Systemic Disease Report MARCH 15, 2014 ■ SYSTEMIC DISEASE REPORT ■ UV PROTECTION ■

5 Patients Who Need UV Protection—and Why, p. 28

March 15, 2014 REVIEW OF OPTOMETRY ■

www.revoptom.com VOL. 151 NO. 3 ■ Systemic Disease Report MARCH 15, 2014 ■ SYSTEMIC DISEASE REPORT ■ UV PROTECTION ■

VISION EXPO EAST PREVIEW Clinical connections and public health imperatives put ODs at the center of primary care. Nutrition and Diabetes: Our Role in Patient Care, p. 44 Obesity Counseling is Within Our Scope, p. 52 What Are the Ocular Manifestations of Hep B?, p. 60 Earn 2 CE Credits: Medical Syndromes That Affect Children’s Vision, p. 70 Review of Systems: The Interactive Eye, p. 87

ALSO INSIDE: The Legacy of AREDS, p. 36 • A Feast of CE at VEE, p. 80

fc_ro0314.indd 1 3/6/14 5:23 PM HEALTH YOU CAN SEE™

For more information visit acuvuepro.com

RO1213_Vistakon TruEye.indd 2 11/20/13 10:35 AM Well beyond comfortable... The only lens shown to be clinically comparable to wearing NO LENS AT ALL ON 5 OF 6 KEY MEASURES OF OCULAR HEALTH*†1:

• Limbal hyperemia • Bulbar conjunctival • Corneal staining hyperemia • Corneal vascularization • Papillary conjunctivitis

The sixth measure was conjunctival staining which diff ered between the lens wearers and spectacle wearers; however, both measures were very low and of limited clinical relevance.

Go beyond ocular comfort and help maintain ocular health.

* A 1-year, randomized, investigator-masked, parallel-group study of 74 subjects (aged 18-51 years) who had never worn soft contact lenses previously. Subjects were randomized to 1-DAY ACUVUE® TruEye® Brand or spectacles. Ocular physiology was assessed at 2 weeks, 1 month, 3 months, 6 months, 9 months, and 1 year using the Efron Grading Scale (a 0- to 4-point scale, with fi ndings recorded to the nearest 0.1). P<0.05 based on 2-sided 95% confi dence intervals. † The sixth measure was conjunctival staining. ACUVUE ® Brand Contact Lenses are indicated for vision correction. As with any contact lens, eye problems, including corneal ulcers, can develop. Some wearers may experience mild irritation, itching or discomfort. Lenses should not be prescribed if patients have any eye infection, or experience eye discomfort, excessive tearing, vision changes, redness or other eye problems. Consult the package insert for complete information. Complete information is also available from VISTAKON® Division of Johnson & Johnson Vision Care, Inc., by calling 1-800-843-2020 or by visiting acuvueprofessional.com. Reference: 1. Morgan P, Chamberlain P, Moody K, et al. Ocular physiology and comfort in neophyte subjects fi tted with daily disposable silicone hydrogel contact lenses. Cont Lens Anterior Eye. 2013;36(3):118-125. ACUVUE®, 1-DAY ACUVUE® TruEye®, HEALTH YOU CAN SEE™, and VISTAKON® are trademarks of Johnson & Johnson Vision Care, Inc. © Johnson & Johnson Vision Care, Inc. 2013 ACU-32440G July 2013

RO1213_Vistakon TruEye.indd 3 11/20/13 10:35 AM News Review

VOL. 151 NO. 3 ■ MARCH 15, 2014

IN THE NEWS Vision Training a Grand

The University of Alabama at Slam for Baseball Team Birmingham has named College baseball players improved vision and won games Kelly K. Nichols, after vision training. By Michael Hoster, Managing Editor OD, MPH, PhD, Photo: University of California, Riverside as dean of he University its School of of California, Optometry, TRiverside following the retirement of Dean Rod W. baseball team enjoyed Nowakowski, OD, PhD. “It is an honor a significant on-field and a privilege to be selected as dean performance boost fol- of the UAB School of Optometry,” Dr. lowing two months of Nichols said. “I look forward to working vision training. Players together with Provost [Linda] Lucas had a 31% improve- and the talented and dedicated faculty ment in visual acuity, to continue the tradition of clinical and which led to 4.4% research excellence.” Dr. Nichols takes fewer strikeouts, an After vision training, the University of California, offi ce on June 25. estimated 41 more runs Riverside baseball team had 41 more runs in 2013. and four or five more Dua’s layer, discovered last year, is winning games in their 2013 season, mer as the simulation progressed, a 15µm layer of the cornea located according to a study in the February which forced the players to focus between the corneal stroma and 17 issue of Current Biology. and concentrate more intensely. Descemet’s membrane. The research- “I didn’t think we would see as “The goal of the program is to ers who found it now report online much of an improvement as we train the brain to better respond to in British Journal of Ophthalmology did,” says UCR head baseball coach the inputs that it gets for the eye,” that Dua’s layer is also linked to the Doug Smith. “Our guys stopped said lead author Aaron Seitz, PhD, trabecular meshwork. They deter- swinging at some pitches and started associate professor of psychology mined that the collagen fi bers of Dua’s hitting at others.” at UC, Riverside. “When we go to layer branch out to form a meshwork The authors believe that this is the gym and exercise, we are able to such that the trabecular meshwork’s the first study to show that percep- increase our physical fitness; it’s the collagen core is actually an extension tual learning can yield quantifiable same thing with the brain. By exer- of Dua’s layer. “This fi nding … has the vision improvements in normally cising our mental processes, we can potential to impact future research into sighted individuals. promote our mental fitness.” the TM and glaucoma,” they concluded. During the study period, the After two months of vision train- players used custom software built ing, the players reported that they The world’s largest manufacturer of into an electronic vision training saw the ball more clearly, were able prescription eyeglass lenses, Essilor program (Ultimeyes, Carrot Neu- to see further on the field and could International, has agreed to buy the rotechnology) for 25 minutes per more easily distinguish between world’s second largest supplier of day, four days a week. The program low-contrast objects. contact lenses, Coastal Contacts Inc., instructed players to find and select “The demonstration that seven for $387 million. The transaction is patterns (Gabor targets) that specifi- players reached 20/7.5 acuity—the expected to close in the second quarter cally stimulated neurons associated ability to read text at three times the of 2014. with the early visual cortex. These distance of a normal observer—is stimuli were made increasingly dim- Continued on page 10

4 REVIEW OF OPTOMETRY MARCH 15, 2014

004_ro0314_news.indd 4 3/6/14 10:54 AM Tonometry Done Right

KAT Keeler quality.

Pulsair Desktop Smallest footprint and simple to use! Purchase a Pulsair Desktop by March 31, 2014 and get a $1,300 Instant Rebate!

Intellipuff The standard for hand held mobility.

Keeler Instruments, Inc. • 456 Parkway • Broomall, PA 19008 • Tel: (800) 523-5620 • Fax: (610) 353-7814 • email: [email protected]

RO0114_Keeler Tono.indd 1 1/6/14 1:46 PM News Review

Exercise Preserves Vision in AMD oderate aerobic exercise exercised mice had nearly twice tective effects of aerobic exercise. helps protect the struc- the number of photoreceptor cells “One point to emphasize is that Mture and function of as those that spent the equivalent the exercise the animals engaged nerve cells in the retina after dam- amount of time on a stationary in is really comparable to a brisk age, say researchers at the Emory treadmill, and their retinal cells walk,” Dr. Pardue says. “One Eye Center and the Atlanta VA were more responsive to light. previous study that examined

Medical Center, who investigated Photo: Salk Institute of Biological Studies the effects of exercise on vision this in a mouse model of macular in humans had examined a select degeneration. group of long-distance runners. The fi ndings, published in the Our results suggest it’s possible February 12 issue of the Journal of to attain these effects with more Neuroscience, are the fi rst to sug- moderate exercise.” gest that aerobic exercise can have The investigators are now test- a direct neuroprotective effect on ing whether other exercise regi- retinal health and vision. mens are even more protective, “This research may lead to tai- and whether exercise is benefi cial lored exercise regimens or combi- After retinal degeneration, mice that for other retinal diseases, such as nation therapies in treatments of exercised had twice the number of photo- glaucoma and diabetic retinopa- retinal degenerative diseases,” says receptors as mice that didn’t exercise. thy. coauthor Machelle Pardue, PhD. “This is a very intriguing study, “Possibly in the near future, oph- The researchers were able to and probably worth following thalmologists could be prescribing show that the effects of exercise up in humans,” says D. Joshua exercise as a low-cost intervention come partly from a growth fac- Cameron, PhD, assistant professor to delay vision loss.” tor called BDNF, which has been at Western University of Health The researchers trained mice to linked in other studies to the Sciences College of Optometry, run on a treadmill for one hour benefi cial effects of exercise. The whose research also centers on the per day, fi ve days per week, for exercised mice had higher levels neurobiological development of two weeks. After the animals were of BDNF in the blood, brain and eye disease. “I would expect that exposed to toxic bright light to retina. humans might require more than induce retinal degeneration, they The researchers also demon- just a few weeks of moderate ex- exercised for two more weeks. strated that chemically blocking ercise, and any changes in humans The investigators found that the BDNF receptors negated the pro- will probably be much less pronounced [because] … the human disease generally progresses over a High-Tech Glasses Help Surgeons ‘See’ Cancer Cells much longer time-frame.” The distinction between normal Photo: Robert Boston/Washington University School of Medicine While exercise likely would tissue and cancerous tissue is contribute to overall health, and not always clear to the naked consequently prevent/delay disease eye. But new high-tech glasses onset—including a progressive eye developed at the Washington disease such as AMD—“advising University School of Medicine in any patient who can safely do St. Louis will bring cancer cells moderate, frequent exercise is to new light. likely to be benefi cial to them for When viewed through the many health reasons, not just eye newly developed eyewear, cancer cells glow blue, helping to ensure that no stray tumor health,” Dr. Cameron says. cells are left behind in surgery. These glasses could reduce the need for follow-up Lawson EC, Han MK, Sellers JT, et al. Aerobic exercise pro- surgeries intended to remove previously unseen cancer cells, investigators say. tects retinal function and structure from light-induced retinal degeneration. J Neurosci. 2014 Feb 12;34(7):2406-12.

6 REVIEW OF OPTOMETRY MARCH 15, 2014

004_ro0314_news.indd 6 3/6/14 10:54 AM RP0214_Diopsys.indd 1 1/30/14 9:56 AM News Review

Two New Optometry Schools Planned he University of three years ago) is mov- Pikeville, located ing forward in Grundy, Tin the Appalachian Va. Mountains of eastern Officials from Appala- Kentucky, announced it will chian College of Optom- create the state’s first college etry recently signed an of optometry. agreement with Emory & University president James Henry College, in Emory, Hurley, EdD, said that the Va., to work together Kentucky College of Optom- toward the development etry will open in the fall The University of Pikeville College of Optometry, to open in of the school of optom- of 2016 with an inaugural 2016, would be Kentucky’s first optometry school. etry in Grundy. The class of 60 students, and agreement formalizes an be housed in a newly built facil- Dr. Hurley said that the new col- effort to achieve accreditation for ity. It would be the 22nd college of lege is necessary to meet the demand the school. optometry in the United States. for eye care. “More than 25% of The school will likely be renamed The university has completed a our counties in the commonwealth Emory & Henry College, School of feasibility study, and an advisory [of Kentucky] don’t have a practic- Optometry, although the final deci- committee (including Kentucky ing optometrist.” Also, there are no sion has not been made, said current optometrists Joe E. Ellis and Jerald other schools of optometry in the president Brian Looney, OD. F. Combs) will help move the college South within hundreds of miles. Nevertheless, the optometry of optometry forward. The univer- However, less than 50 miles away, school expects to open in the fall of sity has also started a search for the the Appalachian College of Optom- 2016 with a class of 48 students, Dr. college’s dean. etry (which was first announced Looney said. Single Injection Restores Light Perception in Blind Mice ntraocular injection of a novel mice with functional, nonfunc- mals is needed to assess the short- compound enables healthy tional or degenerated photore- and long-term safety of DENAQ Iretinal ganglion cells to perceive ceptors. The retinal ganglion and related chemicals,” says lead light in the absence of functioning cells in the diseased-retina mice author Richard H. Kramer, PhD, rod and cone receptors in mice, ac- showed strong light sensitivity professor of molecular and cell bi- cording to a study in the February after DENAQ treatment. But mice ology at the University of Califor- 19 issue of Neuron. with intact photoreceptors had no nia, Berkeley. “It will take several The ﬁ ndings suggest that the response to DENAQ treatment. more years, but if safety can be es- experimental chemical, DENAQ, The researchers determined that tablished, these compounds might could temporarily restore visual the compound only photosensi- ultimately be useful for restoring function in patients with retinitis tized ganglion cells if the subjects’ light sensitivity to blind humans. pigmentosa or age-related macular rods and cones were degenerated. How close they can come to re- degeneration who’ve experienced Thus, they predict that DENAQ establishing normal vision remains severe photoreceptor degenera- could be the most effective in pa- to be seen.” tion. tients with end-stage degenerative Tochitsky I, Polosukhina A, Degtyar VE, et al. Restoring visual function to blind mice with a photoswitch that exploits elec- In this study, a single injection retinal disease. trophysiological remodeling of retinal ganglion cells. Neuron. of DENAQ was administered to “Further testing on larger mam- 2014 Feb 19;81(4):800-13.

8 REVIEW OF OPTOMETRY MARCH 15, 2014

004_ro0314_news.indd 8 3/6/14 10:56 AM 800.735.0357 LEGENDARY haag-streit-usa.com IS INDESTRUCTIBLE

After 1,300 years, the Great Wall finally has company. Brutishly durable exam chairs and stands from Reliance Medical Products. Like the wall, they’re time tested. And hand built with rock solid materials. These are the qualities of a legend that your practice demands.

Follow the nearest path to your Reliance distributor. Call 800.735.0357, or visit reliance-medical.com. Visit us at SECO booth #1221.

RO0314_Reliance.indd 1 2/24/14 3:32 PM News Review

Multivitamins Decrease Cataract Risk in Men ong-term use of daily reduction would nonetheless have multivitamin supplements a large public health impact,” says may lower cataract risk William Christen, ScD, lead au- BUSINESS OFFICES L 11 CAMPUS BLVD., SUITE 100 in men by about 9%, according thor of the study and a researcher NEWTOWN SQUARE, PA 19073

to researchers with Brigham and at Harvard Medical School. CEO, INFORMATION SERVICES GROUP Women’s Hospital and Harvard Interestingly, there were 152 MARC FERRARA (212) 274-7062 •MFERRARA @JOBSON.COM Medical School. new cases of visually signiﬁ cant SALES MANAGER, NORTHEAST, OHIO The randomized, double-blind AMD in the multivitamin group JAMES HENNE study, published in the Febru- compared to 129 in the placebo (610) 492-1017 •JHENNE @JOBSON.COM ary issue of Ophthalmology, was group—a ﬁ nding that seems to SALES MANAGER, SOUTHEAST, WEST MICHELE BARRETT conducted from 1997 to 2011 on contradict results of studies such (610) 492-1014 •MBARRETT @JOBSON.COM

more than 14,600 male doctors as AREDS. However, research- VICE PRESIDENT, OPERATIONS CASEY FOSTER age 50 and older (part of the ers clarifi ed that the studies had (610) 492-1007 •CFOSTER @JOBSON.COM Physicians’ Health Study II). Half different nutrient supplements, VICE PRESIDENT, CLINICAL CONTENT took a common multivitamin, dosing and objectives. PAUL M. KARPECKI, OD, FAAO [email protected] as well as vitamin C, E and beta “This fi nding of more cases of PRODUCTION MANAGER carotene supplements. The others AMD in the multivitamin group SCOTT TOBIN took a placebo. Of the multivita- than in the placebo group, though (610) 492-1011 •STOBIN @JOBSON.COM min group, 945 cases of cataract not statistically signifi cant, does SENIOR CIRCULATION MANAGER HAMILTON MAHER were reported, compared with 872 raise some concerns,” Dr. Christen (212) 219-7870 •HMAHER @JHIHEALTH.COM

for those on placebo—a decreased said. “Clearly, this ﬁ nding needs CLASSIFIED ADVERTISING risk of 9%, researchers say. That to be examined further in other (888) 498-1460 number was four percentage trials of multivitamin supplements SUBSCRIPTIONS $56 A YEAR, $88 (US) IN CANADA, points higher for nuclear cataract. in both men and women.” $209 (US) IN ALL OTHER COUNTRIES.

“If multivitamins really do Christen WG, Glynn RJ, Manson JE, et al. Effects of multi- SUBSCRIPTION INQUIRIES reduce the risk of cataract, even by vitamin supplement on cataract and age-related macular (877) 529-1746 (US ONLY); degeneration in a randomized trial of male physicians. OUTSIDE US, CALL (847) 763-9630 a modest 10%, this rather small Ophthalmology. 2014 Feb;121(2):525-34. CIRCULATION PO BOX 2025 SKOKIE, IL 60076 TEL: (TOLL FREE) 1-877-529-1746 OUTSIDE US: (847)763-9630 Baseball Vision Training FAX: (847)763-9631 Continued from page 4 our function, our potential is greater dramatic and required players to than our normative level of per- stand 40 feet back from the eye formance,” said Dr. Seitz. “Under- chart in order to get a measurement standing the rules of brain plasticity CEO, INFORMATION SERVICES GROUP of their vision,” Dr. Seitz added. unlocks great potential for improve- MARC FERRARA Even more impressive, the play- ment of health and wellbeing.” SENIOR VICE PRESIDENT, OPERATIONS ers began to perform better on the Going forward, the researchers JEFF LEVITZ

diamond. They had fewer strikeouts hope to use their training program SENIOR VICE PRESIDENT, HUMAN RESOURCES and generated more runs follow- to improve poor visual acuity in LORRAINE ORLANDO ing the training period, which the cataract, macular degeneration and VICE PRESIDENT, CREATIVE SERVICES & PRODUCTION MONICA TETTAMANZI researchers believe may have trans- amblyopia patients. ■ VICE PRESIDENT, CIRCULATION lated into an additional four to five EMELDA BAREA Deveau J, Ozer DJ, Seitz AR. Improved vision and on-ﬁ eld team victories during the season. performance in baseball through perceptual learning. Curr “As with most other aspects of Biol. 2014 Feb 17;24(4):R146-7.

10 REVIEW OF OPTOMETRY MARCH 15, 2014

004_ro0314_news.indd 10 3/6/14 10:56 AM RO0314_Coburn.indd 1 2/24/14 3:16 PM The world’s ﬁrst hydrogel, daily

Affordable

SINGLE VISION ASTIGMATISM

RO0314_Sauflon.indd 2 2/25/14 9:16 AM and only silicone disposable family.

Innovation

PRESBYOPIA Exclusively for Eye Care Professionals

For more information contact Sauflon at: T: 800-682-3240 E: info@sauflon.com www.sauflonusa.com

RO0314_Sauflon.indd 3 2/25/14 9:16 AM 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: Protecting the Ocular Surface by Increasing Lipid Layer Thickness (LLT)

SYSTANE® BALANCE Lubricant Eye Drops forms a protective matrix that is Your recommendation counts. designed to replenish the lipid layer for long-lasting relief from LIPID LAYER the symptoms associated with evaporative dry eye (MGD). Make sure your patients US L This unique formulation is QUEO AYER A designed to work on all 3 layers get the lasting symptom of the tear ﬁ lm, speciﬁ cally IN LA relief they need by offering MUC YER MEIBOMIAN increasing LLT. This helps ® GLAND AL EPITH them SYSTANE BALANCE NE ELI create a protective environment OR UM C for the ocular surface.2 Lubricant Eye Drops.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.

RO0314_Alcon Systane.indd 1 2/19/14 11:24 AM Contents Review of Optometry March 2014

Systemic Disease Report 5 Patients Who Need UV 28 Protection and Why Taking a thorough patient history is the first step in formulating personalized recommendations for UV protection. By Cheryl G. Murphy, OD

Nutrition and Diabetes: 44 Our Role in Patient Care If we don’t educate our patients about the dangers of poor dietary habits and sedentary lifestyles, the incidence of diabetic eye disease will continue to soar. By Laurie Capogna, OD, and Barbara Pelletier, OD 36 The Legacy of AREDS AREDS-2 raised eyebrows, but it could also open doors to ‘pharmacogenomics’ and more meaningful use of personal- Obesity Counseling is ized genetic testing. By Dennis Ruskin, OD 52 Within Our Scope You can no longer afford to ignore the problem or simply hand it off to another clinician. Today, helping patients manage 80 A Feast of CE at VEE their body weightWhyW his yone DDry ofr oury EEye fundamentalye TTrialsria lresponsibilities.s The Big Apple has everything you need this March to satisfy By50 Kimberly K.OftenO Reed,ften OD FFailail your appetite for CE. By Cheryl G. Murphy, OD FromFrom diseadiseasese varvariabilityiability to conconfoundingfounding undeunderlyingrlying cconditions,onditions, ttherehere araree countcountlessless reasonreasonss wwhyhy new ddryry eyeyee ddrugsrugs hhaveave ccomeome up sshorthort iinn FDFDAWhatA tetesting.stingg. are the Ocular 60By PPaulaul M. Karpecki,KarManifestationspecki, OD, Co-ChiefCo-Chief ClinicalClin icofal EditorEHepditor B? Eye care professionals may play a role in both the diagnosis and managementA LifetimeL ofi fae numbertime ofoof conditionsf secondary to HBV. By61 Denh Tuyen,DryD rOD,y EEyeandye Andrew S. Gurwood, OD DryDry eyeeye can strikestrike patientspatients ooff any aage.ge. Do you kknownow ththee susubtlebbtle signssigns anandd sysymptomsmpEarntoms 2 tto oCE lolookok Credits: ffor,or, anandd ththee paparticularrticular ttreatmentsreatmments to prpprovide,ovide,, amoamongngg ppatientsatients of difdifferentferent aages?ges?s ByB CCherylheryl G. MedicalMMurphy,urphy, OOD,D, ContributingC Syndromesonttriibuting EditorEditorr That 70 Affect Children’s Vision These conditions aren’t ordinary—nor should be your evaluation and treatment of these children. By Marie Bodack, OD

REVIEW OF OPTOMETRY MARCH 15, 2014 15

015_ro0314_toc.indd 15 3/6/14 5:13 PM Departments Review of Optometry March 2014 4 News Review PRINTED IN U.S.A. 20 Outlook FOUNDING EDITOR FREDERICK BOGER Beyond the Eye 1891-1913 PAUL M. KARPECKI, OD EDITORIAL OFFICES 82 11 CAMPUS BLVD., SUITE 100 22 Chairside NEWTOWN SQUARE, PA 19073 No Cure for the Common Code EMAIL • [email protected] WEBSITE •WWW .REVOPTOM.COM MONTGOMERY VICKERS, OD SUBSCRIPTION INQUIRIES 1-877-529-1746 24 Coding Abstract CONTINUING EDUCATION INQUIRIES An Ounce of Prevention 1-800-825-4696 JOHN RUMPAKIS, OD, MBA EDITOR-IN-CHIEF •JACK PERSICO (610) 492-1006 •JPERSICO @JOBSON.COM 82 Comanagement Q+A EXECUTIVE EDITOR •JOHN MURPHY Red Eye of Olympic Proportions (610) 492-1021 •JMURPHY @JOBSON.COM PAUL C. AJAMIAN, OD MANAGING EDITOR •M ICHAEL HOSTER 84 Cornea + Contact Lens Q+A 90 (610) 492-1028 •MHOSTER @JOBSON.COM Bugs and Drugs SENIOR ASSOCIATE EDITOR/WEB EDITOR •E RIN KELLY JOSEPH P. SHOVLIN, OD (610) 492-1005 •EKELLY @JOBSON.COM

ASSOCIATE EDITOR •F RANK AULETTO 87 Review of Systems (610) 492-1043 •FAULETTO @JOBSON.COM The Interactive Eye DIRECTOR ART/PRODUCTION •JOE MORRIS CARLO J. PELINO, OD (610) 492-1027 •JMORRIS @JOBSON.COM JOSEPH J. PIZZIMENTI, OD ART DIRECTOR •JARED ARAUJO 90 Retina Quiz (610) 492-1032 •JARAUJO @JOBSON.COM No Complaint, No Problem. Right? DIRECTOR OF CE ADMINISTRATION •R EGINA COMBS MARK T. DUNBAR, OD (212) 274-7160 •RCOMBS @JOBSON.COM SPECIAL PROJECTS •JANE COLE 93 Therapeutic Review On The Web ›› (610) 492-1043 •JCOLE @JOBSON.COM Physician, Heal Thyself? EDITORIAL BOARD ALAN G. KABAT, OD Check out our CHIEF CLINICAL EDITOR •P AUL M. KARPECKI, OD ASSOCIATE CLINICAL EDITORS •JOSEPH P. SHOVLIN, OD; multimedia and ALAN G. KABAT, OD; CHRISTINE W. SINDT, OD 97 Research Review DIRECTOR OPTOMETRIC PROGRAMS •A RTHUR EPSTEIN, OD The Evolution of OCT continuing education CLINICAL & EDUCATION CONFERENCE ADVISOR • DIANA L. SHECHTMAN, OD PAUL M. KARPECKI, OD @ www.revoptom.com CASE REPORTS COORDINATOR • NDREW URWOOD PAUL M. KARPECKI, OD A S. G , OD CLINICAL CODING EDITOR •JOHN RUMPAKIS, OD, MBA Digital Edition CONSULTING EDITOR •F RANK FONTANA, OD 100 Product Review EMERITUS CLINICAL EDITOR •R OBERT M. COLE, III, OD Left your Review of Optometry at the COLUMNISTS 104 Meetings + Conferences CHAIRSIDE •M ONTGOMERY VICKERS, OD office? No problem! COMANAGEMENT Q+A •P AUL C. AJAMIAN, OD 105 Advertisers Index Access Review on CORNEA & CONTACT LENS Q+A •JOSEPH P. SHOVLIN, OD your computer or DIAGNOSTIC QUIZ •A NDREW S. GURWOOD, OD mobile device! GLAUCOMA GRAND ROUNDS •JAMES L. FANELLI, OD 107 Classifieds RESEARCH REVIEW •P AUL M. KARPECKI, OD; Go to www.revoptom.com DIANA L. SHECHTMAN, OD 112 Surgical Minute and click on the digimag link to RETINA QUIZ •M ARK T. DUNBAR, OD for the current issue. REVIEW OF SYSTEMS •C ARLO J. PELINO, OD; Let There Be Light JOSEPH J. PIZZIMENTI, OD DEREK N. CUNNINGHAM, OD Facebook and Twitter SURGICAL MINUTE •D EREK N. CUNNINGHAM, OD; WALTER O. WHITLEY, OD, MBA WALTER O. WHITLEY, OD, MBA For daily updates, THERAPEUTIC REVIEW •JOSEPH W. SOWKA, OD; “Like” our page on ALAN G. KABAT, OD 114 Diagnostic Quiz Facebook or “Follow” Dystopian Dystonia us on Twitter! ANDREW S. GURWOOD, OD •www.facebook.com/revoptom •http://twitter.com/#!/revoptom JOBSON MEDICAL INFORMATION LLC

16 REVIEW OF OPTOMETRY MARCH 15, 2014

015_ro0314_toc.indd 16 3/6/14 5:15 PM RO0114_Allergan OD.indd 1 1/2/14 10:20 AM

857-0518 855 lacrivera.com )

( CONTRIBUTING EDITORS PAUL C. AJAMIAN, OD, ATLANTA JEFFREY R. ANSHEL, OD, CARLSBAD, CALIF.

JILL AUTRY, OD, RPH, HOUSTON A FRESH PERSPECTIVE™ FRESH A SHERRY J. BASS, OD, NEW YORK MILE BRUJIC, OD, BOWLING GREEN, OHIO WALTER L. CHOATE, OD, MADISON, TENN. ROBERT M. COLE, III, OD, BRIDGETON, NJ DEREK N. CUNNINGHAM, OD, AUSTIN, TEXAS

ANTHONY S. DIECIDUE, OD, You’ll want to keep an eye on us. on eye an keep to want You’ll STROUDSBURG, PA. Lacrivera. MARK T. DUNBAR, OD, MIAMI

S. BARRY EIDEN, OD, DEERFIELD, ILL. innovative products in the coming months. coming the in products innovative ARTHUR B. EPSTEIN, OD, PHOENIX JAMES L. FANELLI, OD, WILMINGTON, NC

FRANK FONTANA, OD, ST. LOUIS To prove it, we’ll be introducing several several introducing be we’ll it, prove To GARY S. GERBER, OD, HAWTHORNE, NJ ANDREW S. GURWOOD, OD, PHILADELPHIA

MILTON HOM, OD, AZUSA, CALIF. shouldn’t be complicated, painful or expensive. expensive. or painful complicated, be shouldn’t ALAN G. KABAT, OD, FORT LAUDERDALE, FLA. PAUL M. KARPECKI, OD, LEXINGTON, KY.

JEROME A. LEGERTON, OD, MBA, AN IEGO Treating chronic dry eye eye dry chronic Treating S D

We hear you. hear We THOMAS L. LEWIS, OD, PHD, PHILADELPHIA DOMINICK MAINO, OD, MED, CHICAGO

JASON R. MILLER, OD, MBA, POWELL, OHIO PAMELA J. MILLER, OD, JD, HIGHLAND, CALIF. CHERYL G. MURPHY, OD, HOLBROOK, NY industry. JOHN W. POTTER, OD, MA, DALLAS CHRISTOPHER J. QUINN, OD, ISELIN, NJ

JOHN L. SCHACHET, OD, ENGLEWOOD, COLO. JACK SCHAEFFER, OD, BIRMINGHAM, ALA.

CAROL SCHWARTZ, OD, MBA, SAN JOSE DEL CABO, MEXICO JEROME SHERMAN, OD, NEW YORK JOSEPH P. SHOVLIN, OD, SCRANTON, PA. dry eye eye dry JOSEPH W. SOWKA, OD, FORT LAUDERDALE, FLA.

LORETTA B. SZCZOTKA, OD, PHD, CLEVELAND MONTGOMERY VICKERS, OD, ST. ALBANS, W.VA. KATHY C. WILLIAMS, OD, SEATTLE

EDITORIAL REVIEW BOARD up the the up EDWARD S. BENNETT, OD, ST. LOUIS MARC R. BLOOMENSTEIN, OD, SCOTTSDALE, ARIZ.

CHRIS J. CAKANAC, OD, MURRYSVILLE, PA. JERRY CAVALLERANO, OD, PHD, BOSTON

BRIAN CHOU, OD, SAN DIEGO A. PAUL CHOUS, MA, OD, TACOMA, WASH. GLENN S. CORBIN, OD, WYOMISSING, PA. shake shake STEVEN FERRUCCI, OD, SEPULVEDA, CALIF. MURRAY FINGERET, OD, HEWLETT, NY

IAN BEN GADDIE, OD, LOUISVILLE, KY. MATTHEW J. GARSTON, OD, BOSTON

ROBERT M. GROHE, OD, HOMEWOOD, ILL. ANDREW S. GURWOOD, OD, PHILADELPHIA NICKY HOLDEMAN, OD, MD, HOUSTON about to to about MILTON HOM, OD, AZUSA, CALIF. WILLIAM L. JONES, OD, ALBUQUERQUE, NM

ALAN G. KABAT, OD, FORT LAUDERDALE, FLA. PAUL M. KARPECKI, OD, LEXINGTON, KY.

RICHARD B. MANGAN, OD, RICHMOND, IND. RON MELTON, OD, CHARLOTTE, NC BRUCE MUCHNICK, OD, COATESVILLE, PA. We’re We’re MARC MYERS, OD, COATESVILLE, PA. CARLO J. PELINO, OD, JENKINTOWN, PA. JOSEPH PIZZIMENTI, OD, FORT LAUDERDALE, FLA. WILLIAM B. POTTER, OD, FREEHOLD, NJ JOHN RUMPAKIS, OD, MBA, PORTLAND, ORE. MICHAEL C. RADOIU, OD, STAUNTON, VA. LEO P. SEMES, OD, BIRMINGHAM, ALA. DIANA L. SHECHTMAN, OD, FORT LAUDERDALE, FLA. LEONID SKORIN, JR., OD, DO, ROCHESTER, MINN. JOSEPH W. SOWKA, OD, FORT LAUDERDALE, FLA. RANDALL THOMAS, OD, CONCORD, NC WALTER O. WHITLEY, OD, MBA, VIRGINIA BEACH, VA.

015_ro0314_toc.indd 18 3/6/14 4:56 PM Left your Review of Optometry magazine at the ofﬁ ce? No problem!

Get Review sent to your desktop or mobile device! Just simply go to www.revoptom.com and click on the digimag link to get your current issue.

2013 Digimag house ad_RO.indd 1 1/23/13 11:56 AM Outlook

Beyond the Eye We are more than just “eye doctors” —so, let’s make sure that our patients and our medical colleagues know that. By Paul M. Karpecki, OD, Chief Clinical Editor

n considering this month’s ease will not resolve fully unless the exam, we can determine cholesterol focus on systemic disease and systemic disease is controlled. levels (arcus of the cornea, retinal Ithe eye, I see three areas of sig- Such connections often influence Hollenhorst plaques), diabetes (reti- nificance for our profession: the our therapeutic choices, as when nal exam, lens autofluorescence), now-mainstream role of systemic we treat MGD and rosacea with hypertension, brain tumors, rheu- medications in optometry, the value oral tetracyclines, preseptal cellulitis matoid arthritis, sarcoid, rosacea, of routine eye exams in allowing us with oral antibiotics, or Sjögren’s lupus, Sjögren’s and many more. to diagnose numerous systemic dis- with oral secretagogues. We must I think patients would be thrilled eases, and the importance of inter- also be vigilant for ocular side to know these conditions are on professional communications with effects of oral drugs patients may our radar during an ocular health physicians who manage systemic be taking, such as Plaquenil (which examination. It would help us rein- health. All point to better care and requires monitoring for bull’s eye force the need for a wellness visit convenience for our patients. retinopathy), or ocular dryness due at least yearly. I can tell you that to drugs such as antihistamines, patients who have been diagnosed Oral Meds and Optometry contraceptives and antidepressants. with serious systemic diseases at my We in optometry often have the office were truly grateful for that opportunity to marvel at just how Healthy Bodies, Healthy Eyes “routine” eye exam. well the body is connected. Many I’m fascinated that it’s considered patients with ocular manifestations “the norm” to visit a dentist every OD-MD Collaboration of systemic disease won’t improve six months, even in the absence Years ago, I made a preliminary until their systemic health does. of scientific evidence of a need for diagnosis of Sjögren’s in a 48-year- I recall a patient sent to me with semi-annual dental visits. Dentists old lady with severe dry mouth, a diagnosis of a chemical burn reinforce this behavior by perform- nose bleeds, significant tooth decay while working in an Eastern Ken- ing teeth cleaning, so that people and severe dry eye. In a letter to a tucky coal mine. We tried to get get a tangible benefit from the expe- local rheumatologist, I stated, “As his very large corneal abrasion to rience. They also emphasize oral you know, there is a very high cor- close, using bandage lenses, pres- and systemic wellness, looking for relation between non-Hodgkin’s sure patching and ample lubrication diseases ranging from lingual can- lymphoma and Sjögren’s. Yearly (no amniotic membrane options at cers to Sjögren’s syndrome. monitoring would be appreciated.” that time). After seven days battling Surely, an eye examination goes Three days later, he called to a persistent epithelial defect, we much further than a dental visit in thank me for the letter. He said he’d asked if he had any symptoms of ensuring systemic health and ocu- check all his Sjögren’s patients for fatigue, increased urination or fre- lar wellness—nearly every patient NHL going forward. Two years quent thirst. He affirmed all three, would consider the loss of vision far later, he approached me at a meet- so we ordered fasting blood levels. worse than losing teeth. We have ing and said he had diagnosed NHL A normal reading is below 100; his an incredible opportunity to edu- in at least a half dozen patients measured 496! cate patients of the need for well- since our collaboration. And since After a few days of treatment ness exams, perhaps not every six then, he has referred over 100 with metformin by a specialist, he months but at least yearly. Statistics Sjögren’s patients to the practice! not only felt better—his persistent show that most patients only see an We can debate whether the eyes epithelial defect had closed. It was eye doctor once every 26 months! are the window to the soul, but they a clear example of how an ocular Perhaps we need to educate the truly are to the body. And we are condition related to a systemic dis- patient that, via a thorough eye the gatekeepers. ■

20 REVIEW OF OPTOMETRY MARCH 15, 2014

020_ro0314_outlook.indd 20 3/6/14 4:58 PM COMING SOON

A NEW STANDARD FOR

The beauty and cosmetics industry never stops asking “What’s next?” Soon, Alcon will be setting a new standard for color contact lenses. More to come... You’ll never look at color contact lenses the same way.

PERFORMANCE DRIVEN BY SCIENCE™

*Dk/t = 138 @ -3.00D. Important information for AIR OPTIX® COLORS (lotrafi lcon B) contact lenses: For daily wear only for near/far-sightedness. Contact lenses, even if worn for cosmetic reasons, are prescription medical devices that must only be worn under the prescription, direction and supervision of an eye care professional. Serious eye health problems may occur as a result of sharing contact lenses. Although rare, serious eye problems can develop while wearing contact lenses. Side effects like discomfort, mild burning or stinging may occur. To help avoid these problems, patients must follow the wear and replacement schedule and the lens care instructions provided by their eye doctor. See product instructions for complete wear, care, and safety information. © 2014 Novartis 1/14 AOC14002JAD

RO0314_Alcon Colors.indd 1 2/19/14 11:02 AM Chair Side

No Cure for the Common Code ICD-9? Annoying. ICD-10? Weird yet complicated. But those are nothing compared to ICD-11—I didn’t crack the code. The code cracked me. By Montgomery Vickers, OD just “virtually” attended the Duck, Initial Encounter. (Really!) think you mean there are two “Last AOA’s latest ICD-10 webinar. I How about ICD-11 on an even Weeks” or two “Lights” involved. Iliked that I could be there with- easier patient? • How bad was the pain? Was it out actually being there—I even Not so easy. Follow along… bad enough to: Blink, Rub, Wince, attended the webinar in my under- A patient presented with light Yell, Scream, Wet Pants, Get Drunk wear, which created quite a stir at sensitivity OD that started one or Kill Self? This code must be very the Starbucks where I logged on. evening around 7:00 PM and has specific, so if the patient simultane- So began the most absurd 55 persisted for one week. ously Winced and Wet Himself, minutes of my life. If you know me, First, open your “British then the claim will be denied. So, it should disturb you greatly that Reference Manual, Volume 1,” and we’ll just say “YELL,” which is this was my life’s most absurd 55 try to find: code “Y.” minutes. • Right eye—not in Latin, you • Did you answer all the patient’s It took the speaker—who was idiot; in Olde English—RYGHT! questions? You have to code that amazing and intelligent about the Use the code “R.” with a “?” modifier. whole thing—about 15 minutes to • When did this start? One So, in this case, the ICD-11 code describe the best way to code for enchanted EVENING! Code is “E.” is: “REALLY?” one diagnosis on one patient with • What time did this start? 7:00? Yes, really. one specific problem. And this is an No, too specific! Use “AROUND” On a brighter note, ICD-12 will expert in ICD-10, not some numb- or “ABOUT” 7:00. Code is “A.” be much easier because its concept skull old-timer like me! To do this • Light sensitive? Is it spelled depends on the demise of all health right, I’ll have to schedule only one “Lyght,” “Plight”(p is silent), care in the United States by then. patient a day! “Leight,” “Lahyett”? OK, it’s just ICD-12 is actually just a bus “light.” This is easy—just refer to ticket to see a faith healer in Cabo. Get Ready for ICD-11 the second reference manual under One way. ■ I decided to see if I could find “Ouchy Things” and you’ll soon out what’s to come in the next ICD find “LIGHT,” which is coded “L.” evolution. The good news? The • How long has this hung next ICD incarnation addresses the around? Since LAST WEEK? Stick craziness of the ICD-10 system. The an “L” in there again—not to be bad news? It does so by being so confused with the previous “L” stupid that it makes ICD-10 look which, of course, requires a request like the Good Ol’ Days. for a different font (in this case, Here’s a quick example: Comic Sans) The patient presented with acute so as to not onset eye pain and redness plus make the blurry vision, which began at the auditors same moment his face collided with a Fulvous Whistling duck while he was hang-gliding in Venezuela. ICD-9? Easy. It’s 379.91–Eye Pain and 918.1–Corneal Abrasion. ICD-10? There’s a specific code for it: W61.62XA–Struck by

22 REVIEW OF OPTOMETRY MARCH 15, 2014

022_ro0314_chairside.indd 22 3/4/14 9:59 AM Plays well with others. Of course Auto Phoroptor RS® Auto Refraction System connects to EMR systems and Reichert® brand auto refractors, lensometers and acuity systems, including ClearChart® 2. But did you know, Auto Phoroptor RS seamlessly connects to other brands of pre-test devices? Now you won’t have to play favorites with your equipment. Made with pride in the USA.

