ROBERT M. COLE, III, OD, BRIDGETON, NJ MARK T. DUNBAR, OD, MIAMI GLENN S. CORBIN, OD, WYOMISSING, PA. ARTHUR B. EPSTEIN, OD, PHOENIX ANTHONY S. DIECIDUE, OD, STROUDSBURG, PA. JAMES L. FANELLI, OD, WILMINGTON, NC S. BARRY EIDEN, OD, DEERFIELD, ILL. FRANK FONTANA, OD, ST. LOUIS STEVEN FERRUCCI, OD, SEPULVEDA, CALIF. GARY S. GERBER, OD, HAWTHORNE, NJ MURRAY FINGERET, OD, HEWLETT, NY ANDREW S. GURWOOD, OD, PHILADELPHIA IAN BEN GADDIE, OD, LOUISVILLE, KY. ALAN G. KABAT, OD, MEMPHIS, TENN. MILTON HOM, OD, AZUSA, CALIF. DAVID KADING, OD, SEATTLE BLAIR B. LONSBERRY, MS, OD, MED, PORTLAND, ORE. PAUL M. KARPECKI, OD, LEXINGTON, KY. THOMAS L. LEWIS, OD, PHD, PHILADELPHIA JEROME A. LEGERTON, OD, MBA, SAN DIEGO DOMINICK MAINO, OD, MED, CHICAGO JASON R. MILLER, OD, MBA, POWELL, OHIO KELLY A. MALLOY, OD, PHILADELPHIA CHERYL G. MURPHY, OD, HOLBROOK, NY RICHARD B. MANGAN, OD, LEXINGTON, KY. CARLO J. PELINO, OD, JENKINTOWN, PA. RON MELTON, OD, CHARLOTTE, NC JOSEPH PIZZIMENTI, OD, FORT LAUDERDALE, FLA. PAMELA J. MILLER, OD, JD, HIGHLAND, CALIF. JOHN RUMPAKIS, OD, MBA, PORTLAND, ORE. BRUCE MUCHNICK, OD, COATESVILLE, PA. DIANA L. SHECHTMAN, OD, FORT LAUDERDALE, FLA. MARC MYERS, OD, COATESVILLE, PA. JEROME SHERMAN, OD, NEW YORK WILLIAM B. POTTER, OD, FREEHOLD, NJ JOSEPH P. SHOVLIN, OD, SCRANTON, PA. CHRISTOPHER J. QUINN, OD, ISELIN, NJ JOSEPH W. SOWKA, OD, FORT LAUDERDALE, FLA. JACK SCHAEFFER, OD, BIRMINGHAM, ALA. MONTGOMERY VICKERS, OD, ST. ALBANS, W.VA. MICHAEL C. RADOIU, OD, STAUNTON, VA. WALTER O. WHITLEY, OD, MBA, VIRGINIA BEACH, VA. KIMBERLY K. REED, OD, FORT LAUDERDALE, FLA. LEO P. SEMES, OD, BIRMINGHAM, ALA. EDITORIAL REVIEW BOARD LEONID SKORIN, JR., OD, DO, ROCHESTER, MINN. JEFFREY R. ANSHEL, OD, CARLSBAD, CALIF. BRAD M. SUTTON, OD, INDIANAPOLIS JILL AUTRY, OD, RPH, HOUSTON LORETTA B. SZCZOTKA, OD, PHD, CLEVELAND SHERRY J. BASS, OD, NEW YORK TAMMY P. THAN, MS, OD, BIRMINGHAM, ALA. EDWARD S. BENNETT, OD, ST. LOUIS RANDALL THOMAS, OD, CONCORD, NC MARC R. BLOOMENSTEIN, OD, SCOTTSDALE, ARIZ. KATHY C. WILLIAMS, OD, SEATTLE DELIVERING HAND- CRAFTED QUALITY WITH UNSURPASSED VALUE Fashion Optical Displays will lay out your dispensing and waiting areas at no charge. We will work with you until you are satisfied we have created the best possible design for your dispensary. To get started, give us a call or go to our website and fill out our No Obligation Quote Form today! 800.824.4106 UPCOMING SECO 2015 - Atlanta, GA Vision Expo East - New York, NY FASHIONOPTICAL.COM SHOWS Mar. 5-7 BOOTH #931 Mar. 20-22 BOOTH #3535 011_ro0115_toc.indd 15 1/9/15 1:06 PM Outlook PRINTED IN USA FOUNDING EDITOR Optometry, We’ve FREDERICK BOGER 1891-1913 EDITORIAL OFFICES Got You Covered 11 CAMPUS BLVD., SUITE 100 NEWTOWN SQUARE, PA 19073 EMAIL • [email protected] As your scope of practice expands, so does ours. Look for WEBSITE • WWW.REVOPTOM.COM these new editorial additions. By Jack Persico, Editor-in-Chief SUBSCRIPTION INQUIRIES 1-877-529-1746 CONTINUING EDUCATION INQUIRIES ot many 124-year-olds are • Neuro Clinic, another all-new 1-800-825-4696 nimble enough to adapt column, will help you take care EDITOR-IN-CHIEF • JACK PERSICO and improve. As of this of those tricky, intimidating neuro JPERSICO JOBSON COM N (610) 492-1006 • @ . issue, Review of Optometry is just cases yourself instead of referring EXECUTIVE EDITOR • JOHN MURPHY one year shy of its 125th birthday. them out. Drs. Michael Trottini (610) 492-1021 • [email protected] And it’s still going strong and get- and Michael DelGiodice kick it off SENIOR EDITOR • BILL KEKEVIAN ting better every month. this month with a terrific feature, (610) 492-1003 • [email protected] To that end, we’re adding a few “Intro to Neuro” (page 30). Their ASSOCIATE EDITOR • ALIZA MARTIN new things and updating some old bimonthly column starts in March. (610) 492-1043 • [email protected] standbys, to educate you and con- • Focus on Refraction is another DIRECTOR ART/PRODUCTION • JOE MORRIS nect with you even better in 2015. new column that will appear every (610) 492-1027 • [email protected] As your trusted advisor and practice other month, beginning in February. ART DIRECTOR • JARED ARAUJO companion, Review aims to provide Penned by Drs. Marc Taub and Paul (610) 492-1032 • [email protected] answers and guidance for all the Harris, this column brings you back DIRECTOR OF CE ADMINISTRATION • REGINA COMBS clinical challenges you face—from to optometry’s roots—refraction (212) 274-7160 • [email protected] puzzling refraction problems to and optics—by challenging you with SPECIAL PROJECTS/E-PRODUCTS MANAGER • KAREN ROMAN daunting neuro-ophthalmic cases to engaging, real-life cases of patients (610) 492-1037 • [email protected] surgical comanagement, and every- who just won’t refract by the book. EDITORIAL BOARD thing in between. • Urgent Care, by Richard Man- CHIEF CLINICAL EDITOR • PAUL M. KARPECKI, OD ASSOCIATE CLINICAL EDITORS • JOSEPH P. SHOVLIN, OD; Here’s a quick rundown of our gan, OD, will give detailed advice ALAN G. KABAT, OD; CHRISTINE W. SINDT, OD improvements for 2015: on ocular emergencies from chemi- DIRECTOR OPTOMETRIC PROGRAMS • ARTHUR EPSTEIN, OD • Comanagement Q+A by Dr. cal burns to penetrating wounds to CLINICAL & EDUCATION CONFERENCE ADVISOR PAUL M. KARPECKI, OD Paul Ajamian is now Clinical Quan- retinal detachments. It too debuts in CASE REPORTS COORDINATOR • ANDREW S. GURWOOD, OD daries (page 20), with an emphasis February and runs bimonthly. CLINICAL CODING EDITOR • JOHN RUMPAKIS, OD, MBA CONSULTING EDITOR • FRANK FONTANA, OD that better reflects the primary care • Research Review—online! This role that optometrists now embrace. has always delivered the most up- COLUMNISTS CHAIRSIDE • MONTGOMERY VICKERS, OD • Coding Abstract by Dr. John to-date analysis of ocular research CLINICAL QUANDARIES • PAUL C. AJAMIAN, OD Rumpakis has been retooled as and how it affects patient care. Now CORNEA & CONTACT LENS Q+A • JOSEPH P. SHOVLIN, OD DIAGNOSTIC QUIZ • ANDREW S. GURWOOD, OD Coding Connection (page 65). Dr. it will be exclusively online, so you GLAUCOMA GRAND ROUNDS • JAMES L. FANELLI, OD Rumpakis will still bring you all the won’t have to wait for your monthly OCULAR SURFACE REVIEW • PAUL M. KARPECKI, OD URGENT CARE • RICHARD B. MANGAN, OD latest coding and billing updates, issue to keep current on timely news. RETINA QUIZ • MARK T. DUNBAR, OD but with an even greater connection • This issue also kicks off a new REVIEW OF SYSTEMS • CARLO J. PELINO, OD; to the clinical presentations you see six-part series, Essential Procedures JOSEPH J. PIZZIMENTI, OD SURGICAL MINUTE • DEREK N. CUNNINGHAM, OD; every day. He’ll also present cod- at the Slit Lamp (page 22) that pres- WALTER O. WHITLEY, OD, MBA ing sidebars in several key feature ents step-by-step instructions, pho- THERAPEUTIC REVIEW • JOSEPH W. SOWKA, OD; ALAN G. KABAT, OD articles throughout the year. tos and video to guide you through NEURO CLINIC • MICHAEL TROTTINI, OD; • Ocular Surface Review (page the most asked-about new optomet- MICHAEL DELGIODICE, OD FOCUS ON REFRACTION • MARC TAUB, OD; 79) is a brand new column by Paul ric procedures like amniotic mem- PAUL HARRIS, OD Karpecki, OD, that addresses per- branes and even YAG capsulotomy. JOBSON MEDICAL INFORMATION LLC haps the #1 cause of clinical office It’s all a bit ambitious, sure, but visits in optometry—and one of the whenever you’re asked to do more, toughest to get under control. Review will be there to help. ■ 16 REVIEW OF OPTOMETRY JANUARY 15, 2015 016_ro0115_outlook.indd 16 1/9/15 1:08 PM COST OF GOODS SAVINGS CAN ONLY HELP YOU GROW SO MUCH IN THE NEW ERA OF POPULATION HEALTH MANAGEMENT, WHAT’S YOUR PLAN TO WIN: More Patients More Profi ts More Time All of the Above Go To VisionSourcePlan.com and We’ll Give You Ours © Vision Source L.P. 2015. All Rights Reserved. RO0115_Vision Source.indd 1 1/2/15 10:50 AM Chair Side This Column Can Rent a Car! “Chairside” has officially turned 25 years old. Although this column is of legal age to drink and vote, it doesn’t. It’s too busy trying to be funny. By Montgomery Vickers, OD fter bragging for several express himself in Review of times about how utterly hilarious months that 2014 was Optometry. Unfortunately, all of phoropters are, where do you go? Amy 25th year writing the normal optometrists were busy In 25 years, I’ve always tried to “Chairside”—and receiving many, that week, so they called me. The talk about the challenges that you many pats on the back, interspersed good news is I have my two BS and I face personally and profes- with a couple of folks who degrees, so cranking out sionally with some little bit of only read the column a monthly column about humor. Many times herein I have to let me know how nothing in particular is mentioned Dr. Keith Shillington, messed up it is each right up my alley. my organic chem professor, who month—I have now I have even had bitterly reminded me that I could been told that 2015 is, moments of—in my “either laugh or cry” when I started in fact, my 25th year. humble, nonbiased a fire in lab. I chose to laugh. So, please update your opinion—genius. Who Finally, when my little heart baby letters of praise for 2015. didn’t love Blind Bat granddaughter, Grace, was facing Twenty-five Vickers? That got me multiple surgeries and dangerous years… that’s 300 col- the opportunity to times, my readers—you guys!— umns…180,000 words… perform with Bad poured out prayers and donations 4,012 “…”s as I still have Habits, the Eye Docs of Rock, at and much love. I can never repay no clue how to end my sentences… the Rock and Roll Hall of Fame! that, no matter how many times I See what I mean? Of course, I’ve had my share write about how messy my desk is, I blame optometry. Nobody ever of average to below average col- and it surely is. But Grace is doing asked me to write about the other umns––although I did win an very well indeed! important subjects in my life, such award for the column I wrote Thanks to you, “Chairside” as guitars, cowboy boots, cigars about my dog dying, always a remains a team effort. So, keep and the occasional libation. Of timely optometric subject. It’s reading. I am bound to get it right course, that did not matter because interesting to me that the weakest sooner or later. ■ I just put those subjects and many articles get just as much atten- more right into “Chairside” in tion as the better ones. Guess that clever ways like this: “I love cow- means people haven’t quite given boy boots and that reminds me of up on me. blue jeans and big ol’ buckles and But, it’s not always easy to those remind me of retinal detach- come up with optometric humor ments.” month after We all know how funny retinal month. Once detachments can be, right? See, you’ve writ- this stuff writes itself! Besides, ten 40 the last thing you want to read in an optometry publication is stuff about optometry. Hearken Back to 1991 “Chairside” started so a normal, private practice optometrist could 18 REVIEW OF OPTOMETRY JANUARY 15, 2015 018_ro0115_chairside.indd 18 1/8/15 12:53 PM For the 75% of dry eye patients worldwide with evaporative dry eye (MGD) symptoms1... DRY EYE CAN BE RELENTLESS CALM THE STORM WITH LASTING RELIEF SYSTANE® BALANCE Lubricant Eye Drops: Your recommendation counts. Protecting the Ocular Surface by Increasing Lipid Layer Thickness (LLT) SYSTANE® BALANCE Lubricant Eye Drops forms Make sure your patients a protective matrix that is designed to replenish the lipid get the lasting symptom layer for long-lasting relief from relief they need by offering LIPID LAYER the symptoms associated with ® evaporative dry eye (MGD). them SYSTANE BALANCE EOUS LAY This unique formulation is 2 AQU ER Lubricant Eye Drops. designed to work on all 3 layers of the tear fi lm, specifi cally IN LA MUC YER MEIBOMIAN increasing LLT. This helps create GLAND AL EPITH NE ELI R UM a protective environment for the CO ocular surface.2 SYSTANE® Brand products are formulated for the temporary relief of burning and irritation due to dryness of the eye. References: 1. Akpek EK, Smith RA. Overview of age-related ocular conditions. Am J Manag Care. 2013;19 (5 suppl):S67-S75. 2. Korb DR, Blackie CA, Meadows DL, Christensen M, Tudor M. Evaluation of extended tear stability by two emulsion based artifi cial tears. Poster presented at: 6th International Conference on the Tear Film and Ocular Surface: Basic Science and Clinical Relevance; September 22-25, 2010; Florence, Italy. © 2014 Novartis 05/14 SYS14005JAD-B Relief that lasts RO0115_Alcon Systane.indd 1 12/22/14 3:30 PM Clinical Quandaries This Eye is Choking Vision loss and ocular pain are clues to prompt you to ask about a history of heart disease. So, what’s the diagnosis? By Paul C. Ajamian, OD Photo: Joseph J. Pizzimenti, OD A 60-year-old white male iris, which can lead to neovascular- Q reported decreased vision and ization glaucoma,” she says. pain in his left eye that persisted Management of the patient with for about two months. The patient OIS includes ordering a lipid panel recently had an episode of complete for hypercholesterolemia, as well loss of vision, which returned after as a bilateral carotid ultrasound. about 30 seconds. Dilated fundus “It is an absolute must to rule out examination revealed mid-peripheral giant cell arteritis, so I always order retinal hemorrhages 360° in the left a complete blood count with dif- eye. What do I need to be mindful of ferentials to see if there is evidence regarding this patient? Mid-peripheral retinal hemorrhages are of thrombocytosis related to GCA, “This patient seems to be common in ocular ischemic syndrome. as well as a sedimentation rate and A exhibiting signs and symptoms C-reactive protein,” she says. of ocular ischemic syndrome,” says moderate central retinal vein occlu- “The five-year mortality rate is as Trennda Rittenbach, OD. It’s not sion. high as 40% in patients diagnosed a common condition, but she sees “OIS occurs when stenosis or with OIS,” Dr. Rittenbach says.3 it often at the Palo Alto Medical occlusion of the carotid arteries “So, these patients must be coman- Foundation in Sunnyvale, Calif. causes ocular hypoperfusion,” Dr. aged with a vascular surgeon, car- The most frequent symptom of Rittenbach says.2 “The hypoper- diovascular physician or primary ocular ischemic syndrome (OIS) fusion puts the eye in a hypoxic care physician.” is vision loss in the affected eye, state, leading to attenuated arteries, For her own recent experience which is present in more than venous tortuosity and mid-periph- with an OIS patient, Dr. Rittenbach 90% of patients with OIS; about eral hemorrhages.” ordered a carotid ultrasound and 67% have a gradual vision loss Atherosclerosis is usually the referred him back to his vascular over a few weeks to months, Dr. main underlying cause for the physician for consideration of Rittenbach says.1 Other common changes in the carotid arteries, Dr. carotid endarterectomy, pending symptoms include episodes of tran- Rittenbach says, adding that she the ultrasound results. Also, in sient vision loss (amaurosis fugax), diagnosed OIS in a patient recently. her referral letter, she noted that peripheral vision loss and pain.1 “I dug deeper into his medical his- this patient’s blood pressure was Signs of OIS are narrowed tory and found that he already had 158/86mm Hg, which needs to be retinal arteries, beaded and dilated a carotid endarterectomy on his addressed. veins with tortuosity, dot-and-blot right side and a history of athero- Remember, as a health care pro- hemorrhages and microaneurysms sclerosis,” she says. vider, you should check blood pres- located in the mid-peripheral retina She performs auscultation on sure on all your patients, day in and (which may extend to the posterior every patient she suspects has a day out. ■ pole as hypoxia increases), cotton- carotid artery occlusion problem, wool spots, anterior ischemic optic but acknowledges that the sensitiv- 1. Terelak-Borys B, Skonieczna K, Grabska-Liberek I. Ocular ischemic syndrome - a systematic review. Med Sci Monit. neuropathy, rubeosis iridis, iris ity and specificity of auscultation of 2012 Aug;18(8):RA138-44. atrophy and asymmetric cataract.1,2 the carotid arteries is not definitive. 2. Lyons-Wait VA, Anderson SF, Townsend JC, De Land P. Ocular and systemic findings and their correlation with Differential diagnoses of OIS “Also during initial examina- hemodynamically significant carotid artery stenosis: A retro- include diabetic retinopathy (which tion, be sure to look closely for an spective study. Optom Vis Sci. 2002 Jun;79(6):353-62. 3. Hazin R, Daoud YJ, Kahn F. Ocular ischemic syn- is often confused for OIS), hyper- important complication secondary drome: recent trends in medical management. Curr Opin tensive retinopathy and a mild or to OIS: neovascularization of the Ophthalmol. 2009 Nov;20(6):430-3. 20 REVIEW OF OPTOMETRY JANUARY 15, 2015 020_ro0115_cq.indd 20 1/8/15 12:54 PM RP0414_lombart.indd 1 3/26/14 4:57 PM DOWNLOAD LAYAR APP FOR INTERACTIVE EXPERIENCE Slit Lamp Essentials INTERACTIVE PRINT Essential Procedures at the Slit Lamp Foreign Body Removal in 12 Steps Need to remove a foreign body and rust ring? We’ll show you how it’s done. Here’s the first in a new, six-part, print-and-video instructional series. By Joseph Shetler, OD, and Nathan Lighthizer, OD as it a touchdown, or This article is the first in a new did his knee drop just six-part series that will show you, before the goal line? The step-by-step, the essential proce- Wchampionship game is dures you can do at the slit lamp. on and before the review team in Plus, you’ll find a short but thor- the box can make the call, your ough video on the Review website phone rings. “Doc, hate to bother to walk you through each proce- you during the big game, but I dure. just can’t take it any longer. I was working under my car yesterday, 1. Spread the Word The patient in this case was grinding and I thought it would get better, The first step in removing corneal metal without protective eyewear. but…” and the rest is history. foreign bodies is having patients. Removing corneal foreign bodies Despite optometrists’ advances in then write your cell phone or after- can be one of the most rewarding scope of practice and adopting the hours service number on it, and let aspects of the profession. They can medical model, many patients still them know that they will receive interrupt a full day—or the season’s think of the ER or their primary specialized care—and save time and championship game. But when han- care provider when their eyes hurt money—when they call your office dled professionally and efficiently, and they suspect they have some- for an eye emergency. A win-win this procedure not only preserves thing in their eyes. situation. sight but also generates loyal and Do you take every opportunity to Another idea: Can a patient visit referring patients. remind your patients that you and your website or your Facebook your fellow optometrists remove all page and watch a video of you To see a narrated video of kinds of objects from the eye on a removing a corneal foreign body foreign body removal, visit daily basis? A simple technique that and hear your soothing voice? We www.reviewofoptometry. com, or scan this QR code. we’ve found to be very effective is made a video. So can you. (See ours to hand the patient your card, and on www.reviewofoptometry.com.) 22 REVIEW OF OPTOMETRY JANUARY 15, 2015 022_ro0115_f1.indd 22 1/8/15 12:59 PM 2. Set Up Phone Triage The second step is to educate your staff so they are prepared to deal with the patient with a presumed foreign body. It starts at the front desk. Train your welcome leader to recognize the signs of a cor- neal foreign body over the phone and understand the importance of instructing the patient to come directly to the office. We keep it simple and emphasize the three calling cards of corneal problems: pain, photophobia and lacrimation. (Or, in the patient’s After taking a good history, recording visual acuity and anesthetizing the eye, it’s words, “It hurts and waters, espe- time to choose your weapon. A magnetic spud or 25-gauge needle works well to cially in the sun.”) dislodge and remove most superficial metallic foreign bodies without much damage to the surrounding tissue. Always approach the foreign body tangentially to avoid 3. Take a Careful History perforating the cornea. Before you pick up that spud and spin that Alger brush, first take a which insurance company will be best-corrected vision before you thorough history to prepare for the liable, and other safety issues. start. Explaining amblyopia or prior procedure. Like a good investigator, Be sure to note in the record scarring on the witness stand is ask the important questions: what, if the patient had safety eyewear very difficult if your records don’t when, where and how? In the vast on. This could be important to a indicate prior decreased vision, majority of cases, the story is gener- company policy or, if a personal and you find yourself defending ally explained very quickly. incident, it opens the door to edu- 20/decreased vision after you have • What? If the entering substance cate and sell safety glasses to your removed the foreign body. was associated with vegetative mat- patient. A pair of safety glasses can ter or a rusty nail, the answer to seem like a trivial expense in light 5. Anesthetize the Eye this question will influence the type of the pain, missed work and mon- The use of proparacaine prior to of treatment that may be required etary cost of removing a corneal the initial evaluation will make your postoperatively. foreign body. patient more comfortable during • When? This question lends • How? Asking how the injury the process and enhance the effi- itself to the type of education happened will assist you in deter- ciency as well. Instill proparcaine in that you’ll need to provide after mining the force with which the both eyes to reduce the sensitivity removal, as well as being aware if foreign body entered the cornea of each eye and assist in preventing the odds of infection, inflamma- and whether or not other scans will reflex movement. If the initial VA tion and rust have dramatically become necessary to rule out an was in question due to pain, now’s increased with time. Approximately intraocular foreign body. It is also the time to repeat the VA of the four to six hours is all the time important to inquire as to when the involved eye. Proparacaine is typi- required for the fluid of the cornea patient had their last tetanus shot. cally the anesthetic of choice but to begin to decompose the iron for- other topical anesthetics, such as eign body and rust begins to leach 4. Determine Entering tetracaine, also provide the neces- into the surrounding tissue. Visual Acuities sary anesthetic effect. • Where? Although “where?” After the history, be sure that you does not seem as clinically relevant or your staff have recorded best- 6. Choose the Right as “what?” and “when?,” it could corrected vision before you begin Instrument be one of the most sought-after the procedure. For clinical as well as The initial step at the slit lamp is to notations in your record to evalu- medicolegal reasons, it is extremely get the lay of the land. Remember ate worker’s compensation issues, important to know the patient’s that it is certainly possible to have REVIEW OF OPTOMETRY JANUARY 15, 2015 23 022_ro0115_f1.indd 23 1/8/15 12:59 PM Slit Lamp Essentials After the metal particle is removed, re-examine the area. If the Rust never sleeps, so it must be excavated. Here, we used an metal has been lodged for a few hours or more, a pocket of rust Alger brush. Be sure to hold the instrument at an angle, not will likely remain. perpendicularly, to avoid penetration. multiple foreign bodies or one in patient a chance to ask questions forceps may be the best choice. If the fellow eye that the patient may and assess anxiety before proceed- the foreign body is of vegetative be unaware of. The adage, “If it ing. matter, or simply adhered to the isn’t written down, it isn’t done” The instrument you choose will cornea without true penetration, applies as with any medical investi- be determined by the task at hand jeweler’s forceps is often the instru- gation. So, make certain you docu- as well as personal preference. If the ment of choice so that no additional ment the depth of the foreign body, identified foreign body is metallic, tissue is damaged and the material the type of foreign body, the condi- consider using a magnetic spud. simply lifts off the cornea. tion of the fellow eye as well as any The advantage of the magnetic spud additional pertinent information. is that you can sometimes lift out 7. Take a Tangential Approach Be sure to accurately assess the a very superficial metallic foreign Always approach the foreign body depth of the foreign body, keep- body with minimal tissue damage. tangentially to avoid corneal perfo- ing in mind that objects that have The spud is also readily available to ration. Giving the patient a target to penetrated into the stroma are more you for additional depth and scrap- focus on will slow down eye motion likely to result in scarring. Also note ing if you should need it. The other and decrease patient anxiety. Enter- the proximity to the visual axis. advantage of the magnetic spud ing at the temporal peripheral edge After the initial survey and is that you’ll be able to catch the of the foreign body, with a depth assessment of the foreign body, flakes of the metallic material with just slightly deeper than the foreign it’s time to choose your weapon. a swipe around the area, and leave body, generally results in removing As you look over your choices, the wound field clean of debris with the offending agent with minimal take this moment to communicate minimal effort. collateral damage. A subtle flicking with your patient about the proce- In many cases, the best instru- motion usually completes the pro- dure and possible complications. ment is a needle. A 25-gauge 5/8” cedure. If you’re concerned about central needle gives adequate strength and scarring and potential vision loss, is short enough to avoid flexure. 8. Remove the Rust Ring discuss this with the patient before Typically, less surrounding tissue After removal of a metallic foreign the procedure. If you anticipate damage is caused when using a body, re-evaluate the excavation needing the Alger brush, explain the needle than a spud. The blunt edge area for the presence of rust. If process to the patient and give them of the spud dramatically reduces the metal is lodged in the cornea for the opportunity to hear the sound risk of perforation, but in the hands more than four to six hours, rust of the motor and be reassured this of a steady practitioner, the needle will begin to form in the adjacent will be done under anesthetic. is often preferred. tissue. This is typically seen as a Pause a moment to give the In a minority of cases, jeweler’s brownish-orange ring that appears 24 REVIEW OF OPTOMETRY JANUARY 15, 2015 022_ro0115_f1.indd 24 1/8/15 12:59 PM For allergic conjunctivitis1 THE POWER TO CALM THE ITCH BEPREVE®—FIRST-LINE, YEAR-ROUND, WITH BROAD-SPECTRUM ALLERGEN COVERAGE Scan this QR code or visit beprevecoupon.com to • Order samples • Learn about the automatic co-pay program • Help your patients find participating pharmacies INDICATION AND USAGE ® BEPREVE (bepotastine besilate ophthalmic solution) 1.5% is a histamine H1 receptor antagonist indicated for the treatment of itching associated with signs and symptoms of allergic conjunctivitis. IMPORTANT RISK INFORMATION BEPREVE® is contraindicated in patients with a history of hypersensitivity reactions to bepotastine or any of the other ingredients. BEPREVE® is for topical ophthalmic use only. To minimize risk of contamination, do not touch the dropper tip to any surface. Keep the bottle closed when not in use. BEPREVE® should not be used to treat contact lens–related irritation. Remove contact lenses prior to instillation of BEPREVE®. Made by the trusted eye-care specialists at The most common adverse reaction occurring in approximately 25% of patients was a mild taste following instillation. Other adverse reactions occurring in 2%‐5% of patients were eye irritation, headache, and nasopharyngitis. Please see the accompanying prescribing information for BEPREVE® on the following page. Reference: 1. BEPREVE [package insert]. Tampa, FL: Bausch + Lomb, Inc; 2012. For product-related questions and concerns, call 1-800-323-0000 or visit www.bepreve.com. ®/TM are trademarks of Bausch & Lomb Incorporated or its affiliates. ©2014 Bausch & Lomb Incorporated. US/BEP/12/0026(1) 1/14 RO0214_BL Bepreve.indd 1 1/16/14 9:52 AM BEPREVE® (bepotastine besilate ophthalmic solution) 1.5% women. Because animal reproduction studies are cytochrome P450 substrate via inhibition of HIGHLIGHTS OF PRESCRIBING INFORMATION ------WARNINGS AND PRECAUTIONS------not always predictive of human response, CYP3A4, CYP2C9, and CYP2C19. The effect of ® These highlights do not include all the information t 5PNJOJNJ[FUIFSJTLPGDPOUBNJOBUJPO EPOPU BEPREVE (bepotastine besilate ophthalmic bepotastine besilate on the metabolism of needed to use BEPREVE® (bepotastine besilate touch dropper tip to any surface. Keep bottle solution) 1.5% should be used during pregnancy substrates of CYP1A2, CYP2C8, CYP2D6 was not ophthalmic solution) 1.5% safely and effectively. tightly closed when not in use. (5.1) only if the potential benefit justifies the potential studied. Bepotastine besilate has a low potential See full prescribing information for BEPREVE®. t #&13&7&TIPVMEOPUCFVTFEUPUSFBUDPOUBDU risk to the fetus. for drug interaction via inhibition of CYP3A4, CYP2C9, and CYP2C19. lens-related irritation. (5.2) 8.3 Nursing Mothers BEPREVE® (bepotastine besilate ophthalmic t 3FNPWFDPOUBDUMFOTFTQSJPSUPJOTUJMMBUJPOPG Following a single 3 mg/kg oral dose of radiolabeled Excretion: The main route of elimination of solution) 1.5% BEPREVE. (5.2) bepotastine besilate to nursing rats 11 days after bepotastine besilate is urinary excretion (with Initial U.S. Approval: 2009 ------ADVERSE REACTIONS------delivery, the maximum concentration of radioactivity approximately 75-90% excreted unchanged in urine). ------RECENT MAJOR CHANGES------in milk was 0.40 mcg-eq/mL 1 hour after The most common adverse reaction occurring in 13 NONCLINICAL TOXICOLOGY Contraindications (4) 06/2012 administration; at 48 hours after administration the approximately 25% of patients was a mild taste 13.1 Carcinogenesis, Mutagenesis and concentration was below detection limits. The milk ------INDICATIONS AND USAGE------following instillation. Other adverse reactions Impairment of Fertility concentration was higher than the maternal blood BEPREVE® is a histamine H1 receptor antagonist which occurred in 2-5% of subjects were eye Long-term dietary studies in mice and rats were plasma concentration at each time of measurement. indicated for the treatment of itching associated irritation, headache, and nasopharyngitis. (6) conducted to evaluate the carcinogenic potential with allergic conjunctivitis. (1) It is not known if bepotastine besilate is excreted of bepotastine besilate. Bepotastine besilate did To report SUSPECTED ADVERSE REACTIONS, in human milk. Caution should be exercised when not significantly induce neoplasms in mice ------DOSAGE AND ADMINISTRATION------contact Bausch & Lomb Incorporated. at 1-800-323- BEPREVE (bepotastine besilate ophthalmic receiving a nominal dose of up to 200 mg/kg/day Instill one drop into the affected eye(s) twice a day 0000, or FDA at 1-800-FDA-1088 or www.fda.gov/ solution) 1.5% is administered to a nursing woman. for 21 months or rats receiving a nominal dose of (BID). (2) medwatch. up to 97 mg/kg/day for 24 months. These dose 8.4 Pediatric Use ------DOSAGE FORMS AND STRENGTHS------See 17 for PATIENT COUNSELING INFORMATION levels represent systemic exposures Safety and efficacy of BEPREVE (bepotastine Solution containing bepotastine besilate, 1.5%. (3) approximating 350 and 200 times that achieved besilate ophthalmic solution) 1.5% have not been with human topical ocular use. The no observable ------CONTRAINDICATIONS------Revised: 10/2012 established in pediatric patients under 2 years of adverse effect levels for bepotastine besilate Hypersensitivity to any component of this product. (4) age. Efficacy in pediatric patients under 10 years based on nominal dose levels in carcinogenicity of age was extrapolated from clinical trials tests were 18.7 to 19.9 mg/kg/day in mice and 9.6 conducted in pediatric patients greater than 10 FULL PRESCRIBING INFORMATION: 11 DESCRIPTION to 9.8 mg/kg/day in rats (representing exposure years of age and from adults. CONTENTS* 12 CLINICAL PHARMACOLOGY margins of approximately 60 and 20 times the 1 INDICATIONS AND USAGE 12.1 Mechanism of Action 8.5 Geriatric Use systemic exposure anticipated for topical ocular 2 DOSAGE AND ADMINISTRATION 12.3 Pharmacokinetics No overall difference in safety or effectiveness has use in humans). 