Get connected. Visit reichert.com/autophoroptor

Vision Expo East Booth #MS 6713

www.reichert.com

RO0314_Reichert.indd 1 2/27/14 2:09 PM Coding Abstract

An Ounce of Prevention Optometrists are doing a good job catching eye disease. But are we doing enough to prevent it and promote ocular wellness? By John Rumpakis, OD, MBA, Clinical Coding Editor his column spends a great “ocular surface wellness.” It was a to contact lens intolerance, to cata- deal of time on certain basic very interesting meeting with some ract and refractive surgery, depends Tmedical coding and com- of the top experts in our field, dis- on having a healthy ocular surface. pliance concepts—like medical cussing not only what we’re doing But even though we know that necessity and properly recording for ocular surface issues like mei- dry eye and meibomian gland the chief complaint—so that your bomian gland disease or contact disease occur in the majority of office encounters can be legiti- lens dropout, but whether we can Americans, optometrists still tend mately submitted to a medical car- do anything to prevent these condi- to be remedial in our approach to rier for appropriate reimbursement tions from even happening. ocular surface disease rather than of your professional services and preventive. expertise. A parallel to consider: Does the I try to provide advice to help Wellness and Prevention, dermatologist wait for someone to you prevent and avoid any poten- Defined get skin cancer before recommend- tial reimbursement problems. And Wellness: the quality or state of being ing a daily application of sunscreen it got me to thinking: Are we, as in good health, especially as an actively containing an appropriate SPF? Of optometrists, providing adequate sought goal. course not. Each and every patient preventive advice to our patients? Prevention: the act or practice of stop- gets a proactive, preventive state- I realize that most ODs provide ping something bad from happening. ment about skin wellness and a preventive advice every single day: Source: www.merriam-webster.com recommendation for it. • “Don’t sleep in your contacts.” Can’t we do that in our prac- • “Use your glaucoma medica- tices? Couldn’t we remind our tion every night.” A dentist and a dermatologist patients to use artificial tears in • “Take these nutriceuticals to also presented to the group and each eye every time they brush help prevent AMD.” discussed how their professions their teeth? “Two drops a day • “Wear your plus lenses when became proactive on wellness. The keeps your contacts in play.” you read.” dermatologist indicated that much You get the idea. …And so on. It is inherent in of her work is increasingly related what we do for patients. to wellness and prevention. The Wellness and prevention are both Yet, our health care system is dentist made a point that preven- new and old concepts for us. We heading quickly toward outcomes- tion and wellness has been a widely practice them daily—but not in the based care, which aims to prevent accepted mandate within his pro- most modern sense or in a consis- sequelae by providing the best fession since the 1940s. tent manner. treatment and advice before some- The problem lies, of course, in If your goal is to create and thing goes wrong. a single simple question: How do maintain the very best vision and So, what do we as optometrists we get paid for prevention? (More quality of life for your patients, do in the area of both preven- on that important question in an perhaps the answer is very simple: tive care and ocular wellness? upcoming column.) Be your patients’ advocate for the (See “Wellness and Prevention, problems that they encounter today Defined,” above.) Prevent, Don’t Lament and for those that you can prevent Realize that we impact our from happening tomorrow. ■ What Do Dentists Do? patients’ quality of life by main- Please send your questions and I recently was invited to a meet- taining a healthy ocular surface. comments to CodingAbstract@ ing that focused on the subject of Everything from quality of vision gmail.com.

24 REVIEW OF OPTOMETRY MARCH 15, 2014

024_ro0314_coding.indd 24 3/4/14 10:20 AM Tear Film Lipids and Successful Contact Lens Wear

Careful lens selection and clear patient counseling can reduce lipid deposition in contact lens wear. Christine W. Sindt, OD, FAAO

The lipid layer is crucial to normal film chemistry account for some of the produces a different surface environment, tear film function: it limits aqueous variation in patients’ ability to tolerate and, consequently a different degree of evaporation, creates a smooth, stable a soft contact lens material; the other resistance to lipid deposition.1 refracting surface, and provides a barrier important factor is the hydrophobicity of to foreign materials. Itself a complex the lens surface. IN THE CLINIC structure, the lipid layer is composed of On the surface of the lens, the a thin layer of polar lipids that stabilizes effects of lipid deposits can range from the thicker layer of nonpolar lipids that Contact lens wear alters decreased wettability and TFBUT to rides above it (and which acts as a barrier »and thins the tear film frank, visible fouling and a decrease to the environment). This polar lipid in optical clarity. When I see a patient interface adheres the nonpolar lipids to Hydrophobic areas on the with heavily lipid-deposited lenses, I the aqueous compartment and allows »contact lens surface attract take a comprehensive look at their lens the lipid layer to spread evenly across the tear film lipids material, lens solution, care regimen, 1 polar aqueous portion of the tear film. Adhered lipid deposits and eyelid hygiene. I identify and address blepharitis and any associated LENS-TEAR FILM DYNAMICS »break down, further diminishing lens wettability meibomian gland dysfunction in order to When a contact lens is placed ensure a baseline tear film quality. on the eye, it changes the physical Plasma coating can produce If a patient can’t (or doesn’t want chemistry of the ocular environment, »a hydrophilic surface on to) wear a daily disposable lens, I select altering mucin production, decreasing silicone hydrogel lenses, a reusable contact lens material with a tear film stability and increasing tear keeping them relatively highly wettable surface, and pair it with osmolarity.2 The contact lens divides the deposit-resistant a solution that will effectively reduce tear volume, creating a pre-lens tear film lipid deposits and help maintain surface on the surface of the lens and a post- wettability. I also counsel patients lens tear film between the lens and the Both “conventional” hydroxyethyl carefully about their lens care routines, cornea. The average, non-disrupted methacrylate (HEMA)-based lenses and emphasizing the importance of digital tear film is around 4 microns thick, but silicone hydrogel lenses contain both rubbing to help dislodge deposits. the pre-lens tear film is only about 2.5 hydrophilic and hydrophobic polymer Ultimately, my goal is to keep microns.2 chains. These polymer chains tend to patients’ eyes healthy, seeing well, and A thinner tear film is less stable, orient themselves according to their feeling comfortable. Contact lens wear and a thinner lipid layer is associated environment. Dryness in the environment affects the ocular surface in many ways, with reduced tear-film breakup time of the lens—eg, from a TFBUT shorter and certainly impacts tear film stability. (TFBUT): Over a contact lens, the TFBUT than the inter-blink interval—will draw But choosing a lens and care system that is typically about 5 to 10 seconds, the hydrophobic (lipophilic) chains of the can keep the lens surface wettable— compared to 20 to 30 seconds without a lens polymer toward the lens surface, while reducing lipid deposition—should lens in place.3 which can further disrupt tear spreading help maintain patients’ tear film stability Tear lipids can adhere to and lead to lipid deposition. and lens wearing satisfaction. microscopic hydrophobic domains The chemistry of silicone insures that on a silicone hydrogel lens surface. silicone hydrogel lenses have far more Christine W. Sindt, OD, FAAO, is When exposed to light and oxygen hydrophobic polymer chains than HEMA- director of the contact lens service for prolonged periods, these adhered based lenses; and, as a result, silicone and a clinical associate professor of ophthalmology and visual sciences at lipids can degrade, further reducing hydrogel lenses must rely on surface the University of Iowa, Iowa City, IA. lens wettability. Tear film instability, lens modifications to “sequester” these deposition, and reduced lens wettability hydrophobic chains. Such modifications REFERENCES 1. Carney FP, Nash WL, Sentell KB. The adsorption of major can all contribute to symptoms of include plasma treatment, changing the tear film lipids in vitro to various silicone hydrogels over dryness and irritation in wearers. composition and length of the polymer time. Invest Ophthalmol Vis Sci. 2008;49(1):120-4. 2. Keir N, Jones L. Wettability and silicone hydrogel lenses: a chains, and adding wetting agents review. Eye Contact Lens. 2013;39(1):100-8. IMPACT OF LENS MATERIAL (either to the lens itself or to the soaking 3. Rohit A, Willcox M, Stapleton F. Tear lipid layer and contact lens comfort: a review. Eye Contact Lens. 2013 Patient-to-patient differences in tear solution). Each of these techniques May;39(3):247-53.

RO0314_Alcon Air Optix Adv.indd 1 2/24/14 2:40 PM Guarding Your Patients’ Eyes from Harmful Light Part One: the Importance of Education By Kirk Smick, OD

This three-part series will discuss preventative actions for preserving eye health and providing complete protection from the negative effects of ultraviolet (UV) and blue light. Part one will focus on education and offer a basic rundown on UV and blue light, including their sources, as well as risks and beneﬁ ts associated with them. Next month’s column will tackle the topic of protection and prevention; and for the ﬁ nal part of this series, an engaging point-counterpoint awaits you.

s clinicians, we have always suspected that high- LED lighting and electronic devices will continue to damage energy visible (HEV) light, otherwise known as the retinal cells and can eventually lead to retinal cell death. Ablue light, may cause damage to the eye. Thanks Today, we are being exposed to blue light in our homes to dedicated researchers, we now know that blue light, and in our everyday lives at higher levels than ever before, part of the visible light spectrum that reaches the back and these levels will continue to rise in the coming years. side of the eye, can damage the retina and more specifi - Let’s take a closer look at the negative effects of blue light. cally, has been implicated in the development of age- related macular degeneration (AMD).1–3 The Dangers of Blue Light Most patients are familiar with the potential dangers of The most harmful band of blue light is Blue-Violet light, ultraviolet (UV) light, which can penetrate the cornea at as discovered by a joint study conducted by the Paris the front of the eye and cause cataracts; however, very Vision Institute and Essilor International.3 Blue-Violet few patients are aware that certain wavelengths of visible light ranges from 415 nm to 455 nm, and has been light are also damaging to their eyes. Both UV and blue identifi ed as the band of visible light most harmful to light are present everywhere: indoors and outdoors. retinal cells. Additionally, blue light has measurable effects on retinal pigment epithelial cell apoptosis.7 Blue Sources of UV and Blue Light light in this range causes maximum retinal cell death, Sunlight emits both UV and blue light all year long, and and in turn, is one of the risk factors for the development the amount of exposure can vary depending on time of of AMD. The connection between blue light and AMD day, location, and even the season. Although the level makes it imperative for us to educate patients and of exposure can vary, eyes are exposed to UV light 365 help them protect their eyes from these potentially days a year. And 40% of this UV exposure occurs when damaging elements. We’ll delve further into AMD, but we are not in full sunlight, which reinforces the need for before we do, let’s lighten the mood and examine the UV protection on both clear and sun lenses. positive physiological effects of blue light. Sunlight is also a well-established source of blue light, but this energetic light can also transmit to the eye The Positive Side of HEV Light from numerous indoor sources, such as smart phones, Some sun exposure is vital, as it delivers vitamin D to computer monitors and many modern LED and compact the body. Light is essential for us to see and recognize fl uorescent light sources.4 In fact, many of these devices colors, and also plays a key factor in contrast sensitiv- emit an extremely high level of blue light, a fact that many ity. Light also helps in visual acuity, and without enough patients may not realize. of it, vision is affected and is not clear. In addition to Predictably, our patients will be exposed to even visual functions, light is necessary for various non-visual greater levels of indoor blue light in the coming years. In functions of the body. Research has identifi ed that fact, forecasts for LED uptake in the residential segment Blue-Turquoise light, ranging from 465 nm to 495 nm, are at 50% for 2016 and 70% for 2020.5 This is espe- is essential to our vision, as it adjusts the size of the cially concerning, considering the fact that LED sources pupil to allow enough light through.3 Blue-Turquoise light contain 35% harmful blue light levels.6 aids in the regulation of our sleep/wake cycle, and also Cumulative and constant exposure to blue light from helps the body distinguish day from night.3 This in turn,

Sponsored by

26 REVIEW OF OPTOMETRY MARCH 15, 2014

026_ro0314_Essilor_Smick.indd 26 3/7/14 9:42 AM enables us to maintain and regulate memory, mood and hormonal balance. Did you know? Now that we’ve seen that not all light is bad, it’s time to turn back to the detrimental effects of blue light; in Fifty percent of UV exposure received particular, the risk for developing AMD. by the eye has been refl ected by a surface (e.g., clouds, the fl oor, a building).14 AMD: Risk Factors and Prevalence AMD ranks third among the global causes of visual impairment, with a blindness prevalence of 8.7%.8 The Education is Key number of AMD cases is expected to more than double, Clearly we need light in order to function, but we need to from two million in 2010 to fi ve million by 2050,9 and manage what type of light we expose ourselves to, when we is the leading cause of legal blindness in people ages expose ourselves to it and for how long. It is critical that we 65 and older.10 Risk factors for AMD include a genetic educate our patients about the dangers of UV and blue light. background (having a fi rst-generation family member Key questions to ask a patient might include: with the disease) and environmental and lifestyle factors • How do you protect your eyes on a daily basis? (i.e., smoking, diet, BMI and light exposure). • Do you have a family history of macular In my practice, I target specifi c patients with whom I want degeneration/AMD? to discuss AMD risk factors and preventative measures. • How much time do you spend in front of digital devices? Typically, these are patients who have early signs of AMD or • How much time do you spend outdoors? have a parent who has the condition. I also talk to children • How are you currently protecting your eyes against UV who are constantly in front of a computer screen or video damage? game, as well as patients with active lifestyles who are con- As the prevalence of AMD grows, and the use of LED cerned about wellness in all aspects of their healthcare. lighting and digital devices continues to rise, it is essential Optometry is getting more and more involved in the di- for optometrists to remain at the forefront of ensuring that agnosis and management of AMD as the U.S. population our at-risk patients are properly educated on the dangers continues to age, and while the next part in this series will of UV and blue light exposure and are prescribed the ap- primarily focus on prevention and protection, I’ll provide a propriate lenses to protect their precious vision. bit of a teaser on the topic. Dr. Smick is chief of Optometry Services at Clayton Eye Identifying the Lines of Defense Center and an owner of the facility. He also serves as a tech- With AMD on the rise, there is an obvious and im- nical advisor to many companies in the ophthalmic industry mediate need for our profession to step up to the plate. and has helped pioneer several visual advances, including The results of the Age-Related Eye Disease Study 2 bifocal contact lenses. (AREDS2) have shown that combinations of neutraceuti- 11 1. Age-related maculopathy and sunlight exposure evaluated by objective measure- cals can help prevent the onset of AMD. Selective light ment. Br J Ophthalmol. 2008;92(5):630-34. fi lters also offer protection from the damaging effects of 2. Arnault E, Barrau C, Nanteau C, et al. Characterization of the blue light toxicity spectrum on A2E-loaded RPE cells in sunlight normalized conditions. Poster presented harmful Blue-Violet light. at: Association for Research and Vision in Ophthalmology Annual Meeting; May 5-9, ® ™ 2013; Seattle, WA. Another new layer of protection—Crizal Prevencia 3. Press Release: Essilor launches Crizal® Prevencia™: the fi rst preventive lenses offering selective protection from harmful blue light and UV rays. No-Glare lenses (Essilor)—is available for at-risk AMD 4. Light-emitting diodes (LED) for domestic lighting: Any risks for the eye? Behar-Co- patients. Crizal Prevencia offers both front- and back- hen, F, Martinsons, C., et al. Progress in Retinal and Eye Research. 30 (2011)239-57. 5. Lighting the way: perspectives on the global lighting market. Second edition. August of-lens protection from harmful light—including UV and 2012. McKinsey & Company Inc. p. 8. 6. Barrau C, Villette T, Cohen-Tannoudji D. Blue light: Scientifi c discovery. Essilor. 2013 Blue-Violet light—and is designed to selectively fi lter February; 1-49. 7. Light fi ltering in a Retinal Pigment Epithelial Cell Culture Model. Zhou, J, and Spar- out this harmful light while letting benefi cial light pass row, J. Optometry and Vis Sci. 2011 Jun;88(6):759-65. through. Furthermore, it’s proven to defl ect harmful 8. World Health Organization, Available at: http://www.who.int/blindness/causes/priority/en/. Accessed on: February 2014. Blue-Violet light by 20%, which in recent lab tests led to 9. National Eye Institute. Available at: https://www.nei.nih.gov/eyedata/amd.asp. 12,13 Accessed: February 2014. a 25% reduction in retinal cell death. The lenses 10. American Society of Retina Specialists. Available at: http://www.asrs.org/patients/ retinal-diseases/2. Accessed: February 2014. selectively defl ect just the range of HEV light that has 11. Age-Related Eye Disease Study 2 Research Group. Lutein + zeaxanthin and been shown to be responsible for increased cellular omega-3 fatty acids for age-related macular degeneration: the Age-Related Eye Dis- ease Study 2 (AREDS2) randomized clinical trial. JAMA. 2013; 209(19):2005–15. death. With Crizal Prevencia No-Glare lenses, other 12. 25% less light-induced retinal cell death rate vs a naked eye, with a 20% cut of Blue-Violet light. In in vitro experiments conducted by Essilor and Paris Vision Institute, benefi cial light still comes into the eye and penetrates retinal pigment epithelium cells were exposed to Blue-Violet light, reproducing the physiological exposure to sunlight of the 40-year-old eye. the lens, in turn giving us perfectly clear vision. 13. Arnault E, Barrau C, Nanteau C, et al. Characterization of the blue light toxicity spectrum on A2E-loaded RPE cells in sunlight normalized conditions. Poster pre- No matter what method(s) of prevention or protection sented at: Association for Research and Vision in Ophthalmology Annual Meeting; May you employ, it all comes back to education—both ours 5-9, 2013; Seattle, WA. 14. Sasaki H, Sakamoto Y, Schnider C, et al. UV-B exposure to the eye depending on and our patients. solar altitude. Eye & Contact Lens. 2011; 37:4, 191-195.

The opinions expressed in this supplement to Review of Optometry® do not necessarily reﬂ ect the views, or imply endorsement, of the editor or publisher. Copyright 2014, Jobson Medical Information LLC. All rights reserved.

REVIEW OF OPTOMETRY MARCH 15, 2014 27

026_ro0314_Essilor_Smick.indd 27 3/7/14 9:43 AM Clinical Care

Patients Who Need UV Protection and Why Taking a thorough patient history is the first step in formulating personalized recommendations for UV protection. By Cheryl G. Murphy, OD, Contributing Editor

ptometrists and eye care professionals are well versed in relaying the 5importance of daily sun O protection to their patients—but do patients really follow through with these recommendations? Profiling patients and providing them with reasons why they specifically are at risk for damage from UV radiation may help to improve their compliance in using UV protection. UV radiation is harmful to eyes. Overexposure to UV can have short-term effects such as UV keratitis and long-term effects like pinguecula and pterygia, accelera- Julia Garr, OD, of Washington, DC, always educates patients that, while UV-blocking tion of cataracts, and an increased contact lenses help to protect parts of the eye from UV radiation, sunglasses should risk of retinal damage. In addition, also be used to shield the entire eye and the surrounding skin. the skin of the lids—particularly the lower lids and the skin sur- spend outdoors and in what types step in formulating personalized rounding the orbits—need to be of environments. Not only does an recommendations for UV protec- shielded from the sun’s harmful individual’s genetic makeup, physi- tion. rays in order to decrease the chance cal characteristics, age and family Let’s look at five profiles of of cancerous growths in these history matter when assessing their patients who need UV protec- areas. risk of potential damage from UV, tion—and some information that Because UV light is a part of their everyday surroundings and you can give them about why they the natural world, we need to find habits matter as well. Taking a specifically should guard against out how much time our patients thorough patient history is the first UV radiation.

28 REVIEW OF OPTOMETRY MARCH 15, 2014

028_ro0314_f1.indd 28 3/4/14 10:00 AM AS YOUR PATIENT’S DAY CHANGES, SO WILL THEIR IOP.

For your patients in need of a PGA, LOWER IOP SUSTAIN IOP1,2 Choose BAK-free TRAVATAN Z® Solution

INDICATIONS AND USAGE in aphakic patients, in pseudophakic patients with a torn posterior lens capsule, or in patients with known TRAVATAN Z® (travoprost ophthalmic solution) 0.004% is indicated for the reduction of elevated risk factors for macular edema. intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension. Angle-closure, Infl ammatory, or Neovascular Glaucoma — TRAVATAN Z® Solution has not been evaluated Dosage and Administration for the treatment of angle-closure, infl ammatory, or neovascular glaucoma. The recommended dosage is 1 drop in the affected eye(s) once daily in the evening. TRAVATAN Bacterial Keratitis —There have been reports of bacterial keratitis associated with the use of multiple-dose ® Z Solution should not be administered more than once daily since it has been shown that more containers of topical ophthalmic products. These containers had been inadvertently contaminated by frequent administration of prostaglandin analogs may decrease the IOP-lowering effect. TRAVATAN patients who, in most cases, had a concurrent corneal disease or a disruption of the ocular epithelial. Z® Solution may be used concomitantly with other topical ophthalmic drug products to lower IOP. ® If more than 1 topical ophthalmic drug is being used, the drugs should be administered at least Use With Contact Lenses —Contact lenses should be removed prior to instillation of TRAVATAN Z Solution 5 minutes apart. and may be reinserted 15 minutes following its administration. IMPORTANT SAFETY INFORMATION Adverse Reactions Warnings and Precautions The most common adverse reaction observed in controlled clinical studies with TRAVATAN Z® Solution was ocular hyperemia, which was reported in 30 to 50% of patients. Up to 3% of patients discontinued therapy Pigmentation —Travoprost ophthalmic solution has been reported to increase the pigmentation due to conjunctival hyperemia. Ocular adverse reactions reported at an incidence of 5 to 10% in these of the iris, periorbital tissue (eyelid), and eyelashes. Pigmentation is expected to increase as long clinical studies included decreased visual acuity, eye discomfort, foreign body sensation, pain, and pruritus. as travoprost is administered. After discontinuation of travoprost, pigmentation of the iris is likely In postmarketing use with prostaglandin analogs, periorbital and lid changes including deepening of the to be permanent, while pigmentation of the periorbital tissue and eyelash changes have been eyelid sulcus have been observed. reported to be reversible in some patients. The long-term effects of increased pigmentation are Use in Specifi c Populations not known. While treatment with TRAVATAN Z® Solution can be continued in patients who develop noticeably increased iris pigmentation, these patients should be examined regularly. Use in pediatric patients below the age of 16 years is not recommended because of potential safety concerns related to increased pigmentation following long-term chronic use. Eyelash Changes —TRAVATAN Z® Solution may gradually change eyelashes and vellus hair in the For additional information about TRAVATAN Z® Solution, please see Brief Summary of full treated eye. These changes include increased length, thickness, and number of lashes. Eyelash Prescribing Information on adjacent page. changes are usually reversible upon discontinuation of treatment. References: 1. Intraocular Infl ammation —TRAVATAN Z® Solution should be used with caution in patients with active Lewis RA, Katz GJ, Weiss MJ, et al. Travoprost 0.004% with and without benzalkonium 2. intraocular infl ammation (e.g. uveitis) because the infl ammation may be exacerbated. chloride: a comparison of safety and effi cacy. J Glaucoma. 2007;16(1):98-103. Gross RL, Peace JH, Smith SE, et al. Duration of IOP reduction with travoprost BAK-free solution. J Glaucoma. 2008;17(3):217-222. Macular Edema —Macular edema, including cystoid macular edema, has been reported during treatment with travoprost ophthalmic solution. TRAVATAN Z® Solution should be used with caution

RO0314_Alcon Travatan.indd 1 2/19/14 11:31 AM USE IN SPECIFIC POPULATIONS Pregnancy Pregnancy Category C Teratogenic effects: Travoprost was teratogenic in rats, at an intravenous (IV) dose up to 10 mcg/kg/day (250 times the maximal recommended human ocular dose (MRHOD), evidenced by an increase in the incidence of skeletal malformations as well as external and visceral malformations, such as fused sternebrae, domed head and hydrocephaly. Travoprost was not teratogenic in rats at IV doses up to 3 mcg/kg/day (75 times the MRHOD), or in mice at subcutaneous doses up to 1 mcg/kg/day (25 times the MRHOD). Travoprost produced an increase in post-implantation losses and a decrease in fetal viability in rats at IV doses > 3 mcg/kg/day (75 times the MRHOD) and in mice at subcutaneous doses > 0.3 mcg/kg/day (7.5 times the MRHOD). BRIEF SUMMARY OF PRESCRIBING INFORMATION In the offspring of female rats that received travoprost subcutaneously from Day 7 of pregnancy to lactation Day INDICATIONS AND USAGE 21 at doses of ≥ 0.12 mcg/kg/day (3 times the MRHOD), the incidence of postnatal mortality was increased, and TRAVATAN Z® (travoprost ophthalmic solution) 0.004% is indicated for the reduction of elevated intraocular neonatal body weight gain was decreased. Neonatal development was also affected, evidenced by delayed eye pressure in patients with open-angle glaucoma or ocular hypertension. opening, pinna detachment and preputial separation, and by decreased motor activity. DOSAGE AND ADMINISTRATION There are no adequate and well-controlled studies of TRAVATAN Z® (travoprost ophthalmic solution) 0.004% The recommended dosage is one drop in the affected eye(s) once daily in the evening. administration in pregnant women. Because animal reproductive studies are not always predictive of ® TRAVATAN Z® (travoprost ophthalmic solution) should not be administered more than once daily since it human response, TRAVATAN Z Solution should be administered during pregnancy only if the potential has been shown that more frequent administration of prostaglandin analogs may decrease the intraocular benefit justifies the potential risk to the fetus. pressure lowering effect. Nursing Mothers Reduction of the intraocular pressure starts approximately 2 hours after the first administration with A study in lactating rats demonstrated that radiolabeled travoprost and/or its metabolites were excreted in maximum effect reached after 12 hours. milk. It is not known whether this drug or its metabolites are excreted in human milk. Because many drugs

® TRAVATAN Z® Solution may be used concomitantly with other topical ophthalmic drug products to lower are excreted in human milk, caution should be exercised when TRAVATAN Z Solution is administered to a intraocular pressure. If more than one topical ophthalmic drug is being used, the drugs should be nursing woman. administered at least five (5) minutes apart. Pediatric Use CONTRAINDICATIONS Use in pediatric patients below the age of 16 years is not recommended because of potential safety None concerns related to increased pigmentation following long-term chronic use. WARNINGS AND PRECAUTIONS Geriatric Use Pigmentation No overall clinical differences in safety or effectiveness have been observed between elderly and other Travoprost ophthalmic solution has been reported to cause changes to pigmented tissues. The most adult patients. frequently reported changes have been increased pigmentation of the iris, periorbital tissue (eyelid) and Hepatic and Renal Impairment eyelashes. Pigmentation is expected to increase as long as travoprost is administered. The pigmentation Travoprost ophthalmic solution 0.004% has been studied in patients with hepatic impairment and also in change is due to increased melanin content in the melanocytes rather than to an increase in the number patients with renal impairment. No clinically relevant changes in hematology, blood chemistry, or urinalysis of melanocytes. After discontinuation of travoprost, pigmentation of the iris is likely to be permanent, while laboratory data were observed in these patients. pigmentation of the periorbital tissue and eyelash changes have been reported to be reversible in some patients. Patients who receive treatment should be informed of the possibility of increased pigmentation. NONCLINICAL TOXICOLOGY The long term effects of increased pigmentation are not known. Carcinogenesis, Mutagenesis, Impairment of Fertility Iris color change may not be noticeable for several months to years. Typically, the brown pigmentation Two-year carcinogenicity studies in mice and rats at subcutaneous doses of 10, 30, or 100 mcg/kg/day around the pupil spreads concentrically towards the periphery of the iris and the entire iris or parts of the did not show any evidence of carcinogenic potential. However, at 100 mcg/kg/day, male rats were only iris become more brownish. Neither nevi nor freckles of the iris appear to be affected by treatment. While treated for 82 weeks, and the maximum tolerated dose (MTD) was not reached in the mouse study. The high treatment with TRAVATAN Z® (travoprost ophthalmic solution) 0.004% can be continued in patients who dose (100 mcg/kg) corresponds to exposure levels over 400 times the human exposure at the maximum develop noticeably increased iris pigmentation, these patients should be examined regularly. recommended human ocular dose (MRHOD) of 0.04 mcg/kg, based on plasma active drug levels. Travoprost was not mutagenic in the Ames test, mouse micronucleus test or rat chromosome aberration assay. Eyelash Changes A slight increase in the mutant frequency was observed in one of two mouse lymphoma assays in the TRAVATAN Z® Solution may gradually change eyelashes and vellus hair in the treated eye. These changes presence of rat S-9 activation enzymes. include increased length, thickness, and number of lashes. Eyelash changes are usually reversible upon Travoprost did not affect mating or fertility indices in male or female rats at subcutaneous doses up to discontinuation of treatment. 10 mcg/kg/day [250 times the maximum recommended human ocular dose of 0.04 mcg/kg/day on a mcg/kg Intraocular Inflammation basis (MRHOD)]. At 10 mcg/kg/day, the mean number of corpora lutea was reduced, and the post-implantation TRAVATAN Z® Solution should be used with caution in patients with active intraocular inflammation losses were increased. These effects were not observed at 3 mcg/kg/day (75 times the MRHOD). (e.g., uveitis) because the inflammation may be exacerbated. PATIENT COUNSELING INFORMATION Macular Edema Potential for Pigmentation Macular edema, including cystoid macular edema, has been reported during treatment with travoprost Patients should be advised about the potential for increased brown pigmentation of the iris, which may be ophthalmic solution. TRAVATAN Z® Solution should be used with caution in aphakic patients, in pseudophakic permanent. Patients should also be informed about the possibility of eyelid skin darkening, which may be patients with a torn posterior lens capsule, or in patients with known risk factors for macular edema. reversible after discontinuation of TRAVATAN Z® (travoprost ophthalmic solution) 0.004%. Angle-closure, Inflammatory or Neovascular Glaucoma Potential for Eyelash Changes TRAVATAN Z® Solution has not been evaluated for the treatment of angle-closure, inflammatory or Patients should also be informed of the possibility of eyelash and vellus hair changes in the treated eye neovascular glaucoma. during treatment with TRAVATAN Z® Solution. These changes may result in a disparity between eyes in length, thickness, pigmentation, number of eyelashes or vellus hairs, and/or direction of eyelash growth. Bacterial Keratitis Eyelash changes are usually reversible upon discontinuation of treatment. There have been reports of bacterial keratitis associated with the use of multiple-dose containers of topical ophthalmic products. These containers had been inadvertently contaminated by patients who, Handling the Container in most cases, had a concurrent corneal disease or a disruption of the ocular epithelial surface. Patients should be instructed to avoid allowing the tip of the dispensing container to contact the eye, surrounding structures, fingers, or any other surface in order to avoid contamination of the solution by Use with Contact Lenses common bacteria known to cause ocular infections. Serious damage to the eye and subsequent loss of Contact lenses should be removed prior to instillation of TRAVATAN Z® Solution and may be reinserted vision may result from using contaminated solutions. 15 minutes following its administration. When to Seek Physician Advice ADVERSE REACTIONS Patients should also be advised that if they develop an intercurrent ocular condition (e.g., trauma or Clinical Studies Experience infection), have ocular surgery, or develop any ocular reactions, particularly conjunctivitis and eyelid Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed reactions, they should immediately seek their physician’s advice concerning the continued use of in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug TRAVATAN Z® Solution. and may not reflect the rates observed in practice. The most common adverse reaction observed in controlled clinical studies with TRAVATAN® (travoprost ophthalmic solution) 0.004% and Use with Contact Lenses ® TRAVATAN Z® (travoprost ophthalmic solution) 0.004% was ocular hyperemia which was reported in 30 to Contact lenses should be removed prior to instillation of TRAVATAN Z Solution and may be reinserted 50% of patients. Up to 3% of patients discontinued therapy due to conjunctival hyperemia. Ocular adverse 15 minutes following its administration. reactions reported at an incidence of 5 to 10% in these clinical studies included decreased visual acuity, eye Use with Other Ophthalmic Drugs discomfort, foreign body sensation, pain and pruritus. Ocular adverse reactions reported at an incidence of If more than one topical ophthalmic drug is being used, the drugs should be administered at least five (5) ® ® 1 to 4% in clinical studies with TRAVATAN or TRAVATAN Z Solutions included abnormal vision, blepharitis, minutes between applications. blurred vision, cataract, conjunctivitis, corneal staining, dry eye, iris discoloration, keratitis, lid margin crusting, ocular inflammation, photophobia, subconjunctival hemorrhage and tearing. Rx Only Nonocular adverse reactions reported at an incidence of 1 to 5% in these clinical studies were allergy, U.S. Patent Nos. 5,631,287; 5,889,052, 6,011,062; 6,235,781; 6,503,497; and 6,849,253 angina pectoris, anxiety, arthritis, back pain, bradycardia, bronchitis, chest pain, cold/flu syndrome, depression, dyspepsia, gastrointestinal disorder, headache, hypercholesterolemia, hypertension, hypotension, infection, pain, prostate disorder, sinusitis, urinary incontinence and urinary tract infections. In postmarketing use with prostaglandin analogs, periorbital and lid changes including deepening of the eyelid sulcus have been observed. ALCON LABORATORIES, INC. Fort Worth, Texas 76134 USA © 2006, 2010, 2011, 2012 Novartis 4/135/13 TRV13021JADTRV13049JAD

RO0314_Alcon Travatan PI.indd 1 2/19/14 11:40 AM Clinical Care

Construction/Outdoor Workers People who work outdoors are exposed to 10% to 20% more UV light than the average indoor worker.1 Pair that with the fact that UV radiation is usually most intense between the hours of 10 a.m. and 4 p.m.—which coincides with the typical hours of a dayshift or workday—and one can see why outdoor workers must make sun protection a priority. Even if an outdoor worker wears a hat, the brim only blocks his or her eyes from UV light coming from directly overhead. Hats do not protect from indirect UV radiation that is reflected off the ground and low-level, angled surfaces. Jeffrey Roth, OD, of Syracuse, NY, always educates patients on the importance of Most patients realize that direct protection from reflected UV radiation during snowy, wintery months. UV radiation is dangerous, but are not aware that indirect or reflected because the light clouds further Outdoor Enthusiasts UV radiation can also be hazard- scatter the UVR to lower eleva- Even if patients don’t work out- ous. When it comes to the amount tion angles.3 So, ocular exposure doors, they may play outdoors. of UV light that is reflected off of on a partly cloudy day is actually Outdoor enthusiasts who spend an object, the surface of the object greater than on a clear, sunny day. a lot of time outside after work matters. Some surfaces are more Be sure to prescribe high quality or on the weekends also require reflective than others. A surface UVA/UVB protection to outdoor appropriate UV protection. Boat- painted bright white, for example, workers in order to shield them ers, swimmers and beachgoers need reflects about 22% of the sun’s from direct and indirect UV radia- to take note and protect themselves UV radiation.2 (See “How Surfaces tion. properly while spending a day by Reflect UV Radiation,” the waves because sea foam right.) reflects up to 30% of UV Even surfaces that don’t How Surfaces Reflect UV Radiation light, while dry sand can seem to be inherently Ground reflectance is the most critical determinant of ocular reflect more than 15%.2 reflective can be a source exposure to UVB radiation. Here are UVB reflectance percentages Fresh snow and ice of indirect UV radiation. for horizontal surfaces at “high noon” on a sunny day.2 can reflect 80% to 90% For example, dry grass in • Fresh snow 88% of ultraviolet radiation, winter bounces about 3% • Dirty snow 59% so everyone should use to 5% of the sun’s radia- • Sea foam (surf) 25% to 30% UV protection during the tion back up toward our • House paint (white, metal oxide) 22% winter months. However, eyes. • Dry sand 15% to 18% those who spend a con- Another little-known • Concrete pavement 8% to 12% siderable amount of time precaution for outdoor • Wet sand 7% outdoors in the snow, like workers: Sunglasses are • Black asphalt 4% to 9% skiers and snowboarders, essential for partly cloudy • Soil 4% to 6% are at an even higher, more days. The worst exposure • Lawn grass, winter 3% to 5% imminent risk for damage conditions can be with a • Lawn grass, summer 2% to 4% from UV radiation. Intense, high sun and light overcast indirect UV radiation for

REVIEW OF OPTOMETRY MARCH 15, 2014 31

028_ro0314_f1.indd 31 3/4/14 10:01 AM Clinical Care

even as few as two hours can cause longer that people are left unpro- favor by getting their kids into UV keratitis or “snow blindness.”4 tected from the sun’s harmful rays the healthy habit of proactively UV-blocking goggles are a must over the course of their lifetime, protecting their eyes from the sun while out on the slopes to ensure the more likely they will suffer early on in life. protection against the dangerous damage to their eyes. amounts of UV reflected off the What makes the eyes of kids Contact Lens Wearers snow, which can cause this tem- especially vulnerable to UV radia- Some patients may think they porary but debilitating and painful tion, besides the amount of time don’t need to bother wearing sun- corneal condition. they spend outside during child- glasses because their contact lenses Boaters and beachgoers should hood? Children’s crystalline lenses block UVA/UVB. This is simply also wear polarized UVA/UVB- are usually clear as glass at birth, not true. Yes, UVA/UVB-blocking blocking sunglasses because they so UV light is able to pass right contact lenses prevent UV radia- too are at risk for UV keratitis due through. Adults experience a natu- tion from reaching the cornea and to the potential for the high reflec- ral discoloration or slight yellow- structures behind it, like the lens tance of UV radiation off of the ing of the lenses as the crystalline and the retina, but contacts don’t water. lenses mature, which actually helps cover everything. The conjunctiva Climbers and trailseekers, beware: Altitude also influences the intensity of UV radiation. When Blue Light in the Spotlight traveling to higher elevations, Near-UV or blue-violet light is a hot topic in research journals lately. Blue-violet light is vis- UV radiation is more dangerous ible light from natural sources (like sunlight) and artificial light sources (like CFLs and LED whether or not there are snow- screens). It is very close to ultraviolet light in its wavelength and its link to retinal damage is capped mountains. For every 1,000 currently being investigated. feet that we ascend in altitude, our As studies unfold and the knowledge of this newfound hazard is passed on to the public, eyes are subjected to 5% to 7% there will be a growing demand for patient protection from blue-violet as well as UV radia- more UV radiation.5 This is due tion. There are already ophthalmic products on the market that provide both UV-blocking not only to snow, but because the and selective blue-violet filtering protection. atmosphere is thinner at higher altitudes and filters out less UV. Again, eye care professionals to filter out some short wavelength is left vulnerable to UV radiation, need to nudge their outdoorsy light.7 Because of this, adults with as well as the skin of the lids and patients to proactively protect nuclear sclerotic lens changes are brow bone. In addition, the lids themselves from UV so that they slightly better protected against and brow bone are typically areas can enjoy the sunshine and the potential cumulative retinal dam- of the face where most people great outdoors guilt-free and with- age from UV radiation compared avoid applying sunblock because out detriment to their short-term to children who have immature, they fear they will get sunblock in or long-term ocular health. clear crystalline lenses. their eyes. Of course, as adults’ lenses But these spots need protection, Kids mature, they’ll eventually need too. Approximately 5% to 10% of Every parent knows the impor- cataract surgery; and, unless they all skin cancers occur in the eye- tance of protecting their children’s receive UVA-blocking and blue- lids.8,9 Basal cell carcinoma is the skin from the sun, but what about violet light-filtering IOLs, they’ll most frequently encountered (90% their eyes? Kids, who tend to spend again be at an increased risk for to 95%) type of eyelid tumor, more time outdoors than adults, retinal damage. followed by squamous cell carci- make up another patient popula- Every time a parent remembers noma, sebaceous cell carcinoma tion that needs UV-blocking sun to smear sunscreen on their child’s and, lastly, malignant melanoma. protection. Up to 50% of the total face before heading out the door, Although basal cell carcinoma UV we’re exposed to by age 60 the parent should also remember tends to grow slowly and does not occurs before we reach age 20.6 to grab their child’s UVA/UVB- frequently metastasize, it can be Because the long-term effects of blocking sunglasses. Parents will very destructive if left untreated, sun damage are cumulative, the be doing their children a great extending into deeper layers of

32 REVIEW OF OPTOMETRY MARCH 15, 2014

028_ro0314_f1.indd 32 3/4/14 10:01 AM In her lifetime, she’ll have over 160 DENTAL CHECK-UPS. but just 16 EYE EXAMS.