3 DOSAGE FORMS AND STRENGTHS 13 NONCLINICAL TOXICOLOGY been observed between elderly and younger patients. 4 CONTRAINDICATIONS 13.1 Carcinogenesis, Mutagenesis and There was no evidence of genotoxicity in the 11 DESCRIPTION 5 WARNINGS AND PRECAUTIONS Impairment of Fertility Ames test, in CHO cells (chromosome aberrations), BEPREVE (bepotastine besilate ophthalmic 5.1 Contamination of Tip and Solution 14 CLINICAL STUDIES in mouse hepatocytes (unscheduled DNA solution) 1.5% is a sterile, topically administered 5.2 Contact Lens Use 16 HOW SUPPLIED/STORAGE AND HANDLING synthesis), or in the mouse micronucleus test. drug for ophthalmic use. Each mL of BEPREVE 5.3 Topical Ophthalmic Use Only 17 PATIENT COUNSELING INFORMATION When oral bepotastine was administered to male contains 15 mg bepotastine besilate. 6 ADVERSE REACTIONS 17.1 Topical Ophthalmic Use Only and female rats at doses up to 1,000 mg/kg/day, Bepotastine besilate is designated chemically as 6.1 Clinical Trial Experience 17.2 Sterility of Dropper Tip there was a slight reduction in fertility index and (+) -4-[[(S)-p-chloro-alpha -2-pyridylbenzyl]oxy]-1- 6.2 Post-Marketing Experience 17.3 Concomitant Use of Contact Lenses surviving fetuses. Infertility was not seen in rats piperidine butyric acid monobenzenesulfonate. 8 USE IN SPECIFIC POPULATIONS given 200 mg/kg/day oral bepotastine besilate * Sections or subsections omitted from the full The chemical structure for bepotastine besilate is: 8.1 Pregnancy (approximately 3,300 times the systemic prescribing information are not listed 8.3 Nursing Mothers concentration anticipated for topical ocular use 8.4 Pediatric Use in humans). 8.5 Geriatric Use 14 CLINICAL STUDIES FULL PRESCRIBING INFORMATION The most common reported adverse reaction Clinical efficacy was evaluated in 2 conjunctival occurring in approximately 25% of subjects was a allergen challenge (CAC) studies (237 patients). 1 INDICATIONS AND USAGE mild taste following instillation. Other adverse BEPREVE (bepotastine besilate ophthalmic BEPREVE® (bepotastine besilate ophthalmic reactions occurring in 2-5% of subjects were eye Bepotastine besilate is a white or pale yellowish solution) 1.5% was more effective than its vehicle solution) 1.5% is a histamine H receptor antagonist 1 crystalline powder. The molecular weight of for relieving ocular itching induced by an ocular irritation, headache, and nasopharyngitis. ® indicated for the treatment of itching associated bepotastine besilate is 547.06 daltons. BEPREVE allergen challenge, both at a CAC 15 minutes post- with signs and symptoms of allergic conjunctivitis. 6.2 Post Marketing Experience ophthalmic solution is supplied as a sterile, dosing and a CAC 8 hours post dosing of BEPREVE. Hypersensitivity reactions have been reported 2 DOSAGE AND ADMINISTRATION aqueous 1.5% solution, with a pH of 6.8. rarely during the post-marketing use of BEPREVE. The safety of BEPREVE was evaluated in a Instill one drop of BEPREVE into the affected The osmolality of BEPREVE (bepotastine besilate Because these reactions are reported voluntarily randomized clinical study of 861 subjects over a eye(s) twice a day (BID). ophthalmic solution) 1.5% is approximately from a population of unknown size, it is not 290 mOsm/kg. period of 6 weeks. 3 DOSAGE FORMS AND STRENGTHS always possible to reliably estimate their Each mL of BEPREVE® (bepotastine besilate 16 HOW SUPPLIED/STORAGE AND HANDLING Topical ophthalmic solution containing frequency or establish a casual relationship to ophthalmic solution) 1.5% contains: BEPREVE® (bepotastine besilate ophthalmic bepotastine besilate 1.5%. drug exposure. The hypersensitivity reactions Active: Bepotastine besilate 15 mg (equivalent to solution) 1.5% is supplied in a white low density include itching, body rash, and swelling of lips, 4 CONTRAINDICATIONS 10.7 mg bepotastine) polyethylene plastic squeeze bottle with a white tongue and/or throat. Bepreve is contraindicated in patients with a Preservative: benzalkonium chloride 0.005% controlled dropper tip and a white polypropylene history of hypersensitivity reactions to bepotastine 8 USE IN SPECIFIC POPULATIONS Inactives: monobasic sodium phosphate cap in the following size: or any of the other ingredients [see Adverse 8.1 Pregnancy dihydrate, sodium chloride, sodium hydroxide to 5 mL (NDC 24208-629-02) Reactions (6.2)]. Pregnancy Category C: Teratogenicity studies adjust pH, and water for injection, USP. 10 mL (NDC 24208-629-01) have been performed in animals. Bepotastine 5 WARNINGS AND PRECAUTIONS 12 CLINICAL PHARMACOLOGY STORAGE besilate was not found to be teratogenic in rats 5.1 Contamination of Tip and Solution 12.1 Mechanism of Action Store at 15º – 25ºC (59º – 77ºF). during organogenesis and fetal development at To minimize contaminating the dropper tip and Bepotastine is a topically active, direct H1- oral doses up to 200 mg/kg/day (representing a 17 PATIENT COUNSELING INFORMATION solution, care should be taken not to touch the receptor antagonist and an inhibitor of the release systemic concentration approximately 3,300 times 17.1 Topical Ophthalmic Use Only eyelids or surrounding areas with the dropper tip of histamine from mast cells. that anticipated for topical ocular use in humans), For topical ophthalmic administration only. of the bottle. Keep bottle tightly closed when not 12.3 Pharmacokinetics but did show some potential for causing skeletal 17.2 Sterility of Dropper Tip in use. Absorption: The extent of systemic exposure to abnormalities at 1,000 mg/kg/day. There were no Patients should be advised to not touch dropper tip bepotastine following topical ophthalmic 5.2 Contact Lens Use teratogenic effects seen in rabbits at oral doses to any surface, as this may contaminate the contents. Patients should be advised not to wear a contact up to 500 mg/kg/day given during organogenesis administration of bepotastine besilate 1% and 1.5% lens if their eye is red. BEPREVE should not be and fetal development (>13,000 times the dose in ophthalmic solutions was evaluated in 12 healthy 17.3 Concomitant Use of Contact Lenses used to treat contact lens-related irritation. humans on a mg/kg basis). Evidence of infertility adults. Following one drop of 1% or 1.5% bepotastine Patients should be advised not to wear a contact was seen in rats given oral bepotastine besilate besilate ophthalmic solution to both eyes four times lens if their eye is red. Patients should be advised BEPREVE should not be instilled while wearing 1,000 mg/kg/day; however, no evidence of daily (QID) for seven days, bepotastine plasma that BEPREVE should not be used to treat contact contact lenses. Remove contact lenses prior to infertility was observed in rats given 200 mg/kg/ concentrations peaked at approximately one to two lens-related irritation. instillation of BEPREVE. The preservative in hours post-instillation. Maximum plasma day (approximately 3,300 times the topical ocular Patients should also be advised to remove BEPREVE, benzalkonium chloride, may be concentration for the 1% and 1.5% strengths were use in humans). The concentration of radio- contact lenses prior to instillation of BEPREVE. absorbed by soft contact lenses. Lenses may be 5.1 ± 2.5 ng/mL and 7.3 ± 1.9 ng/mL, respectively. labeled bepotastine besilate was similar in fetal The preservative in BEPREVE, benzalkonium reinserted after 10 minutes following Plasma concentration at 24 hours post-instillation liver and maternal blood plasma following a single chloride, may be absorbed by soft contact lenses. administration of BEPREVE. were below the quantifiable limit (2 ng/mL) in 11/12 3 mg/kg oral dose. The concentration in other Lenses may be reinserted after 10 minutes subjects in the two dose groups. 5.3 Topical Ophthalmic Use Only fetal tissues was one-third to one-tenth the following administration of BEPREVE. BEPREVE is for topical ophthalmic use only. concentration in maternal blood plasma. Distribution: The extent of protein binding of Manufactured by: Bausch & Lomb Incorporated bepotastine is approximately 55% and 6 ADVERSE REACTIONS An increase in stillborns and decreased growth Tampa, FL 33637 independent of bepotastine concentration. 6.1 Clinical Trials Experience and development were observed in pups born Under license from: Because clinical trials are conducted under from rats given oral doses of 1,000 mg/kg/day Metabolism: In vitro metabolism studies with human Senju Pharmaceutical Co., Ltd. widely varying conditions, adverse reaction rates during perinatal and lactation periods. There liver microsomes demonstrated that bepotastine is Osaka, Japan 541-0046 observed in the clinical trials of a drug cannot be were no observed effects in rats treated with minimally metabolized by CYP450 isozymes. ®/TM are trademarks of Bausch & Lomb directly compared to rates in the clinical trials of 100 mg/kg/day. Incorporated or its affiliates another drug and may not reflect the rates In vitro studies demonstrated that bepotastine There are no adequate and well-controlled © 2012 Bausch & Lomb Incorporated. observed in clinical practice. besilate does not inhibit the metabolism of various studies of bepotastine besilate in pregnant US/BEP/13/0028 4/13 RRO0214_BLO0214_BL BepreveBepreve PI.inddPI.indd 1 11/16/14/16/14 9:539:53 AMAM Slit Lamp Essentials Don’t be afraid to apply pressure to get the rust out. And take a To get out the last of that deep, stubborn rust, try holding the few passes at it. In between, give the patient the opportunity to Alger brush in your other hand. This automatically reverses the blink. Even so, a trace of rust may remain, as seen here. direction of burr’s rotation within the wound to scour it well. to feather into the surrounding tis- mind that remaining rust will create betic patients typically re-epithelize sue. A dense brown patch is also inflammation and retard healing, so at a slower rate.) Pain management typically noted in the bottom of the do your best to leave the wound as depends on the extent of tissue excavated area. Although the rust clean and rust free as possible. damage and the depth of the for- ring can occasionally be lifted in its If confidently ambidextrous, hold eign body, as well as the level of entirety with a jeweler’s forceps, an the burr in your opposite hand to inflammation and infection. Alger brush will be required in the allow the spinning motion of the A bandage contact lens can also vast majority of cases to free the blade to approach the wound in the reduce discomfort. It creates an area of rust. Be sure to use a clean, opposite direction and loosen stub- artificial surface that provides pro- sterilized tip for each case. born areas of rust. tection from continual tearing of The Alger brush should be After successfully burring the rust the epithelium, promotes healing brought toward the area tangen- away, pass the magnet around the and decreases the risk of corneal tially. Although the stroma is dif- area to remove any filings. Rinse erosion. But use the bandage con- ficult to penetrate with an Alger the eye with saline to clean the field tact lens with caution. If placed on brush, it’s still prudent to work tan- as well. the eye of a patient without contact gentially and not perpendicularly. lens experience, it might inadver- It’s also easier to control the Alger 9. Do a Double Check tently be dislodged or taco-rolled, brush depth from this angle. After successful removal, be certain leading to another phone call from In some cases, slight pressure to re-evaluate the area. Evaluate the patient concerned about the dis- is required to adequately remove with white light, and also look for comfort produced. Also, a bandage the rust. Although the rust may any foreign matter that might have contact lens may contribute to a loosen with time and rise closer fallen into the lower palpebral con- more infective climate, so moni- to the surface, try to remove as junctiva. Do a finalized inspection tor the patient closely. Be sure to much rust as possible at the initial with sodium fluorescein and cobalt remove the contact lens in 24 hours visit to prevent re-entry into the blue filter to review and document to check the cornea for edema and area, which will disturb epithelial the extent of the evacuation and striae as well. healing. A slight amount of rust to be certain no foreign matter or Standard of care dictates that left in the center of the excavated additional foreign bodies exist. corneal foreign body cases be seen pit will dissipate with time, and in 24 hours, but that certainly var- based on the clinician’s judgment, 10. Rx Appropriately ies depending on the severity and it’s often less traumatic to leave a Postoperatively, place the patient the depth of the foreign body. slight amount of rust as opposed to on a broad-spectrum antibiotic for Pressure patching is another excessive tissue disruption. Keep in one week. (Keep in mind that dia- method of controlling pain, but REVIEW OF OPTOMETRY JANUARY 15, 2015 27 022_ro0115_f1.indd 27 1/8/15 1:00 PM THE TIME AND MONEY THAT YOU COMMIT TO YOUR EDUCATION IS A CRITICAL INVESTMENT IN YOUR OPTOMETRIC CAREER. 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Register by Jan 7 and Save Find out more at SECO2015.com SECOINTERNATIONAL.COM FACEBOOK.COM/SECO.INTERNATIONAL TWITTER.COM/SECO_INTL RO0115_House Seco.indd 1 12/22/14 3:55 PM Slit Lamp Essentials After successful removal of the foreign body and residual rust, do a final inspection with white light. Rinse the eye with saline and use a magnet or swab to remove any metal filings or debris, particularly in the lower palpebral conjunctiva. Lastly, stain the eye, then measure and document the lesion. Schedule the patient for a one-day follow up, and prescribe a broad-spectrum antibiotic. finds less favor with patients who tion of the steroid varies depending Corneal foreign bodies can rep- are still leading an active lifestyle, on the depth of the foreign body, resent a scary, vision-threatening and is often unnecessary. the amount of inflammation and the situation to the patient. With the In the case of non-central superfi- risk of scarring, but the most com- proper patient education, foreign cial foreign bodies, a topical antibi- mon dosage is QID for seven to 10 body removal technique and treat- otic is typically all that’s required. If days, followed by a short taper. Be ment, you will have the metal and excessive inflammation has already aggressive and use a strong steroid, rust out of the cornea efficiently occurred or the amount of burring such as prednisolone acetate, diflu- and effectively. Your patient will required was extensive, the use of prednate or loteprednol 0.5%. leave feeling significantly better and homatropine BID for three days, in An amniotic membrane, such you will have gained a patient to conjunction with the topical antibi- as the Prokera Slim device (Bio- your practice. otic, often provides adequate pain Tissue), may also be appropriate for Assuming the phone call came management and decreases the risk those central, deep foreign bodies at half time, you can be back for of iritis. where the risk of scarring is great. the exciting second half and you’ll Topical non-steroidal anti- enjoy it knowing you’ve done inflammatory agents can also assist 11. Revisit on Day One an outstanding service for your in pain management without jeop- Significant healing should be noted patient, and your patient will enjoy ardizing epithelial healing. Steroids, within 24 hours. The most common the second half reassured they are even in the presence of iritis or concerns at postoperative visits are in good hands and made the right ensuing iritis, are relatively contra- infection, iritis and recurrent cor- call. ■ indicated until re-epithialization has neal erosion. Dr. Shetler is an assistant profes- been noted. sor and chief of the university clinic In the case of central foreign bod- 12. Bill Properly facilities at the Oklahoma College ies, its depth determines the level No job is complete until the paper- of Optometry. of medication. Superficial corneal work is done. The code commonly Dr. Lighthizer is the assistant foreign bodies—regardless of their used is 65222 (Corneal foreign dean for clinical care services, location—will not scar. But if the body removal with slit lamp). Be director of continuing education, foreign body is centrally located certain to use modifiers to indicate and chief of both the specialty care and has penetrated into the stro- if more than one foreign body was clinic and the electrodiagnostics mal layer, scarring will result. So, removed. This code does not have clinic at the Oklahoma College of consider steroids to help reduce a global post-op period, so it is Optometry. the scarring and risk for potential appropriate to bill an E/M code for Next month: Amniotic vision loss. The dosage and dura- follow-up visits. Membrane Application REVIEW OF OPTOMETRY JANUARY 15, 2015 29 022_ro0115_f1.indd 29 1/8/15 1:00 PM Neuro An Intro to Neuro-ophthalmic disorders can be intimidating—but you can diagnose and manage manyN of them. Here’s a simpleeuro guide for these serious presentations. By Michael Trottini, OD, and Michael DelGiodice, OD any optometrists avoid diagnosing and manag- ing patients with neuro- Mophthalmic disorders. We may perceive these cases to be very complex, time-consuming and pos- sibly vision- or life-threatening. While challenging, these condi- tions can be successfully managed by optometrists and comanaged with other specialties. This patient with thyroid orbitopathy has moderate proptosis and periorbital edema. This article reviews each element He also has significantly reduced extraocular motility. of the exam, along with the appro- priate ancillary testing required for History whether it’s monocular or binocular. proper diagnosis. Our goals are By taking a detailed history, the Monocular diplopia may be a to give a good clinical approach practitioner can start making a list result of uncorrected refractive for diagnosis and management, to of differential diagnoses, and then error, keratoconus, cataract or help you decide which cases require direct the exam toward narrowing maculopathy. Polyopia, which can non-urgent, urgent or emergent that list to find the etiology. This occur following cerebral damage, attention, and to encourage you to approach helps to keep clinical test- is a perception of two or multiple comanage certain disorders with ing specific to the problem, instead images that can be seen monocu- neurology, neuro-surgery and any of performing unnecessary tests. larly.1 However, this is a very rare other appropriate specialty. Here are some of the more com- complaint and patients will usually (Starting in the March 2015 mon neurologic complaints optom- have a prior neurologic cause such issue, we’ll also be presenting etrists encounter: as stroke or traumatic brain injury. neuro-ophthalmic case reports and • Diplopia. Your first question In patients with true binocular discussions every other month.) about double vision should be diplopia, horizontal diplopia is 30 REVIEW OF OPTOMETRY JANUARY 15, 2015 030_ro0115_f2.indd 30 1/8/15 1:04 PM frequently a result of a sixth nerve AION.2 Retinal emboli and tran- palsy or internuclear ophthalmople- sient ischemic attacks (TIAs) typi- gia (INO), while vertical diplopia is cally cause vision loss for seconds usually from a fourth or third nerve to minutes, while visual phenomena palsy. The diplopia is more promi- from non-neurologic type migraine nent when the patient looks toward may last for hours, but typically the affected muscle. For example, a less than 24 hours. patient with a left sixth nerve palsy • Headaches. Headaches are a will complain of horizontal diplo- very common complaint and often pia that worsens upon left gaze. not a result of serious pathology. Decompensating phorias can be However, certain symptoms or either horizontal or vertical, but characteristics may imply vision- or are usually intermittent rather than life-threatening causes. Headaches constant, as seen with nerve palsies that are newly noted, have differ- and INO. Diplopia from thyroid ent severity, frequency or dura- orbitopathy can also be horizontal tion––as well as those noted upon or vertical, but is typically present waking, those that wake the patient with other signs and symptoms, during the night or those that are such as pain, pressure, proptosis, unresponsive to pain medication or periorbital edema and chemosis/ accompany other neurologic symp- injection. Myasthenia gravis (MG) toms––should all be explored.3 should always be a differential A sudden-onset, severe head- diagnosis, especially if the diplopia ache—typically reported as “the is variable, not consistent with any worst headache of my life”—can of the nerve palsies or if there are be due to an intracranial hemor- other symptoms such as lid ptosis, rhage or carotid artery dissection, fatigue, dysphagia or dyspnea. and should be evaluated emer- • Vision loss/disturbances. Not- gently.3 Neck pain and swelling or ing whether the vision loss is mon- a Horner’s syndrome may be noted ocular or binocular, along with its on the same side of the headache in frequency, can be very helpful in carotid artery dissection patients. narrowing down potential causes. Be sure to rule out giant cell Transient monocular vision loss, or arteritis (GCA) in individuals older amaurosis fugax, may be a precur- than 55 years who experience head- sor to both ocular and systemic ache accompanied by symptoms pathology. A retinal embolus or such as jaw claudication, scalp artery occlusion, carotid artery tenderness, fatigue, weight loss and insufficiency, non-arteritic isch- generalized weakness. emic optic neuropathy (NAION), Headaches that are worse in the arteritic ischemic optic neuropathy morning, exacerbated by changes (AION) or vein occlusion may pres- in posture and accompanied with ent with warning signs of fleeting transient visual obscurations, vision loss. Alternatively, individu- nausea, vomiting and tinnitus are als who experience sudden binocu- typical for increased intracranial lar vision loss are more likely to pressure. have intracranial pathology. Painful, monocular vision loss Documenting the frequency of is characteristic of optic neuritis. vision loss is also helpful in deter- The pain is usually worse with eye mining the cause. Loss of vision movement. Multiple neurological lasting a few seconds can point symptoms—such as paresthesias, to papilledema or an impending ataxia, diplopia, fatigue, Uhthoff’s 030_ro0115_f2.indd 31 1/8/15 1:04 PM Neuro in evaluating patients with diplopia. If there is a small deviation, testing extraocular motilities is not suf- ficient for diagnosing a fourth or sixth nerve palsy. The cover test needs to be measured in all views of gaze in order to localize most devia- tions. We find the easiest method to measure the deviation is to use a prism bar during cover test while the patient is fixating at a distant Compare glaucomatous optic nerve pallor from total cupping (left) to non-glaucomatous target. pallor from optic atrophy due to an old ischemic optic neuropathy (right). Anterior Segment Exam phenomenon and Lhermitte’s defects. For instance, we’ve exam- While the majority of neuro- sign—may be present in patients ined asymptomatic patients with no ophthalmic findings are localized with optic neuritis associated with other exam findings except for con- to the posterior segment of the multiple sclerosis. frontation field defects, which led eye, a number of pertinent findings to diagnoses of pituitary adenomas can manifest within the anterior External Exam and prior cerebrovascular accidents structures. For instance, unilateral • Gross observation. Facial and (CVA). Although confrontation corkscrew vessels of the conjunctiva lid abnormalities can be indicators field testing has a fairly low sen- can be an indication of intracranial of neurologic eye disease. These sitivity for arcuate defects and dural arteriovenous malformation include signs of ptosis, proptosis, bitemporal hemianopsia, it has a (AVM) or carotid cavernous fis- resistance to retropulsion, lagoph- high sensitivity for detection of alti- tula (CCF). The phakomatoses—a thalmos, facial weakness, head turn tudinal defects and homonomous group of congenital disorders char- or tilt, and blepharospasm. hemianopsia.5,6 acterized by systemic hamartosis— It can be helpful to observe the • Pupillary testing. This is a great can manifest as hyperpigmented patient in the waiting room (i.e., objective measurement for identify- lesions of the iris, known as Lisch if they are turning or tilting their ing neuro-ophthalmic conditions. nodules.7 In addition, anterior head, favoring one eye, showing Pupil size should be measured in chamber cell and flare in an elderly difficulty with reading or watching both dark and bright illumination patient may be an indication of ocu- television). This is especially ben- to help differentiate a sympathetic lar ischemia secondary to carotid eficial with children who may not vs. parasympathetic issue. For occlusive disease. be able to give accurate histories or example, Horner’s syndrome, patients who are malingering. which is an oculosympathetic palsy, Funduscopy • Extraocular motility. Perform will have anisocoria greater in dim Posterior segment findings are best extraocular motilities to look for illumination, while a third nerve observed with a combination of any restricted gaze or pursuit defi- palsy will have anisocoria greater viewing modalities including direct, cits. Saccades can also be tested to in bright illumination. Afferent indirect and non-contact high-reso- help localize an issue. For example, pupillary defects will be present lution imaging. slow saccades can be noted with a with optic nerve and retinal disor- In the setting of optic nerve neurogenic process vs. a restrictive ders such as NAION, AION, optic pathology, the optic nerve has only process, which will have normal neuritis and artery occlusions. In two responses to injury: atrophy saccades.4 Finally, the eyes should patients with an Adie’s tonic pupil, or edema, whereby the former is also be examined for nystagmus. the pupil generally has an irregu- the end result of any pathologic • Confrontation field testing. lar shape and a slow constriction, process. Some of the more common While automated perimetry is often with sectoral paralysis. It will causes of pathology include com- the standard of care, don’t skip constrict with pilocarpine 0.125%, pression, ischemia, inflammation, confrontation testing, which can however. infiltration and metabolic or toxic quickly screen for certain key field • Cover test. This test is critical disturbances. Sometimes, congenital 32 REVIEW OF OPTOMETRY JANUARY 15, 2015 030_ro0115_f2.indd 32 1/8/15 1:04 PM anomalies of the optic nerve may sequent testing of the visual field, simulate pathologic processes. color vision, afferent system and The color of the optic disc NFL will allow for quantifying depends on light reflecting off the the pathology. In cases of bilateral surface vessels and nerve fiber layer disc edema, it is critical to assess (NFL). In cases of pseudophakia the appearance of the optic nerve and high myopia, a healthy disc with respect to its rim tissue, NFL, may appear pale. However, in cases vasculature and presence or absence of true optic neuropathy, the clini- of venous pulsation. Bilateral opaci- cal examination may yield isolated fication of the nerve fiber layer, or combined pathological processes splinter hemorrhages at or adjacent such as NFL dropout, loss of peri- to the disc, and lack of spontane- papillary capillaries, visual acuity ous venous pulsation are highly and field defects, as well as an affer- suggestive of increased intracranial ent pupillary defect.8,9 pressure, which warrants emergent Individuals with swelling of neuroimaging to discount an intra- the optic nerve often present as a cranial hemorrhage or mass. In diagnostic challenge. Most cases the event the imaging is unremark- can be categorized based on timing able, then lumbar puncture can be of the event, visual acuity, lateral- scheduled to measure the opening ity, associated systemic symptoms, pressure and evaluate for idiopathic and appearance of the optic nerve intracranial hypertension. and retinal vasculature. Older indi- Lastly, a small physiologic cup viduals who present with painless with normal coloring, anomalous vision loss, optic nerve edema and vasculature branching (i.e., trifur- systemic vascular disease are at risk cations), disc drusen, absence of a for NAION. Accordingly, the optic high watermark sign and no frank nerve may show sectoral edema opacification of the NFL is more with dilated capillaries and an likely to represent pseudopapill- altitudinal visual field defect. None- edema. theless, immediate complete blood However, in most cases, deter- count (CBC) with platelets, erythro- mining true edema from congenital cyte sedimentation rate (ESR) and disc anomalies cannot be made by C-reactive protein (CRP) must be clinical exam alone. Ancillary test- ordered to discount arteritic disease ing of the visual field, B-scan ultra- even when constitutional symptoms sound, optic coherence tomography of temporal arteritis are absent. (OCT) and serial photography of While the two may be indistinguish- the optic disc will allow for both able from a clinical appearance, structural and functional assess- some have described pallid swelling ment. of the disc and worse visual acuity when discussing AION.9 Visual Field Testing Younger individuals who present In neuro-ophthalmic disease, visual with insidious vision loss in one eye field assessment is important for and pain on eye movement with evaluating lesions thought to be either normal or hyperemic swelling affecting the visual pathway, as well of the disc may be suffering from as for monitoring progression of an optic neuritis event or a space- optic nerve disease and intracranial occupying intraorbital process that pathology. It is most commonly occurs with transient vision loss used in guiding treatment and in peripheral gaze positions. Sub- monitoring for conditions such as 030_ro0115_f2.indd 33 1/8/15 1:04 PM Neuro neuromyelitis optica, idiopathic intracranial hypertension, migraine, optic nerve head drusen, compres- sive optic neuropathy and Leber’s hereditary optic neuropathy, as well as Alzheimer’s and Parkinson’s dis- ease.15,16 OCT allows the clinician to quantify the thickness of the retinal nerve fiber layer (RNFL), which is useful in managing disorders of the Which is true disc edema? At left is pseudo disc edema from crowding of the optic optic nerve and residual effects of disc. At right is true disc edema in a patient with a sphenoid wing meningioma. intracranial processes. In particu- lar, it can be of great clinical value idiopathic intracranial hypertension pected screening field defects, loss in differentiating a low-grade disc (IIH), optic neuropathy, pituitary of vision or evidence of optic neu- edema from pseudo-disc edema, adenomas and other sellar lesions.10 ropathy require formal visual field namely optic nerve head drusen While there are diverse applica- assessment. Also, employ formal (ONHD). Specifically, ONHD is tions, visual field testing essen- field testing in patients with acute associated with a focal, hyperreflec- tially serves two main functions: or chronic headache syndromes and tive mass on spectral-domain OCT, localization of the visual pathway transient vision loss despite a nor- along with an adjacent hyporeflec- and assessment for progression or mal ophthalmologic examination, tive region where the outer nuclear regression analysis. (See “Visual as slow-growing intracranial masses layer covers the drusen. Also, Field Defects Associated with and migraine-associated cerebrovas- ONHD has a much thinner peri- Visual Pathways,” page 36.) cular accidents may be identified. papillary RNFL, while disc edema Additionally, testing can be per- Frequency doubling technol- has a much thicker RNFL in the formed by a number of different ogy (FDT) has been developed as nasal quadrant.17 techniques, including confrontation a screening tool for glaucoma.11 (with finger counting, red target Advantages include efficiency and Neuroimaging or facial Amsler), tangent screen, high sensitivity and specificity when Appropriately diagnosing and man- Goldmann kinetic perimetry and compared to SAP in assessing field aging patients with neuro-ophthal- standard automated perimetry loss from optic neuropathy, with mic disease can be both challenging (SAP). The confrontation tech- limitations in ascribing field loss and rewarding. The nature of the nique makes up the majority of located to the chiasm and retrochi- disease course—whether urgent or our screening fields and is reliable asm.12 However, an updated model, emergent—dictates which neuro- and efficient. When compared to FDT (Humphrey Matrix), was imaging study will deliver the most Goldmann and automated perim- found to exhibit greater sensitivity essential information in a timely etry, the confrontation method has for optic nerve, chiasmal and retro- manner. The most common clinical a sensitivity of approximately 20% chiasmal disorders when compared indications for the use of neuroim- for arcuate, 50% for bitemporal, to its former counterpart.13,14 aging are as follows: undetermined 70% for homonymous hemianopia visual loss, unilateral or bilateral and nearly 100% for altitudinal Optical Coherence visual field defects and scotomas, defects.5,6 Tomography anisocoria, ptosis, proptosis, diplo- Remember that while a defect Currently, OCT is commonly pia, ophthalmoplegia, oscillopsia, identified by confrontation field used to demonstrate pathophysi- optic nerve anomalies and pupillary testing has a relatively high predic- ologic phenomena in a variety of defects. tive value of true defects confirmed neuro-ophthalmic disorders. It In general, magnetic resonance with formal perimetry, confronta- has been studied in several neuro- imaging (MRI) is the modality of tion testing has many limitations. ophthalmic conditions, including choice for imaging suspected neuro- Patients in whom there is a history anterior ischemic optic neuropathy, ophthalmic disease processes, while of neurologic deficit, certain or sus- optic neuritis/multiple sclerosis, computed tomography (CT) is more 34 REVIEW OF OPTOMETRY JANUARY 15, 2015 030_ro0115_f2.indd 34 1/8/15 1:04 PM Table 1. A Brief Comparison of CT and MRI Capabilities Computed tomography Magnetic resonance imaging Ionizing radiation No ionizing radiation Excellent visualization of acute Difficult visualization of acute hemorrhage hemorrhage Very sensitive to calcification and bony Difficult visualization of calcification and bony lesions lesions Limited planes Multiplanar imaging Limited visualization near dense bone Dense bone does not impose any limitation Limited contrast resolution in soft Superb soft tissue contrast resolution tissues Quick to obtain, easily available, Limited availability, time consuming, expensive inexpensive appropriate for evaluating intracra- dysfunction of vision, visual field, nial bleeding, osseous lesions of the ocular motility, pupil size and reac- bony orbit or optic nerve calcifica- tivity, eyelid position and function, tions. (See “A Brief Comparison of and cornea sensation. CT and MRI Capabilities,” above.) The most common cause of func- Additionally, both CT and MR tional illness is vision loss. Individu- angiography have been successful as als generally present with severe non-invasive procedures for study- vision loss in one or both eyes ing the arteries in cases of suspected despite a normal ophthalmologic intracranial arterial abnormality.18 examination without refractive These non-invasive angiographic error. Such cases present a diag- studies may be used with conven- nostic challenge and often occupy tional studies to more accurately a great deal of chair time. Follow- assess patients with documented or ing meticulous history, some of the suspected vascular malformations, more common in-office tests are intracranial aneurysms and neoplas- SAP, optokinetic (OKN) drum, mir- tic vascular growths for which con- ror test, finger touching, stereopsis, ventional MRI/CT is unremarkable high plus lens refraction and the or insufficient. 