Think About Your Eyes is Changing That! It’s true. For the vast amount of Americans, their teeth get far more attention than their eyes, even though we know vision is more important. That’s why we created Think About Your Eyes (TAYE), the multi-million dollar advertising campaign dedicated to educating consumers on the beneﬁts of eye health and annual eye exams.

OVER 80% will be reached by advertising multiple times in 2014, and all TAYE messaging OF ADULTS will drive them to the doctor locator. Find a doctor near you.

to get your practice JOIN NOW listed on the locator! Sign up at ThinkAboutYourEyes.com/Enroll

RO0314_Foundation.indd 1 2/26/14 10:16 AM Clinical Care

the skin and invading what their doctors say periorbital tissues and seriously, but what mat- bone.10 ters most is what they do Tumors need to be after they leave the office. removed early before Individualized care and they cause damage prescribed recommenda- to vital ocular struc- tions tend to hold more tures, but detection weight than a blanket can be difficult due to statement that UV is bad. their inward growth By providing each pattern.8,9,11 Eyelid patient with personalized tumors can grow suggestions, as well the under the skin for scientific explanations years before any clue and evidence behind appears on the sur- those suggestions, eye face.8,9,11 care professionals stand Displaying a few In sunny Los Angeles, Maylin Gonzalez, OD, (left) tells her patients a better chance of the pairs of sunglasses in that sunglasses are not just fashionable, they are part of a healthy patient taking their doc- your contact lens dis- lifestyle that includes eating right, exercising and avoiding environ- tor’s directions to heart pensary may remind mental hazards like UV. and protecting themselves both you and your from UV radiation. ■ contact lens patient that the con- ronmental hazards posed by UV 1. International Agency for Research On Cancer. IARC mono- junctiva, lids and unprotected areas light. Patients who suffer from or graphs on the evaluation of carcinogenic risks to humans. of periocular skin also require are at risk for retinal damage need Solar and ultraviolet radiation. IARC Monogr Eval Carcinog Risks Hum. 1992;55:1-316. proper UVA/UVB protection. The to make sun protection a priority. 2. Sliney DH. Physical factors in cataractogenesis: ambient good news is that because con- Epidemiological studies have found ultraviolet radiation and temperature. Invest Ophthalmol Vis tact lenses have taken care of the a relationship between chronic Sci. 1986 May;27(5):781-90. 3. Sliney DH. UV radiation ocular exposure dosimetry. Doc patient’s prescription, a pair of sunlight exposure and AMD.12 Add Ophthalmol. 1994-1995;88(3-4):243-54. non-Rx, high quality sunglasses to this the increasing magnitude of 4. Sliney DH. Epidemiological studies of sunlight and cataract: the critical factor of ultraviolet exposure geometry. will take care of the rest, and then macular degeneration among the Ophthalmic Epidemiol. 1994 Jun;1(2):107-19. the patient can walk out of the eye rapidly growing elderly population. 5. Andersen PA, Buller DB, Walkosz BJ, et al. Environmental cues to UV radiation and personal sun protection in outdoor doctor’s office fully protected. Specifically, researchers predict winter recreation. Arch Dermatol. 2010 Nov;146(11):1241-7. that the number of Americans with 6. Green AC, Wallingford SC, McBride, P. Childhood exposure to ultraviolet radiation and harmful skin effects: Health-Conscious Individuals early AMD is expected to nearly Epidemiological evidence. Prog Biophys Mol Biol. 2011 Dec: Today’s health-conscious indi- double by 2050—from 9.1 million 107(3): 349-355. 7. Sample PA, Esterson FD, Weinreb RN, Boynton RM. 13 viduals are concerned with their to 17.8 million. The aging lens: in vivo assessment of light absorption genetic predispositions for certain If patients have a family history in 84 human eyes. Invest Ophthalmol Vis Sci. 1988 Aug;29(8):1306-11. diseases and illnesses. They also of AMD and other risk factors 8. Cook BE Jr, Bartley GB. Treatment options and future have a desire to take charge and that make them vulnerable to UV prospects for the management of eyelid malignancies: an evidence-based update. Ophthalmology 2001 Nov; minimize their interaction with damage—such as fair skin, light 108(11):2088-98. common toxins and environmental eyes and a fair retina—urge them 9. Abraham J, Jabaley M, Hoopes JE. Basal cell carcinoma of the medial canthal region. Am J Surg. 1973 Oct; hazards. Living a healthy lifestyle to take action against UV radiation 126(4):492-5. helps patients feel empowered, by wearing sun protection for their 10. Wong CS, Strange RC, Lear JT. Basal cell carcinoma. BMJ. 2003 Oct 4;327(7418):794-8. knowing they are doing what they eyes when outdoors. 11. Collin JR. Basal cell carcinoma in the eyelid region. Br J can to directly protect and improve Ophthalmol. 1976 Dec;60(12):806-9. 12. Sui GY, Liu GC, Liu GY, et al. Is sunlight exposure a their health. Eating right, exercis- As with much of optometry risk factor for age-related macular degeneration? A sys- ing and avoiding environmental and medicine, patient education tematic review and meta-analysis. Br J Ophthalmol. 2013 Apr;97(4):389-94. hazards are all parts of living a is crucial when attempting to cul- 13. Rein DB, Wittenborn JS, Zhang X, et al; Vision Health healthy lifestyle. tivate successful compliance with Cost-Effectiveness Study Group. Forecasting age-related macular degeneration through the year 2050: the poten- UV protection can help safe- recommended precautions and tial impact of new treatments. Arch Ophthalmol. 2009 guard our patients’ eyes from envi- treatments. Most patients take Apr;127(4):533-40.

34 REVIEW OF OPTOMETRY MARCH 15, 2014

028_ro0314_f1.indd 34 3/4/14 10:01 AM Extraordinary choices. Extraordinary vision.

Change the way your patients see the world. For patients who want more than an ordinary clear lens, the wide array of Transitions® adaptive lenses™ offers an option for everyone. Transitions lenses seamlessly adjust to changing light conditions while reducing glare, so your patients always see life in the best light. See how to recommend the right lens at 9 out of 10 people who wear Transitions lenses love them. TransitionsPRO.com/products

Transitions, the swirl and XTRActive are registered trademarks and Transitions Adaptive Lenses, Signature, Vantage and Life well lit are trademarks of Transitions Optical, Inc. ©2014 Transitions Optical, Inc. Photochromic performance is inﬂuenced by temperature, UV exposure and lens 1 % ™ material. Transitions Drivewear sun lenses are optimized for sunlight response. They should not be UV BLOCK Life well lit used for night driving. Drivewear is a registered trademark of Younger Mfg. Co.

RO0314_Transitions.indd 1 2/25/14 9:21 AM AREDS

The Legacy of

AREDS-2AREDS raised eyebrows, but could also open doors to ‘pharmaco genomics’ and more meaningful use of personalized genetic testing. By Dennis Ruskin, OD

odern scientific method- is a classic RCT that investigated of primary or secondary random- ology—specifically, the the addition of new nutrients to ization.1 randomized clinical trial the current AREDS formula, while M(RCT)—is considered Dr. Awh’s study predicted subject AREDS-1 a critical component of evidence- response to AMD with antioxidants Widespread public use of com- based medicine to separate fact and zinc. mercial vitamins and minerals to from fiction regarding interven- Although both studies used treat AMD—with few definitive tions, drugs, nutrition and other the same clinical information, answers on their safety and effi- strategies we use to treat our the genomic paper reanalyzed a cacy—initiated the AREDS-1 RCT patients safely and effectively. A statistically significant sample of in 2005. The National Eye Institute well-designed, large-scale clinical subjects’ data and genetic samples (NEI) sponsored this randomized, trial that is considered valid, reli- from AREDS-1. The methodologies placebo-controlled, double-masked able and unchallenged is critical differed significantly, which led to clinical trial primarily concerned to the emergence of a standard of contrasting conclusions in treat- with studying the effects of a nutri- care; however, the results achieved ment. The resulting controversy ent combination on the progression are only as good as the design of places us in a precarious position as of AMD. the clinical trial. we determine appropriate nutrient According to the AREDS-1 find- New research concerning AMD recommendations for patients with ings, the risk to advanced AMD has raised a few eyebrows among moderate or advanced AMD and decreased by 25% in stage III. enthusiasts of ocular nutrition. The those at risk for AMD. Though the formulation slowed the dialogue centers on two particular At times, clinical trials are chal- progression from stage III to stage studies—the AREDS-2, authored lenged due to confounding errors, IV, it did not halt the progression by National Eye Institute Deputy such as investigator bias, inaccurate of AMD (figure 1).1 The zinc subset Clinical Director Emily Chew, assumptions about the drug or had a 21% risk reduction and anti- MD, and a polymorphism genomic nutrient interaction, or an insuf- oxidants had a 17% risk reduction paper, authored by Carl Awh, MD, ficient number of subjects enrolled related to the progression of AMD a private practice ophthalmologist in subsets, causing statistically in stages III and IV (figure 2).2 The in Nashville. Dr. Chew’s research insignificant findings in the analysis evidence did not support the use

36 REVIEW OF OPTOMETRY MARCH 15, 2014

036_ro0314_f2.indd 36 3/6/14 4:29 PM of these supplements benefits: decreased tri- for prevention in the glyceride levels, which early stages I and II. may affect atheroscle- Overall, the results rotic plaque forma- were statistically tion; lowered blood significant but mod- pressure; reduction est. The Cochrane in heart attack risk, Reviews, an RCT stroke and danger- repository that pro- ous abnormal heart vides systematic rhythm in patients with reviews of primary known heart disease; research in human anti-inflammatory health care and health effect in patients with policy, found that rheumatoid arthritis; the generalizability of 1. Though the AREDS-1 forumation slowed progression from stage III to and reduction in risk these findings to other stage IV, it did not halt the progression of AMD. of breast and prostate populations with cancers.12-17 different nutritional Researchers also status was unknown; therefore, progression of AMD). Many clini- wanted to know whether reduced long-term harm from supplementa- cians wanted to change dosing and levels of zinc would affect the for- tion could not be ruled out.3 Beta- include some nutrients not used in mulation’s performance in decreas- carotene, for example, has been AREDS-1, such as the carotenoids ing progression of AMD, and if found to increase the risk of lung lutein and zeaxanthin, which are reduced zinc levels would decrease cancer in smokers and vitamin E found in high concentrations in the genitourinary complications. has been associated with increased macula, but were not commercially There were concerns that current heart-failure risk.3, 4 available at the time of the original or prior smokers had a higher risk There were also some concerns study. Further, previous studies of lung cancer with beta-carotene related to zinc and genitourinary associated high levels of lutein and in the formulation, so investiga- complications. Many clinical inves- zeaxanthin intake with lower risk tors also wanted to test whether tigators questioned the benefits of of AMD.5-8 These nutrients are eliminating beta-carotene altogether zinc and the antioxidant supple- believed to augment macular pig- and substituting lutein/zeaxanthin ments used; they also wanted more ment optic density (MPOD), which would affect the results. time to study the effects of higher protects the photoreceptors and the dose supplements. retinal pigment epithelium from the AREDS-2 Based on the AREDS-1 conclu- oxidative damage associated with Researchers started enrollment sions, should patients with moder- exposure to blue light. for AREDS-2 in 2006 with the ate to severe AMD take antioxidant A follow-up analysis of AREDS-1 intention of studying additional supplements? Some investigators concerned the dietary habits of nutrient combinations against the voiced concerns about how the subjects who answered a food fre- benefits of the existing formula study was funded, and pointed out quency questionnaire at baseline. (Table 3). The primary randomiza- that there had been no replication The study indicated that subjects tion in AREDS included the original of the data. Others noted the lack who consumed fish with long chain formula plus one of the following: of long-term safety information, omega-3 fatty acids experienced • 10mg of lutein/2mg of zeaxan- coupled with only a modest effect a 25% decrease in AMD progres- thin in reducing progression of AMD. sion.9 In addition, several investiga- • Omega-3 fatty acids: 350mg Encouraged by the preliminary tors of independent peer-reviewed docosahexaenoic acid data from AREDS-1, clinical studies have reported findings that (DHA)/650mg of eicosapentae- investigators sought to discover support omega-3 fatty acids in the noic acid (EPA) if manipulation of the original management of AMD.9-11 • Lutein/zeaxanthin plus DHA- formula could achieve double the Other effects of omega-3 in the EPA above AREDS-1 effect (a 50% decrease in literature suggest the following The secondary randomization

REVIEW OF OPTOMETRY MARCH 15, 2014 37

036_ro0314_f2.indd 37 3/6/14 4:29 PM AREDS

evaluated three subsets using the original formula plus one of the following: • No beta-carotene • Low zinc • No beta-carotene and low zinc Interestingly, the addition of lutein and zeaxanthin, and DHA/ EPA, or both in the primary analysis, did not further reduce the risk of progression to advanced AMD.17 The authors of AREDS-2 sought to determine if a statistically significant sample of the general population would benefit from a specific nutrient formula. The study provided useful evidence to justify a redesign of the original AREDS-1 formula, since reducing the level of zinc and eliminating the beta- 2. The zinc subset had a 21% risk reduction and antioxidants had a 17% risk carotene did not reduce the efficacy reduction related to the progression of AMD in stages III and IV. of the supplements. However, there were confounding factors that could the progression in AMD patients. lutein, zeaxanthin and omega fatty have adversely influenced the results. Some possible reasons include use acids, in addition to the original of the ethyl ester form of omega-3, AREDS supplement. AREDS-2 AREDS-2 Uncertainties which is not as bioavailable as the clinical investigator Paul Bernstein, • Study design issues. There were triglyceride form, and the lipid-low- MD, PhD, a leading carotenoid admitted limitations to the study ering effect of 1,000mg of omega- researcher, confirmed this. results due to “a complicated design 3, which may not be sufficient to Dr. Bernstein’s work showed a involving a secondary randomiza- obtain a desirable result. linear relationship between diet or tion which may have affected our Further, many subjects did not carotenoid-rich supplements and a ability to evaluate the role of lutein follow the study guidelines regard- more robust MPOD. He performed and zeaxanthin and DHA+EPA to ing their recommended nutrient an ancillary study on his AREDS-2 the AREDS formula.”17 intake. Approximately 84% of subjects in which he measured • No control group. Due to subjects took slightly more than MPOD and found their “usage of the modest success of AREDS-1 75% of the supplement pills, which lutein and zeaxanthin supplements results, it was ethically necessary could have skewed the results. was exceedingly high, suggesting to offer prior subjects of AREDS-1 Fourteen percent of subjects admit- that we enrolled a very nutrition- the choice of taking the original ted to taking unauthorized addi- ally aware cohort.”20 The inclusion AREDS-1 formula or not. In fact, tional supplements, either alone or of a larger group of subjects who most subjects opted to continue the in combination with their supple- have statistically significant nutrient original formula. Only 19 of about ment pills, during the trial. deficiencies would likely offer more 4,000 (less than 0.05%) of the total • Non-representative sample. practical clinical information than enrolled subjects in AREDS-2 did AREDS-2 inducted mainly female, studies on well-nourished subjects. not take the original AREDS-1 for- well-nourished whites; thus, the • Nutrient interactions. The pri- mula. Therefore, there was no true study sample was not representa- mary study conclusion—that lutein control group to compare findings tive of the biological diversity and zeaxanthin with or without in the AREDS-2 primary analysis. of the general population. The omega-3 fatty acids did not further • Omega-3 confounding fac- study group reported that they reduce the risk of progression— tors. The study showed that taking already consumed supplements, may have been influenced by carot- 1000mg of omega-3 did not affect multivitamins or foods rich in enoid competition.

38 REVIEW OF OPTOMETRY MARCH 15, 2014

036_ro0314_f2.indd 38 3/6/14 4:29 PM UNMATCHED ACCURACY. ANYWHERE.

THE ONE & ONLY RETINOMAX Whether in your office or on the road, the Retinomax hand-held autorefractor / keratometer provides unmatched accuracy and convenience in any testing environment.

Pretest with the gold standard portable autorefractor / keratometer, Retinomax K-Plus and ensure confidence in your test data with measurements that are acquired quickly, easily and accurately. See for yourself why we are called RIGHTon.

Contact S4OPTIK for more information.

5325 Cleveland Street, Suite 303 Virginia Beach, VA 23462 CALL NOW 1-888-224-6012 I www.s4optik.com

RO0314_S4optik.indd 1 2/28/14 9:03 AM AREDS

Interestingly, when compared forward, the evolution of personal- average population statistics, as is with the subgroup that used the ized recommendations will become routine in an RCT like AREDS-1. original AREDS formula plus more commonplace. Rather, the authors sought to com- lutein and zeaxanthin (without pare how the original AREDS for- beta-carotene) to the subgroup in Predicting AMD Pathogenesis mula subsets—zinc, antioxidants, the primary randomization of orig- The human genome has been and zinc plus antioxidants—would inal AREDS formula containing catalogued and genetic varia- affect progression to AMD when beta-carotene, lutein and zeaxan- tions have been identified as single sorted by genotype that were com- thin, there is an 18% lower risk of nucleotide polymorphisms (SNPs), posed of high-risk genes. Dr. Awh AMD progression. This result may which are considered a measure of was specifically interested in results occur because lutein, zeaxanthin genetic similarity used for genotyp- concerning one or two risk alleles and beta-carotene are carotenoids ing or genetic fingerprinting. SNPs of CFH or ARMS2. that do compete for absorption associated with AMD are located Dr. Awh’s study analyzed the human body.20 Carotenoid on genes that affect the biological AREDS-1 data for up to 12 years. competition may explain, in part, pathways of the disease, and have Subjects with the ARMS2 allele(s) why lutein and zeaxanthin had no been confirmed in the literature. benefited more from the formula- overall effect in the primary ran- Genes involved with the completion with zinc alone. Furthermore, domization, but a statistically sig- ment cascade of the immune system these subjects had a higher risk of nificant effect when beta-carotene have a direct effect on the progres- progression to AMD when they was removed in the secondary sion of AMD.23 Thus, AMD has the also were treated with antioxidants. randomization. Therefore, this strongest genetic contribution of all Subjects with the CFH risk allele(s) confounding error may be viewed human multi-genetic diseases.23 benefited more with antioxidants by some observers as a significant Additionally, the pathogenesis than with the complete AREDS-1. study flaw affecting the results of of AMD may be predicted using a Interestingly, when this group was the primary study. combination of fundus diagnosis treated with zinc, there was an and determination of genotype.24 associated increase in the risk to Pharmacogenomics and AMD A currently available, validated progression of AMD. Those with In the past, large-scale RCT stud- genetic test (Arctic Dx) may pro- both one ARMS2 and one CFH ies allowed industry to develop vide greater sophistication in how alleles showed reduced progression “blockbuster” drugs to treat an we view an individual’s future risk using the original AREDS-1 for- average population. Many now of AMD progression.25 Using geno- mula of zinc plus antioxidants. Dr. contend that the future of medical typing, fundus diagnosis and health Awh extrapolated the AREDS-1 studies may focus on a more per- care history together, an individual- data to genotype and predicted that sonalized approach to medicine— ized prediction of advanced AMD the optimal treatment for 49% of that is, developing interventions, risk over time can be generated.24 the study patients would be a nutri- drugs or nutrients to treat subsets ent combination different from the of patients, each of whom may Reanalysis of AREDS-1 complete AREDS-1 formulation. respond differently based on indi- Using Genomic Testing The scientific literature includes vidual genetic factors.21 Genetic research has shown that some studies that support Dr. While the RCT is invaluable in SNPs of human variation comple- Awh’s contention that there could understanding whether one treatment factor (CFH) and age-related be a harmful relationship between ment is better than another on a maculopathy sensitivity 2 (ARMS2) CFH and ARMS2 with nutrients in general platform, the findings may each have important roles in AMD.26 the AREDS-1 formula. A retrospec- be harder to apply individually. Dr. Awh, et al., authored a clini- tive analysis done in 2008 found Research gleaned from a combina- cal study that obtained statistically that the AREDS supplement may tion of RCT and genetic trials may significant AREDS-1 data from be related to the CFH high-risk be on the horizon. Pharmacoge- subjects—including genetic infor- SNP.26 In 2009, researchers found nomics—the way genes influence mation contained in saliva samples. “significant interaction between the response to nutrients and drugs—is In a novel twist of methodologies number of risk alleles for the CFH unique and different for each indi- contrasting RCT and genomic test- Y402H variant and treatment, vidual.22 As genetic research moves ing, investigators did not obtain whereby patients with the (high

40 REVIEW OF OPTOMETRY MARCH 15, 2014

036_ro0314_f2.indd 40 3/6/14 4:30 PM RO0214_Allergan Lumigan.indd 1 1/28/14 2:14 PM ® USE IN SPECIFIC POPULATIONS LUMIGAN 0.01% AND 0.03% Pregnancy: Pregnancy Category C Teratogenic effects: In embryo/fetal developmental studies in pregnant mice and (bimatoprost ophthalmic solution) 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 Brief Summary—Please see the LUMIGAN® 0.01% and 0.03% package AUC levels. insert for full Prescribing Information. At doses at least 41 times the maximum intended human exposure based on blood INDICATIONS AND USAGE AUC levels, the gestation length was reduced in the dams, the incidence of dead LUMIGAN® 0.01% and 0.03% (bimatoprost ophthalmic solution) is indicated for the fetuses, late resorptions, peri- and postnatal pup mortality was increased, and pup reduction of elevated intraocular pressure in patients with open angle glaucoma or body weights were reduced. ocular hypertension. There are no adequate and well-controlled studies of LUMIGAN® 0.01% and 0.03% (bimatoprost ophthalmic solution) administration in pregnant women. Because CONTRAINDICATIONS animal reproductive studies are not always predictive of human response LUMIGAN® None should be administered during pregnancy only if the potential benefit justifies the WARNINGS AND PRECAUTIONS potential risk to the fetus. Pigmentation: Bimatoprost ophthalmic solution has been reported to cause changes Nursing Mothers: It is not known whether LUMIGAN® 0.01% and 0.03% is excreted to pigmented tissues. The most frequently reported changes have been increased in human milk, although in animal studies, bimatoprost has been shown to be pigmentation of the iris, periorbital tissue (eyelid) and eyelashes. Pigmentation is excreted in breast milk. Because many drugs are excreted in human milk, caution expected to increase as long as bimatoprost is administered. The pigmentation should be exercised when LUMIGAN® is administered to a nursing woman. change is due to increased melanin content in the melanocytes rather than to Pediatric Use: Use in pediatric patients below the age of 16 years is not an increase in the number of melanocytes. After discontinuation of bimatoprost, recommended because of potential safety concerns related to increased pigmen- pigmentation of the iris is likely to be permanent, while pigmentation of the periorbital tation following long-term chronic use. tissue and eyelash changes have been reported to be reversible in some patients. Geriatric Use: No overall clinical differences in safety or effectiveness have been Patients who receive treatment should be informed of the possibility of increased observed between elderly and other adult patients. pigmentation. The long term effects of increased pigmentation are not known. Hepatic Impairment: In patients with a history of liver disease or abnormal ALT, Iris color change may not be noticeable for several months to years. Typically, the AST and/or bilirubin at baseline, bimatoprost 0.03% had no adverse effect on liver brown pigmentation around the pupil spreads concentrically towards the periphery function over 48 months. of the iris and the entire iris or parts of the iris become more brownish. Neither nevi OVERDOSAGE nor freckles of the iris appear to be affected by treatment. While treatment with ® LUMIGAN® 0.01% and 0.03% (bimatoprost ophthalmic solution) can be continued in No information is available on overdosage in humans. If overdose with LUMIGAN patients who develop noticeably increased iris pigmentation, these patients should 0.01% and 0.03% (bimatoprost ophthalmic solution) occurs, treatment should be examined regularly. be symptomatic. Eyelash Changes: LUMIGAN® 0.01% and 0.03% may gradually change eyelashes In oral (by gavage) mouse and rat studies, doses up to 100 mg/kg/day did not and vellus hair in the treated eye. These changes include increased length, thickness, produce any toxicity. This dose expressed as mg/m2 is at least 70 times higher ® and number of lashes. Eyelash changes are usually reversible upon discontinuation than the accidental dose of one bottle of LUMIGAN 0.03% for a 10 kg child. of treatment. NONCLINICAL TOXICOLOGY Intraocular Inflammation: LUMIGAN® 0.01% and 0.03% should be used with Carcinogenesis, Mutagenesis, Impairment of Fertility: Bimatoprost was not caution in patients with active intraocular inflammation (e.g., uveitis) because the carcinogenic in either mice or rats when administered by oral gavage at doses inflammation may be exacerbated. of up to 2 mg/kg/day and 1 mg/kg/day respectively (at least 192 and 291 times Macular Edema: Macular edema, including cystoid macular edema, has been the recommended human exposure based on blood AUC levels respectively) for reported during treatment with bimatoprost ophthalmic solution. LUMIGAN® 0.01% 104 weeks. and 0.03% should be used with caution in aphakic patients, in pseudophakic Bimatoprost was not mutagenic or clastogenic in the Ames test, in the mouse patients with a torn posterior lens capsule, or in patients with known risk factors for lymphoma test, or in the in vivo mouse micronucleus tests. macular edema. Bimatoprost did not impair fertility in male or female rats up to doses of 0.6 mg/kg/day Angle-closure, Inflammatory, or Neovascular Glaucoma: LUMIGAN® 0.01% and (at least 103 times the recommended human exposure based on blood AUC levels). 0.03% has not been evaluated for the treatment of angle-closure, inflammatory or PATIENT COUNSELING INFORMATION neovascular glaucoma. Potential for Pigmentation: Patients should be advised about the potential for Bacterial Keratitis: There have been reports of bacterial keratitis associated with increased brown pigmentation of the iris, which may be permanent. Patients the use of multiple-dose containers of topical ophthalmic products. These containers should also be informed about the possibility of eyelid skin darkening, which may had been inadvertently contaminated by patients who, in most cases, had a be reversible after discontinuation of LUMIGAN® 0.01% and 0.03% (bimatoprost concurrent corneal disease or a disruption of the ocular epithelial surface. ophthalmic solution). Use With Contact Lenses: Contact lenses should be removed prior to instillation ® Potential for Eyelash Changes: Patients should also be informed of the possibility of LUMIGAN 0.01% and 0.03% and may be reinserted 15 minutes following of eyelash and vellus hair changes in the treated eye during treatment with its administration. LUMIGAN® 0.01% and 0.03%. These changes may result in a disparity between ADVERSE REACTIONS eyes in length, thickness, pigmentation, number of eyelashes or vellus hairs, Clinical Studies Experience: Because clinical studies are conducted under widely and/or direction of eyelash growth. Eyelash changes are usually reversible upon varying conditions, adverse reaction rates observed in the clinical studies of a drug discontinuation of treatment. cannot be directly compared to rates in the clinical studies of another drug and may Handling the Container: Patients should be instructed to avoid allowing the tip of not reflect the rates observed in practice. the dispensing container to contact the eye, surrounding structures, fingers, or any In clinical studies with bimatoprost ophthalmic solutions (0.01% or 0.03%) the other surface in order to avoid contamination of the solution by common bacteria most common adverse reaction was conjunctival hyperemia (range 25%–45%). known to cause ocular infections. Serious damage to the eye and subsequent loss of Approximately 0.5% to 3% of patients discontinued therapy due to conjunctival vision may result from using contaminated solutions. hyperemia with 0.01% or 0.03% bimatoprost ophthalmic solutions. Other common When to Seek Physician Advice: Patients should also be advised that if they reactions (>10%) included growth of eyelashes, and ocular pruritus. develop an intercurrent ocular condition (e.g., trauma or infection), have ocular Additional ocular adverse reactions (reported in 1 to 10% of patients) with surgery, or develop any ocular reactions, particularly conjunctivitis and eyelid bimatoprost ophthalmic solutions included ocular dryness, visual disturbance, reactions, they should immediately seek their physician’s advice concerning the ocular burning, foreign body sensation, eye pain, pigmentation of the periocular continued use of LUMIGAN® 0.01% and 0.03%. skin, blepharitis, cataract, superficial punctate keratitis, periorbital erythema, Use with Contact Lenses: Patients should be advised that LUMIGAN® 0.01% and ocular irritation, eyelash darkening, eye discharge, tearing, photophobia, allergic 0.03% contains benzalkonium chloride, which may be absorbed by soft contact conjunctivitis, asthenopia, increases in iris pigmentation, conjunctival edema, lenses. Contact lenses should be removed prior to instillation of LUMIGAN® and may conjunctival hemorrhage, and abnormal hair growth. Intraocular inflammation, be reinserted 15 minutes following its administration. reported as iritis, was reported in less than 1% of patients. Use with Other Ophthalmic Drugs: Patients should be advised that if more than one Systemic adverse reactions reported in approximately 10% of patients with topical ophthalmic drug is being used, the drugs should be administered at least five bimatoprost ophthalmic solutions were infections (primarily colds and upper (5) minutes between applications. respiratory tract infections). Other systemic adverse reactions (reported in 1 to 5% of patients) included headaches, abnormal liver function tests, and asthenia. © 2012 Allergan, Inc., Irvine, CA 92612 Postmarketing Experience: The following reactions have been identified during ® ® marks owned by Allergan, Inc postmarketing use of LUMIGAN 0.01% and 0.03% in clinical practice. Because they Patented. See: www.allergan.com/products/patent_notices are reported voluntarily from a population of unknown size, estimates of frequency Made in the U.S.A. cannot be made. The reactions, which have been chosen for inclusion due to either their seriousness, frequency of reporting, possible causal connection to LUMIGAN®, or APC70EN12 based on 71807US13. Rx only a combination of these factors, include: dizziness, eyelid edema, hypertension, nausea, and periorbital and lid changes associated with a deepening of the eyelid sulcus.

RO0214_Allergan Lumigan PI.indd 1 1/28/14 2:16 PM AREDS

9. Seddon JM, Ajani UA, Sperduto RD, et al. Dietary carotenoids, risk) genotype were less likely to The AREDS RCT also opens vitamins A, C, and E, and advanced age-related macular degen- benefit from the antioxidant-min- a new door to clinical genetic eration. Eye Disease Case-Control Study Group. JAMA. 1994 Nov 9;272(18):1413-20. eral supplementation than subjects trials. Dr. Awh predicated his 10. Age-Related Eye Disease Study Research Group; SanGiovanni with the TT and CT genotypes.27 recent work on a clinically rich JP, Chew EY, et al. The relationship of dietary carotenoid and vitamin A, E, and C intake with age-related macular degeneration In 2012, researchers demonstrated time capsule of information from in a case-control study: AREDS Report No. 22. Arch Ophthalmol. that a strong association exists AREDS-1, collected for more than 2007 Sep;125(9):1225-32. 11. Wang J, Foran S, Smith W, Mitchell P. Risk of age-related between all stages of AMD and the 10 years. Study investigators were macular degeneration in eyes with macular drusen or hyperpig- ARMS2 SNP.28 Two years earlier, able to fast-track more than a mentation: The Blue Mountains Eye Study Arch Ophthalmol. 2003 May;121(5):658-63. Stephen Perkins and colleagues decade of data by looking at influ- 12.Blue Mountain Eye Study. Centre for Vision Research. Avail- outlined the biological plausibility ences by genotype rather than by able at: www.cvr.org.au/bmes.htm. Accessed February 18, 2014. 13. SanGiovanni JP, Chew EY, Clemons TE, et al. The relation- 1 of the CFH/zinc interaction. This an average population. ship of dietary lipid intake and age-related macular degeneration publication points specifically at Certainly, the debate to recom- in a case-control study: AREDS Report No. 20. Age-Related Eye Disease Study Research Group. Arch Ophthalmol. 2007 high-risk CFH alleles and zinc.30 mend personalized genetic testing or May;125(5):671-9. 14. Chapman MJ, Ginsberg H, Amaraenco P, et al., Triglyceride- Dr. Awh shared his findings to use a classical RCT will evolve. rich lipoproteins and high-density lipoprotein cholesterol in about genotype and progression Because AMD has the strongest patients at high risk of cardiovascular disease: evidence and guidance for management Eur Heart J (2011) 32 (11): 1345-1361. to AMD using AREDS supple- genetic contribution of all human 15. Appel LJ, Miller ER 3rd, Seidler AJ, et al. Does supplements at the American Academy multi-genetic diseases, it seems likely mentation of diet with ‘fish oil’ reduce blood pressure? A meta- analysis of controlled clinical trials. Arch Intern Med. 1993 Jun of Ophthalmology’s annual meet- that at least some form of person- 28;153(12):1429-38. ing in late 2013. Afterward, Dr. alized genetic testing will help us 16. Hu FB, Bronner L, Willett WC, et al. Fish and Omega-3 Fatty Acid Intake and Risk of Coronary Heart Disease in Women. Chew offered a dissenting view better protect our patients from the JAMA. 2002 Apr 10;287(14):1815-21. and reported that his data did not visual ravages of AMD. ■ 17. Simopoulos A. Omega-3 Fatty Acids in Inflammation and Autoimmune Diseases, , J Am Coll Nutr. 2002 Dec;21(6):495-505. complement hers. As there is no 18. Azrad M, Turgeon, Demark-Wahnefried W. Current Evidence consensus among retina specialists Dr. Ruskin is the president of Linking Polyunsaturated Fatty Acids with Cancer Risk and Pro- gression. Front Oncol. 2013; 3: 224. on the matter, a comprehensive the College of Optometrists of 19. Chew EY, Clemons TE, SanGiovanni JP, et al. Lutein + scientific review is needed to rec- Ontario, and is in private practice zeaxanthin and omega-3 fatty acids for age-related macular degeneration: the Age-Related Eye Disease Study 2 (AREDS2) oncile the conflicting data. in Toronto. He is the current chair randomized clinical trial. JAMA. 2013 May 15;309(19):2005-15. 20. Bernstein P, Ahmed F, Aihua L,et al Macular Pigment Imaging of the Ocular Nutrition special in AREDS2 Participants: An Ancillary Study of AREDS2 Subjects AREDS-1 was the first glimpse interest group within the American Enrolled at the Moran Eye Center. Invest Ophthalmol Vis Sci. 2012 Sep 14;53(10):6178-86. into a nutrient strategy to help Academy of Optometry. He has no 21. Wang Y, Roger I, Connor SL, et al. Competitive inhibition combat AMD based on traditional direct financial interest in any of the of carotenoid transport and tissue concentrations by high dose supplements of lutein, zeaxanthin and beta-carotene. Eur J Nutr. evidence-based science. The exten- products mentioned in this article. 2010 Sep;49(6):327-36. sion study, AREDS-2, confirmed 22. Junod S. FDA + Clinical trials: A short History. FDA. www. 1. Titler MG. The Evidence for Evidence-Based Practice Imple- FDA.gov./aboutfda/whatwedo/history/overviews/ucm304485. that lutein and zeaxanthin are more mentation. In: Hughes RG, ed. Patient Safety and Quality: An htm. Accessed February 20, 2014. beneficial and safer than beta- Evidence-Based Handbook for Nurses. Rockville, MD: Agency for 23. Ma Q, Lu AY. Pharmacogenetics, pharmacogenomics, and Healthcare Research and Quality; 2008. individualized medicine. Pharmacol Rev. 2011 Jun;63(2):437-59. carotene in reducing progression of 2. AREDS: Results National Eye Institute. http://www.nei.nih.gov/ 24. Yu Y, Reynolds R, Rosner B, et al. Prospective assessment of the disease. Studies on the benefits amd/background.asp. Accessed February 18, 2014. genetic effects on progression to different stages of age-related 3. Evans JR, Lawrenson JG. Cochrane Database Syst Rev. 2012 macular degeneration using multistate Markov models. Invest of omega-3 fatty acids are ongoing, Nov 14;11:CD000254. Ophthalmol Vis Sci. 2012;53:1548-56. while many practitioners will con- 4. Hall H. Antioxidant Supplements for Macular Degeneration. 25. Seddon JM, Reynolds R, Yu Y, Rosner B. Validation of a pre- Science-Based Medicine. http://www.sciencebasedmedicine.org/ diction algorithm for progression to advanced macular degenera- tinue to recommend DHA and EPA antioxidant-supplements-for-macular-degeneration. Accessed tion subtypes. JAMA Ophthalmol. 2013 Apr;131(4):448-55. in different forms and dosages. February 18, 2014. 26. Awh C, Lane A, Hawken S, et al. CFH and ARMS2 Genetic 5. Beatty S, Murray IJ, Henson DB, et al. Macular Pigment and Polymorphisms Predict Response to Antioxidants and Zinc in The results of AREDS-2 should Risk for Age-Related Macular Degeneration in Subjects from a Patients with Age-related Macular Degeneration. Presented at: be considered against its ethical con- Northern European Population. Invest Ophthalmol Vis Sci. 2001 2013 American Academy of Ophthalmology Annual Meeting; Feb;42(2):439-46. Nov. 16-19; New Orleans, LA. siderations, including the absence of 6. Richer S, Stiles W, Statkute L. Double-masked, placebo- 27. Klein ML, Francis PJ, Rosner B, et al. CFH and LOC3087715/ controlled, randomized trial of lutein and antioxidants supplemen- ARMS2 Genotypes and Treatment with Antioxidants and Zinc for a control group, design complexity, tation in the intervention of atrophic AMD: Veterans LAST study. ARMD. Ophthalmology. 2008 Jun;115(6):1019-25. nutrient interaction, subject sam- Optometry. 2004 Apr;75(4):216-30. 28. Seddon JM, Reynolds R, Maller J, et al. Prediction Model 7. Richer S, Stiles W, Graham-Hoffman K, et al. Randomized, for prevalence and Incidence of Advanced Age- Related Macular pling issues and the effectiveness double-blind, placebo-controlled study of zeaxanthin and visual Degeneration based on genetic, Demographic and environmental of additional nutrients studied. In function in patients with atrophic age-related macular degenera- Variables. Invest Ophthalmol Vis Sci. 2009 May;50(5):2044-53. tion: The Zeaxanthin and Visual Function Study (ZVF) FDA IND 29. Chakrathy U, McKay GJ, de Jong PT, et al. Arms2 Increases hindsight, it may have been clinically #78, 973. Optometry. 2011 Nov;82(11):667-680.e6 the risk of early and late Age-Related Macular Degeneration in the relevant to analyze more subjects 8. Bernstein PS, Zhao D, Wintch SW, et al. Resonance Raman European Eye Study. Ophthalmology. 2013 Feb;120(2):342-8. Measurement of Macular Carotenoids in Normol Subjects and 30. Perkins SJ, Nan R, Li K, et al. Complement Factor H- Ligand who were less nourished than the in Age-Related macular Degerneration Subjects. Ophthalmology. Interactions: Self Association, multivalency and dissociation individuals reflected in AREDS-2. 2002 Oct;109(10):1780-7. constants. Immunobiology. 2012 Feb;217(2):281-97.

REVIEW OF OPTOMETRY MARCH 15, 2014 43

036_ro0314_f2.indd 43 3/6/14 4:30 PM Nutrition

Systemic Disease Report Nutrition and Diabetes: Our Role in Patient Care If we don’t educate our patients about the dangers of poor dietary habits and sedentary lifestyles, the incidence of diabetic eye disease will continue to soar. By Laurie Capogna, OD, and Barbara Pelletier, OD

hose responsibility is it cholesterol and high blood pres- the incidence of both conditions to educate our patients sure.1 Affected individuals have a increased by more than 20%.3,4 about the importance of five-fold risk of developing type This is a real crisis. However, Wnutrition, lifestyle and II diabetes, and are three times the good news is that we can do excess weight gain with respect to more likely to have a heart attack something about it. Type 2 diabe- diabetes management? Historically, or stroke than healthy individuals. tes is preventable, and it accounts we left this task to the patient’s Currently, the IDF estimates that for 95% of all cases.2 If we educate primary care physician. However, up to 25% of adults worldwide our patients about the relationship with escalating rates of obesity have metabolic syndrome.1 between weight, exercise, dietary and metabolic syndrome in North Data from the 2011 National intake and diabetic eye disease, we America––in addition to a rapidly Diabetes Fact Sheet show that can reduce the incidence of type 2 expanding incidence of vision loss nearly 26 million Americans have diabetes and help prevent associ- secondary to diabetic eye disease–– been diagnosed with diabetes, and ated vision loss. optometrists simply can’t sit on the another 79 million are considered sidelines anymore. pre-diabetic.2 Additionally, seven What’s the Solution? As primary eye care providers, it million Americans suffer from the The typical North American is our responsibility to educate and disease but remain undiagnosed.2 diet contains high amounts of motivate our patients to maintain Diabetes is the leading cause processed, calorie-dense foods that a healthy weight through proper of new cases of blindness among offer little nutritional value, and nutrition and lifestyle modifica- adults aged 20 to 74. The National consequently promote weight gain. tion. Ultimately, their vision and Eye Institute reports that nearly Serving sizes, both in restaurants systemic well-being depend on our half of Americans with diabetes and at home, are expanding in guidance. have diabetic retinopathy.2 Of direct proportion with the waist- those, nearly 5% have sight- lines of millions of Americans. Metabolic Syndrome and the threatening retinopathy, with sig- Further, many people––particu- Diabetes Epidemic nificantly higher rates among Afri- larly children––are consuming too According to the International can, Latino and Native American many soft drinks and sugary bever- Diabetes Federation (IDF), meta- populations.2 ages that can promote type 2 diabe- bolic syndrome is a collective However, one of the most alarm- tes. If these general trends continue term that encompasses several of ing aspects of this epidemic is the into the foreseeable future, more the most dangerous risk factors increasing frequency of both type people will experience signs and for heart attack, including pre- 1 and type 2 diabetes in American symptoms of diabetic eye disease at diabetes, abdominal obesity, high youth. Between 2009 and 2011, increasingly younger ages.

44 REVIEW OF OPTOMETRY MARCH 15, 2014

044_ro0314_f3_final.indd 44 3/4/14 10:07 AM MANUFACTURED IN THE USA

Peer-Reviewed and Published The M&S Smart System® Delivers Science-Based Testing Consistent with the Pelli-Robson Wall Chart

A study conducted by the University of Toronto Hospital for Sick Children, published in the Journal of Ophthalmology (Volume 120, Issue 10, October 2013), concluded that the M&S Smart System® Computerized Visual Acuity and Contrast Sensitivity Testing System can be used as an alternative to the Pelli-Robson wall chart in measuring contrast sensitivity for a wide variety of ophthalmic conditions, in both adults and children.

The Contrast Sensitivity Test on the Smart System gives you: s Fast, accurate testing via a proprietary algorithm s #ONSISTENTLUMINANCEANDCALIBRATION s 2EPEATABLERESULTS s 3UPERIORTECHNICALSUPPORT

For more information, please call or visit our website. **Stop by our Booth (MS6716) at Vision Expo and ask about the Show Special!**

M&S holds US Patents 7,354,155; 7,926,948; 8,425,040; 8,167,429; 8,419,184 & 8,550,631. Other Patents Pending. www.mstech-eyes.com ©2014 M&S Technologies, Inc. Smart System and M&S are registered trademarks of M&S Technologies, Inc. All Rights Reserved. 1-877-225-6101

RO0314_MS Tech.indd 1 2/24/14 3:18 PM Nutrition

Food Choices for Optimal Ocular Health25 independently helpful at reducing Choosing foods that are rich in lutein, zeaxanthin, vitamin C, vitamin E and beta-carotene subjects’ risk of diabetes.5 How- are highly beneficial for maintaining peak ocular health and visual function. ever, according to another cohort In our “Eyefoods” plan, we advocate the following vegetable and fruit choices: from the Nurses’ Health Study, •One daily handful of raw, leafy greens––preferably kale or spinach. physical activity alone does not •Half-cup cooked leafy greens twice a week. eliminate an individual’s risk for •Half-cup of orange vegetables most days, including squash, raw carrots, pumpkin or type 2 diabetes.8 sweet potatoes. It is worth noting that other •Two orange peppers per week––raw and/or cooked. studies challenge this finding, and •Half-cup of green vegetables per day, such as raw and/or cooked broccoli, Brussels indicate that physical activity is sprouts, green peas and green beans. indeed an independent factor in •Up to three servings of kiwi, avocado, cantaloupe, citrus fruit or berries per day. diabetes prevention.11 Specifi- cally, weight control is the most important factor to consider—and According to the Diabetes Pre- Weight Control certainly, physical activity helps vention Program (DPP), lifestyle Excess weight gain is one of the facilitate weight loss. changes for pre-diabetics have fundamental causes of type 2 dia- To achieve optimal health ben- a significant impact on diabetes betes. Indeed, the risk of develop- efits, adults should physically exert prevention.5 The DPP was a two- ing diabetes increases seven-fold themselves for at least 30 minutes year, multicenter, randomized in overweight people, and 20- to per day. Even more importantly, clinical trial that was designed to 40-fold in obese people.7 The most however, children should engage in determine if modest weight loss widely accepted way to determine at least 60 continuous minutes of via dietary alteration and increased a patient’s weight status is to cal- physical activity each day.11 physical activity could prevent or culate his or her Body Mass Index delay the onset of type 2 diabetes (BMI), which is a ratio based upon Dietary Control more effectively than treatment an individual’s weight and height. In order to lose weight, patients with metformin. Waist circumference is another need to expend more calories than Participants began the study predictor of diabetes. According they consume. A diet that closely being overweight and exhibiting to a cohort of the Nurses’ Health adheres to the recommendations blood glucose levels that were Study, the risk of type 2 diabetes made by the Omni-Heart study is higher than normal, but clini- increased progressively in quin- a great way to help reduce weight, cally insufficient for a diagnosis tiles of patients with the largest while ensuring that food intake is of diabetes. The study results waist circumferences (35 inches or of high quality.12 showed that diabetes incidence was greater in women, and 40 inches or Diets constructed in accordance reduced by 58% in participants greater in men).8,9 with these suggestions are rich in who received intensive training Additionally, according to the vegetables and fruits, and low in in proper dietary intake, physical Harvard School of Public Health, saturated/trans fats, sodium and activity and behavioral modifica- losing 7% to 10% of your current added sugar. tions, compared to just 31% who weight can reduce your chances of A standard 2,100-calorie diet received metformin to lower blood developing type 2 diabetes by as should include 11 servings of veg- glucose levels.5 much as 50%.10 For patients who etables and fruit, as well as one At 10-year follow-up, the DPP don’t exercise and/or have poor to two servings each of whole researchers determined that the diets at baseline, this sort of weight grains, low-fat dairy, lean proteins, onset of diabetes could be delayed reduction goal is relatively easy to legumes and nuts. (Every patient’s for at least a decade in patients achieve. For example, those who ideal caloric intake level should be who continued to eat properly and weigh 150lbs would have to lose calculated by his or her dietitian.)12 exercise regularly following the just 10lbs to 15lbs. Closely adhering to such recom- study’s conclusion.6 Considering mendations, however, leaves little these results, it is critical to educate Increased Physical Activity room for foods that are rich in our patients about the protective In the DPP, 2.5 hours of exercise sugar, such as processed sweets and benefits of lifestyle modification. per week (i.e., brisk walking) was soft drinks.

46 REVIEW OF OPTOMETRY MARCH 15, 2014

044_ro0314_f3_final.indd 46 3/4/14 10:07 AM 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 daily (QID) for seven days, bepotastine plasma that BEPREVE should not be used to treat contact contact lenses. Remove contact lenses prior to 1,000 mg/kg/day; however, no evidence of 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 In vitro studies demonstrated that bepotastine another drug and may not reflect the rates © 2012 Bausch & Lomb Incorporated. observed in clinical practice. There are no adequate and well-controlled besilate does not inhibit the metabolism of various studies of bepotastine besilate in pregnant US/BEP/13/0028 4/13

RO0214_BL Bepreve PI.indd 1 1/16/14 9:53 AM Nutrition

Go for Whole Grain Recommended Serving Sizes25 Processed foods and refined Many nutrition and diet plans offer serving size suggestions that can be confusing. Serving grains comprise a large portion of sizes are important to ensure that patients achieve optimal health benefits from each food the average North American’s diet. while not consuming excess calories. Here are our recommendations from “Eyefoods”: These foods yield high glycemic indices and loads, meaning that Food Eyefoods Serving Size Handy Tips they increase blood sugar levels Raw, leafy green One cup One large handful significantly more than healthier, vegetables non-processed alternatives. Other vegetables 1/2 cup Size of a small lemon Whole grains contain more fiber Fruit One medium fruit or 1/2 cup Size of a small lemon and generally have a lower glycemic index than refined grains.13 A Fish and lean protein 100 grams Size of a deck of cards diet rich in whole grains is associ- Nuts 16 grams One small handful ated with a reduced risk of type 2 Whole grains 1/2 cup of cooked or one Size of a small lemon diabetes, whereas high intake levels thin slice of bread of processed foods are directly Oil One tablespoon Preferably olive or canola linked to an increased risk of diabetic disease.14,15 to poor systemic health. However, phrasing as being the most moti- Thus, all patients should make many of them do not know that vating and least disparaging.18,19 an effort to replace refined grains high body weight can increase their Here is an example of how to with whole-grain foods. Despite risk for several serious ocular con- initiate the conversation with your the health benefits of whole grains, ditions. patient, including recommended their caloric content often can be The discussion of weight man- questions from the American Medi- similar to that of refined grains––so agement often is difficult for cal Association: it is important to be mindful of optometrists to initiate during an • “We define a healthy weight proper serving sizes. eye exam. In most situations, an according to body mass index, individual’s body weight can be or BMI, which is based on your Avoid Sugary Drinks quite personal, and the practitioner height and weight. A healthy There is no real cordial way to may be fearful of being perceived BMI is less than 25, overweight is address this point, but––Ameri- as judgmental. In addition to this between 25 and 30, and severely cans must stop drinking calorie- potential stigma, patients generally overweight is defined as a BMI laden soft drinks! Soda, sweet tea, do not expect this conversation to greater than 30. Based on your blended juice drinks and specialty occur in an eye care setting. height and weight your BMI is ‘X.’ coffees all contain large quantities To be effective, you need to This can affect the health of your of empty calories in the form of approach the patient in a cultur- eyes by increasing your risk for dia- simple sugars. They have a high ally sensitive and age-appropriate betic retinopathy and age-related glycemic load and do not provide manner. Counseling alone will not macular degeneration.” satiety, so people do not actually result in weight loss and lifestyle Once the patient is aware of the consume less food at their next alteration. risks associated with an increased meal. Thus, the ultimate goal is to BMI, he or she will be more open Multiple studies have shown increase the individual’s motivation to further discussing weight con- that women who drank at least one and confidence. So, how can you trol. Asking permission shows sugar-sweetened soft drink or fruit achieve this? respect and will help the patient punch beverage per day were at an feel more comfortable during the increased risk for developing type 2 Initiate the Conversation conversation. diabetes.16,17 Research shows that patients Here’s an example: respond best to objective terms, • “I am concerned about your How Can We Help such as “weight” and “BMI,” weight and the impact that it may Motivate Our Patients? rather than more pointed terms, have on your ocular health. I Some of our patients know that such as “overweight” or “obese.” would like to discuss this relation- excess weight gain is directly linked People often view such neutral ship with you today––is that ok?”

REVIEW OF OPTOMETRY MARCH 15, 2014 49

044_ro0314_f3_final.indd 49 3/4/14 10:08 AM Nutrition

Motivational Interviewing It All Starts With Pediatrics Asking the parents open-ended It is important to keep the con- We need to empower, support questions will help initiate the conversation going to achieve patient and motivate the entire family to versation: motivation. The Yale Rudd Cen- inspire children and teens toward a •“Mrs. Smith, what changes ter for Food Policy and Obesity healthier future. But, how can we have you made in your family’s encourages the use of motivational influence families to change behav- diet so far?” interviewing for improving diet, iors when increased intake of high- exercise levels and weight control. calorie foods and reduced levels of Motivating Children Its primary aim is to help empower physical activity is becoming the Your office environment can patients to make their own deci- norm in contemporary America? play an important role in moti- sions about behavioral modifica- Rather than handing them a pre- vating your patients toward a tion. Here are some examples of scription on how to achieve and healthier lifestyle. Run in-office questions that will help to motivate maintain a healthy weight, we need and online contests. Start simple, your patients to make positive life- to be more interactive and assume for example, and challenge kids to style changes:20 a role of motivator and coun- eat five to 10 fruits and vegetables •“How ready do you feel to selor.21-24 per day. change your eating patterns and/or Non-judgmental questions com- Then, instruct them to maintain lifestyle behaviors?” bined with attentive listening will a log for one month and submit •“What kinds of things have help you uncover the beliefs and it to your office to enter a prize you done in the past to change values of the patients and their par- drawing. Similar contests for at your eating habits?” ents. The following questions are least one hour of physical activity •“What types of physical activ- examples that likely will not cause per day also are effective. ity do you enjoy?” the individual to become defensive: Another great initiative is Let’s •To the child: “Do you know Move, Michelle Obama’s campaign It’s a Team Effort your approximate weight and designed to help curtail childhood Once they are ready to make a height? I am going to use this infor- obesity. The initiative’s website change, patients will require addi- mation to calculate your BMI.” (www.letsmove.gov) advises that tional support. Proper guidance is •To the parent: “Your child’s all health care providers include critical to ensure that they achieve BMI is very high. It is important a BMI screening as an aspect of healthy, long-term weight loss that she gains control of her weight patient care, actively prescribe goals. With the abundance of fad before it becomes a bigger problem increased levels of physical activity diets and conflicting information that also can affect her vision.” and healthy eating habits, and to on the Internet and television, how become more involved as a leader can we expect them to sort through Making a Change in their local communities. it all and make realistic decisions? Once the parents are aware of The American Diabetes Associa- the medical and visual implications With appropriate education tion educates patients about the of excess weight gain and poor about the value of proper nutri- importance of their health care dietary/lifestyle habits, they will be tion and lifestyle modification, you team. Consider referring your motivated to help their children. can help your patients achieve and patients to a registered dietitian, The fundamental goal is to achieve maintain a healthy body weight. certified diabetes educator and permanent, long-term changes, This, in turn, will help protect exercise physiologist. which typically should involve life- them against the onset of debilitat- The management of diabetes style modifications for the entire ing systemic and ocular disease. requires a collective effort, and family. Keep in mind that healthy active communication with the Be sure to reiterate that initial dietary practices often transform patient’s primary care provider is goals should be realistically achiev- into life-long habits. Therefore, the essential for effective long-term able, and that changes should be earlier you inspire younger patients care. And don’t forget to remind made incrementally. Also, stress to eat nutritiously and engage in your patients that they are the most that even minimal weight loss can regular physical activity, the less important part of their own health decrease diabetes rates in those likely they will be to develop dia- care team! who are at risk.21-24 betic eye disease in the future. ■

50 REVIEW OF OPTOMETRY MARCH 15, 2014

044_ro0314_f3_final.indd 50 3/4/14 10:08 AM Data from the 2011 national diabetes fact sheet. Available at: Am J Clin Nutr. 2007 Oct;86(4):1210-8. Dr. Capogna is an active partner www.diabetes.org/diabetes-basics/statistics/?loc=db-slabnav. 14. Fung TT, Hu FB, Pereira MA, et al.Whole-grain intake and at Peninsula Vision Associates in Accessed February 11, 2014. the risk of type 2 diabetes: a prospective study in men. Am J 4. Liese AD, D’Agostino RB Jr, Hamman RF, et al. The burden Clin Nutr. 2002 Sep;76(3):535-40. Niagara Falls, Canada, and fre- of diabetes mellitus among US youth: prevalence estimates 15. Liu S, Manson JE, Stampfer MJ, Hu FB, et al A pro- from the SEARCH for Diabetes in Youth Study. Pediatrics. spective study of whole-grain intake and risk of type 2 quently lectures on nutrition and 2006 Oct;118(4):1510-8. diabetes mellitus in US women. Am J Public Health. 2000 patient care. 5. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction Sep;90(9):1409-15. in the incidence of type 2 diabetes with lifestyle intervention or 16. Schulze MB, Manson JE. Sugar-sweetened beverages, Dr. Pelletier is a partner at IRIS metformin. N Eng J Med. 2002 Feb 7;346(6):393-403. weight gain and incidence of type 2 diabetes in young and 6. Knowler WC. 10-year follow-up of diabetes incidence and middle-aged women. JAMA. 2004 Aug 25;292:927-34. in Welland, Ontario, where she weight loss in the Diabetes Prevention Program Outcomes 17. Bazzano L, Li TY, Kamudi J, Hu F. Intake of fruit, vegeta- Study. Lancet. 2009 Nov 14;374(9702):1677-86 bles and fruit juices and risk of diabetes in women. Diabetes practices primary care optometry 7. Hu FB, Manson JE, Stampfer MJ, et al. Diet, lifestyle, and care. 2008 Jul;31(7):1311-7. and lectures about nutrition and the risk of type 2 diabetes mellitus in women. N Engl J Med. 18. Yale University: The Rudd Center for Food Policy and 2001 Sep 13;345(11):790-7. Obesity. How to talk about ‘weight’ with your overweight eye health. 8. Rana JS, Li TY, Manson JE, Hu FB. Adiposity compared and obese patients. Available at: www.yaleruddcenter.org/ with physical inactivity and risk of type 2 diabetes in women. resources/bias_toolkit/toolkit/Module-2/2-01-HowToTalk. Together, they coauthored the Diabetes Care. 2007 Jan;30(1):53-8. pdf. Accessed February 11, 2014. top-selling books “Eyefoods: A 9. Klein S, Allison DB, Heymsfield SB, et al. Waist circumfer- 19. Wadden TA, Didie E. What’s in a name? Patients’ ence and cardiometabolic risk: a consensus statement from preferred terms for describing obesity. Obes Res. 2003 Food Plan for Healthy Eyes” and Shaping America’s Health: Association for Weight Manage- Sep;11(9):1140-6. ment and Obesity Prevention; NAASO, The Obesity Society; 20. DiLillo V, Siegfried NJ, Smith-West D. Incorporating “Eyefoods for Kids: A Tasty Guide the American Society for Nutrition; and the American Diabetes motivational interviewing into behavioral obesity treatment. Association. Am J Clin Nut. 2007 May;85(5):119701202. Cognitive Behavioral Prac. 2003;10:120-30. to Nutrition and Eye Health,” 10. Harvard School of Public Health. Simple Steps to 21. Barlow SE. Expert committee recommendations regarding as well as developed the website Preventing Diabetes. Available at: www.hsph.harvard.edu/ the prevention, assessment, and treatment of child and ado- nutritionsource/preventing-diabetes-full-story/. Accessed lescent overweight and obesity: summary report. Pediatrics. www.eyefoods.com. February 11, 2014. 2007 Dec;120 Suppl 4:S164-92. 11. Mayer-Davis EJ, D’Agostino R Jr, Karter AJ, et al. Intensity 22. Rosenbloom AL, Silverstein JH, Ameniya S, et al. Type 2 and amount of physical activity in relation to insulin sensitiv- diabetes in children and adolescents. Pediatr Diabetes. 2009 1. International Diabetes Federation. Worldwide definition of ity: the Insulin Resistance Atherosclerosis Study. JAMA. 1998 Sep;10 Suppl 12:17-32. metabolic syndrome. Available at: www.idf.org/metabolic- Mar 4;279(9):669-74. 23. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of syndrome. Accessed February 11, 2014. 12. Appel LJ, Sacks FM, Carey VJ, et al. Effects of protein, obesity and trends in body mass index among US children and 2. Centers for Disease Control and Prevention. National dia- monounsaturated fat, and carbohydrate intake on blood pres- adolescents, 1999-2010. JAMA. 2012 Feb 1;307(5):483-90. betes fact sheet: national estimates and general information on sure and serum lipids: results of the OmniHeart randomized 24. Puhl RM, Peterson JL, Luedicke J. Parental perceptions of diabetes and prediabetes in the United States, 2011. Available trial. JAMA. 2005 Nov 16;294(19):2455-64. weight terminology that providers use with youth. Pediatrics. at: www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed 13. Chiu CJ, Milton RC, Klein R, et al. Dietary carbohydrate 2011 Oct;128(4):e786-93. February 11, 2014. and the progression of age-related macular degeneration: a 25. Capogna L, Pelletier B. Eyefoods: A Food Plan for Healthy 3. American Diabetes Association. Statistics about diabetes: prospective study from the Age-Related Eye Disease Study. Eyes. St. David’s, Ontario: LB Media Concepts Inc.; 2011.

044_ro0314_f3_final.indd 51 3/4/14 10:06 AM Obesity

Systemic Disease Report Obesity Counseling is Within Our Scope You can no longer afford to ignore the problem or simply hand it off to another clinician. Today, helping patients manage their body weight is one of our fundamental responsibilities. By Kimberly K. Reed, OD

espite widespread aware- state’s population today.5 efforts aimed at curtailing obesity- ness of the physical, Suffice it to say that contem- related disease appear to be taking financial and psychosocial porary obesity rates in America hold––albeit slowly. Dconsequences of poor simply aren’t sustainable––either But unless your patient base is dietary habits and low levels of financially or medically. overwhelmingly healthy, active, fit physical activity, obesity rates There is a bit of good news, and young, chances are that obe- among American adults remain however. In August 2013, the sity rates in your practice mirror alarmingly high.1 CDC announced that in 18 states, those seen in the general US popu- Currently, 35.7% of all adults obesity rates decreased among lation. Be honest––how often do living in the US are obese.2 When preschool children from low- you discuss weight-related health adjusting for demographic varia- income families when compared complications with your patients? tions, the highest obesity rates are to 2012 figures.4 Several states If you’re like most optometrists, observed in non-Hispanic black also have independently reported it probably isn’t a standard com- women (58.5%) and the lowest progress in reducing childhood ponent of your management plan. rates are observed in non-His- obesity using a multifaceted This approach must change, how- panic white women (32.2%).3 approach of education, school ever, if we are ever going to have In 2012, no state had an obe- lunch improvements and increased a reasonable chance of halting the sity incidence lower than 20%, physical activity levels.5 obesity epidemic. as measured by body mass index It is also worth noting that (BMI).1 Further, 13 states had since 2005, adult obesity rates Obesity’s Impact on the an obesity incidence equal to or have increased more slowly than Eye and Body greater than 30%.4 To put these they did during the two decades During the last three decades, figures into context––just 30 years prior. In fact, from 2012 to we’ve seen a proportionate ago, the highest incidence of adult 2013, only one state’s obesity increase in the incidence of obe- obesity documented in any state’s level increased (Arkansas), while sity and potentially life-threat- population was still lower than all others remained unchanged.5 ening systemic conditions, such that recorded in the least obese So, it seems that comprehensive as hypertension, carotid artery

52 REVIEW OF OPTOMETRY MARCH 15, 2014

052_ro0314_f4_final.indd 52 3/4/14 10:13 AM For the reduction of IOP in patients with POAG or OHTN When it’s important to consider ocular and systemic side effects...

…try

An alternate route to IOP reduction

LEffective at lowering IOP throughout the day and over the long term1-3

LExcellent systemic safety proﬁle including no deleterious effects on CV or pulmonary function in clinical studies1

LEstablished ocular side effects proﬁle: In clinical trials comparing RESCULA and timolol,* both were generally well tolerated regarding ocular adverse events, with similar incidence of hyperemia and similar changes to eyelash length and density1,4,5 – The only events seen signiﬁcantly more often with RESCULA than with timolol were burning and stinging and burning/stinging upon instillation; these events were generally mild and transient2,4

LNo labeled drug-drug interactions1,4

Indication RESCULA (unoprostone isopropyl ophthalmic solution) 0.15% is indicated for the lowering of intraocular pressure in patients with open-angle glaucoma or ocular hypertension. Important Safety Information RESCULA is contraindicated in patients with hypersensitivity to unoprostone isopropyl or any other ingredient in this product. RESCULA has been reported to increase pigmentation of the iris, periorbital tissues, and eyelashes. Patients should be advised about the potential for increased brown iris pigmentation which is likely to be permanent. RESCULA should be used with caution in patients with active intraocular inﬂammation (e.g., uveitis) because the inﬂammation may be exacerbated. Macular edema, including cystoid macular edema, has been reported. RESCULA should be used with caution in aphakic patients, in pseudophakic patients with a torn posterior lens capsule, or in patients with known risk factors for macular edema.

*In pooled safety analyses of pivotal trials comparing RESCULA with timolol maleate 0.5%.4 Please see Brief Summary on reverse and full Prescribing Information, available from your Sucampo representative.

RO0413_Rescula.indd 1 3/25/13 2:18 PM Brief Summary of Prescribing Information for RESCULA. INDICATIONS AND USAGE In clinical studies, the most common ocular adverse reactions with use of Rescula (unoprostone isopropyl ophthalmic solution) 0.15% is indicated for the Rescula were burning/stinging, burning/stinging upon drug instillation, dry lowering of intraocular pressure in patients with open-angle glaucoma or ocular eyes, itching, increased length of eyelashes, and injection. These were reported hypertension. in approximately 10–25% of patients. Approximately 10–14% of patients were DOSAGE AND ADMINISTRATION observed to have an increase in the length of eyelashes ( 1 mm) at 12 months, The recommended dosage is one drop in the affected eye(s) twice daily. while 7% of patients were observed to have a decrease in the length of eyelashes. Rescula may be used concomitantly with other topical ophthalmic drug Ocular adverse reactions occurring in approximately 5–10% of patients were products to lower intraocular pressure. If two drugs are used, they should be abnormal vision, eyelid disorder, foreign body sensation, and lacrimation administered at least five (5) minutes apart. disorder. CONTRAINDICATIONS Ocular adverse reactions occurring in approximately 1–5% of patients were Rescula is contraindicated in patients with hypersensitivity to unoprostone blepharitis, cataract, conjunctivitis, corneal lesion, discharge from the eye, eye isopropyl or any other ingredient in this product. hemorrhage, eye pain, keratitis, irritation, photophobia, and vitreous disorder. WARNINGS AND PRECAUTIONS The most frequently reported nonocular adverse reaction associated with the Iris Pigmentation use of Rescula in the clinical trials was flu-like syndrome that was observed Unoprostone isopropyl ophthalmic solution may gradually increase the in approximately 6% of patients. Nonocular adverse reactions reported in the pigmentation of the iris. The pigmentation change is believed to be due to 1–5% of patients were accidental injury, allergic reaction, back pain, bronchitis, increased melanin content in the melanocytes rather than to an increase in increased cough, diabetes mellitus, dizziness, headache, hypertension, the number of melanocytes. The long term effects of increased pigmentation insomnia, pharyngitis, pain, rhinitis, and sinusitis. are not known. Iris color changes seen with administration of unoprostone Postmarketing Experience isopropyl ophthalmic solution may not be noticeable for several months The following adverse reactions have been identified during post-approval use to years. Typically, the brown pigmentation around the pupil spreads of Rescula. Because these reactions are reported voluntarily from a population concentrically towards the periphery of the iris and the entire iris or parts of of uncertain size, it is not always possible to reliably estimate their frequency or the iris become more brownish. Neither nevi nor freckles of the iris appear to establish causal relationship to drug exposure. be affected by treatment. Treatment with Rescula solution can be continued in Voluntary reports of adverse reactions occurring with the use of Rescula patients who develop noticeably increased iris pigmentation. Patients who include corneal erosion. receive treatment with Rescula should be informed of the possibility of increased pigmentation. There have been rare spontaneous reports with a different formulation of unoprostone isopropyl (0.12%) of chemosis, dry mouth, nausea, vomiting and Lid Pigmentation palpitations. Unoprostone isopropyl has been reported to cause pigment changes (darkening) to periorbital pigmented tissues and eyelashes. The pigmentation is USE IN SPECIFIC POPULATIONS expected to increase as long as unoprostone isopropyl is administered, but has Pregnancy Category C - There are no adequate and well-controlled studies in been reported to be reversible upon discontinuation of unoprostone isopropyl pregnant women. Because animal studies are not always predictive of human ophthalmic solution in most patients. response, RESCULA should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Intraocular Inflammation Rescula should be used with caution in patients with active intraocular Pediatric Use - the safety and efficacy of RESCULA in pediatric patients have inflammation (e.g., uveitis) because the inflammation may be exacerbated. not been established. Macular Edema It is not known whether RESCULA is excreted in human milk. Because many Macular edema, including cystoid macular edema, has been reported. Rescula drugs are excreted in human milk, caution should be exercised when RESCULA should be used with caution in aphakic patients, in pseudophakic patients with is administered to a nursing woman. a torn posterior lens capsule, or in patients with known risk factors for macular No overall differences in safety or effectiveness of RESCULA have been edema. observed between elderly and other adult populations. Contamination of Tip and Solution CLINICAL PHARMACOLOGY To minimize contaminating the dropper tip and solution, care should be taken Mechanism of Action not to touch the eyelids or surrounding areas with the dropper tip of the bottle. Rescula is believed to reduce elevated intraocular pressure (IOP) by increasing Keep bottle tightly closed when not in use. There have been reports of bacterial the outflow of aqueous humor through the trabecular meshwork. Unoprostone keratitis associated with the use of multiple-dose containers of topical isopropyl (UI) may have a local effect on BK (Big Potassium) channels and ophthalmic products. ClC-2 chloride channels, but the exact mechanism is unknown at this time. Use with Contact Lenses STORAGE AND HANDLING Rescula contains benzalkonium chloride, which may be absorbed by soft Store between 2°–25°C (36°–77°F). contact lenses. Contact lenses should be removed prior to application of For more detailed information please read the Prescribing Information. solution and may be reinserted 15 minutes following its administration. Marketed by: ADVERSE REACTIONS Sucampo Pharma Americas, LLC Clinical Studies Experience Bethesda, MD 20814 Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be Revised 01/2013 directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.

References: 1. RESCULA [package insert]. Bethesda, MD: Sucampo Pharmaceuticals, Inc; 2012. 2. Data on file. CSR C97-UIOS-004. Sucampo Pharmaceuticals, Inc. 3. Data on file. CSR C97-UIOS-005. Sucampo Pharmaceuticals, Inc. 4. Data on file. Integrated summary of clinical safety. Sucampo Pharmaceuticals, Inc. 5. McCarey BE, Kapik BM, Kane FE; Unoprostone Monotherapy Study Group. Low incidence of iris pigmentation and eyelash changes in 2 randomized clinical trials with unoprostone isopropyl 0.15%. Ophthalmology. 2004;111(8):1480-1488.

RESCULA is a registered trademark of Sucampo AG. All other trademarks are the property of their respective owners. ©2012 Sucampo Pharma Americas, LLC All rights reserved UNO-1091 Printed in USA 02/2013

RO0413_Rescula PI.indd 1 3/25/13 2:26 PM Obesity

disease, coronary heart disease BMI and Waist Circumference and stroke, type 2 diabetes, sleep Body Mass Index, or BMI, is a simple ratio of height to weight. You can calculate BMI by apnea and certain forms of can- dividing an individual’s weight in kilograms by his or her height in meters squared. (Metric cer.5 The association between measurements not your thing? Don’t worry––you can alternatively divide the individual’s excess body weight and the afore- weight in pounds by his or her height in inches squared, and then multiply the result by a mentioned systemic diseases is conversion factor of 703.) Additionally, several smartphone apps and online calculators will well established. do the math for you (www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm). However, until only recently, Although Body Mass Index is widely used to determine whether patients are overweight the vast majority of care provid- (BMI between 25 and 30) or obese (BMI of 30 or greater), the tool has several drawbacks. ers have not included excess body For example, patients who have a high percentage of muscle mass and very little body fat weight as a primary risk factor cannot be evaluated effectively using conventional BMI calculations. Thus, despite excel- in the pathogenesis of several lent metabolic and health profiles, body builders and competitive athletes often would be visually devastating ocular condi- erroneously classified as obese. tions. The American Optometric Waist circumference is an alternative method to determine a person’s weight status. Association Practice Guidelines Measurements greater than 40 inches (102cm) for men and 35 inches (88cm) for women for Comprehensive Adult Eye are associated with increased health risks. It is important to note, however, that waist and Vision Examination consider circumference measurements offer no additional diagnostic benefit in patients with a BMI patients with diabetes and/or greater than 35. hypertension to be among those “at risk” for significant ocular complications. These patients diets and increase exercise levels.9 patients who exhibit these retinal should undergo a comprehensive Fortunately, the AHA offers findings also are overweight or evaluation annually, compared to an interactive tool on its website obese. Therefore, to reduce the every two years for healthy indi- (www.heart.org) that educates incidence of further disease pro- viduals.2 patients about the various ways gression, weight loss strategies Here’s a brief overview of sev- they can reduce their blood pres- must be addressed in the patient’s eral obesity-related conditions sure via lifestyle modification. comprehensive management plan. that yield both systemic and ocu- Patients can use the program to • Diabetes. In the early 1990s, lar complications: estimate how much lower their approximately 7.8 million Ameri- • Hypertension. More than blood pressure would be if they cans had an active diagnosis of 75% of hypertension cases can be lost five, 10 or even 20 pounds. diabetes. Today, that figure is causally linked to obesity.6 Hyper- The most common ocular mani- approximately 25.8 million.5 tension frequently is associated festations of hypertension include Nearly 40% of US adults cur- with cardiovascular disease, heart hypertensive retinopathy, retinal rently are diabetic or pre-diabetic, failure, ischemic stroke, intrace- vascular occlusions, cranial nerve and most of them don’t even rebral hemorrhage and chronic palsies and optic neuropathy.10-12 know it.5 kidney disease—primary contribu- Frequently, patients present with Worse yet, by 2020, it is esti- tors to morbidity and mortality in mild hypertensive retinopathy, mated that this figure will climb US adults.7 which is characterized by arte- to 50%, yielding an enormous The American Heart Associa- riolar narrowing/constriction, increase in health care spending to tion’s guidelines include a “cau- arteriovenous nicking, or other provide care for these patients.15 tion” or “pre-hypertension” vascular changes that are most So, early intervention for at-risk category, which is defined as a evident at the locations of arteri- patients is essential. systolic blood pressure between ole and venule crossing.13,14 There are clear optometric 120mm Hg and 139mm Hg and/ Typical optometric manage- practice guidelines for the man- or diastolic pressure between ment includes documentation in agement of diabetic retinopathy, 80mm Hg and 89mm Hg.8 In the patient’s chart, proper edu- the most common retinal vascular recent years, patients in this cat- cation about the condition, and cause of vision loss.16 Clearly, egory are more likely to be placed a recommendation to adhere to overweight or obese individuals on antihypertensive therapy rather their primary care provider’s pre- have a much greater likelihood of than instructed to modify their scribed treatment. In most cases, developing type 2 diabetes.

REVIEW OF OPTOMETRY MARCH 15, 2014 55

052_ro0314_f4_final.indd 55 3/4/14 10:13 AM Obesity

The Socioeconomics of Obesity shows, in magazine articles and in • The costs associated with preventable chronic disease care related to obesity range day-to-day life. Teachers, college from $147 billion to nearly $210 billion per year.33 admissions counselors, employers, • Job absenteeism related to obesity costs about $4.3 billion annually.34 nutritionists, and even doctors • In 2012, more than 35% of adults who did not graduate high school were obese–– and nurses may ascribe negative compared to just 22.1% who graduated from college or a technical school.5 attributes to obese people based • Approximately 33% of adults who earn less than $15,000 a year are obese, compared solely upon their weight.22-26 Asso- with 25.4% of those who earn $50,000 or more per year.5 ciated stereotypes are prevalent, • If obesity trends were lowered by reducing the average adult BMI by just 5%, the cost and overweight and obese indi- savings would total $29.8 billion in five years, $158 billion in 10 years and $611.7 billion in viduals often are characterized as 20 years.5 lazy, unsuccessful, undisciplined • On average, obese adults spend 42% more on health care costs than people of a and willless.27 healthy weight.35 The misguided perception that • Obesity-related hospitalization for children and teenagers cost $125.9 million in 2001 shaming obese people could per- and $237.6 million in 2005.36 haps motivate them to lose weight • An investment of $10 per person in proven, community-based programs to increase secondary to guilt is unsupported. physical activity, improve nutrition and prevent tobacco use could save the country more To the contrary, research suggests than $16 billion annually over a five-year period––a 560% return on investment.37 that such callous regard for overweight individuals poses serious health risks, creates social anxiety, So, be sure to refer these patients ing long-term systemic and ocular and interferes with more effec- to their primary care provider for complications.18 tive efforts to reduce or prevent evaluation if a year or more has Obesity is now recognized as obesity.28 Youths who are teased passed since their last physical an independent risk factor for about their weight are more likely examination. Also, be especially age-related macular degenera- to engage in variety of unhealthy diligent when examining obese tion.20,21 Dietary modification can behaviors, including binge eating, patients for early signs of diabetic be highly protective against the anorexia or purging.29,30 eye disease. development and progression To date, wide-scale public • Other common conditions. of early AMD. At-risk patients health efforts have been largely Approximately one-third of all should be encouraged to increase successful in curtailing escalating cancer deaths are linked to either their daily intake of leafy greens obesity rates in America. Both lay obesity or a lack of physical activ- and brightly colored vegetables people and health care profes- ity.17 And while these cancers (e.g., orange peppers), which are sionals alike still believe that the aren’t always detected as primary rich in lutein and zeaxanthin. condition of obesity is an issue of ocular tumors, it is still important Additionally, obese patients personal control.27 to inform patients that being over- should be encouraged to lose And while dietary choices weight or obese can increase their excess weight through increased and lifestyle habits certainly are risk for several types of cancer. physical activity and low-glycemic a primary cause of obesity, the Sleep apnea is strongly asso- diets to further protect against complex and intricate genetic, ciated with obesity, especially AMD. Just keep in mind that endocrine, psychological and when the diagnosis is made via nutritional supplementation behavioral drivers for food intake measurement of waist and neck alone, without comprehensive and energy regulation are not circumference.18,19 Sleep apnea can dietary modification, will not pro- completely understood. contribute to several ocular con- vide optimal protection against Much like patients with an ditions, including glaucoma and macular degeneration.20,21 opioid dependency, many people keratoconus. who struggle with obesity exhibit Continuous Positive Airway The Psychosocial Impact an uncontrollable attraction to Pressure (CPAP) is the mainstay of Obesity food.31,32 In both instances of of therapy for patients with sleep In America, thinner people addiction, the same areas of the apnea; however, weight reduction frequently stigmatize overweight brain are stimulated by similar is far more effective at prevent- people. It occurs on television chemical substances.31,32 Thus, the

56 REVIEW OF OPTOMETRY MARCH 15, 2014

052_ro0314_f4_final.indd 56 3/4/14 10:14 AM 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 Obesity

prevalent belief that overeating optometrists can contribute to however, it is imperative that is entirely the result of reduced these efforts using a sensitive, sup- we educate ourselves about the willpower is unsubstantiated. This portive approach with overweight potential ocular and systemic erroneous generalization impairs and obese pediatric patients and ramifications of obesity, as well obesity intervention efforts and their parents. as develop the skills necessary to reduces access to quality care, Several resources are available help create effective, individual- which can create additional psy- to help calculate pediatric BMIs ized management plans for our chological stress on the patient.27 (up to age 19)––including the patients. But, in order to do so, CDC’s calculation tool, www. we must first disengage from the Connect With Your Patients cdc.gov/healthyweight/children. outdated notion that weight man- Specific, practical and inter- Additionally, this website offers agement is not within our scope active resources are essential an excellent, printable resource of care. ■ when discussing the relationship for parents to help their children Dr. Reed is an associate pro- between obesity and health com- reach and maintain a healthy fessor at Nova Southeastern plications with your patients. weight. Similar information is University College of Optometry Conduct a comprehensive search presented at www.patient.co.uk/ in Fort Lauderdale, Fla., where in your practice area for registered health/obesity-and-overweight-in- she teaches ocular disease, ocular dieticians or other reputable nutri- children, along with a variety of pharmacology and nutrition, and tion and wellness coaches. You interactive resources from the UK. primary clinical care. may find that your community–– Affiliated with the Let’s Move

on a local, county or state level–– initiative, www.healthykid- 1. Fryar CD, Carroll MD, Ogden CL. National Center for already has obesity-counseling shealthyfuture.org offers free Health Statistics. Prevalence of Overweight, Obesity, and resources in place. online training, presentations and Extreme Obesity Among Adults: United States, Trends 1960-1962 through 2009-2010. Available at: www.cdc. For example, community cen- interactive quizzes for children, gov/nchs/data/hestat/obesity_adult_09_10/obesity_ ters often offer cooking instruc- parents and health care provid- adult_09_10.htm. Accessed February 21, 2014. 2. Casser L, Carmiencke K, Goss D, et al. Optometric tion and exercise classes for those ers. These materials are designed Clinical Practice Guideline: Comprehensive Adult Eye and interested in weight loss. Also, to emphasize the fundamental Vision Examination, 2nd ed. St. Louis: American Optomet- ric Association; 2005. walking clubs frequently can be importance of healthier lifestyle 3. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence found at indoor shopping malls. decisions starting in infancy. of obesity and trends in the distribution of body mass Further, a number of excellent Another useful assessment tool index among US adults, 1999-2000. JAMA. 2012 Feb 1;307(5):491-7. websites are available to provide for parents can be found at www. 4. The US Centers for Disease Control and Prevention. useful tools and other information webcalcsolutions.com/Parenting- Adult Obesity Facts. Available at: www.cdc.gov/obesity/ data/adult.html. Accessed February 21, 2014. regarding healthy weight control Assessments/child-obesity-risk. 5. Levi J, Segal L, Thomas K, et al. Robert Wood Johnson strategies, nutritional guidelines Here, visitors can find a simple, Foundation. F as in Fat 2013: How Obesity Threatens and diabetes management. Some eight-question quiz that’s designed America’s Future. Available at: www.rwjf.org/content/dam/ farm/reports/reports/2013/rwjf407528. Accessed February of the most helpful sites include: to help determine a child’s risk of 21, 2014. • www.Heart.org/ becoming overweight. 6. The Obesity Society. Health Effects of Obesity. Available at: www.obesity.org. Accessed February 21, 2014. HEARTORG/Conditions/High- Many of the aforementioned 7. Chobanian AV, Bakris GL, Black HR, et al. The seventh BloodPressure websites offer printable brochures report of the Joint National Committee on Prevention, • www.cdc.gov/healthyweight/ and wall charts designed for pedi- Detection, Evaluation, and Treatment of High Blood Pres- sure: the JNC 7 report. JAMA. 2003 May 21;289(19):2560- index.html atric education and often include 72. • www.diabetes.org literature on associated lifestyle 8. American Heart Association. About high blood pressure. Available at: www.heart.org/HEARTORG/Conditions/ considerations, such as proper HighBloodPressure/AboutHighBloodPressure/About-High- Obesity Management hydration, tobacco avoidance, Blood-Pressure_UCM_002050_Article.jsp. Accessed for Kids and Teens February 21, 2014. exercise routines and good sleep 9. Kaplan NM. Systemic hypertension: Treatment. In: Considering all of the factors habits. Bonow RO, Mann DL, Zipes DP, et al (eds.). Braunwald’s involved, children and teenagers Heart Disease: A Textbook of Cardiovascular Medicine, 9th ed. Philadelphia: Saunders Elsevier; 2011. currently are in the best position Historically, optometrists 10. Chapin J, Carlson K, Christos PJ, Desancho MT. Risk to slow or even reverse the esca- largely have been passive observ- factors and treatment strategies in patients with retinal vascular occlusions. Clin Appl Thromb Hemost. 2013 Dec 11. lating obesity rate in America. As ers in the fight against obesity- 11. Tamhankar MA. Biousse V, Ying GS, et al. Isolated primary health care providers, related disease. Going forward, third, fourth, and sixth cranial nerve palsies from presumed