4 base-out prism test. These tests allow for an object assessment of Nonorganic Vision Loss visual function and binocularity.19 Patients who describe and pres- ent with physical illness in the As optometrists, our profession absence of an organic cause are continues to evolve. Managing and referred to as having functional comanaging neuro-ophthalmic loss. In such cases, it is important cases are well within our scope of to take into account the following practice. High-tech office equip- considerations: nature of the symp- ment is rarely required for diagnosis toms, attitude and motivation of and management of these disor- the individual. Additionally, most ders, and most optometric offices nonorganic disorders can be catego- are equipped with the necessary rized by three types: malingering, resources. Munchhausen syndrome and psy- Often, it can be difficult for chogenic. Patients who present with patients to see a neuro-ophthalmol- nonorganic neuro-ophthalmic dis- ogist, as tertiary practices are fewer orders most commonly complain of in number, appointments are often 030_ro0115_f2.indd 35 1/8/15 1:05 PM Neuro Visual Field Defects Associated with Visual Pathways limited and the distance to travel is usually greater. As a result, optom- Visual Field Defect Lesion Location etrists have now become vital providers in serving patients with neuro-ophthalmic disease. ■ Decreased vision, right eye Right optic nerve Dr. Trottini is in practice at Outlook Eyecare in Monroe Township, NJ. Dr. DelGiodice is in practice at Junctional scotoma Posterior right optic nerve Associated Eye Physicians in Clif- ton, NJ. 1. Cornblath WT, Butter CM, Barnes LL, Hasselbach MM. Spatial characteristics of cerebral polyopia: a case study. Bitemporal hemaniopia Chiasm Vision Res. 1998 Dec;38(24):3965-78. 2. Athappilly G, Pelak VS, Mandava N, Bennett JL. Ischemic optic neuropathy. Neurol Res. 2008 Oct;30(8):794-800. 3. Hainer BL, Matheson EM. Approach to acute headache in adults. Am Fam Physician. 2013 May 15;87(10):682-7. Right homonymous Left optic tract 4. Ramat S, Leigh RJ, Zee DS, Optican LM. What clinical hemaniopia disorders tell us about the neural control of saccadic eye movements. Brain. 2007 Jan;130(Pt 1):10-35. 5. Trobe JD, Acosta PC, Krischer JP, Trick GL. Confrontation visual field techniques in the detection of anterior visual path- way lesions. Ann Neurol. 1981 Jul;10(1):28-34. 6. Johnson LN, Baloh FG. The accuracy of confrontation visual field test in comparison with automated perimetry. J Natl Med Assoc. 1991 Oct;83(10):895-8. Right homonymous Left lateral geniculate 7. Cibis GW, Tripathi RC, Tripathi BJ. Glaucoma in Sturge- sectoranopias nucleus Weber syndrome. Ophthalmology. 1984 Sep;91(9):1061-71. 8. Trobe JD, Glaser JS, Cassady J, et al. Nonglaucoma- tous excavation of the optic disc. Arch Ophthalmol. 1980 Jun;98(6):1046-50. 9. Rader J, Feuer WJ, Anderson DR. Peripapillary vasocon- striction in the glaucomas and the anterior ischemic optic neuropathies. Am J Ophthalmol. 1994 Jan 15;117(1):72-80. 10. Kedar S, Ghate D, Corbett JJ. Visual fields in neuro-oph- Right homonymous superior Left temporal lobe thalmology. Indian J Ophthalmol. 2011 Mar-Apr;59(2):103-9. hemaniopic defect 11. Wall M, Neahring RK, Woodward KR. Sensitivity and spec- ificity of frequency doubling perimetry in neuro-ophthalmic disorders: a comparison with conventional automated perim- etry. Invest Ophthalmol Vis Sci. 2002 Apr;43(4):1277-83. 12. Noval S, Contreras I, Rebolleda G, et al. A comparison Right homonymous inferior Left parietal lobe between Humphrey and frequency doubling perimetry for hemaniopic defect chiasmal visual field defects. Eur J Ophthalmol. 2005 Nov- Dec;15(6):739-45. 13. Huang CQ, Carolan J, Redline D, et al. Humphrey Matrix Right homonymous inferior Left occipital lobe perimetry in optic nerve and chiasmal disorders: comparison with Humphrey SITA standard 24-2. Invest Ophthalmol Vis quadrantanopia (upper bank) Sci. 2008 Mar;49(3):917-23. 14. Taravati P, Woodward KR, Keltner JL, et al. Sensitivity and specificity of the Humphrey Matrix to detect hom- onymous hemianopias. Invest Ophthalmol Vis Sci. 2008 Right homonymous superior Left occipital lobe Mar;49(3):924-8. 15. Subei AM, Eggenberger ER. Optical coherence tomogra- quadrantanopia (lower bank) phy: another useful tool in a neuro-ophthalmologists arma- mentarium. Curr Opin Ophthalmol. 2009 Nov;20(6):462-6. 16. Pasol J. Neuro-ophthalmic disease and optical coherence tomography: glaucoma look-alikes. Curr Opin Ophthalmol. Right homonymous Left occipital lobe 2011 Mar;22(2):124-32. 17. Johnson LN, Diehl ML, Hamm CW, et al. Differentiat- macular-sparing hemaniopia ing optic disc edema from optic nerve head drusen on optical coherence tomography. Arch Ophthalmol. 2009 Jan;127(1):45-9. 18. Weishaupt D, Köchli DV, Marincek B. How Does MRI Right homonymous Tip of the left occipital lobe Work? An Introduction to the Physics and Function of Mag- netic Resonance Imaging. Berlin, Germany: Springer-Verlag scotomas Berlin and Heidelberg GmbH & Co. K; 2008. 19. Miller NR, Newman NJ, Biousse V, Kerrison JB. Walsh and Biousse V, Newman NJ. Neuro-Ophthalmology Illustrated. New York: Thieme; 2009: 41-3. Hoyt’s Clinical Neuro-Ophthalmology: The Essentials. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2008. 36 REVIEW OF OPTOMETRY JANUARY 15, 2015 030_ro0115_f2.indd 36 1/8/15 1:05 PM BIOFINITY MULTIFOCAL LENSES AVAILABLE UP TO -10.00D easy An for you and your presbyopic fit patients. ® CooperVision Biofinity multifocal lenses Biofinity® combine a high-performing 3rd generation multifocal material with a streamlined fitting process. Now even your most challenging presbyopic patients can enjoy the freedom of all-distance clarity and lasting comfort. Balanced Progressive™ Technology enhances vision near, far and intermediate. It also allows for an individualized fi tting for each wearer and each eye. Dominant eye lens Non-Dominant eye lens Distance vision Near vision Spherical central zone Spherical central zone Intermediate vision Intermediate vision Progressive zone Progressive zone Near vision Distance vision Spherical zone Spherical zone Lens edge Lens edge Biofinity & Biofinity XR Biofinity toric Biofinity multifocal Download your Biofinity multifocal 3-step fitting guide at coopervision.com/fitting-guide ©2014 CooperVision, Inc. 1315 12/14 RO0115_Cooper Biofinity.indd 1 12/22/14 11:43 AM Oral Meds Annual Pharmaceutical Issue DropWhen a Isn’t Enough Oral antibiotics and analgesics often are clinically necessary when treating certain ocular conditions. Here’s a rundown of our favorite systemic agents. By Carl H. Spear, OD, MBA, and Mark Obenchain, OD ral medications play a liver and kidney function. Remem- very important and clearly ber that proper liver function is defined role in daily prac- critical for the metabolism of oral Otice. Our profession has medications, and kidney function grown and matured significantly is integral to drug excretion. during the last three decades, and A practical pointer—when now the vast majority of us are encountering patients with exten- able to prescribe more orals than sive medication lists and multiple ever before. Expanded prescribing drug allergies, it may be helpful rights allow us to more effectively to ask them which agents they’ve manage our patients, as well as used in the past for pain manage- bring additional value and savings ment or certain infections. We to the health care system. Which oral antibiotic would be most have several of these patients in Although several categories of appropriate to treat dacryocystitis, as our practice. Over time, many oral medications play an important seen in this patient? of them have learned which pain role in patient care, anti-infectives medications, for example, they can and analgesics are among the A Lesson in History take without difficulty. most frequently prescribed agents. Before initiating oral meds, a com- In order to effectively use these plete ocular and systemic history Oral Anti-Infective medications in clinical practice, is crucial. This includes detailed Agents in Eye Care however, it is essential to balance knowledge of any other medica- We like to employ the “big bottle a number of factors—such as side tions the patient is taking and theory” when prescribing oral effect profiles, drug allergies and whether the individual has any medications. If you look behind pregnancy status—that will ulti- relevant drug allergies. Also, it is the counter in any pharmacy, you mately lead to the success or fail- important document his or her will see all sizes and shapes of pill ure of treatment. general health status—particularly bottles. The understood rule here 38 REVIEW OF OPTOMETRY JANUARY 15, 2015 038_ro0115_f3.indd 38 1/8/15 1:14 PM RO0514_Allergan Restasis.indd 1 4/17/14 2:47 PM RESTASIS® (Cyclosporine Ophthalmic Emulsion) 0.05% BRIEF SUMMARY—PLEASE SEE THE RESTASIS® PACKAGE INSERT FOR FULL PRESCRIBING INFORMATION. INDICATION AND USAGE RESTASIS® ophthalmic emulsion is indicated to increase tear production in patients whose tear production is presumed to be suppressed due to ocular infl ammation associated with keratoconjunctivitis sicca. Increased tear production was not seen in patients Oral Meds currently taking topical anti-infl ammatory drugs or using punctal plugs. CONTRAINDICATIONS RESTASIS® is contraindicated in patients with known or suspected hypersensitivity to any of the ingredients in the formulation. WARNINGS AND PRECAUTIONS is that the medications kept in the Potential for Eye Injury and Contamination To avoid the potential for eye injury and contamination, be careful not to touch the vial tip to your eye or other surfaces. biggest bottles are the ones that Use with Contact Lenses are most often used, so the phar- RESTASIS® should not be administered while wearing contact lenses. Patients with decreased tear production typically should not wear contact lenses. If contact lenses are worn, they should be removed prior to the administration of the emulsion. Lenses may be macy keeps more of them on hand. ® reinserted 15 minutes following administration of RESTASIS ophthalmic emulsion. Although there certainly are times ADVERSE REACTIONS Clinical Trials Experience when less common medications are Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not refl ect the rates observed in practice. needed, it is our experience that In clinical trials, the most common adverse reaction following the use of RESTASIS® was ocular burning (17%). most infectious ocular conditions Other reactions reported in 1% to 5% of patients included conjunctival hyperemia, discharge, epiphora, eye pain, foreign body can be treated with five to six oral sensation, pruritus, stinging, and visual disturbance (most often blurring). Post-marketing Experience agents. The following adverse reactions have been identifi ed during post approval use of RESTASIS®. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal Determining whether the infec- relationship to drug exposure. tious process at hand is acute or Reported reactions have included: hypersensitivity (including eye swelling, urticaria, rare cases of severe angioedema, face swelling, tongue swelling, pharyngeal edema, and dyspnea); and superfi cial injury of the eye (from the vial tip touching the eye chronic is the first decision point in during administration). our medication selection process. USE IN SPECIFIC POPULATIONS Pregnancy Once we have made this determi- Teratogenic Effects: Pregnancy Category C nation, we then go to our “Fabu- Adverse effects were seen in reproduction studies in rats and rabbits only at dose levels toxic to dams. At toxic doses (rats at 30 mg/ kg/day and rabbits at 100 mg/kg/day), cyclosporine oral solution, USP, was embryo- and fetotoxic as indicated by increased pre- and lous Five” oral anti-infectives to postnatal mortality and reduced fetal weight together with related skeletal retardations. These doses are 5,000 and 32,000 times select the most appropriate drug greater (normalized to body surface area), respectively, than the daily human dose of one drop (approximately 28 mcL) of 0.05% RESTASIS® twice daily into each eye of a 60 kg person (0.001 mg/kg/day), assuming that the entire dose is absorbed. No evidence for that individual. of embryofetal toxicity was observed in rats or rabbits receiving cyclosporine at oral doses up to 17 mg/kg/day or 30 mg/kg/day, respectively, during organogenesis. These doses in rats and rabbits are approximately 3,000 and 10,000 times greater (normalized to body surface area), respectively, than the daily human dose. Our ‘Fabulous Five’ Offspring of rats receiving a 45 mg/kg/day oral dose of cyclosporine from Day 15 of pregnancy until Day 21 postpartum, a maternally Oral Antibiotics toxic level, exhibited an increase in postnatal mortality; this dose is 7,000 times greater than the daily human topical dose (0.001 mg/ kg/day) normalized to body surface area assuming that the entire dose is absorbed. No adverse events were observed at oral doses 1. Amoxicillin with or without cla- up to 15 mg/kg/day (2,000 times greater than the daily human dose). There are no adequate and well-controlled studies of RESTASIS® in pregnant women. RESTASIS® should be administered to a vulanic acid. This is a great choice pregnant woman only if clearly needed. for soft tissue infections, such as Nursing Mothers Cyclosporine is known to be excreted in human milk following systemic administration, but excretion in human milk after topical hordeolum, preseptal cellulitis, treatment has not been investigated. Although blood concentrations are undetectable after topical administration of RESTASIS® dacryocystitis and dacryoadenitis.1 ophthalmic emulsion, caution should be exercised when RESTASIS® is administered to a nursing woman. Pediatric Use Amoxicillin is a member of the The safety and effi cacy of RESTASIS® ophthalmic emulsion have not been established in pediatric patients below the age of 16. penicillin family. It does not kill Geriatric Use No overall difference in safety or effectiveness has been observed between elderly and younger patients. bacteria directly, but prevents them NONCLINICAL TOXICOLOGY from multiplying by prohibiting Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenesis: Systemic carcinogenicity studies were carried out in male and female mice and rats. In the 78-week oral (diet) cell wall formation. When clavu- mouse study, at doses of 1, 4, and 16 mg/kg/day, evidence of a statistically signifi cant trend was found for lymphocytic lymphomas in lanic acid is added to amoxicillin, females, and the incidence of hepatocellular carcinomas in mid-dose males signifi cantly exceeded the control value. In the 24-month oral (diet) rat study, conducted at 0.5, 2, and 8 mg/kg/day, pancreatic islet cell adenomas signifi cantly exceeded the it enhances the agent’s bacteri- control rate in the low-dose level. The hepatocellular carcinomas and pancreatic islet cell adenomas were not dose related. The low cidal effect via inactivation of the doses in mice and rats are approximately 80 times greater (normalized to body surface area) than the daily human dose of one drop (approximately 28 mcL) of 0.05% RESTASIS® twice daily into each eye of a 60 kg person (0.001 mg/kg/day), assuming that the entire enzyme beta lactamase. This fur- dose is absorbed. ther prohibits microbial resistance Mutagenesis: Cyclosporine has not been found to be mutagenic/genotoxic in the Ames Test, the V79-HGPRT Test, the micronucleus test in mice and Chinese hamsters, the chromosome-aberration tests in Chinese hamster bone-marrow, the mouse dominant against organisms that produce lethal assay, and the DNA-repair test in sperm from treated mice. A study analyzing sister chromatid exchange (SCE) induction by beta lactamase, such as S. aureus, cyclosporine using human lymphocytes in vitro gave indication of a positive effect (i.e., induction of SCE). 2 Impairment of Fertility: No impairment in fertility was demonstrated in studies in male and female rats receiving oral doses of S. epidermidis and H. influenza. cyclosporine up to 15 mg/kg/day (approximately 2,000 times the human daily dose of 0.001 mg/kg/day normalized to body surface Anyone with children knows area) for 9 weeks (male) and 2 weeks (female) prior to mating. PATIENT COUNSELING INFORMATION that pediatricians prescibe amoxi- Handling the Container cillin and Augmentin (amoxicillin/ Advise patients to not allow the tip of the vial to touch the eye or any surface, as this may contaminate the emulsion. To avoid the potential for injury to the eye, advise patients to not touch the vial tip to their eye. clavulanic acid, GlaxoSmithKline) Use with Contact Lenses for a variety of infections. Aug- RESTASIS® should not be administered while wearing contact lenses. Patients with decreased tear production typically should not wear contact lenses. Advise patients that if contact lenses are worn, they should be removed prior to the administration of the mentin is especially good against emulsion. Lenses may be reinserted 15 minutes following administration of RESTASIS® ophthalmic emulsion. gram-negative H. influenza.2 It is Administration Advise patients that the emulsion from one individual single-use vial is to be used immediately after opening for administration to one available in a variety of formula- or both eyes, and the remaining contents should be discarded immediately after administration. tions and flavors, and is our first Rx Only choice in children with acute infec- tions. Based on package insert 71876US17 © 2013 Allergan, Inc. Irvine, CA 92612, U.S.A. ® marks owned by Allergan, Inc. APC37BD13 Patented. See www.allergan.com/products/patent_notices Made in the U.S.A. 038_ro0115_f3.indd 40 1/8/15 1:14 PM Specifically for use in pediatric during pregnancy. Clinicians also patients, Augmentin is prescribed should keep in mind that pseudotu- as 20mg/kg/day to 40mg/kg/day mor cerebri has been documented for no more than 10 days. Any in patients who use doxycycline–– time we treat children, we always especially in younger individuals.1,5 call their pediatrician as a courtesy Increased photosensitivity and gas- and send a follow-up letter. This tric distress are other common side has proven to be a great practice effects. builder, frequently resulting in Dosages for doxycycline vary referrals. depending upon the patient’s dis- For adults, dosing should be ease state. For severe cases of mei- 500mg to 875mg BID for five to bomianitis, consider a dosage of seven days. Further, because Aug- 100mg BID for two to four weeks, mentin is a Category B drug, it can followed by 50mg BID for two to be used by female patients who are four weeks, then 20mg BID for pregnant or nursing. two to four months. Recent stud- If Augmentin is prescribed, it ies have indicated that doxycycline should be taken with food or milk dosages as low as 20mg BID are to improve clavulanic acid absorp- clinically effective, yield fewer side tion. Be sure to document hepatic Doxycycline is our first choice for the effects and improve compliance.6,7 function in the patient history, management of chronic inflammatory Thus, we use 50mg BID initially because the drug is contraindicated conditions, such as rosacea (top) and for four weeks, then 20mg BID for in those with acute liver injury lid disease (bottom). three to six months. and/or liver disease. For rosacea, 50mg to 100mg 2. Cephalexin. For adults with or other blood disorders due to daily for two to six weeks should soft tissue infections (e.g., preseptal altered vitamin K absorption.1 effectively reduce symptoms. Then, cellulitis, dacryocystitis, dacryo- 3. Doxycycline. If we could the medication can be titrated to adenitis), our first choice is Keflex prescribe only one oral media- 20mg per day as a maintenance (cephalexin, Advancis Pharmaceu- tion, it would be doxycycline. This dose. tical) at a dosage of 250mg to 500 agent is especially useful in treat- Doxycycline also exhibits anti- mg QID for 10 to 14 days. Cepha- ing chronic infections and inflam- inflammatory properties, and lexin is a member of the cepha- matory conditions that affect the reduces the production of inflam- losporin antibiotic class. These lids, such as meibomianitis and matory compounds, such as matrix agents demonstrate a similar mode blepharitis, but also can be used to metalloproteinase (MMP).8 This of action and side effect profile as manage rosacea, chlamydial con- characteristic makes doxycycline the penicillins. junctivitis and recurrent corneal effective against inflammatory lid Keflex is a great choice due to erosions. disease. Studies also have shown cost and proven efficacy. Although A member of the tetracycline that this anti-inflammatory activity Augmentin would be our first class, doxycycline is bacteriostatic can reduce the incidence and sever- choice for pediatric patients, and works by binding to bacterial ity of recurrent corneal erosions.4,9 Keflex can also be dosed at 25mg/ ribosomes and inhibiting protein A dosage of 50mg doxycycline kg/day to 50mg/kg/day. synthesis. Clinically, doxycycline is BID, in conjunction with topi- The cross-sensitivity of cepha- preferred over tetracycline because cal fluorometholone 0.1% TID, lexin and penicillin is reported it is much better absorbed.1,4 for four to eight weeks is recom- to be anywhere from 1% to Doxycycline should be taken on mended to relieve symptoms and 10%.1-3 Thus, you may wish to an empty stomach to further aid decrease recurrence. consider other antibiotic options absorption. Doxycycline is our choice for for patients who have a docu- Doxycycline (and all tetracy- chronic infectious disease, and can mented history of penicillin allergy. clines, in general) are contrain- be prescribed as an alternative for Keflex also is contraindicated in dicated in children younger than acute infections when patients are patients with hemophilia and/ eight years, nursing mothers and allergic to penicillin and/or the REVIEW OF OPTOMETRY JANUARY 15, 2015 41 038_ro0115_f3.indd 41 1/8/15 1:14 PM Oral Meds higher cost of azithromycin is a prescribing azithromycin to For soft tissue infections in consideration. patients with a documented history adults, the proper dosage of tri- 4. Azithromycin. This agent is of cardiac problems. Studies have methoprim/sulfamethoxazole is macrolide antibiotic and derivative shown that the drug can cause an 80mg/400mg to 160mg/800mg of erythromycin. Azithromycin is a elongated QT interval, leading to BID for 10 to 14 days. Take note first-line treatment for chlamydial abnormal heart rhythm and pos- that the medication should not be infections, such as adult inclusion sibly death.13 taken with food. Several pediatric conjunctivitis and trachoma. For 5. Trimethoprim/sulfamethoxa- options are available for children these disease processes, a one-time, zole. A lesser-known but clinically older than two months; however, a cumulative dose of 1,000mg useful oral antibiotic in is trim- the recommended dosage depends (four 250mg capsules or two ethoprim/sulfamethoxazole. Given on the type and severity of the 500mg capsules) should be suf- its broad spectrum of activity and infection. ficient. effectiveness against S. aureus, this To treat soft tissue infections, is our drug of choice if MRSA is Oral Analgesics in Eye Care azithromycin can be administered suspected, for patients with infec- Conditions such as corneal or at 500mg for one day and 250mg tions that are resistant to other conjunctival foreign bodies, cor- for four days. Also, it is our first medications and for healthcare neal abrasions, recurrent corneal choice for patients with known personnel. The medication is gen- erosion, post-refractive surgery, penicillin or cephalosporin aller- erally well tolerated, and is dosed blunt ocular trauma, post-herpetic gies. Azithromycin is safe to use just twice a day. neuralgia and anterior uveitis during pregnancy, and is a great Septra (trimethoprim/sulfameth- could warrant pain management. alternative to amoxicillin and oxazole, Monarch Pharmaceuti- The options for pain management cephalexin for pediatric patients. cals) and Bactrim (trimethoprim/ include over-the-counter medica- Due to a high rate of azithro- sulfamethoxazole, Roche) are tions, prescription medications and mycin prescriptions in the US, contraindicated in children less heavily regulated narcotic analge- S. pneumonia and H. influenzae than two months of age, preg- sics. have developed resistance. Several nant or nursing mothers, patients Analgesics either work peripher- researchers have advocated that with sickle cell disease and those ally (non-steroidal anti-inflamma- prescribing physicians should mini- with sulfa allergies. Patients who tory drugs and aspirin) at the end mize these prescribing habits.10-12 use either medication may be at receptors or centrally (opioids and Furthermore, the FDA has a higher risk of Stevens-Johnson acetaminophen) in the nervous advised clinical discretion, when syndrome.1 system. This fundamental under- standing helps us determine the Guidelines for Judicious Oral Analgesics Use most suitable medication for each When prescribing for pain, you must carefully consider the advantages and limitation of patient. We can also take advan- each drug choice. Side effects such as drowsiness, dizziness, nausea, vomiting and con- tage of the different mechanisms stipation must be taken into account, as well as whether the individual drinks alcohol in of action, as well as the synergistic excess. These potential complications must be discussed with the patient before deciding effect created by using combina- upon an appropriate agent. tion medications that include one Always be cautious of patients who exhibit drug-seeking behavior. Be wary of those who peripherally- and one centrally- “self-diagnose” and/or “self-prescribe,” or patients who seek multiple physicians for the acting agent. same condition. Also, be on the lookout for new patients who present with the exact same Acetaminophen (Tylenol, illness as someone to whom you recently prescribed narcotics. Other safety measures you McNeil Consumer Healthcare), might consider include keeping prescription pads safe, not preprinting DEA numbers, not which is a non-opioid analgesic, pre-signing Rx pads and writing out numbers (e.g., “ten” vs. “10”). helps with pain and fever, but Pay special attention to any pregnant patients who report significant pain. When in does not exhibit anti-inflammatory doubt, there is no harm in contacting or deferring to the individual’s primary care provider properties. The exact mechanism or OB/GYN. Medications that are safe to prescribe in pregnancy include erythromycin, of action is not completely under- azithromycin, amoxicillin, amoxicillin with clavulanic acid and Tylenol #3, as well as the stood, but is thought to work cen- antiviral medications acyclovir, valacyclovir and famciclovir. trally when reducing pain.14 Oral NSAIDs and aspirin, on the 42 REVIEW OF OPTOMETRY JANUARY 15, 2015 038_ro0115_f3.indd 42 1/8/15 1:14 PM other hand, work on the periph- rent use of an opioid eral nervous system by inhibiting and acetaminophen for Contraindications for Narcotic Analgesics cyclooxygenase (COX) at the site pain relief following • Known hypersensitivities of injury. dental operations.15 • COPD Opioids act on the central ner- The study also showed • Liver and kidney problems vous system by blocking incoming that the ibuprofen and • Pregnancy nociceptive signals to the brain, acetaminophen combi- • History of pain medication abuse thus reducing pain sensitivity. It is nation was safer than worth noting that opioids do not any analgesic combinations that 2. Ketoprofen. At one time, have anti-inflammatory properties. included opioids. ketoprofen was available OTC. Over-the-counter Tylenol is the But now, it is a prescription-only Our ‘Fabulous Five’ safest pain management option NSAID prescribed for mild to Analgesic Agents for children and pregnant mothers moderate pain. It is available in 1. Acetaminophen and ibupro- when used as monotherapy.15 The 50mg and 75mg capsules, and fen. These OTC options are solid daily dosage limitation for adults is typically is dosed every six to eight choices for basic pain management. 4,000mg. Further, Tylenol should hours. Additionally, there is a The synergistic effect of centrally- not be prescribed to patients who 200mg QD option; however, total acting acetaminophen and periph- are diagnosed with liver impair- daily dosing should not exceed erally-acting ibuprofen provides ment and/or alcoholism. 300mg. excellent pain management. One Ibuprofen dosing should not We have found ketoprofen is study indicated that combined ibu- exceed 2,400mg/day, and should especially useful in cases where sig- profen and acetaminophen worked be taken with food if the patient nificant ocular inflammation exists, more effectively than the concur- reports gastrointestinal upset. such as trauma-induced anterior Your own custom App for iPhone, Android, iPad and Mobile Website! EyeDocApp makes it easy for Individuals and Businesses to have their own custom App for iPhone, Android and iPad. Now you can use the same technology that Fortune 500 companies are using, for a fraction of the cost! Apps are the most powerful mobile marketing tools in the world! Your custom App can be downloaded by anyone in the world via the iTunes and Android Marketplace. Now all your customers can have your business in their ǡƤǤ Ƥ instantly pop up on their phone, just like a text message. ǡƤ ǡ Ȃ All for $49.99/month Learn more at EyeDocApp.com Exclusively Marketed by Jobson Optical’s Understand. Manage. Grow. 038_ro0115_f3.indd 43 1/8/15 1:13 PM Oral Meds day. Also, Vicoprofen is approved use them to the fullest scope of for patients 16 years of age and your licensure and comfort level to older. ensure that your patients receive 4. Tylenol with codeine. For the best care possible. ■ those who live in states that do not Dr. Spear owns and operates permit optometrists to prescribe Sight and Sun Eyeworks, a five- Schedule II medications, we recom- location optometry/ophthalmology mend Tylenol with codeine (Jans- practice in Pensacola, Fla. sen Pharmaceuticals). While it does Dr. Obenchain is in private not provide the synergistic analge- practice at Sight and Sun Eye- sic effect associated with hydroco- works in Pensacola. In addition to amoxicillin, which oral done and ibuprofen, it does meet anti-infective agent demonstrates good our big bottle criteria, and is one 1. Cooper DH, Krainik AJ, Lubner SJ. The Washington clinical efficacy against preseptal Manual of Medical Therapuetics, 32nd ed. Chapter 12. Anti- of the most frequently prescribed microbials. United States: Wolters Kluwer; 2007. cellulitis, as seen here? opioid analgesics in the US. 2. Rang HP, Dale MM, Ritter JM, Flower RJ. Rang and Dale’s Pharmacology, 6th ed. Drugs used in the treatment of infec- We recommend two formula- tion and cancer. China: Elsevier; 2007. uveitis. Studies have shown that tions––300mg/30mg (Tylenol #3) 3. Preston SL, Briceland LL. Accuracy of penicillin allergy reporting. Am J Hosp Pharm. 1994 Jan 1;51(1):79-84. ketoprofen is superior to OTC and 300mg/60mg (Tylenol #4). 4. Lonsberry B. Doxycycline: Do’s and Don’ts. Rev Optom. ibuprofen for pain management, so Tylenol #3 can be prescribed for 2014 Feb;151(2):38-41. 5. Tabibian JH, Gutierrez MA. Doxycycline-induced pseudo- it is an effective alternative to nar- children older than seven years, tumor cerebri. South Med J. 2009 Mar;102(3):310-1. cotic analgesics.16 and Tylenol 4 can be prescribed 6. van Zuuren EJ, Graber MA, Hollis S, et al. Interven- tions for rosacea. Cochrane Database Syst Rev. 2005 Jul 3. Hydrocodone and ibuprofen. for children older than 13 years. If 20;(3):CD003262. Hydrocodone is six times more being used long-term, it is prudent 7. Yoo SE, Lee DC, Chang MH. The effect of low-dose doxy- 17 cycline therapy in chronic meibomian gland dysfunction. Kor potent than codeine. Unfortu- to taper the medication to avoid J Ophthalmol. 2005 Dec;19(4):258-63. nately, with this increased potency drug dependence. 8. Research in dry eye: report of the Research Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. comes a profoundly higher likeli- 5. Tramadol. In July 2014, the 2007 Apr;5(2):179-93. hood of addiction. DEA universally classified trama- 9. Wang L, Tsang H, Coroneo M. Treatment of recurrent corneal erosion syndrome using the combination of oral Because of a perceived increase dol as a Schedule IV medication. doxycycline and topical corticosteroid. Clin Exp Ophthalmol. in both drug-seeking behavior Ultram (Janssen Pharmaceuticals) 2008 Feb;36(1):8-12. 10. Jenkins SG, Brown SD, Farrell DJ. Trends in antibacterial and opioid abuse during the last is available in 50mg and 100mg, resistance among Streptococcus pneumoniae isolated in the decade, officials from the Drug 200mg and 300mg extended- USA: update from PROTEKT US years 1-4. Ann Clin Micro- biol Antimicrob. 2008 Jan 11;7:1. Enforcement Agency (DEA) reclas- release dosages. Maximum dos- 11. Hoban DJ, Doern GV, Fluit AC, et al. Worldwide preva- sified hydrocodone as a Schedule ing is 300mg/day for moderate to lence of antimicrobial resistance in Streptococcus pneu- moniae, Haemophilus influenzae, and Moraxella catarrhalis II medication in August 2014. severe pain. in the SENTRY Antimicrobial Surveillance Program, 1997– The majority of states only allow 1999. Clin Infect Dis. 2001;32(Suppl. 2):S81–93 12. Serisier DJ. Risks of population antimicrobial resistance optometrists to prescribe Schedule Oral medications are a wonder- associated with chronic macrolide use for inflammatory air- III, IV and V medications.18 ful tool for eye care providers. way diseases. Lancet Respir Med. 2013 May;1(3):262-74. 13. U.S. Food and Drug Administration (FDA). Azithromycin It is your responsibility to learn However, each practitioner’s expe- (Zithromax or Zmax) and the risk of potentially fatal heart whether you live in a state that still rience, confidence and comfort rhythms. FDA Drug Safety Communication, 2013. Avail- able at: www.fda.gov/drugs/drugsafety/ucm341822.htm. permits ODs to prescribe Schedule level with oral prescribing varies Accessed December 28, 2014. II agents. If you are, then Vicopro- dramatically. Involving primary 14. Rang HP, Dale MM. Rang and Dale’s Pharmacology, 6th ed. Section 2 – Chemical Mediators: Anti-inflammatory and fen (AbbVie) is our choice. Again, care providers and other medical immunosuppressant drugs. China: Elsevier; 2007. we like taking advantage of the specialists, as well as pharmacists, 15. Moore PA, Hersh EV. Combining ibuprofen and acet- aminophen for acute pain management after third-molar centrally-acting opioid analgesic can help improve your knowledge extractions: translating clinical research to dental practice. J hydrocodone and the peripherally- of oral medications, appropriate Am Dent Assoc. 2013 Aug;144(8):898-908. 16. Sarzi-Puttini P, Atzeni F, Lanata L, et al. Efficacy of acting ibuprofen. dosing protocols and potential ketoprofen vs. ibuprofen and diclofenac: a systematic review Vicoprofen is available in a adverse effects. of the literature and meta-analysis. Clin Exp Rheumatol. 2013 Sep-Oct;31(5):731-8. 7.5mg/200mg formulation, and Our predecessors have worked 17. Anderson R, Saiers JH, Abram S, Schlicht C. Accuracy in can be taken every four to six long and hard to gain oral pre- equianalgesic dosing conversion dilemmas. J Pain Symptom Manage. 2001 May;21(5):397-406. hours, as needed. Patients should scribing rights in clinical practice. 18. Meers GF, Alldredge BF. Learn to Spot Drug-Seeking not take more than five tablets per Therefore, we encourage you to Behavior. Rev Optom. Feb;151(2):42-8. 44 REVIEW OF OPTOMETRY JANUARY 15, 2015 038_ro0115_f3.indd 44 1/8/15 1:14 PM Left your Review of Optometry magazine at the offi ce? No problem! Read Review on the go from any mobile device! Just simply go to www.reviewofoptometry.com and click on the digimag link to get your current issue. 2014 Digimag house ad_RO.indd 1 10/22/14 2:38 PM Therapeutics Annual Pharmaceutical Issue Off Label, But on Target Using drugs off label is not only permissible, it’s often standard of care. Get to know the following non-FDA-approved indications (if you don’t know them already). By John Murphy, Executive Editor ou’re probably using oph- Louis Catania, OD, an innovator in To that end, here are the best off- thalmic drugs for off-label off-label uses of drugs in eye care. label applications chosen by some uses (those not approved by Not the least of these is the added of optometry’s therapeutic experts. Ythe FDA) more often than costs to the pharmaceutical com- you realize. pany to sponsor clinical trials to Restasis for Uveitis In fact, about half of medications pursue additional labeling, and the “As an immunosuppressive agent, prescribed routinely in eye care are many years required for the FDA cyclosporine has enormous value likely used off label.1 For example, approval process. in all forms of inflammation—well topical antibiotics are generally Thus, off-label drug usage may beyond that caused from dry eye,” approved only for treating bacte- not only be effective, but more Dr. Catania says. rial conjunctivitis—but are even expeditious. Indeed, in the days Specifically, it’s a great off-label more valuable when used off label before optometrists had therapeutic treatment for uveitis, he suggests. against bacterial keratitis. prescribing privileges, Dr. Catania While Restasis (cyclosporine A Not only is this permissible, it’s advocated the use of over-the-coun- 0.05%, Allergan) is known to take good medicine. ter Polysporin ointment for eyelid weeks (or sometimes months) to be “The FDA acknowledges that and conjunctival infections and effective in patients with chronic physicians may prescribe any inflammation—a legal and legiti- dry eye, that’s not the case in legally marketed product for an mate therapy. patients with an acute inflamma- off-label use, as long as it is in the These days, better treatments are tory condition such as uveitis—it best interest of the patient,” accord- available and ODs have the license works quickly. “The literature is ing to a position statement made to use them. But the FDA approval extensive (from as far back as the by the Alliance of Specialty Medi- process is still slow and narrowly 1990s) regarding the efficacy and cine.2 “Off-label use is often the focused, and many treatment response time of topical and oral standard-of-care in the community. needs remain unmet. “Thus, it’s cyclosporine (effects within days) Not using medicines off label could imperative for practitioners to keep vs. steroids (sometimes weeks) for be considered malpractice in many up with the drug literature and uveitis,” Dr. Catania says.3 circumstances.” research, and to recognize legiti- He points to a recent research So, why don’t drug companies mate clinical studies, trials, results poster that showed that topical pursue these indications “on label”? and potential off-label uses,” Dr. cyclosporine hastened improve- There are several reasons, says Catania says. ment when used adjunctively in a 46 REVIEW OF OPTOMETRY JANUARY 15, 2015 046_ro0115_f4.indd 46 1/8/15 1:20 PM small group of patients with recur- rent anterior uveitis. “The patients had statistically significant fewer episodes of anterior uveitis, shorter duration of episodes and fewer total days of inflammation per year while on topical cyclosporine A 0.05%,” the authors reported.4 Barring contraindications, “any immunomodulator that can begin to reduce the extensive use of topi- cal steroids in eye care should be considered by clinical optometric This patient presented with recurrent corneal erosion (left). After debridement, he practitioners as both a primary and began doxycycline 20mg BID for 2.5 months. He’s been symptom-free ever since (right). adjunctive therapy for most exter- nal and uveitis inflammation,” Dr. tions, such as allergic conjunctivitis, takes for the patient to feel relief. Catania says. rosacea, superficial punctate kera- This often leads to discontinuation Start Restasis with the recom- titis (SPK), herpes zoster keratitis, of the medication and the feeling mended BID dosage, Dr. Catania iritis, cyclitis and others. that it didn’t work,” Dr. Ensor says. “However, dosages may Scott Ensor, OD, MS, who says. “A short course of Lotemax have to be increased based on the teaches systemic pharmacology at to ‘jump start’ the process can response to BID and/or the severity Southern College of Optometry in give faster relief and encourage the of the condition.” Memphis, Tenn., says there are two patient to continue the Restasis.”5 main circumstances when he uses Here’s his regimen: Start with Advil for Anterior Uveitis Lotemax for dry eye. Lotemax BID for two weeks, then To shorten or eliminate the use of “The first is when there are vis- use both Restasis and Lotemax oral or high-dose topical steroids for ible signs of inflammation—when BID for another two weeks. At anterior uveitic inflammation, try the disease has progressed to the that time, stop the Lotemax and oral ibuprofen, Dr. Catania says. point where there is visible hyper- continue with the Restasis alone. “As an anti-inflammatory, I emia and/or SPK, and the usual “I have much more success with found its use in dosages as high as lubricant drops are much less effec- Restasis when I follow this plan 2,400 to 3,000mg/day (given stan- tive. The anti-inflammatory proper- than when I use Restasis alone,” dard contraindications) to be valu- ties of Lotemax help decrease those Dr. Ensor says.5 able as a substitute for steroids or signs and hopefully give the patient In either case, “patient education used as adjunct therapy.” a feeling of relief,” he says. and follow-up appointments are He adds, “I even found, when In such cases, the dosage depends essential,” he says. “Many patients used prodromally in certain forms on the severity of the inflamma- are used to the simple artificial tears of recurrent uveitis—Fuchs’ being tion, but is usually BID to QID, Dr. approach to dry eye treatment, and notorious for patients’ prodromal Ensor says. Because loteprednol they don’t understand the difference awareness of an acute attack—ibu- is less likely than other steroids to in getting the corticosteroid,” Dr. profen proved to be effective in cause a rise in intraocular pressure, Ensor says. “They must return to reducing the recurrences and/or the a duration of six months or even the office for IOP monitoring and intensity of the recurrence.” longer is usually safe (although he proper discontinuation (i.e., taper- monitors patients’ progress during ing) of the medication.” Lotemax for Dry Eye this time). Also, be sure to measure Lotemax gel (loteprednol 0.5%, IOP before treatment to compare it Doxycline for RCE Bausch + Lomb) is FDA approved to the post-treatment IOP. Riddle: When is an antibiotic not an for treating inflammation and pain The second circumstance is when antibiotic? following ocular surgery—but it’s starting Restasis. “One of the draw- Answer: When it’s used in a routinely used for a variety of ante- backs to Restasis treatment is the sub-antimicrobial dose as an anti- rior segment inflammatory condi- length of time that it sometimes inflammatory. REVIEW OF OPTOMETRY JANUARY 15, 2015 47 046_ro0115_f4.indd 47 1/8/15 1:20 PM Therapeutics drop comes in handy,” he says. Interestingly, “selective alpha-2 adrenergic receptor agonists, when used at conventional doses of 0.1% or higher, are associated with a number of undesirable side effects, such as rebound hyperemia,” he says. “But the diluted version of this compound does not carry the same effects.” Substitute patients’ tetrahydrozoline with a drop of diluted brimonidine to “get the red How was this discovered? “In out.” Diluted brimonidine also improves comfort and won’t cause rebound hyperemia. the late 1990s, we knew that bri- monidine was a good vasoconstric- Indeed, when used in low doses and begin the healing process. tor, and thus it was applied before (100mg or less), oral tetracyclines About a week later, when the mem- refractive surgery to reduce subcon- offer several anti-inflammatory brane has dissolved, the patient junctival hemorrhage and hyper- benefits—not the least of which begins low-dose doxycycline BID as emia,” Dr. Bloomenstein says.7 is downregulating the proinflam- well as a “soft” steroid (Lotemax) More recently, a study of diluted matory matrix metalloproteinases for two to three months. brimonidine instilled before LASIK (MMPs). “I had one patient who was reduced subconjunctival hemor- In ocular surface conditions, nota- symptomatic almost every day. rhage and injection, and improved bly recurrent corneal erosion (RCE), He’d wake up and his eyes would patient comfort after surgery.8 MMPs break down the epithelial be a little scratchy. And when he For Dr. Bloomenstein’s redness adhesion complexes between the came into the office, he’d show reliever, trial and error led to the epithelium and the basement mem- early signs of recurrent erosion,” dilution that offered the best effect. brane, explains Jeffrey Varanelli, says Dr. Varanelli, who treated “I use the formula of two drops of OD, who practices at Simone Eye the patient with the combina- brimonidine to every 1ml of low- Center in suburban Detroit. tion approach. “That was back in viscosity tear solution,” he says. “So, if we can decrease these March 2014, and he’s been symp- “The drop usually lasts about four inflammatory enzymes with doxy- tom-free ever since.” to six hours, so I tell patients to use cycline, then there’s the potential it when they feel they need it for the for stronger adhesions, less chance A Better ‘Get-the-Red-Out’ whitening effect.” of the adhesions breaking down White eyes look bright and healthy, While this diluted compound is and ideally fewer recurrences of and that’s why people use “get the generally safe for most patients, the corneal erosions,” he says.6 red out” drops like Visine (tetra- best candidates have no signs or For ophthalmic purposes, “low- hydrozoline, McNeil), says Marc symptoms of ocular pathology, he dose” oral doxycycline means 20mg Bloomenstein, OD, director of recommends. or 25mg. If the price of the 20mg optometric services at Schwartz tablets is too steep, prescribe the Laser Eye Center in Scottsdale, Put a Plug in it comparatively less expensive 50mg Ariz. Off-label indications apply not only tablet and tell the patient to cut it in But as optometrists know (and to drugs, but also to devices such as half, Dr. Varanelli says. many patients discover), “redness punctal plugs, says Walt Whitley, He uses a four-pronged combi- relievers” like tetrahydrozoline are OD, MBA, director of optometric nation approach for most patients only a short-term solution because services at Virginia Eye Consultants with RCE. First, he debrides the they frequently lead to rebound in Norfolk, Va. cornea (by instilling tetracaine hyperemia. Like other medical devices, punc- and then using a blade or cellulose Instead, Dr. Bloomenstein pro- tal plugs require FDA clearance sponge) to remove the damaged vides patients with a dilution of the before being marketed to treat dry epithelium. Then, he applies an alpha agonist brimonidine to relieve eye disease. amniotic membrane (or a bandage red eyes. “When I have patients But they have additional uses contact lens) to cover the wound who have chronic red eyes, this besides dry eye, Dr. Whitley says. 48 REVIEW OF OPTOMETRY JANUARY 15, 2015 046_ro0115_f4.indd 48 1/8/15 1:20 PM For instance, he uses temporary, dicts, are drug-releasing punctal Final_Alliance_offlabel_position_statement.pdf. Accessed January 5, 2015. collagen punctal plugs to intensify plugs. Some are already in Phase II 3. Kaçmaz RO, Kempen JH, Newcomb C, et al. Cyclosporine and prolong the effect of medica- clinical trials, including a punctal for ocular inflammatory diseases. Ophthalmology. 2010 Mar;117(3):576-84. tions, particularly in conditions that plug for post-cataract surgery that 4. Michelotti M, Shtein RM, Prabhu SS, Cooney T. Topical require a high therapeutic dose. “In releases dexamethasone and one for cyclosporine A 0.05% for recurrent anterior uveitis. Poster pre- sented at American Society of Cataract and Refractive Surgery acute cases of recurrent corneal ero- glaucoma that provides a sustained Annual Symposium. April 25, 2014; Boston, MA. sion, corneal abrasion or corneal dose of travoprost.10,11 5. Sheppard JD, Donnenfeld ED, Holland EJ, et al. Effect of loteprednol etabonate 0.5% on initiation of dry eye treatment ulcer—in which hourly antibiotic with topical cyclosporine 0.05%. Eye Contact Lens. 2014 doses of topical fluoroquinolone Last but not least, a few words of Sep;40(5):289-96. 6. Dursun D, Kim MC, Solomon A, Pflugfelder SC. Treatment are needed—I’ll insert a temporary caution from Dr. Varanelli, who lec- of recalcitrant recurrent corneal erosions with inhibitors of plug in the lower tear duct, which tures frequently on off-label usage: matrix metalloproteinase-9, doxycycline and corticosteroids. Am J Ophthalmol. 2001 Jul;132(1):8-13. evidently increases the medication’s “Make sure the application is a pru- 7. Norden RA. Effect of prophylactic brimonidine on bleeding residence time on the corneal sur- dent clinical decision that is based on complications and flap adherence after laser in situ keratomi- leusis. J Refract Surg. 2002 Jul-Aug;18(4):468-71. face,” Dr. Whitley says. a firm, scientific rationale and sound 8. Pasquali TA, Aufderheide A, Brinton JP, et al. Dilute brimo- Anecdotally, he says, this seems medical evidence,” he says. “Also, nidine to improve patient comfort and subconjunctival hemor- to speed recovery and enhance be sure to let the patient know that rhage after LASIK. J Refract Surg. 2013 Jul;29(7):469-75. 9. Aritürk N, Oge I, Erkan D, et al. The effects of nasolacrimal compliance. what you’re prescribing is an off- canal blockage on topical medications for glaucoma. Acta But it’s not just for acute condi- label indication, and make sure that Ophthalmol Scand. 1996 Aug;74(4):411-3. 10. Endl MJ, Levenson JH, Walters TR, Majmudar PA. Multi- tions. In a chronic disease such as you document the drug’s use and center evaluation of safety and efficacy of sustained-release glaucoma, where compliance with effects in the chart.” ■ dexamethasone after cataract surgery. Paper presented at American Society of Cataract and Refractive Surgery Annual daily drops is essential, punctal 1. Ask the Ethicist: Off-label Meds. EyeNet. 2011 May;15(5):55. Symposium. April 27, 2014; Boston, MA. occlusion helps to lower IOP just a 2. Alliance of Specialty Medicine. Physician Directed Applica- 11. ClinicalTrials.gov. Phase 2b study evaluating safety and bit more.9 tions (Off Label Use): A Position Statement of the Alliance efficacy of OTX-TP compared to timolol drops in the treatment of Specialty Medicine. October 14, 2011; Washington DC. of subjects with open angle glaucoma or ocular hypertension. The next step, Dr. Whitley pre- Available at: www.specialtydocs.org/weblev/user_upload/ Identifier: NCT02312544. Last updated Dec 4, 2014. THE 2015 SECO SHOW DAILY! The SECO conference, one of the premier educational events of the year, will take place March 4-8, 2015 — and Review of Optometry will be there! Review’s on-site editorial staff will provide live daily coverage of important show news and events, educational highlights, product launches and more. Attendees on-site can pick up the SECO Daily each morning for the latest news and highlights. Those at home can stay in touch, too—a digital edition of the SECO Daily will be posted online, plus an e-newsletter will be sent out each morning with the day’s top stories. Show copies will also be available at Review of Optometry booth #507. To receive the e-News and digital edition, write to [email protected] or sign up at www.jobson.com/globalemail. 046_ro0115_f4.indd2015_seco_house_adUSE.indd 49 1 12/22/141/8/15 1:1811:44 PM AM 2 CE Credits (COPE approval pending) Annual Pharmaceutical Issue Going Antiviral: How to Bring Herpes to a Halt Here’s a review of the most commonly prescribed topical and oral antiviral medications used to manage herpetic eye disease. By Michael J. Lyons, OD t can be difficult and awkward to the viruses can remain dormant for talk about herpes. Yet, humans decades before being reactivated by are the only natural host reservoir changes in the host’s immune sys- Ifor both the herpes simplex virus tem, stress or other environmental (HSV) and the varicella zoster virus factors. (VZV). Studies have indicated that The spectrum of ocular disease adults may test as high as 90% for that is caused by the herpes fam- HSV antibodies and 95% for VZV ily varies widely––from blepharitis antibodies, suggesting a history of at the ocular adnexa all the way prior infections.1,2 to retinitis in the posterior seg- So, maybe instead of being reluc- This patient presented with evidence of ment. One study published in 1980 tant to talk about herpes, we should herpes zoster keratitis. indicated that the specific strain of think about it and ask patients herpes involved, as well as a variety about it more often. Herpes possesses the unique char- of ancillary host factors, can yield Viruses are the smallest of infec- acteristic of incorporating its viral different clinical presentations of tious pathogens, with the herpes genome into the host’s deoxyribo- herpetic ocular disease.4 Because of organism ranging from 120nm to nucleic acid (DNA). This process this, the diagnosis and treatment of 300nm in size. Although tremen- renders the virus undetectable by the ocular herpetic disease becomes a dously small, viruses demonstrate human immune system while allow- challenge––especially in the case of extraordinary latency and patience. ing the host cell to survive.3 Thus, herpes simplex, when the condition Release Date: January 2015 Faculty/Editorial Board: Michael J. Lyons, OD Expiration Date: January 1, 2018 Credit Statement: COPE approval for 2 hours of CE credit is pending Goal Statement: The visual consequence of ocular disease can be for this course. Check with your local state licensing board to see if this painful, devastating and life-long if not treated both promptly and counts toward your CE requirement for relicensure. aggressively. The purpose of this article is not to focus on the different Joint-Sponsorship Statement: This continuing education course is presentations of HSV and VZV, but to describe the antiviral medica- joint-sponsored by the Pennsylvania College of Optometry. tions currently available. It will also offer a glimpse into the future of Disclosure Statement: Dr. Lyons has no relationships to disclose. herpes infection prevention. 50 REVIEW OF OPTOMETRY JANUARY 15, 2015 050_ro0115_f5_osc.indd 50 1/9/15 9:50 AM OPTOMETRIC STUDY CENTER does not exhibit traditional findings. HEDS Gives Prophylactic Treatment a Nod The purpose of this article is not The HEDS study was a set of multicenter, randomized, placebo-controlled trials sponsored by to focus on the different presenta- the National Eye Institute. They were designed to explore some of the questions associated tions of HSV and VZV, but to with the treatment of HSV. Findings relative to antiviral treatment included: describe the antiviral medications • There was no statistically or clinically significant benefit in using oral acyclovir for the currently available. It will also offer treatment of HSV stromal keratitis in patients who received concomitant topical cortico- a glimpse into the future of herpes steroids and trifluridine with regard to time to treatment failure, proportion of patients who infection prevention. failed treatment, number of patients who experienced resolution, time to resolution or six- month best-corrected visual acuity.23 Replication Cycle of Herpes • While the number of patients recruited in this trial was too small to achieve statistically Opinions vary on whether viruses conclusive results, patient outcomes suggest a benefit of oral acyclovir in the treatment of are actually a form of life. Unlike HSV iridocyclitis in those receiving topical corticosteroids and trifluridine prophylaxis.36 most living organisms, viruses have • After ocular HSV resolution within one year, 12 months of treatment with oral acyclovir no cellular structure or metabolism reduces the rate of recurrent ocular and orofacial HSV disease. Long-term antiviral prophylaxis and are unable to self-replicate. is most important for patients with a history of HSV stromal keratitis, because it can prevent However, they do possess DNA and additional episodes and potential loss of vision.37,38 have the ability to evolve through The HEDS illustrated the importance of oral antiviral medications in the treatment of ocular natural selection, making them more HSV disease. However, the study did not account for individualized treatment considerations “life-like.”5 and included just 12 months of follow-up data. It is important to note that a separate research Both simplex and zoster are team showed that long-term oral acyclovir use seems to effectively decrease the number of similar in structure, consisting of a ocular HSV recurrences beyond 12 months.39 Thus, it appears that some strains of ocular HSV double-stranded DNA surrounded disease may benefit from long-term, if not life-long, prophylactic treatment.39 by an icosahedral capsid, with an outer cell membrane containing gly- coproteins, carbohydrates and lipids. 4. Replication. The host’s DNA is rial drugs. This is attributed to the Because they are acellular, viruses used to facilitate viral DNA prolif- behavior of the virus following depend on host cells to provide the eration. attachment to the host. Viruses are structure and metabolism necessary 5. Assembly. New viruses are dependent on the host for growth for replication. formed within the host cell. and replication, so once the virus The primary virus infection starts 6. Release. Viruses exit the host enters the host cell, it becomes part when it binds to and invades a host cell and often experience lysis, result- of the cell’s metabolism, making it cell and then initiates its own DNA ing in cell death. harder to eradicate. replication. After the new viral Additionally, some viruses enter a It is important to note that all components are made, the host cell dormant state and will not immedi- antiviral medications are at least releases new viruses that can infect ately proceed through the entire rep- somewhat toxic to the host cells. other host cells. This type of infec- lication cycle. Viral latency can occur The challenge of creating an effec- tion produces an acute herpetic within weeks of the primary infec- tive antiviral medication is making outbreak that is usually limited by tion, halting the replication of viral it selective for the virus while not the response of the host’s immune DNA inside the host.7 This potential disrupting the host cell too signifi- system.6 outcome is further characterized by cantly. The agent’s ability to perform The replication cycle of the herpes circularization of the viral genome, within these parameters ultimately virus can be summarized into six with only very limited gene expres- determines the clinical usefulness of stages: sion.8 HSV latency usually takes the drug. Most of the antiviral drugs 1. Attachment. Using specialized place in the trigeminal ganglion, and available today are antimetabolites, receptors, the viral cell attaches to VZV latency generally occurs in the which disrupt DNA synthesis, halt the host cell. sensory spinal or cerebral ganglia.6,8 further replication and render the 2. Penetration. The virus enters virus incapable of infecting new the host cell. Treatment Considerations hosts.6 3. Uncoating. This is the process The development of effective anti- The following antiviral medica- of the capsid being removed, releas- viral agents has been much slower tions are listed below in order of ing the DNA into the host cell. than the development of antibacte- development: REVIEW OF OPTOMETRY JANUARY 15, 2015 51 050_ro0115_f5_osc.indd 51 1/9/15 9:50 AM OPTOMETRIC STUDY CENTER Topical agents: HSV and VZV. Vidarabine generally HSV and VZV. It is available in • Idoxuridine. In the early 1950s, is less potent than other available Canada and Europe as a 3% oint- idoxuridine became the first avail- agents, but is still useful in cases of ment, but can be compounded at able topical antiviral medication. It suspected antiviral resistance.10 select pharmacies in the US. It also is was initially developed as an anti- • Trifluridine. This thymidine available as an oral agent. cancer drug.9 analog also was originally developed • Bromodeoxyuridine. This Idoxuridine is a thymidine analog as an anticancer agent.12 Studies agent’s mode of action is similar that inhibits DNA polymerases, have indicated that trifluridine is to that of acyclovir. Bromodeoxy- preventing the incorporation of thy- superior in antiviral efficacy to both uridine is commercially available midine into viral DNA.10 The agent idoxuridine and vidarabine, making in Europe, but not in the US. It is is highly toxic, systemically and topi- it the preferred treatment for infec- important to note that the drug has cally, due to its unselective pairing tious epithelial keratitis.10 But, triflu- been shown to cause liver toxicity.14 with both host and viral DNA. ridine is still toxic to the host cells. • Ganciclovir. Initially approved Today, idoxuridine is available as The agent is available as a 1% for intravenous treatment of a 0.1% solution and 0.5% ointment ocular solution (Viroptic, Monarch cytomegalovirus retinitis in AIDS for topical ocular use, and is avail- Pharmaceuticals), and is effective patients, ganciclovir is now avail- able through compounding pharma- against HSV. able as a 0.15% gel (Zirgan, Bausch cies. The drug is effective against • Acyclovir. Unlike the aforemen- + Lomb). The agent also selectively HSV only. tioned antiviral agents, acyclovir inhibits DNA polymerase in only • Vidarabine. Like idoxuridine, is highly selective and thus far less virus-infected cells. vidarabine was initially developed toxic. Its commercial release in A study published in 1997 as an anticancer drug in 1960.11 1982 marked a profound shift in showed that ganciclovir gel’s thera- The agent also inhibits viral DNA the development of future antiviral peutic efficacy was comparable to polymerase, but this is due to its medications. that of 3% acyclovir ointment, but similarity to adenosine. Vidarabine Acyclovir is guanosine analog, patients tolerated ganciclovir gel is phosphorylated by both host and and like other antiviral agents, it much better.15 viral kinases, but is a more potent requires phosphorylation in order inhibitor of viral DNA polymerase to become activated. However, Oral agents: than host DNA polymerase.6 This acyclovir is only phosphorylated by • Acyclovir. As previously noted, makes the agent safe to use systemi- virus-infected host cells containing acyclovir has become the prototype cally, because it is less toxic to the viral thymidine kinase, making this of antiviral agents due its selective host cell than idoxuridine. significantly more toxic to viruses nature against virus-infected cells. It Vidarabine was once available in than the host.10 Once phosphoryla- is the most frequently prescribed oral the US as a 3% ointment (Vira-A, tion takes place, it selectively inhibits antiviral agent in the United States, Monarch Pharmaceuticals), but was viral DNA synthesis by binding to and has been commercially available discontinued. It is still available on DNA polymerase, resulting in chain for more than two decades. a limited basis as a compounded termination.13 It has demonstrated remarkable ointment. It is effective against both Acyclovir is active against both safety and efficacy against HSV and VZV in both normal and immuno- Growing Concerns of Acyclovir Resistance compromised patients.16 However, HSV’s ever-increasing resistance to antiviral agents is of fundamental concern to both phar- the bioavailability of acyclovir is maceutical researchers and health care providers. Acyclovir resistance has increased with the poor, with just 15% to 30% of the expanded use of antiviral therapy. oral formulation being absorbed.17 Resistance most commonly occurs in immunocompromised patients with chronic and/or In order to achieve better serum progressive infections who’ve been subjected to prolonged or repeated courses of therapy.16 concentrations, higher doses of oral In such patients, an impaired immune system cannot fully suppress viral replication. Hence, acyclovir are required. the remaining medication load is the only means of antiviral activity. Acyclovir is available in 200mg A study published in 2008 showed that 6.4% of viral isolates found in 173 immunocom- capsules and 400mg or 800mg tab- promised patients with herpetic keratitis were resistant to acyclovir.34 In general, antiviral lets (Zovirax, GlaxoSmithKline). resistance should be suspected if the clinical response to therapy is less than that anticipated It is also available in a 200mg/5ml on the basis of prior experience.35 suspension. • Famciclovir. Made available 52 REVIEW OF OPTOMETRY JANUARY 15, 2015 050_ro0115_f5_osc.indd 52 1/9/15 9:50 AM in 1994, famciclovir is a prodrug iridocyclitis and keratitis. HSV kera- of penciclovir. Once famciclovir is titis may be classified into following absorbed, it is rapidly converted to groups and subgroups:10 penciclovir by viral thymidine kinase I. Infectious epithelial keratitis. found in virus-infected cells. a. Corneal vesicles. Similar to acyclovir, famiciclovir b. Dendritic ulcer. inhibits DNA polymerase by com- c. Geographic ulcer. peting with guanosine during viral d. Marginal ulcer. replication. However, the agent is II. Neurotophic keratopathy. approximately 100-fold less potent III. Stromal keratitis. than acyclovir in inhibiting herpes Fluorescein staining of a herpes simplex a. Necrotizing stromal keratitis. virus DNA polymerase activity.16 But keratitis dendrite. b. Immune stromal (interstitial) because of its 65% to 77% bioavail- keratitis. ability and long plasma half-life, it than 48,000 episodes reported annu- IV. Endotheliitis. remains an effective antiviral agent.3 ally.21 For HSV to cause an ocular a. Disciform. Famciclovir is active against HSV infection, it first must enter the body b. Diffuse. and VZV, and is available in 125mg, through mucous membranes or the c. Linear. 