58 REVIEW OF OPTOMETRY MARCH 15, 2014

052_ro0314_f4_final.indd 58 3/4/14 10:14 AM microvascular versus other causes: a prospective study. related macular degeneration: association with physical 29. Neumark-Sztainer D, Falkner N, Story M, et al. Weight- Ophthalmol 2013 Nov;120(11):2264-9. activity, obesity, and serum lipids in the Inter99 eye study. teasing among adolescents correlations with weight status 12. Mohsenin A, Mohsenin V, Adelman RA. Retinal vascu- Invest Ophthalmol Vis Sci 2013 Jun;54(6):3932-40. and disordered eating behaviors. Int J Obes Relat Metab lar tortuosity in obstructive sleep apnea. Clin Ophthalmol. 21. Chakravarthy U, Wong TY, Fletcher A, et al. Clinical Disord. 2002 Jan;26(1):123-31. 2013;7:787-92. risk factors for age-related macular degeneration: a sys- 30. Libbey HP, Story MT, Neumark-Sztainer DR, et al. 13. Henderson AD, Bruce BB, Newman NJ, Biousse V. tematic review and meta-analysis. BMC Ophthalmol. 2010 Teasing, disordered eating behaviors, and psychological Hypertension-related eye abnormalities and the risk of Dec 13;10:31 morbidities among overweight adolescents. Obesity (Silver stroke. Rev Neurol Dis. 2011;8(1-2):1-9. 22. Sikorski C, Luppa M, Brahler E, et al. Obese children, Spring). 2008 Nov;16 Suppl 2:S24-9. 14. Cheung CY, Ikram MK, Sabanayagam C, Wong TY. adults and senior citizens in the eyes of the general public: 31. Rui L. Brain regulation of energy balance and body Retinal microvasculature as a model to study the manifesta- results of a respresentative study on stigma and causation weight. Rev Endocr Metab Disord. 2013 Dec;14(4):387- tions of hypertension. Hypertension. 2012 Nov;60(5):1094- of obesity. PLoS One. 2012;7(10):e46924. 407. 103. 23. Sikorski C, Luppa M, Kaiser M, et al. The stigma of 32. Egecioglu E, Skibicka KP, Hansson C, et al. Hedonic 15. Wang YC, McPherson K, Marsh T, et al. Health and obesity in the general public and its implications for public and incentive signals for body weight control. Rev Endocr economic burden of the projected obesity trends in the USA health – a systematic review. BMC Public Health. 2011 Aug Metab Disord. 2011 Sep;12(3):141-51. and the UK. Lancet. 2011 Aug 27;378(9793):815-25. 23;11:661. 33. Cawley J, Meyerhoefer C. The medical care costs of 16. Cavallerano J. Optometric Clinical Practice Guidelines: 24. Swift JA, Tischler V, Markham S, et al. Are anti-stigma obesity: An instrumental variables approach. J Health Econ. Care of the patient with diabetes mellitus. St. Louis: Ameri- films a useful strategy for reducing weight bias among 2012 Jan;31(1):219-30. can Optometric Association; 2009. trainee healthcare professionals? Results of a pilot random- 34. Cawley, J, Rizzo JZ, Haas K. Occupation-specific 17. American Cancer Society. Cancer Facts and Figures, ized control trial. Obes Facts. 2013;6(1):91-102. absenteeism costs associated with obesity and morbid obe- 2012. Available at: www.cancer.org/acs/groups/content/@ 25. Puhl R, Wharton C, Heuer C. Weight bias among dietet- sity. J Occup Environ Med. 2007 Dec;49(12):1317-24 epidemiologysurveilance/documents/document/acspc- ics students: implications for treatment practices. J Am Diet 35. Finkelstein EA, Trogdon JG, Cohen JW, et al. Annual 031941.pdf. Accessed February 21, 2014. Assoc. 2009 Mar;109(3):438-44 medical spending attributable to obesity: Payer-and 18. Lee Ck, Tefera E, Colice G. The effect of obesity on 26. Puhl RM, Heuer CA. The stigma of obesity: a review service-specific estimates. Health Aff (Millwood). 2009 outcomes in mechanically ventilated patients in a medical and update. Obesity. 2009 May;17(5)941-64. Sep-Oct;28(5):w822-31. intensive care unit. Respiration. Respiration. 2014 Jan 23. 27. Puhl RM, Heuer CA. Obesity stigma: Important con- 36. Trasande L, Liu Y, Fryer G, et al. Effects of Childhood [Epub ahead of print] siderations for public health. Am J Public Health. 2010 Obesity On Hospital Care and Costs, 1999-2005. Health Aff 19. Mazzuca E, Battaglia S, Marrone O, et al. Gender- Jun;100(6):1019-28. (Millwood). 2009 Jul-Aug;28(4):w751-60. specific anthropometric markers of adiposity, meta- 28. Annis NM, Cash TF, Hrabosky JK. Body image and 37. Trust for America’s Health. Prevention for a Healthier bolic syndrome and visceral adiposity index (VAI) in psychosocial differences among stable average weight, America; Investments in Disease Prevention Yield Sig- patients with obstructive sleep apnea. J Sleep Res 2014 currently overweight, and formerly overweight women: nificant Savings, Stronger Communities, 2008. Available Feb;23(1):13-21. the role of stigmatizing experiences. Body Image. 2004 at: http://healthyamericans.org/reports/prevention08. 20. Munch IC, Linneberg A, Larsen M. Precursors of age- May;1(2):155-67. Accessed January 25, 2014.

ARE YOU SEEING See More. Discover More.™ THE FULL PICTURE? Only optomap® provides up to 200° view of the retina in a single capture ∙ 50% more visible retina than other wideﬁeld products1 ∙ optomap results are equal to ETDRS in all categories2 ∙ 66% more pathology was outside traditional imaging ﬁeld of view3 ∙ Clinically supported by more than 250 studies Learn how you can start to see more and discover more with Optos Stop by our booth: #6409 at Vision Expo East

Building The Retina Company

1 Kiss et al. Comparison of ultra-widefield fluorescein angiography with the Heidelberg Spectralis® noncontact ultra-widefield module versus the Optos® optomap. Clin Ophthalmol. 2013, 389-94. 2, 3 Data on file © 2014 Optos. All rights reserved. Optos® and optos are registered trademarks of Optos plc. P/N GA-00190 /1 optos.com Registered in Scotland Number: SC139953 Registered O ce: Queensferry House, Carnegie Campus, Dunfermline, Fife KY11 8GR.

052_ro0314_f4_final.indd 59 3/4/14 10:13 AM Hepatitis B

What are the Ocular Manifestations Hepof B?

Eye care professionals may play a role in both the diagnosis and management of a number of conditions secondary to HBV. By Denh Tuyen, OD, and Andrew S. Gurwood, OD

epatitis B virus (HBV) is pupil sparing third nerve palsy, are assembled into virions, either the most common cause optic neuritis and uveitis.7-11 in the nucleus or cytoplasm, of liver cancer in the which are then released by bud- world.1 Currently, of the Pertinent Anatomy ding through the plasma mem- H 12 14 two billion people infected with Hepatitis B is a DNA virus. brane. HBV worldwide, 600,000 deaths It is comprised of hepatitis B are anticipated to result annu- core antigen (HBcAg), hepati- Epidemiology ally—either secondary to HBV tis B e-antigen (HBeAg), DNA Of the two billion living people complications or hepatocellular polymerase and double-stranded who contracted the virus, approx- carcinoma.2 DNA.13 The entire content of imately 400 million still actively Its modes of transmission HBV is encapsulated by an enve- suffer from chronic HBV.15-17 The include sexual contact, needle lope that houses the hepatitis B virus is hyperendemic in regions sharing, blood transfusion and surface antigen (HBsAg).11 such as Sub-Saharan Africa, transplacental passage from Viruses are obligate intracel- Southeast Asia, China and the mother to neonate.3 Acute HBV lular parasites—they rely solely West Pacific.13,18 infection is associated with on host machinery for replication. general malaise, fever, loss of Viral tropism refers to the ability Pathogenesis appetite, vomiting and jaun- of viruses to infect specific cells. HBV mainly infects hepato- dice.3 Fulminant presentation of When the virus latches onto the cytes. The virus enters the body infection involves liver failure host cell, it integrates into the following an exposure to the accompanied by tissue necrosis.3 cytoplasm in one of three ways: virus particle through either The virus is able to inject itself direct translocation, endocytosis infected blood or bodily fluids. into the host cell to replicate or viral fusion to cell membrane.14 The hepatocyte uncoats itself with a resulting immunological Once inside the cell, viruses start and transforms into a covalently response, causing hepatocellular replicating with the help of host closed circular form of DNA injury.4-6 Common ocular sequel- enzymes. The newly synthesized (cccDNA).13 lae include ischemic retinopathy, viral genome and capsid proteins Viral detection by the host

60 REVIEW OF OPTOMETRY MARCH 15, 2014

060_ro0314_f5.indd 60 3/5/14 3:01 PM A A A "

OCULUS presents the future in corneal topography and dry eye diagnosis! Find out what the new Keratograph 5M with color camera and magniﬁ cation changer can do for you and your patients!

,6,7A A$7A FA%227+A AW H

facebook.com/OCULUSusa

Toll free 888 - 519 - 5375 [email protected] www.oculususa.com

RO0314_Oculus.indd 1 2/24/14 3:29 PM Hepatitis B Photo: Andrew S. Gurwood, OD activates CD8+ T lymphocytes, resulting from a buildup of cel- which directly destroy the infected lular debris secondary to foreign hepatocyte by apoptosis.4,5 CD4+ invasion by either virus or bac- T lymphocytes are also key mem- teria. Retinal vasculitis can be bers of the immune response. induced by the accumulation of They also secrete lymphokines intraretinal inflammatory debris to prompt the activity of B cells, secondary to circulating HBV making specific antibodies to fight infection, and the upregulation of against foreign antigen, and to cellular elements to eliminate it amplify the activities of CD8+ T from the body.22 lymphocytes.4,5 Optic neuropathy is a potential side One study indicated that vascu- Lastly, CD8+ cells release cyto- effect of interferon use. litis was related to an abundance kines, such as interferon gamma, of circulating HBsAg immune which summon macrophages. The body complexes have the potential complex––namely HBsAg bound massive macrophage response to cause further complications by to IgM.22 As retinal vasculitis then leads to liver damage.4,5 HBV producing vasculitis, glomerulo- evolves, blood vessel walls become is not directly cytopathic; instead, nephritis and cryogloblinemia.10,19 inflamed, reducing blood flow to it induces an immune reaction Ocular manifestations of HBV tissues. Subsequently, there is a that leads to liver injury.13 are the result of these circulating disruption in nutrient and oxygen Initially, there is a marked immune complexes, and include distribution to affected tissues, increase in HBsAg and HBcAg various degrees of retinal isch- giving rise to the classic axonal upon infection.14 Once the body emia, which provoke vasculitis stasis observed as the cotton wool detects foreign antigens, anti- (artery occlusion, vein occlusion, spot.23 bodies such as immunoglobulin cotton wool spots), pupil sparing Another study determined that (IgG and IgM) are produced to third nerve palsy, optic neuritis hepatitis C virus (HCV) similarly fight the infection. HBeAg can and uveitis.7-11 had the potential to induce vascu- be detected when viral activity litis and ischemic retinopathy.7 A separate research group completed Circulating antigen-antibody complexes have a clinical trial of 85 patients and observed that 51% of individu- the potential to cause further complications by als with HCV exhibited bilateral producing vasculitis, glomerulonephritis and ischemic retinopathy.24 The clinical features of ischemic retinopa- 10,19 cryogloblinemia. thy included cotton wool spots (CWS) and retinal hemorrhages.23 Through their research, they peaks. The infection stage con- Systemic Symptoms confirmed that the ocular sign of cludes when HBeAg antibodies Systemic manifestations of HBV CWS denotes significant ischemia are formed.18 infection during the acute phase in the affected region. It also pro- Chronic infection is defined of the disease include nausea, vides a palpable sign, indicating by the presence of HBsAg in the vomiting, diarrhea, abdominal ischemic processes are proceeding serum for a period lasting longer discomfort, decreased appetite, in the body at large.7,23,24 than six months.18 During the fatigue, fever, myalgia, dark urine, Herpetic retinal vasculitis chronic phase, IgG is still pro- and yellowing of the skin and eyes (acute retinal necrosis [ARN] and duced to fight the infection—even (jaundice).20,21 progressive outer retinal necrosis while the immunity is taxed. In [PORN]) and collagen vascular this stage, remaining hepatocyte Ocular Manifestations of diseases (CVD) share similar pre- cells continually divide, and Infection sentations.24 Both of these condi- increase the risk for hepatic carci- • Retinal vasculitis. The term tions cause hypoxia secondary to noma.6 vasculitis refers to the pathologic accumulation of inflammatory Finally, circulating antigen-anti- inflammation of blood vessels debris, which impedes retinal

62 REVIEW OF OPTOMETRY MARCH 15, 2014

060_ro0314_f5.indd 62 3/5/14 3:01 PM Ask about optional Slit Lamp & Chart Projector configurations.

(1-800-566-2278)

Or Your Local Lombart Representative. Corporate Office - 5358 Robin Hood Road, Norfolk, VA 23513-2430 757-853-8888 | FAX 757-855-1232 | 800-566-2278 | 800-446-8092 www.lombartinstrument.com ATLANTA•BALTIMORE/WASHINGTON D.C.•BOSTON•BOYNTON BEACH/MIAMI•BRADENTON•CHARLOTTE CHICAGO•CINCINNATI•DALLAS•DENVER•DETROIT•GREENSBORO•HOUSTON•KANSAS CITY•KNOXVILLE•LOS ANGELES MILWAUKEE•MINNEAPOLIS•NEW JERSEY/NEW YORK•NORFOLK•PORTLAND•SACRAMENTO•SAN DIEGO•SAN FRANCISCO

*Lease rate subject to credit approval, 1st payment is paid for by leasing company at signing with 59 remaining rental payme nts of $269 and a $1.00 purchase option. Taxes, freight and installation additional. Hand Instruments optional. Quantities limited. Subject to change without notice.

RP0812_Lombart.indd 1 7/10/12 11:03 AM Hepatitis B

perfusion.23,24 Examples of CVD include systemic lupus erthroma- tosis, Beçhet’s disease, rheumatoid arthritis, sarcoidosis, Sjögren’s syndrome and Reiter’s syndrome. Other conditions, such as anemia, giant cell arteritis, antiplatelet antibody syndrome, diabetes and hypertension, also are capable of such vascu- lopathy.23 • Pupil-sparing third nerve palsy. A literature review uncovered one case in which a 36-year- old man presented with an acute, pupil-sparing third nerve palsy.8 Evi- dence of jaundice and darker urine prompted the clinical investigators to perform enzyme linked immuno-assay (ELISA) testing, which uncovered the presence of HBsAg and IgM. The Examination of this patient revealed an isolated cotton wool spot. Upon subsequent lab testing, it publication concluded was confirmed that this patient had hepatits B. that the deposition of circulating immune complexes system, and eventually causing tis- time (PT) is helpful to assess the produced ischemic infarction of sue destruction.27 Moorfields Eye coagulability of the blood, and the third nerve.8 Hospital in London has supported may indicate liver damage.28 • Optic neuritis and uveitis. the potential for HBV-based uve- Liver function tests (LFT) are Both optic neuritis and general itis.11 useful to determine the extent of uveitis have also been observed liver damage.29 The battery of as consequences of HBV infec- Work-Up liver function tests include alanine tion.8,10,11,26 A study conducted in ELISA testing is essential for transaminase (ALT), aspartate Switzerland indicated that 13% detecting circulating hepatitis viral transaminase (AST), alkaline of uveitis cases may, in part, be proteins—specifically HBsAg, phosphatase (ALP), albumin, attributed to HBV infection––with HBeAg and HBeAg antibodies.18 total proteins, bilirubin, gamma- evidence of HBsAg circulating It is worth noting that the pres- glutamyltransferase (GGT) and within affected individuals’ blood- ence of HBsAg in the blood serum L-lactate dehydrogenase (LD).29 A streams.11,26 It is theorized that for more than six months is an number of results may be indica- persistent HBsAg and HBcAg in indication of chronicity.18 tive of liver damage, including:28 the system leads to constant pro- A complete blood count with - Elevated ALT, AST, ALP, duction of antibodies, resulting in platelets is also useful for detect- bilirubin, GGT and LD. antigen-antibody complex forma- ing other concurrent systemic dis- - Reduced albumin and total tion, activating the inflammatory eases. Additionally, prothrombin protein levels.

64 REVIEW OF OPTOMETRY MARCH 15, 2014

060_ro0314_f5.indd 64 3/5/14 3:44 PM LOTEMAX® GEL–UNIQUE FORMULATION DESIGNED TO CONTROL INFLAMMATION

MUCOADHESIVE TECHNOLOGY— LOW PRESERVATIVE AND TWO <57<33@32B=/263@3B=B63=1C:/@AC@4/13 KNOWN MOISTURIZERS1,2,4,6

DOSE UNIFORMITY— PROVEN EFFICACY AND #=A6/97<5@3?C7@32B=@3ACA>3<22@C5 ESTABLISHED SAFETY1,2,7

Indications and Usage ILOTEMAX®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

Please see brief summary of full prescribing information on adjacent page. References: 1.!$(",!%@3A1@707<5<4=@;/B7=<'3>B3;03@ 2. =<5&!37B@7BH"'7=C"3@;3B&@0( !=B3>@32<=: 3B/0==AB=>3@/B7D3>/7=@/B32 5. =443G" /D7='& *7A1=3:/AB71/<2A327;3@32<=:3B/0=6B6/:;7153: %=AB3@>@3A36B6/:;=:=5G&*$"/G =@B!/C23@2/:3! %=AB3@ 6. !=B3;/F%@3A1@707<5<4=@;/B7=<>@7: 7.&/8>/:& &=3::'7=C"3@;3B&@0( 4M1/1G/<2A/43BG=4:=B3>@32<=:3B/0=/7

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

RP1113_BL Lotemax PI.indd 1 10/16/13 9:52 AM Hepatitis B

- Prolonged PT, indicating clot- myalgia, alopecia and fatigue.14 suppression.13 ting problems. The most common ocular compli- Lamivudine is an effective In the case of optic neuritis and cation associated with interferon drug for patients with cirrhosis uveitis secondary to immune com- therapy is retinal ischemia, which and recurrent hepatitis after liver plex deposition, be sure to test is characterized by CWS, micro- transplant.17 The main disadvan- for:30 vascular abnormalities and hem- tage of the medication is viral - Titrated levels of IgG, IgA, orrhages.32-34 resistance. Entecavir can be used IgM, C3 and C4 on commer- Patients placed on the medi- as an alternative when resistance cial plates. cation should be monitored to lamivudine is detected.17 - Complement haemolytic for fundus changes, visual field • Vaccination has dramatically activity (CH50). abnormalities and retinal nerve reduced the prevalence of HBV - C1q binding (C1qBA) and fiber layer (RNFL) thickness around the globe.13 The vaccina- conglutinin binding competi- alterations every three to four tion is an effective agent that is tion (KgB-CA, CIC) assay.30 months following dosing initia- safe for administration at birth.2 Raised levels of C1qBA and tion.33 Increased RNFL thickness The modality can be used pro- CIC point to an immune com- warrants close observation, and phylactically to prevent perinatal plex etiology, which, as men- any patient who manifests CWS transmission and has been shown tioned earlier, also is associated with Data has shown a large decline in the rate of chronic systemic diseases such as vasculitis, disease occurrence in the children of Taiwan over a arthritis and glomerulonephritis.30 10-year period (9.8% to 1.3%) following the inception of a If vasculitis is successful HBV vaccination program.13 observed, additional tests, such as eryth- rocyte sedimentation rate (ESR), should cease therapy immedi- to be 89% to 98% effective.2 c-reactive protein (CRP), urine aely.34 Data has shown a large decline in tests, imaging (X-ray, CT and Other, less common conditions the rate of chronic disease occur- MRI) of larger vessels, angiogram associated with interferon use rence in the children of Taiwan and biopsy, should be ordered.31 include subconjunctival hemor- over a 10-year period (9.8% to rhage, retinal detachment, optic 1.3%) following the inception of Treatment for HBV neuropathy and elevated intraocu- a successful HBV vaccination pro- • Interferon therapy is admin- lar pressure.29,30,35 Ocular signs gram.13 istered subcutaneously. It modi- typically present from two weeks The HBV vaccine is comprised fies the HBV specific response to six months following therapy of purified HBsAg and is pro- and reduces viral replication.13,14 initation.29 duced via recombinant DNA Interferon is a cytokine released • Nucleotide analogs reduce technology, and typically is by CD8+ T lymphocytes, which HBV replication by mimicking administered in three doses.19 It is recruits macrophages to the site and inserting themselves as a base is the most widely used vaccine in of the insult.15 Recent clinical upon the viral DNA, effectively the world, and is now being con- trials have indicated that the halting HBV replication.13,14 In sidered as the standard of care in pegulated form of interferon is the comparison to interferon, these the United States.2 Furthermore, most efficacious.13 The addition agents are administered orally. the World Health Organization of polyetheylene glycol (PEG) to Current analogs substantially (WHO) is also pushing for vacci- interferon increases the prepara- reduce the amount of HBV DNA, nation in hyperendemic areas.13 tion’s half-life and duration of but have not demonstrated the Hepatitis vaccination is not activity.14 Pegulated interferon is ability to completely eradicate the free from potential side effects. administered weekly for up to 48 virus. There have been a total of 32 weeks. This catagorizes the medication uveitis cases resulting from use Side effects include headache, as a drug for maintaining viral of the hepatitis B vaccination.2

REVIEW OF OPTOMETRY MARCH 15, 2014 67

060_ro0314_f5.indd 67 3/5/14 3:01 PM Hepatitis B

formation of immune complexes due to viral insult can be catastrophic to ocular health, and can result in debilitating diseases, such Photo: Gregory D. Foley, OD as vasculitis induced retinal ischemia, optic neuritis, uveitis and pupil sparing third nerve palsy. Eye care professionals have the potential to play a key role in the diagnosis and management of HBV as well as in its monitoring after treatment by detecting ocular signs such as isolated cotton wool spots and/ or retinal hemorrhages. In cases exhibiting these signs where the etiology is unex- plained, prompt investiga- tion of the underlying cause through laboratory testing is required. When patients This fundus photo demonstrates the active phase of MEWDS, which is typically seen within are managed preemptively 24 hours following hepatitis vaccination. by vaccination, or currently by medications, close moni- Episodes of acute uveitis relating evanescent white dot syndrome toring is warranted, due to risk of to immune complex sequellae also (MEWDS).34 The condition typi- ocular complications. The team have been documented.36,37 cally is seen within a window of approach between the eye care Many reports of uveitis relat- 24 hours following vaccination.36 professional and the general prac- ing to HBV have been published This clinical presentation may be titioner is crucial when managing between 1982 and 2009 from associated with increased levels HBV. ■ databases like the National Reg- of IgG and IgM.34 The ocular istry of Drug-Induced Ocular Side treatments for cases of MEWDS Dr. Tuyen is on staff at Eye Effects, The World Health Orga- from this source are also stan- Physicians and Surgeons and is nization and the FDA.2 Uveitis is dard (cycloplegia and topical currently a clinical consultant at often seen after the first vaccina- anti-inflammatory drops), with The Eye Institute. Dr. Gurwood tion, and typically the manifesta- patients responding well to the is a professor at Salus University tion ensues at day three or later.2 intervention.34 in Elkins Park, Pa. Recurrence of uveitis after the Other ophthalmological symp- 1. Hadziyannis SJ, Papatheodoridis GV. Hepatitis b e anti- second and third vaccinations are toms, such as disc edema, central gen-negative chronic hepatitis b: Natural History and Treat- rare.2 The ocular treatment for vein occlusion and optic neuritis, ment. Seminars in Liver Disease. 2006 May;26(2):130-41. cases of uveitis from this source may be seen after vaccination.34 2. Shepard CW, Simard EP, Finelli L, Fiore AE, et al. Hepatitis B virus infection: epidemiology and vaccination. are standard (cycloplegia and top- Epidemiologic Reviews. 2006 Jun;28(1):112-25. ical steroidal anti-inflammatory HBV infection is the leading 3. Chandrasoma, Para, Taylor CR. Concise Pathology. Nor- walk, CT: Appleton & Lange; 1995. Chapter 42; 631-6. drops), with patients typically cause of liver cancer around the 4. Chisari FV, Ferrari C. Hepatitis b virus immunopatho- responding well to the interven- globe. It is hyperendemic, espe- genesis. Annual Review of Immunology. 1995;13(1):29-60. 5. Chisari FV, Ferrari C. Hepatitis b virus immunopathol- tion. cially in densely populated areas ogy. Springer Seminars in Immunopathology. 1995;17(2- Posterior uveitis also has been such as Africa, Southeast Asia, 3):261-81. 6. Chisari FV, Isogawa M, Wieland SF. Pathogenesis reported––specifically multiple China and the West Pacific. The of hepatitis b virus infection. Pathologie Biologie. 2010

68 REVIEW OF OPTOMETRY MARCH 15, 2014

060_ro0314_f5.indd 68 3/5/14 3:01 PM Aug;58(4):258-66. 18. Ching LL, Ratzlu V, Yuen MF, Poynard T. Viral hepatitis basics/definition/prc-20012602. Accessed May 12, 2013. 7. Zegan ME, Anninger W, Chapman C, Gordon SR. Ocular b. Lancet. 2003 Dec;362(9401):2089-94. 29. Nussenblatt, Robert B, Whitcup SM. Uveitis: Funda- manifestations of hepatitis c virus infection. Current Opin- 19. Rubin, Emanuel, Gorstein F. Rubin’s Pathology: Clini- mentals and Clinical Practice. St. Louis: Mosby; 2004. ion in Ophthalmology. 2002 Dec;13(6):423-7. copathologic Foundations of Medicine. Philadelphia: Lip- Diagnosis:76-87 8. Sood A, Midha V, Sood N, Gupta D. Hepatitis b and pincott Williams & Wilkins; 2004. Viral hepatitis; 762-72. 30. Galli M, Morelli R, Casellato A, Perna MC. Retrobulbar pupil sparing oculomotor nerve paresis. Clinical Infectious 20. Fraunfelder FW, Eric BS, Fraunfelder FT. Hepatitis b optic neuritis in a patient with acute type b hepatitis. Jour- Diseases. 1999 Nov;29(5):1330-1. vaccine and uveitis: an emerging hypothesis suggested by nal of the Neurological Sciences. 1986;72(2-3):195-200. 9. Farthing CF, Howard RS, Thin RN. Papillitis and hepati- review of 32 case reports. Cutaneous and Ocular Toxicol- 31. Mayo Clinic. Vasculitis. Available at: http://www.mayo- tis b. Bmj. 1986 Jun;292(6537):1712. ogy. 2010 Mar;29(1):26-9. clinic.org/diseases-conditions/vasculitis/basics/definition/ 10. Bloom JN, Rabinowicz M, Schulman ST. Uveitis 21. Chambers RB, Downie A, Foote B, Davidorf FH. con-20026049. Accessed May 12, 2013. complicating autoimmune chronic active uveitis. Am J Dis Interferon alfa-associated retinopathy. JAOA. 1997 32. Manesis EK, Moschos M, Brouzas, D, Kotsiras J, et al. Child. 1983 Dec; 137(12):1175-6. Jan;97(1):43-5. Neurovisual impairment: a frequent complication of alpha- 11. Murra PI, Prasad J, Rahi AH. Status of hepatitis b virus 22. Gower RG, Sausker WF, Kohler PF, Thorne GE, et al. interferon treatment in chronic viral hepatitis. Hepatology. in the aetiology of uveitis in great britain. British Journal of Small vessel vasculitis caused by hepatitis b virus immune 1998 May; 27(5):1421-7. Ophthalmology. 1983 Oct;67(10):685-7. complexes. Journal of Allergy and Clinical Immunology. 33. Guyer DR, Tiedeman J, Yannuzi LA, Slakter JS, et al. 12. Sonneveld MJ, Zoutendijk R, Janssen HLA. Hepatitis 1978 Oct;62(4):222-8. Interferon-associated retinopathy. Arch Opthalm. 1993 b surface antigen monitoring and management of chronic 23. Dieter S. The mystery of cotton-wool spots a review of Mar;111(3):350-56. hepatitis b. Journal of Viral Hepatitis. 2011 Jul;18(7):449- recent and historical descriptions. Eur J Med Res. 2008 34. Koktekir BE, Sumer S, Bakbak B, Gedik S, et al. Ocular Jun;13(6):231-66. 57. effects of pegylated interferon alpha in patients with chronic 13. Ocama P, Opio C, Lee W. Hepatitis b virus infec- 24. Abe T, Nakajima A, Satoh N, Koizumi T, et al. Clinical hepatitis b. Cutaneous and Ocular Toxicology. 2013 tion: current status. The American Journal of Medicine. characteristics of hepatitis c virus-associated retinopathy. Oct;32(4):275-8. 2005;118(12):1413.e15-413.e22. Jpn J Opthalmol. 1995;39(4):411-9. 35. Hayasaka S, Masamitsu F, Yamamoto Y, Noda S, et al. 14. Cotran, Ramzi S, Kumar V, Collins T, Robbins SL. Rob- 25. Wensing B, De-Groot Mijnes JD, Rothova A. Necrotiz- Retinopathy and subconjunctival hemorrhage in patients bins Pathologic Basis of Disease. Philadelphia: Saunders; ing and nonnecrotizing variants of herpetic uveitis with 1995. Chapter 19. posterior segment involvement. Arch Opthalm. 2011 with chronic viral hepatitis receiving interferon alpha. Brit- 15. Buster EHCJ, Janssen HLA. Antiviral treatment for Apr;129(4):403-8. ish Journal of Ophthalmology. 1995;79(2):150-52 chronic hepatitis b virus infection-immune modulation or 26. Grob PJ, Martenet AC, Witmer R. Nonspecific immune 36. Baglivo E, Safran AB, Borruat FX. Multiple evanescent viral suppression. The Netherlands Journal of Medicine. parameters and hepatitis b antigens in patients with uveitis. white dot syndrome after hepatitis b vaccine. Brief Reports. 2006 Jun;64(6):175-85 Mod Probl Ophthalmol. 1976;16:254-8. 1996 Sep;122(3):431-32. 16. Kane M. Global programme for control of hepatitis b 27. London WT. Hepatitis b virus and antigen-antibody 37. Muferet E, Guven S, Akyuz U, Bilgiç O, et al. Optic infection. Vaccine. 1995;13 Suppl 1:S47-9. complex disease. N Engl J Med. 1977;296:1528-9. neuritis following hepatitis b vaccination in a 9-year-old 17. Lee WM. Hepatitis b virus infection. N Engl J Med. 28. Mayo Clinic. Liver function tests. Available at: http:// girl. Journal of the Chinese Medical Association. 2009 1997 Dec;337(24):1733-745. www.mayoclinic.org/tests-procedures/liver-function-tests/ Nov; 72(11):594-97.

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.

060_ro0314_f5.indd 69 3/5/14 2:59 PM 2 CE Credits (COPE approval pending)

Systemic Disease Report Medical Syndromes That Affect Children’s Vision These conditions aren’t ordinary—nor should be your evaluation and treatment of these children. By Marie Bodack, OD

ost pediatric patients pres- Ehlers-Danlos syndrome, pseudo- drome have a range of skeletal, car- ent with problems such xanthoma elasticum, osteogenesis diac and ocular anomalies. Patients as blurred vision, an eye imperfecta, Down syndrome and with a “typical” Marfan’s appear- Mturn or reading difficulties. juvenile idiopathic arthritis. ance are tall and thin with long However, like adults, children may arms, legs and fingers. They may be suffer from systemic conditions that Marfan’s Syndrome very flexible and have stretch marks affect their vision and ocular health. • Prevalence/characteristics. on their skin without a history of In some cases, the child and the Marfan’s syndrome is an autosomal weight loss.1 Scoliosis (abnormal parents are aware of the medical dominant, multisystem, connective curvature of the spine) and flat feet condition and are seeking an evalu- tissue disorder with a prevalence of (pes planus) may be present. The ation for related ocular findings. In one in 5,000.1 Patients with Mar- breastbone is sunken into the chest other cases, the family is aware of fan’s have a mutation in the FBN-1 (pectus excavatum) in some individ- the condition, but is unaware that it gene, located on chromosome 15. uals, while it protrudes out (pectus can affect the eyes. FBN-1 encodes for fibrillin-1, a carinatum) in others. And then there are those cases protein involved with the elasticity The most serious and potentially in which the child and family are of connective tissue.2 Mutations can fatal complications of Marfan’s are unaware of the condition, and your manifest as severe and fatal neona- cardiac, including aortic root dila- exam uncovers an ocular anomaly tal cases, or more minor cases with tion, mitral valve prolapse and aortic that leads to the systemic diagnosis. isolated conditions, such as ectopia dissection or aneurysm formation.2 This article reviews some of the lentis (displaced crystalline lens).3 In an effort to help differentiate most notable medical conditions • Systemic findings. Due to a Marfan’s syndrome from other sys- with ocular findings that can affect change in the elasticity of connective temic conditions (including familial children: Marfan’s syndrome, tissue, patients with Marfan’s syn- aortic dilation and/or dissection,

Release Date: March 2014 Faculty/Editorial Board: Marie Bodack, OD Expiration Date: March 1, 2017 Credit Statement: COPE approval for 2 hours of CE credit is pending Goal Statement: Children, like adults, may suffer from systemic con- for this course. Check with your local state licensing board to see if this ditions that affect their vision and ocular health. This course reviews counts toward your CE requirement for relicensure. some of the most notable medical conditions with ocular findings that Joint-Sponsorship Statement: This continuing education course is can affect children. Optometrists can not only manage these patients joint-sponsored by the Pennsylvania College of Optometry. for ocular problems, but may be the first to recognize a serious condi- Disclosure Statement: Dr. Bodack has no financial relationships to tion that leads to an important, possibly lifesaving diagnosis. disclose.

70 REVIEW OF OPTOMETRY MARCH 15, 2014

070_ro0314_f6_osc_MH.indd 70 3/6/14 9:41 AM OPTOMETRIC STUDY CENTER

Case Study on Marfan’s Syndrome Photo: Daniele Saltarelli, OD A 12-year-old male presented for an eye exam for an updated eyeglass prescription. His current Rx was -11.00-1.00x180 OD 20/40, -4.00 sphere OS 20/20. Refraction was stable. No strabismus was present. A dilated exam revealed a lens subluxation superotemporally OD. Fundus evaluation revealed no holes, tears or retinal detachments. Intraocular pressure measured 17mm Hg OD and 18mm Hg OS. On observation, he appeared tall for his age. We suspected Marfan’s based on the subluxated lens, high myopia and physical appearance. We contacted the patient’s pediatrician, who referred the patient to a cardiologist. The patient returned for a follow-up exam and his guardian reported that the cardiologist said that the child was healthy and “did not answer Subluxed lens in another patient with Marfan’s syndrome. any questions about Marfan’s.” The guardian also reported that she had “read up on Marfan’s” and mentioned that the patient has flat feet. She requested a second opinion, so we referred him to a pediatric cardiologist in a Marfan’s clinic. The results of the evaluation and genetic testing confirmed our suspicion that the patient had Marfan’s syndrome. Fortunately, he did not have any cardiac anomalies. We fit the patient with contact lenses, which improved visual acuity to 20/30 OD and 20/20 OS. He also wears protective plano polycarbon- ate lenses. We educated him on the symptoms of a retinal detachment and lens displacement and told to call as soon as possible if he notices decreased vision, flashes or floaters. Also, we (and the cardiologist) advised him to avoid contact sports. He will follow up with cardiology and optometry annually.

Klinefelter syndrome or homocystin- • Ocular findings. The most com- firmed Marfan’s syndrome, perform uria), the diagnostic criteria for Mar- mon ocular anomaly in Marfan’s a dilated exam to look specifically fan’s were recently revised to place is ectopia lentis, affecting approxi- for ectopia lentis, retinal detach- more emphasis on the cardiac and mately 60% of patients.6 The lens is ments, cataracts and glaucoma. In ocular findings.4 The current criteria most commonly subluxed upward, those with ectopia lentis but without include a family history of Marfan’s although any direction is possible. a diagnosis of Marfan’s, refer the syndrome, systemic features, genetic In cases of ectopia lentis, the zon- patient to his or her pediatrician or testing, and the presence or absence ules are thinner, fewer in number, a cardiologist for additional test- of ectopia lentis and/or cardiac irregular in diameter, and have an ing. Biomicroscopic evaluation of anomalies. abnormal attachment to the lens patients with ectopia lentis should In patients with a positive family capsule.7 In some patients, sublux- include observing the crystalline history, a diagnosis of Marfan’s is ation is slowly progressive, being lens in multiple positions of gaze to confirmed if the individual develops noted in the first few years of life, check for movement, which indi- ectopia lentis. If ectopia lentis is not or in the late teens to early twenties. cates instability. present, evaluation looks next at sys- However, in the majority of patients, • Treatment/management. Treat- temic features, then at the presence progression of lens displacement is ment for ectopia lentis can include or absence of aortic dilation or dis- uncommon.8 annual monitoring. If the patient section, and finally, genetic testing. Other ocular findings in patients is young, or if it is the first time a A variety of systemic findings are with Marfan’s syndrome include practitioner is seeing the patient, a assigned a “point value,” according high myopia, cataract, strabismus, dilated exam at six months to moni- to the Marfan’s diagnostic criteria. A glaucoma and retinal detachment.1,8 tor for changes to the subluxation certain number of points indicates a Specifically, exotropia has been may be warranted. In cases when the diagnosis of Marfan’s.5 For example, reported in up to 10% to 19% of subluxation is severe (i.e., causing scoliosis, pes planus and myopia of patients with Marfan’s, while esotro- decreased best-corrected vision or ≥3.00D each equate to one point. pia has been found in approximately at risk for total subluxation), con- A total score of seven points, along 2% of patients.9 One study of 573 sider referral to a cataract surgeon with a positive family history or aor- patients with Marfan’s found that who has experience with Marfan’s tic dilation and/or dissection, con- 5% had glaucoma.10 patients. Surgical lensectomies are firms the diagnosis of Marfan’s. In patients with suspected or con- not routinely performed, as the

REVIEW OF OPTOMETRY MARCH 15, 2014 71

070_ro0314_f6_osc_MH.indd 71 3/6/14 9:41 AM OPTOMETRIC STUDY CENTER

Types of Ehlers-Danlos Syndrome11,14 Prior Type Major Criteria Minor Criteria Inheritance Type Joint hypermobility Frequent joint dislocations, chronic pain, Hypermobility III AD Skin hyperextensibility and/or smooth, velvety feel family history Easy bruising, velvety feel to the skin, Skin hyperextensibility muscle hypotonia, molluscoid pseudo- Classic I, II Atrophic scars AD tumors (fleshy skin lesions with scars), Joint hypermobility family history Frequent bruising Small joint hypermobility, tendon/muscle Thin, translucent skin Vascular IV rupture, early onset varicose veins, easy AD Characteristic facial appearance bruising, pneumothorax, family history Arterial/uterine/intestinal fragility or rupture Joint laxity Severe muscle hypotonia at birth Easy bruising, arterial rupture, microcor- Kyphoscoliotic VI-A AR Progressive scoliosis at birth nea, family history Scleral fragility VII- Joint hypermobility with subluxations Skin hyperextensibility, easy bruising, Arthrochalasia AD A/B Congenital bilateral hip dislocation muscle hypotonia, kyphoscoliosis Severe skin fragility Dermatosparaxis VII-C Easy bruising, soft skin AR Sagging in skin Thin cornea Brittle cornea Ocular fragility VI-B Skin and joint hypermobility AR syndrome* Blue sclera Keratoconus AD = autosomal dominant AR = autosomal recessive * No longer considered a sub-group of EDS, but included for completeness.

risk of retinal detachments has recessive (AR) or X-linked. Diagnosis of EDS is based on approached 25% in these patients.8 Historically, subtypes were classi- a physical examination and may A careful refraction is important fied numerically, so older textbooks include collagen typing from a skin in these patients because the vision may use terms such as “EDS-I” or biopsy, genetic testing and an echo- may be reduced or fluctuate, as in “EDS-VI.” Currently, the preferred cardiogram.11,12 cases of subluxation. Additionally, classification is descriptive of major •Ocular findings. Ocular mani- patients with ectopia lentis should and minor diagnostic criteria, such festations include dermatochalasis, use safety glasses and be instructed as “classic,” “vascular” or “kypho- keratoconus, microcornea, macro- to refrain from contact sports due to scoliotic” (abnormal curvature of cornea, glaucoma, retinal detach- risk of lens migration into the vitre- the spine). ment and myopia.14 Angioid streaks ous or anterior chamber. • Systemic findings. Clinically, have been reported in patients with patients with EDS bruise easily, EDS, but are not part of the diag- Ehlers-Danlos Syndrome have skin hyperextensibility, joint nositic criteria.15 • Prevalence/characteristics. hypermobility and poorly localized A potentially serious ocular com- Ehlers-Danlos syndrome (EDS) pain to varying degrees.11 The most plication, especially in the vascular refers to a group of genetic dis- serious form of the condition is the form, is a carotid-cavernous fistula orders that affect collagen and vascular type, and the most severe (CCF), an abnormal communication extracellular matrix synthesis complication is spontaneous arterial between the arteries and veins in the and structure.11-13 (See “Types of or organ rupture, which can result cavernous sinus. Patients with CCF Ehlers-Danlos Syndrome,” above.) in death. Symptoms of spontaneous may present to an optometrist with The estimated prevalence is one in arterial or organ rupture include a complaint of eye pain, chemosis, 5,000.14 Inheritance can be auto- chest or abdominal pain, or altered proptosis and redness of one or both somal dominant (AD), autosomal mental status.11 eye(s). They also report hearing a

72 REVIEW OF OPTOMETRY MARCH 15, 2014

070_ro0314_f6_osc_MH.indd 72 3/6/14 9:41 AM pulsating sound or noise in their mal recessive disorder with a head. Patients may have extraocu- prevalence of one in 25,000 lar motility restrictions and report to one in 100,000 people.17 diplopia. These individuals require Females are diagnosed twice referral to a hospital for immediate as often as males.18 Patients medical attention. have a defect in the ABCC6 Both the EDS kyphoscoliotic form gene, which is involved with (previously Type VI-A) and EDS the production of multidrug brittle cornea syndrome form (pre- resistance-associated protein viously Type VI-B), are autosomal 6 (MRP6) whose function is recessive and characterized by joint suspected to transport sub- hypermobility and kyphoscoliosis. stances across cell membranes. Of the subtypes of EDS, corneal • Systemic findings. PXE fragility is most frequently associ- is characterized by calcium ated with type VI.12 These patients deposits in the elastic fibers of may be at risk for glaucoma, ectopia connective tissues. The skin lentis and retinal detachments.12,15 is the primary organ affected, However, unlike those with the but the cardiovascular sys- kyphoscoliotic form, patients with tem can be affected as well. Angioid streaks in an adult patient. brittle cornea syndrome also have Patients may have yellowish craniofacial anomalies, gastroin- papules on their skin, especially the systemic conditions associated with testinal problems and characteris- neck. The skin develops an orange angioid streaks include EDS, Paget’s tic hypermobility in the fingers.12 peel appearance (“peau d’orange”) disease and sickle cell retinopathy. Keratoconus has also been reported. and, over time, the lesions can form Choroidal neovascular membranes Currently, brittle cornea syndrome plaques and the skin acquires a more (CNVM) may develop in 70% to is considered a distinct entity and is wrinkled appearance.17 Patients can 86% of patients over time due to not included in most classifications also develop angina pectoris, arterio- breaks in Bruch’s membrane.22 of EDS.16 sclerosis, hypertension, gastrointes- Neither angioid streaks or peau • Treatment/management. Any tinal hemorrhages, renal failure and d’orange retinal appearance affect a patient with EDS should undergo neurological abnormalities.19 patient’s visual acuity. annual eye examinations, includ- Diagnosis is made by biopsy of • Treatment/management. ing slit lamp examination and skin lesions, if present.17 Genetic Patients with PXE, even without dilated fundus examination. The testing is also available. angioid streaks, should undergo Ehlers-Danlos National Foundation • Ocular findings. The retina may annual dilated eye exams to moni- recommends these additional tests develop a mottled appearance, also tor for the development CNVM. at baseline: ocular topography, scan- known as “peau d’orange.” Areas of Optical coherence tomography ning laser ophthalmoscopy, mea- chorioretinal atrophy may be pres- (OCT) testing can also be performed surement of corneal thickness and ent in the mid-periphery.20 when CNVM is suspected. Provide palpebral aperture measurement.14 Angioid streaks, which are breaks patients with an Amsler grid to In patients who present with joint in Bruch’s membrane that pres- monitor their vision at home.17 In hyperextendability, a history of easy ent bilaterally and radiate off the cases in which neovascularization bruising and corneal findings, con- optic disc, are found in 85% of develops, be certain to refer the sider EDS as a differential. Compile patients.20 Depending on retinal patient to a retinal specialist. a detailed patient and family history. pigmentation, they may be red to Treatment for CNVM is similar to If you suspect a diagnosis of EDS, dark brown in color and become that indicated for patients with mac- be sure to communicate with the darker over time. Angioid streaks ular degeneration, and may include patient’s primary care physician. have not been reported in children monthly injections of anti-angio- under age eight, and their incidence genesis drugs, specifically Lucentis Pseudoxanthoma Elasticum increases with age.21 In 50% of (ranibizumab, Genentech) or Avastin • Prevalence/characteristics. cases, angioid streaks are associ- (bevacizumab, Genentech).23,24 For Pseudoxanthoma elasticum (PXE) ated with a systemic condition, with example, one small study of seven is a progressive, primarily autoso- PXE being the most common. Other patients who had CNVM associated

REVIEW OF OPTOMETRY MARCH 15, 2014 73

070_ro0314_f6_osc_MH.indd 73 3/6/14 9:42 AM OPTOMETRIC STUDY CENTER

Types of Osteogenesis Imperfecta19,25 Type Systemic Findings Ocular Findings Type I – Tarda 50% have age-dependent hearing loss, frequent bone fractures, no dental Blue sclera, thin central cornea anomalies Type II – Congenital Lethal form: death from respiratory or cardiac complications in the first few Blue sclera years of life Type III Hearing problems, dental anomalies, scoliosis, short limbs, triangular- Blue sclera may be present at birth, then shaped face resolves Type IV Mild bone deformities, short stature, dental anomalies Blue sclera may be present at birth, then resolves

with PXE found that, after monthly • Systemic findings. Patients suf- der involving chromosome 21. The injections of ranibizumab, best- fer from bones that break easily, and most common presentation is triso- corrected visual acuity increased they may have scoliosis, dentinogen- my 21, affecting 94% of those with from 20/63 to 20/32 on average in esis imperfecta (brittle teeth), hear- Down syndrome. In 5% of cases, a one year, with gains maintained at ing loss and pulmonary disease.25 portion of chromosome 21 is trans- three months post treatment.24 Patients are commonly short in stat- located to another chromosome so As with Marfan’s syndrome, ure and can be prone to nosebleeds. that there are still 46 chromosomes. patients with PXE should avoid put- Diagnosis of OI is based on clini- One percent of patients have mosa- ting their eyes at risk for trauma. cal, dental and radiologic exams. icism, where some cells have 46 Patients who play sports should Genetic testing can also be per- chromosomes and others have 47.29 wear protective goggles. formed. • Systemic findings. Patients with • Ocular findings. Patients often Down syndrome can have multiple Osteogenesis Imperfecta have the characteristic “blue sclera,” systemic conditions, including car- • Prevalence/characteristics. the result of a thin sclera through diac disorders such as atrial septal Osteogenesis imperfecta (OI) is which the choroid is visible. They or ventriculoseptal defects. Other primarily an autosomal dominant may also have a whiter perilimbal possible health problems include multisystem disorder that affects region as compared to the surround- gastroenterological blockage, sleep the development of type I collagen ing sclera. Scleral rupture has been apnea, hearing disorders, hypothy- fibrils, causing their diameter to be reported in pediatric patients after roidism, hip dislocations and dental smaller than normal. Mutations in a history of trauma or chronic eye anomalies.30 COL1A1 and COL1A2, located on rubbing.27 Keratoconus has also Physically, patients with Down chromosomes 17 and 7, respectively, been reported. syndrome have a characteristic have been implicated as the origin of • Treatment/management. appearance including short stature, the mutations.19 Patients should have regular eye flattened nasal bridge, small ears, Traditionally, there were four exams, with careful evaluation small mouth, upward slanting eyes, types of OI affecting the COL1A1 of the integrity of the cornea and epicanthal folds, and short hands and 2 genes. (See “Types of Osteo- sclera. Management of patients and fingers. Some children have genesis Imperfecta,” above.) How- includes protective eyewear, particu- delays in mental and social develop- ever, up to seven new types of OI larly during physical activity, to pre- ment. affecting different genes, including vent scleral rupture from injury.27 Diagnosis of Down syndrome CRTAP or LEPRE, have been iden- Medications for osteoporosis and is frequently based on physical tified. Some of the new forms are physical therapy may be used for appearance at birth. Genetic testing autosomal recessive.26 treating the orthopedic disorders, can be done by amniocentesis dur- Type I is the most common pre- while the more severe deformities ing pregnancy, or with blood work sentation and accounts for 50% of are treated surgically.28 (karyotyping) after birth. Echocar- the cases.25 The exact prevalence is diograms and chest X-rays are used unknown, but an estimated 20,000 Down Syndrome to diagnose cardiac anomalies, while to 50,000 Americans have the con- • Prevalence/characteristics. X-rays of the abdomen identify gas- dition.25 Down syndrome is a genetic disor- troenterological anomalies.

74 REVIEW OF OPTOMETRY MARCH 15, 2014

070_ro0314_f6_osc_MH.indd 74 3/6/14 9:42 AM Photo: Daniele Saltarelli, OD • Ocular findings. Patients with of adult patients Down syndrome tend to have high with Down refractive errors. One study found syndrome) that that 62% of patients with Down do not require syndrome had hyperopia of ≥2.00D treatment.42 compared with 16% of patients • Treatment/ without Down syndrome.31 In the management. same study, 60% of patients with When determin- Down syndrome had astigmatism vs. ing a spectacle only 25% without Down syndrome. prescription, be Astigmatism tends to be oblique.32 sure to obtain an Best-corrected visual acuity, even accurate objec- in the absence of pathology or tive refraction. amblyogenic factors, may not be Testing should 20/20. The etiology of decreased also include vision is not known, but optical measurement of factors appear to play a role.33 accommodative Numerous studies have found that lag with near between 55% to 68% of patients retinoscopy, Broken synechaie in a patient with juvenile idiopathic arthritis. have a significant accommodation such as monocu- lag, even with full correction.34,35 lar estimate method (MEM), Nott or Patients with keratoconus can Subsequent studies have found Bell retinoscopy, and the prescription wear glasses or may be fit with that up to 65% of patients show of an add when indicated. The rec- contact lenses, if indicated. These improved accommodation with bifo- ommended bifocal segment is a flat- patients should be monitored for cal lenses; in some cases, the child’s top 35 set to bisect the pupil, which the development of corneal compli- accommodative ability improves to helps ensure the functional use of the cations, including hydrops. the point that bifocals are no longer add at near. needed.36,37 Other conditions are treated as Juvenile Idiopathic Arthritis Binocular vision dysfunctions are they are in any patient. Strabismus, • Prevalence/characteristics. also common in patients with Down particularly esotropia, may be Juvenile idiopathic arthritis (JIA) syndrome. The prevalence of strabis- accommodative and corrected with refers to a group of autoimmune mus, particularly esotropia, ranges spectacles. In cases in which the inflammatory joint conditions that from 19% to 42%.38-40 Nystagmus deviation does not improve with appear in children under age 16. has been reported in 10% to 30% of glasses, options include monitor- It is considered to result from a patients.37,40,41 ing without intervention, vision combination of genetics and envi- Other ocular findings in these therapy or surgery. Treatment con- ronmental factors. Genes that code patients include blepharitis, cata- siderations should include the mag- for human leukocyte antigen (HLA) racts, keratoconus and Brushfield nitude of the deviation, the ability have been implicated as a possible spots. Blepharitis results from eyelid of the child to complete a therapy risk for developing JIA.43 Its preva- anatomy. Cataracts can be congeni- program and risks of surgery, lence is estimated at one in 1,000 tal or acquired. Congenital cataracts including anesthesia. children in the United States.43 generally present bilaterally. Some Blepharitis is treated with lid • Systemic findings. Patients studies report that congenital cata- scrubs. Parents should also be edu- with JIA have a prolonged inflam- racts are present in 11% to 26% of cated on the recurrent nature of the matory response in one or more patients.40,42 Age-related cataracts condition and need for lid hygiene. joints. Symptoms may include joint appear at an earlier age in these Some patients may benefit from a pain, morning stiffness, swollen patients compared to the general topical antibiotic ointment, such as joints and difficulty with motor population. Keratoconus has been erythromycin or bacitracin, if they activities. reported in 0.5% of patients.42 have frequent flare-ups. The diagnosis of JIA is based Brushfield spots—pale areas of Congenital cataracts are gener- on a clinical examination, which hypoplasia in the peripheral iris—are ally monitored; but if dense, a sur- frequently includes magnetic reso- incidental findings (reported in 1% gical consult is warranted. nance imaging (MRI) of the joints.

REVIEW OF OPTOMETRY MARCH 15, 2014 75

070_ro0314_f6_osc_MH.indd 75 3/6/14 9:42 AM OPTOMETRIC STUDY CENTER

drugs (DMARDs), Types of Juvenile Idiopathic Arthritis37,38 like methotrexate, Type Joints Affected Blood Work Other Signs which are admin- Fever for two weeks prior to or concurrent with arthritis, istered orally or Systemic may have a rash, anemia can be present through injection. Oligoarticular ≤4 for 6 months In patients who are RF+ Polyarticular ≥5 for 6 months + RF Resembles arthritis seen in adults not responsive to methotrexate, based RF- Polyarticular ≥5 for 6 months - RF on joint disease or Psoriasis (patches of red, irritated skin), abnormalities of Psoriatic fingers and nails ocular presentation, biologic-modifying Tenderness at bones, ligaments and connective tissue, Enthesitis and a greater incidence in boys than girls drugs—specifically Humira (adalim- Undifferentiated Do not fit into one category or have multiple characteristics umab, AbbVie), Enbrel (etanercept, RF = rheumatoid factor Amgen), Remicade (infliximab, Janssen Photo: Daniele Saltarelli, OD Blood work includes anti- Biotech) and Orencia (abatacept, nuclear antibody (ANA) Bristol-Myers Squibb)—may be and rheumatoid factor added or substituted. Clinical tri- (RF). als regarding the most efficacious JIA is classified into treatment are ongoing.43 seven types: systemic, As in adult cases, children with oligoarticular, RF positive uveitis are treated according to or RF negative, psoriatic, the anterior chamber reaction. enthesitis-related and Pred Forte (prednisolone acetate undifferentiated. (See 1%, Allergan) is the preferred “Types of Juvenile Idio- topical steroid, although Durezol pathic Arthritis,” above.) (di fluprednate 0.05%, Alcon) may The classifications are also be used. The steroid is dosed made based on the num- frequently initially, then slowly ber of joints affected, Band keratopathy in patient with JIA. tapered as the uveitis resolves. signs and symptoms, Patients’ intraocular pressure (IOP) family history and laboratory test agnosed are at risk of developing should be monitored for a possible results. Oligoarticular JIA accounts synechiae, glaucoma, cataracts and steroid response, which can be for approximately 50% of cases, band keratopathy. treated with a topical medication, while systemic JIA accounts for It is important to educate parents such as a beta-blocker, to lower 10%.44 With the exception of the about the potentially serious ocular IOP. A cycloplegic agent is not enthesitis-related form, girls are complications of JIA and the need routinely used unless the patient is affected more than boys.43 for frequent slit lamp eye exams in pain, or there is a greater risk of • Ocular findings. The most to screen for uveitis.48 (See “Rec- synechiae. serious ocular side effect of JIA is ommended Slit Lamp Screening In cases of uveitis that do not uveitis. Studies have found that an Guidelines for Juvenile Idiopathic improve with topical treatment, average of 13% of patients with Arthritis,” page 77.) especially within three months, JIA develop uveitis.45,46 In patients • Treatment/management. Sys- systemic medications may need to who are ANA positive, up to 30% temic treatment involves a combi- be added or adjusted.49 Therefore, may have uveitis.47 In the majority nation of medications and physical communication with the treating of cases, the patients are asymp- therapy. In the mildest cases, rheumatologist is important. tomatic and do not report the clas- non-steroidal anti-inflammatories sic eye pain or light sensitivity, nor (NSAIDs) are first-line treatment. Treating children can be a does the parent notice any redness. Second-line treatment includes rewarding clinical experience. Yet, Patients in whom uveitis goes undi- disease modifying anti-rheumatic treating those with an underlying

76 REVIEW OF OPTOMETRY MARCH 15, 2014

070_ro0314_f6_osc_MH.indd 76 3/6/14 9:42 AM systemic disease can be excep- tionally gratifying because of the Recommended Slit Lamp Screening Guidelines for changes you can make to a child’s Juvenile Idiopathic Arthritis42 quality of life and how they man- ANA Age of onset of JIA Duration of JIA Exam Frequency age their chronic condition. (years) (years) (months) As primary eye care providers, Positive ≤6 ≤ 4 3 optometrists may be the first to Positive ≤6 > 4 6 recognize a serious systemic condi- Positive ≤6 > 7 12 tion, which could save a patient’s Positive >6 ≤ 26 life and prevent further deteriora- Positive >6 > 2 12 tion. Furthermore, optometrists can Negative 6 46 effectively manage these patients ≤ ≤ for possible ocular complications. Negative ≤6 > 4 12 Because many of the conditions Negative >6 N/A 12 discussed in this review are genetic, Systemic N/A N/A 12 encourage eye examinations for family members of affected Hoyt CS, eds. Pediatric Ophthalmology and Strabismus. New York: 33. Little JA, Woodhouse JM, Lauritzen JS, Saunders KJ. The impact Elsevier Saunders; 2005:656. of optical factors on resolution acuity in children with Down syn- patients, even if they have not been 16. Byers PH, Murray M. Heritable collagen disorders: the paradigm drome. Invest Ophthalmol Vis Sci. 2007;48:3995-4001. diagnosed with a disorder. ■ of the Ehlers-Danlos syndrome. J Invest Dermatol. 2012;132: 34. Cregg M, Woodhouse JM, Pakeman VH, et al. Accommodation E6-E11. and refractive error in children with Down syndrome: cross-sectional 17. What is PXE? PXE International. Available at: www.pxe.org/ and longitudinal studies. Invest Ophthalmol Vis Sci. 2001;42:55-63. Dr. Bodack was a clinical instruc- what-pxe. Accessed November 26, 2013. 35. Haugen OH, Hovding G. Strabismus and binocular function in 18. Genetics Home Reference: Pseudoxanthoma elasticum. National children with Down syndrome. A population-based, longitudinal tor of ophthalmology at Cincin- Library of Medicine. Available at: http://ghr.nlm.nih.gov/condition/ study. Acta Ophthalmol Scan. 2001;79:133-9. nati Children’s Hospital Medical pseudoxanthoma-elasticum. Accessed November 26, 2013. 36. Stewart RE, Woodhouse JM, Trojanowska LD. In focus: the use 19. Traboulsi EI. Connective Tissue, Skin, and Bone Disorders. In of bifocal spectacles with children in Down’s syndrome. Ophthal Center––University of Cincinnati Wright KW, Spiegel PH, eds. Pediatric Ophthalmology and Strabis- Physiol Opt. 2005;25:514-22. College of Medicine. Currently, she mus. New York: Springer; 2003:740-65. 37. Al-Bagdady M, Stewart RE, Watts P, Murphy PJ. Bifocals and 20. Georgalas I, Tservakis I, Papaconstaninou D, Kardara M, et al. Down’s syndrome: correction or treatment? Ophthal Physiol Opt. is the chief of Pediatric Primary Pseudoxanthoma elasticum, ocular manifestations, complications 2009;29:416-21. Care and an associate professor at and treatment. Clin Exp Optom. 2011;94:169-80. 38. Yurdakul NS, Ugurlu S, Maden A. Strabismus in Down syn- 21. Hollander DA, Bhisitkul RB. Miscellaneous Retinal Disorders. In: drome. Journal of AAPOS. 2006 Jan-Feb;43(1):27-30. Southern College of Optometry, in Taylor D, Hoyt CS, eds. Pediatric Ophthalmology and Strabismus. 39. Woodhouse JM, Pakeman VH, Cregg M, et al. Refractive errors Memphis. New York: Elsevier Saunders; 2005:615-24. in young children with Down syndrome. Optom Vis Sci. 1997 22. Lim JI, Bressler NM, Marsh MJ, Bressler SB. Laser treatment of Oct;74(10):844-51. 1. What is Marfan Syndrome? The Marfan Foundation. Available at: choroidal neovascularization in patients with angioid streaks. Am J 40. Liza-Sharmini AT, Azlan ZN, Zilfalil BA. Ocular findings in Malay- www.marfan.org/about/marfan. Accessed November 11, 2013. Ophthalmol. 1993 Oct 15;116(4):414-23. sian children with Down syndrome. Singapore Med J. 2006;47:14-9. 2. Summers KM, West JA, Hattam A, Stark D. Recent developments 23. Zebardast N, Adelman RA. Intravitreal ranibizumab for treatment 41. Tsiaras WG, Pueschel S, Keller C, et al. Amblyopia and in the diagnosis of Marfan syndrome and related disorders. Med J of choriodal neovascularization secondary to angioid streaks in PXE: visual acuity in children with Down’s syndrome. Br J Ophthalmol. Australia. 2012;197:494-7. 5 year follow-up. Semin Ophthal. 2012; 27:61-4. 1999;83:1112-4. 3. Lloyd IC. The Lens. In: Taylor D, Hoyt CS, eds. Pediatric Ophthal- 24. Finger RP, Issa PC, Hendig D, et al. Monthly ranibizumab for 42. Fong AH, Shum J, Ng AL, et al. Prevalence of ocular abnormali- mology and Strabismus. New York: Elsevier Saunders; 2005:432-40. choroidal neovascularizations secondary to angioid streaks in ties in adults with Down syndrome in Hong Kong. Br J Ophthalmol. 4. Loeys BL, Dietz HC, Braverman AC, Callewaert BL. The pseudoxanthoma elasticum: a one-year prospective study. Am J 2013;97:423-8. revised Ghent nosology for the Marfan syndrome. J Med Genet. Ophthalmol. 2011 Oct;152(4):695-703. 43. Juvenile idiopathic arthritis – Genetics Home Reference. US 2010;47:476-85. 25. Types of OI. Osteogenesis Imperfecta Foundation. Available National Library of Medicine. Available at: http://ghr.nlm.nih.gov/ 5. Calculation of Systemic Score. The Marfan Foundation. Available at: www.oif.org/site/PageServer?pagename=AOI_Types. Accessed condition/juvenile-idiopathic-arthritis. Accessed November 27, at: www.marfan.org/dx/score. Accessed November 11, 2013. November 27, 2013. 2013. 6. Maumenee IH. The eye in Marfan syndrome. Trans Am Ophthalmol 26. Ben Amor M, Rauch F, Monti E, Antoniazzi F. Osteogensis imper- 44. Arthritis in Children. American College of Rheumatology. 2013. Soc. 1981; 79: 684-733. fecta. Pediatr Endocrinol Rev. 2013 Jun;10 Suppl 2:397-405. Available at: www.rheumatology.org/practice/clinical/patients/ 7. Ashworth JL, Kielty CM, McLeod D. Fibrillin and the eye. Br J 27. Pirouzian A, O’Halloran H, Scher C, et al. Traumatic and sponta- diseases_and_conditions/arthritis_in_children. Accessed November Ophthalmol. 2000; 84: 1312-17. neous scleral rupture and uveal prolapse in osteogenesis imperfecta. 27, 2013. 8. Traboulsi, EI. Connective Tissue, Skin, and Bone Disorders. In: J Pediatr Ophthalmol Strabismus. 2007 Sep-Oct;44(5):315-7. 45. Sabri K, Saurenmann RK, Silverman ED, Levin AV. Course, com- Taylor D, Hoyt CS, eds. Pediatric Ophthalmology and Strabismus. 28. Osteogenesis Imperfecta Brittle Bone Disease. US National plications, and outcome of juvenile arthritis-related uveitis. J Pediatr New York: Elsevier Saunders; 2005: 740-65. Library of Medicine. Available at: www.ncbi.nlm.gov/pubmedhealth/ Ophthalmol Strabismus. 2008 Dec;12(6):539-45. 9. Izquiredo N, Traboulsi EI, Enger C, Maumenee IH. Strabismus in PMH0002540. Accessed November 27, 2013. 46. Saurenmann RK, Levin RK, Feldman BM, et al. Risk factors for the Marfan Syndrome. Am J Ophthalmol. 1994;117:632-5. 29. Woodhouse M, Maino DM. Down Syndrome. In: Taub MB, Bar- development of uveitis differ between girls and boys with juvenile 10. Izquiredo N, Traboulsi EI, Enger C, Maumenee IH. Glaucoma in tuccio M, Maino DM, eds. Visual diagnosis and care of the patient idiopathic arthritis. Arthritis Rheum. 2010 Jun;62(6):1824-8. the Marfan Syndrome. Trans Am Ophthalmol Soc. 1992;90:111-22. with special needs. Philadelphia: Wolters Kluwer/Lippincott Williams 47. Ravelli A, Felici E, Magni-Manzoni S, et al. Patients with anti- 11. Beighton P, DePaepe A, Steinmann B, et al. Ehlers-Danlos & Wilkins; 2012:31-9. nuclear antibody-positive juvenile idiopathic arthritis constitute a syndromes: revised nosology, Villefranche, 1997. Am J Med Genet. 30. Down Syndrome. A.D.A.M. Medical Encyclopedia (Internet). US homogenous subgroup irrespective of the course of joint disease. 1998;77:31-7. National Library of Medicine. Atlanta, GA. Available at: www.ncbi. Arthritis Rheum. 2005;52:826-32. 12. DePaepe A, Malfait F. The Ehlers-Danlos syndrome, a disorder nlm.nih.gov/pubmedhealth/PMH0001992. Accessed November 48. Heiligenhaus A, Niewerth M, Ganser G, et al. Prevalence and with many faces. Clin Genet. 2012:82:1-11. 11, 2013. complications of uveitis in juvenile idiopathic arthritis in a popula- 13. What are the types of EDS? Ehlers-Danlos Foundation. Available 31. Akinci A, Oner O, Bozkurt OH, et al. Refractive errors and strabis- tion-based nation-wide study in Germany: suggested modification of at: www.ednf.org/eds-types. Accessed December 3, 2013. mus in children with Down syndrome: a controlled study. J Pediatr the current screening guidelines. Rheumatology. 2007;46:1015-9. 14. Ophthalmology Medical Resource Guide. Ehlers Danlos National Ophthalmol Strabismus. 2009 Mar-Apr;46(2):83-6. 49. Heiligenhaus A, Michels H, Schumacher C, et al. Evidence- Foundation, 2008. Available at: www.ednf.org/documents/MRGOph- 32. Haugen OH, Hovding G, Lundstrom I. Refractive development based, interdisciplinary guidelines for anti-inflammatory treatment thalmologyS.pdf. Accessed December 3, 2013. in children with Down’s syndrome: a population based, longitudinal of uveitis associated with juvenile idiopathic arthritis. Rheumatol Int. 15. Drack AV. Patterns of Retinal Disease in Children. In: Taylor D, study. Br J Ophthalmol. 2001;85:714-9. 2012;32:1121-33.

REVIEW OF OPTOMETRY MARCH 15, 2014 77

070_ro0314_f6_osc_MH.indd 77 3/6/14 9:42 AM OPTOMETRIC STUDY CENTER

OSC QUIZ

ou can obtain transcript-qual- with a refractive error of -5.00-1.00x180 angioid streaks includes: ity continuing education credit OD 20/20 and -7.00-2.50x15 OS 20/20. a. Monitoring. Ythrough the Optometric Study During dilation, you notice that the left b. Injection of steroid drugs. Center. Com plete the test form (page crystalline lens is subluxed superiorly. c. Injection of anti-angiogenic drugs. 79), and return it with the $35 fee to: This patient should be referred to which d. Laser treatment. Optometric CE, P.O. Box 488, Canal Street provider? Station, New York, NY 10013. To be eli- a. Cardiologist. 11. Osteogenesis imperfecta is a systemic gible, please return the card within one b. Dermatologist. disease characterized by: year of publication. c. Rheumatologist. a. Frequent bruising. You can also access the test form and d. Geneticist. b. Frequent bone fractures. submit your answers and payment via c. Mental retardation. credit card at Review of Optometry online, 5. The major criteria for the different sub- d. All of the above. www.revoptom.com. types of EDS all include: You must achieve a score of 70 or a. Joint hypermobility or skeletal anomalies. 12. The most common refractive finding in higher to receive credit. Allow eight to 10 b. Skin anomalies or hearing loss. patients with Down syndrome is: weeks for processing. For each Optomet- c. Skin anomalies or joint hypermobility. a. Myopia ≥6.00D. ric Study Center course you pass, you d. Joint hypermobility or hearing loss. b. Oblique astigmatism. earn 2 hours of transcript-quality credit c. Regular astigmatism. from Pennsyl vania College of Optometry 6. A patient who presents with complaints d. Hyperopia ≥2.00D. and double credit toward the AOA Optom- of eye pain and redness, and who reports et ric Recog nition Award—Cate gory 1. hearing a pulsating sound, likely has: 13. A 12-year-old patient with Down syn- Please check with your state licens- a. Carotid cavernous fistula. drome has a refractive error of +2.00D OD ing board to see if this approval counts b. Viral conjunctivitis. and +2.50D OS. Best-corrected visual acu- toward your CE requirement for relicen- c. Scleral rupture. ity using the Snellen chart is 20/40 each sure. d. Blepharoconjunctivitis. eye. The etiology of the decreased vision can be due to: 1. Patients with Marfan’s syndrome have 7. For the patient in question 6, what sys- a. Amblyopia. been found to have a defect in what gene? temic condition is the most likely? b. Brushfield spots. a. ABC6. a. Marfan’s syndrome. c. Dense cataracts. b. COL1A1. b. Pseudoxanthoma elasticum (PXE). d. Optical factors. c. FBN-1. c. Ehlers-Danlos syndrome (EDS). d. LEPRE. d. Juvenile idiopathic arthritis (JIA). 14. When examining a 9-year-old patient with Down syndrome, you find an accom- 2. All of the following are possible sys- 8. Angioid streaks, yellow skin papules and modative lag of +3.50D over her current temic complications of Marfan’s syndrome an orange peel appearance in the retina eyeglasses. The current prescription is EXCEPT: have been associated with which systemic +4.00-1.00x180 OU with 20/30 VA each a. Pes planus. condition? eye. Refraction does not show a change. b. Aortic root dilation. a. Osteogenesis imperfecta (OI). The most appropriate treatment for this c. Pectus excavatum. b. PXE. patient is. d. Transverse myelitis. c. EDS. a. Rx +4.00-1.00x180 OU. d. JIA. b. Rx +4.00-1.00x180/+3.00D add. 3. A 12-year-old patient with Marfan’s c. Rx +3.00-1.00x180/+3.00D add. syndrome reports a history of sudden 9. A patient who presents with dark red d. Rx +5.00-1.00x180 OU. decreased vision after being hit with a streaks radiating off the optic nerve should “header” during a soccer match. The most be educated about the risk of developing: 15. Patients with Down syndrome who likely cause of this patient’s symptom is: a. Cataracts. experience chronic blepharitis may benefit a. Rupture of CNVM. b. Glaucoma. from ophthalmic treatment with which b. Lens subluxation. c. Paget’s disease. medication? c. Hyphema. d. Choroidal neovascular membranes. a. Bacitracin ointment. d. Optic nerve avulsion. b. Polytrim drops. 10. Currently, the treatment for choroidal c. Azithromycin drops. 4. You are examining an adolescent patient neovascular membranes that develop from d. Tobramycin/dexamethasone ointment.

78 REVIEW OF OPTOMETRY MARCH 15, 2014

070_ro0314_f6_osc_MH.indd 78 3/6/14 9:42 AM Examination Answer Sheet OSC QUIZ Valid for credit through March 1, 2017 This exam can be taken online at www.revoptom.com/continuing_education. Upon passing the exam, 16. An 8-year-old patient who presents you can view your results immediately and download a real-time CE certificate. You can also view your with a white and quiet eye with a grade test history at any time from the website. 3+ uveitis should be worked up for which Medical Syndromes That Affect Children’s Vision condition? Directions: Select one answer for each question in the exam and completely darken the a. Toxoplasmosis. appropriate circle. A minimum score of 70% is required to earn credit. b. PXE. Mail to: Jobson - Optometric CE, PO Box 488, Canal Street Station, New York, NY 10013 c. EDS. Payment: Remit $35 with this exam. Make check payable to Jobson Medical Information LLC. d. JIA. COPE approval for 2 hours of CE credit is pending for this course. This course is joint-sponsored by the Pennsylvania College of Optometry 17. A patient with JIA who has chronic There is an eight-to-ten week processing time for this exam. untreated uveitis can be at risk for: a. Band keratopathy. 1. A B C D 1 = Excellent 2 = Very Good 3 = Good 4 = Fair 5 = Poor 2. A B C D Rate the effectiveness of how well the activity: b. Cataracts. 3. A B C D c. Glaucoma. 4. A B C D 21. Met the goal statement: 1 2 3 4 5 d. All of the above. 5. A B C D 22. Related to your practice needs: 1 2 3 4 5 6. A B C D 23. Will help you improve patient care: 1 2 3 4 5 7. A B C D 24. Avoided commercial bias/influence: 1 2 3 4 5 18. Which patient with JIA is at the great- 8. A B C D 25. How would you rate the overall est risk for developing uveitis? 9. A B C D quality of the material presented? 1 2 3 4 5 a. ANA positive, age of onset ≤6 years, 10. A B C D 26. Your knowledge of the subject was increased: 11. A B C D Greatly Somewhat Little duration of JIA ≤4 years. 12. A B C D 27. The difficulty of the course was: b. ANA positive, age of onset >6 years, 13. A B C D Complex Appropriate Basic duration of JIA ≤4 years. 14. A B C D How long did it take to complete this course? c. ANA negative, age of onset ≤6 years, 15. A B C D duration of JIA >4 years. 16. A B C D Comments on this course: 17. A B C D d. ANA negative, age of onset >6 years, 18. A B C D duration of JIA ≤4 years. 19. A B C D Suggested topics for future CE articles: 20. A B C D 19. What is the recommended slit lamp screening interval for the JIA patient Please retain a copy for your records. Please print clearly. described in question 18? You must choose and complete one of the following three identifier types:

a. Every month. 1 SS # - - b. Every three months. Last 4 digits of your SS # and date of birth State Code and License #: (Example: NY12345678) c. Every six months. 2 - 3 d. Every twelve months.