250mg or 500mg tablets. skin. The oral route is the most com- • Valacyclovir. Again, acyclovir’s mon pathway, as it provides access Recurrent HSV Disease primary weakness is its poor bio- to the trigeminal ganglion, which Considering the nature of ocular availability. Valacyclovir is a prodrug ultimately leads to ocular infec- HSV, recurrent disease is a signifi- that converts to acyclovir, which tion. Interestingly, the primary HSV cant issue that can lead to devastat- yields the same mechanism of action, infection upon viral entry may be ing visual impairment and life-long antiviral spectrum and resistance asymptomatic, with just 1% to 6% treatment. In 1989, one research profiles as those of its parent drug.16 of infected individuals exhibiting team evaluated 294 episodes of Following oral administration, vala- clinical manifestations.10 ocular HSV infection and reported cyclovir is hydrolyzed by esterases After entry into the host, and recurrence rates of 9.6% at one year, in the gastrointestinal tract and primary infection with viral replica- 22.9% at two years and 63.2% at liver, converting to acyclovir. This tion within the oral mucosa, HSV 20 years. After a second episode, provides a bioavailability exceeding travels in a retrograde fashion to the 70% to 80% of patients had anoth- 50%, which is three to five times trigeminal ganglion via the maxillary er recurrence within 10 years.22 greater than that of oral acyclo- (V2) or mandibular (V3) branch of Additionally, the Herpes Eye Dis- vir.18 It is available in 500mg and the trigeminal nerve (CN V). There, ease Study (HEDS) followed 346 1,000mg tablets. the virus resides in a latent state dur- patients who were diagnosed with ing the host’s lifetime. ocular HSV within the previous year. Herpes Simplex Virus During a period of systemic and/ The HEDS researchers documented HSV is classified as either type or immunologic stress, viral replica- a recurrence rate of 18% for both 1 (HSV-1) or type 2 (HSV-2). tion starts again in the ganglion, epithelial keratitis and stromal kera- Although HSV-1 usually involves resulting in recurrent disease to titis during the 18-month study peri- the oropharynx and HSV-2 usu- the end organ. However, recurrent od (see “HEDS Gives Prophylactic ally involves the genital area, both disease does not have to follow the Treatment a Nod,” page 61). types have been shown to infect same path. In the case of ocular dis- both areas.19 For the purpose of this ease, for example, HSV travels via Antiviral Dosing and review, we will focus on HSV-1, the ophthalmic nerve (V1). Recommendations because it typically is the root cause Many factors have been implicat- Ocular HSV, especially when recur- of associated ocular disease. (An ed in the reactivation of latent HSV, rent, is a complex condition that exception is herpes keratitis in neo- including sunlight exposure, trauma, doesn’t always follow a set of rules. nates, which is caused by HSV-2 in heat, abnormal body temperature, When talking with colleagues from up to 75% of cases.20) menstruation, emotional stress and other practices, I have also found There are an estimated 20,000 the presence of other infections.10 that treatment strategies vary widely. new cases of ocular HSV in the Clinical manifestations of HSV An example of this is the use of oral United States per year, and more include blepharitis, conjunctivitis, vs. topical antiviral medications REVIEW OF OPTOMETRY JANUARY 15, 2015 53 050_ro0115_f5_osc.indd 53 1/9/15 9:51 AM OPTOMETRIC STUDY CENTER conditions: varicella (chickenpox) and herpes zoster (shingles). It is important to distinguish varicella as the primary infection and herpes zoster as the reactivation of latent VZV within the sensory spinal or cerebral ganglia. Serological studies indicate that 95% of the population within the United States has evidence of prior VZV infections.2 The varicella vaccination was introduced in the United States in 1995. Prior to the vaccination, however, approximately four million cases of VZV infection occurred annually in the US, with the peak age of varicella occurrence at five to nine years.2 In fact, before widespread use of the vaccination, This herpes simplex keratitis patient exhibited diffuse iris atrophy. more than 90% of American chil- dren had been infected with varicella in the treatment of HSV epithelial three times per day for seven before age 15.2 Today, however, the keratitis. days. incidence of varicella in the US has One study, for instance, showed Because herpetic infections heal since declined by 57% to 90%.8 that oral acyclovir may be as at different rates, you may need to effective as topical acyclovir, and modify the aforementioned dosing VZV Reactivation thus some practices prefer this regimens. Also, be sure to discon- The risk of developing herpes zos- approach.23 However, I believe that tinue the topical antiviral medication ter is 10% to 30% in the US.24 Prior as long as you have a consistent plan once the ulcer is healed in order to to the introduction of the varicella in place and keep an open mind, you avoid epithelial toxicity. vaccination, the incidence of herpes will be successful in disease control. zoster ranged from 1.2 to 6.5 cases Oral antiviral dosing per 1,000 individuals––with approx- Topical antiviral dosage recommendations: imately 500,000 cases reported recommendations: • Acyclovir annually in the United States.25 Rates • Idoxuridine - Active: 200mg to 400mg five are gradually increasing among - One drop 0.1% solution every times daily. adults in the United States, but no hour while awake. - Suppression: 400mg to 800mg correlation has been found between - Apply 0.5% ointment five twice daily. its increased incidence and the times per day. • Famciclovir advent of the varicella vaccination.26 • Vidarabine ointment - Active: 250mg three times Upon initial infection with vari- - Apply five times per day until daily. cella, VZV is transported from the ulcer is resolved. - Suppression: 125mg to 250mg vesicular lesions by the sensory • Trifluridine twice daily. axons, where it ultimately enters a - One drop nine times per day. • Valacyclovir state of latency in the dorsal roots • Acyclovir ointment - Active: 1,000mg to 3,000mg or trigeminal ganglia. Reactivation - Apply five times per day. daily. of VZV involves an alteration of the • Bromovinyldeoxyeridine - Suppression: 500mg 1,000mg immune system in association with - Not commercially available in daily. age, trauma and/or neural degenera- United States. tion.8 Once reactivated, the virus • Ganciclovir gel Varicella Zoster Virus replicates within the various ganglia - One drop five times per day As we know, varicella-zoster virus and then travel via axonal transport, until ulcer heals, then one drop (VZV) causes two distinct clinical resulting in the characteristic unilat- 54 REVIEW OF OPTOMETRY JANUARY 15, 2015 050_ro0115_f5_osc.indd 54 1/9/15 9:51 AM eral dermatomal eruption of herpes What to Know About HZO zoster. Cranial nerve involvement Herpes zoster ophthalmicus (HZO) results from herpes zoster involvement in the ophthalmic occurs in 13% to 20% of all cases, division of the trigeminal nerve, and can cause eyelid edema, conjunctivitis, episcleritis, scle- with the trigeminal nerve seen most ritis, keratitis and uveitis. If vesicles present at the side or tip of the nose (i.e., Hutchinson’s frequently.27 sign) the patient’s risk of ocular involvement is approximately 50% to 76%.9 If Hutchinson’s sign is absent, however, the risk decreases to just 34%.8 Currently Available The guidelines listed below are appropriate for short-term treatment of acute herpes zoster Vaccinations ophthalmicus: • Varivax (Merck), a live attenuated • Acyclovir: 800mg five times daily for seven to 10 days. vaccine for varicella, received FDA • Famciclovir: 250mg three times daily for seven days. approval in 1995 and was swiftly • Valacyclovir: 1,000mg three times daily for seven days. incorporated into the recommended Keep in mind, however, that the complexity of HZO may necessitate the use of both oral and immunization schedule for children. topical antiviral therapy over an extended period. The vaccine was recommended for any infants, children, adolescents and adults in the US without a his- incidence reduction of 51%, a ment. Once again, I realized I should tory of chickenpox (and without reduced burden of illness zoster by never forget to consider how com- concurrent pregnancy).8 61% and a reduced incidence of mon this virus can be. ■ After nearly two decades of postherpetic neuralgia by 66%.33 Dr. Lyons is a staff optometrist at varicella vaccinations, disease inci- The duration of the vaccine’s protec- the Uveitis and Cornea Clinic at the dence has been reduced by 57% to tive effect is unknown, and currently Cincinnati Eye Institute and a volun- 90%.28-30 Despite these impressive there is no recommendation for a teer faculty member at the University statistics, controversy still surrounds booster vaccination.8 of Cincinnati. He’s also the founder continued use of the vaccine. In of Focal Pointe Eye Care, a private, 2002, one research team speculated The presentation of herpetic ocu- full-service optometric office in West that the use of vaccinations may lead lar disease is highly variable––the Chester, Ohio. to an increase of adult-onset varicella available antiviral treatment, how- and a greater incidence of herpes ever, is not. The visual consequence 1. Xu F, Schillinger JA, Sternberg MR, et al. Seroprevalence and coinfec- 31 tion with herpes simplex virus type 1 and type 2 in the United States, zoster. The researchers contended of ocular disease can be painful, dev- 1988-1994. J Infect Dis. 2002 Apr 15;185(8):1019-24. that intermittent exposure to those astating and life-long if not treated 2. Straus SE. Overview: the biology of varicella-zoster virus infection. Ann Neurol. 1994;35 Suppl:S4-8. with chickenpox might boost immu- both promptly and aggressively. The 3. Yolton D, Haesaert S. Anti-Infective Drugs. In: Bartlett JD, Jannus SD nity levels to both chickenpox and use of antiviral medications plays an (eds.). Clinical Ocular Pharmocology, 5th ed. Philadelphia: Butterworth- 31 Heinemann; 2008:196-205. herpes zoster. important role in disease control. 4. Wander AH, Centifanto YM, Kaufman HE. Strain specificity of Another research group predicted During the creation of this article, clinical isolates of herpes simplex virus. Arch Ophthalmol. 1980 Aug;98(8):1458-61. that there will be an increase in the I encountered a monocular patient 5. Holmes EC. Viral evolution in the genomic age. PLoS Biol. 2007 Oct incidence of herpes zoster over the with a best-corrected visual acuity 2;5(10):e278.. 6. Yolton DP. Anti-Infective Drugs. In: Bartlett JD, Jannus SD (eds.). next five to 40 years, but after that, of 20/200 who manifested extensive Clinical Ocular Pharmocology, 3rd ed. Philadelphia: Butterworth- the overall risk of herpes will decline ocular surface disease from an old Heinemann; 1995:281-9. 32 7. Kollias CM. Animal models of herpes simplex virus immunity and progressively. traumatic injury. His chief complaint pathogenesis. J Neurovirol. 2014 Nov 12. [Epub ahead of print] • Zostavax (Merck) was approved was a further visual decrease in his 8. Lee WB, Liesegang TJ. Herpes Zoster Keratitis. In: Krachmer JH, Mannis MJ, Holland EJ (eds.). Cornea, 3rd ed. St. Louis: Mosby; in 2006 as an immunization booster only functioning eye. The presenta- 2011:985-1000. for the prevention of herpes zoster tion was far from typical, with severe 9. Kaufman HE, Rayfield MA. Viral conjunctivitis and keratitis: herpes simplex virus. In: Kaufman H (eds.). The Cornea. New York: Churchill in immunocompetent individuals 60 surface inflammation and corneal Livingstone; 1988. years and older with no prior history edema, but no ulceration or intra- 10. Holland EJ, Schwartz GS, Neff KD. Herpes Simplex Keratitis. In: Krachmer JH, Mannis MJ, Holland EJ (eds.). Cornea, 3rd ed. St. Louis: of herpes. It is not indicated in those ocular inflammation. Mosby; 2011:953-84. with prior herpes zoster, because an My initial thought was severe 11. Sneader W. Drug discovery: a History. New York: Wiley; 2005:258. 12. Kaufman HE, Heidelberger C. Therapeutic antiviral action of 5-triflu- outbreak naturally boosts the immu- stem cell disease with neurotrophic oromethyl-2’-deoxyuridine. Science. 1964 Aug 7;145(3632):585-6. nity. Zostavax is made of the same keratopathy—but then I asked 13. Elion GB. The biochemistry and mechanism of action of acyclovir. J Antimicrob Chemother. 1983 Sep;12 Suppl B:9-17. modified virus as Varivax, but given myself: “Could it be herpes?” 14. Liesegang T. Diagnosis and therapy of herpes zoster ophthlamicus. at a higher dosage. On follow-up several days later, Ophthalmology. 1991 Aug;98(8):1216-29. 15. Colin J. Ganciclovir ophthalmic gel (Virgan; 0.15%) in the treatment The Shingles Prevention Study a disciform appearance evolved and of herpes simplex keratitis. Cornea. 1997 Apr;16(4):393-9. reported an overall herpes zoster I immediately began antiviral treat- 16. Kimberlin DW, Whitley RJ. Antiviral therapy of HSV-1 and -2. In: REVIEW OF OPTOMETRY JANUARY 15, 2015 55 050_ro0115_f5_osc.indd 55 1/9/15 9:51 AM OPTOMETRIC STUDY CENTER Arvin A, Campadelli-Fiume G, Mocarski E (eds.). Human Herpesviruses: Dec;101(12):1871-82. varicella zoster virus. J Infect. 2002 May;44(4):211-9. Biology, Therapy, and Immunoprophylaxis. Cambridge: Cambridge 24. Liesang TJ. The varicella-zoster virus disease. Contemp Ophthalmol. 32. Quirk M. Varicella vaccination reduces risk of herpes zoster. Lancet University Press; 2007:1153-74. 2006;5:1-7. Infect Dis. 2002 Aug;2(8):454. 17. Wagstaff AJ, Faulds D, Goa KL. Aciclovir. A reappraisal of its antiviral 25. Jumaan AO, Yu O, Jackson LA. Incidence of herpes zoster, before 33. Oxman MN. A vaccine to prevent herpes zoster and postherpetic activity, pharmacokinetic properties and therapeutic efficacy. Drugs. and after varicella-vaccination-associated decreases in the incidence of neuralgia in older adults. N Engl J Med. 2005 Jun 2;352(22):2271-84. 1994 Jan;47(1):153-205. varicella, 1992-2002. J Infect Dis. 2005 Jun 15;191(12):2002-7. 34. Duan R. Acyclovir-resistant corneal HSV-1 isolates from patients 18. Soul-Lawton J, Seaber E, On N, et al. Absolute bioavailability and 26. Leung J, Harpaz R, Molinari NA, et al. Herpes zoster incidence with herpetic keratitis. J Infect Dis. 2008 Sep 1;198(5):659-63. metabolic disposition of valaciclovir, the L-valyl ester of acyclovir, fol- among insured persons in the United States, 1993-2006: evaluation of 35. Kimberlin DW, Crumpacker CS, Straus SE, et al. Antiviral resistance lowing oral administration to humans. Antimicrob Agents Chemother. impact of varicella vaccination. Clin Infect Dis. 2011 Feb 1;52(3):332-40. in clinical practice. Antiviral Res. 1995 Apr;26(4):423-38. 1995 Dec;39(12):2759-64. 27. Liesegang TJ. Herpes zoster ophthalmicus natural history, risk 36. The Herpetic Eye Disease Study Group. A controlled trial of oral acy- 19. Obara Y. Distribution of herpes simplex virus types 1 and 2 genomes factors, clinical presentation, and morbidity. Ophthalmology. 2008 clovir for iridocyclitis caused by herpes simplex virus. Arch Ophthalmol. in human spinal ganglia studies by PCR and in situ hybridization. J Med Feb;115(2 Suppl):S3-12. 1996 Sep;114(9):1065-1072. Virol. 1997 Jun;52(2):136-42. 28. Zhou F, Harpaz R, Jumaan AO, et al. Impact of varicella vaccination 37. Herpetic Eye Disease Study Group. Oral acyclovir for herpes simplex 20. Waggoner-Fountain LA, Grossman LB. Herpes simplex virus. Pediatr on health care utilization. JAMA. 2005 Aug 17;294(7):797-802. virus eye disease: effect on prevention of epithelial keratitis and stromal Rev. 2004 Mar;25(3):86-93. 29. Marin M, Meissner HC, Seward JF. Varicella prevention in the keratitis. Arch Ophthalmol. 2000 Aug;118(8):1030-6. 21. Liesang TJ, Melton J III, Daly PJ, Ilstrup DM. Epidemiology of ocular United States: a review of successes and challenges. Pediatrics. 2008 38. Herpetic Eye Disease Study Group. Acyclovir for the prevention herpes simplex. Arch Ophthalmol. 1989;107:1155-9. Sep;122(3):e744-51. of recurrent herpes simplex virus eye disease. N Engl J Med. 1998 22. Liesang TJ. Epidemiology of ocular herpes simplex. Arch Ophthal- 30. Weinmann S, Chun C, Schmid DS, et al. Incidence and clinical May;339(5):300-6. mol. 1989;107:1160-5. characteristics of herpes zoster among children in the varicella vaccine 39. Uchoa UB. Long-term acyclovir use to prevent recurrent ocular her- 23. Barron BA. Herpetic eye disease study. A controlled trial of oral era, 2005-2009. J Infect Dis. 2013 Dec 1;208(11):1859-68. pes simplex virus infection. Arch Ophthalmol. 2003 Dec;121(12):1702- acyclovir for herpes simplex stromal keratitis. Ophthalmology. 1994 31. Edmunds WJ. The effect of vaccination on the epidemiology of 4. OSC QUIZ ou can obtain transcript-quality con- 4. What is the correct order of the herpetic 8. What is the primary factor that determines tinuing education credit through the life cycle? the success of an antiviral medication? YOptometric Study Center. Com plete a. Attachment, assembly, release, uncoating, a. Its potency. the test form (page 67), and return it with penetration and replication. b. Its half-life. the $35 fee to: Optometric CE, P.O. Box 488, b. Uncoating, replication, release, attachment, c. Its ability to inhibit the virus while preserv- Canal Street Station, New York, NY 10013. penetration and assembly. ing the host cells. To be eligible, please return the card within c. Attachment, penetration, uncoating, replica- d. The ability to inhibit both HSV and VZV. one year of publication. tion, assembly and release. You can also access the test form and d. Penetration, uncoating, replication, release, 9. What was the first antiviral medication submit your answers and payment via credit assembly and attachment. developed? card at Review of Optometry online, www. a. Acyclovir. reviewofoptometry.com. 5. Which cranial nerve is most frequently asso- b. Idoxuridine. You must achieve a score of 70 or higher ciated with reactivation of herpes simplex? c. Bromovinyldeoxyeridine. to receive credit. Allow eight to 10 weeks a. Optic. d. Vidarabine. for processing. For each Optomet ric Study b. Trigeminal. Center course you pass, you earn 2 hours of c. Oculomoter. 10. Many of the early antiviral medications transcript-quality credit from Pennsyl vania d. Trochlear. were originally designed to be: College of Optometry and double credit a. Anticancer drugs. toward the AOA Optom et ric Recog nition 6. Which statement is true with regard to the b. Antibiotic drugs. Award—Cate gory 1. development of antiviral medications? c. Antifungal drugs. Please check with your state licensing a. Antivirals are difficult to develop due to the d. Antiemetic drugs. board to see if this approval counts toward virus’ ability to become part of the host cell’s your CE requirement for relicensure. metabolism. 11. Most antiviral medications work by: b. There have been many more antiviral a. Inhibiting viral DNA replication. 1. Common characteristics of VZV and HSV medications developed than antibacterial b. Inhibiting host DNA replication. include: medications. c. Lysing host cells that contain viral DNA. a. The ability to remain latent in host nerve c. Antiviral medications typically disrupt the d. Preventing attachment of viral cells to host cells. penetration of the virus into the host cells. cells. b. The ability to produce a variety of ocular d. The most favorable antiviral medications conditions. are those that are non-selective against the 12. Which topical antiviral medication is c. The ability to produce recurrent ocular viral and host cells. known to cause significant liver toxicity? disease. a. Idoxuridine. d. All of the above. 7. What statement about antiviral medications b. Vidarabine. is true? c. Trifluridine. 2. Ocular herpes infections can present in a. All antiviral medications are commercially d. Bromodeoxyuridine. many different fashions; however, the clinical available in the US. manifestation generally is determined by: b. All antiviral medications yield some toxicity 13. Valacyclovir is a prodrug of: a. The nature of the host. on the host cells. a. Acyclovir. b. The nature of the virus. c. All antiviral medications are effective b. Penciclovir. c. The time of year. against HSV and VZV. c. Famciclovir. d. Both a and b. d. All antiviral medications are clinically effec- d. Ganciclovir. tive as either topical or oral formulations. 3. Herpes viruses: 14. Most herpetic ocular infections are caused a. Have the ability to self-reproduce. by: b. Possess unique cells for their metabolism. a. HSV-1. c. Are independent of host cells. b. HSV-2. d. Possess DNA. c. Cytomegalovirus. d. Epstein-Barr virus. 56 REVIEW OF OPTOMETRY JANUARY 15, 2015 050_ro0115_f5_osc.indd 56 1/9/15 9:51 AM OSC QUIZ Examination Answer Sheet Valid for credit through January 1, 2018 15. How many new cases of ocular HSV are This exam can be taken online at www.revoptom.com/continuing_education. Upon passing the exam, reported in the United States each year? you can view your results immediately and download a real-time CE certificate. You can also view your a. 5,000. test history at any time from the website. b. 10,000. c. 20,000. Going Antiviral: How to Bring Herpes to a Halt d. 40,000. Directions: Select one answer for each question in the exam and completely darken the 16. Since the development of the varicella appropriate circle. A minimum score of 70% is required to earn credit. vaccination in 1995: a. There has been a reduction in the number Mail to: Jobson - Optometric CE, PO Box 488, Canal Street Station, New York, NY 10013 of zoster outbreaks. Payment: Remit $35 with this exam. Make check payable to Jobson Medical Information LLC. b. There has been an increase in the number COPE approval for 2 hours of CE credit is pending for this course. of hospitalizations due to severe outbreaks This course is joint-sponsored by the Pennsylvania College of Optometry of varicella. c. There has been no statistical difference in the number of varicella outbreaks. There is an eight-to-ten week processing time for this exam. d. Varicella incidence has been significantly 1. A B C D 1 = Excellent 2 = Very Good 3 = Good 4 = Fair 5 = Poor reduced. 2. A B C D Rate the effectiveness of how well the activity: 3. A B C D 17. The development Zostavax (Merck) has 4. A B C D 21. Met the goal statement: 1 2 3 4 5 resulted in: A B C D 1 2 3 4 5 a. An increase in postherpetic neauralgia. 5. 22. Related to your practice needs: b. A reduction in the incidence and severity 6. A B C D 23. Will help you improve patient care: 1 2 3 4 5 of herpes zoster. 7. A B C D 24. Avoided commercial bias/influence: 1 2 3 4 5 c. Multiple boosters needed to maintain the 8. A B C D 25. How would you rate the overall protective effect of the vaccination. 9. A B C D quality of the material presented? 1 2 3 4 5 d. An increase in the reported cases of 10. A B C D 26. Your knowledge of the subject was increased: varicella. 11. A B C D Greatly Somewhat Little 12. A B C D 27. The difficulty of the course was: 18. The Herpetic Eye Disease Study (HEDS) 13. A B C D Complex Appropriate Basic showed that: 14. A B C D How long did it take to complete this course? a. Oral acyclovir is probably beneficial in the 15. A B C D treatment of iridocyclitis. 16. A B C D Comments on this course: b. Oral acyclovir dramatically enhances the 17. A B C D recovery from HSV stromal keratitis when 18. A B C D used with topical corticosteroids and triflu- 19. A B C D Suggested topics for future CE articles: ridine. 