First Name

20. Patients who have JIA may be taking Last Name which of the following medications? E-Mail a. Adalimumab and methotrexate. The following is your: Home Address Business Address b. Methotrexate and ranibizumab. c. Oral prednisone and methotrexate. Business Name d. Adalimumab and oral prednisone. Address

City State

ZIP

Telephone # - -

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.revoptom.com/continuing_education/ Lesson 109804 RO-OSC-0314

REVIEW OF OPTOMETRY MARCH 15, 2014 79

070_ro0314_f6_osc_MH.indd 79 3/6/14 9:43 AM Vision Expo East A Feast of CE at VEE The Big Apple has everything you need this March to satisfy your appetite for CE. By Cheryl G. Murphy, OD, Contributing Editor

ision Expo East, held March The Special Glaucoma program 26 to 30, is not just about was successfully offered last year eyewear. It’s a full smorgas- at both Vision Expo East and Vbord of education on disease West. “Its aim is to highlight diagnosis and management, clinical the most important skills and application of technology, savvy knowledge that primary eye care business solutions, and more. optometrists need to regularly treat glaucoma,” says Richard To Start Madonna, OD, a member of the One of the most noticeable VEE Conference Advisory Board. changes to the course curriculum Keep your eyes peeled for Dr. Cheryl “Optometry has been granted this year is its early start with the Murphy, and you might see yourself on the privilege to manage glau- new Global Contact Lens Forum, Review of Optometry’s Facebook page. coma in almost every state, yet beginning at 2 p.m. Wednesday, we have been disappointed in March 26, and running through nology, Internet and communica- the number of ODs who say they noon Thursday. This special pro- tion with patients; debates on actively manage the condition,” gram of classes serves up seven contact lens wearing schedules; the Dr. Madonna says. “This pro- COPE-approved credit hours and ocular system’s response to con- gram highlights the areas in which aims to give practitioners sharper tacts, and more. The Global Con- the practitioner needs to be well strategies for a smoother and more tact Lens Forum is hosted jointly by versed in order to effectively pro- successful contact lens practice. the British Contact Lens Associa- vide glaucoma care.” “The main theme of the forum tion and Vision Expo East. He also states that, “the pro- is the business of contact lenses,” gram is taught by practitioners says Kirk Smick, OD, co-chairman A Sizable Entree who regularly manage glaucoma, of the VEE Conference Advisory If you’re looking for something so it provides education that can Board. “The goal is to explore dif- substantial to sink your teeth into be used immediately in practice. ferent aspects of the contact lens this year at VEE, you’ll find the I believe that the courses have practice and demonstrate its contri- conference CE menu packed with something for everyone, from the bution to the overall primary care an inviting 19 hours of credits practitioner who doesn’t regularly optometric practice.” that will satisfy your craving to manage glaucoma to docs experi- Topics include: the use of tech- learn more about glaucoma. enced in glaucoma but who wish

80 REVIEW OF OPTOMETRY MARCH 15, 2014

080_ro0314_f7.indd 80 3/4/14 10:16 AM Vision Expo East is more than an eyeglass fashion show. This year’s meeting offers 325 hours of top-notch continuing education.

to learn a new pearl or two, [as in demand. And, because diabetes center of the eye care professions.” well as those] who just want to be is appearing in epidemic waves More than 50 hours of business involved in the discussion.” in our practices, any course deal- education cover all aspects of staff Attending the entire Special ing with current trends in diabetic and practice management, gov- Glaucoma program provides prac- management is popular.” ernment regulations and audits, titioners with a comprehensive Courses that address children’s as well as dispensary and contact and thorough view of diagnosing, eye conditions are “gaining in lens business. managing and treating glaucoma, popularity as the new Affordable but single classes in the program Care Act will bring many under- Sunday’s Cherry on Top can be taken a la carte. “While the served children into our practices,” Sunday is the last day of courses courses do proceed sequentially he says. at Vision Expo East, and attendees from diagnosis to treatment to Courses on new lens designs and can choose to end it with some- grand rounds, attendees may wish treatments are once again coming thing sweet by registering for the to take only a few of the courses,” into vogue, as doctors and opti- 12th Annual Ocular Nutrition Dr. Madonna says. cians strive to protect their patients Symposium, a full-day CE program from harmful UV and blue light. from the Ocular Nutrition Society. Courses Galore Dr. Smick also notes the impor- (Attendees must pre-register at Still hungry for more? There tance of continuing education on www.ocularnutritionsociety.org.) are plenty of topics and classes to macular degeneration and nutri- “The ONS strives to bring in devour, and the variety is part of tional supplements. “Since the nutrition experts from outside of the Vision Expo’s draw. According completion of the AREDS 2 study, eye care industry to discuss the true to Dr. Smick, “more than 4,000 doctors have been looking for the science behind nutrition,” says ONS optometrists, opticians, practice best formula to prescribe to their president Jeffrey Anshel, OD. “Our managers and office staff come AMD patients,” he says. “Nutra- programs offer insight into how together to take courses at the ceutical prescribing is at an all-time nutrition can bring about positive Vision Expo meetings, [and] Vision high because patients are eager to results for our patients.” Expo educates more eye care pro- find the right solutions to this over- Topics include nutrigenetics in eye fessionals than any other meeting whelming eye disease.” disease, the role of lutein in visual in the United States.” Also new for 2014 are 12 function and in the brain, early Course tracks include clinical, hours of CE that focus on neuro- detection of macular degeneration contact lens, optical technology ophthalmic disease to ensure that structure and function, evidence- and business topics. Specifically, optometrists can diagnose these based nutrition and how to bring “clinical subjects related to allergy, conditions promptly and manage your newfound nutrition knowledge retinal disease and ocular emergen- them properly. into practice. The ONS symposium cies continue to be well attended,” Finally, “Business Solutions is at VEE includes lunch and concludes says Dr. Smick. “New techniques the heart and soul of Vision Expo,” with “a cabernet, chocolate and in refractive surgery and cataract says Dr. Smick. “This meeting has chatter” social hour. surgery comanagement are always come to be known as the business Visit www.visionexpoeast.com. ■

REVIEW OF OPTOMETRY MARCH 15, 2014 81

080_ro0314_f7.indd 81 3/4/14 10:16 AM Comanagement Q+A

Red Eye of Olympic Proportions Bob Costas’s “pink eye” reminds us that the only sure-fire cure for EKC is time. By Paul C. Ajamian, OD A 42-year-old white female Anecdotally, I’ve found mixed Q came in on Friday with a red results; sometimes it makes the eye left eye and swollen eyelid. I put her better, sometimes worse. on an antibiotic. But by Monday, the Early reports have suggested that injection and swelling had progressed Zirgan (ganciclovir 0.15%, Bausch significantly, so I added a + Lomb), which we use for herpetic topical steroid. When I saw her keratitis, can reduce the recovery again on Tuesday, her eye was Two problematic cases of time of adenoviral conjunctivitis if even worse; the cornea was epidemic keratoconjunc- used in the first few days.1 Again, uninvolved but the conjunctiva tivitis: One in our patient I’ve found it helped some patients was ballooning out. She’s mis- (above) and one in sports- but not others. erable, so I’m referring her to caster Bob Costas. More research is needed for both you. Can you help her? these treatments. Until we have I can diagnose her, but dio lights intolerable. When you those—or until a drug is approved A only time will help her. have EKC, you’d pay someone a specifically for adenoviral conjunc- When I saw this patient on lot of money for the magic bullet to tivitis—we can offer comfort and Wednesday, she had a palpable just make it all go away. reassurance. preauricular node on the left side, To that end, recommend cold which told me what I already sus- No Miracle Pill compresses and artificial tears. pected: epidemic keratoconjunctivi- Unfortunately, time is the only Remove pseudomembranes in tis (EKC). guaranteed cure. Of course, a mis- office. Because the virus is so Oddly enough, this patient pre- erable EKC patient doesn’t want to contagious and is transmitted by sented just a few days before Bob hear that. They’ll go from one doc- direct contact, educate the patient Costas made national news with tor to the next, hoping for a better about strict hygiene measures to his debilitating case of “pink eye” answer. prevent infection in the fellow eye during the Winter Olympics. So, if you have a desperate and as well as in other family members. And, in both cases, the diagnosis disbelieving patient—despite your (This goes for you, too. If you even was confounded by conjunctival best efforts to explain otherwise— remotely suspect EKC, use gloves chemosis and swelling of the lids, send him or her for a friendly during examination, and try to which is not unusual with EKC. second opinion. The patient will sterilize everything after the patient This eyelid involvement and che- hopefully stop shopping and let leaves.) mosis might steer you toward a you follow the condition through When my EKC got to the point diagnosis of allergy or preseptal to resolution on its own. that it involved the cornea, I used cellulitis. Having said that, a couple treat- a bandage contact lens; it helped Don’t be fooled. In preseptal cel- ments might be worth a try, and enough to get me through the day. lulitis, the eye is white and quiet. palliative measures for comfort are Also, cycloplegic drops admin- With EKC, it’s red and angry. definitely in order. istered two or three times a day So, too, is the patient! Having Some doctors advocate an off- might help to reduce the pain and had it myself, I can attest that EKC label, one-time, in-office instillation photophobia. ■ makes you miserable and desper- of Betadine 5% Sterile Ophthalmic 1. Tabbara OF. Ganciclovir effects in adenoviral keratocon- ate. Bob Costas went off the air, Prep Solution (povidone-iodine, junctivitis. Poster (B253) presented at Annual Association in part, because his photophobia Alcon), which potentially for Research in Vision and Ophthalmology (ARVO); April made sitting in front of bright stu- “nukes” the entire microbial load. 29-May 4, 2001; Fort Lauderdale, Fla.

82 REVIEW OF OPTOMETRY MARCH 15, 2014

082_ro0314_cmqa.indd 82 3/4/14 10:17 AM IN THE NEW ERA OF MANAGED CARE, 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

RO0114_Vision Source.indd 1 12/23/13 1:04 PM Cornea+Contact Lens Q+A

Bugs and Drugs Does the increasing resistance to antibacterial medications found in a number of organisms pose a threat to your patients? Edited by Joseph P. Shovlin, OD Are the new trends in resis- selected for as a result of antibiotic as the dominant cause of Staph.- Q tance patterns in conjunctivitis use. related eye disease—if this has not and microbial keratitis a concern for Due to this selectivity, “until already occurred,” says Dr. Bron- contact lens wearers? In particular, the 1990s MRSA was primarily ner. Studies currently suggest that what is the status of MRSA-related a hospital-borne disease,” known between one-third and two-thirds infection risk in CL wearers? more formally as hospital acquired of all Staph.-related eye infections (HA)-MRSA, says Dr. Bronner. are the result of MRSA popula- To understand the impact of “However, beginning in the 1990s, tions.1,2 A methicillin-resistant Staphylo- some MRSA strains became more Pertaining specifically to contact coccus aureus (MRSA) as it relates effective colonizers that were lenses, despite the widely recog- to bacterial keratitis, “it’s useful to able to compete with non-MRSA nized increase in incidence of gram- take a step back and look at what strains, and so began to show up negative etiologies in the setting of exactly MRSA means and where in the community in individuals contact lens use in the US, Staph. it came from,” says Aaron Bron- with no history of hospitalization species are still either the first or ner, OD, a staff optometrist at the or antibiotic use.” This is the phe- second most encountered source Pacific Cataract and Laser Institute nomenon of so-called community of contact lens-associated bacterial of Kennewick, Wash. acquired (CA)-MRSA. keratitis, according to Dr. Bron- MRSA colonies result from envi- According to Dr. Bronner, these ner, so it stands to reason that such ronmental stress brought on by CA-MRSA isolates are “more patients will have greater exposure beta-lactam antibiotics. “In these virulent and effective growers than to resistant Staph. species as well. populations, a mutation to the cell HA-MRSA.” Despite this fact, they “As MRSA is becoming more wall protein—which drugs like lost some of their resistance during common among all types of bacte- penicillin, methicillin and cephalo- the transformation. As a result, the rial keratitis, it should be presumed sporins bind to and act against— CA-MRSA isolates are more sus- that it will likely become equally rendered these drugs ineffective by ceptible to antibiotics. more common among contact eliminating their target,” says Dr. “As far as resistance within lens-associated disease,” says Dr. Bronner. other organisms goes, MRSA and Bronner. “Because of the widen- In addition to being transmitted methicillin-resistant Staph. epider- ing distribution of MRSA—as well vertically from parent cell to off- midis (MRSE) are discussed with as the generally prominent role spring, along bacterial cell lineages, great frequency because they are Staph. aureus has in ocular disease these specific mutations are readily the primary causative organisms overall—it can be expected that transmitted horizontally by plas- in severe ophthalmic disease,” MRSA infections will become the mids to non-descendant lines of adds Dr. Bronner. A number of primary Staphylococcal etiology of bacteria, Dr. Bronner says, thereby other important pathogens, such both bacterial keratitis as a whole, widening the spread of resistance. as Pseudomonas aeruginosa and as well as contact lens-associated Although MRSA species are Streptococcal species, are showing bacterial keratitis.” ■ widely able to resist the effects of resistance patterns as well. 1. Asbell PA, Sahm DF, Shaw M, Draghi DC, Brown NP. many conventional antibiotics, Staph. species causing ocular Increasing prevalence of methicillin resistance in serious they were less efficient colonizers disease have been shown to exhibit ocular infections caused by Staphyloccocs auereus in United States: 2000 to 2005. J Cataract Refract Surg. 2008; than many non-MRSA Staph. spe- resistance in dramatically increas- 34: 814-8. cies. As a result, these particular ing numbers. “In fact, MRSA 2. Hsiao CH, Chuang CC, Tan HY, Ma DH, Lin KK, Chang CJ, Huang YC. Methicillin-resistant Staphyloccus aureus species would not routinely cause species may replace methicillin- ocular infection: a 10 year hospital based study. Ophthal- pathology—unless such traits were susceptible Staph. aureus (MSSA) mology. 2012; 119: 522-7.

84 REVIEW OF OPTOMETRY MARCH 15, 2014

084_ro0314_clqa.indd 84 3/5/14 3:02 PM How many other lenses can say they’re more comfortable than ACUVUE® OASYS® Brand Hygroscopic, Contact Lenses? hydrophilic, tear-attracting polymer Silicone NONE. hydrogel

In published clinical studies and those registered on clinicaltrials.gov, ACUVUE® OASYS® Brand has never been beaten for comfort by any leading monthly lens.*

Visit acuvuepro.com to learn more about ACUVUE® OASYS® Brand Family.

* Based on review of published clinical studies and those registered on clinicaltrials.gov with comfort as an endpoint. ACUVUE® Brand Contact Lenses are indicated for vision correction. As with any contact lens, eye problems, including corneal ulcers, can develop. Some wearers may experience mild irritation, itching or discomfort. Lenses should not be prescribed if patients have any eye infection, or experience eye discomfort, excessive tearing, vision changes, redness or other eye problems. Consult the package insert for complete information. Complete information is also available from VISTAKON® Division of Johnson & Johnson Vision Care, Inc., by calling 1-800-843-2020 or by visiting acuvueprofessional.com. ACUVUE®, ACUVUE® OASYS®, HYDRACLEAR®, and VISTAKON® are trademarks of Johnson & Johnson Vision Care Inc. © Johnson & Johnson Vision Care, Inc. 2013 ACU-32200I September 2013

RO1013_Vistakon Oasys.indd 1 10/3/13 11:13 AM FOR THE HEALTH OF YOUR PATIENTS. FOR THE HEALTH OF YOUR PRACTICE.

325 HOURS OF ACCREDITED CONTINUING FEATURED SPEAKERS: EDUCATION FOR EVERY ROLE AND EXPERIENCE LEVEL!

MACULAR DEGENERATION AND NUTRITIONAL SUPPLEMENTS (18 HOURS)

GLAUCOMA (17 HOURS) DAVE ZIEGLER, OD LOUISE A. SCLAFANI, LAURIE PIERCE, LDO, Fellow, American Academy of OD, FAAO ABOM, NCLC NEW GOVERNMENT REGULATIONS & Optometry, and Senior Partner, Associate Professor of Surgery, Instructor, Hillsborough Ziegler Lefﬁngwell Eyecare Section of Ophthalmology, Community College HEALTHCARE UPDATES (9 HOURS) University of Chicago Hospitals Opticianry Program

VISIONOMICS® AND BUSINESS SOLUTIONS, ARE YOU PRACTICING FULL SCOPE OPTOMETRY? INCLUDING RETAIL TRENDS (70 HOURS) Expand your knowledge base to practice to the maximum extent your license allows. Focus on three core competencies — disease diagnosis, treatment and management. NEW TECHNOLOGY (35 HOURS) THE ONLY EYECARE CONFERENCE TO FOCUS ON BUSINESS SOLUTIONS. Keep up with professional trends to ensure you’re utilizing best practices in: processes, OPTICAL BOOT CAMPS (15 HOURS) technology, efficiency, management tactics, marketing, patient service and staffing. YOU CONTROL YOUR CURRICULUM AND YOUR SCHEDULE. GLOBAL CONTACT LENS The 12 unique CE packages are as flexible as you need them to be. Only pay for the FORUM (7 HOURS) hours that you want and participate in the events that interest you. The time and CO-PRODUCED WITH money savings continue with shared event hours for groups and the flexibility to distribute hours as you prefer. THE BRITISH CONTACT LENS ASSOCIATION ALL UNDER ONE ROOF. Connect comprehensive learning at the conference to hands-on experiences with the products at the expansive exhibit hall. This allows you to compare and source the most products and trends all in one place.

THE COMPLETE EYECARE EVENT

EXPAND YOUR FIELD OF VISION EDUCATION: WEDNESDAY, MARCH 26–SUNDAY, MARCH 30, 2014 EXHIBITION: FRIDAY, MARCH 28–SUNDAY, MARCH 30, 2014 Javits Center | New York, NY www.visionexpoeast.com/OD

RO0114_House VEE.indd 1 1/8/14 10:35 AM Review of Systems

The Interactive Eye The Review of Systems can be applied many ways, including head-to-toe screenings. What is ROS, and why does it matter? By Carlo J. Pelino, OD, and Joseph J. Pizzimenti, OD

he eye does not function for documenting medical informa- in isolation. This has tion.1 It provides a structure that Tbeen apparent for a long helps us record our patient notes, time. Nineteenth-century physi- and view those notes subsequently cians skilled in the diagnosis in a manner that gives us a good and treatment of eye diseases understanding of that patient’s branched out by adding otology history. (ear and vestibular diseases), The review of systems (ROS) rhinology (diseases of the nose, has become a standard element of including the sinuses) and lar- the history and the POMR. ROS yngology (diseases of the throat is a list of questions, arranged by and larynx) to their repertoire. organ system, designed to uncover These early EENT physicians Diabetic retinopathy is one of many conditions symptoms of dysfunction and dis- viewed the eye and visual sys- that require ODs to team with providers from ease.2 tem as being closely related other disciplines. to these other organs, so why Applying ROS not treat them all? Optometrists just in different places. You see The ROS can be applied in sev- often shared both office space and diabetic retinopathy; I see diabetic eral ways: patients with audiologists, and periodontitis. You treat uveitis in • As a head-to-toe screening tool many still do so today. Several of a patient with Crohn’s disease; I asked of every patient. our optometric colleagues practice treat their aphthous ulcers (can- • As additional questions asked in multidisciplinary health set- ker sore). You relieve a Sjögren’s only of patients who fall into par- tings. patient’s dry eye; I enhance their ticular risk categories (e.g., reserv- But the connection of the visual diminished saliva production.” ing questions designed to uncover system to the rest of the body pseudotumor cerebri to overweight involves far more than other tis- A True Review females of child-bearing age.) sues of the head and neck. As part There are ever-growing, high- • As a means to describe the of the nervous system, the eye tech diagnostic methods available likely causes of a presenting symp- interacts with virtually every other to us, but the simple case history tom (e.g., patients with a chief organ system. In our bimonthly usually provides 90% of the useful concern of “unilateral eye and column, we attempt to illustrate information, with eye examination head pain” would merit a detailed the fact that many systemic condi- and diagnostic tests used to con- headache and neurologic ROS). tions have ocular complications, firm the diagnosis. and several ocular diseases—and The clinical evaluation of any Today’s clinicians incorporate treatments—have systemic impli- patient, no matter what the disci- the ROS into the overall patient cations. pline, begins with a case history. care strategy. Optometrists are in a position We are all familiar with the Patients’ responses should be to team with providers from vari- major elements of the case history, interpreted within the context of ous other disciplines in the interest from the chief complaint to medi- the rest of their profile, including of patient health and wellness. cations and allergies. The Problem- demographics, risk factors, past A dentist colleague of ours once Oriented Medical Record (POMR) history, and objective data gained remarked, “We do the same thing, has proven to be a useful method from the examination.

REVIEW OF OPTOMETRY MARCH 15, 2014 87

087_ro0314_ros.indd 87 3/6/14 4:34 PM Hungry for success?

At Jobson, we have more effective ways for you to reach the optical market than anyone. So our approach to serving clients is unique. First, we develop a thorough understanding of your speciﬁ c goals. This understanding, plus our extensive offering of products and services, enables us to then suggest solutions that will help achieve those goals. This often includes innovative ideas and premium positions. For advertising information contact Michele Barrett (610-492-1014, [email protected]) or Jim Henne (610-492-1017, [email protected]). Let us satisfy your hunger for success.

www.revoptom.com www.revophth.com

The vision to help you succeed

000_ro0711Reviews_Platter.indd 1 6/14/11 11:04 AM Review of Systems

Review of Systems2,3

The ROS can be applied as a head-to-toe, comprehensive screening tool asked of every patient, as additional questions asked only of patients who fall in particular risk categories, or as a means to describe the likely causes of a presenting symptom.

Below are the various organ systems and corresponding ROS. Keep in mind that these are just the more common symptoms and not an exhaustive list.

Constitutional: weight loss or gain, general state of health, wellbeing, and strength

Endocrine: polydipsia, polyuria, hormone therapy, intolerance to heat or cold, weight changes

Integumentary: hair loss, skin eruptions/rashes/growths, sores that grow and/or don’t heal, lesions changing in size, shape or color, itching

Immunology: reactions to drugs, food, insects, skin rashes, trouble breathing, anemia, bleeding tendency, lymph node enlargement/tenderness

Musculoskeletal: joint pain, swelling or redness, muscle ache, back pain Specific ROS questions can uncover systemtic conditions such as pseudo- Ear/Nose/Throat: pain, mouth sores, change in hearing, poor swallowing, discharge tumor cerebri, pictured here. Respiratory: shortness of breath, chest pain, cough, hemoptysis (coughing up blood), snor- The clinician can then come to ing or stop breathing an informed conclusion about the extent and cause of the patient’s Cardiovascular: chest pain, palpitations, syncope, dyspnea, edema, heart murmurs, vari- symptom(s), and use it to guide cosities their subsequent management. There are few functions of the Gastrointestinal: appetite changes, indigestion/heartburn, abdominal pain, nausea, vomit- human body that operate singu- ing, hematemesis, jaundice, constipation, diarrhea larly, and the visual system is no different. Genitourinary: urgency, frequency, dysuria, nocturia, hematuria, polyuria, unusual urine, It’s just one part of an over- stones, infections, nephritis, hesitancy, incontinence, genital sores, discharge, STD whelmingly complex structure that continually demands our OB/Gyn/Breast: Chronic or past disease, dysmenorrhea, vaginal discharge, postmenopausal insight and attention. bleeding, dysparenia, number and results of pregnancies, breast mass, pain or discharge We owe it to our patients to have a full understanding of how Neurologic: headache, convulsions, paralyses, parathesias, difficulties with memory or these systems interact so we can speech, sensory or motor disturbances, poor muscular coordination (ataxia, tremor), orien- provide them with the best treat- tation (place, time, person) ment and care. ■ Psychiatric: predominant mood, emotional problems, anxiety, depression, previous psychi- 1. Hayes, GM. Medical records: past, present and future. Proc atric care, unusual perceptions, hallucinations AMIA Annu Fall Symp. 1996:454-8. 2. Swartz MH. Review of Systems. In: Swartz Textbook of Physical Diagnosis: History and Examination. 4th ed. Philadel- Hematology/Oncology: chronic/past hematologic/oncologic disease, abnormal bleeding/ phia, PA: WB Saunders; 2002. 3. Bickley L. Review of Systems. In: Bates’ Guide to Physical bruising, new growing lumps/bumps, hypercoaguability Examination. 7th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 1999.

REVIEW OF OPTOMETRY MARCH 15, 2014 89

087_ro0314_ros.indd 89 3/6/14 4:35 PM Retina Quiz

No Complaint, No Problem. Right? This relatively asymptomatic patient was referred for a retinal evaluation. Will an underlying condition threaten her vision in the near future? By Mark T. Dunbar, OD

38-year-old Hispanic female deep and quiet chamber OU. Addi- b. Tapetoretinal. presented at the request of tionally, she exhibited normal irides c. Infectious. Aher primary care optom- and clear lenses. d. Metabolic. etrist. Her eye doctor became Dilated fundus exam showed a concerned when he evaluated her clear vitreous. Both optic nerves 2. What do the small focal retina, and told her that she needed were healthy, with small cups and changes seen on the magnified fun- to see a retina specialist. good rim coloration and perfusion. dus view represent? Her ocular history was sig- The maculae appeared normal with a. Drusen. nificant for myopia. She reported a positive foveal light reflex OU. b. Crystals. seeing well with daily disposable However, located just outside c. Calcium. contact lenses. Her medical history each macula, we saw peculiar reti- d. Lipofuscin. was unremarkable. nal pigment epithelial (RPE) chang- Her best-corrected visual acuity es that extended along the superior 3. What is the correct diagnosis? measured 20/20 OU at distance and inferior arcades OU. We took a. Retinitis pigmentosa. and near with a small myopic cor- wide-field fundus images of both b. Stargardt disease. rection. Ocular motility testing was eyes (figures 1 and 2), as well as c. Cone dystrophy. normal OU. Confrontation visual captured a magnified view along d. Bietti crystalline dystrophy (BCD). fields were full to careful finger the superior arcade OD (figure 3). counting. Her pupils were equally 4. Which principal symptom round and reactive, with no evi- Take the Retina Quiz should we expect our patient to dence of afferent defect. 1. How would you classify the report? The anterior segment examina- fundus changes in our patient? a. Loss of color vision. tion revealed a clear cornea with a a. Degenerative. b. Night blindness.

1, 2. Our patient’s fundus evaluation revealed obvious changes in both eyes (OD left, OS right). What is the correct diagnosis?

90 REVIEW OF OPTOMETRY MARCH 15, 2014

090_ro0314_rq_final.indd 90 3/4/14 10:19 AM c. Loss of central vision. d. Blurred vision.

5. What testing would help us best follow this patient? a. Fluorescein angiography. b. Visual fields. c. Electroretinogram (ERG). d. Both b and c.

For answers, turn to page 114. Discussion The fundus changes seen in our 3. A magnified view along the right superior temporal arcade. patient are characteristic of a tapetoretinal degeneration––a collective The natural history of BCD some difficulty seeing at night, she term used to define a nonspecific, includes progressive vision loss suggested that it did not affect her hereditary degeneration of the RPE and visual field constriction. It is ability to function properly. and photoreceptors. Consider- important to note that advanced BCD patients should be followed ing that there are several different age is not always a marker for via visual fields and ERG studies. hereditary retinal degenerations, disease severity and/or progression In fact, the clinical grading for BCD which one does our patient have? risk.1 Therefore, it is reasonable to has been directly correlated to ERG One clue can be spotted along suggest that environmental factors findings.1 Patients with RPE atro- the superior and inferior arcade (e.g., dietary intake) may affect phy and intraretinal crystals that where, upon close inspection, you lipid metabolism, or that certain are confined to the posterior pole can observe multiple, fine, refractile genetic variables might influence tend to show lesser disturbances retinal crystals. Given these find- phenotypic disease expression.1,3 in the full-field ERG. Indeed, upon ings, we diagnosed our patient with The gene for BCD has been testing, our patient had an ampli- a rare autosomal recessive condi- localized to chromosome 4q35. tude reduction in rod (within 20% tion––Bietti crystalline dystrophy. Affected individuals often present of the low end of normal), mixed Patients with BCD typically exhibit with several different mutations of rod/cone (less than 30% of the low crystals in the corneal limbus, glis- CYP4V2––a member of the cyto- end of normal) and cone (between tening intraretinal crystals in the chrome P450 family, which codes 40% and 50% of the low end of presence of RPE atrophy, pigment for a 525 amino acid protein.1 The normal) function. Further, visual clumping and choroidal sclerosis.1 CYP4V2 gene may play an active fields showed very slow progression Interestingly, our patient didn’t role in fatty acid metabolism and over a six-year period, with slight have corneal crystals. Nonetheless, has been found in various ocular constriction superiorly (OD > OS). there are several published reports tissues, such as the retina and RPE. of BCD patients who presented Biochemical studies have shown Our patient has done very well with the typical retinal findings, but that patients with BCD typically with this condition. She maintains no evidence corneal crystals.1,2 experience abnormal lipid metabo- excellent visual acuity, and is not Most patients who are diagnosed lism.1 In one investigational study, aware of any associated difficul- with BCD develop visual symptoms BCD patients demonstrated a ties. In fact, she wouldn’t have even by the third decade of life. The dis- reduced capacity to convert fatty known that she had a problem if it ease usually progresses very slowly; acid precursors into omega-3 fatty weren’t for her myopia. ■ however, the exact rate can vary acids and were found to have 1. Lee KY, Kob AH, Aung T, et al. Characterization of Bietti based upon the individual’s genetic absent or nonfunctional fatty acid crystalline dystrophy patients with CYP4V2 mutations. Invest construct. The most commonly binding proteins.2 Ophthalmol Vis Sci. 2005 Oct;46(10):3812-6. 2. Mataftsi A. Bietti’s crystalline corneoretinal dystrophy: a reported symptoms are decreased Our patient was relatively cross-sectional study. Retina. 2004 Jun;24(3):416-26. visual acuity and pronounced night asymptomatic, and still had 20/20 3. Kaiser-Kupfer MI, Chan CC, Markello TC, et al. Clinical biochemical and pathologic correlations in Bietti’s crystalline blindness (nyctalopia). acuity. And while she reported dystrophy. Am J Ophthalmol. 1994 Nov 15;118(5):569-82.

REVIEW OF OPTOMETRY MARCH 15, 2014 91

090_ro0314_rq_final.indd 91 3/4/14 10:19 AM CONTINUE YOUR EDUCATION WITH REVIEW

OUR FLAGSHIP TITLE, REVIEW OF OPTOMETRY, IS THE MARKET’S LEADING RESOURCE FOR ALL OF YOUR OPTOMETRY NEEDS. The Review Group is dedicated to

Review of Optometry is your primary source for ground-breaking the constant growth and education clinical information as well as timely news, market trend information and continuing education programs. of the profession. Review offers

Review of Cornea & Contact Lenses serves as a valuable resource for many different publications and all practitioners and features detailed articles focusing on various fitting methods, solutions and corneal cases. Also available is the Review of services to help enhance your Cornea & Contact Lenses “Annual Contact Lenses & Lens Care” Guide, a yearly publication detailing the newest lenses and lens care products. practice and patient care.

The Review Group’s Ophthalmic Product Guide brings you the newest and most innovative products on the market. Published every February and July, the guide provides concise information about new literature, drugs and equipment designed to help your practice thrive.

The Review Group also offers valuable Continuing Education sessions in both print and online formats, allowing a convenient way for you to earn CE credits. In addition, Review also offers an impressive fleet of free e-newsletters, such as Optometric Physician, the Optometric Retina Society quarterly e-newsletter and the Optometric Glaucoma Society E-Journal so you can keep up to date on breaking news and the latest research online.

On top of these products, the Review Group also spearheads meetings and conferences, bringing together experts in the field and providing a forum for practitioners to earn CE credits and learn from others in the profession. www.revoptom.com

Jobson Medical Information LLC Review Professional Publications Group

2014_ro_tsrad.indd 90 1/8/14 2:41 PM Therapeutic Review

Physician, Heal Thyself? While you were sipping eggnog and listening to Bing last Christmas, I was trying to diagnose and treat my own eye infection. By Alan G. Kabat, OD Photo: Hunter Kabat, Florida Gulf Coast University ir William Osler said, “A physician who treats himself Shas a fool for a patient.” In retrospect, I wish I’d read that quote before last Christmas. I suppose all physicians are guilty of diagnosing and treating themselves to some degree. I’m not talking about performing your own colonoscopy or suturing your own head wound. But here’s a question: Who did your last refraction? I’ll bet the majority of you responded, “I did!” Most of us are probably also guilty of treating our own dry eye or ocular allergy symptoms with samples from the cabinet, rather than seeing a colleague. Of course, there is a limit to what we can do physically, ethically and legally in terms of self- treatment. And then there’s the A self-induced corneal abrasion, reflected in the distorted keratographic mires. limit of common sense––which some of us unfortunately fail to this as one of the key diagnostic it would be a huge imposition recognize before it’s too late. features of the dreaded “pink to ask someone to evaluate me. Hence, my Christmas story. eye.” Besides, I had a few drug samples Facing myself in the bathroom in my medicine cabinet for just A Cornea Carol mirror, I got a good look at my such an emergency. This past December 23, I began red, swollen conjunctiva and— Selecting a bottle of TobraDex to feel a burning sensation in my despite not having a slit lamp for ST (tobramycin 0.3%/dexa- right eye. I was just three days into magnification—confirmed my methasone 0.05%, Alcon), I began my winter break from Southern own preliminary diagnosis. I sub- instilling one drop in my right eye College of Optometry, and was up sequently posted on my Facebook every four hours. In between, I late watching TV. Figuring it was page, “Oh the irony...I’m suffering supplemented with artificial tears just my dry eye/blepharitis and from a wicked case of bacterial every half hour or so, and strived lack of sleep, I went to bed. conjunctivitis!” carefully not to rub my eyes so as I awoke on December 24 with Had this been any other time, to avoid spreading the infection a thick mucus discharge and con- I likely would have asked a col- contralaterally. siderable scratchiness in that eye. I league at SCO to take a look. But Unfortunately, I awoke Christ- actually had to pull my lids apart because this was vacation—and mas morning to find that my left with my fingers, and recognized Christmas Eve, no less—I decided eye was involved as well.

REVIEW OF OPTOMETRY MARCH 15, 2014 93

093_ro0314_tr_final.indd 93 3/4/14 10:23 AM Therapeutic Review

enlisted the aid of my 19-year-old son, Hunter. I was hopeful that his lack of knowledge regarding optometry would curtail any dissenting opinions or management strategies. Arriving at the clinic, I pro- ceeded to instill a drop of 0.5%

Photo: Hunter Kabat, Florida Gulf Coast University proparacaine in my left eye and give my son a crash course in the operation of the Oculus Kerato- graph 5M. Between the two of us, we were able to get a couple of decent images of my left eye, which showed a substantial area of corneal erosion. As the proparacaine began wearing off, I quickly instilled two drops of 5% homatropine and a drop of Durezol (difluprednate, Alcon) to protect against uveitis. I added a drop of Moxeza (moxi- floxacin, Alcon) for good measure Fluorescein-enhanced view of my corneal abrasion. as prophylaxis against a potential bacterial keratitis. Bilateral Burgeoning of TobraDex did not help, either. Finally, I inserted a bandage I immediately began treating Unable to keep my eye open and contact lens approved for over- my left eye with the drops, but miserable with pain, I resorted to night wear. I grabbed a few more the discomfort was twice as severe a bottle of hydrocodone pills that samples of preservative-free arti- as that in my right eye. Realizing I had left over from a prior dental ficial tears, signed out with the that both eyes were now involved procedure. Eventually, sleep and security guard and went home to and there was nowhere else for the opioids overcame the discomfort. sleep. infection to spread, I took solace in knowing that I could now wipe Image Thy Father Resolution––Just Before my eyes without guilt. I awoke on December 26 to find New Year’s And I did. I unabashedly wiped, no improvement in my condition. It took several days for my rubbed and clawed at my left I knew that I needed more urgent cornea to heal. The bandage lens eye with the all vigor that a flea- attention and appropriate therapy. improved my comfort level, but ridden mongrel displays while But, being a Type A personality my vision was noticeably reduced gnawing at his own hindquarters. and the self-proclaimed “world’s and it was impossible to use my And as the irritation and swelling worst patient,” I decided that the iPhone or laptop. I ended up sit- in my right eye improved, the pain only physician in Memphis good ting on a couch in a darkened in my left eye grew more and more enough to diagnose and treat me room, watching (or rather, lis- severe. was…well, me. Formulating my tening to) reruns of “Star Trek” By Christmas evening, I’d plan, I resolved to go to my clinic; and “The Big Bang Theory,” and exacerbated my simple bacterial image my eye; and based on those sleeping a lot. conjunctivitis into something far findings, affect a curative course In total, I wore the bandage lens worse. of action. for about 84 hours, all the while Artificial tears offered little Realizing that I needed an instilling Durezol and Moxeza relief. Doubling up on the dose accomplice to execute this plan, I QID.

94 REVIEW OF OPTOMETRY MARCH 15, 2014

093_ro0314_tr_final.indd 94 3/4/14 10:23 AM Even after the erosion resolved, my vision was not 100%. I experienced monocular diplopia and visual discomfort for another 48 hours until things finally returned to normal. What I recall most about my horrific holiday experience was not only the pain, but also the helplessness of being without functional vision. I’ve managed literally hundreds of abrasions, erosions and even a laceration or two—but it is impossible to fully compre- hend the debilitating distress of a corneal injury until you’ve experienced it firsthand. Beyond that, the sheer torment of having useful vision in just one eye was far more distressing than I’d ever imagined. Although Parasol® I don’t think of myself as a developmental optometrist, I have a newfound respect for the value of binocular vision. As doctors, it’s all too easy for A PERFECT FIT us to isolate ourselves emotionally and think of patients simply in ODYSSEY MEDICAL + BEAVER VISITEC terms of a diagnosis and management plan. But when you’re on the The Odyssey Parasol® Punctal Occluder is now part of other side of the exam chair, you Beaver-Visitec International (BVI), a world leader of trusted literally get a different perspective. ophthalmic brands. Not only is the Parasol® a perfect ﬁ t I’m happy to report that I’ve for your dry eye patients, but combining BVI with the suffered no long-term effects of outstanding success of the Parasol®, continues the tradition my infection or trauma, and that of superior knowledge, products and services. my vision has returned to 20/20 in both eyes. While I wouldn’t want For those of you who depend on a quality product from to live through it again, my ordeal Odyssey Medical, WELCOME TO BVI. did help teach me some valuable Your new ordering information: lessons about myself, and reaf- firmed my dedication to caring for 866-906-8080 the visual welfare of those in need. [email protected] I’m proud to be in a profession www.odysseymed.com like optometry with such a tal- www.beaver-visitec.com ented, capable and compassionate group of individuals. Maybe the next time I have a problem, I’ll ask one of you for help. ■

Beaver-Visitec International, Inc. | 411 Waverley Oaks Road Waltham, MA 02452 USA | BVI, BVI Logo and all other trademarks (unless noted otherwise) are property of a Beaver-Visitec International (“BVI”) company © 2014 BVI

093_ro0314_tr_final.indd 95 3/4/14 10:23 AM 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. Research Review

The Evolution of OCT Optical coherence tomography could help monitor disease progression in neurological disorders, such as MS. By Diana L. Shechtman, OD, and Paul M. Karpecki, OD nce viewed primarily as an brain. It is also a unique CNS struc- Compromised macular thickness instrument for observation ture as it lacks myelin, which allows also has appeared in MS patients of retinal disease, the clini- for direct assessment of the effect of with or without ON. This thinning O 5 cal use of optical coherence tomog- MS injury on axonal integrity. seems to be concentrated at the level raphy (OCT) has been expanded to • ON involves inflammation of of the inner retina—more specifical- include several novel applications in the optic nerve and is strongly asso- ly, at the level of the GCC, where the both ophthalmic and neurological ciated with multiple sclerosis. degree of thinning correlates with settings. For example, the exception- In fact, 30% to 70% of patients the extent of RNFL loss.14-17 al resolution of OCT allows clini- with MS will develop an episode of This could provide further insight cians to quantify the thickness of the ON (it’s the presenting sign in 20% on MS pathophysiology, because retinal nerve fiber layer (RNFL) and to 30% of cases). Almost half of the RNFL and GCC thinning in an eye determine the extent of visual dam- patients with ON have white matter without any prior history of ON age following optic nerve injury. lesions consistent with MS. could be attributed to asymptomatic More recently, OCT resolution The five-year risk of developing episodes of subclinical optic neuritis. also has made it possible to quan- MS is highly contingent on the num- Retrograde trans-synaptical tify the thickness of the ganglion ber of MRI lesions, but also may degeneration or primary neurode- cell complex (GCC) in the macular occur in patients with an absence of generation of the ganglion cells and area. Because GCC provides a direct any lesion.6,7 their axons in the absence of inflam- analysis of the integrity of neuronal mation also has been speculated.2 ganglion cells and ultimately their Associated OCT Findings The latter theory suggests that axons, OCT is increasingly being In patients who present with iso- axon and ganglion cell loss may be used to monitor disease progression lated, unilateral ON attack, optical the result of a direct mechanism of and treatment efficacy in patients coherence tomography indicates MS affecting these ocular CNS neu- with several neurological disorders— that RNFL thickness decreases over rons, which makes it possible to use specifically, multiple sclerosis (MS) a period of months and stabilizes RNFL and macular/GCC thickness and optic neuropathy (ON).1-4 around six to 12 months, with an as markers for disease progression in average of 20% NFL thickness loss MS patients. A Review of MS and ON in the affected eye.8,9 The RNFL and ganglion cells also • MS is a chronic neurodegen- The extent of damage does not may be used as models to study the erative disease with inflammatory appear to be a predictive factor of role and efficacy of neuroprotective demyelination that affects the central MS development, as it is mostly agents in MS care. Furthermore, nervous system (CNS). related to the severity of the attack both RNFL and GCC thinning cor- Currently, there is no definitive and/or the presence of pre-existing relate with visual dysfunction, which cure. Disease management focuses damage secondary to previous optic opens the first window in establish- on prevention of long-term disability nerve head injury.5 ing a structure/function paradigm in by restoring function after attacks Interestingly, RNFL thinning CNS injury. 12,13,17,18 and preventing new flare-ups from often develops bilaterally in MS occurring. patients––not just in the eye affected Diagnostic Applications The retinal tissue is an integral by a unilateral attack. One useful OCT application is part of the CNS, and the RNFL is Moreover, MS patients without to aid in the differential diagno- the most proximal region of the any known episodes of ON in either sis between neuromyelitis optica afferent visual pathway, making it eye also show RNFL thinning in (NMO) and optic neuritis associated an ideal interface to examine the both eyes.2,8,10-13 with MS.

REVIEW OF OPTOMETRY MARCH 15, 2014 97

097_ro0314_rr.indd 97 3/6/14 4:59 PM …REVIEW MEETINGS OF CLINICAL EXCELLENCE

SAVE THESE DATES:

SAN DIEGO, CA May 2-4 ORLANDO, FL June 19-22 MINNEAPOLIS, MN July 17-20 TYSONS CORNER, VA September 12-14 (Washington DC area)

*Approval pending For more information visit www.revoptom.com

2013_newtechflyer_noaruba.indd 1 1/28/14 3:47 PM Research Review

Neuromyelitis optica is a simulta- neous inflammation and demyelination of the optic nerve and spinal cord, which also can affect the brain. Unlike typical optic neuritis associated with MS, management of NMO requires early initiation of immunosuppressive therapy to reduce vision loss and neurological disability, making its early diagnosis crucial. Additionally, NMO patients do not demonstrate RNFL thinning in the non-affected eye. Therefore, it has been suggested that an inter-eye asymmetry in RNFL thickness greater than 15µm three or more months after an ON event should alert the physician to evaluate for NMO-IgG antibody testing to aid in confirming the diagnosis of NMO.19 It’s important to be aware of recent advancements in OCT technology, as it constitutes a useful tool in the comanagement of patients who present with this potentially disabling disease. Periodic OCT screening of MS patients could provide insights on disease mechanisms by attempting to draw distinctions between thinning due to episodic inflammatory events vs. insidious disease progression. ■

This SD-OCT scan of a 43-year-old MS patient shows mild GCIP thinning OU. Thanks to Rim Makhlouf, OD,

instructor at Nova Southeastern Uni- 1997 Nov;49(5):1404-13. Ophthalmology. 2006;113:324–32. versity College of Optometry in Ft. 7. Optic Neuritis Study Group. Multiple sclerosis risk after optic 14. Syc SB, Saidha S, Newsome SD, et al. Optical coherence Lauderdale, Fla., for contributing to neuritis: final optic neuritis treatment trial follow-up. Arch Neurol. tomography segmentation reveals ganglion cell layer pathology 2008;65(6):727-32. after optic neuritis. Brain. 2012;135(Pt 2):521-33. this column. 8. Costello FE, Klistorner A, Kardon R. Optical coherence tomog- 15. Albrecht P, Ringelstein M, Müller AK, et al. Degeneration of raphy in the diagnosis and management of optic neuritis and retinal layers in multiple sclerosis subtypes quantified by optical multiple sclerosis. Ophthalmic Surg Lasers Imaging. 2011 Jul coherence tomography. Mult Scler. 2012;18(10):1422-9. 1. Fujimoto JG, Pitris C, Boppart SA, et al. Optical coherence 1;42(4):S28-40. 16. Davies EC, Galetta KM, Sackel DJ, et al. Retinal Ganglion Cell tomography: an emerging technology for biomedical imaging and 9. Klistorner A, Arvind H, Garrick R, et al. Interrelationship of Layer Volumetric Assessment by Spectral-Domain OCT in MS: optical biopsy. Neoplasia. 2000 Jan-Apr;2(1-2):9-25. optical coherence tomography and multifocal visual-evoked Application of a High Precision Manual Estimation Technique. J 2. Petzold A, de Boer JF, Schippling S, et al. Optical coherence potentials after optic neuritis. Invest Ophthalmol Vis Sci. Neuroophthalmol. 2011;31(3): 260-4. tomography in multiple sclerosis: a systematic review and meta- 2010;51:2770-7. analysis. Lancet Neurol. 2010; 9:921-32. 10. Kallenbach K, Frederiksen J. Optical coherence tomography 17. Saidha S, Syc SB, Durbin MK, et al. Visual dysfunction in mul- 3. Kardon RH. Role of the macular optical coherence tomogra- in optic neuritis and multiple sclerosis: a review. Eur J Neurol. tiple sclerosis correlates better with optical coherence tomography phy scan in neuro-ophthalmology. J Neuroophthalmol. 2011; 2007;14(8):841-9. derived estimates of macular ganglion cell layer thickness than 31:353-61. 11. Parisi V, Manni G, Spadaro M, et al. Correlation between mor- peripapillary retinal nerve fiber layer thickness. Mult Scler. 2011; 4. Costello F, Van Stavern GP. Should optical coherence tomog- phological and functional retinal impairment in multiple sclerosis 17(12):1449-63. raphy be used to manage patients with multiple sclerosis? J patients. Invest Ophthalmol Vis Sci. 1999;40:2520-7. 18. Costello F, Coupland S, Hodge W, et al. Quantifying axonal Neuroophthalmol. 2012; 32(4):363-71. 12. Trip SA, Schlottmann PG, Jones SJ, et al. Retinal nerve fiber loss after optic neuritis with optical coherence tomography. Ann 5. Costello F. Evaluating the Use of Optical Coherence Tomogra- layer axonal loss and visual dysfunction in optic neuritis. Ann Neurol. 2006; 59(6):963-9. phy in Optic Neuritis. Mult Scler Int. 2011;2011:148394. Neurol. 2005;58:383–91. 19. Ratchford JN, Quigg ME, Conger A, et al. Optical coherence 6. Optic Neuritis Study Group. The 5-year risk of MS after optic 13. Fisher JB, Jacobs DA, Markowitz CE, et al. Relation of visual tomography helps differentiate neuromyelitis optica and MS optic neuritis. Experience of the optic neuritis treatment trial. Neurology. function to retinal nerve fiber layer thickness in multiple sclerosis. neuropathies. Neurology. 2009; 73(4):302-8.

REVIEW OF OPTOMETRY MARCH 15, 2014 99

097_ro0314_rr.indd 99 3/6/14 4:59 PM Product Review

Dry Eye didates who complain of poor night vision. Nighttime Relief Visit www.global.topcon.com. Patients who suffer from severe dry eye may find nighttime comfort and relief with Retaine PM, a Online interface preservative- Upgraded and User-Friendly free, oil-based Next time you log on to SpecialEyes, you can navi- formula by gate to the Learning Center to access a prescribing OcuSoft. nomogram, custom contact lens fitting guides, hori- Retaine PM zontal visible iris diameter measuring, optical zone is packaged in assessment tips and other useful tools. an economical In addition to the website upgrade, the site offers 5-gram tube, an Arc Length Calculator to accurately calculate arc offering 43% length of the cornea and an Over-Refraction Calcula- more than the tor, which determines the resultant prescription after traditional 3.5 a successful in-office over-refraction is performed. grams. Retaine Visit www.specialeyesqc.com. PM joins a growing line Lenses of branded eye Wrap it Up care products If you’ve been in the market for wrap frames for OcuSoft, to offer in your dispensary, add Zeiss Progressive including artificial tears and nutritional supplements. Choice Plus Visit www.ocusoft.com/retaine. Sport to your list of lens Autorefraction choices. Zeiss Get Refined has extended Add subjective visual acuity testing to refine a its line of patient’s measurements with Topcon’s KR 800S lenses to Auto Kerato-Refractometer with Subjective and include those Glare Testing. specifically The designed for new 5-in-1 wrap frames. KR-800S Zeiss says incor- the Choice porates Plus Sport Topcon’s design Rotary combines Prism tech- advanced customization for the patient’s full pre- nology for scription with its unique prism compensation accuracy method. This combination widens the area of and con- clear vision by as much as 50% over standard lens sistency designs in wrap frames, while dramatically reducing and adds unwanted prism, the company says. on Subjec- Visit www.vision.zeiss.com. tive Visual Acuity Eyewear testing for good measure. Sun Collection Check for near and far distance, contrast sensitiv- Ready for summer? So is Moscot. They’ve ity and have access to a grid and glare test. These pumped-up four selections from their Moscot Origi- tools are particularly useful for cataract surgery can- nals collection to create the Governor, Randall, Ellis

100 REVIEW OF OPTOMETRY MARCH 15, 2014

100_ro314_products.indd 100 3/6/14 11:14 AM and Staten—all infused with rich custom color lenses with lightweight acetate and aluminum elements and perfect for summer eyewear. wood trim. The company describes the Ellis as chunky and Visit www.rye-lye.it. aggressive and the Governor as striking and hefty. As for the Randall and Staten, they are tricked out and Cool Collection full of glamour, respectively. Although best Visit www.moscot.com. known for high-performance sunglasses Cleopatra and goggles for skat- Exotic woods are ers, surfers and snow- the main feature of boarders, Arnette has Rye & Lye’s new now branched out collection from with a frame line that Italy. The line fea- offers a cool-vibe collection for prescription eyeglass tures “Cleopatra,” a wearers. woman’s frame with a Most of Arnette Optical’s line features unisex 1950s chunky cat-eye. frames like the “Dub,” a statement model that comes The company claims the curves of the temples were in black, striped Havana, black and grey horn, or specifically designed to enhance the natural grain of blue ice. Other styles follow a rock-star theme: the exotic wood. Roadie, Auxiliary, Mixer, Lo-Fi, Sync, Fader, and Other eyewear in the collection includes the Frontman. butterfly-shaped Ermione and the Edgar for men, Visit www.Arnette.com. ■

100_ro314_products.indd 101 3/6/14 10:59 AM CE COURSE TOPICS: Ocular Manifestations of Systemic Disease Glaucoma Management Ocular Surface Disease Innovations New Technologies in Eye Care Advances in Contact Lenses Surgical Comanagement Pearls Posterior Segment Grand Rounds Lightning Rounds in Anterior Segment Disease Hilton La Jolla, Torrey Pines Faculty: Paul Karpecki, OD (Program Chair) Jeffry D. Gerson, OD Ron Melton, OD Randall K. Thomas, OD REGISTER 5 WAYS TO REGISTER: NOW! ONLINE: www.revoptom.com/SD2014 EMAIL Lois DiDomenico: [email protected] MAIL: Review Group Meetings c/o Jobson 11 Campus Blvd., Ste. 100 Newtown Square, PA 19073 PHONE: 866-658-1772 FAX: 610-492-1039

*Approval Pending

0514_sandiego_printspreadSPONSORS.indd 1 2/28/14 12:12 PM HILTON LA JOLLA, TORREY PINES Discounted Room Rate: $179/night For reservations, call: 800-445-8667 Discounted room rates limited. Identify yourself as a participant of “Review of Optometry” for group rate. Room rates available 3 days pre/post conference.

Registration Information

Name License # (License numbers are now required for HCP reporting and will only be used for this purpose.)

Practice Affiliation

Mailing Address City State Zip Code

Telephone Fax Email

Name Badge Information (please print clearly)

My Name My Guest Additional Guests

Payment Information Rate per person No. in party Subtotal OD Registration - $495 $495 x ______= $______(includes 15 hours of CE, breakfasts, reception) Call for daily rates. Additional Guest(s) - $45 (12 years and older, includes reception) $45 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 April 2, 2014 Cardholder (print name) • 50% refund on registration fee until April 21, 2014 • No refund past April 21, 2014 Signature

For more information or to register, contact Lois DiDomenico at 866-658-1772 or at [email protected]. *Approval pending

0514_sandiego_printspreadSPONSORS.indd 2 2/28/14 12:12 PM Meetings + Conferences

March 2014 ■ 4-6. NOA Spring Conference. Embassy Suites Downtown/Old ■ 22-23. Spring Conference. Nova Southeastern University Ft. Market, Omaha, Neb. CE hours: 16. Contact Alissa Johnson at Myers Campus, Ft. Myers, Fla. Hosted by: Nova Southeastern (402) 474-7716. Visit www.nebraska.aoa.org/springconference. University. Contact [email protected]. Visit http://optometry. ■ 11-13. New Mexico Optometric Association Annual nova.edu/ce/index.html. Convention. Isleta Resort, Albuquerque, N.M. Hosted by: New ■ 26-30. Vision Expo East. Javits Center, New York. Hosted by: Mexico Optometric Association. CE hours: 22. Email Richard International Vision Expo. Visit www.visionexpoeast.com. Montoya at [email protected] or call (575) 751- ■ 27-29. OAOP Annual Spring Congress. Embassy Suites 7242. Visit www.newmexicooptometry.org. Hotel and Conference Center, Norman, Okla. Hosted by: ■ 12-13. 2014 MOS Primary Care Spring Symposium. Oklahoma Association of Optometric Physicians. Key faculty: Cincinnati Marriott Northeast, Mason, Ohio. Hosted by: The Walt West, OD, Blair Lonsberry, OD, David Talley, OD, Larry MidWest Optometric Society and The Ohio State University Henry, OD, Jason Ellen, OD, Chad Chamberlain, DO, Joyce College of Optometry. Contact Marci at (513) 321-2020. Visit Ardrey, CPC. CE hours: 18. Contact Heatherlyn Burton at heath- www.midwestoptometricsociety.com. [email protected]. Visit www.oaop.org. ■ 12-13. Symposium on Ocular Disease 2014. Crowne Plaza, ■ 29-30. Conference on Comprehensive EyeCare 2014. Tyson’s Corner, Virg. Hosted by: PSS EyeCare. Key Faculty: Sheraton Hotel, Niagara Falls, NY. Hosted by: PSS EyeCare. Joseph Sowka, OD, Murray Fingeret OD, Deepak Gupta, OD, Key Faculty: Joseph Sowka, OD, Paul Ajamian, OD, Anthony and Robert Rebello. CE hours: 18. Email Sonia Kumari at educa- Litwak, OD, Deepak Gupta, OD, and Robert Rebello. CE hours: [email protected]. Visit www.psseyecare.com. 18. Email Sonia Kumari at [email protected]. Visit ■ 23-27. American Academy of Optometry-New Jersey www.psseyecare.com. Chapter. Kingston Plantation, Myrtle Beach, SC. Hosted by: New Jersey Chapter. Key faculty: Randall Thomas, OD, Ron Melton, April 2014 OD, Marc Blumenstein, OD. CE hours: 16. Email Dennis Lyons, ■ 3-6. OptoWest 2014. Esmeralda Hotel, Indian Wells, Calif. OD, [email protected], or call (732) 920-0110. Hosted by: California Optometric Association. Key faculty: Marc ■ 24-26. Mountain West Council of Optometrists Annual Bloomenstein, OD, Sharon Carter, ECOC, Melissa Chun, OD, Congress. Caesars Palace, Las Vegas. Hosted by: MWCO. CE Laurie Guest, CSP, Lynn Hellerstein, OD, FCOVD, Richard Hom, hours: 24. Call 1-888-376-6926. Visit www.mwco.org. OD, MPA. CE hours: 40+. Email Rachael Van Cleave at con- ■ 24-26. 59th Annual Education Meeting. Hilton Savannah [email protected]. Visit www.coavision.org. DeSoto, Savannah, Ga. Hosted by: Contact Lens Society of America. Key faculty: Patrick Caroline, FAAO, Craig Norman, April 3-6, Atlanta FCLSA, Michael Ward, FCLSA, Jason Jedlicka, OD, Brooke 2014 Optometric Business Conference Messer, OD, Edward Bennett, OD, Stephen Byrnes, OD. CE An international Fulbright Scholar and expert on age-related hours: 22. Email Tina Schott at [email protected] or call (703) macular degeneration, a chief economist with Morgan 437-5100. Visit www.clsa.info. ■ Stanley and a leading authority on the Affordable Care 24-27. KOA 2014 Spring Congress. Hyatt Hotel & Lexington Act are just a few of the presenters who will be at the 2014 Convention Center, Lexington, Ky. Hosted by: Kentucky Optometric Business Conference, presented by Independent Optometric Association. CE hours: 21. Email Sarah Unger at Doctors of Optometric Care (IDOC). The conference, held [email protected] or call (502) 875-3516. Visit www.kyeyes.org. ■ from April 3-6 at the Loews Hotel in Atlanta, will include ses- 24-27. Arkansas Optometric Association Spring Convention. sions on financial management, legal issues, health care The Peabody, Little Rock, Ark. Hosted by: Arkansas Optometric reform, reputation management, and several CE and ABO- Association. Email [email protected]. Visit www. certified sessions for ODs and their staff. arkansasoptometric.org. ■ All independent ODs and staff are offered refundable reg- 25-27. 2014 Annual CE Symposium. Renaissance O’Hare, istration of up to $200 through March 17. Chicago, Ill. Hosted by: The Optometric Society and Optometric The conference is part of CE and business management CE. Key faculty: James Fanelli, OD, Ernie Bowling, OD, Robert education programs held throughout the year by IDOC, the Rebello, Steven Newman, OD. CE hours: 14. Email Joel fastest-growing alliance for independent eye care practitio- Rothschild at [email protected]. Visit www.optometricce. ners in the country. In addition to premier business manage- org. ■ ment education, IDOC offers discounts and rebates from 26-27. 22nd Annual Suncoast Seminar. Hyatt Regency more than 65 leading companies in the industry. Clearwater Beach Resort and Spa, Clearwater, Fla. Hosted by: Visit www.idoc.net or call 203-853-3333 for information. Pinellas Optometric Association. CE hours: 14. Email idoc1@aol. com or call (727) 446-8186. Visit www.optometricce.org.

104 REVIEW OF OPTOMETRY MARCH 15, 2014

104_ro0314_m&c.indd 104 3/6/14 4:48 PM Advertisers Index

May 2014 For advertising opportunities contact: ■ 2. Berkeley Glaucoma Day - 2nd Annual. DoubleTree Michelle Barrett (610) 492-1014 or [email protected] Hotel, Berkeley Marina, Berkeley, Calif. Hosted by: University James Henne (610) 492-1017 or [email protected] of California, Berkeley, School of Optometry. Email optoCE@ Scott Tobin (610) 492-1011 or [email protected] berkeley.edu. Visit awww.aoa.org/events/ucb-glaucoma-day. ■ 2-3. Educational Meeting 2014. Mission Inn, Howey-in-the- Alcon Laboratories ...... 14, 21 Optos North America ...... 59 Hills, Fla. Hosted by: Florida Chapter of the American Academy ...... 25, 29, 30, 116 Phone ...... (877) 455-8855 x 100 of Optometry. Featured speakers: Leo Semes, OD, Albert Phone ...... (800) 451-3937 Fax ...... (508) 486-9310 Fax ...... (817) 551-4352 Woods, OD, and Tim Underhill, OD. CE hours: 10. Contact Reichert Technologies ...... 23 Arthur T. Young, OD, at [email protected]. Allergan, Inc...... 17, 41, 42 Phone ...... (888) 849-8955 ■ 2-4. CE in Italy. Rome, Italy. Hosted by: James Fanelli, Phone ...... (800) 347-4500 Fax ...... (716) 686-4545 OD. Key faculty: Joe Pizzimenti, OD, Carlo Pelino, OD, James www.reichert.com Fanelli, OD. CE hours: 12. Contact James Fanelli, OD, at james- Bausch + Lomb ...... 47, 48 [email protected] or call (910) 452-7225...... 65, 66 Reliance Medical ...... 9 ■ 2-4. May Annual Eye Care Conference & Alumni Reunion. Phone ...... (800) 323-0000 Phone ...... (800) 735-0357 Nova Southeastern University, Ft. Lauderdale, Fla. Hosted by: Fax ...... (813) 975-7762 Fax ...... (513) 398-0256 Nova Southeastern University. Key faculty: Carlo Pelino, OD. CE hours: 18. Contact Vanessa McDonald at [email protected] Coburn Technologies ...... 11 S4OPTIK ...... 39 or call (954) 262-4224. Phone ...... (800) 262-8761 Phone ...... (888) 224-6012 www.coburntechnologies.com ■ 4-8. ARVO Annual Meeting. Orange County Convention Sauflon ...... 12-13 Center, Orlando, Fla. Hosted by: ARVO. Email [email protected]. CooperVision ...... 115 Phone ...... (800) 682-3240 ■ 7-8. 118th Annual Meeting and Spring Seminar. DeVos Phone ...... (800) 341-2020 Fax ...... (800) 644-3622 Place, Grand Rapids, Mich. Hosted by: Michigan Optometric [email protected] Association. CE hours: 12. Contact Amy Root at amy@themoa. Diopsys ...... 7 SauflonUSA.com org or call (517) 482-0616. Phone ...... (973) 244-0622 ■ 10-19. AEA Cruises Mediterranean Cruise Seminar. Athens [email protected] Sucampo Pharmaceuticals, Inc. to Venice. Hosted by: AEA Cruises. Key faculty: Louise www.diopsys.com ...... 53, 54 Sclafani, OD, Mark Roanova, OD. CE hours: 12. Contact Marge Phone ...... +01-301-961-3400 McGrath at [email protected] or call (888) 638-6009. Essilor of America ...... 26-27 Fax ...... +01-301-961-3440 ■ 29-31. Oregon’s Meeting. Bend Riverhouse Hotel and www.essilorusa.com [email protected] www.sucampo.com Conference Center, Bend, Ore. Hosted by: Oregon Optometric Keeler Instruments ...... 5 Physicians Association. Key faculty: Jane Weissman, MD, Phone ...... (800) 523-5620 Think About Your Eyes ...... 33 Thomas Hwang, MD, Greg Kaultz, OD, Ryan Bulson, OD, Mark Fax ...... (610) 353-7814 Andre, FAAO. CE hours: 11. Contact Lynne Olson at lynne@ Tomey ...... 51 oregonoptometry.org or call (800) 922-2045. Lacrivera ...... 18 Phone ...... (888) 449-4045 Phone ...... (855) 857-0518 www.tomeyusa.com June 2014 www.lacrivera.com ■ 8. Resident Forum. US Berkeley Campus, Berkeley, Calif. Transitions Optical ...... 35 Hosted by: University of California, Berkeley, School of Lombart Instruments ...... 63 Phone ...... (800) 848-1506 Optometry. CE hours: 8. Email [email protected] or call Phone ...... (800) 446-8092 Fax ...... (813) 546-4732 (510) 642-8802. Visit optometry.berkeley.edu/ce/introduction. Fax ...... (757) 855-1232 Vision Source ...... 83 ■ 13-14. Northwest Residents Conference. Jefferson Hall M&S Technologies ...... 45 Phone ...... (281) 312-1111 on Pacific University Campus, Forest Grove, Ore. Hosted by: Phone ...... (877) 225-6101 Fax ...... (281) 312-1153 Pacific University College of Optometry. CE hours: 10. Email Fax ...... (847) 763-9170 www.visionsource.com Martina Fredericks at [email protected] or call (503) 352- 2207. Visit www.pacificu.edu. Oculus, Inc...... 61 Vistakon ...... 2-3, 85 Phone ...... (888) 284-8004 Phone ...... (800) 874-5278 To list your meeting, please send the details to: Fax ...... (425) 867-1881 Fax ...... (904) 443-1252 Erin Kelly, Senior Associate Editor Email: [email protected] This advertiser index is published as a convenience and not as part of the advertising contract. Every Phone: (610) 492-1005 care will be taken to index correctly. No allowance will be made for errors due to spelling, incorrect page number, or failure to insert.

REVIEW OF OPTOMETRY MARCH 15, 2014 105

104_ro0314_m&c.indd 105 3/6/14 4:53 PM 19TH ANNUAL OPHTHALMIC PRODUCT GUIDE Innovative products to enhance you 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/supplement_toc/s/259/ Download a QR scanner app. Launch app and hold your mobile device over the code to view http://www.revoptom.com/supplement_toc/s/259/.

2014_opg_ad_fullpge.indd 1 1/27/14 11:09 AM Review Classiﬁ eds

Equipment and Supplies / Merchandise Offered

It’s What the Best Pretest on! (800) 522-2275 www.optinomics.com [email protected] www.eyewear4less.com EVERYDAY LOW PRICES - HUGE SELECTION “Per UOMO” FACTORY DIRECT ITALIAN EYEWEAR BRAND NAME OVERSTOCKS, CLOSE-OUTS & SPECIALS Place Your Ad Here! “YOUR PRACTICE YOUR PROFIT” Toll free: 888-498-1460 800-762-0480 E-mail: [email protected]

REVIEW OF OPTOMETRY MARCH 15, 2014 107

ROPT0314.indd 107 2/20/14 8:47 PM Review Classiﬁ eds

Merchandise Offered

SPACE PLANNING INTERIOR DESIGN DISPLAY INNOVATION MANUFACTURING PROFIT BY DESIGN VISIT US SECO BOOTH 1235 VEE BOOTH 4741 WWW.EYEDESIGNS.COM 800.346.8890

FEATURES OF FLOT™ NEW

& - iÛiÃÃ>«Ì«>VivÀ>ÃiVÕÀiwÌ

& ÀÕÃ i`V ÀiwÃ

& Can be used with a variety of materials TM & Flot plugs can be used on solid or lucite panels

& Clean linear look, no frame holders

& Optional LED lighting to edge light shelves

& Interchangeable accessories from case VISIT US AT VEE holders, signage and merchandising hooks BOOTH 4735

Equipment and Supplies Practice For Sale 1HZ,OOXPLQDWHG1HDU&DUGV PRACTICE SALES & APPRAISAL Featured Practices for Sale FLORIDA - OCALA Thriving family-oriented practice grosses $500,000+, open only 4 days per week. High Net Income. Freestanding building with excellent visibility. Fully equipped office includes OCT and patternless edger. TEXAS - FORT WORTH SUBURB 35 years practice consistently grossing $470,000 annually, netting $160,000+ 2,000 sq.ft. freestanding with two fully $GDSWHU equipped exam lanes. 7KHVHZLOOEHWKHODVW1HDU&DUGV 0DQ\LOOXPLQDWHGFDUGVDQGLQVHUWV TENNESSEE - CHATTANOOGA DUHDYDLODEOH \RX OOHYHUEX\ Grossing $400,000+/yr and exhibiting 6ORDQ/HWWHU$PVOHU*ULG/HD1XPEHU 1HYHU\HOORZV$OZD\VEULJKW consistent growth. Beautifully designed /HD6\PERO/DQGROW&+2791HDU( 3ULQWZLOOQHYHUZHDURII office with updated equipment and EMR. 0HWHU/HWWHU0HWHU1XPEHU 8VHWRHPXODWHDFRPSXWHUVFUHHQDWQHDU Great upscale location. :HOOSURWHFWHGLQDUXEEHUL]HGVXUHJULSIUDPH 3KRURSWHU$GDSWHUVROGVHSDUDWHO\ FLORIDA-PALM BEACH COUNTY Grossing $450,000 in 2012. Beautifully designed office. EMR system in place. Priced to Sell.

6LWHVHDUFKWR9LVLWRXU1(:ZHEVLWHIRURXUH[WHQVLYHSURGXFWRIIHULQJV 100% FINANCING AVAILABLE (800) 416-2055 Do you have Equipment www.TransitionConsultants.com and Supplies for Sale?

Contact us today for classified advertising: Toll free: 888-498-1460 • E-mail: [email protected]

108 REVIEW OF OPTOMETRY MARCH 15, 2014

ROPT0314.indd 108 2/20/14 8:47 PM Review Classiﬁ eds

Storage and Design / Practice For Sale / Products and Services / Software

Continuing Medical Education

American Academy of Optometry New Jersey Chapter 12th Annual Educational Conference April 23-27, 2014 Myrtle Beach, South Carolina Hilton Embassy Suites at Kingston Plantation Randall Thomas, OD., F.A.A.O. 16 HOURS Ron Melton, OD., F.A.A.O. CO EP CE Marc Bloomenstein, OD, F.A.A.O. Registration: $475.00 One, Two or Three Bedroom Suites Accommodations Include a Daily Breakfast Buffet and Evening Cocktail Reception PACK YOUR CLUBS! Golf details to follow. For Accommodation and Additional Information, contact: Dennis H. Lyons, OD, F.A.A.O. Phone: (732) 920-0110 E-Mail: [email protected] QUIKEYES ONLINE

WEB-BASED OPTOMETRY EHR Practice Sales • Appraisals • Consulting www.PracticeConsultants.com • $99 per month after low cost set-up fee • Quick Set-Up and Easy to Use PRACTICES FOR SALE • No Server Needed NATIONWIDE • Corporate and Private OD practices Visit us on the Web or call us to learn • 14 Day Free Demo Trial more about our company and the • Users Eligible for 44K incentives practices we have available. www.quikeyes.com [email protected] Place Your Ad Here! Toll free: 888-498-1460 800-576-6935 E-mail: [email protected] www.PracticeConsultants.com

REVIEW OF OPTOMETRY MARCH 15, 2014 109

ROPT0314.indd 109 2/20/14 8:48 PM Review Classiﬁ eds

Continuing Education Professional Opportunities OPTOMETRISTS WANTED

HealthDrive Eye Care Group provides optometric care to very deserving elderly patients residing in nursing homes and assisted living facilities. We currently have the following positions available: POSITION LOCATIONS AND DETAILS: Location: Harrisburg, PA • Part-Time, 2-3 Days a Week • Typical Hours: 8am or 9am to 3pm • Full Malpractice Coverage • Excellent Revenue Potential • Clinical Autonomy • Requires EMR/EHR Documentation Location: Hartford, CT • Full-Time, 5 Days a Week • Typical Hours: 8am or 9am to 3pm • Full Benefits including Dental and 401K • Full Malpractice Coverage • Generous Six Figure Revenue Potential!! • Requires EMR/EHR documentation • Requires Glaucoma Certification

Join our practice and benefit from our management expertise and commitment to quality care.

Please contact Tanya Jones at 857-255-0293 or [email protected] if you are interested in hearing more about our opportunities.

HealthDrive is an Equal Opportunity Employer.

YOU SEE PATIENTS, OCULAR SYMPOSIUM WE DO THE REST! Lectures in Ocular Diagnosis and Treatment +PJO$POOFDUJDVUT &ZF)FBMUI7JTJPO1SPWJEFS Formal Lectures for Optometrists by Noted Subspecialists in Ophthalmology

Friday, Saturday, Sunday, May 30, 31 and June 1, 2014 24 hours CE credits (8 hours each day) SAN FRANCISCO, CALIFORNIA

TOPICS TO INCLUDE t 'VMMBOE1BSU5JNF Refractive Surgery Uveitis Cataract Surgery t 'MFYJCMFTDIFEVMFT Neuro-Ophthalmology Glaucoma Pediatrics t Oculoplastics Retina Systemic Medication 0QQPSUVOJUJFTJO 'BJSĕFME/FX)BWFODPVOUJFT For information call or write: t MPDBUJPOićSFF0wQSBDUJDF 0DVMBS4ZNQPTJVNt10#PYt4BO'SBODJTDPt$"t t t'"9 +PJOBUISJWJOHQSBDUJDFPG FNBJMPDVMBSTZNQ!BPMDPN 0%T.%T BOETVSHJDBMDFOUFST

CONTACT /BODZ/PMMt0QUJ$BSF 1$ Do you have Equipment (SBOEWJFX"WFt8BUFSCVSZ$5 and Supplies for Sale? OOPMM!PQUJDBSFQDOFUt'BY 

Contact us today for classified advertising: Toll free: 888-498-1460 E-mail: [email protected]

110 REVIEW OF OPTOMETRY MARCH 15, 2014

ROPT0314.indd 110 2/20/14 8:48 PM Review Classiﬁ eds

Professional Opportunities Business Opportunities

Earn Passive Income with

Anchorage, AK Individually Designed FULL TIME OPTOMETRIST Full time Optometrist opening with Alaska’s premier Supplement Program eye care practice – Alaska Eye Care Centers, APC. A privately owned, two location practice with 7 doctors is seeking a new graduate or experienced O.D. for • No Inventory or Selling Required employment or potential partnership opportunity. • Free Personal Health Assessment Each location has 4-5 full exam rooms and the appropriate equipment, special testing equipment, • c-GMP Pharmaceutical Grade Supplements optometric pre-testers, and full administrative support. The main office offers full lens manufacturing for both locations. Each office has optical dispensaries consisting Our free online Personal Health Assessment of over 2,500 frames and is serviced by licensed opticians. In addition, each office has full contact lens designs a custom nutrient program for your services, including licensed CL technicians. patient based on lifestyle, family/medical history, This opening is for both locations. Wasilla is a semi-rural current medications as well as the latest medical setting approximately 40 miles from Anchorage, Alaska. The population of the surrounding area is 50,000 and research. Supplements are then shipped directly most services are offered. Housing and utilities are to your patient in convenient, personalized AM comparable to West Coast levels. Entertainment, fine dining and the arts are easily available in Anchorage, a and PM packages. city of more than 298,000 residents. Alaska is one of the most beautiful places to live and practice. For further information, please contact: Email ALASKA EYE CARE CENTERS [email protected] 1345 W. 9th Avenue, Anchorage, AK. 99501 Contact: Deb Foster, Administrator for more information. [email protected] (907) 272-2557 X 1604 • (907) 274-4932 (Fax)

Software

OPTOMETRIST NEEDED

HealthDrive Eye Care Group is a mobile, non-surgical healthcare company that provides the highest standard of ancillary medical care to the elderly residents of extended care facilities. We offer dignified, on-site services in dentistry, optometry, podiatry and audiology. We have a part time optometry position available (2 days/week) to cover the North Shore areas of Massachusetts.We offer very flexible schedules, 100% paid malpractice insurance, mileage reimbursement and established patient base. If you are looking for a rewarding, compassionate job with great pay and flexible schedules then HealthDrive is the perfect job for you!! If you are interested please call Corinne Lord at 857-636-1878 or email a copy of your CV to [email protected]. New grads and retired optometrists are welcome to apply!!

Contact us today for classified advertising: Toll free: 888-498-1460 E-mail: [email protected]

REVIEW OF OPTOMETRY MARCH 15, 2014 111

ROPT0314.indd 111 2/20/14 8:48 PM Surgical Minute By Derek N. Cunningham, OD, and Walter O. Whitley, OD, MBA Let There Be Light Laser surgery for glaucoma—perhaps overlooked today—still plays an important role.

laucoma patients, and their anesthesia. A Goldmann, three-mir- doctors, have much cause ror gonio lens is placed on the eye Gfor optimism in 2014. with methylcellulose and the aiming Many patients can be managed with beam is focused onto the pigmented nothing more than a once-daily trabecular meshwork. Next, the topical drug. For those who need non-thermal laser is applied using more robust IOP lowering, we have short pulses of relatively low energy a broad swath of surgical options, with a larger spot size to target and from the emerging “minimally irradiate only the melanin-rich cells invasive” class to mainstays like The surgeon uses a gonio lens to visual- in the trabecular meshwork. trabs and tubes. Advanced technol- ize the trabecular meshwork during SLT. Treatment is done in single-burst ogy, most notably OCT, provides mode, placing about 50 contiguous insights into disease progression ALT was evaluated in the NEI’s but not overlapping 400µm laser that would have been unheard of a Glaucoma Laser Trial (GLT), spots along 180 degrees. The prin- generation ago, and our burgeon- which compared the procedure’s ciple of selective photothermolysis ing clinical proficiency has allowed safety and long-term efficacy with enables the laser to precisely target glaucoma management to become that of standard medical therapy intracellular melanin granules to routine in optometric practice. for primary open-angle glaucoma. activate individual cells without Despite this renaissance in glau- Eyes treated initially with ALT had disturbing adjacent non-pigmented coma care, the role of patient com- 1.2mm Hg greater IOP reduction, cells. The activated cells release pliance and adherence cannot be 0.6db greater visual field improve- cytokines that trigger a targeted overlooked. Non compliance and ment and better optic disc status macrophage response to the tra- non-adherence rates, reported to than fellow eyes treated initially becular meshwork cells. The mac- be at least 25%, continue to under- with topical medication. Although rophages reactivate the meshwork, mine our best efforts. Common this trial evaluated argon laser treat- reducing fluid outflow resistance reasons include inconvenience, for- ment, modern-day glaucoma laser and lowering intraocular pressure. getfulness, cost and side effects of surgery has largely migrated to The procedure takes about five medications. selective laser trabeculoplasty (SLT) minutes per eye, is relatively pain- and micropulse laser trabeculo- less and there are no restrictions Burning Questions plasty due to their comparable IOP afterwards. Postoperatively, patients Can laser trabeculoplasty match lowering efficacies, but with less are prescribed topical NSAIDs or beat the results of medical ther- damage/scarring and better repeat- or steroids for one week. Clinical apy, while also reducing the impact ability. improvement may take one to three of noncompliance? SLT is an outpatient procedure, months to manifest. Argon laser trabeculoplasty performed with a laser-equipped Benefits of SLT include proven (ALT), introduced in the 1970s, can slit lamp. The energy is produced efficacy as primary, adjunctive or lower IOP by about 25% to 30%. by a specially designed Q-switched, repeat therapy; lack of systemic side Though the exact mechanism still frequency-doubled Nd:YAG laser effects; protection of the trabecular is not known, the laser energy may operating at a 532nm green wave- meshwork; reduced drug costs and have multiple effects on the trabecu- length, with a potential output of improved compliance. Potential side lar tissue, including a mechanical 0.3 to 1.5 millijoules. effects include post-op inflamma- effect from scar formation at the Preoperatively, the patient is tion and IOP spike, which can be burn sites and biologic changes in given one drop of either apracloni- controlled with topical meds. ■ the trabecular endothelial cells. dine or brimonidine, plus topical References available upon request.

112 REVIEW OF OPTOMETRY MARCH 15, 2014

112_ro0314_surgical.indd 112 3/6/14 5:18 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.revoptom.com/continuing_education

Download a QR scanner app. Launch app and hold your mobile device over the code to view www.revoptom.com/continuing_education.

2013_ce_housead_ad.indd 1 5/30/13 3:57 PM Diagnostic Quiz

Dystopian Dystonia By Andrew S. Gurwood, OD

History afferent pupillary defect. Addition- A 67-year-old black female pre- ally, the external, corneal and inter- sented for a consultation regarding nal ocular evaluations were normal. an unusual facial spasm after being The dilated fundus examination admitted to the hospital 15 days was normal. Her intraocular pres- earlier for multiple systemic ill- sure measured 14mm Hg OU. The nesses. She did not experience any pertinent clinical finding is illus- local or generalized head pain, but trated in the photograph. reported an increase in blinking and “eyelid twitching” as early as five Your Diagnosis to seven years ago. How would you approach this Her systemic history was remark- case? Does the patient require any able for medically controlled additional tests? What is your arrhythmia and hypertension. She diagnosis? How would you man- reported no known allergies of any age this patient? What is the likely kind. prognosis? To find out, please visit www. Diagnostic Data revoptom.com. Click on the cover Her best-corrected visual acuity External image of our 67-year-old patient icon for this month’s issue, and measured 20/20 OU at distance and who presented with a facial spasm. What then click “Diagnostic Quiz” under near. We uncovered no evidence of is the most likely diagnosis? the table of contents. ■

Retina Quiz Answers (from page 90): 1) b; 2) b; 3) d; 4) b; 5) d.

Next Month in the Mag And... April features our Corneal Disease Report. • Don’t miss the April issue of Review of Cornea & Topics include: Contact Lenses, devoted to scleral lens topics. • Optometric Study Center: The Pathogens of Corneal Infection (earn 2 CE credits) Feedback •The Role of Corneal Pharmacodynamics in Review of Optometry welcomes questions and comments. E-mail Topical Antibiotic Delivery Jack Persico, editor-in-chief, [email protected], with “Letter • Endothelial Cell Dystrophy: Causes and Remedies to the Editor” as the subject line.

Also inside: Or, write to Review of Optometry, 11 Campus Blvd., Suite 100, •How Hypertension and High Cholesterol Harm the Eye Newtown Square, PA 19073. •Give Your Instruments and Office Equipment a Tune-Up •Visual Field Interpretation: 10 Clues Something is Amiss

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 2025, SKOKIE, IL 60076. SUBSCRIPTION PRICES: US: ONE YEAR $56; TWO YEARS $97, CANADA: ONE YEAR $88, TWO YEARS $160, INT’L: ONE YEAR $209, TWO YEARS $299. FOR SUBSCRIPTION INFORMATION CALL TOLL-FREE (877) 529-1746 (USA ONLY); OUTSIDE USA, CALL (847) 763-9630 OR FAX (847) 763-9631. PUBLICATIONS MAIL AGREEMENT NO: 40612608. CANADA RETURNS TO BE SENT TO BLEUCHIP INTERNATIONAL, P.O. BOX 25542, LONDON, ON N6C 6B2.

114 REVIEW OF OPTOMETRY MARCH 15, 2014

114_ro0314_dq_final.indd 114 3/4/14 10:24 AM Soaking in an infinity pool in the back of a convertible, gliding down Rodeo Drive on a cloudless day.

Impossibly comfortable. A contact lens so comfortable that it tests your patients’ powers of imagination? Absolutely. Thanks to Aquaform® Technology, CooperVision® Biof inity® lenses deliver a combination of breathability and moisture higher than the leading silicone hydrogel brands. In sphere, toric and multifocal designs.

Biof inity® contact lenses Ask your CooperVision Sales Representative about our current promotions.

RO0913_Coopervision.indd 1 8/12/13 2:33 PM THIS IS WHY our new daily disposable toric contact lens is designed for stable vision and refreshes with every blink—no matter what the day may bring.

IN AL TH ZON DU ES

PRECISION CURVE™ Lens Design WITH BLINK-ACTIVATED MOISTURE OPTIC ZONE

D E

N NEW DAILIES® AquaComfort Plus® Toric I H T contact lenses are designed to deliver - A R outstanding visual performance and comfort. T L D U UA S L THIN ZONE

PRECISION CURVE™ BLINK-ACTIVATED SUCCESSFUL WEAR LENS DESIGN MOISTURE Clear vision and Stable design helps Moisture is released with comfort throughout deliver ≤ 5° oscillation every blink, which helps the day. with blink.1* result in a stable tear fi lm. NEW

Visit myalcon.com Over 800 more parameters with the same great design as FOCUS® DAILIES® Toric contact lenses

PERFORMANCE DRIVEN BY SCIENCE™

*Based on investigator assessment of lens rotation, at one week (n=181 lenses); using investigational lenses with -0.75D, -1.50D cylinder powers. References: 1. In a subject-masked clinical trial (n=93); Alcon data on fi le, 2010. See product instructions for complete wear, care, and safety information. © 2013 Novartis 11/13 DAT13016JAD

RO0314_Alcon Dailiels.indd 1 2/19/14 11:28 AM