20. A B C D c. Use of oral acyclovir for 12 months does not reduce the number of recurrent HSV episodes. d. Oral valacyclovir was far superior to acy- Please retain a copy for your records. Please print clearly. clovir in treatment of HSV disease. First Name 19. What clinical presentation suggests a Last Name patient with herpes zoster likely will experi- ence ocular involvement? E-Mail a. Liesegang rings. The following is your: Home Address Business Address b. Vortex keratopathy. c. Hutchinson’s sign. Business Name d. Von Graefe’s sign. Address 20. What is the recommended dosage for the treatment of herpes zoster ophthalmicus City State (HZO)? a. Valtrex 500mg QD. ZIP b. Valtrex 1,000mg QD. Telephone # - - c. Valtrex 500mg TID. d. Valtrex 1,000mg TID. Fax # - - By submitting this answer sheet, I certify that I have read the lesson in its entirety and completed the self- assessment exam personally based on the material presented. I have not obtained the answers to this exam by any fraudulent or improper means. Signature Date TAKE THE TEST ONLINE TODAY! www.reviewofoptometry.com/ Lesson 110890 RO-OSC-0115 continuing_education/ REVIEW OF OPTOMETRY JANUARY 15, 2015 57 050_ro0115_f5_osc.indd 57 1/9/15 9:51 AM Uveitis Practical Pearls for Managing Anterior Uveitis When diagnosing uveitis, let the history and signs guide your treatment plan. By Kyle D. Dohm, OD he uvea, a highly vascu- changeably. The most common Disease Classification, larized section of the eye form of this disease is nongranulo- Workup and Diagnosis located beneath the sclera, matous anterior uveitis, which can When diagnosing anterior uveitis, Tsupplies most of the ocular present as unilateral or bilateral; you must consider a variety of structures with nutrients via the chronic or acute; and idiopathic, presenting signs and associated anterior and posterior branches of infectious, immunological or neo- features. As previously noted, char- the ophthalmic artery. plastic. acteristic symptoms include pain The uvea consists of the iris, Classic symptoms include red- in the form of a dull ache, redness ciliary body and choroid. The iris ness, photophobia and pain often and photophobia. Visually, the controls how much light enters the described as dull ache; however, customary ciliary flush (circum- eye, while the ciliary body produces with chronic forms of the disease, limbal flush) is often seen and the aqueous humor and controls its these symptoms may be completely pupil may be mid-dilated. For an outflow by contracting and widen- absent. Often, a sufficient medical official diagnosis, however, cells ing the trabecular meshwork. The and ocular history can reveal the must be seen in the anterior cham- ciliary body also controls accom- precipitating cause, although even ber, and flare may or may not be modation by contracting and relax- laboratory testing cannot uncover present. It is important to note that ing. the underlying etiology in every flare sometimes can be seen in the The third element, the choroid, instance. anterior chamber when no active is a highly vascularized and pig- Regardless, it is important to inflammation is present, because mented tissue that provides nour- properly classify the uveitis in order long-standing, chronic uveitis dam- ishment to the outer retinal layers to correctly diagnose and treat ages the vasculature integrity of the and absorbs excess light. Inflam- the patient, thus eliminating the iris and ciliary body.1 mation of any of these structures is potential for further complications, To properly diagnose and man- known as uveitis. including blindness. This article age uveitis, you must first cat- One synonym of uveitis is iritis, will review typical signs and symp- egorize it. Anterior inflammation and although iritis is more techni- toms of anterior uveitis, as well as confined to the iris and anterior cally and anatomically specific, discuss essential treatment consid- chamber is termed iritis. When the clinicians often use the terms inter- erations. inflammation also involves the 58 REVIEW OF OPTOMETRY JANUARY 15, 2015 058_ro0115_f6.indd 58 1/8/15 1:27 PM ciliary body, as evidenced by the presence of anterior vitreous cells, it is called iridocyclitis. However, when only the ciliary body is inflamed, it is simply called cyclitis (although this is not usually a clini- cally significant term). Intermediate uveitis, or pars planitis, involves inflammation of the pars plana, the middle portion of the ciliary body. Aggregates of white blood cells, or Fig. 1. Small, resolving mutton-fat keratic Fig. 2. Fine KPs on the endothelium in snowball opacities, accumulated precipitate (KP) in granulomatous uveitis. non-granulomatous uveitis. near the inferior retina are typically seen in pars planitis.1 tion, “granulomatous” typically the correct etiology of the uveitis Posterior uveitis involves inflam- refers to a more severe form of without any further testing or labo- mation in the posterior segment, uveitis, with distinctive features like ratory studies. (See “Derivation of including the retina, choroid, vitre- iris granulomas, Koeppe nodules on Uveitis Etiology from Ocular His- ous and sometimes sclera, while the pupillary margin, Busacca nod- tory,” page 60.)1 pan-uveitis involves all structures of ules in the iris stroma and keratic The “Nine I system,” which the uvea in addition to adjacent tis- precipitates (KPs) on the corneal categorizes inflammation of ocular sues. It should be noted the further endothelium that are large, globular tissues into a specific heading, is posterior the uveitis proceeds in the and greasy, known as mutton-fat another useful classification instru- eye, the greater the risk of associ- KPs (figure 1).1-3,5 A hypopyon may ment (see “The Nine ‘I’ System,” ated systemic disease, the more form in the anterior chamber if the page 62) Any of the nine “I’s” can difficult it will be to treat, and the inflammation goes unchecked. be the root cause of uveitis, with greater the risk of complications. In Common granulomatous uveiti- up to 38% of the cases being idio- any case, the difference between the des include tuberculosis, sarcoidosis pathic.6 specific semantics helps the doctor and Lyme disease.2 Nongranulo- with clinical diagnosis and directs matous ocular inflammation, on Bloody Cues attention to the appropriate areas the other hand, is less severe and is Acute nongranulomatous uveitis of concern. characterized by smaller KPs (fig- can be associated with the human A “name meshing” strategy (see ure 2), fewer (if any) nodules and leukocyte antigen B27 (HLA-B27). “Name Meshing System for Uve- decreased probability of synechiae Additional entities that can be itis Diagnosis,” below) is one tool formation (figures 3 and 4).2,3 Over- linked to HLA-B27 include Reiter that can be used to focus clinical all, granulomatous uveitis is more syndrome, inflammatory bowl thought and provide a tailored, likely to be associated with systemic disease (i.e., ulcerative colitis or cost-effective evaluation and man- disease and more difficult to treat Crohn’s disease), ankylosing spon- agement of the patient’s disease.2-4 with greater risk for complications dylitis, Behçet disease and psoriatic The uveitic entity should be broken than nongranulomatous uveitis. arthritis.1,6,7 These entities are usu- down by its location, duration, Frequently, a specific ocular his- ally anterior and unilateral. Other pathology and laterality.1-4 tory—in conjunction with a careful acute nongranulomatous uveitides In reference to ocular inflamma- slit lamp examination—can lead to include Lyme disease and trauma. Common chronic nongranulo- matous entities include juvenile Table 1. Name Meshing System for Uveitis Diagnosis rheumatoid arthritis and Fuchs’ 3,4,6 LOCATION DURATION PATHOLOGY LATERALITY heterochromic iridocyclitis. Chronic uveitis is usually less Anterior Acute Granulomatous Unilateral Posterior Chronic Nongranulomatous Bilateral symptomatic than acute presenta- tions. Although syphilis is typically Intermediate Recurrent lumped into chronic granulomatous Pan uveitis along with sarcoidosis and REVIEW OF OPTOMETRY JANUARY 15, 2015 59 058_ro0115_f6.indd 59 1/8/15 1:27 PM Uveitis tuberculosis, it can present in any of • C-reactive protein (CRP) is a nemal tests are available, such as the categories as a masquerader.4,6 marker for inflammation and serves microhemagglutination-Treponema Posterior uveitides include as a treatment response monitor.2,4 pallidum (MHA-TP), Treponema tuberculosis, toxoplasmosis, CPR tests are unable to determine pallidum particle agglutination histoplasmosis, sarcoidosis and the cause or location of the inflam- assay (TP-PA) and Treponema herpes––although herpes is often mation within the body, however. pallidum hemaglutination assay anterior as well.3,6 Although usually • Erythrocyte sedimentation (TPHA), but are not as commonly posterior, any form of posterior rate (ESR) is typically ordered in known in the eye care communities uveitis can rarely present anteriorly. conjunction with a CRP test. An as FTA-ABS. An entity that may be miscatego- ESR helps detect inflammation and Both RPR and VDRL typically rized as idiopathic anterior uveitis serves as a monitor for the underly- register positive in primary and is glaucomatocyclitic crisis (i.e., ing etiology. secondary syphilis and negative in Posner-Schlossman syndrome).1 • Antinuclear antibody (ANA) tertiary (latent) syphilis and after This is classically a white eye with testing screens for certain autoim- successful treatment of the disease.4 a mild anterior chamber reaction mune disorders like systemic lupus RPR is commonly chosen over and highly elevated IOP (30mm erythematosus, scleroderma, juve- VDRL because it is both easier to Hg to 60mm Hg). It tends to be nile arthritis, polymyosistis, inflam- administer and less expensive. False unilateral, recurrent and relatively matory bowel disease and psoriasis. positives can occur, however, with asymptomatic.1,5 • Rheumatoid factor (RF) testing both tests. Entities that may disrupt Blood studies often must be can help you diagnose rheumatoid the accuracy of the results include ordered in cases where the history arthritis and Sjögren’s syndrome, but are not limited to tuberculosis, and physical examination do not among others that sometimes over- malaria, lymphoma, lupus, Lyme lead to a definitive diagnosis––espe- lap with ANA testing. disease, viral infections, connective cially in the presence of bilateral, • Rapid plasma regain (RPR), tissue diseases, IV drug use and granulomatous or recurrent uve- venereal disease research labora- pregnancy. itis.6 The “shotgun” approach is tory (VDRL) and fluorescent trepo- • Angiotensin-converting costly, nonspecific and can easily be nemal antibody absorption test enzyme (ACE) supports a sarcoid- avoided with astute clinical skills. (FTA-ABS) are used to screen for osis diagnosis and helps to monitor Here are some of the most com- syphilis. The FTA-ABS is a 24-hour disease activity during treatment. mon laboratory tests used to help test used to detect antibodies to the A serum lysozyme test can also be localize the etiology of uveitis:6-8 bacteria Treponema pallidum and used to test for sarcoidosis. • Complete blood count (CBC) confirm the presence of syphilis. • Chest X-ray (CXR) or com- with differential helps to determine FTA-ABS does not indicate if the puted tomography (CT) scan is the patient’s general health status, disease is active or inactive, how- also helpful when investigating for and can aid in diagnosing a variety ever, and is typically administered tuberculosis or sarcoid nodules in of disorders, such as anemia, infec- after a screening test for active dis- the lungs.6 Normally, when I order tion and leukemia. ease, RPR or VDRL. Other trepo- a CXR to rule out sarcoid, I will Table 2. Derivation of Uveitis Etiology from Ocular History1,3 Onset Course Symptoms Treatment Ocular History Past occurrences Trauma Surgery Past treatments Medical History Illnesses Medications Social History Drug use Sexual history Dietary habits Family History Maternal infections Contagious diseases History of uveitis Illnesses Geographic History Birthplace Foreign travel Other locations (i.e., Ohio) Demographic History Age Gender Race Review of Systems General, Derm, Rheum, Neuro, Resp, GI, GU, Musc-skel 60 REVIEW OF OPTOMETRY JANUARY 15, 2015 058_ro0115_f6.indd 60 1/8/15 1:27 PM request posterior-anterior and lat- Atropine and other similar cyclo- eral (PA/LAT) images. In any case, plegics/mydriatics play an integral it is important to annotate what role in all four objectives.4 Cyclo- you are looking for (i.e., rule out plegic agents act on the vasculature sarcoid nodules in setting of bilat- to help stabilize the blood-aqueous eral uveitis) to help direct the radi- barrier, preventing further leak- ologist in his or her examination. age. By immobilizing the iris, along In a hospital setting, it is also para- with their action in ciliary muscle mount when ordering these tests to paresis, cycloplegics not only help engage the patient’s primary care with pain control, but their dilat- physician (PCP) or appropriate spe- Fig. 3. Area of posterior synechia (iris ing effect is equally important in cialist if abnormalities are found. adhered to lens), with dilated stromal thwarting angle closure and pupil- For eye doctors who do not have iris vasculature. lary block by averting iris to lens access to labs or imaging, sending adhesion. Corticosteroids (usually the patient to his or her PCP with Management of topical for most cases of anterior exact recommendations of what Non-Traumatic Uveitis uveitis) reduce the body’s inflam- tests to order and why will aid in First episodes of mild, unilateral iri- matory response and are a mainstay expediency for the patient and help tis are often idiopathic and associ- in iritis care. They also help reduce guide the PCP who relies on your ated with a viral or sinus infection, capillary permeability and vasodila- expertise for ophthalmic conditions. or traumatic event. Further diag- tion.4,7,13 • Human leukocyte antigen B27 nostic testing usually can be curbed, Other therapeutic options include (HLA-B27) is found on the surface because observation and treatment nonsteroidal anti-inflammatory of white blood cells and is associ- of symptoms is typically sufficient drugs (NSAIDs), immunosuppres- ated with a number of autoimmune in these low-risk cases.2 Depend- sive/immunomodulatory agents disorders, such as ankylosing spon- ing on the severity of inflammation and surgical options (e.g., laser dylitis and Reiter syndrome. It is with a traumatic iritis case, anti- peripheral iridotomy or periocular not necessarily a specific marker for inflammatory medicines sometimes implant).2,3,9,12 Corticosteroid use in any one disease, however, and can can be withheld. However, sound uveitis normally needs to be tapered actually be the singular determining clinical judgment must be exercised in order to prevent rebound inflam- factor in some iritis cases.4 when determining if and when mation. • Purified protein derivative medication use is necessary. Early, frequent steroidal admin- (PPD) tests for latent tuberculosis. For any therapeutic endeavor, a istration classically is prescribed to • Lyme titre and enzyme-linked specific treatment goal is key. Obvi- guarantee a suitable loading dose immunosorbent assay (ELISA), ously, increasing patient comfort in order to aggressively quell the together with anti-Borrelia burg- is paramount in uveitis care. The inflammation. Tapering appropri- dorferi immunoglobulins M and G fundamental purpose in uveitis ately, according to clinical response, (IgM/IgG), are used to detect the management hinges on reducing ensures the proper remission of presence of Lyme disease. ELISA inflammation, thus decreasing mor- the uveitis without a rebound of also can be used to detect HIV, as bidity and the likelihood of other, inflammation.3 However, if a ste- can the Western Blot test.2,7 more serious complications, such as roid is prescribed in traumatic uve- Other uncommon tests for uveitis vision loss and glaucoma. itis, it is generally over a brief time that may have relevance in certain In light of these goals, four main period, eliminating the necessity patient presentations include a objectives should be considered of medication tapering––especially Sjögren’s antibody (SS-A, SS-B) when treating an iritis patient: since the inflammatory stimulus profile, urinalysis and a search for • Decrease pain. (trauma) is gone. viral entities like cytomegalovirus • Prevent posterior synechiae and Increased IOP and posterior (CMV) IgG/IgM antibodies. Recall thus pupillary block. subcapsular cataract (PSC) are two from immunology that IgG repre- • Prevent peripheral anterior syn- primary concerns associated with sents past exposure or immunity to echiae (PAS) and thus angle closure. corticosteroid use; however, these a disease, and IgM represents recent • Re-establish the blood-aqueous complications are not routinely seen exposure or likely active infection. barrier. following short-term use. Likewise, REVIEW OF OPTOMETRY JANUARY 15, 2015 61 058_ro0115_f6.indd 61 1/8/15 1:28 PM Uveitis Table 3. The Nine ‘I’ System2 ting the administration frequency in Inflammatory Autoimmune diseases half every third day. For milder presentations, Infectious Known pathogens loteprednol etabonate gel 0.5% Infiltrative Neoplastic processes administrated at a less frequent Injurious Trauma dosing schedule might be best. For more severe or recalcitrant cases, Iatrogenic Surgery, medications and accidental trauma however, difluprednate ophthalmic Inherited Metabolic and dystrophic diseases emulsion 0.05% QID or Q2H may Ischemic Impaired circulation be appropriate. Some patients may even require oral corticosteroids; Involutional Age-related a common choice is prednisone, Idiopathic Unknown which usually is dosed between 20mg to 40mg at a frequency of increased IOP with concurrent before the trabecular meshwork BID to QID for several days. When corticosteroid use does not always has totally phagocytized the white prescribing oral corticosteroids, mean that the steroid is the cause blood cells and fibrinous protein take note of any systemic illnesses, of the elevation. In uveitis, IOP remnants from the drainage angle.4 as well as other medications that generally is lower than normal–– Prematurely stopping the steroid the patient is using, in case of side although in some cases, it can be treatment prior to complete inflam- effects or interactions between the higher than normal, depending on matory resolution may, in fact, do different medicines. when in the disease process the more harm than good; instead, the As such, you may want to con- patient presents for care.1,4,11 Two steroid treatment should be main- sult with the patient’s PCP prior possible reasons for decreased IOP tained and an IOP-lowering medi- to prescribing oral corticosteroids. include:1,4 cation (i.e., aqueous suppressant), Consideration also should be given • An increase in the release of such as a beta-blocker or carbonic to prescribing an antihistamine that endogenous prostaglandins aug- anhydrase inhibitor, should be acts to inhibit stomach acid produc- ments uveoscleral outflow. added. tion, such as ranitidine (Zantac, • A decrease in aqueous humor It is important to note prosta- GlaxoSmithKline), in order to pre- production by the inflamed ciliary glandin analogs and miotics should vent gastrointestinal upset. At the body.1,4 be avoided in uveitis, because they very least, ensure the patient takes Potential explanations for may increase inflammation.8,10-12 the oral corticosteroid with some increased IOP include: Miotics also increase the risk of food or milk. • Clogging of the trabecular posterior synechiae formation.1 As previously mentioned, cyclo- meshwork with inflammatory cells Adrenergic agonists, such as brimo- plegics, such as homatropine 5.0% and protein. nidine and apraclonidine, generally or atropine 1.0%, are necessary • Trabeculitis, or inflamed, swol- are safe to use in uveitis patients for proper uveitis management. A len meshwork fibers. with increased IOP. common approach may include • Posterior synechiae. When dealing with anterior uve- one drop of homatropine 5% TID • Peripheral anterior synechiae. itis, the exact dosing schedule is for three days, BID for two days • Steroid-induced IOP elevation. more art than science, as each case and QD for one day; however, an • The fact that the “sick” eye is can present differently and slightly extended period over several weeks returning to normal. nuanced strategies can produce may need to be employed for more An IOP rise can occur during the similar, positive results. One typi- severe cases. Remember, because corticosteroid treatment period, cal treatment protocol includes the the eye is inflamed, a dosing strat- but it is not always secondary to administration of one drop of pred- egy that is greater than the half-life the side effects of the corticosteroid nisolone acetate 1.0% every hour of the medication will be needed. itself. As such, the term “steroid- for two to three days, or until mild This is because the medicine is responder” is sometimes wrongly cells (< grade 2) are seen. Then, being metabolized at a much faster attributed to the healing eye’s nor- planned tapering of the steroid can rate in a sick eye. Depending on malization of aqueous production be accomplished by continually cut- severity, the patient should return 62 REVIEW OF OPTOMETRY JANUARY 15, 2015 058_ro0115_f6.indd 62 1/8/15 1:27 PM for a follow-up visit in two to five in an expedited manner. days initially, then as needed. Iritis can range from mild to severe, with vision loss and Management of even blindness occurring if left Traumatic Uveitis untreated. Most cases of iritis that The frequency of uveitis in the present to the primary eye doctor United States matches international are localized anteriorly, mild to numbers at approximately 15 cases moderate in severity and relatively per 100,000 persons.6,7 Trauma is simple to manage. The prognosis the third most common cause of generally is favorable with appro- anterior uveitis.6,7 Morbidity gener- Fig. 4. Posterior synechia partly broken priate treatment and follow-up ally results from symptoms, pos- after instillation of phenylephrine 10% regimens; the pillars for proper terior synechiae, cystoid macular and atropine 1%. management remain corticoste- edema, increased IOP with resul- roids and cycloplegics. Bilateral tant glaucoma, cataract formation medications (i.e., beta-blockers) and recurrent cases may need and retinopathy.4,6,9 Other compli- also should be instituted if IOP is further investigation into the etiol- cations associated with traumatic elevated significantly. Prostaglan- ogy. Overall, it is vital to educate iritis include hyphema, iridodialy- dins and miotics should be avoided, patients about symptoms and the sis, iridoschisis, lens dislocation because they can add to the inflam- importance of future periodic eye and/or opacification, commotio matory effect.8,10-12 examinations to monitor for com- retinae, optic neuropathy, poste- Angle recession is noted if there plications. ■ rior vitreous detachment, retinal is an uneven iris insertion posteri- Dr. Dohm is the department tears and detachments, choroidal orly, allowing a larger-than-normal head of optometry and the associ- rupture, corneal edema and angle band of ciliary body to be seen.8 ate director for medical services at recession.5,9-11 This can be confirmed if the con- Naval Hospital Oak Harbor on Hyphema, if present, is a serious tralateral eye’s gonioscopic find- Naval Air Station Whidbey Island condition requiring close monitor- ings are normal. Angle recession in Oak Harbor, Wash. He has no ing. Patients are typically confined does not always occur with blunt direct financial interests in any of to bed rest with limited activity, trauma, and––if present––does not the products mentioned. where their head should be elevated always produce an elevated IOP at at least 30° and a shield placed over onset. However, microscopic dam- 1. Yanoff M, Duker JS (eds.). Ophthalmology, 2nd ed. St. Louis: Mosby; 2004. the eye for enhanced protection. age to the trabecular meshwork 2. Medscape. Uveitis Classification. Available at: http:// Patients should avoid aspirin, but endothelial cells is possible, with emedicine.medscape.com/article/1208936-overview. Accessed November 8, 2012. can take acetaminophen for pain as resultant IOP increase years after 3. Smith RE, Nozik RM. Uveitis: A Clinical Approach to Diag- needed. the initial trauma.8,10 Regular eye nosis and Management. Baltimore: Williams & Wilkins; 1983. 4. Harkins TJ. Personal communication. Kansas City Veterans Atropine 1.0% should be examinations are needed to moni- Administration Medical Center; Kansas City, MO. Aug-Dec instilled QD to TID and predniso- tor these patients for future compli- 2005. 5. Gold DH. Clinical Eye Atlas. Chicago: AMA Press; 2002. lone acetate 1.0% dosed Q2H to cations. 6. Medscape. Iritis and Uveitis. Available at: http://emedicine. QID. Oral aminocaproic acid, an medscape.com/article/798323-overview. Accessed November 10, 2012. antifibrinolytic, also should be Uveitis may present concurrently 7. Medscape. Uveitis evaluation and treatment. Available at: administered, depending on the with other morbidities. There- http://emedicine.medscape.com/article/1209123-overview. 10-12 Accessed November 10, 2012. size of the hyphema. fore, it is prudent to be thorough 8. Kunimoto DY. The Wills Eye Manual: Office and Emergency Laboratory studies also should when examining a patient with Room Diagnosis and Treatment of Eye Disease, 4th ed. Phila- delphia: Lippincott Williams & Wilkins; 2004. be considered for hyphema cases. anterior segment inflammation. A 9. Kanski JJ. Clinical Ophthalmology: A Systematic Approach. Typical labs ordered include com- methodical case history often can 5th ed. London: Butterworth Heinemann; 2003. 10. Shingleton BJ, Hersh PS, Kenyon KR (eds.). Eye Trauma. plete blood count (CBC) with dif- pinpoint the cause of the inflamma- St. Louis: Mosby; 1991. ferential, prothrombin time (PT), tion. Additionally, knowing what 11. Keil J, Chen S. Contusion injuries and their ocular effects. Clin Exp Optom 2001;84(1):19-25. partial thromboplastin time (PTT), to look for during the slit lamp 12. Kaiser PK, Friedman NJ, Pineda R. The Massachusetts Eye blood urea nitrogen (BUN), cre- evaluation is imperative, so proper and Ear Infirmary Illustrated Manual of Ophthalmology, 2nd ed. Philadelphia: Saunders; 2004. atinine, electrolytes, sickle prep management and further diagnostic 13. Pavan-Langston D. Manual of Ocular Diagnosis and and hemoglobin studies. IOP testing, if needed, can be instituted Therapy, 4th ed. Boston: Little, Brown and Company; 1996. REVIEW OF OPTOMETRY JANUARY 15, 2015 63 058_ro0115_f6.indd 63 1/8/15 1:28 PM Go Further—Without Leaving Home Expand your clinical skills and catch up on your CE requirements, all from the comfort of your own home. Review offers nearly 100 hours of COPE-approved continuing education — right now! It’s just a click away. Our extensive library of exams runs the gamut from keratoconus to fundus autofluorescence, and everything in between. www.reviewofoptometry.com/continuing_education Download a QR scanner app. Launch app and hold your mobile device over the code to view www.reviewofoptometry.com/continuing_education. 2013_ce_housead_ad.indd 1 10/22/14 2:31 PM Coding Connection New Year, New Connections 2015 will be a year full of changes, particularly in medical coding and compliance. We’re starting on this very page. By John Rumpakis, OD, MBA, Clinical Coding Editor Photo: Kyle D. Dohm, OD he New Year has always been associated with change—and T2015 is going to be one filled with it. The area of medical coding and compliance is always subject to changes that are difficult to under- stand, let alone apply to clinical management in your practices. Review of Optometry recognizes this, and is updating the format of our venerable department previ- ously known as “Coding Abstract.” The column is now called “Coding White blood cells in the anterior chamber, seen here, are a characteristic sign of Connection,” intended to provide anterior uveitis, so this presentation doesn’t usually require special tests for diagnosis. you with content that’s more closely connected to the featured monthly Uveitis,” page 58). As we know, ICD-10 require that the systemic clinical topics. Why? Because clini- iritis can be acute or chronic, diagnosis be primary and the ocular cal decisions and coding responsi- depending on the cause of the sequelae are secondary when filing bilities go hand in hand. To truly in flammatory event. Coding for the claim with a medical carrier. master the patient care of any given iritis is fairly simple, yet it is critical It’s rare that the management condition, we also need a good to maintain a proper sequence of of iritis requires special ophthal- command of the documentation events in the medical record. mic tests such as anterior segment and billing aspects that enable it. In other words, was the iritis the photos or OCT, unless you can Our format is going to change as primary cause of the office visit or specifically demonstrate the medical well. In some months, the coding was it a sequelae of another clinical necessity for the specific procedure coverage will come in the form of presentation? and how it aided you in getting a a sidebar integrated into a chosen Be precise in your recording of better clinical outcome. clinical feature that month. Other the chief complaint as well as the times, it’ll be a standalone column secondary reasons that the patient Here’s to starting strong in 2015: like this one. Either way, our goal is in your office that day. Get in the Out with the old and in with the is to make the medical coding and habit of recording specifics such as new! Our format and presentation compliance issues immediately the circumstances (injury or trau- may change, but one thing that you applicable to the clinical content matic) and the laterality (right eye, can always count on is that I’ll con- and situations you encounter on a left eye, both eyes) as this will be tinue to bring you solutions to all of daily basis, in a presentation that required for ICD-10. the core coding and medical record will be seamless as you read the The code for a typical office compliance issues that many of you magazine or web site each month. visit is 920X2 or the appropriate face in day-to-day practice, just as level 992XX code based upon the I have since this column started Coding for Anterior Uveitis relevant history, physical exam and nearly a decade ago. ■ For example, one of the clinical related medical decision making. You can still reach me here at features in this issue concerns the If the iritis is caused by a systemic Review, just at a new email address: management of anterior uveitis or condition, keep in mind that both [email protected]. I iritis (“Practical Pearls for Anterior the ICD-9 and the forthcoming look forward to hearing from you. REVIEW OF OPTOMETRY JANUARY 15, 2015 65 065_ro0115_ccx.indd 65 1/8/15 1:43 PM Optometric Physician delivers UP-TO-DATE news and research to your inbox every Monday morning, allowing you to view all of the latest clinical information on a convenient and consistent basis. Subscribing to Optometric Physician is an effi cient and easy way to stay current with all of the information and events going on in the fi eld. To order your free subscription, e-mail: optometricphysician @jobson.com today. Cornea+Contact Lens Q+A Gas It Up Though anterior chamber injections can be hazardous, are they the best course of action when treating corneal hydrops? Edited by Joseph P. Shovlin, OD Photo: Edward Boshnick, OD Photo: Edward Boshnick, OD I have a patient with corneal Q ectasia following LASIK with an acute corneal hydrops. Apparently, he was a big eye rubber! He is extremely bothered by his loss of vision and is quite light sensitive. Should an ante- rior chamber injection be considered early, or is there no need to rush? Is there any value in injecting retinal gas (C3F8 or SF6) over air if you are treating Fig. 1. Placement of intracameral C3F8 at Fig. 2. After the procedure, the hydrops a patient with corneal hydrops? nonexpansile concentration. has resolved. It’s best to do it earlier rather A than later, and to use gas An alternative approach to man- entrance of aqueous into the cor- rather than air. aging corneal hydrops that has nea.” Thus, he adds, it is important Corneal hydrops, an uncommon become more prevalent in recent to use a nonexpansile concentration complication seen in patients with years is the use of intracameral air of gas (figure 1), as expansion can keratoconus and other corneal or gas as a means to tamponade the lead to a complete fill of the ante- ectatic disorders, occurs when exposure of aqueous to the corneal rior chamber, resulting in pupillary a tear in Descemet’s membrane endothelium. block. Other steps to reduce the risk allows the aqueous humor to enter “Placement of air or gas can be of pupillary block include the use of the stroma, resulting in corneal performed at the slit lamp and can dilating eye drops and placement of edema. While painful and visu- occlude the break in Descemet’s an inferior peripheral iridotomy. ally obstructive, most cases resolve membrane, leading to a dramatic Additional risks, says Dr. Trat- naturally over several months, dur- reduction in corneal edema and a tler, include infection as a result of ing which endothelial cells cover rapid resolution of the condition,” the needle’s entrance into the ante- the break, restoring Descemet’s explains William Trattler, MD, rior chamber. There is also evidence membrane.1 who performs refractive, corneal the presence of the gas in the ante- To supplement the natural heal- and cataract eye surgery at the Cen- rior chamber may induce cataracts, ing process, consider use of topical ter for Excellence in Eye Care in notes Dr. Donnenfeld. He recom- corticosteroids to reduce pain and Miami. Studies have shown mark- mends patients lie on their back for inflammation, as well as glaucoma edly faster improvement compared several days following placement of drugs to lower the IOP and reduce to more conservative treatments.2-4 the gas in the anterior chamber to the hydrostatic forces causing the Dr. Trattler says gas does have a achieve the best results possible. ■ edema, says Eric Donnenfeld, MD, leg up over air. “The advantage of 1. Association of Optometric Contact Lens Educators. Acute a Long Island ophthalmologist who retinal gas is that it will stay within Corneal Hydrops. Available at: www.aocle.org/livingL/hydrops. specializes in laser vision correc- the anterior chamber for a longer html. Accessed December 28, 2014. tion. Topical antibiotics can also period of time, reducing the chance 2. Miyata K, Tsuji H, Tanabe T, et al. Intracameral air injec- tion for acute hydrops in keratoconus. Am J Ophthalmol be prescribed to prevent a second- a second injection is needed.” He 2002;133(6):750-752. ary infection if there is significant cautions there are still associated 3. Panda A, Aggarwal A, Madhavi P, et al. Management of acute corneal hydrops secondary to keratoconus with intra- corneal compromise.1 Subsequent risks with using either, however. cameral injection of sulfur hexachloride (SF6). Cornea. 2007; surgery may be necessary if corneal “The main risk is pupillary block, 26(9):1067-1069. 4. Basu S, Vaddavalli PK, Ramappa M, et al. Intracameral edema persists or resultant corneal as enough air or gas needs to be perfluoropropane gas in the treatment of acute corneal hydrops. scarring affects visual clarity.1 placed within the eye to block the Am J Ophthalmol 2011:118(5):934-939. REVIEW OF OPTOMETRY JANUARY 15, 2015 67 067_ro0115_clqa.indd 67 1/9/15 10:34 AM Review of Systems Tiny Viruses, Major Diseases Herpes, HIV, Ebola, enterovirus and rhinovirus (the common cold) are but a few notable examples. By Carlo J. Pelino, OD, and Joseph J. Pizzimenti, OD rom the Latin virus, meaning to encode four proteins, while the In some RNA viruses, the viral “poison” or “slimy liquid,” most complex can encode 200 or RNA serves as mRNA after infec- Fthese pathogens are recog- more proteins.3 tion. The RNA of some viruses nized as the cause of several dis- A virus cannot reproduce by serves as a template to synthesize eases. We now know that viruses itself. So, when it comes into more RNA within the host cell. are small but powerful microorgan- contact with a host cell, the virus Some of the replicated RNA serves isms that have widespread effects inserts its genetic material and takes as mRNA and is used to produce on the body—including the ocular over the host’s functions. Instead proteins, while the remainder is structures and tissues. of its usual products, the infected packaged in new viral particles.3,5 Furthermore, Ebola, enterovirus, cell produces viral protein and Retroviruses (a family of RNA dengue and Middle East respiratory genetic material. Thus, once the viruses) use RNA as their genetic syndrome (MERS)—viruses many virus infects a susceptible cell, it material, but the host cell must clinicians did not think much about can direct that cell to produce more synthesize a “DNA copy” of the a short time ago—are now causing viruses. RNA before it can be transcribed a great deal of illness and worry In a normal cell, DNA is copied or translated. This task is aided by worldwide. to make mRNA by a process called the action of an enzyme known transcription. The information as reverse transcriptase. HIV is an How to Go Viral stored in mRNA is used (by ribo- example of a retrovirus.5 In the late 1890s, German scientists somes) to assemble proteins from Some viruses remain dormant Friedrich Loeffler and Paul Frosch amino acids, a process called trans- inside host cells for long periods, concluded that foot-and-mouth lation.3,4,5 causing no obvious damage (a stage disease in animals happens not by a The normal sequence is: known as the lysogenic phase). bacteria or toxin, but by an “ultra- But when a dormant visible causative agent”—a minute transcription translation virus is stimulated, it particle, smaller than any bacteria, DNA mRNA protein enters the lytic phase. that is capable of reproduction Here, new viruses are under certain conditions.1,2 replication formed, self-assemble This was an early clue to the and burst out of the nature of viruses; they are genetic In DNA viruses, such as varicella host cell, killing it and going on to entities that lie somewhere in the zoster, when viral genetic material infect other cells.3,5,6 grey area between living and non- enters a cell, it is replicated, tran- A virus that infects only bacteria living states. scribed (mRNA is produced) and is called a bacteriophage.3,5,6 Viruses When found outside of the host translated (proteins are produced that infect animal or plant cells cell, a virus is metabollically inert. from the mRNA).3-5 By this pro- are referred to generally as animal The virus exists as a protein coat, cess, the host cell uses the genetic viruses or plant viruses. Most ani- or capsid, that surrounds either instructions in the virus to make mal viruses do not cross phyla, and DNA or RNA, which codes for the more viruses: some (e.g., poliovirus) infect only virus elements. closely related species, The entire infectious particle, DNA mRNA protein such as primates. called a virion, consists of the outer The host-cell range shell of protein and the nucleic replication of some animal viruses acid within. The simplest viruses viral DNA is further restricted to contain only enough RNA or DNA a limited number of 68 REVIEW OF OPTOMETRY JANUARY 15, 2015 068_ro0115_ros.indd 68 1/9/15 9:53 AM cell types because only these cells Viral Eye Disease have appropriate surface receptors Along with the nose and mouth, to which the virions can attach. eyes are a main access point for viruses. In addition, systemic viral Outbreaks and Vaccines infection from other areas of the The term outbreak describes the body may manifest in ocular tis- sudden rise in the incidence of a dis- sues, causing potentially sight- ease. An epidemic occurs when an threatening complications. (See infectious disease spreads rapidly to “Viruses Encountered Most Fre- many people—well beyond what is This patient with herpes (varicella) quently in the Eye,” below.) expected within a country or a part zoster ophthalmicus was successfully In forthcoming columns, we’ll of a country. treated with oral antiviral medication. present an update on each of these When the infection takes place in viruses frequently encountered several countries at the same time, injection of a killed or weakened within the review of systems. First it turns into a pandemic––an out- organism that produces immunity up in March: HIV. ■ break of global proportions. It hap- in the body against that organism. 1. Witz J. A reappraisal of the contribution of Friedrich Loef- pens when a novel virus emerges While vaccines produce immuniza- fler to the development of the modern concept of virus. Arch among humans.7 The virus causes tion, some infections also cause Virol. 1998;143(11):2261-3. 2. Rott R, Siddell S. One hundred years of animal virology. J serious illness and is easily human immunization after an individual Gen Virol. 1998 Nov;79 (Pt 11):2871-4. transmissible. recovers from that disease. 3. Carter J, Saunders V. Virology: Principles and Applica- tions, 2nd ed. Hoboken, NJ: Wiley; 2013:1-65. The emergence of vaccines has Through use of vaccines, we have 4. Taylor MW. Viruses and Man: A History of Interactions. been one of the greatest advances in eradicated smallpox and nearly Switzerland: Springer International Publishing; 2014:1-40. 5. Genes and Gene Expression. BioChemWeb.org: The public health. A vaccination is the eliminated wild poliovirus. The Virtual Library of Biochemistry and Cell Biology. Available benefits of vaccines appear to signifi- at: www.biochemweb.org/genes.shtml. Accessed December 7, 2014. cantly outweigh the risks. However, 6. Madigan MT, Martinko J (eds.). Brock Biology of Micro- no vaccine is 100% safe or effective organisms, 11th ed. Upper Saddle River, NJ: Prentice Hall; 2006. for everyone because each person’s 7. Porta M (ed.). A Dictionary of Epidemiology, 6th ed. New body reacts to vaccines differently. York: Oxford University Press; 2014:209. Viruses Encountered Most Frequently in the Eye Image: Centers for Disease Control and Prevention FAMILY OPHTHALMIC INVOLVEMENT DNA Virus Families Adenoviridae Epidemic keratoconjunctivitis (most commonly associated serotypes are adenovirus 8, 19 and 37) Herpesviridae Herpes simplex ocular disease Varicella zoster ophthalmicus Cytomegalovirus retinitis (human herpes virus 5) Papoviridae Papilloma (human papilloma virus) of lids, adnexa and conjunctiva This transmission electron micrograph Poxviridae Molluscum contagiosum of lids and adnexa reveals rubella virions in the process of budding from the host cell surface RNA Virus Families to be freed into the host’s system. The Togaviridae Rubella retinopathy rubella virus is known to be the cause of measles. Congenital rubella can result in Retroviridae HIV (affects many ocular tissues) retinopathy. REVIEW OF OPTOMETRY JANUARY 15, 2015 69 068_ro0115_ros.indd 69 1/9/15 9:53 AM DOWNLOAD LAYAR APP FOR INTERACTIVE EXPERIENCE First 150 app downloads and completed forms will be entered into a drawing for FREE MEETING AND REGISTRATION VALUED AT $495 SAVE THE DATE INTERACTIVE PRINT ies a log nd o T r n e h a c t e m REVIEW OF OPTOMETRY T N T EDUCATIONAL MEETINGS OF CLINICAL EXCELLENCE e n w t e s N & T IN VISION CARE SAN DIEGO, CA 2015 APRIL 10-12 CE COURSE TOPICS: Management of Lid Margin Disease Innovations in Eye Care Glaucoma Management Insights Diagnostic Dilemmas and Solutions Emergency and Urgency Diagnosis and Treatment Anterior Segment Disease Diagnosis and Treatment Medical Management of Ocular Disease Comanagement of Cataract and Refractive Surgery Writing Oral Prescriptions NEW!! 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Additional Guest(s) - $45 (12 years and older, includes reception) $45 x ______= $______Concurrent Workshop Sessions (Saturday, April 11, 2:30-4:30pm) Select only one if interested in additional session and credits Dry Eye Workshop - $70 (Earn 2 additional CE Credits) $70 x ______= $______Glaucoma Workshop - $70 (Earn 2 additional CE Credits) $70 x ______= $______TOTAL = $______Check enclosed (make checks payable to Review of Optometry) Charge my: American Express Mastercard Visa CONFERENCE CANCELLATION POLICY Credit Card Number Exp Date • Full refund on registration fee until March 10, 2015 Cardholder (print name) • 50% refund on registration fee until March 28, 2015 • No refund past March 28, 2015 Signature For more information or to register, contact Lois DiDomenico at 866-658-1772 or at [email protected]. *Approval pending 2015_sandiego_spread.indd 2 1/6/15 12:48 PM Retina Quiz Two Decades of Poor Vision After more than 20 years, is it even remotely possible to restore the visual acuity in our patient’s right eye? By Mark T. Dunbar, OD 53-year-old Hispanic male coloration and perfusion. We noted 3. What is the correct diagnosis presented for a second opin- significant retinal changes in his for this patient? Aion on a previous diagnosis. right eye (figure 1). We also noted a. Wet macular degeneration. He reported vision loss in his right changes in the left eye (figure 2). b. Coats’ disease. eye that had persisted for more than Additionally, we ordered a spectral- c. Polypoidal choroidal vascu- 20 years. His medical history was domain optical coherence tomogra- lopathy (PCV). unremarkable. phy (SD-OCT) scan (figure 3). d. Branch retinal vein occlusion The patient was told that “he had with subretinal neovascularization. pressure in his eye,” but admitted Take the Retina Quiz that he didn’t really understand the 1. How would you characterize 4. How should this patient likely diagnosis. He suggested that the the SD-OCT findings documented be treated? vision in his right eye had been fair- in his right eye? a. Laser photocoagulation. ly stable over the past several years a. Retinal pigment epithelium b. Photodynamic therapy (PDT). since he moved to the United States. (RPE) tear. c. Anti-VEGF injection. On examination, his best- b. Exudative retinal detachment. d. Combination PDT and anti- corrected visual acuity measured c. Combination pigment epithe- VEGF therapy. 20/400 OD and 20/20 OS. Extra- lial detachment (PED) and serous ocular motility testing was normal. detachment. For answers, turn to page 90. Confrontation visual fields were d. Macular schisis. full to careful finger counting OU. Discussion Pupils were equally round and reac- 2. How do you account for the There is massive exudation and tive, with trace evidence of afferent areas of RPE hypertrophy OU? subretinal hemorrhage throughout defect in his right eye. The anterior a. Retinal degeneration from the posterior pole of our patient’s segment was unremarkable. His early-stage retinitis pigentosa (RP). right eye. The SD-OCT shows an intraocular pressure measured b. Unreported trauma. irregular pigment epithelial detach- 15mm Hg OU. c. Previous episodes of retinal ment with an overlying serous reti- Dilated fundus exam revealed edema and fluid. nal detachment, as well as cystoid healthy optic nerves, with good rim d. Previous toxoplasmosis. macular edema OD. Figs. 1 & 2. Fundus image of his right eye (left), and widefield view of his left eye (right). How do you explain the pigmentary anomalies? 72 REVIEW OF OPTOMETRY JANUARY 15, 2015 072_ro0115_rq.indd 72 1/8/15 1:31 PM It would be easy to assume that of age, compared to 65+ for AMD.3 these findings, in conjunction with Our patient is 53, much younger the subretinal hemorrhage, are due than the typical AMD patient. to a large, occult choroidal neovas- Finally, AMD is associated with cular membrane. But, that is not the drusen, which typically are not seen likely cause. Instead, he has PCV. in younger PCV patients. Lawrence A. Yanuzzi, MD, first The changes seen in our patient’s described polypoidal choroidal vas- left eye are also quite revealing. We culopathy in 1982.1 The hallmark noted localized areas of bony pig- Fig. 3. Spectral-domain optical coherence feature of PCV is a network of ment spiculing, which likely is due tomography scan through the macula vessels located in the inner choroid to previous PCV activity. It appears of our patient’s right eye. What is the that develop peculiar aneurismal that the patient developed scarring underlying etiology? dilations. The disease is character- from resolved episodes of bleed- ized by multiple, recurrent, serosan- ing, exudation and retinal edema. Lucentis monotherapy.5 guineous detachments of the RPE But, because these features did not Given these findings, it seems and neurosensory retina secondary involve the macula, the patient that combination PDT and Lucen- to leakage and bleeding from these remained completely unaware of tis therapy may yield better lesion aneurismal choroidal vascular any underlying disease process. regression and a longer duration of lesions.1-3 In fact, one of the earliest Photodynamic therapy has treatment effect than either form names for the condition was “pos- emerged over thermal laser as of monotherapy.5 A similar study terior uveal bleeding syndrome,” the treatment of choice for PCV. comparing the clinical efficacy of because of the massive amount of However, more recently, research- Lucentis and Avastin (bevacizumab, hemorrhaging and exudation. Look- ers have investigated the clinical Genentech/Roche) for PCV pro- ing at our patient, you can under- efficacy of intravitreal anti-VEGF duced similar results.6 stand why. therapy. In the earlier disease stages, you The EVEREST study was a We referred our patient to a reti- can sometimes see the aneurismal multicenter, double-masked trial nal specialist for treatment. Consid- polyp-like lesions located below comparing the therapeutic effect of ering his 20-year history of vision the RPE. These appear as reddish- PDT plus Lucentis (ranibizumab, loss, it doesn’t seem likely that he orange, spheroidal lesions. Over Genentech/Roche), PDT monother- will recover much central vision. time, these vessels can slowly begin apy, and Lucentis monotherapy on On the other hand, the retinal find- to bleed with varying amounts of polypoidal choroidal vasculopathy.5 ings do not look consistent with a exudation. Indocyanine green angi- The six-month results indicated process that has been progressing ography (IGC) may be the definitive that PDT plus Lucentis and PDT for two decades. So perhaps, if we test for establishing a diagnosis of monotherapy were superior to can get rid of the fluid and flatten PCV, as the polyp-like aneurysmal Lucentis treatment alone in achiev- his macula, we may be pleasantly dilations are clearly highlighted. ing complete polyp closure regres- surprised at how well he does. Only Keep in mind that PCV easily can sion (77.8% and 71.4% vs. 28.6%, time will tell. ■ be misdiagnosed for wet macular respectively). Eyes treated with PDT 1. Yannuzzi LA. Idiopathic polypoidal coroidal vasculopathy. degeneration. In one study of 167 plus Lucentis also achieved better Presented at the Macula Society Meeting. February 5, 1982; consecutive patients diagnosed with visual acuity. Specifically, patients Miami, Fla. 2. Yannuzzi LA, Sorenson J, Spaide RF, Lipson B. Idio- wet AMD, the researchers deter- who underwent combination PDT pathic polypoidal choroidal vasculopathy (IPCV). Retina. mined that 13 patients (7.8%) actu- and Lucentis gained 10.9 ETDRS 1990;10(1):1-8. 4 3. Yannuzzi LA, Ciardella A, Spaide RF, et al. The expanding ally had PCV. Additionally, PCV letters, those who received Lucentis clinical spectrum of idiopathic polypoidal choroidal vasculopa- tends to present in more darkly monotherapy gained 9.2 letters and thy. Arch Ophthalmol. 1997 Apr;115(4):478-85. 4. Yannuzzi LA, Wong DW, Sforzolini BS, et al. Polypoidal cho- pigmented individuals (i.e., blacks, those who underwent PDT mono- roidal vasculopathy andn neo vascularized age-related macular Hispanics and Asians), compared therapy gained 7.5 letters.5 It is degeneration. Arch Ophthalmol. 1999 Nov;117(11):1503-10. 5. Koh AH, Chen LJ, Chen SJ, et al. Polypoidal choroidal vas- to AMD, which is more frequently important to note that patients who culopathy: evidence-based guidelines for clinical diagnosis and diagnosed in whites. received PDT (either alone or in treatment. Retina. 2013 Apr;33(4):686-716. 6. Cho HJ, Kim JW, Lee DW, et al. Intravitreal bevacizumab and PCV also tends to occur in combination) exhibited better PCV ranibizumab injections for patients with polypoidal choroidal younger individuals––50 to 65 years resolution than those who received vasculopathy. Eye (Lond). 2012 Mar;26(3):426-33. REVIEW OF OPTOMETRY JANUARY 15, 2015 73 072_ro0115_rq.indd 73 1/8/15 1:31 PM Therapeutic Review Don’t Delay Optic Neuritis Dx Because of the close association between optic neuritis and MS, a prompt diagnosis and referral for treatment is paramount. By Joseph W. Sowka, OD, and Alan G. Kabat, OD arly in our training and Today, fortunately, the climate for specific areas of the CNS, careers, we often avoided is much different. Over the past including the optic nerve and peri- Ediagnosing patients with several years, research has made ventricular white matter of the cer- optic neuritis. When the proto- great advances in immunomodula- ebellum, brain stem, basal ganglia typical patient came to us (e.g., tory therapy that can diminish the and spinal cord. Myelin is respon- a young person, often female, disabling effects of MS. Not only sible for insulating the nerves of complaining of color vision loss, are these therapies beneficial in the peripheral and central nervous blurred vision and significant pain reducing disability, but the early system, permitting speeding of upon eye movement, and manifest- initiation of therapy offers the best electrical impulses along nervous ing a relative afferent pupillary patient outcomes. tissues. defect but a normal optic disc Evidence suggests that the cel- appearance), we were hesitant to What is Optic Neuritis and MS? lular immune response contributes make a confirmatory diagnosis of Optic neuritis is an acute, inflam- to the degradation of myelin. This optic neuritis––though it often was matory, demyelinating event of the patchy demyelination likely is our suspicion. optic nerve that may be idiopathic caused by a deposition of mono- Our reluctance stemmed from and localized to the optic nerve, or nuclear cells, such as macrophages the strong association of optic may be or become associated with and B-cells in perivascular regions.6 neuritis with multiple sclerosis other systemic illnesses––notably Loss of myelin greatly slows ner- (MS). While we were able to use MS. Optic neuritis often is the ini- vous conduction and leads to the magnetic resonance imaging (MRI) tial presenting sign of MS.1-3 After neurological deficits seen in MS. to identify characteristic MS brain five years, clinically definite mul- On average, patients experi- lesions, we rarely did so. The tiple sclerosis (CDMS) develops in ence clinical relapses every one reason was that, even if we did 30% of patients who present with to two years during the so-called confirm that optic neuritis was the optic neuritis, although the degree relapsing/remitting phase of the first manifestation of MS, there of neurological impairment is disease––although serial MRI sug- was nothing we could do to treat generally mild at that point.4 The gests that inflammatory lesions are the patient. typical patient with demyelinating practically continuous throughout Usually, optic neuritis would optic neuritis is a young female, this period. spontaneously improve and had a often between the ages of 20 and good visual prognosis. However, 40. In 92% of cases, the vision loss Current MS Therapies there was no accepted treatment is painful––particularly upon eye MS frequently is treated using for MS at that time. We knew that movement.5 immunomodulatory agents. The if we definitively diagnosed optic Multiple sclerosis is an acquired, major drugs used in the United neuritis, the underlying implication multifactorial, autoimmune inflam- States include interferon beta-1b of MS could pose a hardship for matory demyelinating disease that (Betaseron, Bayer HealthCare) and patients who––at that time––could affects the white matter located in interferon beta-1a (Avonex, Biogen have lost or not qualified for medi- the central nervous system (CNS). Idec; and Rebif, Pfizer). Glatiramer cal or disability insurance because MS is defined by recurrent bouts acetate (Copaxone, Teva) also is carriers might suspect they could of CNS inflammation that dam- frequently used.7 be on the hook for a disabling dis- age both the myelin sheath sur- • Betaseron is injected subcuta- ease. Thus, we took a “don’t ask, rounding the axons and the axons neously. The recommended dose don’t tell” policy. themselves. There is a predilection is 0.25mg every other day. It is 74 REVIEW OF OPTOMETRY JANUARY 15, 2015 074_ro0115_tr.indd 74 1/8/15 1:37 PM supplied as 0.3mg of lyophilized has a clinical effect powder in a single-use vial for on the severity of reconstitution. MS development • Avonex is FDA approved and progression. to treat relapsing forms of MS, Betaseron’s decrease the number of disease effects on MS recurrences and to slow the onset are currently of associated physical disabilities. unknown, but are It is indicated for use in people thought to block T who have experienced a first cells from attack- attack and have lesions consistent ing myelin. How- with MS via MRI. ever, the Betaseron Avonex is a once-weekly treat- in Newly Emerging ment that is available in three Multiple Sclerosis dosage forms: a prefilled syringe; for Initial Treat- a single-use, prefilled autoinjector ment (BENEFIT) that uses a covered needle that’s study showed that Swollen optic disc in a patient with optic neuritis and MS. 50% shorter than the standard early treatment with Avonex needle; and an unmixed beta-1b significantly delayed the The immediate-treatment form designed to be used with a time to a second flare-up and con- group exhibited a 40% lower rate standard Avonex syringe. version to CDMS compared with of CDMS, as well as a reduced • Rebif is administered three placebo.8 relapse rate. Also, few patients in times per week, and also is avail- The Controlled High Risk the immediate treatment group able in three dosing forms: Rebif Avonex Multiple Sclerosis Study reached the Expanded Disability Rebidose, a preassembled, pre- (CHAMPS) looked at whether the Status Scale milestone scores of 4.0 filled, single-use autoinjector; the initiation of Avonex in patients or greater (9% of patients) or 6.0 Rebiject II autoinjector, which experiencing a first-time demyelin- or greater (6% of patients). The works with the Rebif prefilled ating event, such as optic neuritis, researchers believed that immedi- syringe and is designed to auto- and who also had MRI brain ate initiation of Avonex at the time mate the injection process; and a abnormalities suggestive of prior of a clinically isolated syndrome ready-to-use, preassembled, pre- demyelinating events could delay (such as optic neuritis) in high- filled syringe. or prevent progression to CDMS.9 risk patients reduced relapse rates • Copaxone is a synthetic Its three-year results were by more than 10 years, and was analogue of the MS-associated very impressive.9 Development associated with better clinical out- antigen, myelin basic protein. of CDMS occurred in 35% of comes.10 Copaxone 40mg is an injectable patients using Avonex and in In the PreCISe study, patients therapy that is taken three times 50% of placebo-treated patients. who used Copaxone experienced per week. Copaxone is available Additionally, patients who used a significantly reduced rate of, and as both a prefilled syringe and an Avonex experienced a decrease in longer conversion time to, CDMS autoinjector. the number and size of new MRI than those who took a placebo–– brain lesions compared to those in with a 45% incidence reduction Is Early Treatment Better? the placebo group.9 overall, and a 66% reduction if Numerous studies have evaluated A 10-year extension of the optic neuritis was the presenting the effectiveness of immunomodu- CHAMPS study looked at whether finding.11 latory therapies in reducing disease immediate initiation of treatment More recently, the same research recurrence, accumulation of dis- at the time of a clinical demyelinat- team noted that initial treatment ability and progression to CDMS. ing event in patients at high risk with Copaxone reduced CDMS Additionally, multiple research for CDMS (those with an abnor- conversion risk by 41% compared groups have sought to determine if mal brain MRI) could alter long- to delayed-treatment, and was the timing of therapeutic initiation term disease progression.10 associated with a 972-day delay REVIEW OF OPTOMETRY JANUARY 15, 2015 75 074_ro0115_tr.indd 75 1/8/15 1:37 PM Therapeutic Review in conversion to CDMS. They MS because there were no inter- 3. Pirko I, Blauwet LK, Lesnick TG, et al. The natural history of recurrent optic neuritis. Arch Neurol. 2004 Sep;61(9):1401-5. concluded that the reduced rate ventions available to help patients. 4. Optic Neuritis Study Group. The five-year risk of MS after of CDMS conversion, as well as Now, the immunomodulatory optic neuritis. Experience of the optic neuritis treatment trial. Neurology. 1997 May;49(5):1404-13. lower MRI measures of disease therapies available have clearly 5. Beck RW. Optic neuritis study group. Neurologic impairment 10 activity and lesion burden, sup- shown to reduce the burden of years after optic neuritis. Arch Neurol. 2004 Sep;61(9):1386-9. 6. Confavreux C, Vukusic S. Accumulation of irreversible dis- port initiating Copaxone treatment MS, and that early treatment can ability in multiple sclerosis: from epidemiology to treatment. soon after the first clinical symp- delay the onset and taper the sever- Clin Neurol Neurosurg. 2006 Mar;108(3):327-32. 7. Plosker GL. Interferon1b: a review of its use in multiple scle- 12 toms suggestive of MS manifest. ity of CDMS. rosis. CNS Drugs. 2011 Jan;25(1):67-88. Further, they recommend continu- When encountering optic neuri- 8. Kappos L, Polman CH, Freedman MS, et al. Treatment with 12 interferon beta-1b delays conversion to clinically definite and ing treatment to sustain benefits. tis, internuclear ophthalmoplegia McDonald MS in patients with clinically isolated syndromes. or any condition associated with Neurology. 2006 Oct 10;67(7):1242-9. 9. Jacobs LD, Beck RW, Simon JH, et al. Intramuscular inter- Clearly, there has been a para- MS, the treatment paradigm dic- feron beta-1a therapy initiated during a first demyelinating event digm shift in the way that we tates prompt diagnosis with a risk in multiple sclerosis. CHAMPS Study Group. N Engl J Med. 2000 Sep 28;343(13):898-904. diagnose and manage patients with assessment and referral to a physi- 10. Kinkel RP, Dontchev M, Kollman C, et al. Association optic neuritis and other conditions between immediate initiation of intramuscular interferon beta-1a cian skilled in the management of at the time of a clinically isolated syndrome and long-term out- associated with MS development. patients with MS. This will ensure comes: a 10-year follow-up of the Controlled High-Risk Avonex While eye care practitioners are Multiple Sclerosis Prevention Study in Ongoing Neurological that appropriate intervention will Surveillance. Arch Neurol. 2012 Feb;69(2):183-90. not going to manage patients with be started to provide patients with 11. Comi G, Martinelli V, Rodegher M, et al. Effect of glatiramer MS, we frequently are the individ- ■ acetate on conversion to clinically definite multiple sclerosis the maximum benefit. in patients with clinically isolated syndrome (PreCISe study): uals to diagnose conditions associ- a randomised, double-blind, placebo-controlled trial. Lancet. ated with the disease. 1. Chan JW. Optic neuritis in multiple sclerosis. Ocul Immunol 2009 Oct 31;374(9700):1503-11. Inflamm. 2002;10(3):161-86. 12. Comi G, Martinelli V, Rodegher M, et al. Effects of early Before, we never rushed to make 2. Soderstrom M. Optic neuritis and multiple sclerosis. Acta treatment with glatiramer acetate in patients with clinically iso- the diagnosis of optic neuritis and Ophthalmol Scand. 2001 Mar;79(3):223-7. lated syndrome. Mult Scler. 2013 Jul;19(8):1074-83. 074_ro0115_tr.indd 76 1/8/15 1:38 PM VISIONARIES IN EDUCATION, FASHIONSHION AND TTECHNOLOGY Are you practicing full-scope medical eyecare? It’s no surprise that more Optometrists and Opticians International Vision Expo offers advanced education choose to continue their education at International focused on the core competencies of your practice: Vision Expo than at any other conference globally. management of eye disease, contact lens technology, Whether it’s new ideas, new products, new applications practice management and other optical topics. By or new processes, innovation and education are what expanding your knowledge base, you’ll enhance the improve the quality of treatment and service you scope of your practice and patient offerings to the provide your clients and patients. maximum extent your license allows. International Vision Expo has added new tracks to International Vision Expo brings together world-class address trending industry topics including Retail, visionaries from all areas of clinical care to provide Wearable Technology and the Ocular Wellness extensive, leading-edge education in ocular disease, Program. Also new this year, look for an increase in contact lenses and therapeutics. classroom collaboration and engagement with more With hundreds of medical and diagnostic exhibitors courses featuring technology, and infusing crowd and 333 hours of education under one roof, you sourced learning for maximum peer-to-peer impact. can extend your learning with hands-on product and equipment demonstrations. INTERNATIONAL VISION EXPO 2015 EDUCATION: THURSDAY, MARCH 19–SUNDAY, MARCH 22 EXHIBITION: FRIDAY, MARCH 20–SUNDAY, MARCH 22 JAVITS CENTER | NEW YORK, NY | VisionExpoEast.com | #VisionExpo PROUD SUPPORTER OF: RO0115_House Vision Expo.indd 1 12/17/14 3:55 PM 19TH ANNUAL OPHTHALMIC PRODUCT GUIDE Innovative products to enhance your practice The future is in your hands. One tap, many possibilities. Experience the digital edition on your handheld device. Use your smart device to scan the code below or visit: www.revoptom.com/supplements/ Download a QR scanner app. Launch app and hold your mobile device over the code to view http://www.revoptom.com/supplements 2014_opg_ad_fullpge.indd 1 6/20/14 9:32 AM Ocular Surface Review The Evolution of Dry Eye Our understanding of dry eye has become more sophisticated in recent years. So too should our approach to care. By Paul M. Karpecki, OD he concept of dry eye, or at requires two key things: acquisi- least an understanding of tion of tears in a reservoir, and then Tthe need for tears, has been measurement. Although those capa- recognized by healers for over 3,500 bilities were not as readily available years, as the first mention of our then as they are today, the science tears was recorded in 1550 BC as of hyperosmolarity as an underlying “the water within” in ancient Egyp- finding began almost 75 years ago. tian documents known as the Ebers In the early 1960s, it was discov- Papyrus.1 However, the discipline of ered that a decrease in lacrimal gland ocular surface care didn’t actually secretion leads to ocular surface des- begin until the mid-1850s, when iccation.10 In the 1970s, the multilay- a mechanism of tear secretion was Dry eye in a patient who presented with ered ocular surface was recognized first proposed. The modern era of superficial punctate keratitis. as an integrated functional unit. This dry eye began in 1973 when Frank is analogous to our present efforts Holly explained the role of mucin. • Digital device use. Studies show to consider the conjunctiva, cornea, Soon thereafter, the work of Tseng, the average American spends three to lacrimal and meibomian glands as Plugfelder, Lemp, Korb, Nichols and five hours on electronic devices daily.5 interrelated parts of a functional others allowed us to develop a better • Systemic diseases. Diabetes is anatomical unit. understanding of the interaction of just one example of a systemic dis- The late 1970s brought us the first the ocular surface and tear film. ease with a significant connection mention of the role of meibomian Today, dry eye is one of the lead- to dry eye; it is expected to increase glands in the pathogenesis of evapo- ing causes of patient visits to eye from 29 million Americans in 2012 rative tear loss, and the role of the care providers (ECPs) in the US.3 to 54 million in 2050.6,7 lipid layer in preventing the loss of Although anywhere from 20 to 30 • The aging population. Demo- aqueous was identified soon after- million people have early signs and graphic trends and life expectancy ward.10,11 These clinical findings have symptoms of dry eye (depending on gains will expand the senior citizen affected how we manage dry eye dis- the study cited), only eight million population from 14% in 2013 to ease and play a key role in the tests patients manage their condition with 20% in 2050.8 and treatments being administered. artificial tears at a minimum, and a These trends—which clearly Despite our knowledge today, much lower percentage are actually indicate a pressing need for ongoing there is no “gold standard” for the receiving ongoing treatment from education in the field of dry eye—are diagnosis of dry eye disease; instead, an ECP.4 Studies around the world the impetus for this new bimonthly we must interpret multiple testing show similar numbers, though column, “Ocular Surface Review.” results. This fundamental piece of certain regions like Asia may have the dry eye puzzle is similar to the as much as 33% of the population Past Meets Present management of glaucoma, where experiencing significant dry eye.2 Along the historic path, there were many objective and subjective factors Simply put, dry eye is the number some great, early insights that impact play a part in revealing the evidence one medical condition that moti- how the disease is diagnosed and that helps determine the diagnosis. vates patients to see their ECP—and managed today. The combination of these as well it will only grow. The predisposing The first mention of increased as other key findings—like MMP-9, factors that will likely make this dis- tear osmolarity was in 1941 by Von blink analysis, eyelid apposition and ease increase in prevalence are: Bahr and colleagues.9 But osmolarity symptomatology—all provide the REVIEW OF OPTOMETRY JANUARY 15, 2015 79 079_ro0115_osr.indd 79 1/9/15 1:09 PM Ocular Surface Review data we need to diagnose dry eye. = increase in protein/lipid ratio → adoption lifecycle will have an amaz- Part of the reason we have to tear film stability impaired equal to ing effect not only on dry eye disease employ multiple tests in the diagnosis or greater than evaporative stress. patients and more advanced forms is because signs and symptoms of All of these studies were published like Sjögren’s syndrome, but also DED are poorly correlated.12,13 In in 2014 and will have major impli- contact lens wearers, those who use fact, many patients with significant cations to how we manage dry eye electronic devices more than three symptoms may have milder forms of going forward. They also have signif- hours a day and patients preparing dry eye. As the nerves downregulate icant areas of overlap, even though for procedures such as cataract sur- and signs become more apparent, the original cause may be different. gery. Getting involved now will help the symptoms decrease. In fact, one your practice and, most importantly, study showed less than 60% of dry Routine Check-ups your patients’ quality of life. ■ eye patients (based on objective Given the progression of this disease, Excerpts taken from the Dry signs) were actually symptomatic.14 one might surmise the most appro- Eye Summit, which took place on The progressive nature of this priate future protocol might be that December 12, 2014 in Dallas/Fort disease also increases the impor- of the dental model. In this anal- Worth, with input from 30 of the top tance of recording objective findings ogy, patients—especially those with educators in ocular surface disease. like meibography, osmolarity, MG early symptoms such as end-of-day expression, inflammatory marker contact lens discomfort or decreased 1. Hirschberg J. The History of Ophthalmology, Vol. 1: Antiquity. Translated by FC Blodi. Bonn, West Germany: Verlag JP Wayen- testing, lid margin evaluation, vital wear time—should be evaluated borgh, 1982. dye staining, blink analysis and lid and managed routinely, even in the 2. Gayton, JL. Etiology, prevalence, and treatment of dry eye dis- 15 ease. Clin Ophthalmol. 2009; 3: 405–412. apposition. absence of symptoms, to prevent 3. Sullivan, D.A., Hammitt, K.M., Schaumberg, D.A. et al. Report With this many factors to continu- future damage or loss of glands. of the TFOS/ARVO Symposium on Global Treatments for Dry Eye Disease: An unmet need. Ocul Surf. 2012; 10: 108–116 ally monitor and evaluate, modern In the 1850s, when dry eye 4. Dahl AA and Davis CP. Dry Eye Syndrome (Dry Eyes, Kerato- dry eye care can seem daunting. research began, people didn’t know conjunctivitis Sicca). Available at: www.medicinenet.com/dry_eyes/article.htm. Fortunately, a few recent studies are to brush their teeth, and they eventu- Accessed September 19, 2014. helping to connect the dots. ally lost them. Today, because of the 5. U.S. Dept of Labor. American Time Use Survey Summary. Available at: www.bls.gov/news.release/atus.nr0.htm. Accessed One recent paper found that vari- use of electronic devices in particu- October 1, 2014. ability between eyes in osmolarity lar, patients are losing their meibo- 6. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2014. Available at: www.cdc.gov/diabetes/pubs/ testing is a hallmark sign of DED. mian glands. We should be assessing statsreport14/national-diabetes-report-web.pdf. Accessed October For example, the difference in osmo- this every year at a minimum and 1, 2014. 7. Centers for Disease Control and Prevention. Number of larity readings between the eyes suggest that patients manage the Americans with Diabetes Projected to Double or Triple by 2050. would be within 5mOsmol/L, and early disease before it progresses. Available at: www.cdc.gov/media/pressrel/2010/r101022.html. both eyes would have readings under Our eyelids are like our gums— Accessed October 1, 2014. 8. Ortman JM, Howard H, Victoria VA. An Aging Nation: The Older 300mOsmol/L. they need to be managed daily. Population in the United States. May 2014. Available at: www.cen- A second critical new finding, also Patient education should stress the sus.gov/prod/2014pubs/p25-114.pdf. Accessed October 1, 2014. 9. Von Bahr G. Konnte der Flussigkeitsabgang durch die cornea published in late 2014, mapped the importance of daily at-home care von physiologischer bedengtung sein. Acta Ophthalmol (Copenh). inflammatory cascade. The sequence with lid wipes and warm compress- 1941;19:125-34. 10. Asbell PA, Lemp MA (eds.). Dry Eye Disease: The Clinician’s is as follows: increased osmolarity es. In the office, we can offer thermal Guide to Diagnosis and Treatment. Thieme Publications; 2006 → inflammation → tear film instabil- pulsation treatment, mechanical 11. Jester JV, Nicolaides N, Smith RE. Meibomian gland studies: histologic and ultrastructural investigations. Invest Ophthalmol Vis ity → rapid tear film break-up time cleaning devices that remove bio- Sci. 1981;20:537-47 → change in VA → eventually other films and debridement/scaling of 12. Nichols KK, Nichols JJ, Mitchell GL. The lack of association between signs and symptoms in patients with dry eye disease. symptoms and signs. the lid margin. When the lids are Cornea. 2004 Nov;23(8):762-70. Another landmark study looked at inflamed, we may need to use medi- 13. Sullivan BD, Crews LA, Messmer EM, et al. Correlations between commonly used objective signs and symptoms for the the effect of desiccating stress on the cations like topical cyclosporine or diagnosis of dry eye disease: clinical implications Acta Ophthal- mouse meibomian gland function.16 corticosteroids, and in advanced mol. 2014;92:161-166. 14. Bron AJ, Tomlinson A, Foulks GN, et al. Rethinking dry The proposed cascade is as follows: cases, orals like doxycycline. eye disease: a perspective on clinical implications. OculSurf. low humidity → chronic evapora- We must embrace this new 2014;12(2 Suppl):S1-S31. 15. Rao SN. Topical cyclosporine 0.05% for the prevention tive stress → increased meibocyte understanding of OSD to help our of dry eye disease progression. J Ocul Pharmacol Ther. 2010 production > oil production → dila- patients live with the most common Apr;26(2):157-64. 16. Suhalim JL, Parfitt GJ, Xie Y, et al. Effect of desiccating stress tion of ducts, extensive and possible condition they will face for decades on mouse meibomian gland function. Ocular Surface 2014, Vol. obstruction → short maturation time to come. Working to shorten the 12 (1):59-68. 80 REVIEW OF OPTOMETRY JANUARY 15, 2015 079_ro0115_osr.indd 80 1/9/15 1:09 PM The Rick Bay Foundation for Excellence in Eyecare Education www.rickbayfoundation.org Support the Education of Future Healthcare & Eyecare Professionals About Rick Scholarships will be awarded to advance the education Rick Bay served as the publisher of students in both Optometry and Ophthalmology, of The Review Group since 1991. and will be chosen by their school based on qualities that To those who worked for him, embody Rick’s commitment to the profession, including he was a leader whose essence was based integrity, compassion, partnership and dedication to the in a fi erce and boundless loyalty. greater good. To those in the Interested in being a partner with us? industry and the professions he served, he will be remembered Visit www.rickbayfoundation.org for his unique array of skills (Contributions are tax-deductible in accordance with section 170 of the Internal Revenue Code.) and for his dedication to exceeding the expectations of his customers, making many of them fast friends. (The Rick Bay Foundation for Excellence in Eyecare Education is a nonprofi t, tax-exempt organization under section 501(c)(3) of the Internal Revenue Code.) rickbay_housead.indd 1 2/28/14 1:14 PM Surgical Minute By Derek N. Cunningham, OD, and Walter O. Whitley, OD, MBA Conquering Cataracts Today’s techniques put “premium” outcomes within reach of more patients than ever. ataract surgery has come endothelium, manipulate tissues and a long way in the past few maintain space during surgery. Cdecades. From extracapsular Then, a secure, clear corneal extraction to phacoemulsifica- incision is made to achieve a stable tion with clear corneal incisions anterior chamber, minimize surgi- to femtosecond laser-assisted sur- cally induced astigmatism, provide gery, cataract removal has evolved adequate instrument maneuver- dramatically, thanks to continu- ability and prevent post-op wound ous innovations in techniques and leaks. This is followed by a con- technology. As primary eye care tinuous, curvilinear capsulotomy providers, it is important for us to (capsulorhexis) to enable hydrodis- remember where we stand with Premium IOLs, such as this Alcon Restor section, prevent posterior capsule regard to traditional surgery and multifocal, allow correction of near tears and allow for the implanta- why we’ve seen so many recent vision. Note the concentric rings of the tion, fixation and centration of advances. Our role is to prepare and diffractive optics visible centrally. the IOL within the capsular bag. educate our patients for cataract Hydrodissection is performed to removal, review their IOL options involved in the preoperative work- reduce zonular stress during phaco and discuss our perioperative up, including topography, biometry, by mobilizing the nucleus and epi- responsibilities. A simple, generic IOL calculations, any presence of nucleus. Next, phacoemulsification referral for cataract surgery is no ocular pathology, and IOL selec- fractures the cataract’s nucleus, longer sufficient. tion, will directly contribute to indi- which is followed by the removal of Patients want to improve their vidualized postoperative outcomes. the remaining epinucleus and cortex quality of life following cataract A 2012 study found modern cat- with irrigation/aspiration. surgery and to be less dependent aract surgery outcomes to be within Once complete, the IOL is on corrective lenses after the pro- +/- 0.50D of the target refraction implanted and centered within the cedure. During the cataract evalua- in just 71% of cases.1 With many capsular bag. Finally, the surgeon tion, patients must be informed of patients electing to pay out of removes any remaining viscoelastic all available treatment options and pocket for premium IOLs, expecta- to minimize intraocular pressure ultimately decide which IOL option tions are at an all-time high. And as spikes, then checks the clear corneal best suits their visual needs. consistent as we believe our cataract incision to ensure it is secure. Every available IOL option comes surgeons can be, isn’t it nice to Be sure patients understand that with some sort of compromise, and know we can help to further perfect many variables in the pre-op work- patients must have realistic visual our patients’ surgical outcomes? up (e.g., topography, biometry, IOL expectations. Many patients have Let’s review modern-day surgical calculations, lens choice, any ocular spoken with friends or family mem- techniques with phacoemulsification pathology) influence outcomes. As bers who’ve undergone surgery, and and clear corneal incisions. a result, the approach will be highly often hear “I don’t have to wear individualized—and so will the glasses.” What these patients don’t Modern Cataract Removal results. Future columns will delve understand is that multiple variables First, a paracentesis is created to into how the technologies of mod- provide access for the surgical ern cataract surgery address these To see a narrated video of instruments. Next, an injection of patient-specific factors. Stay tuned! ■ this procedure, visit www. intracameral lidocaine and visco- reviewofoptometry.com, or 1. Behndig A, Montan P, Stenevi U, et al. Aiming for emmetropia scan the QR code. elastic is placed into the anterior after cataract surgery: Swedish National Cataract Register study. chamber to protect the corneal J Cataract Refract Surg. 2012 Jul;38(7):1181-6. 82 REVIEW OF OPTOMETRY JANUARY 15, 2015 082_ro0115_surgical.indd 90 1/9/15 10:32 AM DOWNLOAD LAYAR APP FOR INTERACTIVE EXPERIENCE First 150 app downloads and completed forms will be entered into a drawing for FREE MEETING AND REGISTRATION VALUED AT $495 INTERACTIVE PRINT es and T gi re o a l t o m REVIEW OF OPTOMETRY n e EDUCATIONAL MEETINGS OF CLINICAL EXCELLENCE h T n c t e N s T w T e & N E ON CAR IN VISION2015 CARE PAUL KARPECKI, OD PROGRAM CHAIR Save these Dates PHILADELPHIA, PA NOVEMBER 6-8 MAUI, HI JULY 23-26 CHARLESTON, SC Includes hands-on workshops JUNE 12-14 NEW SAN DIEGO, CA UpUp toto APRIL 10-12 For more information visit www.reviewofoptometry.com 17 CE Credits (COPE approval pending) *Approval pending 2015meetings_V2.indd 1 12/3/14 4:05 PM Product Review Diagnostic Equipment standalone unit via a software application and can be Adjustable Slit Lamp used automatically or manually with or without pupil Hai Laboratories recently dilation. announced a new slit lamp, Visit www.centervue.com. the Hai Elevate, that allows a comfortable exam experience Dry Eye Management for patients of all body types. FDA Clears Punctal Occluder for Dry Eye The slit lamp’s base is shorter The FDA recently cleared Lacri- than other devices to accom- vera’s VeraPlug punctal occluder modate larger patients. The for use in treating chronic dry eye. first point of contact between Available in three sizes—small, patient and tabletop can be medium and large—the VeraPlug raised to the upper chest so is individually packaged and the patient can easily reach preloaded on a sterile, dispos- the chinrest. able inserter/dilator. The device Visit www.hailabs.com. includes a unique shaft design and low-profile dome to offer easy New Software for Spectralis insertion and better patient com- New spectral-domain optical coherence tomography fort, the company says. software (Glaucoma Module Premium Edition, Hei- Visit www.lacrivera.com. delberg Engineering) can improve serial analysis of glaucoma patients and suspects by using anatomic regis- Contact Lenses tration to track progression. The program combines an Patient Education Initiatives anatomic positioning system (APS) and specific scan pat- Bausch + Lomb is launching consumer education terns to better analyze the optic nerve head, the retinal efforts on proper contact lens wear and care using nerve fiber layer and ganglion cell layer to permit earlier social media. The campaign encourages people to visit diagnosis of glaucoma, the company says. their eye doctor. The programs include: The APS detects the fovea and optic nerve head and • Bausch + Lomb Ultra Contact Lenses: Keeping uses them as landmarks to create a map of the eye and Up With Today’s Advances in Digital Technology center on the optic nerve head. • Biotrue Oneday Contact Lenses: What’s in Your Visit www.heidelbergengineering.com. Dryness Survival Kit? • PureVision 2 Multi-Focal Contact Lenses for True-Color Retinal Scanner Presbyopia: Do Your Eyes Show Your Age? CenterVue recently announced 510(k) FDA clearance • Biotrue Multi-purpose Solution: The Eye-opening for its Eidon true-color confocal scanner for retinal Facts About Binge-Watching disease detection. Visit www.bausch.com. The technology is the first to combine Silicone Hydrogel Lens Enters US Market confocal imaging CooperVision has announced wider distribution of and white light Clariti 1-day silicone hydrogel contact lenses in the illumination, the US market. This expansion is a result of Cooper- company says, Vision’s recent acquisition of Sauflon Pharmaceuticals for imaging of the earlier this year. central retina and The Clariti 1-day lenses are manufactured with a periphery. high water content for good oxygen transmissibility, Eidon includes says the manufacturer, and are available with sphere three imaging powers from +8.00D to -10.00D, a base curve of modes—true-color, 8.6mm and a diameter of 14.1mm. Toric and multifo- red-free and infrared—and automatic patient sens- cal options are also available. ing, alignment and focus capabilities. It operates as a Visit www.coopervision.com. ■ 84 REVIEW OF OPTOMETRY JANUARY 15, 2015 084_ro0115_products.indd 92 1/8/15 2:33 PM Meetings + Conferences Advertisers Index February 2015 For advertising opportunities contact: ■ 6-8. 2015 PBCOA Winter Seminar. PGA National Resort Michele Barrett (215) 519-1414 or [email protected] & Spa, Palm Beach Gardens, FL. Hosted by: Palm Beach James Henne (610) 492-1017 or [email protected] County Optometric Association. CE hours: 20. Key faculty: Carl Pelino, OD and Kimberly Reed, OD. To register, go to: Alcon Laboratories ...... 19, 92 www.pbcoa.org. Phone ...... (800) 451-3937 ■ 7-8. Destination CE. Crowne Plaza Hotel, New Orleans, Fax ...... (817) 551-4352 LA. Hosted by: Southern College of Optometry. CE Hours: 12. Key Faculty: Michael Gerstner, OD, FAAO; Whitney Allergan, Inc...... 7, 8, 39, 40 Hauser, OD; Mike Dorkowski, OD, FAAO; John Rumpakis, Phone ...... (800) 347-4500 OD, MBA.To register, call 800-238-0180, ext. 5, or email Bausch + Lomb ...... 13, 14 [email protected]. Phone ...... (800) 323-0000 ■ 13-15. 54th Annual Contact Lens and Primary Care Fax ...... (813) 975-7762 Congress. Sheraton Kansas City Hotel at Crown Center. Kansas City, Mo. Hosted by: Heart of America Contact Lens Bausch + Lomb ...... 25, 26 Society. To register, go to www.hoacis.org. Phone ...... (866) 246-8245 ...... www.bausch.com ■ 13-17. Ski Vision 2015. Westin Snowmass Luxury Resort. Snowmass Village, Co. Hosted by: AAO and UABSO. CE CooperVision ...... 37, 91 hours: 20. Key faculty: Murray Fingeret, OD, Leo Semes, OD, Phone ...... (800) 341-2020 Jack Schaeffer, OD, Jack Cioffi, MD, David Friedman, MD, PhD, and more. To register, go to http://skivision.com. Fashion Optical Displays ...... 15 ■ 19-22. 115th TOA Annual Convention. Downtown Austin Phone ...... (800) 824-4106 Hilton Hotel, Austin. Hosted by: Texas Optometric Association. Fax ...... (530) 877-2013 CE hours: 27. Key faculty: Ian Ben Gaddie, OD, FAAO, Steven Icare USA ...... 10 Ferucci, OD, FAAO and Diana Shechtman, OD, FAAO. To reg- Phone ...... (888) 389-4022 ister, call Sherry Balance at (512) 707-2020 or email sherry@ ...... www.icare-usa.com txeyedoctors.com. ■ 20-21. 2015 Winter Conference. Grand Summit Hotel Keeler Instruments ...... 5 Sugarloaf, USA, Carrabassett Valley, ME. Hosted by: Maine Phone ...... (800) 523-5620 Fax ...... (610) 353-7814 Optometric Association. To register, call (207) 237-2000. ■ 26-28. Montana Optometric Association Winter Education Lombart Instruments ...... 21 Symposium Big Sky 2015. Big Sky Resort, Big Sky, MT. Phone ...... (800) 446-8092 Hosted by: Montana Optometric Association. CE hours: 13. Fax ...... (757) 855-1232 Key faculty: Bruce Onofrey, OD, RPh, FAAO, FOGS; Curtis R. Baxstrom, OD. To register, go to www.mteyes.com. US Ophthalmics...... 31, 33, 35 Phone ...... (888) 334-4640 March 2015 ...... [email protected] ...... www.usophthalmic.com ■ 4-8. SECO 2015. Georgia World Congress Center, Atlanta, Ga. Hosted by: SECO. To register, go to: www. Vision Source ...... 17 seco2015.com. Phone ...... (281) 312-1111 ■ 20-22. Vision Expo East. Jacob K. Javits Convention Fax ...... (281) 312-1153 Center. New York, New York. Hosted by: International Vision ...... www.visionsource.com Expo and Conference. To register, go to www.visionexpoeast. Vistakon ...... 2-3 com. Phone ...... (800) 874-5278 To list your meeting, please send the details to: Fax ...... (904) 443-1252 Jack Persico, Editor-in-Chief Email: [email protected] This advertiser index is published as a convenience and not as part of the advertising contract. Every Phone: (610) 492-1006 care will be taken to index correctly. No allowance will be made for errors due to spelling, incorrect page number, or failure to insert. REVIEW OF OPTOMETRY JANUARY 15, 2015 85 085_ro0115_m&c.indd 85 1/8/15 2:54 PM Review Classifi eds Merchandise Offered Products and Services Conference 86 REVIEW OF OPTOMETRY JANUARY 15, 2015 ROPT0115.indd 86 1/6/15 2:40 PM Review Classifi eds Merchandise Offered BUILDING YOU A BETTER BUSINESS SPACE PLANNING INTERIOR DESIGN DISPLAY INNOVATION MANUFACTURING WWW.EYEDESIGNS.COM 800.346.8890 FREE GIFT IRU WKH ŵUVW SHRSOH WR FRQWDFW XV 5HI FRGH 237 H[S [email protected] TO REQUEST OUR CATALOG & DESIGN SERVICES CALL 610.489.7620 FREE GIFTIRUWKHŵUVWSHRSOHWRFRQWDFW XV5HIFRGH 237H[S Equipment and Supplies It’s What the Best Pretest on! (800) 522-2275 www.optinomics.com [email protected] Targeting Optometrists? CLASSIFIED ADVERTISING WORKS Contact us today for classified advertising: Toll free: 888.498.1460 • E-mail: [email protected] REVIEW OF OPTOMETRY JANUARY 15, 2015 87 ROPT0115.indd 87 1/6/15 2:40 PM Review Classifi eds Continuing Medical Education Continuing Education American Academy of Optometry Eagle Eye 31st Annual New Jersey Chapter Palm Beach Winter Seminar 13t h Annual Educational Conference Seminars April 22-26, 2015 February 6th to 8th, 2015 Myrtle Beach, South Carolina JULY 18-25, 2015 Hilton Embassy Suites at Kingston Plantation Dr. Mark Friedberg, M.D. Erik Schmidt OD, FAAO Founding Editor of the 16 HOURS Wills Eye Manual COPE CE JULY 16-23, 2016 Dr. Alan Kabat, OD., F.A.A.O. Nathan Lighthizer OD, FAAO Registration: $475.00 www.PBCOA.org One, Two or Three Bedroom Suites PGA National Resort & Spa Accommodations Include a Daily Breakfast Buffet and Evening Cocktail Reception WORLD CLASS MUSKY, 400 Avenue of the Champions PACK YOUR CLUBS! Palm Beach Gardens, FL 33418 Golf details to follow. WALLEYE, SMALLMOUTH For Accommodation and Additional Information, contact: Featured Speakers: Dennis H. Lyons, OD, F.A.A.O. FISHING Carlo Pelino, O.D., F.A.A.O. Phone: (732) 920-0110 Kimberly Reed, O.D., F.A.A.O. E-Mail: [email protected] Classes include: • Eagle Lake Island lodge *20 hours COPE approved CE including 8 hours TQ • Eagle Lake Ontario *Florida Jurisprudence • 12 hours of CE *Medical Errors Exhibit Hall: *over 25 industry supporters Contact Dean Springer OD We’re looking forward to seeing you! Do you have CE Programs? [email protected] Rooms are filling up fast, book now! CONTACT US TODAY FOR CLASSIFIED ADVERTISING Phone: 715-637-2020 Conference registration www.pbcoa.org Toll free: 888-498-1460 Room registration link E-mail: [email protected] Tinyurl.com/2015PBWS Software Medical Facility Optometrists The American Board of Certification in Medical Optometry is utilized at accredited medical facilities to verify specialist-level compe- Take a closer look... tence in medical optometry. ABCMO certifies specialized competence of a higher level than that required for licensure and general practice. at Eyecom for your Visit www.abcmo.org to learn why medical facilities require board certification of specialists electronic health record needs! and why only ABCMO board certification in the specialty of medical optometry is accepted. Questions? [email protected]. NOTICE: After August 1, 2003, all applicants for ABCMO board certification must have com- pleted an ACOE residency in medical optometry and passed the Advanced Competence in Medical Optometry examination of the NBEO. tablet compliant www.abcmo.org share patient data securely over 25 years experience Scientia est Potentia cloud-based access anytime, anywhere Contact us today for classified advertising: Toll free: 888-498-1460 800.788.3356 www.eyecom3.com E-mail: [email protected] 88 REVIEW OF OPTOMETRY JANUARY 15, 2015 ROPT0115.indd 88 1/6/15 2:41 PM Review Classifi eds Professional Opportunities WORCESTER STAFF OPTOMETRIST FULL TIME/RELIEF Bard Optical is a leading Midwest vision care FT OD NEEDED organization in business for over 70 years and DOCTOR ƵƐLJƉƌĂĐƟĐĞǁŝƚŚƚǁŽ we are still growing. The company is based in ŽƉŚƚŚĂůŵŽůŽŐŝƐƚƐĂŶĚƚǁŽ Peoria, IL with 20 retail offices throughout the &ÊÙãtÊÙã«͕dy central Illinois area, as far north as Sterling ŽƉƚŽŵĞƚƌŝƐƚƐƐĞĞŬƐ&dŽƉƚŽŵĞƚƌŝƐƚ͘ and as far south as Jacksonville. Once again ^ĂƚƵƌĚĂLJƐĂŶĚŽŶĞůĂƚĞĞǀĞŶŝŶŐ this year we were named to the Top 50 Optical Retailers in the United States by Vision WŽƐŝƟŽŶ ĂǀĂŝůĂďůĞ ĨŽƌ ĨƵůů ƌĞƋƵŝƌĞĚ͘ŽŵƉĞƟƟǀĞĐŽŵƉĞŶƐĂƟŽŶ Monday – currently ranking 37th. A progres- ĂŶĚďĞŶĞĮƚƐ͘ sive optometric staff is vital to the continued ƟŵĞͬƌĞůŝĞĨ ĚŽĐƚŽƌ ŝŶ &Žƌƚ growth of our organization whose foundation Contact: Michele Rickert is based on one-on-one patient service. We tŽƌƚŚ͕ dy ĨŽƌ ůĂƌŐĞ ŐƌŽƵƉ are currently accepting CV/resumes for Phone: 508-853-2020 optometrists focused on full scope primary ƉƌĂĐƟĐĞ͕ ϱ< ƐŝŐŶŝŶŐ ďŽŶƵƐ͕ medical patient care. The candidate must have Email: [email protected] an Illinois license with therapeutics. The prac- ĞdžĐĞůůĞŶƚ ƐĂůĂƌLJ͕ ƉĂŝĚ ǀĂĐĂ- tice includes (but is not limited to) general optometry, contact lenses, and geriatric care. ƟŽŶƐ͕ Θ ƉĂŝĚ ƉƌŽĨĞƐƐŝŽŶĂů Salaried, full-time positions are available with excellent growth programs and benefits. ůŝĂďŝůŝƚLJŝŶƐƵƌĂŶĐĞ͘ Some part-time opportunities may be avail- able also. Please email your information to Place Your [email protected] or fax to 309-693-9754. Mailing address if more convenient is ϰϬ«ÊçÙóÊÙ»ó»ó®ã« Bard Optical, Attn: HR, 8309 N Knoxville Ad Here! Avenue, Peoria, IL 61615. Ask about ÄÊ^çÄùÝ opportunities within Bard Optical. We have 888-498-1460 openings in several existing and new offices Toll free: opening soon in central Illinois. Call Angela at Bard Optical is a proud E-mail: [email protected] Associate Member of the (817) 738-6672 x11 Illinois Optometric Association. or e-mail curricular vitae to www.bardoptical.com ĂŵŽŶŬΛůƵĐŬŽƉƟĐĂů͘ĐŽŵ Practice For Sale PRACTICE SALES & APPRAISAL Expert Services for: Buying or Selling a Practice Practice Appraisal Practice Financing Practice Sales • Appraisals • Consulting www.PracticeConsultants.com Partner Buy-in or Buy-out Do you have PRACTICES FOR SALE CE Programs? Call for a Free Consultation NATIONWIDE (800) 416-2055 Visit us on the Web or call us to learn www.TransitionConsultants.com more about our company and the CLASSIFIED practices we have available. ADVERTISING [email protected] WORKS OPTOMETRIC PRACTICE FOR SALE NORTHEASTERN PA 800-576-6935 Very Successful ongoing optometric prac- Contact us today for ƟĐĞĨŽƌƐĂůĞŝŶEŽƌƚŚĞĂƐƚĞƌŶW͘dŚĞƉƌĂĐ- www.PracticeConsultants.com classified advertising: ƟĐĞŝƐŐƌŽƐƐŝŶŐϲϬϬ<ͬLJƌ͘dŚŝƐƉƌĂĐƟĐĞŝƐ ŽŶĞŽĨĂŬŝŶĚǁŝƚŚĂǀĞƌLJůĂƌŐĞĂŶĚďƌŽĂĚ Toll free: 888-498-1460 ƉĂƟĞŶƚďĂƐĞĂŶĚůĂƌŐĞĐŽŶƚĂĐƚůĞŶƐďĂƐĞ͘ dŚĞ ƉƌĂĐƟĐĞ ƐĞƌǀŝĐĞƐ ŵĂŶLJ ǀŝƐŝŽŶ ĐĂƌĞ E-mail: [email protected] ƉƌŽŐƌĂŵƐƚŚĂƚůĞŶĚƐƚŽŝƚƐƐƵĐĐĞƐƐ͕ĂůŽŶŐ ǁŝƚŚ Ă ĨƵůů ĐŽŵƉůĞŵĞŶƚ ŽĨ ĚŝƌĞĐƚ ƉĂLJŝŶŐ ƉĂƟĞŶƚƐ͘/ǁŝůůďĞǁŝůůŝŶŐƚŽǁŽƌŬŝŶƚŚĞ Do you have ƉƌĂĐƟĐĞ͘ CE Programs? Serious replies only. CONTACT US TODAY FOR CLASSIFIED ADVERTISING Email: [email protected] Toll free: 888-498-1460 ó®ã«ÊÃÖ½ãÄÃÄÊÄãã®Ä¥Ê E-mail: [email protected] REVIEW OF OPTOMETRY JANUARY 15, 2015 89 ROPT0115.indd 89 1/6/15 2:41 PM Diagnostic Quiz Her Vision is on the Bubble By Andrew S. Gurwood, OD History ary to unsustainable fixation. She A 47-year-old black female pre- was pseudophakic OS, with poste- sented with a chief complaint of rior capsular opacification. blurry vision in her right eye. She Intraocular pressure measured explained that her vision had been 15mm Hg OU. Dilated fundus eval- poor since she underwent retinal uation revealed areas of dense PRP reattachment surgery secondary OU, evidence of focal laser to both to advanced proliferative diabetic maculae, and an attached and flat retinopathy (PDR) OS six months retina OS with no new neovascular earlier. fronds or retinal breaks. Her ocular history was remark- able for PDR OU, which was Your Diagnosis treated with panretinal photo- This patient with a history of How would you approach this coagulation (PRP) and vascular proliferative diabetic retinopathy case? Does this patient require endotheilial growth factor (VEGF) reported poor vision in her left eye any additional tests? What is your inhibitor injections; clinically following retinal reattachment surgery. diagnosis? How would you man- significant macular edema OU, What is the correct diagnosis? age this patient? What’s the likely which was treated with focal laser prognosis? and VEGF therapy; and tractional She reported no known allergies To find out, please visit Review retinal detachment OS, which was of any kind. of Optometry Online, www. repaired by a retina specialist six reviewofoptometry.com. Click months prior. Diagnostic Data on the cover icon, and then click Her systemic history was remark- Her best-corrected visual acuity “Diagnostic Quiz” under this able for hypertension and type measured 20/50 OD and 20/100 month’s table of contents. ■ 1 diabetes mellitus, which were OS at distance and near. Her exter- Thanks to Peter J. Perno, BS, a properly controlled with valsartan/ nal examination uncovered an fourth-year student at Salus Uni- hydrochlorothiazide, metformin, afferent pupillary defect OS, with a versity in Elkins Park, Pa., for his glipizide and insulin. decompensated esophoria second- contributions to this case. Retina Quiz Answers (from page 72): 1) c; 2) c; 3) c; 4) d. Next Month in the Mag • Will ODs Treat Wet AMD Someday? February features our Innovations in Eye Care Report. • Have You Kept Up With These Advances in Contact Lens Topics include: Materials? • Glaucoma: Beyond the Optic Nerve • Optometric Study Center: Understanding the Efferent Visual • The Science of Dry Eye and Allergy System (earn 2 CE credits) REVIEW OF OPTOMETRY (ISSN 0147-7633) IS PUBLISHED MONTHLY, 12 TIMES A YEAR BY JOBSON MEDICAL INFORMATION LLC, 100 AVENUE OF THE AMERICAS, NEW YORK, NY 10013-1678. PERIODICALS POSTAGE PAID AT NEW YORK, NY AND ADDITIONAL MAILING OFFICES. POSTMASTER: SEND ADDRESS CHANGES TO REVIEW OF OPTOMETRY, PO BOX 81, CONGERS, NY 10920-0081. SUBSCRIPTION PRICES: US: ONE YEAR $56; TWO YEARS $97, CANADA: ONE YEAR $88, TWO YEARS $160, INT’L: ONE YEAR $209, TWO YEARS $299. FOR SUBSCRIPTION INFORMATION CALL TOLL-FREE (877) 529-1746 (USA); OUTSIDE USA, CALL (845) 267-3065. OR EMAIL US AT [email protected]. PUBLICATIONS MAIL AGREEMENT NO: 40612608. CANADA RETURNS TO BE SENT TO BLEUCHIP INTERNATIONAL, P.O. BOX 25542, LONDON, ON N6C 6B2. 90 REVIEW OF OPTOMETRY JANUARY 15, 2015 090_ro0115_dq.indd 90 1/8/15 1:44 PM All eyes deserve clariti. clariti 1 day—now available for practices everywhere. The world’s fi rst and only family of silicone hydrogel daily disposable contact lenses designed for every patient type—sphere, toric and multifocal. High Oxygen High Water Low UV Aff ordable Transmissibility Content Modulus Protection Upgrade Now you can prescribe all of your patients with healthy, comfortable, aff ordable silicone hydrogel 1 day lenses— which will make all eyes very happy indeed. To learn more, contact your CooperVision representative today or visit CooperVision.com/practitioner. RO0115_Cooper Clariti.indd 1 12/22/14 11:42 AM THIS IS WHY OPTI-FREE® PureMoist ® Solution allows patients to wear contact lenses MORE COMFORTABLY1 AND LONGER each day.2 The HydraGlyde® Moisture Matrix attaches and forms a hydrophilic environment across the surface of the lens—providing moisture from morning ’til night.2-4 57.6 3X FEWER PATIENTS reported end-of-day dryness5† 19.0 End-of-Day Dryness 0 20% 40% 60% 80% 100% Percentage of wearers in agreement Before switching to OPTI-FREE® PureMoist ® MPDS With OPTI-FREE® PureMoist ® MPDS †Based on a global survey of 10,611 contact lens wearers who tried OPTI-FREE® PureMoist® for two weeks. Talk to your patients about the benefit of OPTI-FREE® brand products. Learn more at MYALCON.COM PERFORMANCE DRIVEN BY SCIENCE™ References: 1. Campbell R, Kame G, Leach N, et al. Clinical benefits of a new multipurpose disinfecting solution in silicone hydrogel and soft contact lens users. Eye & Contact Lens. 2012;38(2):93-101. 2. Alcon data on file, 2011. 3. Lally J, Ketelson H, Borazjani R, et al. A new lens care solution provide moisture and comfort with today’s contact lenses. Optician. 2011;241:42-46. 4. Davis J, Ketelson HA, Shows A, Meadows DL, A lens care solution designed for wetting silicone hydrogel materials. ARVO Meeting Abstracts. 2012;38(2):93-101. 5. Lemp J, Kern JR. Results from global survey of contact lens-wearer satisfaction with OPTI-FREE® PureMoist® MPDS. Clinical Optometry. 2013:5 39-46. © 2014 Novartis 4/14 OPM14001JAD RO0115_Alcon Opti Free.indd 1 12/18/14 10:26 AM